Optimal dental management in patients on long-term antiplatelet treatment is not clearly defined. Antiplatelet discontinuation increases the risk of thrombotic complications, whereas uninterrupted antiplatelet therapy, which is the currently recommended approach, is assumed to increase the bleeding hazard after dental procedures. We sought to prospectively compare the risk of immediate and late postextraction bleeding in patients receiving uninterrupted single or dual antiplatelet therapy. We recruited 643 consecutive patients referred for dental extractions. In total 111 (17.3%) were on clinically indicated antiplatelet therapy: aspirin (n = 42), clopidogrel (n = 36), and aspirin and clopidogrel (n = 33). Controls (n = 532, 82.7%) were not on antiplatelet treatment. Immediate and late bleeding complications were recorded. Compared to controls the risk of prolonged immediate bleeding was higher in patients on dual antiplatelet therapy (relative risk [RR] 177.3, 95% confidence interval [CI] 43.5 to 722, p <0.001) but not in patients on aspirin alone (RR = 6.3, 95% CI 0.6 to 68.4, p = 0.2) or clopidogrel alone (RR = 7.4, 95% CI 0.7 to 79.5, p = 0.18); however, all immediate bleeding complications in all treatment groups were successfully managed with local hemostatic measures. No patient developed any late hemorrhage. In conclusion, dental extractions may be safely performed in patients receiving single or dual antiplatelet therapy when appropriate local hemostatic measures are taken, thus averting thrombotic risk of temporary antiplatelet discontinuation.
The purpose of this study was to prospectively assess the risk of immediate and late-onset bleeding complications during uninterrupted single or dual antiplatelet therapy in patients undergoing dental extractions.
Methods
The study was conducted from October 2009 through April 2010 at the Aristotle University Dental School, Thessaloniki, Greece. All consecutive patients referred for dental extractions were prospectively screened for study participation. We excluded patients with hematologic, renal, or liver disease; bone marrow disorders; alcoholism; or any concurrent medication affecting hemostasis such as oral or parenteric anticoagulants or anti-inflammatory drugs. Patients who needed extractions of deciduous teeth, surgical extractions, extractions in deferent quadrants, or multiple extractions (>3 teeth) were excluded based on previous studies assessing the bleeding risk of multiple extractions in orally anticoagulated patients. Based on their medications, study participants were categorized as a treatment group receiving uninterrupted aspirin and/or clopidogrel and a control group receiving no antiplatelets. The study protocol was approved by the institutional ethical committee, and all study participants provided informed consent.
All patients were treated in morning sessions. Maxillary and anterior mandibular teeth were extracted under local anesthetic infiltration in the buccal and palatal or lingual aspect of the teeth. Posterior mandibular teeth were extracted under a combination of inferior alveolar nerve block anesthesia and anesthesia infiltration buccally and lingually. Each extraction site was infiltrated with lidocaine solution 2% 1.8 ml with epinephrine 1:80,000 to ensure similar local hemostatic effects of epinephrine.
Wound management included removal of granulation tissue, sharp bony edges, or foreign bodies. After extractions patients were instructed to bite on a pressure pack for 30 minutes. If bleeding was still present, it was by our definition considered prolonged postextraction bleeding. In these cases, a piece of oxidized cellulose gauze (Surgicel; Ethicon Inc, Somerville, New Jersy) was sutured over the inlet of the postextraction socket (3-0 silk sutures); patients then bit on a pressure pack for 30 minutes for a second time and were evaluated before leaving the clinic. 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 complaints of bleeding were recorded. Sutures, if placed, were removed at 6 days.
Postextraction bleeding complications were categorized according to time of occurrence as immediate, occurring during the extraction session at the clinic, or late, occurring any time thereafter. Prolonged immediate bleeding was defined by the need to use hemostatic gauze when blood extended beyond the tooth socket after 30 minutes of biting on a pressure pack. Late bleeding complications were defined as clinically significant when they extended beyond 12 hours, made the patient call or return to the dental practitioner or to an emergency department, resulted in a hematoma or ecchymosis within the oral soft tissues, or required blood transfusion.
Statistical analyses were performed with SPSS 17.0 (SPSS, Inc., Chicago, Illinois). Continuous variables are presented as mean ± SD and categorical variables as actual number and percentage. Continuous variables were tested for normality of distribution by Kolmogorov–Smirnov test and were compared by Student’s t test or Mann–Whitney test between 2 study groups and by analysis of variance or Kruskal–Wallis test among >2 study groups. Categorical variables such as incidence of bleeding were compared by chi-square test or Fisher’s exact test, as appropriate. Relative risk (RR), defined as the ratio of bleeding incidence between 2 groups, and corresponding 95% confidence interval (CI) are reported for comparison of bleeding risk between groups. All statistical tests were 2-sided and were considered statistically significant at the 0.05 level.
The authors had full access to and take responsibility for the integrity of the data. All authors have read and agreed to the report as written.
Results
During the study period 1,262 consecutive patients were screened, and 643 patients meeting the inclusion and exclusion criteria were enrolled, undergoing 903 dental extractions. One hundred eleven patients (17.3%) were on long-term antiplatelet therapy with aspirin and/or clopidogrel. Patients’ demographic and procedural characteristics and indications for antiplatelet treatment are presented in Tables 1 and 2 , respectively. To account for the intraindividual heterogeneity of procedural indications in patients with >1 extracted tooth, we compared numbers of teeth, and not patients, with different extraction indications across study groups ( Table 1 ).
| Variable | Aspirin (n = 42) | Clopidogrel (n = 36) | Aspirin and Clopidogrel (n = 33) | Controls (n = 532) | p Value | ||
|---|---|---|---|---|---|---|---|
| Control vs Aspirin | Controls vs Clopidogrel | Controls vs Aspirin and Clopidogrel | |||||
| Age (years) | 66.6 ± 7.5 | 66.5 ± 6.8 | 63.2 ± 7.9 | 62 ± 9.5 | <0.001 | 0.003 | 0.29 |
| Men | 26 (62%) | 20 (56%) | 23 (70%) | 281 (53%) | 0.27 | 0.87 | 0.07 |
| Number of teeth extracted | 56 | 59 | 54 | 734 | |||
| Indication for extraction ⁎ | |||||||
| Periodontitis | 26 (46%) | 25 (42%) | 24 (45%) | 363 (49%) | 0.68 | 0.30 | 0.30 |
| Radicular lesion | 4 (7%) | 3 (5%) | 11 (20%) | 88 (12%) | 0.38 | 0.14 | 0.09 |
| Severe decay | 25 (45%) | 30 (51%) | 19 (35%) | 269 (37%) | 0.25 | 0.06 | 0.88 |
| Other | 1 (2%) | 1 (2%) | 0 | 14 (2%) | 0.70 | 0.63 | — |
| Indication | Aspirin (n = 42) | Clopidogrel (n = 36) | Aspirin and Clopidogrel (n = 33) | p Value | ||
|---|---|---|---|---|---|---|
| Aspirin vs Clopidogrel | Clopidogrel vs Aspirin and Clopidogrel | Aspirin vs Aspirin and Clopidogrel | ||||
| Acute coronary syndrome | 1 (2%) | 5 (14%) | 5 (15%) | 0.09 | 1.00 | 0.08 |
| Percutaneous coronary intervention | 5 (12%) | 6 (17%) | 22 (67%) | 0.75 | 0.001 | 0.001 |
| Coronary bypass | 7 (17%) | 7 (19%) | 4 (12%) | 0.77 | 0.52 | 0.75 |
| Atrial fibrillation | 1 (2%) | 1 (3%) | 2 (6%) | 1.00 | 0.6 | 0.58 |
| Stroke | 6 (14%) | 0 | 0 | — | — | — |
| Primary prevention | 20 (48%) | 16 (44%) | 0 | 0.82 | — | — |
| Other | 2 (5%) | 1 (3%) | 0 | 1.00 | — | — |
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