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DRUG INFORMATION ROUNDS

Hemostatic Mouthwashes in Anticoagulated Patients Undergoing Dental Extraction

Assistant Professor, Department of Pharmacy Practice, College of Pharmacy, Southwestern Oklahoma State University, Oklahoma City, OK

Susan E Fugate, PharmD

Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma

Reprints: Dr. Patatanian, c/o Pasteur Medical Bldg., Department of Pharmacy Practice, College of Pharmacy, Southwestern Oklahoma State University, 1111 N. Lee St., Suite 241, Oklahoma City, OK 73103-2600, fax 405/601-1201, edna.patatanian{at}swosu.edu

OBJECTIVE: To evaluate the efficacy and safety of local acting hemostatic agents in patients who are undergoing dental extraction(s) and are taking oral anticoagulants.

DATA SOURCES: A search of MEDLINE (1966-July 2006), International Pharmaceutical Abstracts (1970-July 2006), and EMBASE (1966-July 2006) was conducted using the key terms anticoagulation, warfarin, hemostatic mouthwashes, epsilon aminocaproic acid, tranexamic acid, dental extraction, and oral surgery. Bibliographies of relevant papers were reviewed for additional references.

STUDY SELECTION AND DATA EXTRACTION: English-language literature, including abstracts, clinical trials, and review articles, were reviewed. Clinical trials were included if they evaluated hemostatic mouthwashes in patients receiving continued anticoagulation and undergoing dental extractions or various oral surgeries including dental extraction. Eight clinical trials met study selection criteria for evaluation of hemostatic mouthwashes in anticoagulated patients undergoing dental extraction. Eight studies evaluated tranexamic acid; one assessed epsilon aminocaproic acid. All studies were reviewed for efficacy and safety of hemostatic mouthwashes and intensity of continued anticoagulation therapy.

DATA SYNTHESIS: Eight small studies enrolled populations that varied in the indications for oral anticoagulation (OA), target INR ranges, and oral surgeries performed. Patients receiving uninterrupted OA and using hemostatic mouthwashes had no greater and, in some cases, lesser bleeding incidence compared with various other treatment groups (including interrupted OA, uninterrupted OA, autologous fibrin glue with uninterrupted OA, and reduced OA with heparin bridge). No severe adverse effects were reported. No studies assessed the risk of thromboembolism between the different treatment strategies.

CONCLUSIONS: Findings in recent studies indicate that dental extractions in anticoagulated patients can be performed without temporary discontinuation of oral anticoagulant therapy with the use of hemostatic mouthwashes to control localized bleeding. This practice should be more widely adopted due to minimized bleeding and thromboembolic risks.

Key Words: aminocaproic acid, dental extraction, hemostatic mouthwash, tranexamic acid, warfarin

Published Online, November 7, 2006. www.theannals.com, DOI 10.1345/aph.1H295