OBJECTIVE: To compare the prevalence of gingivitis estimated by the 2018 European Federation of Periodontology/American Academy of Periodontology (EFP/AAP) classification with the other case definitions and assess the ability of this classification system in discriminating sociodemographic and clinical factors associated with the presence of gingivitis in a cohort study.
METHODS: A multistage random sample of 1134 12-year-old adolescents was submitted to a full-mouth examination according to the Community Periodontal Index. Socioeconomic and clinical variables were collected at baseline. Gingivitis was considered according to the following criteria: (a) ≥ 10% of bleeding sites (the 2018 EFP/AAP criteria); (b) ≥ 15% of bleeding sites; and (c) the mean full-mouth bleeding sites. Adjusted multilevel Poisson regression assessed the association between independent variables at baseline and each definition of gingivitis at 2-year follow-up.
RESULTS: Seven hundred forty-two 14-year-old adolescents were re-revaluated at follow-up. The prevalence of gingivitis was 28.7% according to 10% of bleeding threshold. The 2018 EFP/AAP criteria and other definitions showed higher prevalence and mean of gingivitis for low-household income adolescents and for those with higher levels of dental plaque and untreated dental caries. Nonetheless, the highest strengths of association were observed for the threshold of ≥ 15% of bleeding sites.
CONCLUSIONS: The 2018 EFP/AAP case definition of gingivitis showed a similar discriminant validity compared to the 15% threshold and the mean full-mouth bleeding sites.
CONCLUSIONS: The 2018 EFP/AAP classification allows the discrimination of important risk factors and should be used for the establishment of priorities for large-scale therapeutic programs.

BACKGROUND: Conflicting recommendations exist addressing the management of direct oral anticoagulants (DOACs) for invasive dental procedures.
OBJECTIVE: To determine the safety of DOAC continuation compared to warfarin continuation for dental extractions with regards to bleeding outcomes.
METHODS: A single-center, prospective, cohort study was performed to compare 7-day bleeding outcomes between patients who continued their DOAC, and patients on warfarin with an International Normalized Ratio (INR) between 2.0 and 4.0. Blood tests including oral anticoagulant drug levels were measured immediately prior to extraction. The gauze used to apply pressure to the socket was weighed before and after extraction to estimate blood loss. Patients were contacted by phone 2 and 7 days after extraction.
RESULTS: Eighty-six patients on a DOAC had a total of 145 teeth extracted, and 21 patients on warfarin had 50 teeth extracted. There were no major bleeding events. The rate of minor plus clinically relevant nonmajor bleeding was comparable between the DOAC and warfarin cohorts (36% and 43%, respectively; odds ratio, 0.75; 95% confidence interval, 0.29-1.98). Preextraction apixaban and dabigatran levels were comparable between bleeders and nonbleeders, while rivaroxaban levels were higher in those who bled. The weight change of gauze used to tamponade the socket was similar between the 2 cohorts.
CONCLUSIONS: Dental extractions on patients continuing DOACs led to bleeding rates similar to patients on warfarin with an INR between 2.0 and 4.0. There is no need to adjust DOAC dosing prior to dental extractions.

Cessation versus continuation of antiplatelet drugs in patients undergoing dental implant surgery is a controversial issue. The present study evaluated postoperative bleeding during and after dental implant surgery in patients taking aspirin (ASA) or clopidogrel.
The present study is a case-and-crossover study. Patients who were using antiplatelet drugs and receiving 2 bilateral dental implants in the posterior region of the mandible were studied. During session 1, dental implants were placed without stopping the intake of antiplatelet drugs. During session 2, antiplatelet drugs were stopped for 5 days. In group 1, platelet activity was measured by an assay based on flow cytometry and represented the platelet reactivity index. In group 2, platelet function analysis was used to monitor the antiplatelet effect of ASA. Bleeding severity was assessed using a visual analog scale for 72 hours after dental implant placement during sessions 1 and 2. Use of antiplatelet drugs was the predictive factor of the study and bleeding severity and platelet function were the outcomes of the study.
Twenty-two patients composed group 1 (clopidogrel 75 mg) and 20 composed group 2 (ASA 80 mg). In group 1, bleeding severity was 4.86 ± 0.77 during session 1 and 4.59 ± 0.66 during session 2. Data analysis showed no difference in bleeding severity between sessions 1 and 2 in group 1 (P = .72). In group 2, bleeding severity was 4.05 ± 0.94 during session 1 and 3.9 ± 0.85 during session 2. There was no difference in bleeding severity between sessions 1 and 2 in patients taking ASA (P = .19).
The results suggest that continuing the intake of antiplatelet drugs did not increase bleeding after placement of dental implants.

OBJECTIVE: Tranexamic acid (TXA) is widely used in the prevention of postsurgical oral bleeding. Tranexamic acid in addition to further surgical measures is widely utilized in prevention of post-surgical oral bleeding. The aim of the present study was to investigate: Can oral hemostasis be achieved by merely compression and topical application of tranexamic acid in different anticoagulant regimes among patients attending a general emergency department? Where are the limits to this procedure? Which has the greater impact on surgeons\' choice for an invasive hemostatic approach-bleeding quality or oral anticoagulant therapy?
METHODS: A retrospective cohort study of 542 patients who consecutively received treatment for oral bleeding was performed. We surveyed the values of the diverse hemostatic approaches. Special attention was granted to patient anticoagulant regimen and quality of the oral bleeding event.
RESULTS: A total of 199 of 542 (36.7%) oral bleeding events were stopped by compression with a gauze or gauze soaked with TXA (4.8%). Stopping an oral bleeding event with wound compression can be improved by factor 1.6 if the gauze is soaked with tranexamic acid (4.8%), p ≤ 0.05. LMWH presented significantly more moderate bleeding than bloody oozing of the wound, p < 0.05. The quality of bleeding had a strong influence on oral surgeons\' decisions to apply further surgical means. Sutures and native collagen fleeces were the favored methods to stop moderate and severe bleeding (p < 0.05).
CONCLUSIONS: Topical application of TXA aids as a useful supportive tool to stop mild bleeding events such as the bloody oozing of an oral wound. The quality of an oral bleeding episode should be considered in the choice of hemostatic measure. Hemostatic approaches should begin with the least invasive procedure. TXA is a helpful tool.

OBJECTIVE: The present work is a controlled, blinded, and randomized clinical trial comparing hemostatic measures for the control of post-tooth extraction hemorrhage in patients on anticoagulation therapy with warfarin.
METHODS: The sample consisted of 37 patients (37.8% male and 62.2% female) with a mean age of 45.5 years. After randomization, 20 patients were allocated to the control group (conventional hemostasis measures) and 17 to the study group (addition of local tranexamic acid). All variables that could influence the outcome were similar between the groups and no significant difference was seen (p > 0.05).
RESULTS: In the assessment of immediate hemostasis, for the control group, the time to achieve cessation of bleeding was 9.1 (± 3.6) minutes. For the study group this was much lower, and this difference (6.018 / confidence interval of 95%, 4.677 to 7.359) was statistically significant (p < 0.001). In evaluating the control of intermediate hemorrhage, the use of tranexamic acid was more significantly associated with the absence of bleeding, especially in the first 24 h.
CONCLUSIONS: Thus, this measure of local hemostasis in topical form with gauze compression and irrigation was shown to be more effective in reducing the time to attain immediate hemostasis, and in preventing intermediate hemorrhage.

The purpose of this study was to retrospectively investigate the multivariate relationships between specific risk factors and postoperative hemorrhage after tooth extraction in patients who were prescribed oral antithrombotic therapy. Risk factors for postoperative hemorrhage after tooth extraction were evaluated using univariate and multivariate analyses. Patient characteristics such as age and gender; the presence or absence of known comorbidities such as diabetes mellitus, hypertension, cerebral infarction, and alcohol consumption; and perioperative diarrhea were assessed. The drug used for antithrombotic therapy, preoperative blood test results, the presence or absence of preoperative antibiotics or nonsteroidal anti-inflammatory drug (NSAID) administration, the total number of extracted teeth, and the type of surgical procedures were also evaluated. We found that the preoperative administration of antibiotics (odds ratio (OR) = 2.52), an increased prothrombin time international normalized ratio (PT-INR) value (OR = 1.94), and the extraction of multiple teeth (OR = 2.10) were significantly associated with postoperative hemorrhage. There was no significant association between postoperative hemorrhage and any other demographic factors or comorbidities, including concomitant alcohol use. We demonstrated the multivariate relationship between the risk factors and postoperative hemorrhage after tooth extraction in patients receiving oral antithrombotic therapy. Surgeons should be aware of these risks and monitor the PT-INR of anticoagulated patients.

The aim of this study was to assess the risk of bleeding after tooth extraction in patients taking aspirin or clopidogrel. This case-crossover study evaluated patients taking aspirin (80mg/day) or clopidogrel (75mg/day) and undergoing tooth extraction. In the first session, extraction was performed without discontinuing aspirin (group 1) or clopidogrel (group 2). In the second session, patients ceased using antiplatelet drugs 5days prior to tooth extraction. Bleeding was evaluated using a visual analogue scale (VAS) for 72h after tooth extraction. The platelet function assay (PFA) was performed for group 1 and flow cytometry assessment of vasodilator-stimulated phosphoprotein (VASP) was performed for group 2, in both sessions. Thirty-eight patients were studied: 20 in group 1 and 18 in group 2. Analysis of the data did not demonstrate any difference in bleeding severity between sessions 1 and 2 in either group (P>0.05). There was a significant difference between sessions 1 and 2 in group 1 for the mean collagen/epinephrine membrane closure time (PFA) (P=0.001). A significant difference in platelet reactivity index (flow cytometry for VASP) was noted between sessions 1 and 2 in group 2 (P=0.001). According to this case-crossover study, dental extraction can be performed safely without withdrawal of aspirin or clopidogrel.

OBJECTIVE: The aim of this study was to validate a standardized pragmatic approach to manage new oral anticoagulants (NOACs) in patients who undergo dental extractions.
METHODS: This prospective case-control study in patients undergoing dental extraction included 26 patients (mean age 76 years, 57% male) treated with dabigatran, rivaroxaban, or apixaban and 26 matched controls. Regardless of timing of extraction, drug regimen, or renal function, patients were instructed to skip only the dose on the morning of the procedure. A procedural bleeding score was recorded and early and delayed bleeding was assessed at day 1 and day 7. Bleeding events were compared with a prospectively matched control group not taking any antithrombotic drug.
RESULTS: There was no difference in the procedural bleeding score or in early bleeding events (5 in both groups). However, delayed bleeding occurred more frequently in anticoagulated compared to non-anticoagulated patients (7 versus none, p = 0.01).
CONCLUSIONS: Skipping the morning dose of NOACs avoids excess bleeding during and early after the procedure. However, anticoagulated patients had an increased risk of delayed bleedings. Further study is needed to determine the optimal post-procedural management.
CONCLUSIONS: This is the first prospective study for the management of patients on NOACs undergoing dental extraction. Our pragmatic approach, omitting only a single morning dose, can guide clinical practice. Both patients and physicians should be aware of the increased delayed bleeding risk.

BACKGROUND: Various anticoagulant therapy regimes bear the risk of postsurgical bleeding events after dental extractions. Local hemostyptic measures, e.g., collagen fleeces, are applied by surgeons to prevent such bleedings. No standard protocol in prevention of bleeding events has met general acceptance among surgeons yet.
OBJECTIVE: The purpose of this retrospective study was to determine if post-operative bleeding can be prevented by suturing native collagen fleeces into extraction wounds immediately after teeth removal, regardless what anticoagulant regime is performed.
METHODS: A total of 741 extraction units were removed from 200 consecutive in-ward patients with or without alternation of different anticoagulant therapy regimes. Anti-vitamin K agents were the most prescribed drugs (n = 104, 52 %), followed by Acetylsalicylate (ASS) (n = 78, 39 %). Nineteen (9.5 %) patients received a dual anti-platelet therapy. Out of 104 patients receiving an anti-vitamin K agent (phenprocoumon), 84 patients were bridged, 20 patients continued to their anticoagulant therapy without alterations. Following careful tooth extraction, extraction sockets were filled using a native type I and III porcine collagen sponge (Collacone, Botiss Biomaterials, Berlin), supported by single and mattress sutures for local hemostasis. Post-operative bleeding events were rated according to their clinical relevance.
RESULTS: In the post-operative phase, 8 out of 200 consecutively treated patients experienced a post-operative bleeding event. All of them had been designated for a long-term anti-vitamin K therapy (p ≤ 0.05), and extractions were performed under a heparin bridging regime (n = 6) or an uninterrupted anti-vitamin K agent therapy (n = 2). No bleeding events occurred in patients with ASS 100 therapy or low-dose LMWH therapy (p ≤ 0.05), or in patients with dual anti-platelet therapy (0 out of 24). None of the bleeding events put patients\' health at risk or required systemic intervention.
CONCLUSIONS: Sufficiently performed local hemostyptic measures, like the application of collagen fleeces in combination with atraumatic surgery, bears a great potential for preventing heavy bleeding events in hemostatic compromised patients, regardless of their anticoagulant therapy.

OBJECTIVE: Untreated dental infections pose a threat for immunocompromised liver transplant (LT) recipients. Therefore, pretransplant dental evaluations are recommended. However, risk of bleeding should be considered among patients with end-stage liver disease, and prophylactic blood transfusions may be used to prevent bleeding. We performed a retrospective study of the incidence of and risk factors for oral surgery-related bleeding in candidates for LT and hypothesized that complications may occur despite preoperative and perioperative hemostatic actions.
METHODS: One hundred thirty-four patients who had tooth extractions performed by oral and maxillofacial surgeons before LT were studied. The primary endpoint was bleeding between 24 hours and 2 weeks after extraction. Bleeding risk was analyzed by preoperative platelet (PLT) count and international normalized ratio (INR). Invasiveness of procedures, severity of liver disease, PLT, INR, prophylactic transfusions of PLT, fresh frozen plasma, and tranexamic acid (TA) were included in univariate and multivariate logistic regression analyses to further assess risk.
RESULTS: Twelve patients exhibited minor bleeding; four despite PLT >100 × 10(9)/L and INR <1.5. Increased bleeding associated with INR and prophylactic transfusions by univariate analysis; by multivariate analyses, prophylactic TA (odds ratio [OR] = 8.0; 95% confidence interval [CI] 1.7-37.0), and PLT (OR = 8.3; 95% CI 1.1-62.7) remained significant.
CONCLUSIONS: Most extractions were safe, but prophylactic transfusions did not ensure adequate hemostasis. Local hemostatic measures and close follow-up are warranted.