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To Bleed or Not to Bleed Jay B. Reznick, DMD, MD

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by Jay B. Reznick, DMD, MD

One of the frequent issues in my practice is the protocol for patients who are taking anticoagulant medications. Things have changed in this regard since the time I was in dental school. Back then, we were required to get a physician's consultation and clearance before we treated any patient with any type of medical disorder. Many times we were amazed about how nonsensical doctor's recommendations were, but would be liable in a court of law if we had not taken their advice and the case went awry, so we went along. After entering oral and maxillofacial surgery residency, and later as a medical student, I came to appreciate that most physicians know next to nothing about dentistry. Many of them could not even tell you how many teeth an adult should have. Therefore, they based their recommendations on what they knew from medical surgery. If a patient has postoperative bleeding in the abdomen, chest, shoulder, nose or brain, they can be in serious trouble. Patients are placed on anticoagulant medications, such as Coumadin, Plavix, or aspirin in order to prevent formation of a blood clot in the coronary arteries, brain, abdomen or extremities following a stroke, mesenteric thrombosis, bypass grafting, deep venous thrombosis, or to prevent a thrombotic event when there are significant risk factors. So, patients who are on these medications are on them for good reason.

In medicine, clinical decisions are made by carefully evaluating the benefits, risks and complications of the various treatment options. When it comes to taking patients off anticoagulant medications, the risk of having significant and uncontrollable intraoperative or postoperative bleeding is compared with the risk and consequences of the patient having another thrombotic event. When we are talking about surgical procedures such as bowel resection, joint replacement, coronary artery bypass or septoplasty, such bleeding can be widespread or from a large blood vessel, and can be hard to adequately control in an anticoagulated patient. This can lead to disaster, and thus is weighed against the risk of a stroke, myocardial infarction or pulmonary embolus. For these types of procedures, it is commonplace to take patients off of their anticoagulant a few days before surgery so that their hemostatic mechanism is intact at the time of operation, and then to restart the medication once the critical period for bleeding has passed, which is usually two to three days. This makes the patient's surgery safer from the perspective of perioperative bleeding, but abruptly stopping their anticoagulant medication for surgery actually puts them into a hypercoaguable state, which increases their risk of thrombotic complications above their baseline risk.

For patients who have an increased risk of thrombosis because of their history, or the presence of a mechanical heart valve, that window of normal or hypernormal coagulation can be narrowed by following a protocol of intravenous heparin, which is stopped and restarted within hours of the surgical procedure. This requires the patient be hospitalized for at least two days before and two days after surgery, no matter how minor the procedure might be. Many of the patients who required this (during my residency) were cardiac patients who needed some infected, unrestorable teeth removed before heart surgery, or to prevent endocarditis from developing in the susceptible heart. After oral surgery, the patients were again anticoagulated, and if they were to have subsequent cardiac surgery, it would usually be done a week or so later. Luckily for the ambulatory patient, in the mid- 1990s low molecular weight heparins (LMWH), a new class of anticoagulant, were introduced. These obviated the need for hospital admission for all but the highest risk patients. The patient would be given a supply of syringes and would self-administer the drug subcutaneously in the period before and after surgery. This generally had to be coordinated with the patient's cardiologist to arrive at the best dosing regimen.

This was about the time that I started in private practice, and although using LMWHs was certainly much easier than hospitalization and intravenous heparinization, it was still a hassle, both for patients and dentists. This however, was the protocol that the cardiologists and hematologists had developed for all surgeons to follow. These regimens were developed by physicians who applied the same rules for abdominal surgery, neurosurgery, orthopedic surgery and oral surgical procedures. It always seemed to me that this was overkill. I remembered from residency and practice that most cases of bleeding from an extraction site, no matter how severe, could be controlled by packing with gauze, and maintained with a hemostatic agent, such as Gelfoam, Surgicel or topical thrombin. Unlike the abdominal cavity, chest or knee, where surgical bleeding can be widespread and cannot be easily controlled by packing, most oral surgical sites are very accessible to the surgeon and are very easily packed to control bleeding. Usually dentists or oral surgeons do not encounter many major blood vessels. As a dental student, I remember reading an article in one of my journals about research conducted at a dental school in Israel, in which they treated patients on Coumadin no differently than patients who were not anticoagulated. They found that for minor oral surgical procedures, including extraction of two to three teeth, biopsies, small mucosal excisions and quadrant alveoloplasty, that intraoperative bleeding was not appreciably different, and postoperative bleeding episodes occurred at only a slightly higher rate. When postoperative bleeding was encountered, it was usually managed very easily with local packing and hemostatic agents. They recommended that the protocol for managing the anticoagulated patient be modified to reflect their findings. I did not hear much about this afterward. I even suggested to my fellow residents and faculty that we consider the findings of this research, but was told to continue our standard protocol. Being a lowly resident, I went along with my superiors.

Once I got into private practice, I was in a better position to push the envelope and decided to keep some of my patients on their anticoagulants for surgery. I started experimenting first with single extraction cases, carefully minimizing my incisions and packing the socket with Gelfoam. I found that intraoperative bleeding was basically normal, and that the postoperative bleeding incidence did not increase. I soon expanded my range to include quadrant extractions, alveoloplasty, and various limited soft tissue procedures. I continued packing the sockets with Gelfoam, and used my cautery or laser for the soft tissue surgeries. Again, I found no increase in bleeding, either during or after surgery. Every other oral surgeon in my area was taking their patients off of Coumadin for simple single tooth extractions. This variation in protocol was one of the things that helped build my practice in its earlier days.

In January 2000 the Journal of the American Dental Association (JADA) published the article "Myths of Dental Surgery Patients Receiving Anticoagulant Therapy."¹ This article reviewed a number of scholarly papers dating back to 1954 and came to the conclusion that embolic complications, including death, following abrupt short-term discontinuation of anticoagulants for dental surgery, were three times more likely than were bleeding complications when anticoagulants were continued perioperatively, as long as INR (International Normalized Ratio) was less than 4.0. Another article, in the November 2003 issue of JADA presented "Lack of a Scientific Basis for Routine Discontinuation of Oral Anticoagulation Therapy Before Dental Treatment."¹ This article reviewed the previous literature – an analysis of the various anticoagulant drugs, laboratory tests, and assessment of risks related to this clinical problem – and came to a similar conclusion.

These papers brought a new line of thinking into the mainstream, and gave me the license to include this in my teachings of oral surgery to the masses. Every patient must be viewed as an individual, based on their risk factors.

For the majority of anticoagulated patients who are to undergo a minor oral surgical procedure, so long as their INR is less than 3.5, we can typically follow the guidelines I have discussed. Remember, the physician's recommendation is based on their knowledge of medical surgery not oral surgery, and they will always tell you the patient must be taken off Coumadin, Plavix or aspirin for surgery. Try to be as atraumatic as possible in performing surgery. Use minimally invasive techniques as much as possible, and pack the site with topical hemostatic material. You will find that your patients will be impressed by your up-to-date knowledge on the subject, grateful that you are not putting them at increased risk for a thrombotic complication, and looking out for their best interests. It is always good to be better than your competition. And, this is a simple way to do it.

References
1. Articles can be downloaded free of charge from the JADA Web site at www.jada.ada.org
Author’s Bio
Dr. Jay B. Reznick is a Diplomate of the American Board of Oral and Maxillofacial Surgery. He received his Dental degree from Tufts University, and his M.D. degree from the University of Southern California, and trained in Oral and Maxillofacial Surgery at L.A. County-USC Medical Center. His special clinical interests are in the areas of facial trauma, jaw and oral pathology, dental implantology, sleep disorders medicine, laser surgery, and jaw deformities. He also has expertise in the integration of digital photography and 3D imaging in clinical practice. Dr. Reznick is one of the founders of the Web site OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques. He is the Director of the Southern California Center for Oral and Facial Surgery in Tarzana, California. He can be reached at jreznick@sccofs.com.
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