Review question

We reviewed the evidence about whether antifibrinolytic medicine (drugs that prevent breakdown of a blood clot), such as tranexamic acid or epsilon aminocaproic acid, can prevent oral bleeding after minor oral surgery or dental extractions in people using oral anticoagulants (blood thinners that are taken by mouth) without interruption during the procedure.

Background

People on continuous oral anticoagulant treatment are at an increased risk of bleeding complications during and after oral surgery or dental extractions. There are two types of oral anticoagulant treatment: vitamin K antagonists (VKAs) (e.g. warfarin and coumarin) and direct oral anticoagulants (DOACs) (e.g. dabigatran, rivaroxaban, apixaban, edoxaban). DOACs are becoming an increasingly popular alternative for VKAs, traditionally used for preventing blood clotting in people at risk of thrombosis. The number of bleeds and the severity of each bleed depend on medication-related factors (such as the degree of anticoagulation, measured by the international normalised ratio (INR)), surgery-related factors (such as the size of the wound or the number of roots extracted), as well as patient-related factors (such as inflammation of the gums or blood vessel diseases). The INR level is important to determine how well the anticoagulant treatment is preventing blood clots. Within the desired range of the INR level, a person has both the least risk of blood clotting complications and the least risk of excessive bleeding. In routine practice antifibrinolytic medicine is often used before, during and after minor oral surgery or dental extractions for people using oral anticoagulants. The question is whether there is reliable scientific evidence for this practice.

Search date

The evidence is current to: 04 January 2018.

Study characteristics

We did not find any trials of antifibrinolytic medicine for preventing bleeding after minor oral surgery or dental extractions in people using DOACs. This review includes four trials (253 participants) in people continuously treated with VKAs during minor oral surgery or dental extractions. The earliest included trial was published in 1989 and the most recent one in 2015. The mean age of all participants was 60 years. The follow-up time in all trials was seven days.

Key results

Overall, the included trials showed a reduction in the number of bleeds after dental extraction when using tranexamic acid solution in the mouth. Combining the results of the separate trials it appeared that antifibrinolytic medication reduces the bleeding rate after dental extractions by 25% when compared to placebo (‘dummy’ treatment). However, there was no difference in bleeding rate between people treated with tranexamic acid and those treated with standard care (e.g. gauze compression or stitches). Side effects of the antifibrinolytic medication rarely occurred and did not lead to individuals discontinuing tranexamic acid treatment.

No evidence was found for people being treated with DOACs. It could, however, be argued that, if antifibrinolytic medicine is effective in people on continuous treatment with VKAs, it might also work for people receiving other comparable anticoagulant drugs.

Quality of evidence

In relation to the review‘s two primary outcomes of number of postoperative bleeds and side effects of therapy, we judged there to be moderate-quality evidence.

In the two trials comparing tranexamic acid with placebo, the risk of bias, in relation to trial design, was considered to be low, in the two trials comparing tranexamic acid to standard care (gelatin sponge and sutures; or dry gauze compression) the risk of bias was considered to be moderate. This was mainly due to the lack of blinding (a way of making sure that the people involved in the trial do not know which trial arm they are assigned to) and inadequate allocation concealment (using the play of chance to assign participants to comparison groups to prevent selection bias) in two of these trials. There were differences between the trials with regards to different standard care treatments.