Dental Management of Antiplatelet-Receiving Patients: Is Uninterrupted Antiplatelet Therapy Safe?

Abstract

The population of patients eligible for chronic antiplatelet treatment is expanding globally, in tandem with the rising prevalence of cardiovascular disease and the increasing use of percutaneous coronary interventions. While antiplatelet agents have revolutionized the management of atherosclerotic disease and its thrombotic complications, the potential of bleeding remains an inherent risk. Temporary withdrawal of antiplatelet therapy may therefore seem an attractive option in iatrogenic settings that pose a bleeding hazard; in this case, however, the benefit of averting antiplatelet-induced hemorrhage needs to be balanced against the risk of potentially fatal thrombosis, particularly in the expanding cohort of patients with drug-eluting stents (DES). Dental extractions represent the most frequent minor surgical procedures in the general population, yet the optimal dental management of antiplatelet-receiving patients is insufficiently explored. Sporadic cases of postextraction bleeding have been reported in the setting of continuous aspirin therapy, but reports of serious or life-threatening hemorrhage are extremely rare. Very few studies have systematically assessed the effect of aspirin or clopidogrel on the procedural outcome of dental treatment; these studies generally focused on the safety of dental procedures in the setting of uninterrupted antiplatelet monotherapy. The safety of dual antiplatelet therapy has been studied to an even lesser extent, and even these studies were limited by their retrospective design and by the small and heterogeneous patient populations. In the most comprehensive relevant report, Napenas et al included 29 patients receiving dual antiplatelet treatment and found a very low frequency of prolonged postextraction bleeding; however, the heterogeneity of the invasive procedures and the absence of a group of antiplatelet-naive controls limited the interpretation of their results. In light of the paucity of relevant studies, and particularly the absence of prospective investigations, defining a strategy to optimally balance the bleeding risk of uninterrupted antiplatelet therapy versus the thrombotic hazard of temporary antiplatelet withdrawal before dental procedures has been an unanswered question for a frequent clinical problem. Current recommendations suggest uninterrupted antiplatelet therapy in patients with DES undergoing dental procedures. In striking contrast to these recommendations, however, antiplatelet agents are frequently interrupted in everyday practice. This is clearly an empirical, rather than an evidence-based approach, based on excessive concerns about potential postextraction bleeding complications. Aiming to address this gap of evidence-based practice, the safety of dental extractions during uninterrupted single or dual antiplatelet treatment was recently assessed in a prospective fashion. In a study published in the American Journal of Cardiology, we included 643 patients referred for dental extractions. Of them, 42 (6.5%) were on clinically indicated daily low-dose aspirin, 36 (5.6%) were on clopidogrel, 33 (5.1%) were on both aspirin and clopidogrel, while 532 antiplatelet-naive patients served as controls. Treatment groups and controls were well matched clinically and received similar procedural treatment, thereby allowing for direct