For those taking vitamin K antagonists (VKAs), tranexamic acid (TXA) mouthwash may reduce dental bleeds after an extraction or minor surgery, although the reduction is no greater than with standard care, according to a new Cochrane Review

"Patients using VKAs or direct oral anticoagulants (DOACs) have an increased risk for bleeding problems after minor oral surgery or dental extractions," Dr. Karin PM van Galen of University Medical Centre Utrecht in the Netherlands told Reuters Health. "However, anticoagulant treatment is preferably continued, since dose reduction or discontinuation increases the risk of potentially life-threatening thromboembolism."

"In a prior Cochrane review, we found a beneficial effect of TXA and epsilon aminocaproic acid (EACA), administered systemically, in reducing the number of bleeds, the amount of blood loss and the need for therapeutic clotting factor concentrates after minor oral surgery or dental extractions in people with hemophilia," she said by email.

Anticoagulants

"In this systematic review of people on anticoagulants who need to undergo (the same procedures), we found that TXA mouthwash can safely be used to prevent oral bleeding," she said.

"Overall, we found a reduction in the number of bleeds after dental extraction when using TXA mouthwash compared to placebo and no potential harm," Dr. van Galen noted. "However, when TXA was compared to alternative local hemostatic measures, such as gelatin sponge and suturing, there was no unequivocal superior effect of TXA."

The researchers searched the literature through January 4, 2018, for controlled trials of people on continuous treatment with VKAs or DOACs who underwent oral or dental procedures using antifibrinolytic agents (TXA or EACA) to prevent perioperative bleeding, compared with no intervention or usual care.

Two trials compared TXA with placebo and two compared TXA with gelatin sponge and sutures and dry gauze compression. All participants had international normalized ratio values within the therapeutic range, and TXA was applied locally.

The two trials comparing TXA with placebo showed a statistically significant reduction in the number of major postoperative bleeding episodes requiring intervention, with a pooled risk difference (RD) of -0.25.

The two trials that compared TXA with either gelatin sponge and sutures or with dry gauze compression showed no difference between the TXA and the standard care group (RD 0.02). The combined RD of all included trials was -0.13

No side effects of antifibrinolytic therapy required treatment withdrawal. Despite heterogeneity between trials concerning hemostatic measures used in the control groups, the trials were comparable in design and baseline participant characteristics.

"The small number of identified randomized controlled trials, the relatively small number of participants included in the trials and the differences in standard therapy and treatment regimens between trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in this population," the authors state.

Because there were no trials of people on DOACs undergoing dental procedures, "a beneficial effect of antifibrinolytic therapy can currently only be assumed based on data from the people using VKAs," they conclude.

"Awaiting new studies, antifibrinolytics could still be considered in people undergoing oral or dental procedures without DOAC interruption, considering its safety and efficacy in people on VKAs or with congenital hemophilia.," Dr. van Galen said. "However, other local hemostatic measures could be equally effective."

Hematologist and transfusion medicine specialist Dr. Nadine Shehata of the Mount Sinai Hospital/ the University of Toronto said in an email to Reuters Health that she agrees with the findings and the conclusions of the authors regarding the small number of patients, the heterogeneity of the studies, and the lack of studies of DOACs.

Using an antifibrinolytic "appears to be an option for those who cannot/should not discontinue anticoagulation to reduce the risk of bleeding with no short-term major adverse events in (studies with) a small number of patients," she concluded.