Aspirin Management for Tooth Extraction
Primary Recommendation
Continue aspirin therapy without interruption for dental extractions, as the risk of thrombotic complications from discontinuation far outweighs the minimal and manageable bleeding risk associated with the procedure. 1
Evidence-Based Rationale
The decision to continue aspirin is supported by multiple high-quality guidelines and research:
The American College of Cardiology, American Heart Association, American Dental Association, and American College of Surgeons jointly state that there is little or no indication to interrupt antiplatelet drugs, including aspirin, for dental procedures. 1
A prospective randomized controlled trial demonstrated no statistically significant difference in postoperative bleeding between patients taking aspirin (325 mg/day) and those on placebo during tooth extraction. 1, 2
Multiple studies confirm no well-documented cases of clinically significant bleeding in patients on aspirin therapy undergoing dental extractions. 1, 3, 4
Risk Assessment Framework
Bleeding Risk vs. Thrombotic Risk
Simple dental extractions (1-2 teeth) are classified as low bleeding risk procedures (0%-2% risk of major bleeding). 5
The risk of thrombotic events from aspirin discontinuation is significantly greater than the risk of dental bleeding, with discontinuation increasing the absolute risk of stroke or cardiovascular events by approximately 2% within 30 days. 6
For patients with coronary stents, aspirin discontinuation carries an especially high risk of stent thrombosis, a catastrophic event that frequently leads to myocardial infarction or death. 5, 6
Practical Management Protocol
Preoperative Planning
Inform the patient that continuing aspirin is safer than stopping it, and provide clear instructions about what constitutes abnormal bleeding and when to seek care. 1
Verify the patient's cardiovascular indication for aspirin (coronary artery disease, prior stroke, peripheral arterial disease, or coronary stents). 6
Intraoperative Hemostasis
Use local anesthesia with vasoconstrictor to minimize bleeding. 5
Apply local hemostatic measures including absorbable gelatin sponge, sutures, and tranexamic acid mouth rinse if needed. 1, 5
These local measures are highly effective at controlling any minor bleeding that may occur during dental procedures. 1, 3, 4
Postoperative Management
Mild bleeding in the first 30 minutes is common and successfully managed with local hemostasis or compression with gauze. 4
No major hemorrhage requiring emergency intervention has been documented in patients continuing aspirin for simple extractions. 4, 7
Special Considerations
Dual Antiplatelet Therapy (DAPT)
For patients on aspirin plus clopidogrel/ticagrelor/prasugrel, both agents should ideally be continued for dental procedures to minimize the risk of stent thrombosis. 1
If a P2Y12 inhibitor must be stopped for a more extensive procedure, aspirin should absolutely be continued to mitigate stent thrombosis risk. 1
Multiple Extractions
Multiple dental extractions (≥3 teeth) are classified as higher bleeding risk procedures (2%-4% risk). 5
Even for multiple extractions, continuation of aspirin with enhanced local hemostatic measures is generally safer than discontinuation. 5, 4
Postoperative Analgesia
Use acetaminophen (paracetamol) as first-line analgesia postoperatively. 5
Avoid NSAIDs in patients on aspirin therapy, as they can impair aspirin's cardioprotective effects and increase bleeding risk. 5, 6
COX-2 inhibitors (celecoxib) have less effect on platelet function and may be used if necessary. 5
Common Pitfalls to Avoid
Never discontinue aspirin based solely on concern for bleeding without considering the patient's thrombotic risk. The evidence shows that bleeding time may be prolonged but clinically significant bleeding is rare and manageable. 2, 8
Do not use bridging therapy with low molecular weight heparin for aspirin. This promotes bleeding, is difficult to reverse, and is less effective at preventing thrombotic events. 9
Ensure medication reconciliation to identify over-the-counter NSAIDs that patients may be taking concurrently. 6
Have local hemostatic agents readily available before beginning the procedure (gelatin sponge, sutures, tranexamic acid rinse). 1, 5