Postoperative hemorrhagic complications can be severe and may require aggressive interventions including hospitalization. Minor hemorrhages are more common and dealt with by routine office procedures.
A literature review and guideline development process conducted by the Oral Medicine and Oral Surgery Francophone Society found that, based on the agreement among professionals in the field, interruption of therapy before dental procedures is unnecessary. Many similar procedures carry a low risk of bleeding, and any bleeding that occurs can usually be controlled by local hemostasis.[9
Other than invasive procedures it also has an impact on clinical assessments such as bleeding on probing. In one trial, 54 patients were divided into three groups. The first group took 81 mg aspirin for seven days, a second group took 325 mg aspirin daily for seven days, and the third group took placebo daily for the same duration. This study concluded that the effects of aspirin could impair diagnostic assessments and treatment planning decisions for the clinicians.[10
In a prospective study by Ardekian et al
] 39 patients taking aspirin were studied. Nineteen continued the anti-platelet therapy, while 20 stopped taking aspirin seven days prior to the extractions. Intraoperative bleeding was controlled in 33 patients with gauze packs and sutures. Six patients had tranexamic acid added to the local packing. Finally, it was observed that no patient experienced bleeding immediately or in the week following the procedure.
In a retrospective study of 43 patients on single or dual anti-platelet therapy who underwent 88 invasive procedures consisting of extractions, periodontal surgery, and subgingival scaling and root planing, Napenas et al
] found no differences between patients receiving single or dual anti-platelet therapy.
A prospective observational study was used to quantitatively assess the amount and severity of bleeding encountered with dentoalveolar surgery in two groups, one on anti-platelet therapy, and the other, a group of healthy controls. They demonstrated no difference in blood loss after a minor oral surgical procedure.[13
A prospective trial on 155 patients under anti-platelet therapy reaffirms the fact that local measures are sufficient to control post-extraction hemorrhages. It seems advisable to be cautious with regard to the number of teeth to be extracted during the same session, and it has been recommended that not more than three teeth are to be extracted at a time, and that these should either be adjacent or correlative, and not in different parts of the dental arch. For molar teeth, no more than two adjacent teeth should be extracted.[14
There is controversy among dentists and physicians regarding the appropriate dental management of patients receiving dual anti-platelet therapy, due to the lack of clinical studies about hemorrhagic risk in these patients. Options before a dental clinician includes modifying dual anti-platelet therapy by altering the dosage or switching to monotherapy or discontinuing therapy.
However, when a definite increase in intraoperative bleeding is feared, or when surgical hemostasis is difficult, aspirin can be replaced by a shorter acting nonsteroidal anti-inflammatory drug, given for a 10-day period and interrupted the day before surgery, and postoperative anti-platelet treatment should be resumed immediately after surgery (first six hours).[4
A recent consensus opinion from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association recommended continuing aspirin and clopidogrel therapy for minor dental surgical procedures in patients who have coronary artery stents, or delaying treatment until the prescribed regimen is completed.[15
The hemorrhagic risk related to dental extraction is a rare complication. The incidence of post-extraction hemorrhagic complications, including other risk factors, does not exceed the average of 0.2 and 2.3%.[16
In specific extenuating circumstances, if discontinuation is essential, it should be limited to three or fewer days, as increased risk for thrombotic events increases when discontinuation is between four and 30 days.[17