Surgical management of patients under antithrombotic treatment

The aim of this paper is to provide surgical technique indications for tooth extractions and to indicate the correct post-operative management of the clot, in order to minimize the risk of bleeding complications. Methods: First of all, in order to manage any postoperative complications, surgeries should be performed in the morning or early in the afternoon, and within the first days of the week, to avoid that complications occur when the dental clinic is closed. Moreover, in the event of multiple extractions, it is advisable to divide surgical treatment into several sessions, to expose a less extensive vascular bed and to perform sessions of shorter duration. The use of anaesthetics containing vasoconstrictor is not contraindicated, as they offer the advantage of both a bloodless surgical field and a hemostatic effect. Nevertheless, the surgeon should consider the risk of adrenalinerebound effect. It is therefore advisable to monitor the patient for at least half an hour after surgery if an adrenaline-containing anaesthetic has been used. It is also useful to minimize surgical trauma both on hard and soft tissues. Flap incisions should be avoided and, if they are really ecessary, flap-elevation should not exceed the mucogingival line on the buccal side and should be avoided on the lingual side of the mandible, especially in the molar region, to avoid blood spreading in the deep anatomical spaces, where there are greater chances of diffusion, and the surgeon would have greater difficulties of both inspection and access. If bone removal is needed, for surgical access or bone margin remodelling, the smallest quantity of bone tissue should be removed. Accurate curettage and rinsing of the surgical field are also advisable to avoid both the presence of residual bone chips from drilling and bleeding due to the residual granulation tissue. Local haemostatics are also useful to improve hemostasis, and a criss-cross horizontal mattress suture is advisable to press and stabilize gingival margins. In case of surgeries involving masticatory areas, clot stabilization can be improved by using pre-operatively manufactured customized protective plates or immediate prostheses, which also avoid that residual opposing teeth may exert any postoperative trauma on the surgical wound. Finally, in the postoperative period, the patient should maintain good oral hygiene and, if analgesic drugs are needed, those which do not have a synergistic effect with the antithrombotic drug should be chosen.