Managing Anticoagulant Patients Undergoing Dental Extraction by using Hemostatic Agent: Tranexamic Acid Mouthrinse.

BACKGROUND: Patient who is on antiplatelet therapy had an impaired fibrin formation which leads to fibrinolysis which is the main reason behind postextraction bleeding.
OBJECTIVES: The aim of the study is to manage anticoagulated patient who has to undergo dental extraction by using hemostatic agent and the objective is to rule out potential risk factor which may trigger bleeding.
METHODS: One hundred patients with anticoagulant and antiplatelet therapy and having International Normalized Ratio (INR) in-between 1.9 and 3.5 were selected. Postextraction instruction use 5 ml of 10% tranexamic acid mouthrinse four times a day for next 7 days was suggested. All demographic data, history of anticoagulant and antiplatelet therapy, details of bleeding, and treatment requirement were recorded to identify potential risk factor.
RESULTS: Of 100 subjects, 16 were reported postextraction bleeding on days 1 and 2 which was controlled by tranexamic acid pressure pack. Bleeding from extraction socket of 10 patients was stopped by gelatin foam. No life-threatening risk was observed. In patients with age group of 41-60 years whose INR value was ≥2.5, the number of teeth undergoing extraction, whose bleeding time was increased, and were on long duration of antiplatelet and anticoagulation therapy might increase the risk of bleeding.
CONCLUSION: Use of tranexamic acid mouthrinse after extraction is an effective way to control bleeding on patients who are under antiplatelet therapy with at therapeutic INR level is a secure and allowable method of minimizing postextraction oozing. Copyright:

INTRODUCTION

Increasing number of patients with increased age requires dental extraction under anticoagulant and antiplatelet therapy on long term. Literature shows many controversies regarding dental management protocols for patients who are taking anticoagulant and antiplatelet medicines. Earlier, it was stated that clinician must reduce or stop antiplatelet therapy to minimize the risk of excessive bleeding post extraction.[1] To prevent thromboembolism in patients with arterial fibrillation and prosthetic heart valve, oral anticoagulant and antiplatelet are used to prevent systemic embolism.[2]

However, oral anticoagulant and antiplatelet therapy possess major drawbacks like more prone to bleed after traumatic events and surgical treatment. Patients who are usually taking anticoagulant are older in age and are present with multiple comorbidities and are under many medications.[3]

When a patient is taking antiplatelet drug, it takes a longer time to stop bleeding and primary hemostasis cannot be achieved; as a result, bleeding time is prolonged.[4] The most common anticoagulant drug used is warfarin which prevents clot formation.[5] Patient who were on anticoagulant and antiplatelet therapy if stopped prior to any surgical procedure may cause fatal condition which may lead death. After withdrawal of this drug, thromboembolism occurs.[678]

Antifibrinolytic agents like tranexamic acid can be used as a mouthwash to stop postextraction bleeding. Tranexamic acid mouthrinse is used for 7 days every 6 hourly which prevents blood clot in tooth socket without fibrinolysis which leads to minimum postextraction oozing.[9]

The aim of the study is to manage postextraction bleeding of anticoagulated patient with tranexamic acid mouthrinse. The main objective is to rule out potential risk factor, which may trigger bleeding.

MATERIALS AND METHODS

The study was designed as a comparative interventional study. For this study, 100 subjects were selected with inclusion criteria as: (1) age >18 years or older, (2) subject under anticoagulant and antiplatelet who requires extraction of teeth, (3) International Normalized Ratio (INR) value between 1.9 and 3.5 on the day of surgery. Exclusion criteria were (1) patient who fails to give informed consent, (2) patient who has a bleeding disorder or liver failure, and (3) INR value <1.9 or INR >3.5.

Prior to surgery, complete detail history of the patient was recorded and informed consent was obtained. Before extraction, patients' bleeding time, INR, and APTT were recorded. Patients with heart disease were kept under prophylactic management according to the American Heart Foundation Guidelines.

Atraumatic extraction socket was irrigated with 10% tranexamic acid solution, a pressure pad soaked in tranexamic acid solution for 10 min was used. If the bleeding was not stopped, gelatine sponge was placed and the procedure repeated till bleeding stops completely. If the patient continues to bleed, then the patient was infused with fresh frozen plasma, Vitamin K, or Desmopressin (1-Deamino-8-D-arginine vasopressin). Postextraction antibiotics + analgesic, tranexamic acid tablets (500 mg dissolved in 5 ml sterile water rinse for 2 min 4 times a day), and posttreatment INR on 4th day was prescribed. Apart from this, the patient was asked to have a soft diet and not to spit on the day of surgery. The patient was asked about any problem or side effect associated with the use of tranexamic acid solution.

Statistical analysis was done using IBM SPSS 21.0 Armonk, New York, USA; data were expressed in numbers, percentage, mean, and standard deviation. Paired and unpaired t-test was used. P < 0.05 was considered statistically significant.

RESULTS

Table 1 shows distribution of subjects according to age in years, gender, and habit of tobacco smoking where P < 0.05 was found to be significant compared to 41–60 years with others. Table 2 depicts the preextraction mean values of blood parameters. Table 3 gives the detailed information about etiological disorders leading to anticoagulant medication and their distribution of patients. Table 4 shows distribution of patients based on the day of postoperative bleeding and event which caused bleeding. Pre- and postoperative INR values are compared in Table 5. No statistically significant difference was found when INR values compared preoperative with postoperative (P < 0.05).

Table 1

Distribution of patients based on the age, gender, and smoking

Variables	Subgroup	n (%)
Age (years)	20-40	11* (11.00)* (P=0.03)
	41-60	62 (62.00)
	61-80	37* (37.00)* (P=0.04)
Gender	Male	55 (55.00)
	Female	45* (45.00)* (P=0.03)
Smoking	Yes	53 (53.00)
	No	47* (47.00)* (P=0.05)

*P<0.00

Table 2

Mean values of blood parameters pre extraction

Blood parameters	Mean±SD
INR	2.208±0.351
Platelet count	2.321±0.242
Bleeding time	3.553±0.327

SD: Standard deviation, INR: International normalized ratio

Table 3

Distribution of patients based on the reason for being on anticoagulant medication

Reason for being on anticoagulant medication	n (%)
CAD	71* (71.00)* (P=0.01)
RHD	13 (13.0)
AVR	1 (1.0)
IHD	3 (3.0)
Atrial fibrillation	8 (8.0)
TVD	1 (1.0)
ACHD	1 (1.0)
CAD+IHD	1 (1.0)
CHD/ASD	1 (1.0)

*P<0.05 significant CAD with others. CAD: Coronary artery disease, CHD: Coronary heart disease, ASD: Atrial septal defect, IHD: Ischemic heart disease, RHD: Rheumatic heart disease, AVR: Aortic valve replacement, TVD: triple vessel coronary disease, ACHD: Adult Congenital Heart Disease

Table 4

Distribution of patients based on the day of postoperative bleeding and event which caused bleeding

Parameters	n (%)
Day of postoperative bleeding (day)
No	73*(73.0) (P=0.03)
1st	16# (16.0)
2nd	7 (7.0)
3rd	2 (2.0)
4th	2 (2.0)
Cause of bleeding
No	73* (7300)* (P=0.01)
Spontaneous	24 (2400)
Trauma	3 (3.0)

*P<0.05 significant compared no with others

Table 5

Comparison of pre- and postoperative international normalized ratio

Status	INR (mean±SD)	P
Preoperative	2.28±0.35	0.89
Postoperative	2.36±0.58

INR: International normalized ratio, SD: Standard deviation

DISCUSSION

Tranexamic acid is an antifibrinolytic drug which binds to lysine binding sites of plasminogen. Therefore, it blocks the binding of plasminogen to fibrin like histidine-rich glycoprotein.

In dentistry, after dental extraction, local hemostasis advancing materials and technique are used widely if a patient undergoes dental extraction who were under antiplatelet or anticoagulant treatment.

Nowadays, many methods are used to reduce postextraction bleeding like socket suturing by ordinary suture material or gluconic polymer-based sterile knitted fabric also stops bleeding from extraction socket. It binds hemoglobin to oxycellulose which forms a gelatinous mass which acts as scaffold for clot formation and clot stabilizer. It is an absorbable material which does not hamper healing or bone regeneration.

Other reliable measures are gelatin foam, topical bovine thrombin, and use of microfibrillar collagen. Beriplast-composite biological tissue adhesives which mimic the final stage of blood clotting give better hemostasis. Fibrin glue, human fibrinogen concentrate, absorbable collagen paste, and calcium alginate are also beneficial in hemostasis.[10]

Our study was conducted to prove an easy, less risky, and secure tranexamic acid mouthrinse to manage postextraction hemorrhage in patients who had a previous history of coagulant and antiplatelet therapy.

Ramstrom et al.[1] (1993) found that 8.7% of 46 patients reported with an adverse effect of mouthrinse such as e taste, nausea, slight burning sensation, and tedious which were similar to our study. Literature shows that all previous studies used 10 ml of 4.8% tranexamic acid mouthrinse, but in our study, we used 5 ml of 10% tranexamic acid mouthrinse. The reason behind this was as 10 ml of 4.8% tranexamic acid solution have the same amount of active solution as 5 ml of 10% solution.

One of the major concerns associated with removal of teeth in patients who were under anticoagulant or anti-ptatelet was uncontrolled bleeding or a thromboembolic event. In our study, we did not require systemic therapy or admission to the hospital. Bleeding was controlled by finger pressure either at home by the patient or by the dental surgeon by local measures.

No thromboembolic event or medical emergencies occurred as tranexamic acid mouthrinse has the least systemic absorption and was spit out immediately after 2 min. Studies have been done which show if swallowed accidentally, it does not have any side effects.[11]

Wahl (1998) reported that 774 patients (98%) who require dental extraction were on anticoagulant or antiplatelet therapy reported no oozing or insignificant oozing which were managed by local hemostatic material. This was alike our study which shows it was a safe method for managing patients.[12]

About 4.5% per year population is at risk of systemic embolism for a patient with nonvalvular atrial fibrillation who was not at an antithrombotic therapy.[1314] Hence, anticoagulant/antiplatelet reduces risk of embolism by 66%. About 75% of risk reduced in patients who are under anticoagulant.[15]

Study shows if INR ≥2.5, maxillary molar was at more risk to bleed. Our study also shows that some areas of the mouth were more prone to postextraction bleeding. Maxillary teeth bleed more than mandibular teeth molars were more prone comparatively to anterior teeth and the least were mandibular premolar, canine and incisor region.

INR used to predict how a patient on oral anticoagulants has to undergo dental extraction should be managed. Higher the INR value denotes high prevalence of hemorrhage. This study shows there was no statistically significant difference between the incidence of bleeding below an INR <2.5 and an INR ≥2.5 and this study shows if INR exceeded 3.0, the bleeding was significantly greater.

Our study proposes that many patients can be managed who are under anticoagulant/antiplatelet therapy. Of the total of 100 patients treated, 16 reported immediate postextraction bleeding on the next day and after a week. All the patient were managed by tranexamic acid pressure pack alone, while 10 patients reported to the dental surgery department where oozing was controlled by using gelatin foams (local hemostatic measures)16 with tranexamic acid pressure pack. No patient was admitted to the hospital for systemic management.

CONCLUSION

In this study, we used 5 ml of 10% tranexamic acid solution, whereas literature shows higher concentrations (10 ml of 4.8%) of tranexamic acid. Hence, there was the least possibility of local effect for preventing fibrinolysis. Our study concludes that postsurgical topical use of tranexamic acid mouthrinse in patients who require removal of teeth at therapeutic INR level was a safe and allowable method to reduce postextraction bleeding. Identification of risk factors prior to extraction gives the surgeon an opportunity to reduce the likelihood of bleeding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.