Int. J. Oral Maxillofac. Surg.

2016; 45: 12931298

http://dx.doi.org/10.1016/j.ijom.2016.02.010, available online at http://www.sciencedirect.com

Clinical Paper
Oral Surgery

Dental extraction without

stopping single or dual
antiplatelet therapy: results of a
retrospective cohort study

S.-Y. Lu 1, C.-Y. Tsai 1, L.-H. Lin 1,

S.-N. Lu 2
1

Oral Pathology and Family Dentistry Section,

Department of Dentistry, Kaohsiung Chang
Gung Memorial Hospital and Chang Gung
University College of Medicine, Kaohsiung,
Taiwan; 2Division of HepatoGastroenterology, Department of Internal
Medicine, Kaohsiung Chang Gung Memorial
Hospital and Chang Gung University College
of Medicine, Kaohsiung, Taiwan

S.-Y. Lu, C.-Y. Tsai, L.-H. Lin, S.-N. Lu: Dental extraction without stopping single or
dual antiplatelet therapy: results of a retrospective cohort study. Int. J. Oral
Maxillofac. Surg. 2016; 45: 12931298. # 2016 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to investigate the incidence of bleeding after
dental extraction without stopping antiplatelet therapy. Postoperative bleeding was
assessed in a total of 1271 patients who were divided into two groups: a study group
comprising 183 patients on antiplatelet therapy (aspirin 125 patients/185 occasions;
clopidogrel 42 patients/65 occasions; dual therapy 16 patients/24 occasions) who
underwent 548 dental extractions on 274 occasions, and a control group comprising
1088 patients who were not receiving any antiplatelet or anticoagulant therapy and
underwent 2487 dental extractions on 1472 occasions. The incidence of
postoperative bleeding was higher in the study group (5/274, 1.8%) than in the
control group (10/1472, 0.7%), and also in the dual antiplatelet subgroup (1/24,
4.2%) than in the single antiplatelet subgroups (clopidogrel: 2/65, 3.1%; aspirin: 2/
185, 1.1%); however, these differences were not signicant. Postoperative bleeding
was managed successfully by repacking with Gelfoam impregnated with
tranexamic acid powder in 12 patients and by resuturing in three of the control
patients undergoing extraction of impacted teeth with ap elevation. These ndings
indicate that there is no need to interrupt antiplatelet drugs before dental extraction.

It is not uncommon for physicians and

dentists to routinely stop a patients antiplatelet therapy for 7 to 10 days, or for at
least 3 days, prior to dental extraction in
order to avoid the risk of bleeding. However, the interruption of antiplatelet therapy
is associated with a progressive recovery
of platelet function and the potential risk of
a rebound of thrombotic arterial events.1
0901-5027/01001293 + 06

Excessive thromboxane A2 activity and

decreased brinolysis have been noted following aspirin interruption, thereby exposing the patient to a higher risk of recurrent
thrombosis, stroke, myocardial infarction
(MI), or other coronary event.2 Although
the risk is small, it outweighs the risk of
oral bleeding.3,4 Clinically, the present
researchers have witnessed two strokes

Key words: extraction; antiplatelet; aspirin;

clopidogrel.
Accepted for publication 18 February 2016
Available online 11 March 2016

occurring in two Chinese female patients

with hypertension and diabetes who had
been taking aspirin for the prevention of
cardiovascular disease (CVD). Both had
been instructed to stop taking aspirin 7 days
before a single dental extraction procedure
at a dental clinic and experienced cerebrovascular events 2 days later. The chronological link between aspirin withdrawal and

# 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

1294

Lu et al.

the acute thromboembolic events may not

have been a matter of chance.
Antiplatelet therapy has been reported
to have reduced the overall mortality from
vascular disease by 15% and non-fatal
vascular complications by 30%.1 Lowdose aspirin remains the cornerstone of
oral antiplatelet therapy. Prophylactic aspirin use in the USA has been estimated at
33% in high-risk individuals (e.g., those
with coronary artery disease (CAD), MI,
stroke, or peripheral vascular disease),
16% in those with multiple CVD risk
factors, and 1249% in those with diabetes.5 Diabetes is a complex metabolic
disease with increased macrovascular
and microvascular complications, which
are responsible for 65% of deaths in
patients with type 2 diabetes.6 Atrial
brillation (AF) is the most common sustained arrhythmia. Among patients with
AF, the annual rate of stroke without any
preventive treatment is approximately 5%,
2- to 7-fold higher than the rate in those
with sinus rhythm.7 Such cardioembolic
strokes are often fatal or severely disabling. Stroke prevention in AF requires
the use of oral anticoagulants (OAC), with
antiplatelet therapy only having a weak
efcacy.7 The OAC warfarin has been the
primary therapy for stroke prevention in
AF due to its efcacy in therapeutic range,
convenience of once-daily dosing, and
relatively low cost. However, warfarin
use is associated with a number of limitations, including an unpredictable dose
response and excessive bleeding when
not controlled adequately. Novel oral
anticoagulants (NOAC), including dabigatran, rivaroxaban, and apixaban, have
now been proved to provide a signicant
reduction in stroke risk without increasing
the risk of intracranial haemorrhage,
although dabigatran has been shown to
increase the relative risk of MI by 33%
when compared to warfarin.7
In Taiwan, half of AF patients (54.3%)
take antiplatelet agents alone.810 Although a national representative cohort
study has shown a progressive increase
in the use of warfarin among Taiwan
Chinese patients over time, usage rates
(24.7%) are still low when compared with
Western populations (3965%).10 Randomized trials have shown that warfarin
reduces the relative risk of stroke by 64%,
while antiplatelet agents only reduce this
by 22%.810 It is clear that anticoagulation
management among Chinese patients is
suboptimal.810 Under circumstances of
poor anticoagulation control, the cessation
of antiplatelet medications prior to dental
surgery will, most likely, expose the
patient to a fatal risk of thromboembolism.

Therefore, the routine perioperative withdrawal of antiplatelet therapy in these

patients may have devastating consequences.
Aspirin begins irreversibly inhibiting
thromboxane A2-induced platelet aggregation within 1 h of ingestion, and clopidogrel
selectively inhibits adenosine diphosphate
(ADP)-induced platelet aggregation within
2 h; this lasts for 710 days of the mean
platelet life.11,12 Dual therapies with
aspirin and clopidogrel have a synergistic
antiplatelet effect, as the two drugs affect
platelet aggregation by different mechanisms. Compared with aspirin alone, dual
oral antiplatelet therapy can provide an
additional 20% reduction in the relative
risk of MI or stroke.1113 Dual antiplatelet
therapy and newer antiplatelet agents are
associated with greater antithrombotic efcacy, but also with a higher bleeding risk
than aspirin. However, studies have
reported that no patients taking non-aspirin
or dual antiplatelet regimens have had
bleeding complications while undergoing
dental surgery that have required more than
local haemostatic measures.1416
Most Western studies have reported that
single antiplatelet therapy should not be
stopped prior to dental surgical procedures
and that patients on dual antiplatelet therapy may need to be referred to a hospitalbased dental clinic.14,15 In Taiwan, the
debate about continuing or stopping antiplatelet therapy prior to dental extraction
has been going on for a long time, with
opinions varying between institutions
and doctors. In over 25 years of clinical
practice, the present researchers have not
withheld antiplatelet therapy in any of
their patients seeking dental extraction.
Perioperative bleeding has been shown
not to differ signicantly between patients
who continue antiplatelet therapy and
those who stop it of their own accord.
Sufcient haemostasis can be obtained
using local measures.3,16
The aim of this retrospective study was
to evaluate the incidence of postoperative
bleeding after dental extraction in patients
without interruption of single or dual antiplatelet therapy. (Table 1 provides a list
Table 1. Descriptions of all related acronyms
and abbreviations.
Acronym
AF
AHA
CAD
CVA
CVD
OAC
MI
NOAC

Description
Atrial brillation
American Heart Association
Coronary artery disease
Cerebrovascular accident
Cardiovascular disease
Oral anticoagulant
Myocardial infarction
Novel oral anticoagulant

of all acronyms and abbreviations related

to this study, for reading convenience.)
Patients and methods

The study was approved by the necessary

institutional review board and comprised a
total of 1363 consecutive subjects who
underwent dental extractions performed
by the same qualied dentist (the corresponding author) in the family dentistry
department of the study hospital between
January 2010 and June 2014. Data were
retrieved from the chart notes made at
each visit, and the following factors were
investigated: patient clinico-demographic
parameters (sex, age, dental disease, and
medical illness), history of antiplatelet
therapy (aspirin, clopidogrel, dual therapy), number and types of tooth extraction
(simple or complicated extraction), and
incidence of postoperative bleeding.
Patients with a history of alcoholism, concomitant anticoagulant therapy, platelet
counts below 60 109/l, interrupted antiplatelet therapy, liver dysfunction, or any
systemic disease affecting postoperative
bleeding or coagulopathies were excluded
from the study. A total of 92 patients
were excluded from the study because
of warfarin therapy (65 patients), platelet
counts below 60 109/l (two patients),
and interruption of antiplatelet therapy
by the individual him/herself (25 patients).
The remaining 1271 patients who underwent 3035 dental extractions on 1746
occasions were divided into two groups
(Table 2). A convenience sample of 1088
consecutive patients who had never been
on antiplatelet therapy comprised the
control group. The study group comprised
183 patients, of whom 125 were on aspirin
(100 mg/day), 42 were on clopidogrel
(75 mg/day), and 16 were on dual therapy
(100 mg aspirin plus 75 mg clopidogrel)
(Table 2). The antiplatelet agents were
being used for CAD (76 patients), cerebrovascular accident (CVA) (58 patients),
AF (15 patients), hypertension (11
patients), primary prevention in diabetes
(nine patients), peripheral artery disease or
deep vein thrombosis (ve patients), heart
valve replacement (four patients), and
organ transplantation (ve patients). All
were dental outpatients and had been
advised against interrupting antiplatelet
therapy in any way before dental extraction. In accordance with the American
Heart Association (AHA) guidelines, an
appropriate regimen of antibiotic prophylaxis was administered to patients with
cardiac valvular disease or an organ transplant.17 All procedures were planned with
the patients informed consent.

Extraction without stopping antiplatelet therapy

1295

Table 2. Tooth extractions in the control group of patients (not taking antiplatelet or warfarin therapy) and the study group of outpatients on
continuing antiplatelet therapy.
Study group (n = 183)
Sex
Male
Female
Age, years, mean (range)
Number of tooth extractions (occasions)
Number of tooth extractions (postoperative bleeding)
Number of simple extractions
Number of complicated extractions
Mean number of teeth extracted per case
Reason for extraction (postoperative bleeding)
Periodontitis
Deep caries or residual roots
Impaction
Postoperative bleeding (number of patients/occasions)
Aspirin
Clopidogrel
Aspirin + clopidogrel
a
b

Control group (n = 1088)

P-value
0.79

110
73
72.0 (2094)
548 (274)
548 (5)
489 (5)
59 (0)
2.0

513
575
48.9 (995)
2487 (1472)
2487 (10)
1669 (7)
818 (3)
1.7

190 (3)
350 (2)
8 (0)
5/274 (1.8%)
2/185 (1.1%)
2/65 (3.1%)
1/24 (4.2%)

576 (5)
1298 (2)
613 (3)
10/1472 (0.7%)

0.94
0.81
0.80
0.98
0.03a
0.26
0.40
0.07b
0.49
0.50
0.43

Postoperative bleeding was signicantly higher in patients with periodontitis (P = 0.03).

No signicant difference in the incidence of postoperative bleeding was found between the study group and the control group (P = 0.07).

Before dental extraction, all patients

received local anaesthesia using 2%
(20 mg/ml) lidocaine hydrochloride with
1/80,000 (12.5 mg/ml) epinephrine. The
tooth extraction was performed with minimal invasion, and inamed granulation
tissue was curetted completely. The extraction was considered complicated when
the tooth was removed using additional
surgical procedures such as mucoperiosteal ap reection, tooth separation, and
bone cutting. The standard haemostatic
measures for each extraction involved
packing the site with Gelfoam, followed
by biting on a dry gauze pad. Suturing was
not performed routinely unless indicated,
depending on the extent of the wound.
Immediate bleeding was recorded if haemostasis was not achieved by dry gauze
compression for 10 min; in such cases the
socket was repacked with Gelfoam impregnated with tranexamic acid (TXA)
powder. If this failed, sutures were
inserted and the patient was kept under
observation for the next 30 min before
being discharged.
Patients were given a leaet outlining
the usual post-extraction instructions and a
24-h on-call emergency telephone number
to contact if any serious bleeding occurred
during non-ofce
hours.
Patients
experiencing bleeding 1 h after extraction
and having to return to the hospital were
considered as having delayed bleeding;
patients who were able to manage the
bleeding themselves at home were not
included. All patients were reviewed by
telephone call 24 h later or at clinical
follow-up 7 days postoperatively if they
were able to return to the hospital, in order
to check on the following: the occurrence

of any delayed bleeding, adequacy of the

gauze pressure packing in stopping bleeding, and need for professional help.
Data were analyzed using IBM SPSS
Statistics version 19.0 software (IBM
Corp., Armonk, NY, USA). One-way
analysis of variance (ANOVA) was used
to analyze age and the mean number of
extracted teeth. Categorical data such as
the extraction type and the incidence of
postoperative bleeding in relation to single
or dual antiplatelet therapy between the
two groups were analyzed using Fishers
exact test or the x2 test, as appropriate.
Statistical signicance was set at a P-value
of less than 0.05.
Results

Patient clinico-demographic data and the

results of the study are summarized in
Table 2. A total of 1271 patients were
included in the study and divided into
two groups: (1) study group, n = 183
(110 male and 73 female, mean age

72.0 years, range 2094 years); (2) control

group, n = 1088 (513 male and 575 female, mean age 48.9 years, range 995
years). There was no signicant difference
in sex distribution, mean age, or in the
types or number of teeth extracted
between the two groups. Aspirin was the
most used antiplatelet drug (68.3% of the
study patients), followed by clopidogrel
(23.0%) and dual therapy (8.7%)
(Table 3). Most patients were taking single
antiplatelet therapy for the prevention of
primary or secondary CVD, including
14 out of 15 patients with AF receiving
aspirin alone. Dual therapy was assumed
in 14 patients with coronary drug-eluting
stents, one AF patient, and one CVA
patient.
A total number of 3035 extractions were
performed on 1746 occasions in all
patients. In the control group, 2487 teeth
were extracted on 1472 occasions (mean
1.7 per occasion, range 112), whereas in
the study group, 548 teeth were extracted
on 274 occasions (mean 2.0 per occasion,

Table 3. Main indications for antiplatelet drug prescription in the study group.
Main indication

Aspirin

Coronary artery disease

Cerebrovascular accident
Atrial brillation
Hypertension
Diabetes (primary prevention)
PAD/DVT
Heart valve replacement
Transplantation (liver, renal, heart)
Total
%

51
35
14
10
7
3
2
3
125
68.3%

Clopidogrel
11
22
0
1
2
2
2
2
42
23.0%

PAD, peripheral arterial disease; DVT, deep vein thrombosis.

Dual
therapy

Total patients,
n (%)

14
1
1
0
0
0
0
0
16
8.7%

76
58
15
11
9
5
4
5
183
100%

(41.5%)
(31.7%)
(8.2%)
(6.0%)
(4.9%)
(2.7%)
(2.2%)
(2.7%)

1296

Lu et al.

Fig. 1. Numbers of teeth extracted and occasions of extraction. Postoperative bleeding was not
associated with the number of tooth extractions. (*Immediate postoperative bleeding occurred
once.).

range 17). The distribution of teeth

extracted on each occasion is shown in
Fig. 1.
Immediate postoperative bleeding occurred in 10 patients in the control group
(patients who underwent 16 tooth extractions) and in ve patients in the study
group (patients who underwent 13 tooth
extractions). However, none of the
patients reported any delayed bleeding
necessitating a return to the hospital. In
the telephone records, 24 patients (six
patients (3%) from the study group and
18 patients (2%) from the control group)
reported mild bleeding, which they had
simply controlled by biting on a new dry
gauze. The incidence of postoperative
bleeding was higher in the study group
(5/274, 1.8%) than in the control group
(10/1472, 0.7%), but the difference was
not signicant (P = 0.07) (Table 2). In the
study group, the incidence of postoperative bleeding was higher in patients on
dual therapy (1/24, 4.2%) than in those
on aspirin alone (2/185, 1.1%) or clopidogrel alone (2/65, 3.1%); however, the
differences were not signicant. The incidence of postoperative bleeding in the two
groups was not associated with the number
of tooth extractions, the types of extraction, or single or dual antiplatelet therapy
(all P-values > 0.05, Table 2).
Among the 15 patients who developed
immediate postoperative bleeding, eight
cases involved periodontitis that was complicated by either acute inammation or
alveolar abscess. With respect to the reasons for extraction, periodontitis was
found to be associated with postoperative
bleeding in both groups (P < 0.05).
Local haemostasis with Gelfoam sponge
was sufcient in most patients. Immediate
postoperative bleeding occurred in

ve conrmed cases in the study group

and seven cases in the control group and
could be managed by repacking with
Gelfoam impregnated with TXA powder
followed by pressure; suturing was not
necessary. The wounds were sutured only
in those patients who had undergone surgical extractions of teeth with ap elevation,
including three patients in the control group
with immediate postoperative bleeding.
Discussion

Planning dental extractions for patients on

antiplatelet therapy implies facing a decision to either stop the drugs and bring
about a possible lethal thrombosis, or continue the drugs and confront the eventuality of excessive bleeding. The risk of a
thromboembolic event is difcult to estimate, but is probably 0.005%.1,4 Mounting
evidence supports a platelet rebound phenomenon after abrupt antiplatelet withdrawal.2 This rebound period is
characterized by increased thromboxane
production, decreased brinolysis, and a
resultant clinical prothrombotic state.2
The mean platelet life-span being 710
days, about 50% of normally functioning
platelets are recovered within 5 days after
aspirin withdrawal, while platelet thromboxane biosynthesis recovers more
rapidly, with its urinary thromboxane metabolites close to normal levels after 3
days.4 The mean delay in stroke and MI
after aspirin cessation is approximately 10
days (range 417 days), which is consistent with the time interval of the platelet
rebound effect.12 Ferrari et al. reported
that 51 of 383 CAD patients were admitted
for acute coronary syndrome events within
1 month (mean 10 days) after stopping
aspirin therapy, for an incidence among

CAD patients of 13% and an overall incidence of 4% (51 of 1236 patients).12 Collet et al. reported that nine of 475 MI
patients (1.9%) had discontinued aspirin
therapy within 15 days prior to intended
surgery.4 The present researchers have
witnessed two diabetic females who were
rescued from a stroke at 2 days after tooth
extraction because their aspirin had been
stopped for 7 days prior to their procedures. These data suggest that aspirin cessation might lead to lethal thrombosis,
particularly in patients with prior CVD
and indications for aspirin treatment. Although the risk is low, the outcome is
serious.
As early as 1987, Salzman stated that
the haemostatic defect induced by aspirin
in patients with otherwise normal haemostasis is usually minor.18 A number of
studies have shown no difference in the
incidence of bleeding after invasive oral
surgical procedures between patients receiving single and dual antiplatelet therapy.3,15 Wahl reported that of 1283 patients
on single or dual antiplatelet agents who
experienced 2308 dental extractions on
1334 occasions, no more than 35 (2.7%
of patients and 2.6% of occasions) had
bleeding complications, and only two
patients (0.2%) required more than local
measures for haemostasis.3
Park et al. reported that dental extractions were safe without stopping dual
or triple antiplatelet agents in coronary
drug-eluting stent patients; only two of
100 (2%) had postoperative bleeding,
which could be controlled easily with
the application of pressure.19 However,
the risk of stent thrombosis in drug-eluting
stents is increased in the perioperative
setting and is strongly associated with
the cessation of antiplatelet therapy. Based
on the evidence that post-extraction bleeding problems in patients on antiplatelet
therapy are not more severe than those
in patients with normal coagulation, it
appears logical to continue antiplatelet
therapy for dental surgery.
From the results of this study, it is clear
that postoperative bleeding was not a
problem following dental extraction for
patients whose single or dual antiplatelet
medications were not stopped and who
were treated under local anaesthesia on
an outpatient basis. None of the patients
with immediate bleeding required a blood
transfusion, parenteral TXA, or the administration of vitamin K, or needed to stop
antiplatelet agents. Postoperative haemostasis can be managed successfully by
repacking with Gelfoam plus TXA powder, which is safe, simple, and less troublesome than continuing TXA mouthwash

Extraction without stopping antiplatelet therapy

for days.20 Sutures were not considered to
be necessary; sutures were made only on a
case-by-case basis and depending on the
extent of the trauma. In fact, this remains
the standard of care in the authors daily
practice. Among the 15 cases of postoperative bleeding, 12 were simple extractions
rather than invasive dental procedures,
eight of which involved periodontitis.
Many dental studies have reported local
haemostasis to be less successful when
acute inammation is present, which is
compatible with the present results.14,21,22
Platelet function is commonly assessed
using the cutaneous bleeding test.23 Aspirin can double the baseline bleeding time,
but this can still be within or just outside
the normal range. Only 2025% of
patients using low-dose aspirin have an
abnormal bleeding time.24 Clopidogrel as
a more potent antiplatelet agent can prolong the bleeding time by 1.53-times
normal, but no single antiplatelet drug
(aspirin, clopidogrel, triusal, or ticlopidine) appears to promote haemorrhage
more than any other.25,26 As a correlation
between bleeding time test results and the
rate of surgical bleeding complications has
not yet been established, the cutaneous
bleeding time test should not be used to
estimate the bleeding risk in patients on
antiplatelet therapy; moreover the test has
no role in the prediction of bleeding in the
dental setting.23,24
The American Diabetes Association
and AHA have conrmed the prophylactic effects of aspirin and other antiplatelet
agents in the prevention of thrombotic
CVDs.27,28 However, the American College of Cardiology and AHA suggest that
warfarin or dual antiplatelet therapy
should be the rst choice of antithrombotic agent among patients with AF or
CAD with drug-eluting stents.13,19,29,30
Although aspirin is less efcacious than
warfarin or newer antiplatelet agents, it
has been found to be the most used
agent.10,11,27 In this study, aspirin was
also found to be the most used antiplatelet drug (68.3%), and 14 out of 15
patients with AF were receiving aspirin
alone (Table 3). These ndings coincide
with the observations of other studies.10,26,27 It is clear that an efcacious
antithrombotic therapy to prevent stroke
remains underused in Taiwan Chinese
patients and that most AF patients have
not been treated appropriately.
A large national representative cohort
study from Taiwan showed that there was
no difference between antiplatelet therapy
and warfarin with regard to the risk of
ischaemic stroke, while for bleeding,
aspirin had a lower risk compared to

warfarin.10 This may reect poor anticoagulation control, highlighting opportunities for improved stroke prevention with
alternative strategies, such as the NOACs,
and the importance of continuous antiplatelet therapy throughout the perioperative period of dental surgery. For patients
with established CVD, especially those
taking aspirin or other antiplatelet agents
for thrombotic prophylaxis, this should be
considered a critical therapy.
The dentist today is seeing an increasing
number of patients on antiplatelet drugs to
prevent thrombosis who require dental
surgery. The ndings of the present study
suggest that there is no need to stop single
or dual antiplatelet therapy prior to dental
extraction. It is time to teach patients and
dentists, as well as physicians, that antiplatelet withdrawal preoperatively may
invite a remote but fatal risk of thromboembolism. Bleeding complications, while
inconvenient, do not carry the same risks
as thromboembolic complications. Local
haemostatic measures are sufcient to
control bleeding for those receiving continuous antiplatelet medications, and good
surgical techniques must be employed in
all oral surgical procedures.
Funding

The study was supported in part by a

CMRP research grant from the Chang
Gung Memorial Hospital, Kaohsiung,
Taiwan (CMRPG8C0642 to Shin-Yu
Lu) after proper Institutional Review
Board approval.
Competing interests

The authors whose names are listed certify

that they have no afliations with or involvement in any organization or entity
with any nancial interest (such as honoraria; educational grants; participation in
speakers bureaus; membership, employment, consultancies, stock ownership, or
other equity interest; and expert testimony
or patent-licensing arrangements), or nonnancial interest (such as personal or
professional relationships, afliations,
knowledge, or beliefs) in the subject matter
or materials discussed in this manuscript.
Ethical approval

The study was approved by the Institutional

Review Board of Chang Gung Memorial
Hospital (102-2101B to Shin-Yu Lu).
Patient consent

Not required.

1297

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Lu et al.

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Address:
Shin-Yu Lu
Oral Pathology and Family Dentistry Section
Department of Dentistry
Kaohsiung Chang Gung Memorial Hospital
123 Dapi Road
Niaosong District
Kaohsiung 833
Taiwan
Tel: + 886 7 7317123x2371;
Fax: + 886 7 7317123x2243
E-mail: jasminelu@adm.cgmh.org.tw