e58
Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
Jou nal sec ion: O al Su ge y
Publica ion Types: Resea ch
Clinical p ac ice guideline o he spanish socie y o o al su ge y
o o al su ge y in pa ien s wi h coagula ion diso de s
Ja ie Valenzuela-Mencia 1, Ma ía Ángeles Se e a-Figallo 2, Daniel To es-Laga es 3, Guille mo Machuca-
Po illo 4, Elena Sánchez-Fe nández 5, Edua d Valmaseda-Cas ellón 6, Ma ía Peña ocha-Diago 7, Nu ia
Fe nández-Mos ei ín 8, José Manuel Somoza-Ma in 9, Alba Pé ez-Ja dón 10, Cin ia Micaela Chamo o-
Pe onacci 11, Abel Ga cía-Ga cía 12
1 O al Su ge y eaching eam. Uni e si y o Se ille
2 Full P o esso in In eg a ed Den is y in Special Pa ien s, O al Medicine and O al Su ge y. Uni e si y o Se ille
3 Tenu ed P o esso o O al Su ge y. Uni e si y o Se ille
4 Tenu ed P o esso o Den is y in Special Pa ien s. Depa men o S oma ology. Facul y o Den is y. Uni e si y o Se ille
5 Full P o esso o O al Su ge y. Depa men o S oma ology. Facul y o Den is y. Uni e si y o G anada.
6 Tenu ed P o esso o Odon os oma ology. Facul y o Medicine and Heal h Sciences. Uni e si y o Ba celona. Resea che o
he g oup “Den al and Maxillo acial Pa hology and The apeu ics” o he Biomedical Resea ch Ins i u e o Bell i ge (IDIBELL)
7 Full P o esso o O al Su ge y. Depa men o S oma ology. Facul y o Medicine and Den is y. Uni e si y o Valencia
8 Medical A ea Specialis in Haema ology and Haemo he apy. Haemos asis Depa men . Haema ology and Haemo he apy Se -
ice. Miguel Se e Uni e si y Hospi al. Za agoza
9 Associa e P o esso . Depa men o Su ge y and Medical-Su gical Speciali ies. Facul y o Medicine and Den is y. Uni e si y
o San iago
10 Heal h Resea ch Ins i u e o San iago de Compos ela (IDIS)
11 Heal h Resea ch Ins i u e o San iago de Compos ela; Uni e si y o San iago de Compos ela
12 Tenu ed P o esso o S oma ology. Facul y o Medicine and Den is y. Uni e si y o San iago de Compos ela. Heal h Resea ch
Ins i u e o San iago de Compos ela. Head o he Maxillo acial Su ge y Se ice o he Uni e si y Hospi al Clinic o San iago de
Compos ela o he Galician Heal h Se ice (SERGAS)
Co espondence:
c/ En e ios S/N, 15706
San iago de Compos ela. Spain
cin ia.chamo [email protected]
Recei ed: 04/04/2023
Accep ed: 08/05/2023
Abs ac
Backg ound: The numbe o pa ien s ea ed wi h coagula ion diso de s, and mo e speci ically wi h an icoagulan
he apy, has inc eased wo ldwide in ecen yea s due o inc eased li e expec ancy in de eloped coun ies. The
p o ocols o managing his ype o pa ien in o al su ge y has a ied o e ecen yea s, especially a e he appea -
ance o new di ec -ac ing o al an icoagulan s (DOACs). The assessmen o isk o bleeding in his ype o pa ien
when unde going a su gical p ocedu e con inues o be a con o e sial issue o pa ien s, den is s and gene al p ac-
i ione s. The objec i e o his documen is o o e ecommenda ions, based on e idence, o decision making o
pa ien s wi h coagulopa hies who equi e den al su gical in e en ion.
doi:10.4317/medo al.26063
Valenzuela-Mencia J, Se e a-Figallo MÁ, To es-Laga es D, Machu-
ca-Po illo G, Sánchez-Fe nández E, Valmaseda-Cas ellón E, e al.
Clinical p ac ice guideline o he spanish socie y o o al su ge y o o al
su ge y in pa ien s wi h coagula ion diso de s. Med O al Pa ol O al Ci
Bucal. 2024 Jan 1;29 (1):e58-66.
A icle Numbe :26063 h p://www.medicinao al.com/
© Medicina O al S. L. C.I.F. B 96689336 - pISSN 1698-4447 - eISSN: 1698-6946
eMail: [email p o ec ed]
Indexed in:
Science Ci a ion Index Expanded
Jou nal Ci a ion Repo s
Index Medicus, MEDLINE, PubMed
Scopus, Embase and Emca e
Indice Médico Español
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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
In oduc ion
The numbe o pa ien s wi h coagula ion diso de s,
and wi h an icoagulan he apy, has inc eased wo ld-
wide in ecen yea s due o inc eased li e expec ancy in
de eloped coun ies. (1). In ac , couma in de i a i es
and i amin K an agonis s (VKAs) such as Wa a in
(Aldocuma ®) and acenocouma ol (Sin om®) a e
wo o he 100 medica ions mos p esc ibed in de el-
oped coun ies (2). Al hough VKAs ha e been he gold
s anda d an icoagulan ea men o o e 60 yea s, in
ecen decades, new di ec -ac ing o al an icoagulan s
(DOACs) ha e p og essi ely been in oduced, whose
e ec s a e mo e p edic able as hey ha e a b oade
he apeu ic ange (3).
Managemen o pa ien s wi h coagula ion diso de s,
whe he acqui ed o congeni al, con inues o be an issue
ha conce ns pa ien s, den is s and gene al p ac i io-
ne s (4,5). P o essionals who mus decide he guidelines
o managing hese pa ien s, abo e all wi h ega d o
con inua ion o an icoagulan /an iagg egan ea men
when hey will unde go a su gical p ocedu e (6), ha e
doub s due o he p o ocols ha ing unde gone a ia ions
in a ela i ely sho pe iod o ime (7-9).
Den al ex ac ion is a common p ocedu e, and in he
case o an icoagula ed pa ien s, den is s usually consul
he need o al e he medica ion guidelines due o he
pe cei ed isk o po en ial uncon olled bleeding a e
he den al ea men (10). Shi e al. (2017) ca ied ou a
me a-analysis which included s udies wi h an icoagula -
ed pa ien s wi h VKAs and DOACs and asce ained ha
he isk o pos ope a i e bleeding in an icoagula ed pa-
ien s was g ea e (RR: 2,7) in compa ison wi h heal hy
indi iduals. Ne e heless, he ela i e isk was signi i-
can ly g ea e o pa ien s ea ed wi h VKAs (RR=3)
han o hose ea ed wi h DOACs (RR=1.6) (11).
I mus be aken in o accoun ha cu en clinical p ac-
ice guidelines o pa ien s wi h coagula ion diso de s
a e based on s udies ca ied ou in di e en geog aphic
a eas o he wo ld, whose idiosync asies equi e a c i i-
cal iew o allow ex apola ion o he esul s globally o
ou daily p ac ice. The majo i y o he li e a u e a ail-
able on he haemo hagic isk o an icoagula ed pa ien s
who equi e a den al ex ac ion and a e ea ed wi h a
couma in d ug e ol e a ound Wa a in (12-15), how-
e e , in Spain he couma in d ug used mos is aceno-
couma ol (16).
Ano he signi ican aspec is he de e mina ion o he
ideal INR (In e na ional No malized Ra io) alue o
ea ing pa ien s. Some clinical guidelines o man-
aging an icoagula ed pa ien s, such as he Sco ish
Den al Clinical E ec i eness P og amme (SDCEP)
a ailable on h ps://www.sdcep.o g.uk/media/ypnl-
2cpz/sdcep-managemen -o -den al-pa ien s- aking-
an icoagulan s-o -an ipla ele -d ugs-2nd-edi ion.pd ,
ecommend no al e ing he an icoagulan ea men
guidelines in pa ien s who ha e an INR lowe han 4, i
being ecommended ha his INR is de e mined in he
24 hou s p io o he den al ea men o wi h alidi y
o up o 72 hou s i i s alue is usually s able o e ime.
Howe e , almos hal o an icoagula ed pa ien s p esen
di icul ies achie ing adequa e con ol o INR (Spanish
Fede a ion o An icoagula ed Pa ien Associa ions). In
o he Spanish guidelines, such as ha published by he
Spanish Socie y o Ca diology and he Spanish Soci-
e y o Epidemiology and Public Heal h, his alue is
educed o an INR o 3, ecommending no o ea he
pa ien wi hou consul ing he doc o and adjus ing he
dose o he an icoagulan in case o p esen ing a g ea e
INR. In line wi h he main guidelines on ca diology
a a global le el, i is conside ed ha he desi ed INR
in pa ien s unde an icoagulan ea men mus be be-
ween 2 and 3 (17).
Due o e e y hing desc ibed abo e, his Clinical P ac-
ice Guideline (CPG) has been p epa ed by he Span-
ish Socie y o O al Su ge y (SECIB) wi h he in en ion
o p esen ing an e alua ion o he cu en e idence on
pa ien s wi h coagula ion diso de s and helping p o es-
sionals o heal h sciences o make clinical decisions.
Ma e ial and Me hods: Based on he indica ions o he “P epa a ion o Clinical P ac ice guidelines in he Na ional
Heal h Sys em. Me hodological manual”, we ga he ed a g oup o expe s who ag eed on 15 PICO ques ions based
on managing pa ien s wi h coagula ion diso de s in den al su gical p ocedu es, such as i ing o implan s o den al
ex ac ions.
Resul s: The 15 PICO ques ions we e answe ed based on he a ailable e idence, being limi ed in mos cases due o
he lack o a con ol g oup. Two o he PICO ques ions we e answe ed by he expe s wi h a g ade C ecommenda ion,
while he es we e answe ed wi h g ade D.
Conclusions: The esul s o his e iew highligh he need o unde ake well designed clinical ials wi h con ol
g oups and wi h a ep esen a i e sample size.
Key wo ds: O al su ge y, coagulopa hies, den al ex ac ion, den al implan , o al an icoagulan s, hepa in, wa a in,
acenocouma ol.
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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
and conc e e me hodology o he bibliog aphic sea ch
based on: a) sea ches in da abases such as MEDLINE/
PubMed, EMBASE, Coch ane Lib a y; b) he subjec
heading wi h he sea ch e ms and o he Boolean ope a-
o s (AND, OR, NOT), as well as he use o keywo ds,
Em ee and MeSH; and c) he sea ch esul s indexing
all bibliog aphic e e ences. 6) E alua ion and syn he-
sis o he e idence: He e he esul o he e alua ion o
each one o he s udies e e enced in he p e ious sec-
ion is lis ed. The analysis discussed de e mines he
quali y o he scien i ic e idence on which we will base
he ecommenda ions made and which i will subse-
quen ly be necessa y o know o de ine he “s eng h”
o he ecommenda ion. To ca y ou he analysis, we
use e i ica ion empla es o checklis s o he Sco ish
In e collegia e Guidelines Ne wo k (SIGN) a ailable on
h ps://www.sign.ac.uk/media/2038/sign50_2019.pd ,
o e alua e he andomised clinical ials (RCT), sys-
ema ic e iews and me a-analysis, coho s udies, case-
con ol s udies, s udies o diagnos ic es s and economic
e alua ions; OSTEBA da ashee s o e alua ing case
se ies and he AGREE ools o e alua ing he CPGs.
7) P epa a ion o conclusions: This inal poin includes
he ecommenda ions ha he g oup o mula es on he
ini ial PICO clinical ques ion, as well as he g ade o
his ecommenda ion. The ools ha he au ho s ha e
used o ca y ou his ecommenda ion (e alua ing he
quali y o he e idence and g ading he s eng h o he
ecommenda ion) a e called SIGN, om he Ox o d
Cen e o E idence-Based Medicine (CEBM), he
wo ha ha e been used being speci ically: he Modi-
ied SIGN o issues on diagnosis, and he SIGN o he
es o he issues ( ea men , p ognosis, ae iology, e c.).
A e ca aloguing each piece o e idence ound which
esponds o a PICO ques ion, we gi e hem a deg ee
o ecommenda ion, classi ied by he le e A, B, C
o D and whose meaning can be obse ed in Table 1.
Ma e ial and Me hods
The g oup o au ho s o his CPG has ollowed a ig-
o ous me hodological p ocess o i s p epa a ion,
based on he indica ions o he documen “P epa a-
ion o Clinical P ac ice Guidelines in he Na ional
Heal h Sys em. Me hodological manual” o he wo k-
ing g oup o upda ing he Manual o he P epa a ion
o Clinical P ac ice Guidelines in he Spanish Na ional
Heal h Sys em, and he ecommenda ions a ailable
on GuíaSalud (h ps://po al.guiasalud.es/wp-con en /
uploads/2019/01/manual_gpc_comple o.pd ). and he
ecommenda ions a ailable on GuíaSalud. Likewise,
he scien i ic bibliog aphy a ailable om Decembe
2011 o Decembe 2021 has been e iewed, ollowing
he sea ch s a egies included in he CPG (h ps://po -
al.guiasalud.es/wp-con en /uploads/2023/03/gpc_622_
ci ugia_bucal_ as o nos_coagulacion_secib_compl.
pd ). Addi ionally, o each clinical issue aised, a wo k
shee was c ea ed (own c ea ion) in which he ollow-
ing aspec s we e de ailed: 1) Clinical doub : Issue on
which he au ho s o mula e he clinical ques ion, and
which a ises om expe knowledge on he subjec ma -
e and he p o essional expe ience o each o hem. 2)
PICO ques ion: Ques ion which aises he clinical is-
sue, and which is s uc u ed so as o inco po a e he
Pa ien (o a ge popula ion o whom he in e en ion
is in ended), he In e en ion/Compa ison (in e en ion
measu ed as a compa ison o no wi h ano he ca ied
ou ) and Ou come (expec ed esul upon applying he
indica ed in e en ion). 3) In oduc ion: Con ex ualisa-
ion o he scien i ic knowledge ha exis s in ela ion
wi h he speci ic pa hology on he clinical doub aised,
accompanied by he PICO ques ion and he ecommen-
da ion. 4) Type o ques ion: Classi ica ion o he ype o
ques ion om he ollowing possibili ies: epidemiologi-
cal/e iological, diagnos ic, he apeu ic o p ognos ic. 5)
Me hodology used: This sec ion desc ibes he speci ic
G ade o ecommenda ion
ABased on a leas a me a-analysis, a sys ema ic e iew, a 1++ clinical ial, o on a olume o scien i ic e idence made up
o s udies classi ied as 1+ and o high consis ency wi h each o he .
BVolume o scien i ic e idence made up o s udies classi ied as 2++, di ec ly applicable o he a ge popula ion o he
guideline and demons a ing high consis ency wi h each o he ; o scien i ic e idence ex apola ed om s udies classi ied
as 1++ o 1+.
CVolume o scien i ic e idence made up o s udies classi ied as 2+ di ec ly applicable o he a ge popula ion o he
guideline and demons a ing high consis ency wi h each o he ; o scien i ic e idence ex apola ed om s udies clas-
si ied as 2++.
DLe el 3 o 4 scien i ic e idence o scien i ic e idence ex apola ed om s udies classi ied as 2+.
Table 1: Summa y o e idence and ecommenda ions on clinical p ac ice acco ding o GRADE (G ading o Recommenda ions, Assessmen ,
De elopmen , and E alua ions).
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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
8) Recommenda ions o u u e esea ch: In he p ocess
o p epa ing a CPG, knowledge gaps a e iden i ied o
which he au ho s may conside i necessa y o ecom-
mend u u e lines o esea ch, i hey conside hem pe -
inen o pa ien s and p o essionals. In ou case, hese
p oposals a e in ended o be as speci ic as possible so
ha hey a e use ul and unde s andable o u u e e-
sea ch p ojec s.
- De elopmen g oup o he guideline
The SECIB is a scien i ic associa ion c ea ed o o e
adequa e suppo o all p o essionals who call o an
up- o-da e scien i ic space o O al Su ge y. To ul il i s
objec i es, he Associa ion has commissioned a g oup
o expe s wi h de eloping a CPG on managing pa ien s
wi h coagula ion diso de s in den al su gical p oce-
du es, such as i ing o implan s o den al ex ac ions.
This Guideline has been c ea ed add essing di e en
cases o co e he wides ange o possible scena ios
ha o al heal h p o essionals ace wi h his ype o pa-
ien . The g oup ha has p epa ed his CPG is made up
o clinical and uni e si y expe s o he heal h sciences
depa men : specialis s in o al su ge y wi h ex ensi e
ca ee s in eaching and esea ch, specialis s in he ield
o haema ology and haemo he apy, p o essionals wi h
ex ensi e expe ience in managing pa ien s wi h coagu-
la ion diso de s in o al su gical p ocedu es, expe s in
o al su ge y, o al medicine and enowned esea che s.
This CPG has been p epa ed and e alua ed based on he
scien i ic e idence a ailable and is in ended o be use-
ul o pa ien s and p o essionals om di e en ields:
den is s, s oma ologis s, o al su geons, maxillo acial
su geons, doc o s and clinical specialis s o he heal h
sciences depa men .
- Exhaus i e sea ch o scien i ic e idence
The i s app oach o he bibliog aphy h ough he
MEDLINE/PubMed da abase con ibu ed o de ining
he scope and objec i es o he guideline. A i s p e-
limina y sea ch o he bibliog aphy was ca ied ou
be ween Sep embe and Oc obe 2021. The e e ences
we e downloaded on he Mendeley manage , and hanks
o he e iew by he panel o expe s i was possible o
de ec he impo an e e ences ha had been omi ed.
The second phase o he sea ch began in Oc obe 2021,
once he ini ial app oach had been e alua ed and i was
conside ed necessa y o ede ine bo h he sea ch c i e ia
and he scope o he guidelines hemsel es. The c i e-
ia o de eloping he ques ions in PICO o ma we e
de eloped, a ask ca ied ou om No embe 2019 o
Sep embe 2021, bu which con inued being comple ed
un il Decembe 2021 hanks o weekly ale s, o upda e
he ma e ial. The comple e ex s o hese e e ences
we e sha ed wi h he panel o expe s h ough Mende-
ley. F om he exhaus i e sea ch o he bibliog aphy, he
ques ions we e cons uc ed gene a ing lis s o speci ic
issues which could be conside ed. C i e ia o inclusion
and exclusion we e also de ined: in gene al, any e e -
ence which was no w i en in English, F ench o Span-
ish was excluded, and he publica ion da e was limi ed
o he las 10 yea s. Finally, a selec ion was ca ied ou
on he i les and abs ac s o he a icles iden i ied in
he sea ches o elimina e hose which did no ul il he
sea ch c i e ia. Wi h ega d o sou ces o in o ma ion,
MEDLINE ( h ough i s PubMed in e ace) and he
EMBASE da abase we e used. Sea ch s a egies we e
de eloped o bo h wi h he pu pose o es ic ing o
b oadening he scope: combina ion o con olled lan-
guage ocabula y ( he MeSH and Em ee hesau uses)
and e ms in ee language o ph ases which appea ed
in i les o abs ac s. The e e ences we e s o ed in a
p i a e g oup on Mendeley, h ough which he e was
access o he ull ex , wi h a display o ma king and
making anno a ions on he e e ences. The a icles we e
pas ed in o he ull ex di ec ly on he Mendeley e -
e ence manage . Using he Mendeley social module,
e iewe s we e also able o check whe he any o he
a icle had been published and add hei commen s.
Addi ionally, o each one o he e e ences, Mendeley
di ec ly loaded he associa ed ags, bu added a gene al
ag o iden i ying o which PICO ques ion o ques-
ions ha e e ence co esponded, as well as he ype o
s udy (clinical ial, sys ema ic e iew, me a-analysis,
e c.). Finally, a inal documen was p epa ed wi h all he
e e ences co esponding o each PICO ques ion o he
CPG. The sea ch s a egies we e e iewed ollowing he
documen by Sampson e al. “An e idence- based p ac-
ice guideline o he pee e iew o elec onic sea ch
s a egies” (18).
Resul s
1. In an icoagula ed pa ien s wi h a couma in d ug
(acenocouma ol o wa a in) who equi e a den al ex-
ac ion, is he e an inc eased haemo hagic isk in
compa ison wi h non-an icoagula ed pa ien s? And
wha i hey a e also aking an iagg egan medica ion?
Den al ex ac ion in an icoagula ed pa ien s wi h di-
couma inics appea s p edic able i he INR anges a e
con olled, ex ac ing a single oo h and applying local
haemos a ic measu es o con ol he haemo hage. The
isk o pos ope a i e bleeding o hese pa ien s appea s
simila o he isk o heal hy indi iduals when he INR
alue does no exceed 2.2. I we ake in o accoun o he
condi ions such as INR g ea e han 3 o se e al ex ac-
ions, he e idence a ailable is limi ed o answe ing
his ques ion, he e o e in hese cases i is ecommended
o con ac he pa ien ’s doc o o decide a ea men plan
(G ade C ecommenda ion). Wi hou doub , in his e-
iew we ha e lacked mo e s udies on acenocouma ol,
as he majo i y included pa ien s ea ed wi h wa a in
o did no speci y he i amin K an agonis medica ion
adminis e ed. The s udies designed o assess he isk o
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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
bleeding mus e y clea ly de ine aspec s such as: he
moni o ing ime o he pa ien , which we ecommend
being a leas 7 days; he main isk a iable, which we
ecommend being den al ex ac ion, as he medical con-
di ion o he pa ien may a y a di e en imes; he INR
ange ha will be es ablished o include an icoagula ed
pa ien s; he a ge popula ion (as he polymo phism o
isoenzyme CYP2C9 p e alen in he Asian popula ion
a ec s he clea ance o wa a in); as well as also egis-
e ing whe he he pa ien has p e iously been ea ed
wi h an ibio ics and concomi an ea men wi h pla ele
an iagg egan s.
2. In an icoagula ed pa ien s wi h hepa in who equi e
a den al ex ac ion, wha inc ease in haemo hagic isk
exis s in compa ison wi h non-an icoagula ed pa ien s?
And wha i hey a e also aking an iagg egan medica-
ion?
E idence on den al ex ac ions in pa ien s ea ed wi h
hepa in mos ly e e s o an icoagula ed pa ien s wi h
acenocouma ol who ha e been ea ed wi h b idge
he apy wi h hepa in o a den al ex ac ion. Publica-
ions appea o e lec an inc eased isk o bleeding in
compa ison wi h he guideline o con inue wi h he an i-
coagulan ea men . Ne e heless, i appea s ha local
haemos a ic measu es should be su icien o manag-
ing o con ain he pos -ex ac ion haemo hage in any
case (G ade D ecommenda ion). I mus be aken in o
accoun ha he e idence o hese esul s is limi ed,
and i should be expec ed ha in ligh o e iewed publi-
ca ions, his li e a u e will dec ease, as he guideline o
no eplacing he an icoagulan ea men wi h subcu a-
neous hepa in appea s o ha e mo e p edic able esul s.
3. In an icoagula ed pa ien s wi h DOACs who equi e
a den al ex ac ion, wha inc ease in haemo hagic isk
exis s in compa ison wi h non-an icoagula ed pa ien s?
And wha i hey a e also aking an iagg egan medica-
ion?
The e idence on isk o pos ope a i e bleeding a e
den al ex ac ions in pa ien s ea ed wi h DOACs ap-
pea s o demons a e an inc eased isk o bleeding in
compa ison wi h heal hy indi iduals (G ade D ecom-
menda ion). Ne e heless, he e idence o hese esul s
is limi ed and he e ogeneous. In he majo i y o he a -
icles included he e is no a signi ican ep esen a ion
o pa ien s ea ed wi h DOACs o o all ypes comme -
cialised in Spain. The majo i y o s udies a e e ospec-
i e and apply di e en p o ocols in hese pa ien s, such
as he con inua ion o he ea men , he in e up ion o
he dose on he day o su ge y o suspension up o 5
days be o e he ex ac ion. This makes con olled clini-
cal ials wi h a ep esen a i e sample size o all ypes
o DOACs and heal hy indi iduals necessa y.
4. In an icoagula ed pa ien s wi h a couma in d ug
(acenocouma ol o wa a in) who equi e i ing o den-
al implan s, is he e an inc eased haemo hagic isk
in compa ison wi h non-an icoagula ed pa ien s? And
wha i hey a e also aking an iagg egan medica ion?
The con inua ion o he an icoagulan ea men in pa-
ien s unde going simple p ocedu es in i ing implan s
does no en ail a signi ican inc ease in he isk o haem-
o hages compa ed wi h s opping o educing he ea -
men , he e o e i s suspension is no jus i ied (G ade D
ecommenda ion). Fu u e lines o esea ch should s udy
he po en ial e ec o o al an icoagulan s on he isk o
haemo hages h ough andomised clinical ials wi h
an adequa e sample size, e alua ing he e ec o his
ype o medica ion on pa ien s unde going i ing o im-
plan s o allow alid conclusions o be ob ained. These
ials should be ca ied ou wi h pa ien s unde going
only implan su ge y, as i he pa ien s a e unde going
di e en su gical echniques hese esul s a e no con-
clusi e o any o hem. Addi ionally, i should be e alu-
a ed whe he he join use o o al an icoagulan s and
an iagg egan medica ion al e s he haemo hagic isk,
o he eby be able o c ea e p o ocols which guide clini-
cal p ac ice. Likewise, i should be compa ed be ween
pa ien s who con inue hei an icoagulan ea men and
hose who s op i , o he eby be able o ob ain esul s
wi h su icien scien i ic e idence o con ibu e o guid-
ing clinical p ac ice.
5. In an icoagula ed pa ien s wi h hepa in who equi e
i ing o den al implan s, wha inc ease in haemo -
hagic isk exis s in compa ison wi h non-an icoagula -
ed pa ien s? And wha i hey a e also aking an iagg e-
gan medica ion?
T ea men wi h hepa in in pa ien s unde going simple
p ocedu es in he i ing o implan s does no en ail a
signi ican inc ease in he isk o haemo hages, he e-
o e hei con inua ion du ing his ype o su ge y is
ecommended (G ade D ecommenda ion). The subs i-
u ion o he o al an icoagulan wi h hepa in in pa ien s
unde going simple p ocedu es in he i ing o implan s
does no o e bene i s wi h ega d o he isk o haem-
o hages, he e o e his ac ion is no jus i ied. (G ade D
ecommenda ion). Fu u e lines o esea ch should s udy
he po en ial e ec o hepa in on he isk o haemo -
hages h ough andomised clinical ials, e alua ing
he e ec o his ype o medica ion on pa ien s unde -
going i ing o implan s o allow alid conclusions o be
ob ained. These ials should include a la ge sample o
pa ien s, as well as g oups whe e he e is a compa ison
be ween he con inua ion o he ea men wi h hepa-
in, s opping his ype o he apy and a con ol g oup,
o be able o analyse whe he hese si ua ions al e he
isk o haemo hages. Addi ionally, i should be e alu-
a ed whe he he join use o hepa in and an iagg egan
medica ion al e s he isk o haemo hages, o he eby
be able o c ea e p o ocols which guide clinical p ac ice.
6. In an icoagula ed pa ien s wi h a di ec -ac ing o al
an icoagulan (DOAC) who equi e i ing o den al im-

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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
plan s, is he e an inc eased haemo hagic isk in com-
pa ison wi h non-an icoagula ed pa ien s? And wha i
hey a e also aking an iagg egan medica ion?
Pa ien s being ea ed wi h di ec -ac ing o al an icoag-
ulan s may be ea ed sa ely wi h osseoin eg a ed im-
plan s. In aope a i e bleeding may be sligh ly g ea e ,
al hough pos ope a i e bleeding appea s o be simila o
ha o pa ien s who do no ake an icoagulan s (G ade
D ecommenda ion). The e is no clinical in o ma ion
o de e mining he e ec ha he addi ional admin-
is a ion o a pla ele an iagg egan may ha e on hese
pa ien s. Fu he s udies should be ca ied ou includ-
ing la ge samples, as he cu en samples only ha e a
limi ed numbe o cases. I would also be necessa y o
inc ease he me hodological quali y o he s udies, as
he e a e nume ous biases which limi he s eng h o
he ecommenda ions.
7. In pa ien s wi h he edi a y coagulopa hies who e-
qui e a den al ex ac ion, wha inc ease in haemo hagic
isk exis s in compa ison wi h heal hy indi iduals? And
wha abou in pa ien s who equi e den al implan s?
The e is no su icien in o ma ion on he inc eased
isk o in aope a i e o pos ope a i e bleeding in pa-
ien s wi h he edi a y coagulopa hies in compa ison
wi h heal hy indi iduals in den al ex ac ion o implan
ea men s. Den al ex ac ions may be ca ied ou a -
e e alua ing he se e i y o he coagulopa hy. In he
mos se ious cases, i is necessa y o gua an ee a mini-
mum ac o be o e he den al ex ac ion. Cases o hae-
mophilia wi h inhibi o an ibodies mus be conside ed
se ious and may equi e g ea e p epa a ion o he pa-
ien . The e o e, he e is no su icien da a on he ea -
men wi h den al implan s in pa ien s wi h he edi a y/
congeni al coagulopa hies, such as haemophilia o Von
Willeb and disease. Ne e heless, den al implan s may
be i ed, as he isk o bleeding appea s lowe han o
den al ex ac ions (G ade D ecommenda ion). The e-
o e, i mus be conside ed whe he i is necessa y o
ca y ou gene al anaes hesia o seda ion, a oid unk
anaes hesia echniques, ca y ou a h ee-dimensional
diagnosis wi h compu ed omog aphy, and ake mea-
su es o p e en bleeding (local haemos a ic measu es
and e alua ing sys emic measu es such as coagula ion
ac o s) be o e, du ing and a e he in e en ion (G ade
D ecommenda ion). In any case, an indi idual e alua-
ion o he case should be ca ied ou wi h he haema ol-
ogy uni o haemophilia cen e. S udies wi h a la ge
amoun o e idence should be ca ied ou , because o
da e only case se ies, isola ed clinical cases, documen s
by expe s and a clinical p ac ice guideline a e a ail-
able, and he e o e he e a e no s udies wi h g ade 2
e idence. Speci ic s udies should be ca ied ou o se-
lec la ge samples o pa ien s wi h each coagulopa hy,
especially he mos equen , such as haemophilia A and
Von Willeb and disease, in o de o p epa e p o ocols
o speci ic guidelines o each one. The me hodological
quali y o he s udies should also be inc eased, design-
ing obse a ional s udies ha may o e a minimum o
g ade 2 e idence.
8. In an icoagula ed pa ien s wi h a couma in d ug
(acenocouma ol o wa a in) who equi e a den al ex-
ac ion, wha educ ion o haemo hagic isk is p o-
duced by local haemos a ic measu es in compa ison
wi h non-an icoagula ed pa ien s? And wha i hey a e
also aking an iagg egan medica ion?
In an icoagula ed pa ien s unde going simple ex ac-
ions i is no ecommended o s op he an icoagulan
ea men , ecommending he applica ion o local hae-
mos a ic measu es (G ade C ecommenda ion). No lo-
cal haemos a ic measu e has been demons a ed as
supe io o he o he s, he e o e i is ecommended o
use hose which ha e mo e e idence, such as su u es,
collagen o cellulose sponges, as well as comp ession
wi h gauze soaked in anexamic acid (G ade C ecom-
menda ion). The appea ance o pos ope a i e haemo -
hages is associa ed wi h he age o he pa ien , he e o e
in olde pa ien s unde going simple ex ac ions he use
o local haemos a ic measu es is ecommended (G ade
C ecommenda ion). Fu u e lines o esea ch should
s udy he e ec o di e en local haemos a ic measu es
h ough andomised clinical ials e alua ing he e ec
o hese measu es on an icoagula ed pa ien s unde -
going ex ac ions o allow alid conclusions o be ob-
ained. These ials mus be ca ied ou on la ge samples
o pa ien s whe e he an icoagula ion is no s opped and
wi h INR in he ange ecommended in he main guide-
lines and p o ocols. Wi h ega d o he abo e, pa ien s
wi h an INR o be ween 2 and 4 should be included, as
i is common o ind pa ien s wi h INR le els o e 3, and
o he eby be able o e alua e whe he hese haemos a ic
measu es con inue o be e ec i e o such INR alues.
Addi ionally, he e ec i eness o hese haemos a ic
measu es should be s udied in pa ien s who combine
an icoagulan and an iagg egan ea men , o he eby
be able o c ea e p o ocols which guide clinical p ac ice
in his ype o pa ien .
9. In an icoagula ed pa ien s wi h hepa in who equi e a
den al ex ac ion, wha educ ion o haemo hagic isk
is p oduced by local haemos a ic measu es in compa i-
son wi h non-an icoagula ed pa ien s? And wha i hey
a e also aking an iagg egan medica ion?
Due o he cu en lack o e idence, u u e lines o e-
sea ch should ocus on being able o answe his PICO
ques ion h ough well designed clinical ials e alua -
ing he e ec i eness o he di e en local haemos a ic
measu es in pa ien s ea ed wi h hepa in unde going
ex ac ions. In an icoagula ed pa ien s wi h hepa in and
unde going ex ac ions, i is ecommended o ca y ou
an exhaus i e anamnesis o he pa ien o asce ain he
ime hey ha e been ea ed and o p ecisely know he
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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
hal -li e o he hepa in used. The su gical p ocedu e
should be ca ied ou a he ime o maximum dec ease
o he plasma concen a ions o he d ug, o hen con-
inue wi h he an icoagulan ea men , simul aneously
applying local haemos a ic measu es, such as comp es-
sion wi h d y gauze o p e e ably soaked in anexamic
acid, he su u e o he wound o he use o di e en
ypes o haemos a ic sponges o d essings (G ade D
ecommenda ion).
10. In an icoagula ed pa ien s wi h DOACs who equi e
a den al ex ac ion, wha educ ion o haemo hagic isk
is p oduced by he local measu es in compa ison wi h
non-an icoagula ed pa ien s? And wha i hey a e also
aking an iagg egan medica ion?
Due o he lack o quali y scien i ic e idence in he li -
e a u e on his issue, an expe opinion is p oposed. In
an icoagula ed pa ien s wi h a di ec an icoagulan d ug
and unde going ex ac ions, i is ecommended o p e-
cisely know he hal -li e o he d ug used, he den al
ex ac ion ha ing o be ca ied ou a he ime o maxi-
mum dec ease o he plasma concen a ions o he spe-
ci ic an icoagulan , delaying i s adminis a ion a leas 4
hou s a e he ex ac ion, simul aneously applying lo-
cal haemos a ic measu es such as su u es, di e en hae-
mos a ic sponges o d essings, o comp ession wi h d y
gauze o p e e ably soaked in anexamic acid (G ade
D Recommenda ion). Taking in o accoun he cu en
limi ed e idence and i s me hodology, u u e lines o
esea ch should ocus on being able o answe his PICO
ques ion h ough well designed clinical ials e alua -
ing he e ec i eness o he di e en local haemos a ic
measu es in pa ien s ea ed wi h di ec an icoagulan s
unde going ex ac ions compa ed wi h heal hy con ols
and wi h an adequa e sample size.
11. In an icoagula ed pa ien s wi h a couma in d ug
(acenocouma ol o wa a in) who equi e a den al ex-
ac ion, wha educ ion o haemo hagic isk is p o-
duced he PHARMACOLOGICAL TREATMENT
in compa ison wi h non-an icoagula ed pa ien s? And
wha i hey a e also aking an iagg egan medica ion?
Due o he lack o quali y scien i ic e idence in he li -
e a u e on his issue, an expe opinion is p oposed. In
an icoagula ed pa ien s wi h a couma in d ug and un-
de going ex ac ions he con inua ion o he o al an i-
coagulan ea men is ecommended, wi h concomi an
use o local haemos a ic measu es consis ing o su u es,
comp ession wi h d y gauze o p e e ably soaked in
anexamic acid, haemos a ic sponges o d essings,
wi hou he need o use pha macological ea men o
educe he haemo hagic isk (G ade D ecommenda-
ion). Fu u e lines o esea ch should ocus on being
able o answe his PICO ques ion h ough well de-
signed clinical ials e alua ing he e ec i eness o he
di e en pha macological ea men s aimed a p omo -
ing haemos asis in an icoagula ed pa ien s wi h couma-
in d ugs unde going ex ac ions.
12. In an icoagula ed pa ien s wi h hepa in who e-
qui e a den al ex ac ion, wha educ ion o haemo -
hagic isk is p oduced by he PHARMACOLOGICAL
TREATMENT in compa ison wi h non-an icoagula ed
pa ien s? And wha i hey a e also aking an iagg egan
medica ion?
In an icoagula ed pa ien s wi h hepa in and unde go-
ing ex ac ions i is ecommended o use local hae-
mos a ic measu es consis ing o su u es, comp ession
wi h d y gauze o p e e ably soaked in anexamic acid,
haemos a ic sponges o d essings, wi hou he need o
use pha macological ea men o educe he haemo -
hagic isk (G ade D ecommenda ion). Fu u e lines o
esea ch should ocus on being able o answe his PICO
ques ion h ough well designed clinical ials e alua -
ing he e ec i eness o he di e en pha macological
ea men s aimed a p omo ing haemos asis in pa ien s
ea ed wi h hepa in unde going ex ac ions.
14. In pa ien s wi h he edi a y coagulopa hies who e-
qui e a den al ex ac ion, wha educ ion in haemo -
hagic isk is p oduced by local haemos a ic measu es
in compa ison wi h heal hy indi iduals? And wha
abou in pa ien s who equi e den al implan s?
When making a ecommenda ion on his issue, he e
is no a icle ha has ully add essed he PICO ques-
ion ha we aise, as none ha e s udied he educ ion
o haemo hagic isk in compa ison wi h heal hy indi-
iduals. The le el o ecommenda ion o his sec ion is
he opinion o he expe s signing he guideline (G ade
D ecommenda ion). Wi h ega d o pu ely mechanical
measu es, we ha e no ound bibliog aphy whe e hey
a e applied only o he haemo hagic con ol, as oday
hey a e usually used wi h obliga o y consul a ion o
he haema ologis and combined wi h pha macological
measu es. The e a e ha dly any s udies in his g oup o
pa ien s o whom den al implan s a e i ed, he e o e
he e idence is insu icien . Among he mos impo -
an conside a ions a e: he p epa a ion o a ea men
plan a e p epa ing he clinical his o y and consul ing
he haema ologis , he ea men being ca ied ou i s
hing in he mo ning and a he s a o he week, and
unde aking he den al p ocedu es in a single session
whene e possible. Fu u e lines o esea ch should o-
cus on being able o answe his PICO ques ion h ough
well designed clinical ials e alua ing he e ec i eness
o local measu es aimed a p omo ing haemos asis in
pa ien s wi h congeni al coagulopa hies unde going ex-
ac ions.
15. In pa ien s wi h he edi a y coagulopa hies who e-
qui e a den al ex ac ion, wha educ ion in haemo -
hagic isk is p oduced by PHARMACOLOGICAL
TREATMENT in compa ison wi h heal hy indi idu-
als? And wha abou in pa ien s who equi e den al im-
plan s?
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Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
When making a ecommenda ion on his issue, no a -
icle has ully s udied he PICO ques ion ha we aise.
The e is no conclusi e e idence, and h ough he bib-
liog aphy we canno answe his ques ion. The le el o
ecommenda ion o his sec ion is he opinion o he
expe s signing he guideline (G ade D ecommenda-
ion). Based on ou clinical expe ience, he pha maco-
logical ea men mus always be ca ied ou h ough
consul a ion wi h he haema ologis . Al hough su i-
cien , he e is mo e li e a u e on an i ib inoly ic ea -
men in den al ex ac ions han in implan s. In case o
doub , he su ge y mus be ca ied ou in a hospi al
en i onmen . The au ho s o he a icles included in
his e iew highligh ha u he esea ch is necessa y
o imp o e he base o e idence in ea men o people
wi h haemophilia and Von Willeb and disease, as well
as o he a e congeni al diso de s.
Ex e nal alida ion
The me hodological suppo eam was made up o a
echnical expe on me hodology and heal hca e based
on e idence, and a lib a ian specialised in he ield o
Heal h. Addi ionally, an ex e nal me hodological sup-
po model was used (19), and o easons o e ec i e-
ness and e iciency, an ex e nal consul an was inco po-
a ed in he p epa a ion and de elopmen o p ojec s (20).
Discussion
The numbe o pa ien s ea ed wi h coagula ion diso -
de s and, mo e speci ically, wi h an icoagulan he apy
has inc eased h oughou he wo ld in ecen yea s due
o he inc ease in li e expec ancy in de eloped coun ies.
P o ocols o he ea men o his ype o pa ien s in
o al su ge ies ha e changed in ecen yea s, especially
a e he appea ance o he new di ec o al an icoagu-
lan s (DOACs). E alua ion o he isk o bleeding in his
ype o pa ien when unde going a su gical p ocedu e
con inues o be a con o e sial issue o pa ien s, den-
is s, and amily physicians.
The p o essionals who mus decide he guidelines o
he ea men o hese pa ien s, especially wi h ega d o
he con inua ion o an icoagulan /an ipla ele ea men
when hey a e going o unde go a su gical p ocedu e,
ha e doub s because he p o ocols ha e unde gone a i-
a ions o e a ela i ely sho pe iod o ime.
This guide is aimed a p o essionals in Den is y and
S oma ology, whe he hey a e gene alis s o specialis s,
who p ac ise o al su ge y in uni e si y cen es, den al
clinics, p ima y ca e cen es o hospi als, bo h in he
public and p i a e sphe es. Consul a ion o hese ecom-
menda ions, based on cu en scien i ic e idence, should
help make he apeu ic decisions ha p omo e excellence
in o al su ge y in pa ien s wi h coagula ion diso de s.
This guide in e enes in di e en a eas o he su gical
ca e p ocess in pa ien s wi h coagula ion diso de s. I
allows he use o know he ele an aspec s o conside
in pa ien s wi h coagulopa hies, as well as he a ailable
e idence o p oceed wi h hem. I also makes p o es-
sionals awa e o he impo ance o indi idualising he
cases o an icoagula ed pa ien s and he alue o in e -
consul a ions be ween heal h p o essionals.
Re e ences
1. Chahine J, Khouda y MNMN, Nas S. An icoagula ion use p io
o common den al p ocedu es: A sys ema ic e iew. Ca diol Res
P ac . 2019;2019:1-13.
2. Bale i B. Should wa a in be discon inued be o e a den al ex ac-
ion? A decision- ee analysis. O al Su g O al Med O al Pa hol O al
Radiol Endod. 2010;110:691-7.
3. Johns on S. An e idence summa y o he managemen o pa ien s
aking di ec o al an icoagulan s (DOACs) unde going den al su -
ge y. In J O al Maxillo ac Su g. 2016;47:618-30.
4. Lanau N, Ma eque J, Gine L, Zabalza M. Di ec o al an icoagu-
lan s and i s implica ions in den is y. A e iew o li e a u e. J Clin
Exp Den . 2017;9:e1346-54.
5. Hewson ID, Daly J, Halle KB, Libe ali SA, Sco CLM, Spaile
G, e al. Consensus s a emen by hospi al based den is s p o iding
den al ea men o pa ien s wi h inhe i ed bleeding diso de s. Aus
Den J. 2011;56:221-6.
6. Caliskan M, Tükel HC, Benlidayi ME, Deniz A. Is i necessa y
o al e an icoagula ion he apy o oo h ex ac ion in pa ien s
aking di ec o al an icoagulan s? Med O al Pa ol O al Ci Bucal.
2017;22:e767-73.
7. Bajkin BV, Popo ic SL, Selako ic SD. Randomized, p ospec i e
ial compa ing b idging he apy using low-molecula -weigh hepa-
in wi h main enance o o al an icoagula ion du ing ex ac ion o
ee h. J O al Maxillo ac Su g. 2009;67:990-5
8. Se ano-Sánchez V, Ripollés-de-Ramón J, Collado-Yu i a L,
Vaello-Checa I, Colmene o-Ruiz C, Helm A, e al. New ho izons in
an icoagula ion: Di ec o al an icoagulan s and hei implica ions in
o al su ge y. Med O al Pa ol O al Ci Bucal. 2017;22:e601-8
9. Se ano-Sánchez V, Ripollés-de-Ramón J, Collado-Yu i a L,
Vaello-Checa I, Colmene o-Ruiz C, Helm A, e al. New ho izons in
an icoagula ion: Di ec o al an icoagulan s and hei implica ions in
o al su ge y. Med O al Pa ol O al Ci Bucal. 2017;22:e601-8
10. Hong C, Napenas JJJJ, B ennan M, Fu ney S, Lockha P, C. H, e
al. Risk o pos ope a i e bleeding a e den al p ocedu es in pa ien s
on wa a in: A e ospec i e s udy. O al Su g O al Med O al Pa hol
O al Radiol. 2012;114:464-8.
11. Shi Q, Xu J, Zhang T, Zhang B, Liu H. Pos -ope a i e Bleeding
Risk in Den al Su ge y o Pa ien s on O al An icoagulan The a-
py: A Me a-analysis o Obse a ional S udies. F on Pha macol.
2017;8:58.
12. Febbo A, Cheng A, S ein B, Goss A, Samb ook P. Pos ope a i e
Bleeding Following Den al Ex ac ions in Pa ien s An icoagula ed
Wi h Wa a in. J O al Maxillo ac Su g. 2016;74:1518-23.
13. Kusa uka Y, Ku i a H, Saku ai S, Suzuki S, Nakanishi Y, Ka -
suyama Y, e al. E ec o single-dose ex ended- elease o al azi h o-
mycin on an icoagula ion s a us in wa a inized pa ien s. O al Su g
O al Med O al Pa hol O al Radiol. 2013;115:148-51.
14. Ka aoka T, Hoshi K, Ando T. Is he HAS-BLED sco e use ul in
p edic ing pos -ex ac ion bleeding in pa ien s aking wa a in? A
e ospec i e coho s udy. BMJ Open. 2016;2;6:e010471.
15. B ennan Y, Gu Y, Schi e M, C ow he H, Fa alo o EJ, Cu now
J. Den al ex ac ions on di ec o al an icoagulan s s. wa a in: The
DENTST s udy. Res P ac Th omb Haemos . 2020;4:278-84.
16. Dalmau Llo ca MR, Aguila Ma ín C, Ca asco-Que ol N,
He nández Rojas Z, Fo cadell D ago E, Rod íguez Cumplido D,
Cas o Blanco E, Gonçal es AQ, Fe nández-Sáez J. An icoagula ion
Con ol wi h Acenocouma ol o Wa a in in Non-Val ula A ial
Fib illa ion in P ima y Ca e (Fan as-TIC S udy). In J En i on Res
Public Heal h. 2021;18:5700.
17. Holb ook A, Schulman S, Wi DM, Vand ik PO, Fish J, Ko acs
e66
Med O al Pa ol O al Ci Bucal. 2024 Jan 1;29 (1):e58-66. O al su ge y and coagulopa hies
MJ, e al. E idence-based managemen o an icoagulan he apy:
An i h ombo ic The apy and P e en ion o Th ombosis, 9 h ed:
Ame ican College o Ches Physicians E idence-Based Clinical
P ac ice Guidelines. Ches . 2012;14:e152S-84S.
18. Sampson M, McGowan J, Cogo E, G imshaw J, Mohe D, Le e-
b e C. An e idence-based p ac ice guideline o he pee e iew o
elec onic sea ch s a egies. J Clin Epidemiol. 2009;62:944-52.
19. Ha ey G, Lo us-Hills A, Ryc o -Malone J, Ti chen A, Ki son
A, McCo mack B, e al. Ge ing e idence in o p ac ice: he ole and
unc ion o acili a ion. J Ad Nu s. 2002;37:577-88.
20. S e le CB, Leg o MW, Ryc o -Malone J, Bowman C, Cu an G,
Guihan M, e al. Role o "ex e nal acili a ion" in implemen a ion o
esea ch indings: a quali a i e e alua ion o acili a ion expe iences
in he Ve e ans Heal h Adminis a ion. Implemen Sci. 2006;1:23.
Funding
This s udy was pa ly unded by a p e-doc o al g an (on a compe i-
i e basis) om he Heal h Resea ch Ins i u e o San iago de Com-
pos ela ha was awa ded o Alba Pé ez Ja dón. This wo k has no
been inanced by any en i y.
Con lic o in e es
The au ho s ce i y ha he e is no con lic o in e es .
E hics
This wo k has no equi ed app o al by an e hics commi ee since i
is a bibliog aphic e iew, so i has no been necessa y o ob ain any
in o med consen .
Au ho s con ibu ions
Concep ualiza ion, design, me hodology bibliog aphic sea ch, da a
collec ion and analysis o he esul s: Valenzuela-Mencia, Ja ie ;
Se e a-Figallo, Ma ía Ángeles; To es-Laga es, Daniel; Machuca-
Po illo, Guille mo; Sánchez-Fe nández, Elena; Valmaseda-Cas el-
lón, Edua d; Peña ocha-Diago, Ma ía; Fe nández-Mos ei ín, Nu ia;
Somoza-Ma in, José Manuel; Pé ez-Ja dón Alba; Chamo o-Pe o-
nacci Cin ia Micaela; Ga cía-Ga cía, Abel.
Valida ion: Daniel To es-Laga es and Ga cía-Ga cía Abel.
W i ing—o iginal d a : Valenzuela-Mencía, Ja ie and Se e a-
Figallo, Ma ía-Ángeles.
W i ing— e iew: Valenzuela-Mencía, Ja ie and Daniel To es-
Laga es.
Edi ing: Daniel To es-Laga es.
All au ho s ha e ead and ag eed o he published e sion o he
manusc ip .