In patients taking antiplatelet medications who are undergoing dental surgery, physicians and dentists must weigh the bleeding risks in continuing antiplatelet medications versus the thrombotic risks in interrupting antiplatelet medications. Bleeding complications requiring more than local measures for hemostasis are rare after dental surgery in patients taking antiplatelet medications. Conversely, the risk for thrombotic complications after interruption of antiplatelet therapy for dental procedures apparently is significant, although small. When a clinician is faced with a decision to continue or interrupt antiplatelet therapy for a dental surgical patient, the decision comes down to “bleed or die.” That is, there is a remote chance that continuing antiplatelet therapy will result in a (nonfatal) bleeding problem requiring more than local measures for hemostasis versus a small but significant chance that interrupting antiplatelet therapy will result in a (possibly fatal) thromboembolic complication. The decision is simple: It is time to stop interrupting antiplatelet therapy for dental surgery.
The history of aspirin (acetylsalicylic acid) dates back more than 2000 years ago, when Hippocrates recommended chewing on willow leaves (which contain salicylic acid) during childbirth for analgesia. In 1899, the chemist Felix Hoffman of Bayer AG (Leverkusen, Germany) was the first to isolate pure acetylsalicylic acid, later calling it “Aspirin” for commercial manufacture and sale. Since then, Bayer AG lost or sold its rights to the trademark, and the “wonder drug” aspirin is widely used for its analgesic, antipyretic, anti-inflammatory, and anti-thrombotic effects.
Aspirin’s antithrombotic indications include atrial fibrillation, history of angina or myocardial infarction, coronary artery disease prevention, history of coronary bypass surgery, and percutaneous coronary intervention and stent implantation. Newer antiplatelet medications include clopidogrel (Plavix; Bristol-Myers Squibb, New York, NY), ticlopidine (Ticlid; Roche Laboratories, Basel, Switzerland), cilostazol (Pletal; Otsuka America Pharmaceuticals Inc, Rockville, Md), dipyridamole (Persantine; Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Conn), ticagrelor (Brilinta; AstraZeneca, Paddington, London), and prasugrel (Effient; Ube Industries, Ube, Japan). Some of these newer agents are associated with greater antithrombotic efficacy but also higher bleeding risks than aspirin. When dental surgery is contemplated in patients taking 1 or more of these medications, dentists and physicians must weigh the potential bleeding risks in continuing the medications versus the thromboembolic risks in interrupting them before dental surgery.
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–Michael J. Wahl, DDS
This article originally appeared in the April 2014 issue of The American Journal of Medicine.
