Kämmerer Peer W, Frerich Bernhard, Liese Jan, Schiegnitz Eik, Al-Nawas Bilal
Department of Oral, Maxillofacial and Plastic Surgery, University Medical Centre of Rostock, Schillingallee, 35, 18057, Rostock, Germany,
Clin Oral Investig. 2015 Mar;19(2):171-80. doi: 10.1007/s00784-014-1366-3. Epub 2014 Nov 22.
Oral anticoagulation therapy (OAT) with vitamin K inhibitors protects the patients from thromboembolic events. It may however lead to excessive hemorrhage during and after an oral surgery procedure. The aim of this systematic review was to evaluate the justifications to reduce, withdraw, or alter OATs prior to minor oral surgery procedures to manage bleeding events.
A systematic MEDLINE search was conducted for clinical studies in English or German language from 1994 to 2014 comparing patients treated with OAT, without OAT, as well as patients with altered OAT for oral surgery purposes. Relevant outcome parameters were: postoperative local hemostasis, bleeding episodes, occurrence of thromboembolic events, and other complications due to the anticoagulation medication. A hand search for references cited in the identified publications completed the review.
After screening of 1755 abstracts, 16 clinical studies were identified according to the selection criteria. Due to the heterogeneity of the obtained data, aggregation and synthesis were not possible. There was no significant difference in bleeding events comparing patients under continued OAT to those with reduced, altered, and/or discontinued OAT medications. Minor bleeding events in the test and control groups were successfully stopped with local measures. However, no superiority of a single hemostatic measure could be identified. Neither the international normalized ratio (INR), within the therapeutic range (2-4), nor the extent of the minor oral surgery procedure had an influence on postoperative bleeding episodes.
There is strong evidence that OAT patients undergoing minor oral surgery should not discontinue their medication in order to prevent thromboembolic complications.
Nonetheless, INR should be less than 4, local hemostatic measures are of high importance and patients need to be instructed and closely monitored as minor bleedings might occur more often in OAT patients.
使用维生素K拮抗剂进行口服抗凝治疗（OAT）可保护患者免受血栓栓塞事件的影响。然而，在口腔外科手术过程中及术后，它可能导致出血过多。本系统评价的目的是评估在小型口腔外科手术前减少、停用或改变OAT以处理出血事件的合理性。
对1994年至2014年期间以英文或德文发表的临床研究进行系统的MEDLINE检索，比较接受OAT治疗、未接受OAT治疗以及为口腔手术目的改变OAT治疗的患者。相关结局参数包括：术后局部止血、出血事件、血栓栓塞事件的发生以及抗凝药物引起的其他并发症。对已识别出版物中引用的参考文献进行手工检索以完成本评价。
在筛选了1755篇摘要后，根据选择标准确定了16项临床研究。由于所获数据的异质性，无法进行汇总和综合分析。持续接受OAT治疗的患者与OAT药物减少、改变和/或停用的患者相比，出血事件无显著差异。试验组和对照组的轻微出血事件通过局部措施成功止血。然而，未发现单一止血措施具有优越性。治疗范围内（2 - 4）的国际标准化比值（INR）以及小型口腔外科手术的范围均未对术后出血事件产生影响。
有强有力的证据表明，接受小型口腔外科手术的OAT患者不应为预防血栓栓塞并发症而停用药物。
尽管如此，INR应小于4，局部止血措施非常重要，并且需要对患者进行指导并密切监测，因为OAT患者可能更频繁地发生轻微出血。
