Hemostatic Agents for the Management of Bleeding Risk Associated with Oral Anticoagulant Therapy Following Tooth Extraction: A Systematic Review

Round 1

Reviewer 1 Report

I think it's an excellent review of management of extractions for patients on anti-coagulant therapy, the only suggestion i would make is dedicate one paragraph or at least give a mention of anti-platelet therapy as there are frequently patients, on at least one anti-platelet medication and often on dual anti platelet therapy at least in the acute setting. Whilst this may be outside of the scope of what you are reviewing as a surgeon looking to read a literature review on managing extractions on patients on any type of anti-coagulant it would be helpful; understanding if there are any other concerns or altered management. If you do not want to mention anti platelet therapy at least allude to the fact that if there is combined medication, there may be a slight deviation from your suggestions.

Author Response

We thank the Reviewer for such a positive remark on our manuscript. We inserted the following paragraph on antiplatelet therapy in the Discussion section:

Although the superiority of one hemostatic measure above the other cannot to date be stated in patients taking oral anticoagulants, it should be noted that such measures require further investigations even in the presence of other systemic conditions affecting coagulation capacity. Considering medication induced bleeding risk, some studies addressed the issue of antiplatelet therapy in the dental setting. Although this topic falls beyond the scope of the present review, it is important to mention how antiplatelet drugs, used alone (single antiplatelet therapy, SAPT), or in combination (dual antiplatelet therapy, DAPT) may affect clotting formation, leading to prolonged post-extraction bleeding and hemorrhagic complications [42]. Current literature reports that the use of local hemostatic agents may be sufficient in managing the bleeding risk without changing the algorithm of antiplatelet therapy [43]. From this perspective, the performance of randomized clinical trials to further assess the role of hemostatic agents following dental surgery is advised, taking into account a broader variety of systemic conditions.

Reviewer 2 Report

Dear Authors

The manuscript is interesting and with a not commonly subject nowadays, but still very important. I have only a few questions for you:

1- The introduction could discuss more about dental extractions and its complications ; you just added one reference and a very small paragraph about it. 

2- Much of the information you gave on the results section is already in table1, so please, reduce this and increase the discussion, that is small, if you think that there are 22 articles included;

3- All the bias and diferences in the methodologies may be discussed better, since they appear to have influenced the conclusion

Thank you

Author Response

We would like to thank the reviewer for the comments. The manuscript was edited according to reviewers’ suggestions. Please find below pint-by-point response.

Dear Authors

The manuscript is interesting and with a not commonly subject nowadays, but still very important.

We thank the Reviewer for this positive remark on our manuscript.

I have only a few questions for you:

1- The introduction could discuss more about dental extractions and its complications ; you just added one reference and a very small paragraph about it. 

We added the following paragraph on dental extractions and bleeding complications as suggested:

Patients under oral anticoagulant therapy are more prone to bleeding complications and hematoma formation following dental procedures. Tooth extractions are the most frequently performed oral surgical procedures, and bleeding or oozing are frequently occurring complications [8-9]. The surgical trauma on both hard and soft tissues can be related to the development of post-extraction bleeding, although inflammation and/or infection of the extraction site can be concurrent factors [10]. In patients treated with oral anticoagulants, the bleeding risk is enhanced, therefore different recommendations have been proposed, including anticoagulant therapy modulation through reduction, suspension, or bridging [11]. However, it has also been suggested that therapy discontinuation may expose to a higher risk of thromboembolism against a modest risk of hemorrhage in patients with an INR within the therapeutic range [12].

2- Much of the information you gave on the results section is already in table1, so please, reduce this and increase the discussion, that is small, if you think that there are 22 articles included;

The Discussion section was implemented as suggested.

3- All the bias and differences in the methodologies may be discussed better, since they appear to have influenced the conclusion

The following paragraph discussing issues related to the methodologies of the included studies and reporting study limitations was added to the Discussion section:

The present study has some limitations. First, the paucity of studies evaluating patients treated with DOACs hindered to draw firm conclusions on this increasingly employed class of anticoagulants. Secondly, the heterogeneity in the methodologies reported in the included studies did not allow the performance of meta-analyses. Similarly, the presence of different comparative groups could also be a confounding factor. Finally, the included studies were all at moderate/high risk of bias, thus affecting reliability of the analysis.

Round 2

Reviewer 2 Report

Thanks for the improvements!

Best regards