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Oral Medicine

Should Aspirin therapy be stopped for Routine dental procedures?

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From Dr. Cesare Ciavarro, Coronation Dental Specialty Group

Dental patients often present while being treated with different forms of anticoagulation therapy, among which Aspirin remains one of the most commonly encountered drugs.

Aspirin, or Acetylsalicylic Acid (ASA), works as a cyclo-oxygenase inhibitor, thereby blocking prostaglandin and thromboxane production and ultimately preventing  platelets from aggregating (1, 2).     Besides its anti-inflammatory and analgesic features, this drug can also be used alone or in combination with other anticoagulants to prevent unwanted thrombi, thereby diminishing Cerebrovascular and/or Cardiovascular embolic events.  (3, 4)

Nonetheless, there are still many questions regarding the potential bleeding hazards associated with this drug with respect to Dental treatment.   As Aspirin is known to affect bleeding times, it is not uncommon for Physicians and Dentists to routinely stop therapy prior to simple dental procedures ranging from restorative work to minor Oral Surgery, such as extractions and implants (5).   It is well known that only a fraction of patients on the drug actually have altered bleeding times, and this becomes clinically significant in minor procedures only when local measures are unattainable or neglected (5).    As such, it is well established that withholding Aspirin is unwarranted for Oral Surgical and minor Dental procedures, since the literature shows perioperative bleeding is no different in patients who continue the drug when compared with those who have stopped it (5, 6, 7).     Unfortunately, the unnecessary practice of routine perioperative withdrawal of  Aspirin in these patients may be devastating (8).  There are multiple studies showing the long term sequella of short term stoppage from the drug.  For example, the percentage of permanently disabling consequences and fatal arterial or venous thromboembolic events after cessation can range from 20 to 40 percent respectively (9).

In nearly 10 years of Clinical practice and throughout my Surgical residency training,    I have not withheld Aspirin in any of my patients, regardless of treatment performed in our Oral and Maxillofacial institution.  In fact, this remains the standard of care in our practice.    As such, our clinicians have yet to encounter any anecdotal issues affiliated with ASA related  postoperative bleeding  especially when adequate local measures are used.

References
1. Branco FP; Marcos Pinheiro LP; Volpato MC;  Dias de Andrade E. Analgesic choice in dentistry. Part I: The mechanism of action    Braz J Oral Sci. July-September 2005 – Vol. 4 – Number 14
2. Pulcinelli FM,  Pignatelli P, Celestini A, Riondino S, Paolo Gazzaniga PP,  Violi F,   Inhibition of platelet aggregation by aspirin progressively decreases in long-term treated patientsJ Am Coll Cardiol. 2004;43(6):979-984
3. Antiplatelet Trialists’ Collaboration [No authors listed].   Collaborative overview of randomised trials of antiplatelet therapy–I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients.. BMJ. 1994 Jan 8;308(6921):81-106.
4. De Gaetano G, Cerletti C, Dejana E, Vermylen J.  Current issues in thrombosis prevention with antiplatelet drugs.  Drugs. 1986 Jun;31(6):517-49.
5. Pototski M, Amenabar JM. Dental management of patients receiving anticoagulation or antiplatelet treatment. J Oral Sci 2007;49:253-8.
6. Abdullah M. Al-Harkan, , Ghassan A. Al-Ayoub, Should Antiplatelet and Anticoagulant Medications Be Discontinued before Minor Oral Surgery Procedures? J Can Dent Assoc 2012;78:c24
7. Burger, W, Chemnitius, J, Kniessl, GD;  Low-dose aspirin for secondary cardiovascular prevention Journal of Internal Medicine 2005; 257: 399–414
8. Kovich, O., Otley, C.C. Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation. Journal of the American Academy of Dermatology, 2003
9. Anderson S, Jamrozik K, Broadhurst R and Stewart-Wynne EG  .  Predicting survival for 1 year among different subtypes of stroke. Results from the Perth Community Stroke Study, Stroke. 1994;25:1935-1944

10 Comments

  1. T. Brown January 9, 2013

    Is this resoponse the same for Plavix and Pradix?

    Reply
    1. I don’t stop either Plavix or Pradaxa; but I’ll check with Cesare too.

      Pradaxa has a very short 1/2-life, so if bleeding is too brisk, it’s gone quickly.

      1. Harry G December 10, 2017

        In case of plavix is it necessary to get INR or Full blood count report before a single dental extraction

  2. p.n.goyal January 17, 2013

    Normally I stop ASA & Plavix for 3days i.e. 1day before the procedure, proc.day & next day.
    Recently in one case the Physician did not allow to discontinue the anticoagulant so I did not but no prob.
    Does this mean I should not discontinue anticoagulant?

    Reply
    1. normally, we don’t stop them. ASA has a 1/2 life of 7 days so the day before will have little effect. plavix, I believe, has a shorter 1/2 life. At one point I remember reading an article that the average additional blood loss from asa in major surgery is 2%. Since our blood loss is so low to start with, the additional amount lost is not (usually) signficiant.

    2. btw – sorry for the delay in responding. i didn’t read your comment to the end.

  3. George Cadigan January 22, 2013

    Anecdotally I have found no problems with minor oral surgery while the patient is taking Plavix or Aspirin. All that is required is diligent compliance with the patient biting on a gauze pad for an hour or two instead of 20 to 30 minutes.

    Reply
  4. Cesare Ciavarro January 22, 2013

    Although the literature does not recommend cessation of any of the aforementioned drugs prior to most Oral surgery procedures, I strongly recommend consideration of the entire patient’s medical history as a whole, and reviewing concomitant medications prior to making generalizations. The coice will also vary with the comfort level of the practicioner, and degree of difficulty of each particular case. When in doubt, communication with the patient’s primary caregiver/Family physcian and arriving at a mutual decision that is beneficial for the patient would be advised.

    Reply
  5. Waji Khan January 23, 2013

    From my conversation with medical colleagues, it is not routinely recommended to stop any anti-coagulation without an understanding of why the anticoagulation is in place. It should also be understood that there are many mechanisms to achieve hemostasis which can be controlled both surgically and medically when minor oral surgery is required. Taking a patient off Coumadin or Pradexa who is anticoagulated as a result of A-fib, and has an INR between 2-3, is more likely to have a stroke than bleed to death.

    Reply
  6. Farel Anderson January 23, 2013

    I have treated these patients for over 40yrs. I put great effort into evaluating them well,including talking to their physician and giving strict and firm post-surgical instructions. That has failed me thrice.

    Reply

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