Vol. 92 No.

3 September 2001

ORAL SURGERY
ORAL MEDICINE
ORAL PATHOLOGY
ORAL AND MAXILLOFACIAL SURGERY

Editor: Larry J. Peterson

Comparison of 2 hemostatic agents for the prevention of

postextraction hemorrhage in patients on anticoagulants
Wayne Halfpenny, FRCS, FDSRCS,a Julian S. Fraser, BDS,b and David M. Adlam, FRCS,
FDSRCS,c Cambridge, United Kingdom
ADDENBROOKES HOSPITAL

Objective. The objective of this study was to compare the use of a resorbable oxycellulose dressing with a fibrin adhesive for
the prevention of postextraction hemorrhage in patients taking anticoagulants.
Study design. A control group of 26 patients with a preoperative international normalized ratio (INR) in the range of 2.0 to
4.2 had extractions performed with the use of local anesthesia and the socket(s) dressed with a resorbable oxycellulose
dressing and sutured with a resorbable suture. The study group with a comparable INR range of 2.1 to 4.1 was treated in a
similar manner, except the sockets were dressed with a fibrin adhesive.
Results. No discernible difference in the postoperative outcome with regard to hemorrhage was noted. Postoperative pain was
reported more frequently in the group that used a resorbable oxycellulose dressing. Only 1 patient had significant postoperative bleeding.
Conclusions. This study shows that in patients receiving warfarin whose INR is within the therapeutic range, the fibrin adhesive is as effective as the resorbable oxycellulose dressing in preventing postextraction hemorrhage.
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:257-9)

The management of those patients receiving oral anticoagulation and requiring dental extractions has altered
in recent years as an appreciation of the need to balance
the risk of a postextraction hemorrhage against the risk,
with potentially a more serious outcome, of a thromboembolic event has materialized.1-3 There has been a
growing trend to maintain levels of anticoagulation and
treat any subsequent postextraction hemorrhage with
local measures, such as Surgicel (Johnson & Johnson,
Berkshire, UK) packing, fibrin adhesive, and tranexamic acid rinses.1,2,4 Recently the use of the argon
beam coagulator in this situation has been described.5
A number of protocols have been suggested in the
past. These included giving patients heparin before
treatment6-8 and adjusting or ceasing the warfarin dose
in the days before surgery.3,7,9,10 For the past 5 years
the usual approach within our department has been to
aSpecialist

Registrar.
Fellow.
cConsultant, Department of Oral and Maxillofacial Surgery,
Addenbrookes Hospital.
Received for publication Nov 14, 2000; returned for revision Jan 19,
2001; accepted for publication Feb 23, 2001.
Copyright 2001 by Mosby, Inc.
1079-2104/2001/$35.00 + 0 7/12/115463
doi:10.1067/moe.2001.115463
bClinical

maintain the patients current level of anticoagulation,

to check the international normalized ratio (INR) on
the day of treatment, and to proceed if it is within the
range of 2.0 to 3.5. Hemostasis is achieved by local
measures, namely, the placement of a Surgicel dressing
and suturing of the socket.
This study was designed to compare an alternative
hemostatic agent Beriplast P (fibrin adhesive; Centeon
LTD, West Sussex, UK) with Surgicel. Our usual
protocol was followed, although for the purposes of
this study, patients with a preoperative INR within
the accepted therapeutic range of 2.0 to 4.5 were
included.11-13

MATERIAL AND METHODS

Before commencement of the study local ethical
committee approval was sought and granted. All
patients currently taking warfarin who were referred
for extractions were asked to participate in the study.
Those patients with an INR on the day of the procedure
outside the study range (2.0 to 4.5) were excluded, as
were those patients who had a history of liver disease
or who were taking any medication affecting liver
function and hemostasis. A total of 50 patients
receiving warfarin and fulfilling these criteria
consented to take part in the study; of these, 4 were lost
257

258 Halfpenny, Fraser, and Adlam

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

September 2001

Fig 1. Mechanism of action of Beriplast P.

Table I. Indications for anticoagulation and ideal therapeutic range

Indication

Ideal INR

Deep vein thrombosis

Pulmonary embolism
Valvular disorders
Prosthetic valve replacement
Dilated cardiomyopathy
Coronary artery bypass graft
Atrial fibrillation
Cerebrovascular accident
Procoagulation disorder

2.0-3.0
2.0-3.0
2.0-4.5
3.0-4.5
2.0-3.0
3.0-4.5
1.4-2.8
2.0-3.0
3.0-4.5

No. of
patients
7
9
3
9
1
2
12
2
1

Table II. Patient and treatment details

Demographics
Number
Male:female
Age, range (y)
Age, mean (y)
Warfarin
Dose, range (mg)
Dose, mean (mg)
INR, range
INR, mean
Extractions
No. of teeth, range
No. of teeth, mean
Difficulty of extraction
Simple
Surgical
Duration, range (min)
Duration, mean (min)

Study (Beriplast P)

Control (Surgicel)

20
13:17
33.4-83.4
66.5

26
17:9
38.2-79.3
64.8

1-10
4.6
2-4.1
2.7

3-9
5.4
2.1-4.1
2.9

1-6
2

1-4
1.5

14
6
2-60
20

19
7
3-25
9.8

to follow-up and have not been included in the results.

Indications for anticoagulant therapy in these patients
are summarized in Table I. Patients were allocated to
either the Surgicel (n = 26) or the Beriplast P (n = 20)
group by using a randomized list supplied in sealed
envelopes, which were opened after written consent
was obtained.
Extractions were performed with the patients under
local anesthesia by using either 2% lignocaine with

Table III. Details of postextraction pain experienced

in the 2 groups
Severity of
pain
No pain
Moderate pain
Severe pain

Study (n = 20)
(Beriplast P)

Control (n = 26)
(Surgicel)

12
5
3

8
16
2

1:80,000 adrenaline or 3% prilocaine with felypressin. A

local infiltration technique was used where possible,
although regional blocks of the inferior alveolar, long
buccal, and lingual nerves were used. Antibiotic prophylaxis, following the recommended regimens in the
British National Formulary,14 was given when indicated.
Extractions were carried out in the least traumatic way
possible. Simple elevation or forceps removal was used
(simple extraction); however, if necessary, a mucoperiosteal flap was raised and bone was removed and roots
were divided with a drill (surgical extraction). The duration of surgery was also recorded. Once the extractions
were completed, the sockets were dressed with either
Surgicel or Beriplast P and then sutured with softgut.
Pressure was then applied by having the patient bite
firmly on a gauze pack until hemostasis was achieved.
Postoperative instructions were given in regard to
appropriate postoperative analgesia, avoiding aspirin
and nonsteroidal analgesic anti-inflammatory drugs,
the action to be taken if there was any postoperative
bleeding, and arrangements for emergency treatment
and review. All patients were reviewed at 1 week in the
absence of any postoperative complications requiring
earlier review, and the incidence of postoperative
bleeding, pain, and other complications was noted.
Pain was recorded on a visual analogue scale and
graded as no pain, moderate pain, or severe pain.

RESULTS
A total of 46 patients receiving warfarin were treated.
The patient details of the 2 groups are shown in Table
II. No patients from either the Surgicel or the Beriplast

ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY

Volume 92, Number 3

Halfpenny, Fraser, and Adlam 259

P group experienced immediate postoperative bleeding.

One patient from the Surgicel group (age, 59.0 years;
INR, 3.6; single tooth surgical extraction, 15 minutes
duration) had a postextraction hemorrhage at 24 hours
necessitating further suturing, as did a patient from the
Beriplast P group (age, 68.6 years; INR, 4.2; single
tooth simple extraction, 15 minutes duration). A single
patient from the Beriplast P group required hospital
admission with a persistent intermittent bleed (age,
81.8 years; INR, 3.0; surgical extraction of 6 teeth, 60
minutes duration); hemorrhage was stopped after 48
hours, although his admission was prolonged because
of social factors. Pain was reported in both groups in
varying severity (Table III).

This study supports previous findings that severe postoperative hemorrhage is not generally a problem after
dental extractions on patients receiving warfarin whose
anticoagulant regime has not been altered and who are
treated under local analgesia on an outpatient basis with
local measures. Beriplast P appears to be as effective as
Surgicel in preventing postextraction hemorrhage in
these patients and has the additional advantage of
demonstrating tissue adhesion. This may be advantageous in areas where access or suturing is difficult.

DISCUSSION
Patients receiving warfarin who present for dental
extractions need to be managed in a manner that allows
for treatment without putting them at undue risk of
postoperative hemorrhage or thromboembolic event.
The growing trend of maintaining the level of anticoagulation when removing teeth requires effective local
measures for reliable hemostasis.1,2,4 Surgicel has been
widely used in these circumstances and has proved to
be an effective hemostatic agent.15 It is a glucose
polymer-based sterile knitted fabric prepared by the
controlled oxidation of regenerated cellulose. Its local
hemostatic action depends on the binding of hemoglobin to oxycellulose, allowing the dressing to expand
into a gelatinous mass, which in turn acts both as scaffolding for clot formation and as a clot stabilizer.
Beriplast P is a biologic adhesive containing thrombin,
fibrinogen, factor XIII, and aprotinin. Thrombin
converts fibrinogen to unstable fibrin clot, factor XIII
stabilizes the clot, and aprotinin prevents its degradation
(Fig 1). Under the circumstances of wound healing,
fibroblasts move through the fibrin meshwork, forming
a more permanent framework composed of collagen
fibers. The product poses virtually no risk of transmission of viral infections because of the pasteurization of
the plasma components and has little or no antigenic
potential.16 Beriplast P is currently available on a named
patient basis, although a product license for use in the
clinical setting described has been applied for.
In this study limited numbers preclude statistical evaluation; however, there appears to be little difference
between the 2 treatment modalities with respect to postoperative hemorrhage. Postoperative pain was reported
more frequently in the Surgicel group, although the
reasons for this are unclear. The single patient requiring
admission with postextraction hemorrhage had the most
teeth removed (6), the longest procedure (60 minutes),
and was 1 of the oldest patients (81.8 years).

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Reprint requests:
W. Halfpenny, FRCS, FDSRCS
10 Pebmarsh Rd
Colne Engaine
Colchester
Essex CO6 2HD
UK
wayne@whalfpenny.freeserve.co.uk