Perioperative Management of Dental Patients on Antiplatelet Medications

  • Michael J. Wahl


When dental patients on continuous antiplatelet medications present for dental surgery, a decision must be made to continue antiplatelet therapy with potential increased bleeding risks or to interrupt therapy with potential increased embolic risks. But dental surgery is unlike other types of surgery in that major vessels are unlikely to be encountered and most bleeding complications are easy to access without additional surgeries both perioperatively and postoperatively. Of more than 3522 dental patients undergoing more than 6265 dental surgical procedures without interrupting antiplatelet therapy reported in the medical and dental literature, no more than 86 patients (a 2.4% minor bleeding incidence) required additional local measures for hemostasis, and still only two patients (in separate reports) suffered bleeding complications requiring more than local measures for hemostasis, a remarkably low incidence of serious bleeding complications of 0.06%. A close look at these two cases, one over 30 years old and the other over 50 years old, shows that they do not support interrupting antiplatelet therapy for dental surgery. Of 702 patients undergoing at least 752 interruptions of antiplatelet therapy for dental procedures, there were at least 19 embolic complications (2.5% of cessations). These embolic complications included myocardial infarction, stent thrombosis, coronary artery syndrome, and cerebrovascular strokes. Since the review of the literature of antiplatelet interruption for dental procedures includes some case reports and some studies that were not prospective, randomized, and controlled, it is virtually certain that the actual incidence of embolic complications with antiplatelet interruption for dental procedures is significantly lower than 2.5%, but there certainly is an increased embolic risk, regardless of the reason for the interruption. As a result, antiplatelet therapy should not be interrupted for dental surgery.


Antiplatelet agents Aspirin Dental Dental surgery Stroke 


  1. 1.
    Guyatt GH, Akl EA, Crowther M, et al. for the American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based practice guidelines. Chest. 2012;141(2 (Suppl)):7S–47S.CrossRefGoogle Scholar
  2. 2.
    Ardekian L, Gaspar R, Peled M, et al. Does low-dose aspirin therapy complicate oral surgical procedures? J Am Dent Assoc. 2000;131(3):331–5.CrossRefGoogle Scholar
  3. 3.
    Valerin MA, Brennan MT, Noll JL, et al. Relationship between aspirin use and postoperative bleeding from dental extractions in a healthy population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2006;102(3):326.CrossRefGoogle Scholar
  4. 4.
    Brennan MT, Valerin MA, Noll JL, et al. Aspirin use and post-operative bleeding from dental extractions. J Dent Res. 2008;87(8):740–4.CrossRefGoogle Scholar
  5. 5.
    Krishnan B, Shenoy NA, Alexander M. Exodontia and antiplatelet therapy. J Oral Maxillofac Surg. 2008;66:2063–6.CrossRefGoogle Scholar
  6. 6.
    Medeiros FB, deAndrade AC, Angelis GA, et al. Bleeding evaluation during single tooth extraction in patients with coronary artery disease and acetylsalicylic acid therapy suspension: a prospective, double-blinded and randomized study. J Oral Maxillofac Surg. 2011;69(12):2949–55.CrossRefGoogle Scholar
  7. 7.
    Varghese KG, Manoharan S, Sadhanandan M. Evaluation of bleeding following dental extraction in patients on long-term antiplatelet therapy: a clinical trial. Indian J Dent Res. 2015;26:252–5.CrossRefGoogle Scholar
  8. 8.
    Eapen BV, Baig MF, Avinash S. An assessment of the incidence of prolonged postoperative bleeding after dental extraction among patients on uninterrupted low dose aspirin therapy and to evaluate the need to stop such medication prior to dental extraction. J Maxillofac Oral Surg. 2016.
  9. 9.
    Omar HR, Socias SM, Powless RA, et al. Clopidogrel is not associated with increased bleeding complications after full mouth extraction: a retrospective study. JADA. 2015;146(5):303–9.PubMedGoogle Scholar
  10. 10.
    Napeñas JJ, Hong CH, Brennan MT, et al. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. J Am Dent Assoc. 2009;140(6):690–5.CrossRefGoogle Scholar
  11. 11.
    Lillis T, Ziakas A, Koskinas K, et al. Safety of dental extractions during uninterrupted single or dual antiplatelet treatment. Am J Cardiol. 2011;108(7):964–7.CrossRefGoogle Scholar
  12. 12.
    Dudek D, Kuliczkowski W, Kaczmarski J, et al. Response to dual antiplatelet therapy does not impact bleeding risks in patients undergoing oral surgery after acute coronary syndromes. Cardiology. 2015;132(2):119–23.CrossRefGoogle Scholar
  13. 13.
    Girotra C, Padhye M, Mandlik G, et al. Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: a prospective study. Int J Oral Maxillofac Surg. 2014;43:99–106.CrossRefGoogle Scholar
  14. 14.
    Lu S-Y, Tsai C-Y, Lin L-H, Lu S-N. Dental extraction without stopping single or dual antiplatelelt therapy: results of a retrospective cohort study. Int J Oral Maxillofac Surg. 2016;45:1293–8.CrossRefGoogle Scholar
  15. 15.
    Bajkin BV, Bajkin IA, Petrovic BB. The effects of combined oral anticoagulant-aspirin therapy in patients undergoing tooth extractions. J Am Dent Assoc. 2012;143(7):771–6.CrossRefGoogle Scholar
  16. 16.
    Zhao B, Wang P, Dong Y, Zhu Y. Should aspirin be stopped before tooth extraction? A meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:522–30.CrossRefGoogle Scholar
  17. 17.
    Nathwani S, Martin K. Exodontia in dual antiplatelet therapy: the evidence. Br Dent J. 2016;220(5):235–8.CrossRefGoogle Scholar
  18. 18.
    Wahl MJ. Dental surgery and antiplatelet agents: bleed or die. Amer J Med. 2014;127:260–7.CrossRefGoogle Scholar
  19. 19.
    Bajkin BV, Urosevic IM, Stankov KM, Petrovic BB, Bajkin IA. Dental extractions and risk of bleeding in patients taking single and dual antiplatelet treatment. Br J Oral Maxillofac Surg. 2015;53(1):39–43.CrossRefGoogle Scholar
  20. 20.
    Broekema FI, van Minnen B, Jansma J, Bos RRM. Risk of bleeding after dentoalveolar surgery in patients taking anticoagulants. Br J Oral Maxillofac Surg. 2014;52:e15–9.CrossRefGoogle Scholar
  21. 21.
    Cañigral A, Silvestre F-J, Cañigral G, et al. Evaluation of bleeding risk and measurement methods in dental patients. Med Oral Patol Oral Cir Bucal. 2010;15(6):e863–8.CrossRefGoogle Scholar
  22. 22.
    Cardona-Tortajada F, Sainz-Gómez E, Figuerido-Garmendia J, et al. Dental extractions in patients on antiplatelet therapy. A study conducted by the Oral Health Department of the Navarre Health Service (Spain). Med Oral Patol Oral Cir Bucal. 2009;14(11):e588–92.CrossRefGoogle Scholar
  23. 23.
    Clemm R, Neukam FW, Rusche B, Musazada S, Schmitt CM. Management of anticoagulated patients in implant therapy: a clinical comparative study. Clin Oral Impl Res. 2016;27:1274–82.CrossRefGoogle Scholar
  24. 24.
    Darawade DA, Kumar S, Desai K, et al. Influence of aspirin on post-extraction bleeding—a clinical study. J Int Soc Prev Community Dent. 2014;4(Suppl 1):S63–7.CrossRefGoogle Scholar
  25. 25.
    Dézsi BB, Koritsánszky L, Braunitzer G, et al. Prasugrel versus clopidogrel: a comparative examination of local bleeding after dental extraction in patients receiving dual antiplatelet therapy. J Oral Maxillofac Surg. 2015;73:1894–900.CrossRefGoogle Scholar
  26. 26.
    Duygu G, Ozcakir-Tomruk C, Guler N, Sencift K. Assessment of effects of antiplatelet drugs on bleeding risk after teeth extractions. Biotechnol & Biotechnol Equip. 2010;24(3):2040–3.CrossRefGoogle Scholar
  27. 27.
    Flanagan D. Tranexamic acid tamponade to control postoperative surgical hemorrhage. J Oral Implantol. 2015;41(3):e82–9.CrossRefGoogle Scholar
  28. 28.
    Garnier J, Truchot F, Quero J, et al. 218 tooth extractions in patients taking platelet aggregation inhibitors. [Article in French. Rev Stomatol Chir Maxillofac. 2007;108(5):407–10.CrossRefGoogle Scholar
  29. 29.
    Hanken H, Tieck F, Kluwe L, et al. Lack of evidence for increased postoperative bleeding risk for dental osteotomy with continued aspirin therapy. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119:17–9.CrossRefGoogle Scholar
  30. 30.
    Hemelik M, Wahl G, Kessler B. Tooth extraction under medication with acetylsalicylic acid. Mund Kiefer Gesichtschir. 2006;10(1):3–6.CrossRefGoogle Scholar
  31. 31.
    Hepsö HU, Lökken P, Björnson GHC. Double-blind crossover study of the effect of acetylsalicylic acid on bleeding and post-operative course after bilateral oral surgery. Eur J Clin Pharmacol. 1976;10:217–25.CrossRefGoogle Scholar
  32. 32.
    Jimson S, Amaldhas J, Jimson S, Kannan I, Parthiban J. Assessment of bleeding during minor oral surgical procedures and extraction in patients on anticoagulant therapy. J Pharm Bioallied Sci. 2015;7(Suppl 1):S134–7.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Kale TP, Singh AK, Kotrashetti SM, Kapoor A. Effectiveness of hemcon dental dressing versus conventional methods of haemostasis in 40 patients on oral antiplatelet drugs. Sultan Qaboos Univ Med J. 2012;12(3):330–5.CrossRefGoogle Scholar
  34. 34.
    Lemkin SR, Billesdon JE, Davee JS, et al. Aspirin-induced oral bleeding: correction with platelet transfusion. A reminder. Oral Surg. 1974;37(4):498–501.CrossRefGoogle Scholar
  35. 35.
    Madan GA, Madan SG, Madan G, Madan AD. Minor oral surgery without stopping daily low-dose aspirin therapy: a study of 51 patients. J Oral Maxillofac Surg. 2005;63(9):1262–5.CrossRefGoogle Scholar
  36. 36.
    McGaul T. Postoperative bleeding caused by aspirin. J Dent. 1978;6(3):207–9.CrossRefGoogle Scholar
  37. 37.
    Morimoto Y, Niwa H, Minematsu K. Hemostatic management of tooth extractions in patients on oral antithrombotic therapy. J Oral Maxillofac Surg. 2008;66:51–7.CrossRefGoogle Scholar
  38. 38.
    Morimoto Y, Niwa H, Minematsu K. Risk factors affecting postoperative hemorrhage after tooth extraction in patients receiving oral antithrombotic therapy. J Oral Maxillofac Surg. 2011;69:1550–6.CrossRefGoogle Scholar
  39. 39.
    Morimoto Y, Niwa H, Minematsu K. Hemostatic management for periodontal treatments in patients on oral antithrombotic therapy: a retrospective study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:889–96.CrossRefGoogle Scholar
  40. 40.
    Nooh N. The effect of aspirin on bleeding after extraction of teeth. Saud Dent J. 2009;21:57–61.CrossRefGoogle Scholar
  41. 41.
    Olmos-Carrasco O, Pastor-Ramos V, Espinilla-Blanco R, et al. Hemorrhagic complications of dental extractions in 181 patients undergoing double antiplatelet therapy. J Oral Maxillofac Surg. 2015;73:203–10.CrossRefGoogle Scholar
  42. 42.
    Park MW, Her SH, Kwon JB, Lee JB, et al. Safety of dental extractions in coronary drug-eluting stenting patients without stopping multiple antiplatelet agents. Clin Cardiol. 2012;35(4):225–30.CrossRefGoogle Scholar
  43. 43.
    Partridge CG, Campbell JH, Alvarado F. The effect of platelet-altering medications on bleeding from minor oral surgery procedures. J Oral Maxillofac Surg. 2008;66:93–7.CrossRefGoogle Scholar
  44. 44.
    Pawalk DF, Itkin AB, Lapeyrolerie FM, Zweig B. Clinical effects of aspirin and acetaminophen on hemostasis after exodontics. J Oral Surg. 1978;36:944–7.Google Scholar
  45. 45.
    Pereira CM, Gasparetto PF, Santos Carneiro D, et al. Tooth extraction in patients on oral anticoagulants: prospective study conducted in 108 Brazilian patients. ISRN Dent. 2011;2011:203619.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Sadhasivam G, Bhushan S, Chiang KC, Agarwal N, Vasundhar PL. Clinical trial evaluating the risk of thromboembolic events during dental extractions. J Maxillofac Oral Surg. 2016;15(4):506–11.CrossRefGoogle Scholar
  47. 47.
    Sammartino G, Maenzi G, Miro A, et al. Local delivery of the hemostatic agent tranexamic acid in chronically anticoagulated patients. J Craniofac Surg. 2012;23(6):e648–52.CrossRefGoogle Scholar
  48. 48.
    Sánchez-Palomino P, Sánchez-Cobo P, Rodriguez-Archilla A, et al. Dental extraction in patients receiving dual antiplatelet therapy. Med Oral Patol Oral Cir Bucal. 2015;20(5):e616–20.CrossRefGoogle Scholar
  49. 49.
    Shah A, Shah ST, Shah I, Rehman ZU. Post extraction bleeding associated with long-term maintenance dose of aspirin 75–150 mg. Pakistan Oral Dent J. 2012;32(2):199–202.Google Scholar
  50. 50.
    Sung EC, Brar LK, Chung E, et al. Dental treatment in the cardiothoracic intensive care unit for patients with ventricular assist devices awaiting heart transplant: a case series. Oral Surg Oral Med Oral Pathol Oral Radiol. 2014;118:194–201.CrossRefGoogle Scholar
  51. 51.
    Svensson R, Hallmer F, Englesson CS, Svensson PJ, Becktor JP. Treatment with local hemostatic agents and primary closure after tooth extraction in warfarin treated patients. Swed Dent J. 2013;37(2):71–7.PubMedGoogle Scholar
  52. 52.
    Thomason JM, Seymour RA, Murphy P, et al. Aspirin-induced post-gingivectomy haemorrhage: a timely reminder. J Clin Periodontol. 1997;24(2):136–8.CrossRefGoogle Scholar
  53. 53.
    Wahl MJ, Schmitt MM. Postextraction bleeding in a patient taking antithrombotics: report of a case. Gen Dent. 2016;64(3):60–3.PubMedGoogle Scholar
  54. 54.
    Zirk M, Fienitz T, Edel R, et al. Prevention of post-operative bleeding in hemostatic compromised patients using native porcine collagen fleeces – retrospective study of a consecutive case series. Oral Maxillofac Surg. 2016;20:249–54.CrossRefGoogle Scholar
  55. 55.
    Candemir B, Güleç S, Özdemir AO, Kumbasar D. Very late drug-eluting stent thrombosis in a patient with an INR of 4.4. Arch Turk Soc Cardiol. 2010;38:561–3.Google Scholar
  56. 56.
    Collet J-P, Himbert D, Steg PG. Myocardial infarction after aspirin cessation in stable coronary artery disease patients [Letter]. Int J Cardiol. 2000;76:257–8.CrossRefGoogle Scholar
  57. 57.
    Ferrari E, Benhamou M, Cerboni P, Marcel B. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis. J Am Coll Cardiol. 2005;45(3):456–9.CrossRefGoogle Scholar
  58. 58.
    Ferreira-González I, Marsal JR, Ribera A, et al. Background, incidence, and predictors of antiplatelet therapy discontinuation during the first year after drug-eluting stent implantation. Circulation. 2010;122:1017–25.CrossRefGoogle Scholar
  59. 59.
    Gagneja M, Gagneja P, Steelman R, Shaughnessy R, Johannes PW. Oral surgery in a child with a prosthetic aortic valve and pulmonary artery stent at risk for thromboembolism. J Clin Pediatr Dent. 2007;32(2):151–4.CrossRefGoogle Scholar
  60. 60.
    Kovacic JC, Lee P, Karjgikar R, et al. Safety of temporary and permanent suspension of antiplatelet therapy after drug eluting stent implantation in contemporary “real world” practice. J Intervent Cardiol. 2012;25:482–92.CrossRefGoogle Scholar
  61. 61.
    Loomba A, Loomba K, Bains R, Bains VK. Management of a dentigerous cyst in a medically compromised geriatric patient: a case report. Gerodontology. 2012;29(2):e1190–4.CrossRefGoogle Scholar
  62. 62.
    Derogar M, Sandblom G, Lundell L, et al. Discontinuation of low-dose aspirin therapy after peptic ulcer bleeding increases risk of death and acute cardiovascular events. Clin Gastroenterol Hepatol. 2013;11(1):38–42.CrossRefGoogle Scholar
  63. 63.
    García Rodríguez LA, Cea-Soriano L, Martín-Merino E, Johansson S. Discontinuation of low dose aspirin and risk of myocardial infarction: case-control study in UK primary care. Brit Med J. 2011;343:d4094.CrossRefGoogle Scholar
  64. 64.
    García Rodríguez LA, Cea Soriano L, Hill C, Johansson S. Increased risk of stroke after discontinuation of acetylsalicylic acid: a UK primary care study. Neurology. 2011;76(8):740–6.CrossRefGoogle Scholar
  65. 65.
    Biondi-Zoccai GGL, Lotrionte M, Agostoni P, et al. A systematic review and meta-analysis on the hazards of discontinuing or not adhering to aspirin among 50,279 patients at risk for coronary artery disease. Eur Heart J. 2006;27:2667–74.CrossRefGoogle Scholar
  66. 66.
    Sibon I, Orgogozo JM. Antiplatelet drug discontinuation is a risk factor for ischemic stroke. Neurology. 2004;62:1187–9.CrossRefGoogle Scholar
  67. 67.
    Maulaz AB, Bezerra DC, Michel P, et al. Effect of discontinuing aspirin therapy on the risk of brain ischemic stroke. Arch Neurol. 2005;62(8):1217–20.CrossRefGoogle Scholar
  68. 68.
    Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue aspirin in the perioperative period: a randomized, controlled trial. Br J Anaesgth. 2010;104(3):305–12.CrossRefGoogle Scholar
  69. 69.
    Mantz J, Samama CM, Tubach F, et al. Impact of preoperative maintenance or interruption of aspirin on thrombotic and bleeding events after elective non-cardiac surgery: the multicentre, randomized, blinded, placebo-controlled STRATAGEM trial. Br J Anaesth. 2011;107(6):899–910.CrossRefGoogle Scholar
  70. 70.
    Broderick JP, Bonomo JB, Kissela BM, et al. Withdrawal of antithrombotic agents and its impact on ischemic stroke occurrence. Stroke. 2011;42:2509–14.CrossRefGoogle Scholar
  71. 71.
    Grines CL, Bonow RO, Casey DE, et al. Prevention of premature discontinuation of antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation. 2007;115:813–8.CrossRefGoogle Scholar
  72. 72.
    Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e326S–50S.CrossRefGoogle Scholar
  73. 73.
    Armstrong MJ, Gronseth G, Anderson DC, et al. Summary of evidence-based guideline: periprocedural management of antithrombotic medications in patients with ischemic cerebrovascular disease. Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80(22):2065–9.CrossRefGoogle Scholar
  74. 74.
    Mashour GA, Moore LE, Lele AV, Robicsek SA, Gelb AW. Perioperative care of patients at high risk for stroke during or after non-cardiac, non-neurologic surgery: consensus statement from the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol. 2014;26(4):273–85.CrossRefGoogle Scholar
  75. 75.
    American Dental Association. Anticoagulant and antiplatelet medications and dental procedures. Available: January 21, 2017.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Michael J. Wahl
    • 1
  1. 1.Christiana Care Health SystemWilmingtonUSA

Personalised recommendations