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British Journal of Oral and Maxillofacial Surgery 53 (2015) 3943

Dental extractions and risk of bleeding in patients taking

single and dual antiplatelet treatment
Branislav V. Bajkin a, , Ivana M. Urosevic b , Karmen M. Stankov b , Bojan B. Petrovic a ,
Ivana A. Bajkin b
a
b

Dental Clinic of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Hajduk Veljkova 12, 21000 Novi Sad, Serbia
Clinical Center of Vojvodina, Faculty of Medicine Novi Sad, University of Novi Sad, Hajduk Veljkova 1, 21000 Novi Sad, Serbia

Accepted 11 September 2014

Available online 11 October 2014

Abstract
Our aim was to evaluate the effects of single and dual antiplatelet treatment on postoperative bleeding in patients having dental extractions.
The prospective clinical study included 160 patients who were taking antiplatelet drugs. The first group (n = 43) were taking 2 drugs, mostly
aspirin and clopidogrel, and the second group (n = 117) were taking a single antiplatelet drug in the form of aspirin (n = 84), clopidogrel
(n = 20), and ticlopidine (n = 13). All patients had simple dental extractions, and local haemostasis was with resorbable collagen sponges,
without suturing of the wound. The control group comprised 105 healthy subjects with a similar number of dental extractions. Bleeding was
an event if it continued for more than 12 h, made the patient call or return to the dental practice or emergency department, induced a large
haematoma or ecchymosis within the oral soft tissues, or required blood transfusion.
A total of 110 teeth were extracted on 59 occasions in the dual drug group, and 232 teeth on 128 occasions in the single drug group.
Bleeding was recorded after extraction in only one patient on dual aspirinclopidogrel treatment, which was mild and easily controlled by
local haemostasis. The incidence of postoperative bleeding did not differ significantly among the three groups (2 = 4.3, p = 0.11). However,
the wound was sutured to achieve effective initial local haemostasis in 4/59 (6.8%) and 2/128 (1.6%) occasions of tooth extractions in the dual
and single drug groups, respectively, and none in the control group (2 = 10.02, p = 0.007). Patients taking single or dual antiplatelet drugs
may have teeth extracted safely without interruption of treatment using only local haemostatic measures.
2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Aspirin; Thienopyridines; Antiplatelet therapy; Bleeding; Oral surgery; Tooth extraction

Introduction
Antiplatelet agents are widely used in the prevention and
management of arterial thrombosis, and the common indications for their long-term use are ischaemic heart disease,
previous myocardial infarction, coronary artery bypass and
placement of a stent, non-haemorrhagic stroke, transient
ischaemic attacks, and peripheral arterial disease.

Corresponding author. Tel.: +381 62770665; fax: +381 21526120.

E-mail address: bajkinb@eunet.rs (B.V. Bajkin).

Low doses of aspirin, clopidogrel, ticlopidine, and dipyridamole are the most common antiplatelet drugs, and they
inhibit platelet function by different mechanisms. Aspirin
irreversibly inactivates the enzyme cyclo-oxygenase and
thereby prevents synthesis of thromboxane A2 , which has
an important role in platelet aggregation. Aspirin affects the
activity of platelets during their lifetime (710 days). Clopidogrel, ticlopidine, and prasugrel (thienopyridines) inhibit
adenosine-diphosphate receptors and are also effective during
the lifetime of a platelet. Dipyridamole inhibits the reuptake
of adenosine and increases cAMP.1

http://dx.doi.org/10.1016/j.bjoms.2014.09.009
0266-4356/ 2014 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

40

B.V. Bajkin et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 3943

These drugs are sometimes combined, because they work

in different ways. The combination of low-dose aspirin and
clopidogrel is mainly used to prevent thrombotic complications after percutaneous insertion of a coronary stent.2,3
Despite the benefits of antiplatelet drugs they are not
without risk in that they can increase the risk of bleeding,
particularly gastrointestinal bleeding, haemorrhagic stroke,
and postoperative bleeding. In patients who take combinations of antiplatelet drugs, the risk is higher because of their
synergistic effect.2
Because of the fear of excessive bleeding, physicians often
recommend discontinuation of antiplatelet drugs several days
before oral operations,4,5 but this can expose patients to the
risk of thromboembolism.69 Several studies have shown that
there is no need to discontinue aspirin before dentoalveolar
surgery.1017 Nevertheless, there is a lack of published evidence about perioperative dental management of the patients
on dual and non-aspirin antiplatelet drugs.4,5,13,18
Our aim was to evaluate the effect of single and dual
antiplatelet drugs on postoperative bleeding in patients who
had teeth extracted.

Patients and methods

The prospective clinical study took place from September
2010 to December 2013. All patients provided written
informed consent, and the study was approved by the local
Ethics Committee.
The dual group comprised 43 patients who were
taking two antiplatelet drugs (asprin + clopidogrel,
aspirin + ticlopidine and aspirin + prasugrel) and the
single group 117 who were taking aspirin, clopidogrel, or
ticlopidine alone. All participants were told to continue to
take their antiplatelet drugs regularly. The control group
comprised 105 healthy patients who were not taking any
drugs.
All patients required a simple extraction of one or
more teeth under local anaesthesia with no need for a
mucoperiosteal flap. Patients with liver disease, alcoholism,
those taking anticoagulant therapy or non-steroidal antiinflammatory drugs that could interact with aspirin, those
who had had a serious haemorrhage after dental extractions
before starting the antiplatelet drugs, those who discontinued
their drugs for whatever reason, and minors, were excluded
from the study.
All dental extractions were done in the outpatient clinic by
one surgeon with minimal trauma. The local anaesthesia was
achieved using 2% lignocaine with 1/80 000 adrenaline. The
same local haemostatic measures were used for all patients.
Extraction sockets were packed with a collagen sponge without primary suture of the wound. Afterwards patients were
asked to hold the sterile gauze in a firm bite for 30 min. The
patients were then observed for 2 h. If there was any bleeding after extraction a gauze pressure pad was applied to the
wound for 10 min. This was repeated, if needed, twice, after

Table 1
Indications for antiplatelet medication.
Indication

Dual
antiplatelet
treatment
(n = 43)

Single
antiplatelet
treatment
(n = 117)

Coronary artery stents

After myocardial infarction
After coronary artery bypass
Angina pectoris
Ischaemic heart disease and
thrombophlebitis
Ischaemic heart disease and
cerebrovascular disease
Ischaemic cerebrovascular disease
After peripheral vascular surgery
Thrombophlebitis
Valvar heart disease
Thrombophilia
Primary prevention

28
7
3
3
1

14
21
25
30
0

0
0
0
0
0
0

10
4
4
1
1
2

which the wound was sutured with a non-resorbable 3/0 black

silk suture.
All patients were given a list of postoperative instructions
and the telephone number of a surgeon who could be contacted in case of postoperative bleeding. Paracetamol was
recommended for relief of pain. All participants were examined after 30 min and 2 h, and then on the first, second, and
fifth days later. Patients who were unable to come for a regular check-up were contacted by telephone to find out if they
had had any bleeding. They were also instructed to call the
surgeon if any bleeding occurred. Any sutures were removed
on the fifth day. Bleeding was identified as an event using
criteria recommended by Lockhart et al.19 if it continued for
more than 12 h; was enough to make the patient call or return
to the dental practice or emergency department; resulted in the
development of a large haematoma or ecchymosis within the
oral soft tissues; or required a blood transfusion. We recorded
all the cases where the wound required a suture for successful local haemostasis before discharge (two hours after the
procedure), but we did not consider it a bleeding event.
We used the 2 test to evaluate the significance of differences in postoperative bleeding between the groups. The
significance of differences between parametric variables was
assessed using the analysis of variance. Probabilities of less
than 0.05 were accepted as significant.

Results
We initially studied 192 patients who were taking antiplatelet
drugs. Nineteen patients who discontinued their antiplatelet
dugs several days previously, for whatever reason, were
excluded from the study. Thirteen patients who required a
more complex extraction were also excluded. A total of 160
patients therefore met the study inclusion criteria 43 in the
dual group and 117 in the single group. The indications for
treatment are shown in Table 1. The control group consisted
of 105 healthy subjects.

B.V. Bajkin et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 3943

41

Table 2
Characteristics of the three groups of patients. Data are number (%) of patients unless otherwise stated.
Variable
Sex
Male
Female
Mean (SD) age (years)
Treatment
Aspirin + clopidogrel
Aspirin + ticlopidine
Aspirin + prasugrel
Aspirin
Clopidogrel
Ticlopidine
No. of extractions (occasions)
No. of teeth extracted
Total
Mean (SD) (/occasion)
Range
Single/multiple extractions
Reasons for extraction
Periodontal disease
Deep caries
Suturing for local haemostasis
No. with postoperative bleeding

Dual aniplatelet treatment (n = 43)

Single antiplatelet treatment (n = 117)

Controls (n = 105)

32
11
61.1 (10.2)

66
51
63.4 (10.8)

61
44
61.2 (11.3)

39
2
2

59

84
20
13
128

127

110
1.9 (0.8)
14
23/36

232
1.8 (1)
15
62/66

246
1.9 (0.9)
15
49/78

53
57
4 (6.8%)
1 (1.7%)

108
124
2 (1.6%)
None

113
13
None
None

There were no significant differences among the three

groups in sex (p = 0.13) or age (p = 0.26). Aspirin was the
most commonly prescribed antiplatelet agent in both groups;
all these patients took a dose of 100 mg, except 1 in the dual
group and 2 in the single group who took 300 mg. Details are
shown in Table 2.
One patient in the dual group (aspirinclopidogrel) developed postoperative bleeding (Table 2). This patient returned
to the clinic the same day with prolonged bleeding after
the extraction of 3 upper molars. The bleeding was easily controlled by suturing and compression of the wound.
None of the patients in the single group developed postoperative bleeding, but one (taking aspirin) developed a
minor haematoma on the cheek the day after extraction
of two upper molars and suturing of the wound, which
absorbed spontaneously within a few days. There was no
significant difference in the incidence of postoperative bleeding among the 3 groups (2 = 4.34, p = 0.11). However,
the wound required suturing to achieve effective initial
haemostasis in 4/59 (6.8%) occasions of tooth extractions
in the dual group, in 2/128 (1.6%) occasions in the single group, and in none of the control patients (2 = 10.02,
p = 0.007).

Discussion
Antiplatelet agents are widely used for the prevention
and treatment of various ischaemic cardiovascular and
cerebrovascular conditions. The Antithrombotic Trialists
Collaboration confirmed in a meta-analysis that antiplatelet
drugs had a protective effect in acute myocardial infarction or
ischaemic stroke, both stable and unstable angina, previous

myocardial infarction, stroke or cerebral ischaemia, peripheral arterial disease, and atrial fibrillation.20,21 Those studies
confirmed that antiplatelet agents had a substantial benefit in
the secondary prevention of occlusive vascular events, but for
primary prevention their use should be weighed against the
increased risk of bleeding.21
Each antiplatelet agent has its own mechanism of action
that affects platelet aggregation differently. Because of these
different mechanisms and their synergistic effects, combinations of two antiplatelet drugs are possible and are
sometimes used. For example, clopidogrel together with lowdose aspirin is recommended in patients with stents,2,3 and
this combination is increasingly used.1
The perioperative management of patients taking
antiplatelet drugs includes balancing the risk of bleeding
if they are continued, and the risk of thromboembolism if
they are not.69 The risk of thrombosis of a stent after premature discontinuation of dual antiplatelet treatment is well
recognised,3 and is the main cause of late thrombosis with
serious consequences: reported mortality from presumed or
documented thrombosis ranges from 20% to 45%.3 The
American College of Chest Physicians recommends continuing the antiplatelet drugs perioperatively in patients who
require operation within 6 weeks of placement of a metal
stent or within 6 months of placement of a drug-eluting
stent.22
Several recently published studies have reported that
minor oral procedures can be safely (without a risk of
bleeding) done in patients taking low doses of aspirin.1016
Recommendations based on these results advocate continuation of the low-dose aspirin during dental extractions.3,2225
However, the number of patients included in these studies
was small, and the authors therefore suggested that further

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B.V. Bajkin et al. / British Journal of Oral and Maxillofacial Surgery 53 (2015) 3943

research is necessary. There has also been insufficient evidence so far about the risk of bleeding during oral procedures
in patients taking thienopyridine alone or together with
aspirin.1,35,22,25
Another recent study stated that there was no need to discontinue either the anticoagulant or aspirin in the patients
taking the combined oral anticoagulant-aspirin regimen who
required dental extraction.10 Several recent studies have also
included patients on dual antiplatelet treatment who required
oral surgery. The authors of these studies concluded that the
continuation of dual antiplatelet drugs is relatively safe, but
emphasised the need of further research because sample sizes
were small.5,12,18
We recorded only 1/43 patients (59 occasions of tooth
extractions) who developed mild postoperative bleeding)
when taking dual antiplatelet drugs after extractions of 3
upper molars. None of the 117 patients (128 occasions
of tooth extractions) in the single drug group (including
20 patients taking clopidogrel and 13 taking ticlopidine),
developed a postoperative haemorrhage. However, suturing
of the wound to achieve effective initial local haemostasis was needed in 4 and 2 patients taking dual and
single antiplatelet drugs, respectively, but not in healthy
subjects.
We did not measure bleeding time in any of our patients.
Those taking antiplatelet drugs may have prolonged bleeding time, but the test is not reliable enough to predict the
risk of bleeding after dental surgery.1,25 Indeed, some recent
reports about dental extractions in patients taking antiplatelet
drugs have reported that the bleeding time was almost always
within the normal range.14,16 The platelet aggregation test is
more sensitive, but it is not in use in everyday practice.25 We
know of only one small sample study in which the platelet
aggregation test was used before dental extractions,13 and
this suggests that this and other platelet function tests may be
important for further research.
The point of discussion can also be the definition of a
bleeding event. There is no standard approach to defining
bleeding after oral surgical procedures in patients taking
antithrombotic drugs. Different authors have used different
criteria for bleeding, making the results of these studies hard
to compare. In our study, we used the criteria given by Lockhart et al.19 which are in our opinion good for defining a
clinically important bleed.10
This study has some potential limitationsfirst, its relatively small sample size, and second that we studied only
procedures with a low risk of bleeding (simple single and
multiple extractions).
It is also worth noting that an appreciable number of
patients 19 of 192 (10%) who were not included in the
study discontinued their antiplatelet drugs, usually aspirin,
several days before the procedure for whatever reason. It
seems that it takes time to educate our patients that teeth may
be extracted safely without the discontinuation of antiplatelet
drugs. An interdisciplinary discussion of this topic would be
exceptionally useful.

Conict of interest statement

There is no conflict of interest.

Ethical approval/conrmation of patients permission

The study was approved by the local Ethics Committee. All
patients provided written informed consent to take part in the
study.

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