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S.-Y. Lu, C.-Y. Tsai, L.-H. Lin, S.-N. Lu: Dental extraction without stopping single or
dual antiplatelet therapy: results of a retrospective cohort study. Int. J. Oral
Maxillofac. Surg. 2016; 45: 12931298. # 2016 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. The aim of this study was to investigate the incidence of bleeding after
dental extraction without stopping antiplatelet therapy. Postoperative bleeding was
assessed in a total of 1271 patients who were divided into two groups: a study group
comprising 183 patients on antiplatelet therapy (aspirin 125 patients/185 occasions;
clopidogrel 42 patients/65 occasions; dual therapy 16 patients/24 occasions) who
underwent 548 dental extractions on 274 occasions, and a control group comprising
1088 patients who were not receiving any antiplatelet or anticoagulant therapy and
underwent 2487 dental extractions on 1472 occasions. The incidence of
postoperative bleeding was higher in the study group (5/274, 1.8%) than in the
control group (10/1472, 0.7%), and also in the dual antiplatelet subgroup (1/24,
4.2%) than in the single antiplatelet subgroups (clopidogrel: 2/65, 3.1%; aspirin: 2/
185, 1.1%); however, these differences were not signicant. Postoperative bleeding
was managed successfully by repacking with Gelfoam impregnated with
tranexamic acid powder in 12 patients and by resuturing in three of the control
patients undergoing extraction of impacted teeth with ap elevation. These ndings
indicate that there is no need to interrupt antiplatelet drugs before dental extraction.
# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1294
Lu et al.
Description
Atrial brillation
American Heart Association
Coronary artery disease
Cerebrovascular accident
Cardiovascular disease
Oral anticoagulant
Myocardial infarction
Novel oral anticoagulant
1295
Table 2. Tooth extractions in the control group of patients (not taking antiplatelet or warfarin therapy) and the study group of outpatients on
continuing antiplatelet therapy.
Study group (n = 183)
Sex
Male
Female
Age, years, mean (range)
Number of tooth extractions (occasions)
Number of tooth extractions (postoperative bleeding)
Number of simple extractions
Number of complicated extractions
Mean number of teeth extracted per case
Reason for extraction (postoperative bleeding)
Periodontitis
Deep caries or residual roots
Impaction
Postoperative bleeding (number of patients/occasions)
Aspirin
Clopidogrel
Aspirin + clopidogrel
a
b
P-value
0.79
110
73
72.0 (2094)
548 (274)
548 (5)
489 (5)
59 (0)
2.0
513
575
48.9 (995)
2487 (1472)
2487 (10)
1669 (7)
818 (3)
1.7
190 (3)
350 (2)
8 (0)
5/274 (1.8%)
2/185 (1.1%)
2/65 (3.1%)
1/24 (4.2%)
576 (5)
1298 (2)
613 (3)
10/1472 (0.7%)
0.94
0.81
0.80
0.98
0.03a
0.26
0.40
0.07b
0.49
0.50
0.43
Table 3. Main indications for antiplatelet drug prescription in the study group.
Main indication
Aspirin
51
35
14
10
7
3
2
3
125
68.3%
Clopidogrel
11
22
0
1
2
2
2
2
42
23.0%
Dual
therapy
Total patients,
n (%)
14
1
1
0
0
0
0
0
16
8.7%
76
58
15
11
9
5
4
5
183
100%
(41.5%)
(31.7%)
(8.2%)
(6.0%)
(4.9%)
(2.7%)
(2.2%)
(2.7%)
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Lu et al.
Fig. 1. Numbers of teeth extracted and occasions of extraction. Postoperative bleeding was not
associated with the number of tooth extractions. (*Immediate postoperative bleeding occurred
once.).
CAD patients of 13% and an overall incidence of 4% (51 of 1236 patients).12 Collet et al. reported that nine of 475 MI
patients (1.9%) had discontinued aspirin
therapy within 15 days prior to intended
surgery.4 The present researchers have
witnessed two diabetic females who were
rescued from a stroke at 2 days after tooth
extraction because their aspirin had been
stopped for 7 days prior to their procedures. These data suggest that aspirin cessation might lead to lethal thrombosis,
particularly in patients with prior CVD
and indications for aspirin treatment. Although the risk is low, the outcome is
serious.
As early as 1987, Salzman stated that
the haemostatic defect induced by aspirin
in patients with otherwise normal haemostasis is usually minor.18 A number of
studies have shown no difference in the
incidence of bleeding after invasive oral
surgical procedures between patients receiving single and dual antiplatelet therapy.3,15 Wahl reported that of 1283 patients
on single or dual antiplatelet agents who
experienced 2308 dental extractions on
1334 occasions, no more than 35 (2.7%
of patients and 2.6% of occasions) had
bleeding complications, and only two
patients (0.2%) required more than local
measures for haemostasis.3
Park et al. reported that dental extractions were safe without stopping dual
or triple antiplatelet agents in coronary
drug-eluting stent patients; only two of
100 (2%) had postoperative bleeding,
which could be controlled easily with
the application of pressure.19 However,
the risk of stent thrombosis in drug-eluting
stents is increased in the perioperative
setting and is strongly associated with
the cessation of antiplatelet therapy. Based
on the evidence that post-extraction bleeding problems in patients on antiplatelet
therapy are not more severe than those
in patients with normal coagulation, it
appears logical to continue antiplatelet
therapy for dental surgery.
From the results of this study, it is clear
that postoperative bleeding was not a
problem following dental extraction for
patients whose single or dual antiplatelet
medications were not stopped and who
were treated under local anaesthesia on
an outpatient basis. None of the patients
with immediate bleeding required a blood
transfusion, parenteral TXA, or the administration of vitamin K, or needed to stop
antiplatelet agents. Postoperative haemostasis can be managed successfully by
repacking with Gelfoam plus TXA powder, which is safe, simple, and less troublesome than continuing TXA mouthwash
warfarin.10 This may reect poor anticoagulation control, highlighting opportunities for improved stroke prevention with
alternative strategies, such as the NOACs,
and the importance of continuous antiplatelet therapy throughout the perioperative period of dental surgery. For patients
with established CVD, especially those
taking aspirin or other antiplatelet agents
for thrombotic prophylaxis, this should be
considered a critical therapy.
The dentist today is seeing an increasing
number of patients on antiplatelet drugs to
prevent thrombosis who require dental
surgery. The ndings of the present study
suggest that there is no need to stop single
or dual antiplatelet therapy prior to dental
extraction. It is time to teach patients and
dentists, as well as physicians, that antiplatelet withdrawal preoperatively may
invite a remote but fatal risk of thromboembolism. Bleeding complications, while
inconvenient, do not carry the same risks
as thromboembolic complications. Local
haemostatic measures are sufcient to
control bleeding for those receiving continuous antiplatelet medications, and good
surgical techniques must be employed in
all oral surgical procedures.
Funding
Not required.
1297
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Address:
Shin-Yu Lu
Oral Pathology and Family Dentistry Section
Department of Dentistry
Kaohsiung Chang Gung Memorial Hospital
123 Dapi Road
Niaosong District
Kaohsiung 833
Taiwan
Tel: + 886 7 7317123x2371;
Fax: + 886 7 7317123x2243
E-mail: jasminelu@adm.cgmh.org.tw