口服新型抗凝药患者牙拔除术后出血情况分析

 目的　分析口服新型抗凝药患者牙拔除术后出血情况。方法　选取2018年1月至2019年8月于大连市口腔医院心电监护门诊行牙拔除术的口服抗凝药患者212例作为研究组,其中口服新型抗凝药直接凝血酶抑制剂达比加群酯患者67例（凝血酶抑制剂组）,口服新型抗凝药直接Ⅹa因子抑制剂利伐他班或阿哌沙班患者59例（Ⅹa因子抑制剂组）,口服华法林患者86例（华法林组）。选取同期行牙拔除术的未服用抗凝药患者99例作为对照组。观察并记录各组患者牙拔除术后0.5、1、24、72 h的出血情况。结果　术后0.5、24 h各组出血发生率总的比较,差异有统计学意义（χ2值分别为9.79、8.13,P值分别为0.021、0.044）。进一步组间两两比较发现,各研究组出血发生率高于对照组,且华法林组出血发生率高于凝血酶抑制剂组和Ⅹa因子抑制剂组,差异均有统计学意义（均P < 0.05）,而两新型抗凝药组（凝血酶抑制剂组与Ⅹa因子抑制剂组）比较,差异无统计学意义（P > 0.05）。术后1、72 h各组出血发生率比较,差异均无统计学意义（χ2值分别为4.06、5.56,P值分别为0.251、0.165）。结论　相较于口服华法林患者,口服新型抗凝药患者牙拔除术后出血发生率更低,故口服新型抗凝药患者无需因简单的牙拔除术而调整或中断服用抗凝药。     

口服新型抗凝药患者牙拔除术后出血情况分析

目的　分析口服新型抗凝药患者牙拔除术后出血情况。方法　选取2018年1月至2019年8月于大连市口腔医院心电监护门诊行牙拔除术的口服抗凝药患者212例作为研究组,其中口服新型抗凝药直接凝血酶抑制剂达比加群酯患者67例（凝血酶抑制剂组）,口服新型抗凝药直接Ⅹa因子抑制剂利伐他班或阿哌沙班患者59例（Ⅹa因子抑制剂组）,口服华法林患者86例（华法林组）。选取同期行牙拔除术的未服用抗凝药患者99例作为对照组。观察并记录各组患者牙拔除术后0.5、1、24、72 h的出血情况。结果　术后0.5、24 h各组出血发生率总的比较,差异有统计学意义（χ2值分别为9.79、8.13,P值分别为0.021、0.044）。进一步组间两两比较发现,各研究组出血发生率高于对照组,且华法林组出血发生率高于凝血酶抑制剂组和Ⅹa因子抑制剂组,差异均有统计学意义（均P < 0.05）,而两新型抗凝药组（凝血酶抑制剂组与Ⅹa因子抑制剂组）比较,差异无统计学意义（P > 0.05）。术后1、72 h各组出血发生率比较,差异均无统计学意义（χ2值分别为4.06、5.56,P值分别为0.251、0.165）。结论　相较于口服华法林患者,口服新型抗凝药患者牙拔除术后出血发生率更低,故口服新型抗凝药患者无需因简单的牙拔除术而调整或中断服用抗凝药。     

持续口服华法林对牙种植体植入术后出血的影响

目的:探讨桥接抗凝与非桥接抗凝在接受牙种植体植入手术的患者围手术期的出血风险。方法:前瞻性分析口服华法林并且行牙种植体植入术的患者80例,按照术前是否接受桥接抗凝治疗,分为桥接抗凝组,非桥接抗凝组。统计两组患者基本信息及围手术期并发症情况。比较术中,术后1 h,术后1 d和术后7 d术区出血情况。结果:两组患者均未出现动静脉血栓形成症状。桥接抗凝组共38例,植入植体42颗。非桥接抗凝组共42例,植入59颗植体。术中桥接抗凝组明显出血15例,非桥接抗凝组18例。术后1 h桥接抗凝组明显出血8例,非桥接抗凝组12例;术后1 d术区出血桥接抗凝组4例,非桥接抗凝组5例;术后7 d术区出血桥接抗凝组1例,非桥接抗凝组2例。各时间两组间均无统计学差异。结论:长期口服华法林(国际标准化比值在治疗范围内)的患者在实施牙种植体植入时术前无需停用华法林,非桥接抗凝治疗同样安全和有效。     

止血环酸作为抗凝治疗患者口腔手术的漱口剂——一种替代停抗凝治疗的方法

当抗凝治疗患者口腔手术时,通常是采取减少或停用抗凝药物来降低出血的危险性。本研究的目的是比较止血环酸作为一种漱口剂和传统的停用抗凝治疗对抗凝治疗患者口腔手术后的出血情况。 材料和方法 正在接受口服抗凝剂治疗的30例心瓣膜修补患者,需要拔除患牙,术前预防性抗菌治疗(术前一小时给羟氨苄青霉素3 g),局麻下由同一口腔外科医师操作。拔牙前按牙松动度,根据是否作粘膜瓣和凿骨,将其分为简单拔牙术和复杂拔牙术。     

人工心脏瓣膜置换术患者牙拔除术的临床研究

目的观察116例（170颗牙齿）心脏瓣膜置换术后长期口服华法令的患者,在暂停抗凝药物与不停抗凝药物两种情况下,拔牙术中、术后的出血情况,探讨对该类患者安全的拔牙方法。方法对116例瓣膜置换术后口服华法令抗凝治疗的患者进行拔牙手术,根据患者有无华法令的停药史,分为停药组49例（68颗）,非停药组67例（102颗）。停药组术前停药3天,术后次日恢复用药,共拔除牙齿68颗;非停药组在不中止、不减量抗凝剂的情况下进行牙齿拔除术,术后常规拔牙创牙龈缝合,共拔除牙齿102颗。结果停药组44例患者共计61颗牙齿,非停药组61例患者共计93颗牙齿,术后均无明显出血,效果良好。停药组5例7颗牙齿、非停药组6例9颗牙齿,术后出血经局部再处理后,均达到良好止血效果。停药组与非停药组术后出血率无显著性差异。结论大多数长期口服华法令的患者拔牙时可不停药、不减量,均可获得良好效果。     

35例次血友病患者的拔牙观察

作者报道自１９８６～１９９１年对血友病及血管性假性血友病患者进行拔牙３５例次、拔除患牙４７个，取得良好结果。术前进行预防性处理：输注凝血因子及口服抗纤溶药物（ＥＡＣＡ），儿童患者拔除松动乳牙１３／１８例次，术前仅服抗纤溶药物，术后继续抗纤溶治疗及局部止血措施，观察一周，６例成人重型血友病术后输注了凝血因子，用于治疗术后出血或预防术后出血。作者还对血友病患者口腔出血的临床表现及治疗进行了讨论。     

下颌复杂阻生智齿拔除手术并发症的药物控制

目的:探索下颌复杂阻生智齿拔除手术并发症的简便有效药物控制方案.方法: 选取双侧下颌第三磨牙复杂阻生且类型相似病例90 例,分2 次拔除.首次手术局麻药物中加入地塞米松5 mg,术后口服抗生素3 d; 第2 次手术时分组,首次出现中度肿胀或疼痛等并发症者改为术前口服一次抗生素,首次轻度反应者不再使用地塞米松.比较2 次手术后并发症情况.结果:术后并发症程度与拔牙难度、手术时间和药物应用方案相关,术前应用抗生素可以更为有效的控制并发症,放弃使用地塞米松后,出现较多肿胀和张口受限情况.结论: 术前联合应用抗生素和地塞米松可以有效控制复杂阻生牙术后并发症,药物应用方案应根据术前难度评估确定.     

持续服用抗凝药物老年患者焦虑状态对拔牙术后并发症的影响

目的:探讨牙科焦虑对持续服用抗凝药物的老年患者拔牙术后并发症的影响。方法:采用牙科焦虑症调查量表分析持续服用抗凝药物的老年拔牙患者，根据评分分为无焦虑组和有焦虑组。统计两组患者的基本信息及围手术期并发症情况。结果:纳入研究对象共73例，无焦虑组共48例，平均年龄69.5岁，焦虑组共25例，平均年龄66.5岁。两组患者在年龄分布，性别，术前患牙情况及部位，全身疾病情况均无明显差异，围手术期均未出现心血管症状。两组术后出血及疼痛病例数无统计学差异，术后感染3例均出现在焦虑组。结论:持续口服抗凝药物老年人在行口腔拔牙术后，心理状态对术后出血情况可能无影响，但是对高龄全身情况差的患者增加感染的可能性。     

163例长期使用华法林或抗血小板药物患者拔牙的临床研究

目的:探讨长期使用抗凝药物的患者,拔牙围手术期使用低分子肝素钠替代抗凝的安全有效性。方法 :163例长期使用华法林或抗血小板药物且需拔牙治疗的患者,入院后即停用抗凝药物,围手术期使用低分子肝素钠替代抗凝治疗,华法林组患者INR(国际标准化比值)<2.0,及抗血小板药物组患者,均停用原药物5 d后拔牙(术前12 h停用低分子肝素钠),观察手术24 h后出血情况,分析其安全性、有效性。结果:163例患者围手术期均未出现血栓栓塞、心梗、脑梗等心脑血管并发症。口服华法林患者87例,手术后24 h出血4例;口服抗血小板药物患者76例,手术后24 h出血1例。出血风险低(5/163)。结论:长期使用华法林或抗血小板药物患者,围手术期使用低分子肝素钠替代抗凝的处理方案是安全有效的。     

华法林对老年人拔牙术后出血影响的临床观察

目的 探讨国际标准化比值(international normalized ratio,INR) ＜2.5、拔牙术前不停服抗凝剂华法林的可行性.方法 选取门诊100例拔牙术前不停服华法林且INR值＜2.5的60岁以上拔牙患者为观察组,200例拔牙术前未服抗凝及抗血小板药物的60岁以上拔牙患者为对照组,均拔除单颗非阻生牙,观察拔牙术后不同时间段的出血情况.结果 两组患者拔牙术后5、10、30 min、24h 出血发生率差异有统计学意义(P＜0.05),48 h两组均无出血发生(出血发生率为0％).结论 经规范的拔牙操作同时有术后积极的出血监控和相应的止血处理措施,老年人拔除单颗非阻生牙术前INR值＜2.5不停服华法林是可行的.     

Abstracts from other journals

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalized Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4·1 may lead to an increase in minor postextraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.     

Can warfarin be continued during dental extraction? Results of a randomized controlled trial

A randomized controlled trial was set up to investigate whether patients who were taking warfarin and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the intervention group (warfarin continued). The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by patients at home. Continuing warfarin when the INR is < 4.1 may lead to an increase in minor post-extraction bleeding after dental extractions but we found no evidence of an increase in clinically important bleeding. As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental extractions should be reconsidered.     

口服抗凝药物老年患者拔牙术中的临床治疗体会

目的:总结在服用抗凝药物的老年患者拔牙术中的治疗经验。方法:选择2018年1月~2019年6月口腔科就诊的46例(服用阿司匹林患者28例,波立维11例,法华林7例)长期口服抗凝药物且需要拔牙老年患者,拔牙前行凝血酶原时间和国际标准化率检测,分别在术后30分钟、1和24小时对治疗结果进行观察和分析。结果:拔牙术后30分钟出血15例,术后1小时内出血4例,术后24小时复诊出血1例。结论:INR在1.5~2.5范围,拔牙创局部止血处理,且压迫观察1小时,有效地预防抗凝治疗的老年患者在不停用抗凝药的情况下拔牙术后出血的情况。     

Risk of postoperative bleeding following dental extractions in patients on antithrombotic treatment

IntroductionThe risk of bleeding after dental extractions in patients taking antithrombotic medication is not well known. This study aims to investigate the incidence of postoperative bleeding following dental extractions in adult patients taking antithrombotic medication in Saudi Arabia.MethodsThis retrospective study included 539 patients aged 18–93 years who attended 840 appointments for dental extractions from January 2012 to June 2016 at a tertiary care hospital in Saudi Arabia. Patients who returned with a complaint of bleeding were treated with local hemostatic measures as outpatients.Results and Conclusion: Only 1.7% of extraction appointments were associated with postoperative bleeding. The highest risk of bleeding was noted in patients receiving warfarin (3.88%), whereas those on clopidogrel had no significant risk of bleeding. Women were found to have the highest rate of bleeding, particularly those on newer oral anticoagulant medications.Dental extractions can be safely done in adults receiving antithrombotic treatment, provided established guidelines are followed; therefore, dental professionals must exercise caution when planning invasive dental treatment for patients on continued antithrombotic therapy.     

Bleeding after dental extractions in patients taking warfarin

OBJECTIVE: To assess the incidence of bleeding after dental extractions in subjects taking warfarin continuously before and after extractions whose International Normalised Ratio (INR) was below 4.0 at the time of extraction. METHODS: This was a case series study of 150 patients without controls who required extraction of at least one tooth under local anaesthetic. All sockets were subsequently packed with absorbable oxycellulose and sutured. RESULTS: A total of 58 women and 92 men were included (mean age 66 years); their ages were similar. The mean INR (S.D.) was 2.5 (0.56), although most patients had an INR less than 2.5 (n=101). Ten patients (7%) bled after extraction, enough to require a return to hospital. Five patients of 101 with an INR2.5 out of 49 bled after extraction (p=0.29). Bleeding after extraction was not associated with operative antibiotics. All patients who bled were managed conservatively and none was admitted to hospital. CONCLUSION: Patients taking warfarin whose INR is up to 4.0 and who have dental extractions in hospital do not have clinically significant bleeds post-operatively.     

Safety of tooth extraction in patients receiving direct oral anticoagulant treatment versus warfarin: a prospective observation study

The aim of this study was to compare the safety of tooth extraction in patients receiving direct oral anticoagulants (DOACs) or warfarin without cessation of their antithrombotic treatment. This prospective observational study included 367 patients undergoing tooth extraction (119 receiving DOACs and 248 receiving warfarin). All extractions in DOAC patients were performed 6–7 h after taking DOACs in consideration of the half-life in blood under continued antithrombotic treatment. To examine the potential postoperative bleeding risk related to the time of extraction and the drug concentration of blood, activated partial thromboplastin time (APTT) in dabigatran and prothrombin time (PT) in rivaroxaban were measured three times after administration. A total of 390 tooth extractions were performed: 128 in the DOAC patients and 262 in warfarin patients. Postoperative bleeding occurred in four extractions (3.1%) in the DOAC group and in 23 (8.8%) in the warfarin group. There was no statistically significant difference between the two groups (odds ratio: 2.362, 95% confidence interval (CI) 0.819–6.815, p = 0.112). APTT and PT prolongation in almost all cases decreased with time after taking the medicine. Our findings suggest that interruption of DOAC therapy is not necessary for tooth extraction if the procedure is performed at least 6 h after the last dose.     

阿司匹林对不同部位牙周炎患牙拔牙创凝血影响的比较分析

目的 探讨阿司匹林对不同部位重度牙周炎患牙拔牙创凝血影响的差异及原因。 方法 选取需拔除单颗重度牙周炎患牙的服药者160例（年龄50~80岁,剂量100 mg/d,服药时间＞2周）;包括上下颌前牙各30例,前磨牙各20例,磨牙各30例。对病例进行光学法血小板聚集率检测（LTA）后,在不停药情况下拔牙。根据拔牙创凝血分级表（Ⅰ、Ⅱ级凝血正常,Ⅲ~Ⅴ级出血依次增加）评估创面,对病例的凝血情况和正常凝血者的血小板聚集率（PAgT）进行比较,分析阿司匹林对不同部位拔牙创抗凝作用的差异及可影响该药作用的因素。 结果 ①在上颌前牙、前磨牙、磨牙病例中,凝血正常者比例分别为43%、15%、10%,下颌该比例分别为93%、30%、20%;其中下颌中切牙、侧切牙病例凝血均正常,其余牙位病例中出现Ⅲ、Ⅳ级,Ⅴ级未见。②上颌前牙、前磨牙、磨牙凝血正常者的PAgT分别为（14.01±1.05）%,（15.27±0.62）%,（16.83±0.57）%,三者差异有统计学意义（P=0.037）;下颌分别为（12.83±1.64）%,（13.92±0.87）%,（15.44±0.92）%,三者差异有统计学意义（P=0.041）;并且,上颌前牙、前磨牙、磨牙凝血正常者的PAgT均高于下颌同名牙病例,差异均有统计学意义（P分别为0.028,0.047,0.044）。③Ⅲ、Ⅳ级病例拔牙创周围颌骨及牙槽突骨质较疏松,血供丰富,牙周膜面积较大。 结论 ①阿司匹林可对重度牙周炎患牙（除下颌中切牙、侧切牙）拔牙创产生抗凝作用。②对于上、下颌牙列,前牙、前磨牙、磨牙创面正常凝血所需的PAgT逐渐升高,依次更易受到该药抗凝作用的影响;同时,上颌拔牙创正常凝血所需的PAgT高于下颌同名牙,故该药对上颌创面的影响较下颌明显。③患牙周围颌骨及牙槽突的血供、牙周膜面积等因素可影响拔牙创出血量;创面出血越多,其正常凝血的PAgT越高,阿司匹林对其抗凝作用越明显。     

抗血小板治疗患者拔牙术后出血的临床观察

目的：研究持续小剂量口服抗血小板药物阿司匹林对拔牙术后出血发生率的影响。方法：87例患者按完全随机化分组方法分为两组,治疗组45例,共拔牙88个;对照组42例,共拔牙63个。治疗组持续阿司匹林治疗。对照组拔牙术前7d停用阿司匹林。比较两组病例拔牙术后出血发生率的差异。结果：治疗组（持续阿司匹林治疗）和对照组（停止阿司匹林治疗）拔牙术后出血发生率分别为3.4%和1.6%,两组差异无统计学意义（p〉0.05）。结论：对于长期小剂量应用阿司匹林的患者,拔牙术前不必停药,适当的局部止血处理可有效避免术后严重出血并发症的发生。