DENTAL MANAGEMENT OF PATIENTS ON ANTIPLATELET THERAPY: LITERATURE UPDATE
Abstract
ABSTRACT
Antiplatelet drugs are used in the prevention and management of arterial and venous thrombi. These drugs are associated with an increase in bleeding
time and risk of post-operative hemorrhage. Because of this, dental surgeons recommend their patients to stop the therapy before surgical procedures
which may in turn cause fatal thromboembolic complications. This article reviews the commonly used antiplatelet drugs, dental management of
patients on these drugs when subjected to minor oral surgical procedures. The objective of this article is to review various literature, whether to
discontinue or continue antiplatelet therapy during dental surgical procedures, and current consensus and recommendations have been established.
It is concluded that antiplatelet monotherapy and even antiplatelet dual therapy can be safely continued on patients during dental surgical procedures,
and there is no need for altering or discontinuing the drugs. Post-operative bleeding can be managed by local hemostatic measures.
Keywords: Aspirin, Antiplatelet therapy, Bleeding, Thromboembolism, Dental extraction.
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REFERENCES
Becker DE. Antithrombotic drugs: Pharmacology and implications for
dental practice. Anesth Prog 2013;60(2):72-9.
Robless P, Mikhailidis DP, Stansby G. Systematic review of antiplatelet
therapy for the prevention of myocardial infarction, stroke or
vascular death in patients with peripheral vascular disease. Br J Surg
;88(6):787-800.
Lewis HD Jr, Davis JW, Archibald DG, Steinke WE, Smitherman TC,
Doherty JE rd, et al. Protective effects of aspirin against acute
myocardial infarction and death in men with unstable angina. Results
of a Veterans Administration Cooperative Study. N Engl J Med
;309(7):396-403.
Sear JW, Higham H. Issues in the perioperative management
of the elderly patient with cardiovascular disease. Drugs Aging
;19(6):429-51.
Harder S, Klinkhardt U, Alvarez JM. Avoidance of bleeding during
surgery in patients receiving anticoagulant and/or antiplatelet
therapy: Pharmacokinetic and pharmacodynamic considerations. Clin
Pharmacokinet 2004;43(14):963-81.
Bennett CL, Davidson CJ, Raisch DW, Weinberg PD, Bennett RH,
Feldman MD. Thrombotic thrombocytopenic purpura associated with
ticlopidine in the setting of coronary artery stents and stroke prevention.
Arch Intern Med 1999;159(21):2524-8.
Weber R, Weimar C, Diener HC. Antiplatelet agents in stroke
prevention: Acute and long-term treatment strategies. Hamostaseologie
;29(4):326-33.
De Schryver E, Algra A, Van Gijn J, Weinberg PD, Bennett RH,.
Dipyridamole for preventing stroke and other vascular vents in patients
with vascular disease. Stroke 2008;39:1397.
Payne DA, Hayes PD, Jones CI, Belham P, Naylor AR, Goodall AH.
Combined therapy with clopidogrel and aspirin significantly increases
the bleeding time through a synergistic antiplatelet action. J Vasc Surg
;35(6):1204-9.
Randall C. Surgical Management of the Primary Care Dental Patient
on Antiplatelet Medication. Available from: http://www.ukmi.nhs.uk/
activities/specialistServices/.
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(4):498-501.
McGaul T. Postoperative bleeding caused by aspirin. J Dent
;6(3):207-9.
Daniel NG, Goulet J, Bergeron M, Paquin R, Landry PE. Antiplatelet
drugs: Is there a surgical risk? J Can Dent Assoc 2002;68(11):683-7.
Conti CR. Aspirin and elective surgical procedures. Clin Cardiol
;15(10):709-10.
Speechley JA, Rugman FP. Some problems with anticoagulants in
dental surgery. Dent Update 1992;19(5):204-6.
Scher KS. Unplanned reoperation for bleeding. Am Surg
;62(1):52-5.
Scully C, Wolff A. Oral surgery in patients on anticoagulant therapy.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94(1):57-64.
Little JW, Miller CS, Henry RG, McIntosh BA. Antithrombotic agents:
Implications in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2002;93(5):544-51.
Burger W, Chemnitius JM, Kneissl GD, Rücker G. Low-dose
aspirin for secondary cardiovascular prevention - cardiovascular
risks after its perioperative withdrawal versus bleeding risks
with its continuation - Review and meta-analysis. J Intern Med
;257(5):399-414.
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.
Elad S, Chackartchi T, Shapira L, Findler M. A critically severe gingival
bleeding following non-surgical periodontal treatment in patients
medicated with anti-platelet. J Clin Periodontol 2008;35(4):342-5.
Schrodi J, Recio L, Fiorellini J, Howell H, Goodson M, Karimbux N.
The effect of aspirin on the periodontal parameter bleeding on probing.
J Periodontol 2002;73(8):871-6.
Foulke CN. Gingival hemorrhage related to aspirin ingestion. A case
report. J Periodontol 1976;47(6):355-7.
Bashein G, Nessly ML, Rice AL, Counts RB, Misbach GA. Preoperative
aspirin therapy and reoperation for bleeding after coronary artery
bypass surgery. Arch Intern Med 1991;151(1):89-93.
Ferraris VA, Ferraris SP, Lough FC, Berry WR. Preoperative aspirin
ingestion increases operative blood loss after coronary artery bypass
grafting. Ann Thorac Surg 1988;45(1):71-4.
Toyoda K, Yasaka M, Iwade K, Nagata K, Koretsune Y, Sakamoto T,
et al. Dual antithrombotic therapy increases severe bleeding events
in patients with stroke and cardiovascular disease: A prospective,
multicenter, observational study. Stroke 2008;39(6):1740-5.
Dogne JM, de Leval X, Benoit P, Delarge J, Masereel B, David JL. Recent
advances in antiplatelet agents. Curr Med Chem 2002;9(5):577-89.
Lordkipanidzé M, Diodati JG, Pharand C. Possibility of a rebound
phenomenon following antiplatelet therapy withdrawal: A look
at the clinical and pharmacological evidence. Pharmacol Ther
;123(2):178-86.
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(3):456-9.
Chassot PG, Delabays A, Spahn DR. Perioperative antiplatelet therapy:
The case for continuing therapy in patients at risk of myocardial
infarction. Br J Anaesth 2007;99(3):316-28.
Anderson CS, Jamrozik KD, Broadhurst RJ, Stewart-Wynne EG.
Predicting survival for 1 year among different subtypes of stroke: Results
from the Perth community stroke study. Stroke 1994;25(10):1935-44.
Sibon I, Orgogozo JM. Antiplatelet drug discontinuation is a risk factor
for ischemic stroke. Neurology 2004;62(7):1187-9.
Kovich O, Otley CC. Thrombotic complications related to
discontinuation of warfarin and aspirin therapy peri-operatively for
cutaneous operation. J Am Acad Dermatol 2003;48(2):233-7.
McFadden EP, Stabile E, Regar E, Cheneau E, Ong AT, Kinnaird T, et al.
Late thrombosis in drug-eluting coronary stents after discontinuation of
antiplatelet therapy. Lancet 2004;364(9444):1519-21.
Maulaz AB, Bezerra DC, Michel P, Bogousslavsky J. Effect of
discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch
Neurol 2005;62(8):1217-20.
Vaclavik J, Taborsky M. Antiplatelet therapy in perioperative period.
Eur J Intern Med 2011;22:26-32.
Wahl MJ, Howell J. Altering anticoagulation therapy: A survey of
physicians. J Am Dent Assoc 1996;127(5):625-6.
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(22):2667-74.
Collet JP, Himbet F, Steg PG. Myocardial infarction after aspirin
cessation in stable coronary artery disease patients. Int J Cardiol
;76(2-3):257-8.
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
;110(16):2361-7.
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(1):39-43.
Verma G, Tiwari AK, Chopra S. Aspirin and exodontia: A comparative
study of bleeding complications with aspirin therapy. Int J Dent Sci Res
;1:50-3.
Olmos-Carrasco O, Pastor-Ramos V, Espinilla-Blanco R, Ortiz-Zárate A,
GarcÃa-Avila I, RodrÃguez-Alonso E, et al. Hemorrhagic complications
of dental extractions in 181 patients undergoing double antiplatelet
therapy. J Oral Maxillofac Surg 2015;73(2):203-10.
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
;115(6):813-8.
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ;
American College of Chest Physicians Antithrombotic Therapy and
Prevention of Thrombosis Panel. Executive summary: Antithrombotic
therapy and prevention of thrombosis, 9
th
ed. American College of
Asian J Pharm Clin Res, Vol 9, Issue 3, 2016, 26-31
Kumar
Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest
;141 2 Suppl:7S-47.
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(1):99-106.
Hanken H, Tieck F, Kluwe L, Smeets R, Heiland M, Precht C, et al.
Lack of evidence for increased postoperative bleeding risk for dental
osteotomy with continued aspirin therapy. Oral Surg Oral Med Oral
Pathol Oral Radiol 2015;119(1):17-9.
Nooh N. The effect of aspirin on bleeding after extraction of teeth.
Saudi Dent J 2009;21(2):57-61.
van Diermen DE, van der Waal I, Hoogstraten J. Management
recommendations for invasive dental treatment in patients using oral
antithrombotic medication, including novel oral anticoagulants. Oral
Surg Oral Med Oral Pathol Oral Radiol 2013;116(6):709-16.
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(3):e15-9.
Bajkin BV, Bajkin IA, Petrovic BB. The effects of combined oral
anticoagulant-aspirin therapy in patients undergoing tooth extractions:
A prospective study. J Am Dent Assoc 2012;143(7):771-6.
Morimoto Y, Niwa H, Minematsu K. Risk factors affecting
postoperative hemorrhage after tooth extraction in patients receiving
oral antithrombotic therapy. J Oral Maxillofac Surg 2011;69(6):1550-6.
Napeñas JJ, Oost FC, DeGroot A, Loven B, Hong CH, Brennan MT,
et al. Review of postoperative bleeding risk in dental patients on
antiplatelet therapy. Oral Surg Oral Med Oral Pathol Oral Radiol
;115(4):491-9.
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(8):740-4.
Brennan MT, Wynn RL, Miller CS. Aspirin and bleeding in dentistry:
An update and recommendations. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2007;104(3):316-23.
Krishnan B, Shenoy NA, Alexander M. Exodontia and antiplatelet
therapy. J Oral Maxillofac Surg 2008;66(10):2063-6.
Partridge CG, Campbell JH, Alvarado F. The effect of platelet-altering
medications on bleeding from minor oral surgery procedures. J Oral
Maxillofac Surg 2008;66(1):93-7.
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(9):1262-5.
Brennan MT, Shariff G, Kent ML, Fox PC, Lockhart PB. Relationship
between bleeding time test and postextraction bleeding in a healthy
control population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
;94(4):439-43.
Ferraris VA, Swanson E. Aspirin usage and perioperative blood loss
in patients undergoing unexpected operations. Surg Gynecol Obstet
;156(4):439-42.
Rajah SM, Salter MC, Donaldson DR, Subba Rao R, Boyle RM,
Partridge JB, et al. Acetylsalicylic acid and dipyridamole improve
the early patency of aorta-coronary bypass grafts. A double-blind,
placebo-controlled, randomized trial. J Thorac Cardiovasc Surg
;90(3):373-7.
Zhao B, Wang P, Dong Y, Zhu Y, Zhao H. Should aspirin be stopped
before tooth extraction? A meta-analysis. Oral Surg Oral Med Oral
Pathol Oral Radiol 2015;119(5):522-30.
Napenas JJ, Hong CH, Brennan MT, Furney SL, Fox PC, Lockhart PB.
The frequency of bleeding complications after invasive dental treatment
in patients receiving single and dual antiplatelet therapy. J Am Dent
Assoc 2009;140(6):690-9.
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(7):964-7.
Gaspar R, Ardekian L, Brenner B, Peled M, Laufer D. Ambulatory
oral procedures in patients on low-dose aspirin. Harefuah
;136(2):108-10, 175.
Sonksen JR, Kong KL, Holder R. Magnitude and time course of
impaired primary haemostasis after stopping chronic low and medium
dose aspirin in healthy volunteers. Br J Anaesth 1999;82(3):360-5.
Blinder D, Manor Y, Martinowitz U, Taicher S, Hashomer T. Dental
extractions in patients maintained on continued oral anticoagulant:
Comparison of local hemostatic modalities. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod 1999;88(2):137-40.
Ardekian L, Gaspar R, Peled M, Brener B, Laufer D. Does low-dose
aspirin therapy complicate oral surgical procedures? J Am Dent Assoc
;131(3):331-5.
Smout J, Stansby G. Current practice in the use of antiplatelet agents
in the peri-operative period by UK vascular surgeons. Ann R Coll Surg
Engl 2003;85(2):97-101.
Cañigral A, Silvestre FJ, Cañigral G, Alós M, Garcia-Herraiz A,
Plaza A. Evaluation of bleeding risk and measurement methods in
dental patients. Med Oral Patol Oral Cir Bucal 2010;15(6):e863-8.
Park MW, Her SH, Kwon JB, Lee JB, Choi MS, Cho JS, et al. Safety
of dental extractions in coronary drug-eluting stenting patients without
stopping multiple antiplatelet agents. Clin Cardiol 2012;35(4):225-30.
Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation
Acute Coronary Syndromes of European Society of Cardiology,
Bassand JP, Hamm CW, Ardissino D, Boersma E, Budaj A, et al.
Guidelines for the diagnosis and treatment of non-ST-segment elevation
acute coronary syndromes. Eur Heart J 2007;28(13):1598-660.
Morimoto Y, Niwa H, Minematsu K. Hemostatic management for
periodontal treatments in patients on oral antithrombotic therapy: A
retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
;108(6):889-96.
Duygu G, Ozcakir-Tomruk C, Guler N, Sencift K. Assessment of effects
of antiplatelet drugs on bleeding risk after teeth extractions. Biotechnol
Biotechnol Equip 2010;24:2040-3.
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(12):2949-55.
Eichhorn W, Burkert J, Vorwig O, Blessmann M, Cachovan G, Zeuch J,
et al. Bleeding incidence after oral surgery with continued oral
anticoagulation. Clin Oral Investig 2012;16(5):1371-6.
Sahebally SM, Healy D, Coffey JC, Walsh SR. Should patients taking
aspirin for secondary prevention continue or discontinue the medication
prior to elective, abdominal surgery? Best evidence topic (BET). Int J
Surg 2014;12(5):16-21.
Wahl MJ. Dental surgery and antiplatelet agents: Bleed or die. Am J
Med 2014;127(4):260-7.
Thomas S, Katbab H, abu Fanas SH. Do preoperative cutaneous
bleeding time tests predict the outcome of intraoral surgical bleeding?
Int Dent J 2010;60(4):305-10.
Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management
considerations for the patient with an acquired coagulopathy. Part 1:
Coagulopathies from systemic disease. Br Dent J 2003;195(8):439-45.
Borea G, Montebugnoli L, Capuzzi P, Magelli C. Tranexamic acid as
a mouthwash in anticoagulant-treated patients undergoing oral surgery.
An alternative method to discontinuing anticoagulant therapy. Oral
Surg Oral Med Oral Pathol 1993;75(1):29-31.
Sindet-Pedersen S, Ramström G, Bernvil S, Blombäck M. Hemostatic
effect of tranexamic acid mouthwash in anticoagulant-treated patients
undergoing oral surgery. N Engl J Med 1989;320(13):840-3.
Pototski M, Amenábar JM. Dental management of patients receiving
anticoagulation or antiplatelet treatment. J Oral Sci 2007;49(4):253-8.
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