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Tooth extraction can be performed safely in patients on antiplatelet drugs when local hemostatic measures are taken, thereby sidestepping the heightened thrombotic risk from temporarily stopping therapy. The findings were published online July 25, 2011, ahead of print in the American Journal of Cardiology.

Investigators led by George Giannoglou, MD, of Aristotle University Medical School (Thessaloniki, Greece), prospectively studied 643 patients who underwent 903 dental extractions. Of those, 111 patients were receiving long-term antiplatelet therapy—42 aspirin alone, 36 clopidogrel alone, and 33 dual therapy—for indications such as ACS, PCI, and primary prevention. The remaining 532 patients served as controls. 

Prolonged immediate bleeding (defined as bleeding that occurs during the extraction session and requires use of hemostatic gauze for blood extending beyond the tooth socket after 30 minutes of biting on a pressure pack), occurred in two-thirds of patients on dual antiplatelet therapy, which was significantly more often than in controls (0.4%). However, among patients on antiplatelet monotherapy, bleeding was no more common than among controls (table 1).

Table 1. Prolonged Immediate Bleeding by Type of Antiplatelet Therapy

^a Compared with controls.

Not surprisingly, bleeding was more common in dual antiplatelet therapy patients compared with those receiving aspirin alone (RR 28; 95% CI 4.0-197; P < 0.001) or clopidogrel alone (RR 24; 95% CI 3.4-168.3; P < 0.001).

All cases of prolonged immediate bleeding were successfully treated with local hemostatic measures such as suturing a piece of gauze over the empty tooth socket and having the patient once again bite on a pressure pack for 30 minutes.

None of the controls and no patient on antiplatelet monotherapy developed a late hemorrhagic complication. One patient on dual antiplatelet therapy who had immediate bleeding reported bleeding after consumption of hard food on the fifth day after extraction, but bleeding stopped spontaneously within 10 minutes and therefore did not meet the criteria for significant late bleeding.

Bleeding Readily Controlled

The authors write, “Overall, although postextraction bleeding events are likely to occur under uninterrupted combined antiplatelet therapy, these are limited [to] the immediate postprocedure time frame, occurring within the safe environment of a dental clinic, and are controllable with appropriate local hemostatic treatment.”

The investigators point out that most hemorrhagic complications occurred in the setting of periodontitis and that local inflammation might predispose these patients to bleeding after extraction. “Presence of periodontitis could thus enable risk stratification of patients who are more likely to develop hemorrhage while receiving antiplatelets to ensure a higher index of suspicion and prompt appropriate hemostatic measures,” they conclude.

In a telephone interview, Neal S. Kleiman, MD, of Methodist DeBakey Heart and Vascular Center (Houston, TX), told TCTMD the study addresses an issue that “is tremendously important, and there has been some question” about how to manage patients on antiplatelet therapy who are scheduled for an invasive dental procedure.”

“This was very much needed,” agreed Joel J. Napeñas, DDS, of Carolinas Medical Center (Charlotte, NC) in a telephone interview with TCTMD. “It is a perfect follow-up to our retrospective study [Napeñas JJ, et al. J Am Dent Assoc. 2009;140:690-695] that yielded very similar findings.”

He noted he has often encountered patients at his dental clinic who are on antiplatelet therapy and who have been told by a previous dentist or other provider to discontinue the drugs for an extraction, or who have stopped taking the medication on their own initiative.

Invasiveness Overestimated

“I think other providers may overestimate the degree of invasiveness of our procedure,” Dr. Napeñas said. “But even without data like these to back it up, we routinely tell patients we would rather you not stop your medications, that we can manage extraction safely.

“I may be in a bit of a bubble in an academic medical center, but I think dentists in general practice are a little more afraid of treating patients on single or dual antiplatelet therapy. I advise them to consult with the patients’ physicians. The last thing we [dentists] want to do is unilaterally make a decision to discontinue their therapy.”

Dr. Napeñas also commended the investigators for highlighting the role of periodontitis in bleeding risk. “In my clinical experience, generally it’s patients with periodontally involved teeth who give you more problems with respect to bleeding, regardless of whether they are on antiplatelet therapy.”

“So far [the data] look pretty convincing” in favor of no interruption, Dr. Kleiman observed. However, the study included only 33 patients on dual antiplatelet therapy, which is inadequate to exclude a low risk of fatal bleeding, he cautioned. Overall, the study cannot be considered definitive, he stressed. 

Dr. Napeñas said more research may be needed “to tip the scale in favor of sound clinical practice,” suggesting that future studies should address situations excluded in the current paper, such as multiple extractions and patients with coagulopathies.

Premature to Extrapolate Results to Newer Antiplatelets

Dr. Kleiman remarked that in his practice, he pointedly tells patients on dual antiplatelet therapy, “Don’t stop [your medications] unless you talk to me directly,” warning them against using their own judgment or following the advice of a dentist or other practitioner about to perform an invasive procedure.

Also, he noted, “as with any operation [for such patients], the question has to be asked, How badly does the patient need the procedure? Can it wait a year?”

Though, in general, dual antiplatelet therapy should be maintained during procedures such as dental extraction, there are exceptions, Dr. Kleiman noted, such as being on triple therapy that includes warfarin. Moreover, it is premature to extrapolate these results to prasugrel and ticagrelor, he noted, adding that future studies will probably have to be done to determine the safety of noninterruption with these more potent antiplatelet agents.

Finally, Dr. Kleiman observed, if there is a compelling reason for a patient to undergo a dental operation and interruption of antiplatelet therapy is deemed appropriate, the drugs should be resumed within 3 to 4 days.

Study Details

Patients with immediate bleeding did not differ significantly in gender, age, and number or type of extracted teeth across treatment groups.

Wound management included removal of granulation tissue, sharp bony edges, or foreign bodies. All patients were given appropriate postoperative instructions and were advised to immediately report any hemorrhagic complication. Patients were interviewed by telephone at the end of the day of extraction, and bleeding complaints were recorded. Sutures, if placed, were removed at 6 days.

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