LITERATURE REVIEW

Tranexamic Acid Tamponade to Control Postoperative

Surgical Hemorrhage
Dennis Flanagan, DDS

When preparing for oral surgery, patients taking anticoagulants usually should not discontinue their medication because of the risk of a
thromboembolic event. The therapeutic effect of many anticoagulants is not readily measured, so preoperatively, the surgeon cannot
know the true risk for postoperative hemorrhage. The risk of a thromboembolic event usually outweighs the concerns of controlling

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postoperative hemorrhage. Hemophilia patients are also at risk for postoperative bleeding. Single extractions probably do not pose a
serious risk for postoperative hemorrhage. However, when a mucogingival flap is raised in these patients, there may be prolonged
bleeding. Surgical sponges saturated with aqueous tranexamic acid solution and compressed onto the bleeding site with biting pressure
may stop bleeding. Bleeding was stopped in the case example presented here after three 10-minute compressions over 30 minutes in a
patient taking aspirin and clopidogrel for a previous thromboembolic event and a metal coronary stent. The clot formed is very fragile and
is prone to bleeding, so it should not be disturbed. This technique needs to be studied for efficacy.

Key Words: hemorrhage, coagulation, bleeding, bleeding control, local bleeding control, oral bleeding, oral surgery, dental implant,
anticoagulants.

INTRODUCTION cessation of anticoagulant therapy, thus minimizing the risk.6

The decision to stop or bridge anticoagulant therapy for an

T
he implant dentist can be confronted with patients
impending implant surgery is ultimately a clinical decision
who present with anticoagulant therapy for treatment
made by the implant dentist based on the magnitude of the
of various systemic conditions. Warfarin has been the
surgical wound, postoperative hemorrhage considerations, and
most frequently used anticoagulant, being the 21st
the thromboembolic risk. The cessation of anticoagulant,
most common prescription in the United States in 2011.1,2 It is
including aspirin and clopidogrel, may cause thrombosis.7
an anticoagulant for which the expected bleeding can be
These patients may be at the highest risk for a vascular event if
measured by the international normalized ratio (INR), which
anticoagulant therapy is ceased or bridged.7
measures the extrinsic coagulation cascade. This indicates to
Tranexamic acid, trans-4-(aminomethyl)cyclohexanecarbox-
the implant dentist whether patients may need to have the
ylic acid (TA; Cyclokapron, Pfizer, New York, NY; Figure 1) is
dosage of medication reduced to decrease the anticoagulation
derived from lecithin. It has been used systemically for many
so that the surgery will not induce prolonged bleeding. Drugs
years to minimize post- and intraoperative hemorrhage. Topical
with an antiplatelet effect, such as aspirin and clopidogrel
use has not been extensive. With the advent of anticoagulants
(Plavix), are commonly used.3 Tests to monitor their effect are
for which the therapeutic effect cannot be monitored
not widely available. Newer anticoagulants, such as rivaroxiban
conveniently, a topical hemostatic agent may be very beneficial
(Xaroleto) and dabigatran (Pradaxa), are being used more
if cessation or bridging is inappropriate.9
widely.4 Their therapeutic effect is not easily measured for
The aim of this article is to review the topical use of TA to
preoperative consideration.5 The implant dentist may not know
control postoperative bleeding for minor oral surgical proce-
preoperatively which patients will not stop bleeding quickly
dures in patients taking anticoagulant therapy and for whom the
after implant surgery. Cessation of an anticoagulant may have
decision has been made not to cease anticoagulant therapy.10
serious cardiovascular sequelae, such as myocardial infarction
or embolic cerebrovascular stroke.6–9 Cessation may have a 6%
risk for an adverse thromboembolic event.7 Stopping antico-
MATERIALS AND METHODS
agulant therapy should be done only after consultation with
the patient’s physician. Bridging therapy may be instituted Literature search
where low-molecular-weight heparin is administered to tem-
porarily perform the anticoagulant therapy.8 This may be done An electronic literature search was performed using the key
for some patients to allow for postsurgical clotting. Neverthe- word tranexamic acid AND hemorrhage. All addressed non-
less, many patients may undergo minor oral surgery without topical use of TA except one.

Patient usage
Private practice, Willimantic, Conn.
Corresponding author, e-mail: dffdds@comcast.net We included 10 patients who underwent an oral surgical
DOI: 10.1563/AAID-JOI-D-13-00158 procedure including extraction, apically positioned or partial

e82 Vol. XLI / No. Three / 2015

 Flanagan

FIGURE 1. Molecular configuration of tranexamic acid—trans-4-

(aminomethyl)cyclohexanecarboxylic acid.

thickness mucogingival flap. All patients had a tamponade of

an aqueous saturated solution of TA. Most bleeding stopped in

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10 minutes, and the patients on anticoagulant therapy
bleeding stopped with 1 or 2 additional applications.

CASE EXAMPLE

In 2009, a 51-year-old man with a history of high blood pressure

and cholesterol and cardiac stent surgery 7 years prior (2003),
presented for implant-supported restorative treatment. Clinical
and radiographic examination revealed maxillary right (teeth
Nos. 1–5) and mandibular left partial edentulism (tooth No. 19)
with moderate bone atrophy. Treatment options were dis-
cussed. The remaining teeth were to be restored as well. The
mandibular left premolars were deemed poor to guarded
periodontal, coronal, or endodontic prognosis.
Telephone consultation with his physician revealed that the
patient took the following medications daily: famotidine
besylate (Pepcid) 10 mg, rosuvastatin (Crestor) 10 mg,
ezetimibe (Zetia) 10 mg, lisinopril (Zestril) 20 mg, metoprolol
(Toprol) 100 mg, clopidogrel (Plavix) 75 mg, aspirin 81 mg, and FIGURE 2. One week postoperative healing of example patient.
L-thyroxine (Synthroid) 50 mg. The physician determined that
the patient would tolerate dental implant surgery well. The risk (Imprint, 3M ESPE) impression was made. A porcine collagen
for a thrombosis would be minimized by not discontinuing the matrix (MucoGraft) was placed under the flap to increase the
dual antiplatelet drugs, clopidogrel and aspirin. Implants were thickness of collagenous tissue. Healing caps were placed and
successfully placed at the maxillary right and restored without bleeding was controlled with a local anesthetic infiltration and a
cessation of anticoagulant therapy with no hemorrhagic tea bag compress. No sutures were placed, but a bis-acryl stent
sequellae. The maxillary right implants and restorations was placed. The patient was instructed on postoperative care and
(treatment by D.F.) were placed in 2010 and had been in left in good condition with no bleeding. However, that night, the
successful function for 2 years. patient awoke because of bleeding from the site. He went to a
In 2012, the mandibular left premolars were extracted with
local hospital emergency department for treatment. The
infiltration local anesthesia using articaine (Septocaine). The
physician on duty controlled the bleeding again with moistened
implants were placed flaplessly at the first molar site and
tea bag compression. The next morning, the patient was seen
immediately at the first premolar site, again without discon-
and the site was bleeding again. The stent was removed. A
tinuing the anticoagulant therapy. The premolar extraction
saturated aqueous solution (16%) of TA was made by dissolving
sites were filled with calcium sulfate and covered with collagen
plugs (Salvin) and secured with a 3-0 chromic suture. No TA powder in approximately 10 mL of water and soaking into 2 3
prolonged postoperative bleeding occurred. 2 surgical sponges. The sponges were placed on the surgical site
At second-stage uncover surgery for the left mandible, the and compressed with the patient’s biting pressure for 10 minutes.
anticoagulants were again not stopped. After facial and lingual This was repeated twice. After the third compression, the
infiltration of 1.6 mL articaine (Septcaine) at the No. 19 site, an bleeding stopped completely. The patient was monitored for
approximately 15-mm-long partial-thickness facial surgical flap another 30 minutes, and there was no reoccurrence of bleeding.
with releasing incisions was raised and apically positioned. The The patient was instructed as to home care and was dismissed.
No. 21 implant had adequate attached tissue and did not require He was called 2 hours later, and he reported no bleeding from the
augmentation, and the gingival overgrowth here was removed site. The patient again reported no bleeding from the site 2 days
with a medium-coarse high-speed diamond stone. Abutment later. He subsequently returned 1 week later for follow-up and
analogues were placed, and an open tray polyvinyl siloxane was healing well with no bleeding reoccurrence (Figure 2). Three

Journal of Oral Implantology e83

Tranexamic Acid
weeks later, the fixed partial denture was fitted, adjusted, and
definitively cemented with resin-modified glass ionomer cement
(FujiCem).
DISCUSSION
Example patient with TA tamponade
Oral anticoagulant therapy does not contraindicate dental
implant surgery.6,9 Discontinuing anticoagulant therapy is not
advisable for minor oral surgery, such as single tooth extraction
and implant placement. When there are more invasive
procedures such as large flap and autogenous bone grafting,
anticoagulant cessation or bridging therapy may be instituted.
Topical agents and compression are generally effective in
controlling postoperative bleeding in minor sites in these
patients.9–12 However, there is no definition of a ‘‘minor’’ site.
The extent of anticoagulation in individual patients may vary
due to dosage and timing, individual physiologic metabolism,
or circadian variations. This creates an uncertain physiologic
parameter for the dentist. The above patient had 3 prior
‘‘minor’’ oral surgeries and no bleeding complications. The
uncovery second-stage flap in the left mandible was a slightly
larger surgical wound than the previous surgeries. The stent
protected the flap wound but did not apply pressure and
prevented direct contact with the applied tea bags. After the
stent was removed, the wound was exposed for direct
compression and contact with the TA solution. The patient
may have altered his dosing by inconsistent drug compliance
that resulted in less anticoagulation in the early surgeries and
more during the last flap surgery. This may have contributed to
the bleeding episode that required TA tamponade.
The polypharmacy in the example patient herein may be of
concern. Among other drugs, he was taking famotidine
(Pepcid), rosuvastatin (Crestor), ezetimibe (Zetia), metoprolol,
and lisinopril. Famotidine is an H2 receptor antagonist that may
rarely induce thrombocytopenia. This patient, however, was not
thrombocytopenic. Rosuvastatin is a statin drug that does not
have significant vascular side effects. Its clearance can be
affected by some anticoagulants—clopidogrel not being one of
those. Ezetimibe inhibits cholesterol intestinal absorption and
rarely induces thrombocytopenia. Metoprolol is a selective b-1
blocker for hypertension with no hemorrhagic effects. Lisino-
pril, an angiotensin-converting enzyme (ACE) inhibitor, rarely
may induce anemia, leukopenia, and thrombocytopenia, which
may alter clotting. ACE inhibitors, such as lisinopril, may slightly
inhibit platelet function by various mechanisms.13,14 There is no
evidence that the patient was not taking his L-thyroxine.
Hypothyroidism may induce a bleeding tendency.15 It is not
certain whether the patient was using any complementary or
alternative medication (CAM). CAMs may cause significant
perioperative bleeding.16,17 The patient had no clinical evi-
dence of a blood dyscrasia.
This patient had a metal coronary artery stent placed 7
years prior and was chronically taking clopidogrel. Clopidogrel
is a thienopyridine antithrombic drug used in coronary
syndrome, peripheral vascular disease, cerebrovascular disease,
and coronary stents.18 Coronary stents have become routine
treatment for atherosclerotic coronary arteries. The stent can
e84 Vol. XLI / No. Three / 2015
reduce patient mortality and can improve symptoms.18,19 Drug-
eluting stents are now available, and discontinuing anticoag-
ulant therapy may be possible with a low risk for serious
complications.19 For coronary stent patients on clopidogrel,
routine platelet function may be monitored, but this can be
inconvenient and may not improve the clinical results.20 There
is no consensus as to the most appropriate anticoagulant
therapy. Aspirin alone may be the best antiplatelet regimen.21
After coronary stent surgery, dual anticoagulant therapy with
clopidogrel and aspirin is well accepted.22 However, with
clopidogrel, there is important patient variability in the
antiplatelet response.22 These are genetically related and may
have increased risks for bleeding sequelae.22 These issues may
affect the potential for dental implant surgery hemorrhage,
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which may have been at least contributory to the incident
reported here.
Clotting mechanism
Thrombogenesis (clotting) is the result of a complex cascade of
biological chemical events.23 Generally, platelets become
activated by tissue factor released from injury to epithelium.
There then occurs a cascade of biochemical reactions by the
extrinsic and intrinsic pathways that contribute to the
conversion of prothrombin to thrombin, which in turn converts
fibrinogen to fibrin. Fibrin is then cross-linked to stabilize the
clot.
Pharmacology of TA
Tranexamic acid (TA) is a derivative of lysine that has been used
as a first-line treatment to control bleeding of menorrhagia (at
least 80 mL blood loss per cycle) and cardiac surgery.24–26 Peak
plasma concentration is reached within 1 hour with intravenous
injection with a dose of 10 mg/kg.27,28 After 24 hours, 90% of
TA is excreted in the urine, and the elimination half-life is 80
minutes.29 Oral administration of 10 to 15 mg/kg produces
peak plasma concentration within 3 hours.29 Taking TA with
food does not reduce or increase gastrointestinal absorption.30
Tranexamic acid does accumulate in tissue and joint and
synovial fluid.27,31 Tranexamic acid will pass the placental
barrier and be concentrated in breast milk.28,32 Studies have not
shown any teratogenic effects.33
Tranexamic acid is antifibrinolytic by binding to plasmin-
ogen, preventing it from converting to plasmin in the clotting
cascade. Plasmin degrades fibrin.34 Tranexamic acid is much
more potent than alpha-aminocaproic acid and epsilon or para-
aminomethyl benzoic acid in this action.33 In this competitive
inhibition activity, it bonds to the Kringle class disulfide linked
proteins that interact with clotting factors.35 Tranexamic acid
inhibits plasmin action and with high dosage will reduce
plasmin formation.35 The antifibrinolytic action of TA may also
act by reducing capillary leakage of the serum protein albumin,
so as to maintain intravascular blood volume.36 Topical
application may provide a high enough dose to accomplish
local coagulation, but in the past, most use has been parenteral
or via oral administration. Inhibition of plasminogen may
additionally inhibit angiogenesis and bone repair, but this may
not be clinically significant.37 In addition, cartilage matrix and
osteoblast formation may be inhibited by TA.37 The relatively

rapid clearance of TA precludes any significant inhibition of
osseous healing.
Intravenous use of TA
In major surgical procedures, a preoperative intravenous TA
dose of 20 mg/kg has been shown to reduce the postoperative
blood loss of bimaxillary osteotomy surgery as compared with
placebo.38
Intravenously administered TA is cleared at approximately
the same rate as the patient’s glomerular filtration rate.39 The
minimum safe nontoxic dosage of this drug has not been
determined. The serum concentration of intravenous TA shows
high variation between patients, so the patient should be
monitored for this parameter.40 Intravenous administration
should not exceed 100 mg/min to avoid dizziness and
hypotension.
Transdermal enhanced administration may be possible with
a carbamic acid salt ester of TA, which may facilitate
treatment.41 This approach was done in an effort to trans-
dermally administer as a TA ester. The intradermally placed
ester would then dissociate into an active metabolite to
successfully cause skin barrier homeostasis.
Because of its inhibition of fibrinolysis, TA may be an
important drug for bleeding in factor XI patients in whom high
fibrinolytic activity occurs.42
Topical TA therapy may decrease the risk of secondary
hemorrhage in ambulatory ophthalmic patients with hyphe-
ma.43
Tranexamic acid enhances ultrafiltration volume in dialysis
patients, of which the mechanism of action is unknown.44 Thus,
there may be a decreased therapeutic action of drugs that
depend on ultrafiltration for clearance.
A Cochrane review found that when TA was administered
intravenously at the time of surgery, it reduced bleeding, with
no significant side effects.45
In mice, the lethal dose for 50% of subjects (LD50) is more
than 10 mg/kg. Symptoms of overdose may include nausea,
vomiting, diarrhea, and/or hypotension. Thus, TA should be
injected intravenously slowly, less than 1 mL/min. There is no
evidence of teratogenicity, mutagenicity, or fertility effects, so
TA is classed as a category B drug by the US Food and Drug
Administration Pharmaceutical Pregnancy Categories. Throm-
bosis may occur when TA is intravenously administered with
factor IX or anti-inhibitor coagulant.46
Tranexamic acid is used in oral surgical patients with
hemophilia for short-term use (2–8 days) to reduce or prevent
hemorrhage following tooth extraction. Patients with most
clotting disorders get an abnormal fibrin network because of
lower or delayed thrombin production. The clotting process in
patients with hemophilia is compromised, making the clot
more soluble, and cross-linking in the fibrin polymer does not
effectively occur.47 Patients with the rare factor XI bleeding
disorder have varying tendencies of hemorrhage. Surgical
bleeding has been successfully treated in these patients with
TA and recombinant activated factor VII.42 In addition, TA may
be used to prevent episodes of angioedema by preventing
activation of the initial complement protein. Thus, TA may have
multiple modes of pharmacologic action that need to be
investigated.
Flanagan
Systemic dosing techniques of TA have produced variations
in efficacy for optimal treatment, and it is difficult to maintain
stable therapeutic serum concentrations.48 Thus, individual
patients may exhibit variable blood concentrations during oral
or intravenous administration, making dosage titration diffi-
cult.48
Successful control of vaginal postpartum hemorrhage
exceeding 800 mL was effective with high-dose TA with a
loading infusion dose of 4 g and 1 g/h for 6 hours.49 The high
levels of plasminogen activator found in uterine and cervical
tissue may explain the beneficial effects of TA.50
Oral administration of TA
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Absorption after oral administration is about 40%, and
bioavailability is not affected by taking with food. Tranexamic
acid is eliminated by renal glomerular filtration, with only about
5% being metabolized.
Tranexamic acid has been used to successfully treat
menorrhagia in von Willebrand’s disease with a single daily
4000-mg oral dose for 3–5 days.51
Most patients can tolerate 3–6 g/d orally of TA, and it may
be considered a first-line treatment for bleeding control of
some conditions.24
However, the oral administration of 1 g 4 times a day for 4
days of TA can produce nausea, vomiting, diarrhea, and
abdominal pain in 12% of patients.52
Dental surgical patients with hemophilia who were treated
with TA 1 g 3 times a day for 5 days beginning 2 hours prior to
surgery had significantly less postoperative bleeding as
compared with a placebo group.53 Hospital stay time can also
be reduced with treatment.54
Anticoagulants and TA local hemorrhage control
No anticoagulant acts to 100% prevent coagulation. Tranexa-
mic acid may act locally to act on any clotting that may occur to
stabilize that clot and any further clotting activity that can
occur. With time, the clotting can be significant to stop local
bleeding at the oral surgical site. Hence, TA may be effective
with a multiplicity of anticoagulants.
Warfarin (Coumadin) is an anticoagulant that is widely used.
It acts by inhibiting the vitamin K recycling metabolism in the
formation of prothrombin and affects factors II, VII, IX, and X in
the clotting cascade.1,55 Warfarin takes about 2–5 days to
become clinically significant and the same to reverse its activity
with vitamin K therapy.55 Warfarin interacts with many
medications and foods that may increase or decrease its
effects. The INR measures the blood level of warfarin, which
optimally ranges from 2.5–4.5 depending on the condition
being treated.56 The INR is calculated by dividing the patient’s
prothrombin time (PT) by a standard control PT as determined
by the World Health Organization. This ratio standardizes
results for laboratory testing differences. Excessive alcohol use
can increase the INR. Leafy green vegetables and some oils are
high in vitamin K and may decrease the action of warfarin.
Warfarin increases the risk for osteoporosis fracture in men.57
Broad-spectrum antibiotics may reduce gastroenteral bacteria
that generate vitamin K, thus increasing the effects of
Journal of Oral Implantology e85
Tranexamic Acid
warfarin.58 The TA tamponade may be able to control local oral
bleeding with these patients.
Enoxaparin (Lovenox) is a low-molecular-weight heparin
that is used to treat patients with a history of deep vein
thrombosis or pulmonary embolism.5,59 It is administered by
subcutaneous injection by a health care provider or the patient.
It acts by activating thrombin III and inhibits clotting factor Xa,
which converts prothrombin to thrombin, preventing the fibrin
clot. Heparin-induced thrombocytopenia, a decrease of plate-
lets by 50%, is a very rare side effect of enoxaparin caused by an
interaction with immunospecific antibodies and carries a
significant risk for thrombosis.60 Tranexamic acid may be a
local antidote to enoxaparin because of its stabilization of the
fibrin clot. Any clotting that forms may be induced to prolong
and resist breakdown.
Clopidogrel (Plavix) is a thienopyridine antiplatelet antico-
agulant.18,61 It acts as a P2Y(12)-ADP receptor antagonist to
prevent thrombosis.18 It is metabolically inactivated by
carboxylesterase-1 into carbolic acid metabolites.62 Genetic
variations can be responsible for a spectrum of drug
responses.63 About 25% of patients may not fully respond to
therapy.61 Since clopidogrel is a prodrug that is transformed
into an active metabolite by hepatic CYP2C19 patients, genetic
variations of this enzyme may have a subtherapeutic response
or no response.61,64 Because of this, each oral surgical patient
taking clopidogrel should be treated with caution and
hemorrhagic control measures should be ready to be instituted
if anticoagulant therapy is not to be stopped or bridged.
Anticoagulant bridging therapy can be done with low-
molecular-weight heparin to anticoagulate the patient with a
measurable method. Since clopidogrel is an antiplatelet and TA
is an antifibrinolytic and some clotting would occur from an
alternative pathway, topical TA tamponade may be helpful in
oral bleeding control in these patients because of the different
mechanisms of action.
Rivaroxaban inhibits factor Xa in the clotting cascade and is
administered orally daily.65 The factor Xa does not recover for
about 24 hours, and the drug has no antagonist. A tamponade
of TA is an antifibrinolytic and may contribute to local
hemorrhage control in patients taking rivaroxaban.
Aspirin (acetylsalicylic acid [ASA]) is a nonsteroidal anti-
inflammatory drug with antiplatelet anticoagulant activity.
Acetylsalicylic acid inhibits platelet aggregation by blocking
formation of platelet thromboxane A2. The thromboxane
metabolites are responsible for the aggregating ability of
platelets.66
The example patient presented above was taking 81 mg
oral ASA daily working in tandem with the oral clopidogrel. The
combination of clopidogrel and aspirin is used for anticoagu-
lant therapy but is not recommended by current guidelines.67
However, some patients will be prescribed this dual therapy
because of their specific cardiovascular issues, such as having
an implanted metal coronary stent surgery. The TA was
effective in stopping the local oral bleeding after 30 minutes
of tamponade in this dual-therapy patient.
Dabigatran (Pradaxa) is a synthetic anticoagulant that
directly inhibits thrombin and is not influenced by dietary
vitamin K.68 The usual dose is 150 mg twice a day. Blood level
monitoring is not required, but, again, the implant dentist may
e86 Vol. XLI / No. Three / 2015
not be able to predict preoperatively the patient’s ability to
postoperatively coagulate. Since there may be different
mechanisms of action of TA, a tamponade may be able to
control local oral bleeding by fibrin stabilization.
Topical use of TA
Topical TA has been used in ophthalmic, coronary, dental, and
hemophiliac surgery.
Topical ophthalmic TA may cause enhanced therapeutic
intraocular drug concentrations in hyphema (blood in the iris or
cornea) patients with minimal toxicity.69 This treatment intends
to prevent additional bleeding in the eye.
Microhemorrhage after coronary artery bypass surgery can
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be controlled with topical compression with TA reducing total
blood loss.70
Tranexamic acid has been used systemically and locally to
reduce postextraction and periodontal surgical bleeding by its
antifibrinolytic activity during operative procedures in hemo-
philiac and cirrhosis patients.71–74 Topical TA for oral-dental
activity has been primarily used as a mouth rinse for
postoperative bleeding in hemophilia patients.11,72,74 In addi-
tion, a 4.8% tranexamic mouthwash for 2 days has been used to
control postextraction bleeding in patients taking warfarin.12 In
a study by Waly, dual TA mouthwash and systemic TA was
compared with systemic TA alone, and dual therapy was found
to be dramatically superior in postextraction bleeding in
children with hemophilia.72
In patients with von Willebrand’s disease, oral or topical TA
has been used to control oral bleeding such as frenum tears
and lacerations of the lips and buccal mucosa.75,76
When 10 mL of 5% aqueous TA is administered orally as an
oral rinse for 2 minutes, it can be detected at a therapeutic level
in saliva for 2 hours but is undetectable in blood plasma.71,72
Systemic TA can be administered with an oral rinse to
significantly reduce postoperative bleeding.77
When oral surgery is performed on patients with hemo-
philia who are anticoagulated, the surgery should be per-
formed as atraumatically as possible by an experienced
surgeon.78 Extraction sockets can be filled with collagen plugs
soaked in 5% TA and secured with a resorbable suture. A 5% TA
3-times-daily postoperative 7-day oral rinse may be additionally
prescribed. Alternatively, surgical sponges soaked in a 5% TA
solution may be used by the patient to bite on to promote
fibrin clot stability.
Hewson et al78 evaluated the postoperative course of 50
hemophilia patients for 113 extractions. They were prescribed a
postoperative regimen of 5% TA oral rinse 3 times a day for 7
days and 5% TA surgical sponge tamponade as necessary for
any moderate bleeding. Patients were treated with clotting
factor replacement therapy coverage if it was their normal
protocol depending on the severity of their disease. On the
eighth day, 41 patients had no bleeding incidents, 6 had mild
bleeding, 3 had moderate postoperative bleeding that was
treated with the tamponade, and no patient had severe
postoperative bleeding. What minimum clotting factor replace-
ment level to provide a hemostatic effect in various surgical
procedures is not known, but TA may be able to reduce the
concentration of the therapy in these patients.79
Tranexamic acid may be better used in a surgical sponge as

FIGURE 3. Immediate postoperative bleeding.
a direct pressure tamponade when there is active bleeding
(Figures 3 and 4). The most appropriate concentration of the TA
solution is not known. The patient treated here was given TA
topically as a saturated solution.
Some patients take 2 anticoagulants for dual therapy. Here,
TA may be used with other topical modalities, such as a tea
bag, to induce local hemorrhage control. These conditions
need to be studied for appropriate treatment to be ascertained.
In another placebo-controlled study, TA oral rinse alone
was able to control gingival bleeding after dental scaling in
hemophilia patients.80 No preoperative clotting factor replace-
ment therapy was used with the TA rinse in these hemophilia
patients.
Contraindications
Tranexamic acid is contraindicated for sensitivity, subarachnoid
hemorrhage, macroscopic hematuria, and ongoing acute
venous or arterial thrombosis.1 There may be a risk for
thromboembolism if TA is administered after high doses of
prothrombin complex concentrates. Intravenous TA should not
be used to stop bleeding in the upper urinary tract, where clot
formation may cause an obstruction. Because of its renal
clearance, the intravenous TA dosage should be reduced in
patients with renal insufficiency.
Epinephrine, compression, tannins, and ice for bleeding
control
Local circumferential injection of the surgical site with an
epinephrine containing local anesthetic may be a consider-
ation. However, in cardiac patients, this may be contraindicat-
ed, especially after the administration of the local anesthetic for
intraoperative pain control.
Compression by itself may stop bleeding but may not
significantly contribute to the cessation in anticoagulated
patients.81 Tranexamic acid pressure tamponade may be an
Flanagan
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FIGURE 4. Bleeding controlled with tranexamic acid tamponade.
important modality for bleeding control in these patients. A TA
oral rinse was not used in the case example to preclude a
potential dislodging or lifting of the surgical flap by the
circulating solution in the mouth.
A moistened tea bag has been used with compression to
stop postoperative bleeding from third molar extraction. Tea
leaves contain tannic acid and tannins that may induce
vasoconstriction.82–84 There is a recent report of successful
use of combined tannic acid and aluminum potassium sulfate
as a sclerosing agent for hemorrhoids in patients taking
anticoagulants and those not taking anticoagulants.85
Ice applications may not adequately slow bleeding and
may impair coagulation and hemostasis. Ice may be more
useful in controlling pain.86
In patients in whom stents are to be placed, a tamponade
should be used to control hemorrhage before the stent is
applied.87 The stent may preclude direct contact of the TA with
the bleeding surgical site. The clot formed is very fragile and
cannot be disturbed lest bleeding restarts.
CONCLUSIONS
There is a risk of an adverse thromboembolic event for
anticoagulant cessation when planning oral surgical proce-
dures. While the risk is low, about 6%, the risk for such an event
may be life threatening or seriously debilitating. The patient
should, however, stop using CAMs for a week or two before the
surgery, as some of these may contribute to perioperative
bleeding.8 Thus, local bleeding control is a preoperative
consideration for the dental implant surgical patient if cessation
is inappropriate.
The very small number of patients reported herein does not
qualify as a high level of evidence. Topical TA treatment for
hemorrhage control needs to be investigated for efficacy.
A saturated aqueous solution of TA may be used topically
Journal of Oral Implantology e87
Tranexamic Acid
in a surgical sponge with biting compression to control
postoperative bleeding in dental implant patients and poten-
tially in those who are taking anticoagulants. The clot formed is
fragile and prone to rebleeding. Many anticoagulants cannot be
readily measured by clinical testing and thus place the patient
at risk for postoperative hemorrhage. Local bleeding control
measures in these patients may be a preoperative consider-
ation. While TA may not directly interact with anticoagulants, its
antifibrinolytic action stabilizes any clotting that does occur.
Tranexamic acid may have additional metabolic activity related
or unrelated to coagulation. This report has a low level of
credibility. Research is needed to determine if TA is truly
effective. A congener of TA or a local submucosal injection of
TA may be most efficacious. In the end, TA may be considered
to be part of an armamentarium for postoperative hemorrhage
control of localized oral sites.
ABBREVIATIONS
ACE: angiotensin-converting enzyme
ASA: acetylsalicylic acid
CAM: complementary or alternative medication
INR: international normalized ratio
PT: prothrombin time
TA: tranexamic acid
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