Bleeding Evaluation During Single Tooth Extraction in Patients With Coronary Artery Disease and Acetylsalicylic Acid Therapy Suspension: A Prospective, Double-Blinded, and Randomized Study

doi:10.1016/j.joms.2011.02.139

Journal of Oral and Maxillofacial Surgery

Volume 69, Issue 12, December 2011, Pages 2949-2955

https://doi.org/10.1016/j.joms.2011.02.139 Get rights and content

Purpose

Acetylsalicylic acid (ASA) has been used for the primary and secondary prevention of cardiovascular events. To reduce bleeding, the administration of ASA has traditionally been suspended before dental procedures; however, this suspension potentially increases the risk of thromboembolic events. The effect of ASA on the amount of bleeding that occurs during tooth extraction procedures is controversial, and perioperative guidelines recommend that ASA administration should not be altered for such procedures. The aim of this study was to evaluate the amount of bleeding that occurs during the intraoperative period of tooth extraction procedures in patients with coronary artery disease who are either undergoing acetylsalicylic acid (ASA) therapy or who have been instructed to suspend their ASA use.

Patients and Methods

Sixty-three patients with coronary artery disease who required tooth extraction were enrolled in this study. All patients were receiving 100 mg/d of ASA at the time of enrollment and were randomly placed into 2 groups: group S, which was comprised of patients whose ASA therapy was suspended 7 days before tooth extraction, and group NS, comprised of patients whose ASA therapy was unaltered. A platelet aggregation test was carried out on the day of the operation, and the amount of bleeding was measured during the intraoperative period by means of aspirated blood collection. All the extractions were performed by the same surgeon, who was unaware of whether the patient's ASA therapy had been suspended.

Results

The mean (± SD) volume of bleeding was 12.10 ± 9.37 mL for patients who underwent ASA therapy suspension and 16.38 ± 13.54 mL for those patients whose treatments were unaltered (P = .151). Local hemostatic methods were sufficient to control bleeding, and there were no reported episodes of hemorrhaging during the intra- and postoperative periods. The platelet reactivity index values exhibited statistically significant differences between the 2 investigated groups (P = .004). The platelet reactivity index values for group S and group NS were 242.58 ± 71.26 and 192.09 ± 60.54, respectively.

Conclusion

There was no difference in the amount of bleeding that occurred during tooth extraction between patients who continued ASA therapy versus patients who suspended their ASA therapy. The platelet reactivity test demonstrated a reduction in platelet aggregation in the ASA therapy group (group NS), but this reduction was without clinical consequence.

Section snippets

Patients

Eighty-three patients with CAD who were undergoing ASA therapy were selected between February 2007 and April 2009 at a tertiary cardiology hospital. The inclusion criteria for this study included an indication of the need for at least 1 molar extraction (superior or inferior) and the presence of CAD that was being treated with an ASA therapy of 100 mg/d. Patients were excluded if they were receiving anticoagulation treatment or undergoing any other type of antiplatelet therapy; had blood

Results

Eighty-three coronary patients were initially evaluated, and 20 of these patients were excluded from the investigation for a variety of factors, including the presence of an impacted third molar (4 patients), dental abscess (2 patients), absence of a blood test (9 patients), laboratory technical errors (9 patients), thrombocytopenia (1 patient), and an accident with the aspiration pump during the intraoperative procedure (2 patients).

Sixty-three patients (22 females and 41 males) attended the

Discussion

In this study, CVD patients undergoing ASA therapy who had an indication for molar extraction were randomly placed into 2 groups: 1 with the suspension of ASA therapy for a period of 7 days before the start of the procedure and 1 with no change in ASA therapy.

There was no significant difference in the amount of bleeding that occurred during tooth extraction between the 2 groups (groups S and NS).

Currently, the use of ASA therapy is considered a risk factor for hemorrhagic complications during

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The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists.
The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control.
The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period.
Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.
The role of hemostatic agents after tooth extractions: A systematic review and meta-analysis
2023, Journal of the American Dental Association
Hemostatic agents are used to control bleeding after tooth extraction and have been compared with conventional measures (that is, sutures or gauze pressure) in several studies. The objective of this systematic review was to evaluate the benefits of topical hemostatic agents for controlling bleeding after tooth extractions, especially in patients receiving antithrombotic therapy.
The authors conducted a literature search in MEDLINE (PubMed), Scopus, and the Cochrane Central Register of Controlled Trials, including prospective human randomized clinical trials in which researchers compared hemostatic agents with conventional methods and reported the time to achieve hemostasis and postoperative bleeding events.
Seventeen articles were eligible for inclusion. Hemostatic agents resulted in a significantly shorter time to achieve hemostasis in both healthy patients and patients taking antithrombotic drugs (standardized mean difference, –1.02; 95% CI, –1.70 to –0.35; P = .003 and standardized mean difference, –2.30; 95% CI, –3.20 to –1.39; P < .00001, respectively). Significantly fewer bleeding events were noted when hemostatic agents were used (risk ratio, 0.62; 95% CI, 0.44 to 0.88; P = .007). All forms of hemostatic agents (that is, mouthrinse, gel, hemostatic plug, and gauze soaked with the agent) had better efficacy in reducing the number of postoperative bleeding events than conventional hemostasis measures, except for hemostatic sponges. However, this was based on a small number of studies in each subgroup.
The use of hemostatic agents seemed to offer better bleeding control after tooth extractions in patients on antithrombotic drugs than conventional measures.
Findings of this systematic review may help clinicians attain more efficient hemostasis in patients requiring tooth extraction. This systematic review is registered in the PROSPERO database. The registration number is CRD42021256145.
Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline
2022, Chest
The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug.
Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines.
A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures.
Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
Intra-alveolar epsilon-aminocaproic acid for the control of post-extraction bleeding in anticoagulated patients: randomized clinical trial
2018, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
The five episodes of severe bleeding are described in detail in Table 6. Currently, several authors advocate maintaining anticoagulant therapy in patients undergoing simple tooth extraction1,2,9,17,25–31. In the present study, there was only one (0.7%) immediate bleeding episode and 23 (16.4%) late bleeding episodes.
The aim of this study was to compare the effectiveness of the intra-alveolar administration of epsilon-aminocaproic acid (EACA) and daily gentle rinsing with EACA mouthwash with that of routine postoperative procedures for the control of bleeding after tooth extraction in anticoagulated patients. A randomized clinical trial was conducted involving 52 patients submitted to 140 tooth extractions, assigned randomly to two groups. The intervention group was treated with intra-alveolar administration of EACA immediately after surgery and gentle rinsing with EACA mouthwash during the postoperative period. The control group received routine postoperative recommendations. A single episode of immediate bleeding occurred in the intervention group. Late bleeding episodes occurred in 23 procedures (16.4%): 11 (15.7%) in the intervention group and 12 (17.1%) in the control group. Among the patients with late bleeding, 18 (78.3%) events were classified as moderate and were controlled by the patient applying pressure to a gauze pack placed over the extraction socket. The remaining five cases (21.7%) required re-intervention. No statistically significant difference in the frequency of postoperative bleeding was observed between the groups. Thus, routine measures were as effective for the control of bleeding after simple tooth extractions in anticoagulated patients as the topical administration of EACA.
Incidence and treatment of complications in patients who had third molars or other teeth extracted
2018, British Journal of Oral and Maxillofacial Surgery
The aim of this study was to compare the incidence of complications after extraction of third molars (M3) or other teeth, and to describe their management. We made a retrospective cohort study of patients having M3 or other teeth extracted, and recorded complications up to two years’ follow-up. A total of 142 complications developed after 2355 procedures (6%) – 7% after extraction of M3 compared with 5% after extractions of other teeth (p = 0.024). The three most common complications were wound infection (2%), pain without apparent cause (<1%), and oroantral communication (<1%). Patients who had M3 extracted were at increased risk of complications compared with those who had other teeth extracted (Odds ratio (OR) 1.5, p = 0.024), particularly for infection (OR 5.9, p < 0.001) and hypoaesthesia (OR 8.4, p = 0.027). Half of all patients with a complication were treated with antibiotics orally. The incidence of postoperative bleeding was 0.6% as a result of suboptimal management of antithrombotic drugs in extractions of teeth other than M3. Finally, optimal treatment of the complications was compared with the available evidence. Prevention and treatment of these complications could reduce the incidence, particularly of bleeding.
Quantification of bleeding during dental extraction in patients on dual antiplatelet therapy
2017, International Journal of Oral and Maxillofacial Surgery
Citation Excerpt :
Dental interventions resulting in bleeding in patients on medications that change haemostasis have been the subject of multiple studies and publications, reflecting the fear dental practitioners feel in managing this group of patients35–37. Different clinical research studies have shown that the use of ASA does not constitute a risk for uncontrollable bleeding during invasive dental procedures12,17,34. However, single therapy has since been replaced by dual therapy (ASA + clopidogrel), elevating the risk of bleeding.
In spite of the possibility of triggering thromboembolic events, many professionals indicate the suspension of antiplatelet agents before dental surgical procedures. The aim of this study was to perform a quantitative assessment of intraoperative bleeding in patients on dual antiplatelet therapy. A case–control study was conducted in patients on dual antiplatelet therapy (APT group) and in patients who did not use these medications (control group). The following examinations were requested: complete blood cell count, blood coagulation tests, and platelet aggregation. The quantity of bleeding was measured intraoperatively by collection of aspirated blood. The mean volume of blood lost during the surgical procedure was 6.10 ml in the control group and 16.07 ml in the APT group (P = 0.002). The mean volume of blood lost per minute was 0.60 ml/min in the control group and 1 ml/min in the APT group (P = 0.001), with local haemostatic methods being sufficient to control the bleeding. There was no postoperative bleeding complication in any case. Patients on dual antiplatelet therapy presented a larger volume of bleeding, but this could be controlled by means of local haemostatic measures. Therefore, there is no need to stop either of the two dual antiplatelet therapy medications before dental extractions.

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Dentoalveolar surgeryBleeding Evaluation During Single Tooth Extraction in Patients With Coronary Artery Disease and Acetylsalicylic Acid Therapy Suspension: A Prospective, Double-Blinded, and Randomized Study

Purpose

Patients and Methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

Br J Anaesth

J Am Dent Assoc

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Maxillofac Surg

J Oral Surg

J Dent

Dent Clin North Am

Aspirin-induced post-gingivectomy haemorrhage: A timely reminder

J Clin Periodontol

Management of dental patients taking common hemostasis altering medications

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

Dental management of patients receiving anticoagulation or antiplatelet treatment

J Oral Sci

Dentoalveolar surgery
Bleeding Evaluation During Single Tooth Extraction in Patients With Coronary Artery Disease and Acetylsalicylic Acid Therapy Suspension: A Prospective, Double-Blinded, and Randomized Study