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Vol. 119 No.

1 January 2015

Lack of evidence for increased postoperative bleeding risk


for dental osteotomy with continued aspirin therapy
Henning Hanken, MD, DMD,* Ferdinand Tieck, DMD,* Lan Kluwe, PhD, Ralf Smeets, MD, DMD, PhD,
Max Heiland, MD, DMD, PhD, Clarissa Precht, MD, Marc Eichhorn, DMD, and
Wolfgang Eichhorn, MD, DMD, PhD
Objective. Dental osteotomy, the removal of an impacted, ankylosed, or severely destroyed tooth requiring an osteotomy, is
more invasive than other minor dental procedures and therefore also has a higher bleeding risk. A considerable number of
patients under antiplatelet therapy interrupt their therapy perioperatively, which, however, increases the risk of
thromboembolism.
Study Design. This retrospective study assessed postoperative bleeding incidence for a total of 297 dental osteotomies with
continued aspirin therapy, compared with that of 179 similar procedures on patients who were not on any anticoagulation or
anti-platelet therapy. All procedures were carried out on an outpatient basis.
Results. Postoperative bleeding event was rare in both groups, 5 (1.7%) and 2 (1.1%), respectively, and the difference was not
significant (P .7).
Conclusions. Continued aspirin therapy in patients undergoing dental osteotomies has no effect on the incidence of
postoperative bleeding and should not be interrupted. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:17-19)

When patients receiving antiplatelet drugs undergo


surgery, including dental surgery, a perioperative
cessation of their therapy is often considered because of
the risk of bleeding.1-7 However, such perioperative
cessation of the antiplatelet therapy exposes the patients
to a higher risk of thromboembolism.8,9 Data from more
than 50,000 patients showed that aspirin withdrawal was
associated with a 3-fold higher risk of major cardiac
events.10 Therefore, recent consensus is against altering
or interrupting antiplatelet therapy for dental procedures.
However, despite repeated recommendation, perioperative cessation of antiplatelet therapy is still frequently
practiced for some invasive dental procedures.4 In
particular, many patients interrupt their therapy on their
own without consulting their medical professionals.
Indeed, not many studies addressing bleeding risk of
invasive dental procedures, especially dental osteotomy,
have been carried out on patients receiving antiplatelet
drugs.11 In this observatory study, we followed postoperative bleeding events for 297 osteotomy procedures
with continued aspirin therapy and compared the data
with those of 179 similar procedures on patients not
receiving any anticoagulation or antiplatelet therapy.

MATERIALS AND METHODS


In this retrospective study, all patients with dental
osteotomy and ongoing aspirin 100 mg/d therapy
*These two authors contributed equally.
Department of Oral and Maxillofacial Surgery, University Medical
Center Hamburg-Eppendorf, Hamburg, Germany.
Received for publication Aug 13, 2014; accepted for publication Aug
21, 2014.
2015 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2014.08.016

between January 1, 2000, and December 31, 2010, were


included in the study, and the medical records were
revisited for postoperative bleeding events. Patients
were excluded from this study, if additional antiplatelet
or anticoagulant medication was taken with aspirin and
if aspirin therapy was stopped before the operation. A
total of 476 dental osteotomy procedures were included
in this study: 297 procedures were carried out in 195
patients with continued antiplatelet therapy with aspirin,
and 179 procedures in 165 patients not on any anticoagulation or antiplatelet therapy. Loco-regional anesthesia was obtained using articaine (40 mg/mL) with
epinephrine 1:200,000 (Ultracain D-S, Sano-Aventis,
Frankfurt, Germany) and scandicain 4% (Scandicain 4%,
AstraZeneca, Wedel, Germany) in patients suffering
from recent (less than 6 months) myocardial infarction,
those who had coronary bypass, and those with insufciently controlled hypertension. Patients with cardiac
valvular disease received prophylactic antibiotic therapy
according to the recommendations of the American
Heart Association.12 The teeth were removed via access
of a mucoperiosteal ap, reduction of the surrounding
bone, and, if necessary, separation of teeth with burs.
We used collagen as a local hemostatic agent; single,
interrupted sutures for wound closure (Mersilene 3-0;

Statement of Clinical Relevance


In an outpatient setting, continued aspirin therapy
has no effect on the incidence of postoperative
bleeding in patients with dental osteotomies. Dental
osteotomies can be safely performed without interrupting antiplatelet treatment.
17

ORAL AND MAXILLOFACIAL SURGERY


18 Hanken et al.

Ethicon, Hamburg, Germany); and an acrylic splint.


Postoperative pain was treated with ibuprofen tablets
400 mg/d for 3 days or more if needed. If postoperative
bleeding occurred, a combination of suture, methyloxycellulose, brin glue, and acrylic splint was used.
Simple extraction of teeth was not included in this study.
Each procedure was dened as an independent case
whether or not they were performed on the same patient.
All surgical procedures were performed by the last
author (W.E.) in an outpatient clinic. All patients were
reviewed by the same surgeon (W.E.) on days 1, 7, 10
and 14, suture removal was performed on day 7 after the
procedure, and no patient was lost to follow-up. Hemorrhage was registered as an event when it required
additional surgical intervention.13
The incidences of bleeding in the study and control
groups were compared by using Fishers exact test with
two-sided hypothesis. The number of molar teeth and
the number of front teeth that had postoperative
bleeding in the procedures were compared with those
that did not have postoperative bleeding using t test
with two-sided hypothesis. P < .05 was considered
statistically signicant.
Ethical committee approval
Because of the retrospective nature of this study, it was
granted an exemption by the authors institution.

RESULTS
Postoperative bleeding was only recorded in a total of
7 cases: 5 (1.7%) among the 297 procedures with
continued aspirin therapy and 2 (1.1%) among the 179
procedures on patients not receiving any anticoagulation therapy (Table I). This difference was not
signicant (P .7).
The mean number of the removed molar teeth is
2.5  0.8 for the 7 procedures that had postoperative
bleeding, signicantly larger than that (1.2  0.03,
P < .001) for the 469 procedures that did not have
postoperative bleeding (see Table I). In contrast, the
number of front teeth did not differ signicantly between the two groups (2.5  1.5 vs 1.5  0.1; P .09).
Local measures were sufcient for hemostasis in
all cases. All patients had good wound healing at the
end.
DISCUSSION
With the increasing age of the population in the
industrialized countries, the use of aspirin is becoming
more common. When these patients need oral or
maxillofacial treatment, the surgeon has to outweigh the
risk of heavy surgical bleeding against the risk associated with perioperative cessation of the antiplatelet
treatment. Several studies1-7 favor the interruption of

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January 2015

Table I. Effect of continued aspirin therapy and other


factors on postoperative bleeding incidence
Postoperative Bleeding

Two-Sided Fishers
Exact Test or t Test

Features/Parameters

No

Yes

Antiplatelet Therapy
Aspirin
No
Age of Patient (y)

292
177

5 (1.7%)
2 (1.1%)

P .7

68  11

65  20

P .5

277
192

3
4

P .5

1.2  0.03
1.5  0.1

2.5  0.8
2.5  1.5

P < .001
P .09

Gender
Male
Female
Number of Teeth
Molar teeth
Front teeth

aspirin therapy in order to minimize the risk of perioperative bleeding. Studies on cardiac, orthopedic, and
otolaryngologic surgeries have shown an increased
bleeding risk in patients taking medications that alter
platelet function.14-16 Postoperative bleeding has more
serious consequences for surgeries of the abdomen or
thoracic cavity, which have compartment spaces where,
after wound closure, postoperative bleeding is invisible.
In contrast, the consequences of possible hemorrhage
in non-compartment surgeries is greatly outweighed
by the risk associated with cessation of antiplatelet
therapy, which can result in acute coronary syndrome
in serious cases.8-11,13-16 Dental surgery is a noncompartment procedure, and bleeding in the oral cavity
is immediately visible and can therefore be treated
without delay.17,18 Recently, we reported a signicantly
increased bleeding rate (7.4%) for oral surgeries with
continued phenprocoumon anticoagulation.13 However,
all 47 bleeding events were manageable, and more than
95% of them could be resolved by local hemostatic
measures, and only two cases needed an additional
short-term modulation of the anticoagulation therapy.
In contrast to phenprocoumon, we did not nd any
evidence for an increased bleeding risk for dental
osteotomy under continued aspirin therapy. The sample
size of 297 cases and 179 controls in our study is
considerably large. The lack of signicant difference in
the bleeding rates between the two groups therefore
strongly argues against interruption of anticoagulation
therapy with aspirin for dental osteotomy.
Our data adds further solid and reliable evidence
supporting the consensus for continuing antiplatelet
therapy with aspirin for dental procedures, including
osteotomy.19

CONCLUSION
This study emphasizes that continued aspirin therapy
in patients undergoing dental osteotomies has no effect
on the incidence of postoperative bleeding. Dental

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Volume 119, Number 1

osteotomy can be safely performed without interrupting


antiplatelet treatment with aspirin also in an outpatient
setting.
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Reprint requests:
Wolfgang Eichhorn
Department of Oral and Maxillofacial Surgery
University Medical Center Hamburg-Eppendorf
Martinistr. 52
D-20246 Hamburg
Germany
mkg-balingen@t-online.de