Should aspirin (acetylsalicylic acid) therapy be continued in patients undergoing multiple dental extractions, especially those with a history of coronary artery disease?

From the Guidelines

Aspirin therapy should generally be continued in patients undergoing multiple dental extractions, especially those with a history of coronary artery disease. The risk of serious cardiovascular events from discontinuing aspirin therapy typically outweighs the risk of increased bleeding during dental procedures. For patients taking low-dose aspirin (81-100 mg daily) for secondary prevention of cardiovascular disease, maintaining this medication is recommended 1. While there may be slightly increased bleeding during the procedure, this can usually be managed effectively with local hemostatic measures such as pressure, sutures, gelatin sponges, or tranexamic acid rinses.

Key Considerations

• The dentist should be informed about the patient's aspirin regimen before the procedure.
• The rationale for continuing aspirin is that its antiplatelet effects are crucial for preventing thrombotic events in patients with coronary artery disease, and the abrupt discontinuation can lead to a rebound hypercoagulable state, potentially triggering serious cardiovascular events such as myocardial infarction or stroke 1.
• In rare cases where excessive bleeding is anticipated, the decision to modify aspirin therapy should be made collaboratively between the dentist and the patient's cardiologist, weighing individual risks and benefits.
• According to the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention, aspirin should be continued indefinitely after PCI 1.

Management of Bleeding Risk

• Local measures during surgery, such as absorbable gelatin sponge and sutures, can reduce the incidence and severity of oral bleeding.
• The unlikely occurrence of bleeding once an initial clot has formed suggests that interrupting antiplatelet drugs for dental procedures may not be necessary 1.
• The benefits of aspirin in patients with coronary artery disease outweigh the risks of bleeding during dental procedures, and therefore, aspirin therapy should be continued in these patients 1.

From the Research

Aspirin Therapy in Patients Undergoing Multiple Dental Extractions

• The decision to continue or discontinue aspirin therapy in patients undergoing multiple dental extractions, especially those with a history of coronary artery disease, is a complex one 2, 3, 4, 5, 6.
• Studies have shown that the risk of bleeding associated with aspirin use is not significantly increased in patients undergoing dental extractions, and that the benefits of continuing aspirin therapy may outweigh the risks 4, 6.
• A study published in the Journal of Dental Research found that aspirin use did not cause increased bleeding following a single tooth extraction, and that whole-blood aggregation results were significantly different between the aspirin and placebo groups 4.
• Another study published in the Journal of Oral and Maxillofacial Surgery found that there was no difference in the amount of bleeding that occurred during tooth extraction between patients who continued ASA therapy versus patients who suspended their ASA therapy 6.
• However, a systematic review and meta-analysis published in the journal Catheterization and Cardiovascular Interventions found that early discontinuation of aspirin showed a decreased risk of peri-operative bleeding, but no difference in major adverse cardiac events (MACE) 5.
• The American Heart Association recommends that patients with coronary artery disease who are taking aspirin should continue to take it unless there is a strong contraindication, such as active bleeding or a high risk of bleeding 3.

Clinical Implications

• The available evidence suggests that aspirin therapy can be continued in patients undergoing multiple dental extractions, especially those with a history of coronary artery disease, without a significant increase in the risk of bleeding 2, 3, 4, 5, 6.
• However, the decision to continue or discontinue aspirin therapy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 5.
• Local hemostatic methods, such as suturing and pressure, can be used to control bleeding in patients who are taking aspirin and undergoing dental extractions 6.
• Patients with coronary artery disease who are taking aspirin should be closely monitored for signs of bleeding or other complications during and after dental extractions 3.