With an ageing population there are growing numbers of patients with cardiovascular and cerebrovascular disease and an increasing number being prescribed antithrombolytics. dual antiplatelet therapy comprises acetylsalicylic acid (aspirin) in combination with agents, such as clopidogrel, ticlopidine, ticagrelor, or prasugrel. All these drugs inhibit platelet function which increases the risk of bleeding.
The aim of this review was to evaluate the risk of bleeding complications in patients on dual antiplatelet therapy (DAPT) compared to patients on single antiplatelet therapy (SAPT) or no antiplatelet therapy (no APT) for patients undergoing oral surgery.
Methods
Searches were carried out in the Cochrane Library, PubMed, Embase, CINAHL and Web of Science databases. Studies investigating complications with minor oral surgery in patients on DAPT treatment published in English, Dutch or French were considered. This was supplemented by hand screening or oral and maxillofacial surgery journals. Two reviewers independently selected studies extracted data and assessed risk of bias in terms of selection, performance, detection, attrition and reporting bias
Results
- 16 studies (9 prospective and 5 retrospective controlled cohorts, 2 case-controlled) were included.
- All 16 studies were at high risk of selection bias.
- Peri-operative bleeding
- Meta-analysis suggests that while peri-operative bleeding risk for DAPT was significantly higher than that for patients on SAPT it did not differ significantly from patients not taking antiplatelet drugs.
| No of studies | Risk Ratio (95%CI) | Risk difference (95%CI) | |
| DAPT v SAPT | 2 | 10.16 (1.74 – 59.28) | 0.35 (I0.27 – 0.96) |
| DAPT v no APT | 2 | 6.50 (0.94 to 44.77) | 0.19 (0.01 – 0.39) |
- Post-operative bleeding
- Meta-analysis suggests the post-operative bleeding risk for patients on DAPT was significantly higher than for patients on SAPT and no APT.
| No of studies | Risk Ratio (95%CI) | Risk difference (95%CI) | |
| DAPT v SAPT | 4 | 2.6 (11.26 – 5.42) | 0.01 (0.00 – 0.03) |
| DAPT v no APT | 4 | 3.63 (1.09 – 12.03) | 0.01 (0.01 – 0.02) |
Conclusions
The authors concluded: –
the risk of perioperative bleeding with minor oral surgery is elevated for patients on DAPT compared to those on SAPT, but not compared to patients not taking antiplatelet drugs. The risk differences were not significant though. The postoperative bleeding risk is significantly higher for DAPT than for SAPT and no APT. Again, the risk differences were only 1% and not significant. Therefore, the higher bleeding risk for DAPT may be clinically irrelevant. Local haemostatic measures, such as gauze pressure and sutures, possibly supplemented by sponges or tranexamic acid (TXA) measures, were sufficient to stop bleeding in all reported cases. Therefore, it is advisable to continue DAPT therapy before minor oral surgery such as dental extractions, and to apply at least gauze and sutures to prevent bleeding. Other haemostatic measures, such as sponges and TXA, can be applied additionally to prevent bleeding and to manage unexpected bleeding events.
Comments
While a good range of databases has been searched limiting inclusions to a small number of languages means that some relevant studies could have been excluded. The authors identified 16 studies none of which are randomised controlled trials which means that there is a high risk of selection bias in all of the included studies which needs to be considered when interpreting the findings. Also only a small number of studies contributed to the meta-analyses. There is also heterogeneity between the studies all but two of the studies used gauze pressure as a primary haemostatic control with some also employing sutures while 5 studies used absorbable sponges, 3 also used tranexamic acid. The authors also point out that the complexity of surgery, simple versus surgical or the number of teeth extracted which may influence the risk was not available in the included studies. The 2015 guidance from the Scottish Dental Clinical Effectiveness Programme recommended treatment without interrupting antiplatelet drugs. However they higlighter that low quality of the available evidence and the limited number of studies of low quality identified in this review further higlights the need for high quality well conducted and reported research in this area.
Links
Primary Paper
Ockerman A, Bornstein MM, Leung YY, Li SKY, Politis C, Jacobs R. Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2019 Jun 24.pii: S0901-5027(19)31171-3. doi: 10.1016/j.ijom.2019.06.002. [Epub ahead of print] Review. PubMed PMID: 31248706.
Other references
Dental Elf – 21st Aug 2019
Direct anticoagulant agents: management before invasive dental procedures
