After carefully reading the assigned article, please write a two to three paragraph summary of the article’s contents. The summary may not exceed 500 words. The idea of the summary is to prepare a report that would quickly inform your dental office co-workers of the clinically important facts contained in the article. The goal is to be brief and discuss the clinically significant points only. For this article summary, the focus should be on the clinical management of a patient on anti-platelet therapy.The summary must be submitted in Word Doc. RubricJournal Article Summary – 2018Journal Article Summary – 2018CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeSpelling and Grammar – One point deduction for each spelling/grammatical error.10.0 ptsThis criterion is linked to a Learning OutcomeContent – The extent to which the salient information in the article is covered.75.0 ptsThis criterion is linked to a Learning OutcomeLength – completed within two to three paragraphs and under 500 words.15.0 ptsThis criterion is linked to a Learning OutcomeSubmit Assignment by Due Date5 point deduction for each day assignment is late.0.0 ptsTotal Points: 100.0
discontinuing_antiplatelet_therapy.pdf
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Pharmacotherapeutics
Perspective of cardiologists on the continuation
or discontinuation of antiplatelet therapy before
dental treatment: a questionnaire-based study
Ruchi Banthia, MDS
n
Pallavi Singh
n
Priyank Banthia, MDS
n
Rajbhan Singh, MBBS, DMd
Antiplatelet and anticoagulant agents have been extensively researched
and developed as potential therapies in the prevention and management
of arterial and venous thrombi. These medications are associated with
an increase in bleeding time and risk of intraoperative and postoperative
hemorrhage in the dental office. There is some controversy regarding
whether these agents should be temporarily discontinued before dental
procedures. In order to gain insight into this controversy, a survey of 50
P
latelets provide the initial hemostatic
plug at the site of vascular injury. They
are also involved in pathological processes and serve as an important contributor to arterial thrombosis possibly leading
to myocardial infarction and cerebrovascular stroke.1 Various antiplatelet and anticoagulant agents are used for the prevention
and management of arterial thrombi.2
The most common of these are low-dose
aspirin (75-300 mg daily), clopidogrel,
dipyridamole, and warfarin.3,4 Antiplatelet
therapy is associated with the inhibition
of platelet aggregation. When platelets
are inhibited, it takes longer for primary
hemostasis to occur, hence bleeding time
is prolonged, leading to an increased risk
of intraoperative and postoperative hemorrhage during dental procedures.3,5,6 Dental
practitioners are encountering more and
more cardiac patients taking antiplatelet
medications in their routine practice. A
decision needs to be made whether to temporarily discontinue antiplatelet therapy
before performing any dental procedure
on a patient with this medical history. The
dilemma lies in the fact that although these
medications increase the risk of hemorrhage during dental procedures, temporarily stopping them can put the patients at
risk of thromboembolic events, such as
stroke.6 Therefore, a medical opinion and
consent is mandatory for the management
of cardiac patients in the dental office, and
the risk of occurrence of thromboembolic
event must be weighed against the risk of
hemorrhage. Previously, discontinuation of
antiplatelet therapy for either 3 or 7 days
64
November/December 2014
Santosh Gupta
n
Sapna Raje
cardiologists was conducted regarding suggested guidelines for dentists
in the management of patients who are taking anticoagulant medication.
Received: March 14, 2013
Accepted: June 13, 2013
was recommended prior to dental procedures to avoid excessive bleeding, but with
increasing concern over the thromboembolic risk, this is no longer recommended.7
There is a great deal of confusion and
controversy among dental surgeons regarding this issue. This study sought to obtain
evidence-based results by conducting a
survey on 50 cardiologists with the goal of
helping to resolve the controversy.
Materials and methods
A structured questionnaire consisting
of 7 questions was prepared by 2 of the
study’s coauthors (R. Banthia and P.
Banthia). Verbal consent was obtained
over the telephone from 72 cardiologists
and the questionnaires were distributed
by 2 different coauthors (P. Singh and
R. Singh). The physicians were asked
to respond in 2-3 days. The first 50
responses received were accepted for use
in the study. The data was collected and
the responses analyzed (Table).
Discussion
Antiplatelet therapy agents (also known
as blood thinners) are used mainly for
the inhibition of platelet activation or
aggregation. They are effective in arterial
circulation where anticoagulants have
little effect.7 Aspirin irreversibly acetylates
cyclooxygenase, inhibiting the production
of thromboxane A 2, resulting in decreased
platelet aggregation.8 Clopidogrel
selectively inhibits ADP-induced
platelet aggregation. Dipyridamole is
an adenosine reuptake inhibitor and
General Dentistry
n
www.agd.org
Key words: antiplatelet therapy, bleeding risk,
thromboembolic events, dental treatment
phosphodiesterase inhibitor with antiplatelet and vasodilating activity.9
Most of the cardiologists surveyed use
either aspirin as monotherapy, or aspirin
and clopidogrel as dual therapy. Aspirin
and clopidogrel have synergistic antiplatelet effects that block complementary pathways in a platelet aggregation cascade.10,11
Dipyridamole is another antiplatelet
therapeutic agent. Oral antiplatelet regimens vary in different institutions, but the
recommendations of the American College
of Chest Physicians in 2006 were that aspirin (75-162 mg) should be prescribed and
continued indefinitely for all patients with
stable coronary artery disease (CAD), and
clopidogrel in combination with aspirin is
advised for all stable CAD patients with a
risk profile that indicates a high likelihood
of developing acute myocardial infarction.12
The effect on primary hemostasis is
minimal when antiplatelet agents are
used as monotherapy in patients, with
no additional risk factors for impaired
clotting.13 The risk of bleeding may
increase in combination therapy cases.14
While aspirin can double the bleeding
time, this may still be in normal range.
Only 20%-25% of patients on aspirin
were reported to have abnormal bleeding
times. Burger et al observed that patients
on an aspirin regimen have, on average,
an increased (1.5-fold) risk of intraoperative hemorrhagic risk, without an increase
in surgical morbidity and mortality.15
Clopidogrel, being a more potent antiplatelet agent, can cause a 1.5 to 3-fold
increase in bleeding times.16,17
Table. Survey results
Questions
Responses
1. Which antiplatelet agent do you
most frequently prescribe?
Ninety percent of the doctors prescribed either aspirin as a monotherapy, or aspirin and clopidrogel as a dual therapy.
The remaining 10% used other antiplatelet agents such as dipyramidole.
2. Do you recommend stopping
antiplatelet therapy before
dental procedures?
A. Before minor dental
procedures (such as
scaling and extractions)?
3. On which criteria did you base your
decision to continue or discontinue
the antiplatelet therapy?
Fifty percent of the doctors based their decision on both clinical experience and evidence-based research.
Twenty-five percent of the doctors based their decision solely on evidence-based research, and 25% based
their decisions predominantly on their clinical experience.
4. When ‘written medical consent’ is
required by a dental practitioner,
what protocol do you follow?
A. What investigations do you
recommend?
5. Have you ever been consulted for
a bleeding episode—in a patient on
antiplatelet therapy—by a dental
office?
Five percent of the doctors had been consulted for the management of 1 or 2 bleeding episodes.
6. How many episodes of thromboembolic events have been
reported to you in cases where
discontinuation of antiplatelet
therapy was recommended?
All of the doctors encountered 1 or 2 cases of thromboembolic events after discontinuation of antiplatelet therapy.
B. Before surgical
procedures?
C. If ‘yes’, why?
Discontinuation of
All the doctors were in favor antiplatelet therapy was
Eighty percent of the
of stopping antiplatelet
recommended to avoid the
doctors were in favor of not therapy before surgical
risk of postoperative and
stopping the antiplatelet
procedures.
intraoperative bleeding and
therapy before minor
risk of haemorrhage.
dental procedures. Twenty
percent recommended
the discontinuation of
antiplatelet therapy.
All of the doctors recommend
bleeding time, clotting time, ECG,
routine investigations, and blood
sugar level tests. Ten percent of the
doctors request a chest X-ray and
an international normalized ratio
(INR) blood test, as well.
B. Do you advise an INR?
Ten percent of the doctors advised
INR routinely; 90% advised it
only when the patient is on an
oral anticoagulant, such as low
molecular weight heparin or
warfarin.
D. If ‘yes’, for how
many days?
Sixty percent of the
doctors were in favor
of stopping antiplatelet
therapy 5 days prior to
the dental procedure.
Thirty percent recommended
the discontinuation of
antiplatelet therapy 7 days
prior to the procedure.
Ten percent recommended
discontinuation starting
3 days prior, and continuing
2 days postoperatively.
C. Do you have printed consent
forms in your clinic?
Eighty percent of the doctors did
not have printed consent forms.
7. What is your final recommendation? All of the doctors recommended discontinuation of the antiplatelet therapy before surgical procedures.
Eighty percent recommended continuation of antiplatelet therapy before minor dental procedures, while 20%
advised discontinuation of these agents before minor procedures.
Eighty percent of the cardiologists surveyed were not in favor of discontinuing
antiplatelet therapy before minor dental
procedures. However, all of the doctors
surveyed were in favor of stopping antiplatelet therapy for surgical procedures.
This discontinuation was recommended
to avoid the risk of postoperative and
intraoperative bleeding.
Ardekian et al investigated the effect of
aspirin on the hemorrhagic risk in patients
undergoing dental extractions.18 None
of the patients reported any episode of
uncontrolled bleeding immediately after
the procedure or in the following week.18
Intraoperative bleeding was managed
either by suturing, gauze packs, and/or use
of tranexamic acid in local packing.18
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The pharmacological actions of
clopidogrel and dipyridamole suggest that
patients taking these medications will be
at no greater risk of excessive bleeding
than those taking aspirin. While clopidogrel has shown an increased bleeding
time compared to aspirin, it has proved
to be clinically more potent; and it has
been established that there is no risk of
General Dentistry
November/December 2014
65
Pharmacotherapeutics Perspective of cardiologists on antiplatelet therapy and dental treatment
excessive bleeding when using clopidogrel
during dental procedures.15-19 If a patient
is on a dual therapy of aspirin and clopidogrel, it is recommended that the dental
procedure be performed in a hospital
setting, in order to more proactively
manage any severe bleeding episode, as
such patients are at a higher risk of hemorrhage. Patients with underlying hepatic,
renal, or bone marrow disorders often
have disease-related bleeding disorders.
Bleeding risk also increases with age and
with heavy alcohol consumption.4
Sixty percent of the cardiologists surveyed were in favor of stopping antiplatelet
therapy 5 days prior to the dental procedure. Thirty percent recommended the discontinuation of antiplatelet therapy 7 days
prior to the procedures. Ten percent recommended discontinuation starting 3 days
prior, continuing 2 days postoperative.
All patients on antiplatelet therapy may
have drug-induced alterations of platelets,
the degree of which varies from person to
person. Aspirin irreversibly inhibits platelet
aggregation within 1 hour of ingestion, and
clopidogrel does so within 2 hours. This
inhibition lasts for the lifetime of platelets,
approximately 7-10 days. This effect is
only overcome by the production of new
platelets.20 Complete recovery of platelet
aggregation may occur in 50% of cases
by Day 3, and in 80% of cases by Day 4
postoperative.21 Ferrari et al concluded that
when aspirin (either 75 or 300 mg) was
stopped in healthy patients after 2 weeks
of therapy, all bleeding times returned to
normal after 6 days.22 The action of dipyridamole is reversible and ceases about 24
hours after the drug is discontinued.16
Only 5% of the medical practitioners
surveyed had been consulted for the
management of 1 or 2 bleeding episodes.
Lockhart et al suggested that postoperative
bleeding is considered significant if the
bleeding continues beyond 12 hours, causes
the patient to call or return to the dental
office or emergency department, results
in the development of a large hematoma
or ecchymosis within oral soft tissues, or
requires a blood transfusion.23
Life-threatening bleeding after dental
surgery is rare.24 According to Matocha,
the incidence of postextraction hemorrhagic complications is 0.2%-2.3%.25
McGaul reported a case of sublingual
hematoma in mandibular anterior teeth
66
November/December 2014
following periodontal flap surgery in a
patient on long-term antiplatelet therapy
which resolved on its own.26 Thomason
et al reported severe bleeding following a
gingivectomy in a patient taking 150 mg
aspirin qd, which was resolved by platelet
transfusion.27
Napenas et al found no differences in
hemorrhages following dental treatments
such as extractions, periodontal surgery,
subgingival scaling, and root planing
between patients receiving single or
dual antiplatelet therapy.28 In a study by
Partridge et al, the amount of blood loss
was found to be similar in patients on
antiplatelet therapy and healthy patients
(controls) during dentoalveolar surgery.29
The Antiplatelet Trialists’ Collaboration
concluded that long-term antiplatelet therapy caused reductions in mortality, relative
risk of myocardial attack, and cerebrovascular incidents; with only a mild (0.12%)
increase of spontaneous hemorrhage risk.30
All the doctors surveyed who had been
asked for consent before dental therapy on
their patients with antiplatelet regimens
recommended bleeding time, clotting
time, ECG, routine investigations, blood
sugar level, and blood pressure tests. Only
10% of the doctors advised chest X-rays,
and only 10% advised an International
Normalized Ratio (INR) in order to
know the status of coagulation. An INR
is advised for all patients on warfarin or
heparin therapy.31
Although there is no suitable test to
assess the increased risk of bleeding in
patients taking antiplatelet therapy, platelet function is normally assessed using the
cutaneous bleeding time test. In a normal
healthy patient, bleeding time ranges from
2 to 10 minutes.32 Prothrombin time (PT)
and partial thromboplastin time have
been used to evaluate anticoagulant levels.
The INR was introduced in 1983 by the
World Health Organization Committee
on Biological Standards, who defined the
INR as the ratio of the patient’s PT to
a control PT, raised to the power of the
International Sensitivity Index (ISI).33
The INR is a more reliable and sensitive
test for determining the level of anticoagulation as it depends on both the patient’s
blood and the sensitivity of the assigned
ISI value. The PT alone would not be
an accurate gauge in the evaluation of a
patient’s anticoagulant status. A patient
General Dentistry
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with a normal coagulation profile would
have an INR of 1. It is recommended that
a patient undergoing invasive treatment
should have a PT 1.5-2.0 times the normal
value (INR = 1.5-2.5 when the ISI is 1).33
In patients on antiplatelet therapy, the
recommended INR is 2.0-3.0 for most
procedures. This range of INR (2.0-3.0,
average 2.5) minimizes the risk of both
hemorrhage and thromboembolic events.34
Nevertheless, minor surgical dental procedures can safely be performed with an
INR between 2 and 4, while being aware
that local measures may be needed to
control bleeding.6 In patients on warfarin
and heparin, the INR should be checked
within 24 hours prior to the procedure.31
A correlation between bleeding time test
results and the rate of surgical bleeding
complications has not been established.35
Shalom & Wong concluded that cutaneous bleeding tests should not be used to
estimate the hemorrhagic risk in patients
on anticoagulant therapy.36 Of the doctors surveyed, all reported 1 or 2 cases of
thromboembolic events after discontinuation of antiplatelet therapy.
Thromboembolic events following
the cessation of antiplatelet medications
have also been reported in the literature.
One retrospective analysis study reported
that out of 475 patients admitted with
myocardial infarction, 11 (2.3%) had
discontinued aspirin within 15 days prior
to the attack.37 Nine patients discontinued
aspirin due to a planned procedure, 1 of
which was a dental procedure.37 Another
study by the same author reported that
5% of the patients who were admitted for
acute coronary syndrome had admitted
they had stopped using oral anticoagulant
agents, and the authors concluded that a
rebound effect occurs after an interruption of oral antiplatelet medication.38 In a
study by Ferrari et al, the mean delay time
between aspirin withdrawal and an acute
coronary event was 10 ± 1.9 days (range
4-17 days); and 13 of the patients (25.5%)
who discontinued their aspirin medication
did so prior to dental treatment.22 Maulaz
et al reported the mean interval between
treatment disruption and cerebral infarction was 9.5 ± 7 days.39 Kovich & Otley
estimated that the risk of thromboembolic
events associated with the withdrawal of
aspirin 3-14 days days prior to cutaneous
surgery was approximately 0.005%.40
Management of patients
on antiplatelet therapy in
a dental office
According to Scully & Wolff, oral surgical procedures must be done at the
beginning of the day, as it allows more
time to deal with any bleeding episode.41
Procedures should also be performed early
in the week so that prompt management
of any delayed bleeding can be done.
Local anaesthetic containing a vasoconstrictor should be administered. Field blocks
are contraindicated. If no alternative exists,
local anaesthetic should be administered
cautiously with repeated aspiration.42,43
Atraumatic and careful manipulation of
tissues is recommended. Bleeding should
be stopped by local measures, such as use of
pressure packs for 15-30 minutes, packing
of sockets with absorbable hemostatic dressings (oxidised cellulose, haemocollagen, or
resorbable gelatin sponge), and suturing.42,43
The use of aspirin leads to increased
bleeding time. If it increases to >20 minutes
and surgery has to be performed as an emergency procedure, 1-desamino-8-D-arginine
vasopressin can be used to shorten the bleeding time.44 This involves the enhancement
of Von Willebrand’s factor which in turn
acts as a platelet aggregant. It can be used
at a dose of 0.3 µg/kg of body weight—not
exceeding 20-24 µg—or as a nasal spray.
This should be administered under a
physician’s guidance as this can cause druginduced thrombosis in older subjects.8
Paracetamol is the painkiller drug of
choice for patients on antiplatelet therapy.
Nonsteroidal anti-inflammatory drugs
(NSAIDs) are avoided, as they carry the
potential risk of increasing bleeding time
by having a reversible effect on platelet
aggregation and function.4 To ensure the
absence of any antiplatelet effect, NSAIDs
should be discontinued 5 half-lives before
the procedure.45
Scully & Cawson developed the following list of instructions to be given to
patients for the management of a clot in
the postoperative period.46
• Rest until the local anesthetic wears
off and the clot forms (2-3 hours).
• Avoid rinsing the mouth for 24 hours.
• Do not suck forcefully or disturb
the socket with the tongue or any
foreign objects.
• Avoid hot liquids and hard foods for
the first day.
• Avoid chewing on the affected side
until it is clear that a stable clot has
formed.
• Apply pressure over the socket using a
folded clean handkerchief or gauze pad
for 20 minutes if bleeding continues or
restarts. If bleeding does not stop, consultation with the dentist is advised.46
Patients with the following medical
problems taking antiplatelet medications should not be treated in primary
care without medical advice or should be
referred to a hospital-based dental clinic:
liver impairment and/or alcoholism; renal
failure; hemostasis disorders; and patients
currently receiving cytotoxic medication or
dual antiplatelet therapy.42,43,47
A consensus opinion from American
Heart Association, American College of
Cardiology, Society for Cardiovascular
Angiography and Interventions, American
College of Surgeons, and American …
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