J Oral Maxillofac Surg

66:2063-2066, 2008

Exodontia and Antiplatelet Therapy

Balasubramanian Krishnan, MDS, DNB, MOMS RCPS (Glasgow),*
Nithin A. Shenoy, MDS, and
Mohan Alexander, MDS, MOMS RCPS (Glasgow)
Purpose: The fear of excessive bleeding often prompts the physician to stop long-term, low-dose

antiplatelet therapy before any surgical procedure. This may put the patient at risk of an adverse
thromboembolic event. We undertook an assessment of the incidence of prolonged postoperative
bleeding after dental extractions among patients on uninterrupted antiplatelet therapy, and evaluated
the need to stop such medications before dental extractions.
Patients and Methods: Eighty-two patients requiring dental extractions were included in this study, of
whom 57 were on antiplatelet therapy (aspirin). Patients were divided into 3 groups. Group 1 consisted
of patients in whom antiplatelet therapy was interrupted (n 25), group 2 consisted of those continuing
their medication (n 32), and group 3 comprised healthy patients not on antiplatelet therapy (n 25).
Preoperative bleeding time and clotting time were determined in all patients. The surgical procedure
involved single or multiple teeth extractions under local anesthesia with a vasoconstrictor. All patient
groups were similar regarding age, gender distribution, dosage of antiplatelet drug, and medical condition for which the drug was prescribed. Events of single or multiple teeth extractions were also
comparable among the 3 groups. Pressure packing was performed in all cases as in routine dental
extractions. One-way analysis of variance was performed to determine the significance of prolonged
bleeding among groups.
Results: The mean bleeding times in groups 1, 2, and 3 were 3 minutes, 2 minutes and 45 seconds,
and 1 minute and 49 seconds, respectively. The mean clotting times in groups 1, 2, and 3 were 5
minutes and 4 seconds, 4 minutes and 52 seconds, and 3 minutes and 42 seconds, respectively. No
patient in any group had any episode of prolonged or significant bleeding from the extraction sites.
Local hemostasis had been satisfactorily obtained in all cases with the use of a pressure pack for 30
minutes.
Conclusions: Routine dental extractions can be safely performed in patients on long-term antiplatelet
medication, with no interruption or alteration of their medication. Such patients do not have an increased
risk of prolonged or excessive postoperative bleeding.
2008 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 66:2063-2066, 2008
Advances in medical science have ensured an increased lifespan for human beings. Unfortunately, this
has come at the price of a greater incidence of medically compromising conditions in a large proportion
Received from the Department of Oral and Maxillofacial Surgery,
Mahatma Gandhi Postgraduate Institute of Dental Sciences, Indira
Nagar, Pondicherry, India.
*Lecturer.
Former Postgraduate Trainee.
Former Professor and Head.
Address correspondence and reprint requests to Dr Alexander: Oral and Maxillofacial Surgery, D.J. Dental College, Niwari Road, Modinagar 201204, Uttar Pradesh, India; e-mail:
mohanalexin@yahoo.com
2008 American Association of Oral and Maxillofacial Surgeons

0278-2391/08/6610-0013$34.00/0
doi:10.1016/j.joms.2008.06.027

of such individuals. Of particular interest to the oral

and maxillofacial surgeon are those patients who are
maintained on oral antiplatelet agents. Although
newer antiplatelet agents are available, aspirin continues to be favored because of its low cost and reliable
efficacy. The fear of uncontrolled or excessive
bleeding prompts medical practitioners to stop or
alter these drugs before surgical procedures. However, considerable debate has been generated with
regard to balancing the risk of a postsurgical hemorrhage with that of precipitating a thromboembolic event. Stopping or altering antiplatelet therapy may expose such patients to the risk of
thromboembolism, myocardial infarction, or cerebrovascular accidents.1
We undertook an assessment of the incidence of
prolonged postoperative bleeding after dental extractions among patients on uninterrupted antiplatelet

2063

2064

EXODONTIA AND ANTIPLATELET THERAPY

therapy, and evaluated the need to stop such medications before dental extractions.

Patients and Methods

Our Ethics and Research Committee approved the
study, conducted over a period of 25 months (from
2004 to 2006). Informed consent was obtained from
all patients in this study.
Eighty-two patients requiring dental extractions
were included. Among these, 57 were on antiplatelet
therapy (aspirin) for various cardiac ailments. All patients underwent estimations of bleeding time (BT;
Dukes method) and clotting time (CT; slide method)
on the day of extractions. Those with a preoperative
bleeding time of more than 20 minutes, a history of
bleeding disorders, concomitant anticoagulant therapy, newer antiplatelet drugs along with aspirin, pregnancy, or alcoholism, and minors, were excluded
from the study. The cardiac condition for which the
drug was prescribed, and the duration and dose of
medication, were recorded (Table 1).
Potential complications while performing surgical
procedures with uninterrupted or interrupted antiplatelet therapy were explained to all patients by a
single investigator (B.K.) and were then divided into 2
groups, depending on their choice. Group 1 comprised patients in whom antiplatelet therapy would
be stopped before dental extractions. Group 2 consisted of patients who would undergo dental extractions without any interruption or alteration of antiplatelet therapy. A third group included healthy
patients who had never received any kind of antiplatelet therapy (control group).
Before the procedure, all patients received a local
anesthetic injection (2% lignocaine with vasoconstrictor). Extractions (single or multiple) were performed
by the same operator (N.A.S.) in all cases, with as little
trauma as possible. Patients were instructed to bite on
a pressure pack for 30 minutes. Evidence of bleeding
from the extraction site beyond this time period was
considered to be prolonged postoperative bleeding.
All patients were discharged only after ensuring that

Table 1. CARDIAC AILMENTS FOR WHICH

ANTIPLATELET MEDICATIONS WERE PRESCRIBED

Cardiac Ailments

Number of Patients

Myocardial infarction
Ischemic heart disease
Coronary artery disease
Post bypass
Valvular surgery

12
15
10
12
8

Krishnan, Shenoy, and Alexander. Exodontia and Antiplatelet

Therapy. J Oral Maxillofac Surg 2008.

satisfactory hemostasis had been achieved at the extraction site. Patients were instructed to report back
immediately in case of any complaint of postoperative
bleeding. Clinically significant bleeding2 was defined as bleeding that:
1. Continued beyond 12 hours of the operative
procedure;
2. Caused a patient to call or return to the dental
office or emergency department;
3. Resulted in the development of a large hematoma within the soft tissues; and
4. Required a blood transfusion.
Analysis of variance was used to evaluate results
among the 3 groups and determine statistical significance, if any.

Results
Among the 57 patients on antiplatelet therapy included in the first 2 groups, 25 patients were in group
1, and 32 were in group 2. The control group comprised 25 patients. All patient groups were similar
with regard to age and gender distribution. The 2
treatment groups were also comparable with regard
to dosage of antiplatelet drug and the medical condition for which the drug had been prescribed. Events
of single or multiple teeth extractions were also comparable among the 3 groups. Aspirin doses were 75 or
150 mg per day. Duration of dosage ranged from 4
months to 348 months in group 1 ( SD of 83
months), and between 1 and 348 months in group 2
( SD of 50 months). In the first 2 groups, 15 patients
gave a history of having undergone extractions after
the initiation of antiplatelet therapy. Of these, 8 had
stopped their medication before the extractions on
the advice of their physician. This duration of interruption before the extractions ranged from 2 to 7
days. The remaining 7 did not alter their medications,
because they had not consulted their physician before
the dental extractions. However, none of these 15
patients reported any event of uncontrolled or prolonged bleeding after their dental extractions. In
group 1, interruption of antiplatelet therapy ranged
from 1 to 10 days, with a mean of 4.7 days. The BT
estimate among patients in group 1 ranged from 1
minute and 45 seconds to 12 minutes and 50 seconds,
with a mean of 3 minutes ( SD of 2 minutes and 45
seconds), whereas in group 2, this range was from 1
minute and 45 seconds to 5 minutes and 45 seconds,
with a mean of 2 minutes and 45 seconds ( SD of 1
minute and 38 seconds). Group 3 BT values ranged
from 1 minute and 5 seconds to 3 minutes and 25
seconds, with a mean of 1 minute and 49 seconds (
SD of 0 minutes and 39 seconds). The CT values

2065

KRISHNAN, SHENOY, AND ALEXANDER

Table 2. COMPLEXITY OF EXODONTIA PROCEDURE

Group Extracted
Group 1
Group 2
Group 3

Type of Teeth
Extracted

Number of Teeth

Anterior
Premolars
Molars
Anterior
Premolars
Molars
Anterior
Premolars
Molars

5
6
17
11
10
19
6
11
13

Krishnan, Shenoy, and Alexander. Exodontia and Antiplatelet

Therapy. J Oral Maxillofac Surg 2008.

ranged from 3 minutes and 15 seconds to 10 minutes

and 15 seconds, with a mean of 5 minutes and 4
seconds ( SD of 1 minute and 38 seconds) in group
1, whereas in group 2, CT values ranged from 3
minutes and 35 seconds to 7 minutes and 10 seconds,
with a mean of 4 minutes and 52 seconds ( SD of 1
minute and 4 seconds). Group 3 CT values ranged
from 3 minutes and 10 seconds to 10 minutes and 40
seconds, with a mean of 3 minutes and 42 seconds (
SD of 1 minute and 53 seconds). All these values were
within acceptable limits, and no significant statistical
difference was observed among the 3 groups.
Twenty patients in group 1 underwent extraction
of a single tooth, and 5 had multiple teeth extracted.
In group 2, 10 patients underwent removal of multiple teeth, whereas the control group contained only 4
patients with extraction of multiple teeth. The 3
groups did not differ in the complexity of their operative procedures (Table 2). No patient in any group
had any episode of prolonged or significant bleeding
from the extraction sites. Local hemostasis had been
satisfactorily obtained in all cases with the use of a
pressure pack for 30 minutes.

Discussion
Until the early 1980s, aspirin was used as an antiinflammatory, analgesic, and antipyretic drug. Side
effects of aspirin, such as gastrointestinal irritation
and ulcers, and asthma-like attacks in asthmatic patients, limited the administration of aspirin to short
periods. However, the antiplatelet effect of aspirin is
elicited at low doses of 0.5 to 1.5 mg/kg/day, whereas
analgesic and anti-inflammatory effects are achieved
at doses of 5 to 10 mg/kg/day and more than 30
mg/kg/day, respectively.3 Platelets play a key role in
thrombosis, atherosclerosis, and acute coronary syndromes such as myocardial infarction and angina.
Consequently, the concept of inhibition of platelet
activity as an appropriate antithrombotic therapy

gained considerable support, and has been achieved

with low doses of aspirin. The Anti-Platelet Trialists
Collaboration,4 in a meta-analysis of 287 studies involving 135,000 patients, confirmed the prophylactic
effects of aspirin and other oral antiplatelet drugs
after a previous myocardial infarction, in angina, after
stroke, and after bypass surgery, and established the
efficacy of these drugs in both genders. Vascular
events are reduced by 20% to 25% in the first few
years after the index event, and all-case mortality is
reduced by 12%. The last few decades have seen an
increased use of low-dose aspirin, either alone or in
combination with other drugs, as a secondary preventive drug.
Platelets provide a lipoprotein surface that catalyzes reactions such as formation of thrombin.
In addition, a contractile protein, thrombosthenin,
present in platelets, plays an important role in clot
retraction.5 It was reported that estimation of BT
might reflect the extent to which platelet function
might be affected by medications such as aspirin.6
The CT test was also suggested to measure platelet
function in patients on aspirin therapy.7 However, a
correlation between BT test results and rate of surgical bleeding complications has not been established.8
Bleeding time does not specifically or accurately reflect in vivo platelet function, and abnormal BTs were
reported in various disorders not associated primarily
with hematologic disturbances.9 Little et al10 suggested that aspirin-affected platelets did not lead to a
significant bleeding problem unless the BT was
greater than 20 minutes. Gaspar et al11 and Sonksen et
al12 claimed that prolongation of BT, within acceptable limits, did not exert any significant effect on
intraoperative or postoperative bleeding after dental
extractions. However, the scientific rationale for considering this time period of 20 minutes as safe is not
clear. More expensive options such as platelet function analyzers, the ristocetin test, and flow cytometry
have been used to analyze platelet function, but none
can accurately assess the increased risk of bleeding in
patients taking antiplatelet drugs. The easy availability
of both BT and CT tests was the sole reason for their
use in this study. Considerable controversy has been
generated regarding patients on aspirin therapy requiring surgical procedures. Recommendations to
stop the drug 7 to 10 days before the procedure
appear to be based on the irreversible effect exerted
by aspirin on platelets.13,14 Sonksen et al,12 in a study
of 52 healthy volunteers on a 7-day course of aspirin,
showed that the BT was below 10 minutes within 48
hours of stopping aspirin therapy. Hence, withdrawal
of the drug for 5 or more days, as recommended,
appears to be erroneous. However, this test was performed on healthy volunteers, and a simple extrapolation to patient subgroups may be unjustified. Also,

2066
considerable interindividual variability in the magnitude of aspirins effect on primary hemostasis is
present and may have influenced the results.
Fijhneer et al,15 in conducting a review, pointed
out the scarcity of literature regarding dermatologic,
cataract, ear, nose, and throat, and dental surgeries
involving patients on aspirin therapy. Although some
studies in patients undergoing cardiovascular surgery
concluded that aspirin involved a risk for increased
bleeding,16,17 similar studies in the dermatologic,18
ophthalmic,19 and orthopedic20 literature support the
view that it is not necessary to stop aspirin before
undergoing minor surgical procedures. Shalom and
Wong21 compared patients using aspirin to those
without while undergoing excision of cutaneous and
subcutaneous lesions, and found no differences in the
bleeding patterns of the 2 groups. Studies by Gaspar
et al11 and others22-24 concluded that hemostasis
posed no problems during ambulatory oral surgical
procedures among patients on aspirin therapy, and
recommended continuation of antiplatelet therapy
without any interruption. These findings are in concurrence with our observations. Whereas various haemostatic measures such as gelatin sponge, tranexamic
acid mouth rinse, and fibrin glue have been used to
control bleeding, a routine pressure-pack application
was sufficient to control bleeding in all patients in our
study, and required no additional measures.
The drawbacks of our study may include a failure to
homogenize the duration of interruption of antiplatelet therapy in group 1, which ranged from 1 to 10
days. This was because some patients had stopped
aspirin as per the advice of their physicians and
wanted the extractions done the same day of their
visit to the department. However, this did not significantly alter the results. Patients with no previous
history of extractions were advised by their dental
school physician to interrupt aspirin therapy for 5
days before their extractions.
There is a possibility that by choosing their own
treatment, patients might have introduced bias into
the study, based on their own past surgical/bruising/
bleeding tendencies, regardless of their recorded
bleeding times. However, this possibility seems minimal, because none of the 15 patients who had a
previous history of extraction had reported any incident of uncontrolled postextraction bleeding.
An initial attempt at randomization had to be abandoned because several patients refused to provide
consent. It was evident that patients were more comfortable following their physicians advice or choosing treatment on their own, rather than being placed
in either group randomly.
This study concludes that routine dental extractions can be safely performed in patients on longterm, low-dose aspirin, with no interruption of the

EXODONTIA AND ANTIPLATELET THERAPY

medication, and such patients do not have an increased risk of prolonged or excessive postoperative
bleeding.

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