ABC | Volume 111, Nº3, September 2018

Original Article Andrade et al Anticoagulation and dental procedure Arq Bras Cardiol. 2018; 111(3):394-399 1. Lopes RD, Al-Khatib SM, Wallentin L, Yang H, Ansell J, Bahit MC, et al. Efficacy and safety of apixaban comparedwithwarfarin according to patient risk of stroke and of bleeding in atrial fibrillation: a secondary analysis of a randomised controlled trial. Lancet. 2012;380(9855):1749-58. Erratum in: Lancet. 2013;381(9862):204. 2. Ruff CT, Braunwald E. Will warfarin ever be replaced? J Cardiovasc Pharmacol Ther. 2010;15(3):210-9. 3. Firriolo FJ, Hupp WS. Beyond warfarin: the new generation of oral anticoagulants and their implications for themanagement of dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(4):431-41. 4. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, HannaM, et al; ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-92. 5. Connoly SJ, Ezekowitz MD, Yusuf S, Eikelboom L, Oldgren J, Parekh A, et al; RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139-51. Erratum in: N Engl J Med. 2010;363(19):1877. 6. Healey JS, Eikelboom J, Douketis J, Wallentin L, Oldgren J, Yang S, et al; RE- LY Investigators Periprocedural bleeding and thromboembolic events with dabigatrancomparedwithwarfarin:results fromtheRandomizedEvaluation of Long-TermAnticoagulation Therapy (RE-LY) randomized trial. Circulation. 2012;126(3):343-8. Erratum in: Circulation. 2012;126(10):e160. 7. Magalhães LP, FigueiredoMJ, Cintra FD, Saad EB, Kuniyoshi RR, Teixeira RA, et al. II Diretrizes brasileiras de fibrilação atrial. Arq Bras Cardiol. 2016;106(4 supl.2):1-22. 8. Curtin C, Hayes JM, Hayes J. Dental implications of new oral anticoagulants for atrial fibrillation. Dent Update. 2014;41(6):526-8, 530-1. 9. DavisC,RobertsonC,ShivakumarS,LeeM.ImplicationsofDabigatran,adirect thrombin inhibitor, for oral surgery practice. J CanDent Assoc. 2013;79:d74. 10. Iwabuchi H, Imai Y, Asanami S, Shirakava M, Yaname GY, Ogiuchi H, et al. Evaluation of post-extraction bleeding incidence to compare patients receiving and not receiving warfarin therapy: a cross-sectional, multicentre, observational study. BMJ Open. 2014;4(12):e005777. 11. Oldgren J, Healey JS, Ezekowitz M, Commerford P, Avezum A, Pais P, et al; RE-LY Atrial Fibrillation Registry Investigators. Variations in cause and management of atrial fibrillation in a prospective registry of 15400 emergency department patients in 46 countries. The RE-LY Atrial Fibrillation Registry. Circulation. 2014;129(15):1568-76. 12. Lopez-GalindoM, Bagan JV. Apixaban and oral implications. J Clin ExpDent. 2015;7(4):e528-34. References Implications A recent survey has revealed that dentists are well informed about anticoagulation. They, however, tend to overestimate the risk of bleeding, being cautious about their treatment management, which differs in different parts of the world. 25 A Brazilian systematic review has highlighted the risk of bleeding in individuals taking anticoagulants, as well as the efficacy and safety of dental interventions in that population. 26 It is worth noting that the present study is pioneer in Brazil on approaching that practice in patients with nonvalvular AF, and its results should be used to foster the understanding of the magnitude of bleeding in that specific population when taking that class of drug. Study limitations The present study has some limitations: impossibility of being double-blind because of the lack of funding to pay for a double-dummy study, with specific placebo for the two drugs tested and their false INR for monitoring in the dabigatran group. In addition, choosing a continuous variable for primary outcome makes the analysis of subtle differences between the groups more objective, allowing a smaller sample size with statistical adequacy; however, that number is small to assess more robust and rare outcomes in this type of intervention. Conclusions This study suggests that, regarding dental extraction, there is no statistically significant difference in the intensity of bleeding of patients taking dabigatran as compared to those taking warfarin. Bleeding 24 hours after the procedure was less frequent among patients on dabigatran. Author contributions Conception and design of the research: Andrade MVS, Andrade LAP, Feitosa GS, Feitosa Filho GS; Acquisition of data: Andrade MVS, Andrade LAP, Bispo AF, Freitas LA; Analysis and interpretation of the data and Statistical analysis: Andrade MVS, Andrade MQS, Feitosa Filho GS; Obtaining financing and Writing of the manuscript: Andrade MVS; Critical revision of the manuscript for intellectual content: Andrade MVS, Feitosa GS, Feitosa Filho GS. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This article is part of the thesis of Doctoral submitted by Marcus Vinicius Santos Andrade, from Escola Bahiana de Medicina e Saúde Pública / Fundação Bahiana para Desenvolvimento das Ciências (FBDC). Ethics approval and consent to participate This study was approved by the Ethics Committee of the Hospital Santa Izabel da SantaCasadeMisericórdiadaBahiaunder the protocol number 1.857.480. CAAE: 61125916.10000.5520. All the procedures in this study were in accordancewith the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study. 398