Erden İsmail, Çakcak Erden Emine, Aksu Tolga, Gölcük Şükriye Ebru, Turan Burak, Erkol Ayhan, Akçakoyun Mustafa, Sayın Tülin
Department of Cardiology, Kocaeli Derince Training and Research Hospital; Kocaeli-Turkey.
Anatol J Cardiol. 2016 Jul;16(7):467-473. doi: 10.5152/AnatolJCardiol.2015.6130. Epub 2015 Sep 15.
The management of anticoagulated patients with warfarin during dental extraction is an intricate issue. We carefully designed the current study so that the amount of bleeding was measured with objective methods and the data from the same patient in different dental extraction appointments could be compared, eliminating the bleeding diathesis differences of patients.
This prospective and controlled study was conducted in 36 adult patients with prosthetic valve requiring multiple tooth extractions. The first dental extraction was performed without the discontinuation of warfarin therapy, and the second procedure was performed with a discontinuation of warfarin and bridging with low-molecular weight heparin (LMWH). The two dental extraction protocols in the same patient group were compared. The total amount of bleeding was calculated as the difference between the weights of gauze swabs used before and after the tamponade; the number of gauze swabs used for bleeding control in the first 48 h was recorded.
The median number of used gauze swabs was 2.5 (IQR: 1-5) and 3.0 (IQR: 2-7) in the first and second dental extraction procedures, respectively. The median bleeding time was 50.0 (IQR: 20-100) in the first procedure compared with 60.0 (IQR: 40-140) min in the second procedure. The mean amounts of bleeding were 2194±1418 mg in the first dental extraction procedure and 2950±1694 mg in the second dental extraction procedure. The median number of used gauze swabs, the median bleeding time, and the mean amount of bleeding were statistically higher in the second dental extraction procedure (P<0.001).
Continued warfarin treatment at the time of dental extractions reduces the total amount of bleeding compared with bridging therapy in patients with prosthetic valves.
华法林抗凝患者拔牙时的管理是一个复杂问题。我们精心设计了本研究，以便用客观方法测量出血量，并可比较同一患者在不同拔牙预约时的数据，消除患者出血素质差异。
本前瞻性对照研究纳入36例需要多次拔牙的人工瓣膜成年患者。首次拔牙时未停用华法林治疗，第二次拔牙时停用华法林并用低分子肝素（LMWH）进行桥接治疗。比较同一患者组的两种拔牙方案。出血量计算为填塞前后使用的纱布拭子重量之差；记录前48小时用于控制出血的纱布拭子数量。
首次和第二次拔牙过程中，使用纱布拭子的中位数分别为2.5（四分位间距：1 - 5）和3.0（四分位间距：2 - 7）。首次拔牙过程中出血时间中位数为50.0（四分位间距：20 - 100）分钟，第二次为60.0（四分位间距：40 - 140）分钟。首次拔牙过程中的平均出血量为2194±1418毫克，第二次拔牙过程中为2950±1694毫克。第二次拔牙过程中使用纱布拭子的中位数、出血时间中位数和平均出血量在统计学上更高（P<0.001）。
对于人工瓣膜患者，拔牙时继续使用华法林治疗与桥接治疗相比可减少总出血量。
