Dental extraction can be performed safely in patients on aspirin therapy: a timely reminder

Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

A Knowledge and Practice Survey Among Dentists in Saudi Arabia Analysing Myths and Misconceptions in Dentistry and Oral Surgery: What Do Dentists Believe?

Introduction To ensure safe and effective practice, dental practitioners must stay up-to-date with all scientific updates involving their profession. In this regard, many outdated myths and misconceptions may be persistently believed and practiced. This study aimed to examine dental misconceptions circulating among dentists in Saudi Arabia. Methods An electronic survey was administered to Saudi Arabian dental practitioners classified and registered with the Saudi Commission of Health Specialties. It collected their demographics, career and experience details, and responses to 16 questions that targeted different myths. Logistic regression was used to analyze factors associated with their knowledge. Results A total of 519 dentists answered the survey, of which 54% were male with a mean age of 32 ± 9 years and a mean practice of 7 ± 8 years. More than half (57%) practiced general dentistry. In most (69%) of the questions, 40% of the respondents answered incorrectly. The proportion of incorrect answers to some questions reached 62%. Years of teaching, years in practice, and doctor rank had no association with the knowledge score. Conversely, the type of practice and specialty had multiple statistically significant associations (p < 0.05). Conclusion This study shows that many myths, despite being debunked for more than 20 years, are still circulating among Saudi Arabian dentists, including many young dentists. Academic institutions must urgently address these concepts and the science that disproves them; dentists must implement up-to-date, evidence-based knowledge in their practice.

Prospective Comparative Evaluation of Post-extraction Bleeding in Cardiovascular-Compromised Patients with and without Antiplatelet Medications

BACKGROUND AND OBJECTIVE

A considerable number of patients consulting a dental surgeon are on antiplatelet therapy, and an interruption of these agents for 3 to 7 days has been practised by majority of them prior to dental surgical intervention fearing excessive bleeding, risking the patient for the occurrence of adverse thrombotic events. The dental and medical literature shows a very low risk of excessive bleeding associated on the continuation of antiplatelet therapy. The objective of this study is to compare the bleeding following single-firm molar tooth extraction in patients who interrupt and those who continue antiplatelet therapy perioperatively.

METHODOLOGY

This is a prospective descriptive study on 170 patients on long-term low-dose antiplatelet therapy with 2 groups, each containing 85 patients-Group 1 with patients who interrupted antiplatelet therapy for 5 days before extraction and Group 2, patients who continued it perioperatively. A single molar tooth extraction was done under local anaesthesia with a vasoconstrictor. Gauze pressure pack was placed for 60 min. Socket was observed every 15 min for 1 h to look for excessive post-extraction bleeding.

RESULTS

No statistically significant differences were found in post-extraction bleeding between the patients who stopped antiplatelet therapy and those who continued it.

CONCLUSION

The bleeding risk when continuing long-term low-dose antiplatelet therapy following a single molar tooth extraction is minimal. Bleeding, if excessive, can be easily controlled by gauze pressure pack or other local haemostatic agents. Thus, dental extractions can be performed on these patients without interrupting the antiplatelet drug pre-operatively provided a thorough medical history, physician's consent and coagulation profile have been obtained prior to the procedure.

Effect of antiplatelet therapy on minor dental procedures

Introduction:

Minor oral surgical procedures are very common. Acetylsalicylic acid generically known as aspirin is used clinically as an analgesic, antipyretic, anti-inflammatory, and as a medication to prevent platelet aggregation.

Objective:

The aim of this study was to determine if aspirin or clopidogrel was associated with bleeding after minor oral surgical procedures.

Materials and Methods:

One hundred patients who were planned for extraction of the third molar were divided into two groups. In Group A, patients on antiplatelets were included and in Group B, patients who discontinued the drug before 5 days of procedure were included. The bleeding time of all patients was checked before extraction. The surgical procedure involved simple extraction of a single third molar tooth under local anesthesia. The extraction socket was sutured with 3–0 silk. A pressure pack of gauze was given for 1 h. Bleeding after 1 h and 24 h was compared between two groups. A Chi-square test was used to compare the variables.

Results:

None of the patients showed active bleeding in the postoperative period. The results for postsurgical bleeding were statistically insignificant with P = 0.05.

Conclusion:

Minor surgical procedures such as single-tooth extraction can be carried out without discontinuation of the antiplatelet therapy.

A Comparative Evaluation of the Effectiveness of Chitosan-Based Dressing and Conventional Method of Hemostasis in Patients on Oral Antithrombotic Therapy without Therapy Interruption

Aims and Objectives:

To assess the effectiveness of chitosan-based dressing after extraction in individuals on antithrombotics, without modification of their treatment schedule.

Materials and Methods:

A randomized comparative study was carried out on 40 subjects who had two extraction sites, in dissimilar quadrants. The surgical site was chosen at random and post-extraction hemostasis was achieved by a custom-cut chitosan dressing (study site) and sterile cotton gauze dressing (suturing if required) at control site. Patients were reviewed on the first, third, fifth, and seventh postoperative days and every week till 4 weeks. The parameters assessed were timing of hemostasis, pain scores, and pus discharge.

Results:

Out of 40 study subjects, 24 (60%) were males and 16 (40%) were females. The age was 40–65 years (mean age 54 years). The mean time for hemostasis was 0.63 ± 0.27 min in study group, whereas for controls, it was 9.10 ± 2.28 min. The difference in postoperative pain was significant (P = 0.001) on days one, five, and seven. In chitosan group extraction sites, dry socket was not seen, whereas four patients on day three and five patients on day five after extraction experienced dry socket in pressure gauze dressings group, with an insignificant difference (P = 0.058). In chitosan group extraction sites, no pus discharge was seen. Whereas four patients on days three and five after extraction had pus discharge in patients where pressure dressings were applied, with an insignificant difference (P = 0.058).

Conclusion:

Chitosan dressing is a competent hemostatic agent that significantly reduced the post-extraction bleeding, with better pain control. Chitosan group had no incidences of dry socket and pus discharge.

Risk of Hemorrhage Attributed to Underlying Chronic Diseases and Uninterrupted Aspirin Therapy of Patients Undergoing Minor Oral Surgical Procedures: A Retrospective Cohort Study

Objectives

This study aimed to estimate the risk of bleeding following minor oral surgical procedures and uninterrupted aspirin therapy in high-risk patients or patients with existing chronic diseases compared to patients who did not use aspirin during minor oral surgery at a public hospital.

Methods

This retrospective cohort study analyzed the data of 2912 patients, aged 20 years or older, who underwent 5251 minor oral surgical procedures at a district hospital in Thailand. The aspirin group was comprised of patients continuing aspirin therapy during oral surgery. The non-aspirin group (reference) included all those who did not use aspirin during surgery. Immediate and late-onset bleeding was evaluated in each procedure. The risk ratio of bleeding was estimated using a multilevel Poisson regression.

Results

The overall cumulative incidence of immediate bleeding was 1.3% of total procedures. No late-onset bleeding was found. A significantly greater incidence of bleeding was found in the aspirin group (5.8% of procedures, p<0.001). After adjusting for covariates, a multilevel Poisson regression model estimated that the bleeding risk in the aspirin group was 4.5 times higher than that of the non-aspirin group (95% confidence interval, 2.0 to 10.0; p<0.001). However, all bleeding events were controlled by simple hemostatic measures.

Conclusions

High-risk patients or patients with existing chronic diseases who continued aspirin therapy following minor oral surgery were at a higher risk of hemorrhage than general patients who had not used aspirin. Nonetheless, bleeding complications were not life-threatening and could be promptly managed by simple hemostatic measures. The procedures could therefore be provided with an awareness of increased bleeding risk, prepared hemostatic measures, and postoperative monitoring, without the need for discontinuing aspirin, which could lead to more serious complications.

Should aspirin be stopped before tooth extraction? A meta-analysis

OBJECTIVE

To carry out a standard meta-analysis to determine if aspirin should be stopped before tooth extraction.

STUDY DESIGN

The PubMed, ScienceDirect, EBSCOhost, and Science Citation Index databases were searched for studies published up to September 30, 2014. Eligible studies were restricted to randomized controlled trials (RCTs) and controlled, nonrandomized trials.

RESULTS

Three RCTs and seven controlled trials met the inclusion criteria (covering 1752 patients: 529 on aspirin therapy and 1223 not on aspirin therapy). The results showed that the risk of postoperative hemorrhage was significantly higher in patients on aspirin therapy (relative risk [RR] = 2.46; 95% confidence interval [CI]: 1.45-4.81) but that bleeding time (BT) was not significantly different between the two groups (standardized mean difference [SMD] = 0.63; 95% CI: -0.04 to 1.31). Sensitivity analyses showed that the results were unstable.

CONCLUSIONS

We could reach a conclusion that BT is prolonged or hemorrhage is exacerbated by long-term use of aspirin. We recommend not stopping long-term aspirin use before tooth extraction but enhancing hemostasis methods, if necessary.