According to the results of a Greek study published in the American Journal of Cardiology, antiplatelet therapy may not need to be stopped prior to dental extractions, as long as appropriate local haemostatic measures are taken.

The authors note that the optimal dental management of patients on long-term antiplatelet therapy is not clearly defined.  Whereas stopping therapy prior to procedures increases the risk of thrombotic complications, not doing do may increase the bleeding hazard.  The purpose of this study was to compare the risks of immediate and late post-extraction bleeding in patients receiving single or dual antiplatelet therapy.  To their knowledge, this is the first study to prospectively assess the safety of dental extractions performed in patients on uninterrupted antiplatelet therapy. 

The study included 643 consecutive patients referred to the Aristotle University Dental School in Thessaloniki, who met the inclusion criteria.  Those with haematological, liver or renal disease and those taking other medications affecting homeostasis were excluded, as were those who needed complicated or multiple extractions.  Participants were categorised as one of the following: 1) treatment group (those receiving uninterrupted aspirin and/or clopidogrel; n=111); and 2) control group (those receiving no antiplatelets; n=532).  In the treatment group, 42 patients were receiving aspirin, 36 clopidogrel and 33 the combination of both (dual antiplatelet therapy).   

All patients had their extractions completed in the morning clinic session.  Patients were instructed to bite on a pressure pack for 30 minutes following the procedure; if bleeding was still present (prolonged post-extraction bleeding) then a piece of gauze was sutured over the socket and they were re-evaluated before leaving the clinic.  All patients were given post-operative instructions and advised to immediately report any haemorrhagic complications.  Patients were interviewed by telephone at the end of the day.  Bleeding complications were recorded and defined as immediate (occurring during the extraction session at the clinic) or late (occurring at any point thereafter).  Late 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 haematoma or ecchymosis within the oral soft tissues, or required blood transfusion.    

The main findings were as follows:

• The risk of prolonged immediate bleeding was higher in those receiving dual antiplatelet therapy (67%; relative risk [RR] 177.3, 95% CI 43.5 to 722, p<0.001) than in controls (0.4%)

• The risk of bleeding in the aspirin (2.4%) and clopidogrel (2.8%) monotherapy groups was not statistically significantly different compared to controls

• All immediate bleeding complications in all treatment groups were successfully managed with local haemostatic measures (as described above). 

• No patient developed any late haemorrhage

The authors conclude that the results of their ‘real-world’ study “support the safety of dental extractions on uninterrupted single and dual antiplatelet therapy with appropriate local haemostatic measures."  They note that although post-extraction bleeding events are more likely to occur under uninterrupted combined antiplatelet therapy, these appear to be limited to the immediate post-procedure time frame, occurring within the safe environment of a dental clinic, and are controllable with local haemostatic treatment.

They do however emphasise that their study does not provide answers about the safety of extractions while taking antiplatelets in all cases; certain patients were excluded and only aspirin and clopidogrel use was investigated.  The safety of extractions in patients receiving newer antiplatelet agents will need to be further evaluated.