1. Post oral surgery bleeding for adult patients receiving antithrombotic therapy

3. Saudi Arabia

5. King Fahd Medical City is a large tertiary care hospital with 1095 beds. The American College of Chest Physicians guidelines recommend that routine dental procedures including extractions, scaling and restorative treatment could be done without the interruption of Warfarin, a Vitamin K Antagonist (VKA) if the International Normalized Ratio (INR) is within the therapeutic range and local hemostatic agents are used.¹ The American Heart Association guidelines recommend that anticoagulant such as Clopidogrel do not need to be stopped for dental procedures.² The recommendation in the Journal of Canadian Dental Association is that Enoxaparin should have the morning dose held.³ The American Dental Association stated ‘ it is generally agreed that anticoagulant [including antiplatelet] drug regimens should not be altered prior to dental treatment.’ 4 Background

6. Little existing data in Saudi Arabia for antithrombotic (anticoagulant and anti-platelet) therapeutic doses and their effects on post-oral surgery bleeding. 5 There is an urgent need to standardize the practice for treating such patients because evidence from a survey we conducted showed that a high number of local dentists are unwilling or unsure how to treat patients on antithrombotic medications. This will lessen the delays that the patient faces in receiving treatment. Rationale

7. Survey about perceptions of dentists in Saudi Arabia about treating patients on anti-thrombotic therapy

8. Dentist familiarity with antithrombotic medications No. of dentists

9. What % of dentists would not treat a patient or are unsure how to treat on antithrombotic medications

10. Objectives Is to assess the post oral surgery bleeding incidence in adult patients on antithrombotic once implementing the following protocol: Warfarin: Medication to be continued. Recent (within 24 hours) INR values to be within therapeutic range. Clopidogrel: Medication to be continued. Enoxaparin: Morning dose to be held. Local hemostatic agents available to be used as deemed necessary i.e. sutures, collagen, tranexamic acid. To reduce the interruption of antithrombotic medications

11. Study Design A prospective cohort single-centre two year study of all patients on antithrombotic medications undergoing oral surgery within King Fahd Medical City (KFMC) Department of Dentistry. All patients within the inclusion criteria were monitored

12. Inclusion and exclusion criteria Inclusion Patients for oral surgery in KFMC Department of Dentistry and under the care of a KFMC physician Patients treated under local anesthesia Patients 18 years old or over Taking the afore-mentioned antithrombotic medications according to the protocol described Exclusion Patients treated under general anesthesia Any patients stopped antithrombotic medication without physician approval Sub-therapeutic or supra-therapeutic INR values for patients taking Warfarin Patients with advanced liver disease

13. Variables

14. Methodology Protocol: Local hemostatic agents available to be used as deemed necessary i.e. sutures, collagen, tranexamic acid. Warfarin: Medication to be continued. Recent (within 24 hours) INR values to be within therapeutic range. Clopidogrel: Medication to be continued. Enoxaparin: Morning dose to be held. All patients who were underwent oral surgery procedures were monitored for post-operative bleeding. Bleeding was defined as serious post-operative bleeding after the patient has been discharged from the clinic > 12 hours, or bleeding necessitating return to a medical facility and further measures (e.g. use of hemostatic agents).

15. Results Out of 353 visits there were only two incidences of bleeding necessitating return to a medical facility (0.56%) The average INR value for the patients receiving Warfarin was 1.9 Treatment done: 826 extractions 14 alveolectomies 3 bone grafts 2 implants 1 biopsy

16. Antithrombotic Medications 353 cases 147 Clopidogrel 122 Warfarin 86 Enoxaparin

17. Antithrombotic Medications studied Anticoagulant Vitamin K Antagonist (VKA) Warfarin Anticoagulant Low Molecular Weight Heparin (LMWH) Enoxaparin Antiplatelet P2Y12 receptor inhibitors Clopidogrel

18. Number of teeth extracted per notation 21 27 36 32 26 16 15 2115 21 16 21 32 3128 3343 18 19 21 19 3416 2722 30 36 31 28 35 37

19. Patient Demographics - Gender

20. Patient Demographics – Age distribution (Average age = 50.7 years, range 18 - 88 years)

21. Patient Demographics – Medical Conditions

22. Conclusion Our finding supported the following for patients undergoing oral surgery procedures provided local hemostatic agents are available to use as necessary: Warfarin: can safely be continued during oral surgery procedures as long as the INR is within the therapeutic range Clopidogrel: can safely be continued during oral surgery procedures Enoxaparin: the morning dose should be held

23. Obstacles we faced Some loss of patients to follow up The recent introduction of Novel Oral Anticoagulants (NOACs) such as Dabigatran and Rivaroxaban mean that they should be studied for incidence of bleeding. To include dental hygiene patients. Recommendations for further study

24. ¹ Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9 th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;141(2) (Suppl):e326S-50S. Available: http://journal.publications.chestnet.org/data/Journals/CHEST/23443/112298.pdf Accessed: February 19, 2013http://journal.publications.chestnet.org/data/Journals/CHEST/23443/112298.pdf ² Grines CL, Bonow RO, Casey DE et al. Prevention of premature discontinuation of antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007;115:813-8. Available: http://circ.ahajournals.org/content/115/6/813.full.pdf+html http://circ.ahajournals.org/content/115/6/813.full.pdf+html ³ Davies C, Robertson C, and Shivakumar S. Implications of Dabigatran, a Direct Thrombin Inhibitor, for Oral Surgery Practice. J Can Dent Assoc 2013;79:d74 4 American Dental Association, Anticoagulant, antiplatelet medications and dental procedures http://www.ada.org/2959.aspx?currentTab=1 Accessed: February 27, 2013 http://www.ada.org/2959.aspx?currentTab=1 5 Al-Mubarak, S., Al-Ali, N., Abou Rass, M. et al Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy Br. Dent. J. 2007; 203(7);e15 6 Nooh, N., Dental Management of patients receiving anticoagulant therapy Saudi Dental Journal, Volume 21, No.1, January – April 2009 References