Evaluation of post-extraction bleeding in patients taking low dose aspirin

Background: Acetylsalicylic acid (ASA) generically known as Aspirin is an analgesic, antipyretic, anti-inflammatory and also an antiplatelet drug. In order to avoid excessive bleeding and to be on the safer side, dentists have traditionally advised their patients to stop taking aspirin before extraction of teeth although this surgical procedure can be done without cessation of aspirin intake. Objective: The purpose of the study was to assess the necessity of interrupting aspirin therapy prior to dental extraction. Materials and Methods: A cross sectional study was conducted in November 2015 at outpatient department of dentistry, BIRDEM Hospital, Dhaka. Sample of 50 patients who took low dose aspirin (75mg) once daily were purposely selected for this study. The blood pressure of all the subjects was recorded preoperatively. The extractions were done atraumatically under local anesthesia using 2% lidocaine with 1:100,000 epinephrine. A gelatin sponge piece was placed in socket and closed by atraumatic silk. The subjects were instructed to apply pressure pack with sterile gauze for 30 min. Evaluation was done in every 10 minutes for 30 minutes. Results: Among 50 patients, 82.0% patients were suffering from IHD. Simple extraction was done in 92.0% of patients while the remaining extractions were done surgically. 68% was managed by pressure pack and gelatin sponge while 26.0% were managed by pressure pack only. According to Post-extraction bleeding, it was found that the bleeding time was 10 min in case of 94% patients while only 2% showed 30 minutes of bleeding time. Conclusion: The study revealed that it is not necessary to alter or stop aspirin therapy and local hemostatic measures are sufficient to control bleeding. Therefore it can be assumed that extraction can be done without cessation of low dose aspirin and avoiding the life threatening issues.


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Website: https://www.banglajol.info/index.php/UpDCJ Acetylsalicylic acid (ASA) generically known as aspirin is used clinically as an analgesic, antipyretic, anti-inflammatory agents and as a medication to prevent platelet aggregation. It is indicated for long term use in patients susceptible to the formation of emboli, such as patients who have suffered from stroke, angina or myocardial infarctions (Anonymous, 2002). 3 Aspirin blocks the synthesis of thromboxane A2 by irreversibly inhibiting cyclooxygenase 1, thereby diminishing platelet aggregation. It widely used in low dose as an anti-platelet agent in patients having myocardial ischemia or risk of stroke. 4 Though the incidence of spontaneous bleeding is very rare according to studies but it can occur. Following dental surgical procedure, hemorrhagic mishaps are rare except for few cases of required platelet transfusions. 5 Nowadays it is recommended to go for various dental procedures without interrupting aspirin therapy 6,7 as inhibiting antiplatelet therapy has risk for developing thrombo-embolic event. 8,9 Dental Literature regarding Increased Bleeding with Use of Aspirin Therapy Literature review reveals that clinical trials involving dental extraction and anti platelet therapy started in 1970 and it is still going on. Studies conducted in 1970s by Lemkin et al and Mc Gaul et al have documented that there is increased postoperative bleeding after dental extraction and recommended to discontinue aspirin. Few authors recommended stopping aspirin 7 days preoperatively. Few other authors recommended stopping aspirin for 3 days or lesser than that. The rationale for such recommendation is that, after 3 days of interruption of aspirin, sufficient number of newer platelets will be present in the circulation for effective hemostasis. 10 Dental Literature regarding Safety of Continued Aspirin Therapy prior to Tooth Extraction Brennan et al. reviewed the literature regarding the management of patients on aspirin requiring oral surgical procedures. They also recommended continuation of aspirin during dental extractions based on results of studies with high level of evidences. Gaspar et al. concluded that ambulatory oral surgical procedures can be performed in patients on aspirin therapy as hemostasis posed no problem. Hence, they recommended continuation of aspirin therapy without interruption prior to oral surgical procedures. Oral Medicine and Oral Surgery Francophone Society conducted a literature review and gave recommendations for management of patients on antiplatelet therapy based on the agreement among professionals in the field. The society stated that interruption of antiplatelet therapy prior to dental procedures is unnecessary. The risk of bleeding is very low and local hemostatic measures are usually successful.
Allard et al. stated that the review of available literature is in favor of not stopping aspirin or clopidogrel in case of simple dental surgical procedures. Krishnan et al. in a prospective clinical study performed extraction procedures on normal patients and ptients who stopped aspirin preoperatively [25 subjects in each group]. Simple intra-alveolar extractions were performed and hemostasis was achieved with wet gauze pressure pack for 30 minutes. 1 In contrast to the previous studies, Madan et al and Valerin et al in their study have stated that there is increased risk of thrombotic outcomes with the discontinuation of low dose aspirin therapy. Ardekian et al found that a daily dose of 100 mg of Aspirin did not increase the bleeding during tooth extraction. There was a statistical significance in bleeding time between the groups that continued and withdrew aspirin before tooth extraction. Thus the patients need not stop taking Aspirin before dental surgery, provided that heamorrhagic risk is not greater than thromboembolic risk associated by interrupting the dose of the drug. According to Crispian Scully et al., for uncomplicated forcep extraction of 1 to 3 teeth there is no need to interfere the aspirin dose. 7 Matocha concluded in his study that the risk of bleeding after dental extraction is minimal in the patients with aspirin therapy and did not exceed 0.2-2.3%. 11 Napeñas et al conducted a literature review of bleeding complications in dental patients taking antiplatelet agents in 2013. The authors concluded there is no need to stop single or dual antiplatelet therapy for invasive dental procedures, and local measures are adequate for hemostasis. 12 In department of dentistry, BIRDEM, traditionally aspirin therapy was interrupted for 3-5 days before extraction of tooth. The purpose of this study was to assess whether safe extraction procedure can be carried out without any alteration in aspirin therapy by assessment of post extraction bleeding time in case of cardiac patients.

Methods:
A cross sectional study was conducted in November 2015 with informed written consent from patients and their parents in BIRDEM Hospital, Dhaka. 50 patients were included as the sample who were taking low dose aspirin (75mg) once daily Data collection method included dental clinical examination, anthropometric measurements and a questionnaire comprised of some questions related to their age, sex, height, weight, medical history and extraction of teeth. The blood pressure of all the subjects were recorded preoperatively. The extractions were done least traumatically as possible under local anaesthesia using 2% lidocaine with 1:100,000 epinephrine. A gelatin sponge piece was placed in socket and closed by atraumatic silk which was removed after 5 days. The subjects were instructed to apply pressure pack on a piece of sterile gauze for 30 minutes. Evaluation was done in every 10 Website: https://www.banglajol.info/index.php/UpDCJ minutes during the 30 minutes time period. If bleeding stopped, then they were discharged with advice and contact information. Patients were also advised to provide information about any further incident of post-operative bleeding with accurate timing. Follow up was given contacted by phone 12 h, 24 h, 48 h and 5 days post-operatively. If there was any bleeding after initial 30 minutes, the patient was re-examined, managed accordingly and evaluated after 30 min. Patients were discharged after being that homeostasis has been achieved. If the subjects reported over the phone that bleeding still persisted, patient was instructed to return for further evaluation and management. Data from each procedure was collected and then statistical analysis was done by using SPSS.

Results:
According to this study, out of 50 patients, 28 were male and 22 were female (Table 1). Between the age range of 40-85, 40% patient belonged to age group 51-60 years (table 2). Majority of the patients were suffering from IHD (82%). (Table  3) Extractions were done in few cases admitted in hospital while most of the extractions were done in outdoor (Table 4). Teeth were extracted by local anesthetic infiltration in 36 patients while the remaining extractions were done by infiltration and nerve block (Table 5). Majority (46/50) of extractions were simple and hemostasis was achieved by pressure pack and gelatin sponge in 34 cases ( Table 6). 2 case required thermocoagulation to arrest bleeding along with pressure pack and gelatin sponge ( Table  7). More than 50% extractions were done from lower mandibular teeth especially the posterior molars. Among them, there were 13 cases of 3 rd molar extractions (Table 8, 9 and 10). Hemostasis was achieved within 10 minutes after extraction in majority of the cases (47/50) while the remaining 3 had post extraction bleeding time of more than 10 minutes (Table 11). Table 1 shows the distribution of the study patients by sex.

Discussion:
Routine dental extractions can be safely performed in patients on long-term antiplatelet medication, with no interruption or alteration of their medication. Such patients do not have an increased risk of prolonged or excessive postoperative bleeding. Many authors recommended not stopping aspirin which is also recommended in our present study. Madan et al. (2005) in a study included 51 patients (32 males, 19 females), ranging in age from 45 to 70 years. 13 Similarly findings found in this present study, Male : female ratio 1.3:1, ranging in age from 51-60 years.  11 Preoperative values were within normal limits for all patients. Aspirin was not stopped for a single patient. There was no excessive intraoperative bleeding in all cases except 1; there was no postoperative bleeding in all cases. 13 Similarly findings found in this present study, the bleeding time is 10 min in case of 94% patient and only 2% shows 30 min of bleeding time.

Conclusion:
It is important to balance the benefits and risks regarding whether dental treatment is continued with or without stopping the medication. Based on the clinical review of patient, it can be concluded that dental extractions may be safely performed in patients receiving aspirin therapy to avoid the thrombotic risk. Existing data indicates there is no necessity to alter or stop these drugs and that local hemostatic measures are sufficient to control bleeding.