|Year : 2017 | Volume
| Issue : 1 | Page : 20-23
Evaluation of role of antiplatelet therapy on bleeding after dental extraction
Santosh Kumar S Mathpati1, Vasanti A Jeergal2, MP Sadananda3, Sharanpriya4, Veerbhadreshwar Kalyani5, Harshvardhan Reddy6
1 Department of Oral and Maxillofacial Surgery, AME's Dental College and Hospital, Raichur, Karnataka, India
2 Department of General Medicine, Srinivas Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India
3 Department of Oral and Maxillofacial Surgery, KGF College of Dental Sciences, KGF, Kolar, Karnataka, India
4 Department of Conservative Dentistry and Endodontics, HKDET's Dental College and Hospital, Humnabad, Dist. Bidar, Karnataka, India
5 Department of Oral and Maxillofacial Surgery, HKDET's Dental College and Hospital, Humnabad, Dist. Bidar, Karnataka, India
6 Department of Orthodontics, HKDET's Dental College and Hospital, Humnabad, Dist. Bidar, Karnataka, India
|Date of Web Publication||28-Feb-2017|
Santosh Kumar S Mathpati
Department of Oral and Maxillofacial Surgery, AME's Dental College and Hospital, Raichur, Karnataka
Source of Support: None, Conflict of Interest: None
Aims and Objectives: Antiplatelet therapy results in altered platelet function and increased bleeding time (BT). The present study was done to evaluate antiplatelet therapy on bleeding after dental extraction. Materials and Methods: In this prospective case–control study, a total of 150 patients requiring dental extraction were divided into two equal groups; Group I: with 75 patients on antiplatelet therapy and Group II: with 75 patients who have discontinued antiplatelet therapy 5 days before the dental extraction. Informed consent was obtained from the participants, and ethical approval was obtained from the Institutional Ethical Committee. Prior to extraction, BT of all the participants was recorded. Simple extraction for single-molar tooth was done in both the groups under local anesthesia. Suturing followed by pressure pack was placed after extraction. BT after extraction was statistically compared between the groups after 1 h and 24 h using Chi-square test with P < 0.05. Results: None of the patients in both the groups showed active bleeding 1 h and 24 h postoperatively. No bleeding was seen in 71 patients in Group I and 74 patients in Group II after 24 h. Conclusion: The present study showed no significant difference in BT in both the groups. Hence, single-tooth extraction can be done in patients on long-term antiplatelet therapy without discontinuation or alteration of medication.
Keywords: Antiplatelet, aspirin, bleeding, dental extraction, platelet function
|How to cite this article:|
Mathpati SS, Jeergal VA, Sadananda M P, Sharanpriya, Kalyani V, Reddy H. Evaluation of role of antiplatelet therapy on bleeding after dental extraction. J Int Oral Health 2017;9:20-3
|How to cite this URL:|
Mathpati SS, Jeergal VA, Sadananda M P, Sharanpriya, Kalyani V, Reddy H. Evaluation of role of antiplatelet therapy on bleeding after dental extraction. J Int Oral Health [serial online] 2017 [cited 2020 Aug 5];9:20-3. Available from: http://www.jioh.org/text.asp?2017/9/1/20/201092
| Introduction|| |
Antiplatelet drugs are used to interfere with platelet function, which are used in cerebrovascular and coronary artery diseases for thromboembolic disorders. Aspirin and thiopyridines (e.g., clopidogrel) are the commonly used antiplatelet drugs. Aspirin increases the bleeding time (BT) by preventing platelet aggregation by irreversibly inhibiting the cyclo-oxygenase-1 (COX-1) enzyme. Complete inhibition of COX-1 enzyme and maximal antiplatelet effect occurs with aspirin at low doses of 75 mg/day. Aspirin at low doses of 75–150 mg/day can be used for long-term prevention of heart attacks and strokes and moderate doses of 160–325 mg/day for the immediate anticlotting benefit. Aspirin dose >320 mg/day may even decrease the effectiveness as an antiplatelet agent due to the inhibition of prostacyclin production.
Many dentists and medical practitioners discontinue aspirin therapy before surgical procedure due to fear of excessive postoperative bleeding risk in patients on antiplatelet therapy. However, stoppage of this medication may increase the risk of serious thromboembolism, myocardial infarction, or cerebrovascular accident. Discontinuation of daily antiplatelet (aspirin/clopidogrel) can worsen the existing disease condition. Collet et al. found higher rate of death or myocardial infarction with discontinued antiplatelet therapy compared to others.
It has been well known that bleeding complications are common after extraction and gingival surgeries, whereas the association of bleeding episodes in patients on aspirin therapy is unclear. There is very limited information available regarding dental management of patients on antiplatelet therapy. Hence, the present study was undertaken to evaluate the role of antiplatelet therapy on bleeding after dental extraction.
| Materials and Methods|| |
One hundred and fifty patients presenting to the oral and maxillofacial surgery outpatient department, diagnosed with tooth indicated for simple dental extraction and giving a history of cardiovascular diseases, receiving 100 mg of aspirin daily were included in the study after obtaining physician consent. These 150 patients requiring dental extraction were divided into two equal groups; Group I: with 75 patients on antiplatelet therapy (test) and Group II: with 75 patients who have discontinued antiplatelet therapy (control) 5 days before the dental extraction. Information on physical fitness of all patients was obtained from the physician. Sample size was calculated according to the statistical formula: 4pq/l 2, wherep = 50, q = 100 − p, and l = 10% of p). Participants were selected for the case–control prospective study by simple random method and divided into Group I and Group II. Control group was selected from 150 participants and asked to discontinue the antiplatelet therapy 5 days prior to the procedure. Informed consent was obtained from the participants, and ethical approval was obtained from the Institutional Ethical Committee. In this single-blind study, investigators were unaware of the test or control group. The study was done from March 2013 to August 2014.
The exclusion criteria include blood pressure above 140/90 mmHg, bleeding and clotting disorders, impacted and grossly destructed tooth, Grade II or III mobile tooth, history of uncontrolled bleeding episode, and liver diseases. Prior to extraction, BT of all the participants was recorded.
Simple extraction for single-molar tooth was done in both the groups under local anesthesia. Suturing with 3-0 silk was done followed by pressure pack placement in the extraction area. All the extractions were done by a single trained investigator. Patients were discharged 1 h after extraction. After extractions, the patients were prescribed antibiotics in accordance with the American Heart Association guidelines to prevent subacute bacterial endocarditis. Bleeding was evaluated 1 h and 24 h postoperatively. All the patients were requested to contact immediately after 24 h for any uncontrolled bleeding.
Postoperative bleeding was assessed for the presence or absence of bleeding, oozing, and active bleeding. Oozing is considered when blood completely turns the pack into red but does not fill the mouth with blood. Active bleeding was considered when the socket was bleeding sufficiently to fill the mouth with blood frequently. Local hemostat was used to control any incidence of uncontrolled bleeding. Both the groups were compared statistically using SPSS statistical softwar package by IBM Corp., Armonk, NY, version 21, and Chi-square test was used to compare the variables at significance of P < 0.05.
| Results|| |
Both Groups I and II were compared for BT after extraction with respect to age and duration (months) of antiplatelet therapy [Table 1]. None of the patients in both the groups showed active bleeding at 1 h and 24 h postoperatively [Table 2] and [Table 3]. No bleeding was seen in 71 patients in Group I and 74 patients in Group II after 24 h. Oozing was seen in four patients in Group I and one subject in group II after 24 hours of dental extraction [Table 3]. There was no significant uncontrolled bleeding after dental extraction in both the groups [Table 2].
|Table 1: Intergroup comparison of age, duration of antiplatelet therapy, and bleeding time|
Click here to view
| Discussion|| |
Hemostasis primarily depends on vascular and platelet-mediated event (platelet plug formation and secondarily complex cascade of clotting factors). Any disturbance in this mechanism can results in either bleeding or thrombosis. Platelet plays a major role in the pathogenicity of thrombotic process; antiplatelet drugs are used to prevent this process in patients with cerebrovascular disorders. Antiplatelet action of aspirin is mainly due to its irreversible inhibitory action of cyclooxygenase by acetylation of enzyme's serine hydroxyl group.
Antiplatelet therapy is commonly advised in patients with acute coronary heart disease. Combinations of two antiplatelet drugs (e.g., aspirin and clopidogrel) are used in dual antiplatelet therapy for the prevention of cerebrovascular accidents and myocardial infarction in patients with acute coronary syndromes. Aspirin even at low doses of about 0.5–1 mg/kg/day tends to inhibit platelet function for the entire lifespan of the platelet which is approximately 10 days.
Discontinuation of antiplatelet therapy can result in adverse consequences of arterial thromboembolism which are much more serious, as approximately 20% of these episodes are fatal and 40% of episodes can lead to serious permanent disability.
This study was undertaken to evaluate antiplatelet therapy on bleeding after dental extraction. The present study compared patients on aspirin therapy with those who discontinued it 5 days prior to extraction. In our study, both Groups I and II were compared for BT after extraction with respect to age and duration (months) of antiplatelet therapy [Table 1].
None of the patients in both the groups showed active bleeding 1 h and 24 h postoperatively. No bleeding was seen in 71 patients in Group I and 74 patients in Group II after 24 h. Oozing was seen in four patients in Group I and one subject in group II after 24 hours of dental extraction [Table 3]. There was no significant uncontrolled bleeding after dental extraction in both the groups [Table 2]. Similar results were observed by Varghese et al. with 190 patients after single molar extraction.,,,,
Medeiros et al. found no difference in the amount of bleeding that occurred during tooth extraction between patients who continued acetylsalicylic acid (ASA) therapy versus patients who suspended their ASA therapy. Brennan et al. observed no differences in oral BT, cutaneous BT, secondary outcome measures, or compliance. Karsl et al. confirmed that dental extraction can be done without a significant risk of bleeding and without altering the anticoagulant regimen in patients receiving warfarin who have an international normalized ratio (INR) from 1 to 4. Bajkin et al. concluded that extractions can be performed safely in patients taking single or dual antiplatelet drugs without interruption of treatment using only local hemostatic measures. Sánchez-Palomino et al. concluded that in patients with dual antiplatelet therapy, dental extraction can be safely performed along with suturing with the use of tranexamic acid. In contrast to our study, Lu et al. suggested cessation of aspirin 3–5 days prior to surgical procedures.
Ringel and Mass from their questionnaire survey on dentists observed that majority of dentists perform tooth extraction in patients on aspirin therapy but not on Vitamin K antagonists. They concluded that dentists should be updated on recent recommendations.
The level of bleeding risk in patients on antiplatelet therapy depends on the nature and severity of disorder, type, localization, and extent of surgical intervention needed. Improper management can lead to hemorrhage, hematoma formation or airway obstruction, and ultimately life-threatening situation to the patient. Santoshkumar in his review article concluded that during most of the minor dental surgical procedures, bleeding can be easily controlled by local hemostatic measures and antiplatelet dual therapy need not be altered or stopped before minor oral surgical procedures.
From the present study, it can be observed that dental extractions can be done safely in patients on antiplatelet therapy without altering or modifying its dose to avoid the complications of thromboembolism, provided there should be sufficient local measures to control postoperative bleeding. Bleeding can be controlled with suturing and pressure pack for 30 min or with the use of local hemostatic agents such as tranexamic acid and epsilon-aminocaproic acid. During surgical procedure, trauma should be minimized, cauterization must be performed, if necessary, and to achieve hemostasis, granulation tissue should be removed from the inflamed area. Hematologic examination should be performed prior; INR and physician consultation must be obtained. The data of the present study can be used in health-care maintenance. It indicates safer dental extraction procedures in patients on antiplatelet therapy.
A limitation of the study includes lesser sample size and patients were on only aspirin therapy. Further research is required to evaluate the role of different antiplatelet drug therapies on bleeding during different oral surgical procedures on larger sample size.
| Conclusion|| |
The present study showed no significant difference in BT in both the groups. Hence, single-tooth extraction can be done in patients on long-term antiplatelet therapy without discontinuation or alteration of medication.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Varghese KG, Manoharan S, Sadhanandan M. Evaluation of bleeding following dental extraction in patients on long-term antiplatelet therapy: A clinical trial. Indian J Dent Res 2015;26:252-5.
Verma G. Dental extraction can be performed safely in patients on aspirin therapy: A timely reminder. ISRN Dent 2014;2014:1-11.
Collet JP, Montalescot G, Blanchet B, Tanguy ML, Golmard JL, Choussat R, et al.
Impact of prior use or recent withdrawal of oral antiplatelet agents on acute coronary syndromes. Circulation 2004;110:2361-7.
Sánchez-Palomino P, Sánchez-Cobo P, Rodriguez-Archilla A, González-Jaranay M, Moreu G, Calvo-Guirado JL, et al.
Dental extraction in patients receiving dual antiplatelet therapy. Med Oral Patol Oral Cir Bucal 2015;20:e616-20.
Krishnan B, Shenoy NA, Alexander M. Exodontia and antiplatelet therapy. J Oral Maxillofac Surg 2008;66:2063-6.
Lu SY, Tsai CY, Lin LH, Lu SN. Dental extraction without stopping single or dual antiplatelet therapy: Results of a retrospective cohort study. Int J Oral Maxillofac Surg 2016;45:1293-8.
Lillis T, Ziakas A, Koskinas K, Tsirlis A, Giannoglou G. Safety of dental extractions during uninterrupted single or dual antiplatelet treatment. Am J Cardiol 2011;108:964-7.
Darawade DA, Kumar S, Desai K, Hasan B, Mansata AV. Influence of aspirin on post-extraction bleeding – A clinical study. J Int Soc Prev Community Dent 2014;4 Suppl 1:S63-7.
Broekema FI, van Minnen B, Jansma J, Bos RR. Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants. Br J Oral Maxillofac Surg 2014;52:e15-9.
Medeiros FB, de Andrade AC, Angelis GA, Conrado VC, Timerman L, Farsky P, et al.
Bleeding evaluation during single tooth extraction in patients with coronary artery disease and acetylsalicylic acid therapy suspension: A prospective, double-blinded, and randomized study. J Oral Maxillofac Surg 2011;69:2949-55.
Brennan MT, Valerin MA, Noll JL, Napeñas JJ, Kent ML, Fox PC, et al.
Aspirin use and post-operative bleeding from dental extractions. J Dent Res 2008;87:740-4.
Karsli ED, Erdogan Ö, Esen E, Acartürk E. Comparison of the effects of warfarin and heparin on bleeding caused by dental extraction: A clinical study. J Oral Maxillofac Surg 2011;69:2500-7.
Bajkin BV, Urosevic IM, Stankov KM, Petrovic BB, Bajkin IA. Dental extractions and risk of bleeding in patients taking single and dual antiplatelet treatment. Br J Oral Maxillofac Surg 2015;53:39-43.
Lu MM, Zhuang XH, Gao YM. Correlation between platelet aggregation rates of aspirin users and intra-socket clotting after extraction of a maxillary tooth with periodontitis. Shanghai Kou Qiang Yi Xue 2014;23:328-32.
Ringel R, Maas R. Dental procedures in patients treated with antiplatelet or oral anticoagulation therapy – An anonymous survey. Gerodontology 2016;33:447-52.
Santoshkumar MP. Dental management of patients on antiplatelet therapy: Literature update. Asian J Pharm Clin Res 2016;9:26-31.
[Table 1], [Table 2], [Table 3]