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Table of Contents   
ORIGINAL RESEARCH  
Year : 2015  |  Volume : 26  |  Issue : 3  |  Page : 252-255
Evaluation of bleeding following dental extraction in patients on long-term antiplatelet therapy: A clinical trial


1 Department of Oral and Maxillofacial Surgery, Government Dental College, Kottayam, India
2 Department of Maxillofacial Surgery, Meditrina Hospital, Ayathil, Kollam, Kerala, India

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Date of Submission05-Dec-2014
Date of Decision29-Dec-2014
Date of Acceptance14-Feb-2015
Date of Web Publication14-Aug-2015
 

   Abstract 

Objective: The aim of this trial was to evaluate the bleeding after dental extractions among patients on uninterrupted antiplatelet therapy. Materials and Methods: A total of 190 patients under oral antiplatelet drugs requiring extraction of a single molar tooth were randomly assigned to two groups. Group A consisted of 95 patients on uninterrupted antiplatelet therapy and Group B consisted of 95 patients who have discontinued antiplatelet medication 5 days prior to extraction. The bleeding time of all patients was checked prior to extraction. The surgical procedure involved simple extraction of a single molar tooth under local anesthesia. The extraction socket was sutured with 3–0 silk. Pressure pack with gauze was given for 1 h. Bleeding after 1 h, 24 h, 48 h, and 5 days were compared between two groups. Chi-square test was used to compare the variables. P < 0.05 was taken as significant. Results: None of the patients in either group had any significant uncontrollable bleeding after extraction. Conclusion: Hence, we recommend routine single tooth extractions in patients on long-term antiplatelet medication, without interruption or alteration of their medication. Such patients do not have an increased risk of prolonged or excessive postoperative bleeding.

Keywords: Antiplatelets, aspirin, clopidogrel, dental extraction, hemostasis, postextraction bleeding

How to cite this article:
Varghese K G, 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

How to cite this URL:
Varghese K G, Manoharan S, Sadhanandan M. Evaluation of bleeding following dental extraction in patients on long-term antiplatelet therapy: A clinical trial. Indian J Dent Res [serial online] 2015 [cited 2020 Feb 27];26:252-5. Available from: http://www.ijdr.in/text.asp?2015/26/3/252/162893
Antiplatelet drugs are those drugs that interfere with platelet function. They are used in thromboembolic disorders such as coronary artery diseases and cerebrovascular diseases. Commonly used oral antiplatelet drugs include aspirin and thienopyridines (e.g., clopidogrel).

Aspirin irreversibly inhibits the enzyme cyclo-oxygenase-1 (COX-1) that produces thromboxane A2, thus preventing platelet aggregation and consequently increasing the bleeding time. When aspirin is given in low doses (75 mg/day), the complete inhibition of the COX-1 enzyme and hence maximal antiplatelet effect may take several days. At a dose of 160–325 mg/day, the maximal antiplatelet effect of aspirin occurs within 30 min. Thus, aspirin at low doses (75–150 mg/day) is used for the long-term prevention of heart attacks and strokes, whereas moderate doses (160–325 mg/day) of aspirin are given in situations where an immediate anti-clotting effects are needed (such as in the treatment of acute heart attacks and unstable angina).

Clopidogrel is a prodrug that alters adenosine diphosphate receptors on platelets and inhibits platelet aggregation. Like aspirin, the onset of action of clopidogrel is dose-related. Maximal antiplatelet effect occurs several days after initiation of clopidogrel (75 mg/day).

Optimal dental management in patients on long-term antiplatelet treatment is not clearly defined. Bleeding complications from extractions and gingival surgery have been documented in earlier case reports of patients on aspirin.[1][2][3] The fear of excessive bleeding often prompts the surgeon to stop long-term, low-dose antiplatelet therapy before any surgical procedure. This obviously put the patient at risk of an adverse thromboembolic event.[4],[5] This protocol also increases the number of visits for extraction especially in cases of multiple extractions.

The aim of this trial was to evaluate the bleeding after dental extractions among patients on uninterrupted antiplatelet therapy.


   Materials and Methods Top


A total of 190 patients under oral antiplatelet drugs requiring extraction of a single molar tooth were selected for the trial, after getting fitness for extraction from the concerned physician. The participants were randomly assigned to two groups based on computer-generated randomization list. Group A consisted of 95 patients on uninterrupted antiplatelet therapy and Group B consisted of 95 patients who have discontinued antiplatelet medication 5 days prior to extraction. The sample size was calculated using the software OpenEpi, version 2 (AG Dean, KM Sullivan, MM Soe), open source calculator.

Those patients with any of the following conditions were excluded: Liver disease, blood pressure >140/90 mmHg, bleeding or clotting disorders, history of prolonged bleeding episodes, impacted tooth, Grade II/III mobile tooth, uncontrolled systemic diseases. The bleeding time of all patients was checked prior to extraction. The surgical procedure involved simple extraction of a single molar tooth that is indicated for extraction under local anesthesia (2% lignocaine with 1:80,000 adrenaline). All extractions were done by the same surgeon. None of the patients required open method. The extraction socket was sutured with 3–0 silk. Pressure pack with gauze was given for 1 h. The patient was asked to bite the pack firmly and not to spit during this period.

Assessment of variables

After 1 h, the pack was removed, and the socket was examined by a surgeon who was not informed whether the patient has discontinued antiplatelet drug or not. A clean, dry wound was recorded as "no bleeding." Wound with mild oozing of blood that completely turns the pack into red but does not fill the mouth with blood was recorded as "oozing." When the socket was bleeding sufficiently to fill the mouth with blood frequently, it was recorded as "active bleeding." Any incidence of bleeding was controlled by local hemostatic measures as required. Patients were discharged after achieving hemostasis. Amoxicillin 500 mg TID for 5 days and tramadol 50 mg BD for 3 days were prescribed for all patients. They were contacted by telephone after 24 h and 48 h to enquire about any occurrence of bleeding and were recalled after 5 days for evaluation and suture removal. Data were analyzed using SPSS version 21 (SPSS Statistics software package is produced by SPSS Inc., it was acquired by IBM corporation in 2009). Chi-square test was used to compare the variables. P < 0.05 was taken as significant.


   Results Top


Group A was comprised of 65 males and 30 females, and Group B was comprised of 54 males and 41 females. The two groups of the study were comparable with respect to age, duration of antiplatelet therapy and bleeding time. The data are shown in [Table 1].
Table 1: Comparison of age, duration of antiplatelet therapy, and bleeding time between two groups


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In Group A, 57 patients were on aspirin (75–150 mg), 7 patients were on clopidogrel 75 mg, and 31 patients were on combination of clopidogrel and aspirin (75/150 mg). In Group B, 27 patients were on aspirin (75–150 mg), 14 patients were on clopidogrel 75 mg, and 54 patients were on combination of clopidogrel and aspirin (75/150 mg).

Evaluation of bleeding status

None of the patients in either group had any significant uncontrollable bleeding after extraction. 11 patients (11.57%) in Group A had oozing 1 h after extraction, six receiving aspirin (6.31%) and 5 patients (5.26%) receiving dual therapy. All patients were managed by pressure application. In Group B, 8 patients (8.42%) had oozing after 1 h, 2 patients receiving aspirin (2.10%), 2 patients on clopidogrel (2.10%) and 4 patients on dual therapy (4.21%).

Only six patients (6.3%) in Group A and two patients (2.10%) in Group B had oozing after 24 h, which were also controlled by pressure and required no expert intervention. None of the patients had any signs of bleeding after 48 h. There were no significant findings on the 5th day of evaluation. The data are shown in [Table 2] [Table 3] [Table 4].
Table 2: Bleeding status after 1 h


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Table 3: Bleeding status after 24 h


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Table 4: Comparison of bleeding in relation to the type of drug


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The differences in the bleeding status between the two groups after 1 h as well as after 24 h were not significant statistically (P > 0.05).


   Discussion Top


Patients with acute coronary syndrome who discontinued daily aspirin have worse short-term outcomes than individuals not previously on aspirin therapy.[6][7][8][9] In a prospective evaluation of 1358 patients admitted for suspected acute coronary syndrome, Collet et al. found that those patients who recently discontinued antiplatelet drugs had higher 30-day rates of death or myocardial infarction compared to others.[10]

Bleeding complications from extractions and gingival surgery have been documented in earlier case reports of patients on aspirin.[1][2][3] However, it is unclear if these bleeding episodes were associated directly with aspirin use or other factors.

A large meta-analysis[11] involving 50,279 patients taking aspirin for secondary prevention showed that their risk of developing major cardiovascular events after aspirin withdrawal was 3 times higher than in those who continued aspirin therapy. The average time from aspirin withdrawal to a thrombotic cardiovascular event was 10.7 days. The analysis indicates that aspirin withdrawal had clear prognostically adverse consequences for patients with ischemic heart disease.

In the present study, bleeding after extraction was compared in two groups that are comparable with respect to age, duration of antiplatelet therapy, and bleeding time. Bleeding time has been commonly suggested as a reasonable measure of bleeding risk for patients who take aspirin, and this test can often reveal increased bleeding time results in patients who take aspirin.[12],[13]

Only those cases requiring a single molar tooth extraction were included in the present trial which further adds to the uniformity of the two groups. Assessment of bleeding was done by a surgeon who was blinded from the antiplatelet status of the patient. This reduces the bias in the evaluation.

None of the patients in either group had any uncontrollable bleeding after extraction. Recent clinical trials have demonstrated similar results after minor oral surgical procedures.[9],[14],[15] Girotra et al., in their analysis of 546 patients on antiplatelet drugs found a prolonged bleeding incidence in those patients on dual drugs (aspirin and clopidogrel) and recommended higher hemostatic measures.[16] But in our trial, the incidence of bleeding after single molar tooth extraction in patients taking combination of aspirin and clopidogrel was not significant.

In a randomized controlled trial of 63 patients with coronary artery disease, no difference was found in the amount of bleeding that occurred during tooth extraction between patients who continued antiplatelet therapy versus patients who suspended their antiplatelets.[17]

Hence, we recommend routine dental extractions especially single tooth extractions in patients on long-term antiplatelet medication, without interruption or alteration of their medication. Such patients do not have an increased risk of prolonged or excessive postoperative bleeding.


   Conclusion Top


Antiplatelet therapy is a widely used medication to control thrombotic events. This study demonstrated that extraction of single molar tooth in patients under long-term oral antiplatelet therapy did not cause significant bleeding postoperatively. All postoperative bleeding was controlled by suturing and pressure packing alone. There was no difference in the risk of bleeding that occurred during tooth extraction between patients who continued antiplatelet therapy versus patients who suspended their antiplatelet therapy.







 
   References Top

1.
Lemkin SR, Billesdon JE, Davee JS, Leake DL, Kattlove HE. Aspirin-induced oral bleeding: Correction with platelet transfusion. A reminder. Oral Surg Oral Med Oral Pathol 1974;37:498-501.  Back to cited text no. 1
    
2.
McGaul T. Postoperative bleeding caused by aspirin. J Dent 1978;6:207-9.  Back to cited text no. 2
    
3.
Thomason JM, Seymour RA, Murphy P, Brigham KM, Jones P. Aspirin-induced post-gingivectomy haemorrhage: A timely reminder. J Clin Periodontol 1997;24:136-8.  Back to cited text no. 3
    
4.
Oake N, Jennings A, Forster AJ, Fergusson D, Doucette S, van Walraven C. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: A systematic review and meta-analysis. CMAJ 2008;179:235-44.  Back to cited text no. 4
    
5.
Grines CL, Bonow RO, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, et al.Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: A science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007;115:813-8.  Back to cited text no. 5
    
6.
Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: A special risk for late stent thrombosis. J Am Coll Cardiol 2005;45:456-9.  Back to cited text no. 6
    
7.
Aspirin: Quitting cold turkey could be dangerous. Studies have linked aspirin withdrawal to heart attacks. Harv Health Lett 2005;30:6.  Back to cited text no. 7
    
8.
Fischer LM, Schlienger RG, Matter CM, Jick H, Meier CR. Discontinuation of nonsteroidal anti-inflammatory drug therapy and risk of acute myocardial infarction. Arch Intern Med 2004;164:2472-6.  Back to cited text no. 8
    
9.
Valerin MA, Brennan MT, Noll JL, Napeñas JJ, Kent ML, Fox PC, et al. Relationship between aspirin use and postoperative bleeding from dental extractions in a healthy population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:326.  Back to cited text no. 9
    
10.
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.  Back to cited text no. 10
    
11.
Biondi-Zoccai GG, Lotrionte M, Agostoni P, Abbate A, Fusaro M, Burzotta F, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J 2006;27:2667-74.  Back to cited text no. 11
    
12.
Scully C, Wolff A. Oral surgery in patients on anticoagulant therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:57-64.  Back to cited text no. 12
    
13.
Little JW, Miller CS, Henry RG, McIntosh BA. Antithrombotic agents: Implications in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:544-51.  Back to cited text no. 13
    
14.
Ardekian L, Gaspar R, Peled M, Brener B, Laufer D. Does low-dose aspirin therapy complicate oral surgical procedures? J Am Dent Assoc 2000;131:331-5.  Back to cited text no. 14
    
15.
Madan GA, Madan SG, Madan G, Madan AD. Minor oral surgery without stopping daily low-dose aspirin therapy: A study of 51 patients. J Oral Maxillofac Surg 2005;63:1262-5.  Back to cited text no. 15
    
16.
Girotra C, Padhye M, Mandlik G, Dabir A, Gite M, Dhonnar R, et al.Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: A prospective study. Int J Oral Maxillofac Surg 2014;43:99-106.  Back to cited text no. 16
    
17.
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.  Back to cited text no. 17
    

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Correspondence Address:
Sudheesh Manoharan
Department of Maxillofacial Surgery, Meditrina Hospital, Ayathil, Kollam, Kerala
India
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Source of Support: State Board of Medical Research, Kerala, Conflict of Interest: None


DOI: 10.4103/0970-9290.162893

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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