Is Alteration of Warfarin Regimen Necessary Before Dental Extractions

+ MODEL Journal of Dental Sciences (2015) xx,1e7

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ORIGINAL ARTICLE Is alteration of warfarin regime necessary before dental extractions in Taiwanese patients? Results of a retrospective cohort study Shin-Yu Lu a,b*, Chi-Yu Tsai a,b, Sheng-Nan Lu b,c, Liang-Ho Lin a,b a Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan b Chang Gung University College of Medicine, Kaohsiung, Taiwan c Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan

Received 30 December 2014; Final revision received 4 February 2015 Available online ---

KEYWORDS Abstract Background/purpose: Most Western studies do not recommend interrupting extraction; warfarin therapy or replacing it with heparin priortotoothextractioniftheinternational oral anticoagulants; normalized ratio (INR) levels are maintained. However, this issue remains controversial in tranexamic acid; Taiwan. The aim of this study was to investigate whether Taiwanese patients who had an warfarin INR within the therapeutic range required cessation of warfarin prior to dental extractions. Materials and methods: A total of 60 patients on warfarin with INR <4.0 who underwent 207 dental extractions in 70 occasions were divided into two groups. Thirty-two patients were allocated to the control group (warfarin stopped and switched to heparin under hospitalization) with average preoperative INR (range) from 2.30 (1.32e3.12) brought down to 1.14 (1.04 e1.32), and 28 patients were allocated to the study group (warfarin continued) with an average preoperative INR of 1.95 (1.06e3.08). Results: The incidence of postoperative bleeding in the study group was higher (3/33, 9.1%) than in the control group (3/37, 8.1%), but this difference was not significant. Local hemostasis with Gelfoam sponge was sufficient in most patients. Postoperative hemorrhage can be suc- cessfully managed by repacking with Gelfoam impregnated with tranexamic acid powder in five patients and resuturing in one patient. Conclusion: The study proved that dental extractions can be performed without interruption or alteration of warfarin regime in Taiwanese patients, provided the INR is below 4.0. A

* Corresponding author. Oral Pathology and Family Dentistry Section, Department of Dentistry, Kaohsiung Chang Gung Memorial Hospital, 123 Tai-Pei Road, Niaosong District, Kaohsiung 833, Taiwan. E-mail addresses: [email protected], [email protected] (S.-Y. Lu). http://dx.doi.org/10.1016/j.jds.2015.03.006 1991-7902/Copyright ª 2015, Association for Dental Sciences of the Republic of China. Published by Elsevier Taiwan LLC. All rights reserved.

Please cite this article in press as: Lu S-Y, et al., Is alteration of warfarin regime necessary before dental extractions in Taiwanese patients? Results of a retrospective cohort study, Journal of Dental Sciences (2015), http://dx.doi.org/10.1016/j.jds.2015.03.006 + MODEL 2 S.-Y. Lu et al

sufﬁcient hemostasis can be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin. Copyright ª 2015, Association for Dental Sciences of the Republic of China. Published by Else- vier Taiwan LLC. All rights reserved.

Introduction incidence of major bleeding or thromboembolic events.19e22 The efficacious antithrombotic therapy to prevent stroke in Taiwan recommended maintaining an INR of 2.0 to It is very common in primary care dental practice to stop 24 warfarin therapy for a few days prior to oral surgery in 3.0; however, it remained underused. order to limit bleeding problems. It has been assumed that In Taiwan, whether to maintain, discontinue, or reduce discontinuing warfarin for a short period presents negligible antithrombotic therapy for dental extraction has long been risk to the patient; however, stopping warfarin for several debated, and approaches vary between institutions and days can lead to a rebound hypercoagulable state and in- doctors. In one case, a cardiac surgeon referred a number crease the risk of thromboembolic events.1e6 Although the of patients on warfarin to our department for dental risk is small, it outweighs the risk of oral bleeding.3e9 extraction and administered bridging anticoagulation with Clinically, we have experienced a mortal risk that heparin under hospitalization. His conventional practice occurred in a 68-year-old Taiwanese female with hyper- had been to let individuals stop warfarin several days prior tension, diabetes, and a stroke after cessation of warfarin. to extractions and administer bridging anticoagulation with She reported being asked to stop warfarin for 5 days prior to heparin under hospitalization, to do an INR on the day of < extraction of a mobile premolar. Two days after tooth operation, and to proceed if the INR was 1.5 and close to extraction, she was sent to the emergency room because of 1.0. The warfarin treatment was reinstated later on the day a sudden onset of chest tightness, cold sweating, dizziness, following dental extraction. This approach tried to avoid a and dyspnea. An acute myocardial infarction with total residual anticoagulant effect at the time of the procedure, occlusion of the right coronary artery was diagnosed, and a and dealt with the doctor’s perception of an increased risk percutaneous coronary intervention was performed. Her of serious bleeding if warfarin was not interrupted. physician strongly suggested that warfarin therapy need not Warfarin therapy is problematic with a narrow thera- be modified or discontinued for simple single dental peutic index, wide interaction with foods and drugs, a long e e extractions. half-life of 48 72 hours, and delayed-onset of 76 96 hours Most Western countries do not recommend reducing or of action after cessation as well as restarting treatment. e interrupting warfarin therapy, or replacing it with heparin Accordingly, patients may have at least 2 3 days of sub- 2e8 therapeutic anticoagulation around the time of surgery and prior to dental extraction. Studies have shown that if an 4e6,9 international normalized ratio (INR) is below 4.0, no increase the risk of thromboembolic events. If patients < marked differences in the incidence or volume of post- with INR 4 could be treated routinely without altering extraction bleeding happen.3e15 The optimal therapeutic their warfarin regime, then it is possible that most dental range of anticoagulation therapy varies for different in- extractions could be done in general practice on the same dications and for patients with various characteristics. Both day as regular INR blood monitoring. This would be more the British Society for Hematology and the American Col- convenient, cost-effective, and quicker for the patients, lege of Chest Physicians recommend moderate-intensity and would help to reduce hospital waiting lists. anticoagulation (INR 2.0e3.0) for most indications of To the best of our knowledge, this is the first retro- warfarin, such as prophylaxis and treatment of venous spective study in Taiwan to evaluate the incidence of thrombosis, pulmonary embolism, and prevention of sys- postoperative hemorrhage after dental extraction in pa- temic embolism secondary to valvular heart disease or tients with warfarin therapy temporarily modified with atrial fibrillation. The exceptions that require high- heparin, and in patients without interruption of warfarin intensity anticoagulation (INR 3.0e4.5) are patients with therapy. mechanical heart-valve prostheses.16e18 Despite both recommendations originating from clinical trials conducted in Materials and methods Western people, the same recommendations have been adopted for anticoagulation therapy in populations of The study was approved by the Institutional Review Board different ethnic backgrounds. However, they have shown of Chang Gung Memorial Hospital. A total 65 consecutive lower warfarin requirements in Asians (3 mg daily) patients on warfarin were referred by either general den- compared with Whites (4e6 mg daily), suggesting that tists or medical practitioners for dental extractions that Asians are more sensitive than Whites to the anti- were performed by the same qualified dentist (the first 19e23 coagulation effect of warfarin. A cohort study of Hong author) at the Family Dentistry Department of Kaohsiung Kong Chinese patients receiving warfarin therapy with INR Chang Gung Memorial Hospital between January 2010 and >2.4 reported high incidence of major bleeding, and the June 2014. Data were collected from the chart notes made INR of 1.8e2.4 appeared to be associated with the lowest at each visit. Investigated items included patient

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