Should Brilinta (ticagrelor) be held before oral tooth extraction in patients with cardiac stent placement?

Management of Ticagrelor (Brilinta) During Tooth Extraction in Patients with Cardiac Stents

Recommendation Summary

Patients on ticagrelor (Brilinta) following cardiac stent placement should NOT discontinue their medication before dental tooth extractions, as the risk of stent thrombosis far outweighs the minimal bleeding risk that can be effectively managed with local hemostatic measures.

Rationale for Continuing Ticagrelor

The decision to maintain antiplatelet therapy during dental procedures is based on several key considerations:

1. Risk of Stent Thrombosis: Premature discontinuation of antiplatelet therapy significantly increases the risk of stent thrombosis, which can lead to myocardial infarction and death 1. This risk is particularly high within the first year after stent placement.

2. Minimal Bleeding Risk: Clinical studies demonstrate that the risk of significant bleeding during dental procedures in patients on antiplatelet therapy is minimal and can be effectively controlled with local hemostatic measures 2, 3.

3. Professional Guidelines: Multiple professional societies, including the American College of Chest Physicians, American College of Cardiology, and American Heart Association, recommend continuing antiplatelet therapy during dental procedures 2.

Evidence Supporting Continued Antiplatelet Therapy

Research specifically examining dental procedures in patients on antiplatelet therapy shows:

• The frequency of postoperative bleeding in patients taking ticagrelor is only 5.9%, with no cases of prolonged bleeding 3.
• For patients on dual antiplatelet therapy (DAPT), the bleeding rate is slightly higher at 8.3% but still manageable with local measures 3.
• A study of 100 patients undergoing dental extractions while on multiple antiplatelet agents found only 2 cases of excessive bleeding, both easily controlled 4.

Management Protocol for Dental Extractions

Pre-Procedure:

• Consult with the patient's cardiologist if the patient has high-risk factors for stent thrombosis (multiple stents, long stents, bifurcation stents, history of stent thrombosis, diabetes) 2.
• Continue ticagrelor at the prescribed dose without interruption.

During Procedure:

• Implement local hemostatic measures:
  • Absorbable gelatin sponge
  • Suturing
  • Local pressure application
  • Tranexamic acid mouthwash

Post-Procedure:

• Provide clear instructions on managing minor bleeding (applying pressure with gauze).
• Avoid prescribing NSAIDs for pain management in patients taking antiplatelet therapy.
• Schedule follow-up to monitor for any delayed bleeding complications.

Special Considerations for Ticagrelor

Ticagrelor has a more rapid onset and offset of action compared to clopidogrel. If discontinuation is absolutely necessary for major oral surgery (which is rarely the case), the 2017 ESC guidelines suggest that ticagrelor should be discontinued at least 3 days before surgery, compared to 5 days for clopidogrel 1. However, this recommendation applies to major surgery with high bleeding risk, not routine dental extractions.

Common Pitfalls to Avoid

1. Routine discontinuation of antiplatelet therapy before dental procedures.
2. Failing to distinguish between antiplatelet agents and anticoagulants when making recommendations.
3. Recommending NSAIDs for post-procedure pain in patients taking aspirin or other antiplatelet agents.
4. Not implementing adequate local hemostatic measures during the procedure.

Conclusion

The evidence strongly supports continuing ticagrelor during dental extractions. The minimal and manageable bleeding risk is far outweighed by the potentially catastrophic consequences of stent thrombosis that could result from premature discontinuation of antiplatelet therapy.