Ashok Kumar*, Adil Khan**, Mozaffer Rahim Hingorjo***, Asghar Mehdi****
How to CITE:
J Pak Dent Assoc.2011; 20 (2): 115-117
The purpose of our study was to review the current trend of dental practitioners in Karachi about stopping or not, low dose aspirin before tooth extraction.
A total of 68 Dentists were included in the study, belonging to private clinics (n = 34) and working in two of the dental college hospitals of Karachi (n = 34). Data was collected with the help of a close ended questionnaire containing two questions: Do you stop aspirin before tooth extraction? Is it due to fear of bleeding?
Out of a total of 68 dentists, 22.1% were in favour of continuing aspirin while 77.9% practiced to stop it before tooth extraction. In the individual groups, 9 (26.5%) private dental practitioners were in favour of continuing low dose aspirin and the remaining 25 (73.5%) were not in favour of that. Out of 34 practitioners working in hospitals only 6 (17.6%) continued to use aspirin during tooth extraction whereas 28 (77.9%) were in favor of discontinuation before the procedure. The reason given for stopping the drug by all those in favor of this practice was fear of perioperative bleeding.
Majority of dental practitioners in Karachi still consider stopping low dose aspirin before tooth extractions, a practice that needs to be discouraged at all levels.
Aspirin, Bleeding, Tooth extraction.
Aspirin, a wonder drug and Nobel Prize earner for John Robert Vane who discovered that aspirin inhibits prostaglandin biosynthesis, is one of the drugs that has changed the outcome of patients with coronary artery disease, increasing their average life expectancy worldwide. Being an anti-platelet agent, dentists are frequently worried about its potential side effect of causing bleeding especially after tooth extraction. Aspirin, a Non Steroidal Anti Inflammatory Drug (NSAID), also known as acetyl salicylic acid (ASA) is known to decrease platelet aggregation by inhibiting cyclo-oxygenase I (COX1), through a selective acetylation of human COX 1; the effect lasts for the life of platelet (approximately 10 days). Aspirin inhibits COX 1 irreversibly by binding to the active site of the enzyme at the arginine 120 residue and acetylating the serine 529 residue. Acetylation prevents arachidonic acid from gaining contact with Tyr385, which is the normal first step in its cyclo-oxygenation, leading to inhibition of production of Thromboxane A .1 Aspirin is 150 to 200 2 times more potent inhibitor of COX1 than COX2, and COX1 is sensitive to low doses of aspirin (40-80 mg daily).2,3 Inhibition of collagen induced platelet aggregation is optimal at a dose of 160 mg.4,5
Inhibition of COX1, inhibits the production of Thromboxane A2, which under normal circumstances binds platelet molecules together to create a patch over damaged walls within blood vessels. Because the platelet patch can become too large and also block blood flow, locally and downstream, aspirin is also used long term, at low doses, to help prevent heart attacks, strokes and blood clot formation in people at high risk for developing blood clots. Long term prophylactic use of aspirin has been recommended for the individuals with diabetes who are at risk of cardiovascular diseases.6 Due to the anti-platelet effect of aspirin and some individual case reports of bleeding following dental procedures,7 a common fear prevails of homeostatic complications during or after dental procedures. A common practice among dentists is to advise patients to discontinue aspirin therapy for some days prior to tooth extractions / oral surgical procedures, but no clear guidelines exist for dose alteration8 and clinical trials have also been contradictory. Given the goal for aspirin in these clinical situations, discontinuation of aspirin must be weighed against the potential for significant bleeding during or following an invasive dental procedure if aspirin is continued
The purpose of our study is to review the current trend of dental practitioners in Karachi about stopping or not, low dose aspirin before tooth extraction..
A close ended questionnaire containing the following two questions was created:
Do you stop aspirin before tooth extraction?
Is it due to fear of bleeding?
The questionnaire was given to private dental practitioners and practitioners of two dental college hospitals of Karachi. Two groups of 3rd year students were selected to conduct the survey. They visited the practitioners personally and after taking informed consent the answers to these two questions were recorded..
A total of 68 dentists were included in the study, belonging to private clinics (n = 34) and working in Fatima Jinnah Dental College and Hospital Karachi (n = 34). Out of a total of 68 dentists, 22.1% were in favor of continuing ASA; the remaining 77.9% practiced to stop ASA before tooth extraction.
Looking at individual groups, 9 (26.5%) private dental practitioners were in favor of continuing low dose aspirin and the remaining 25 (73.5%) were not in favor of that.Out of 34 practitioners working in hospitals only 6 (17.6%) continued to use ASA during tooth extraction whereas 28 (77.9%) were in favor of discontinuation before the procedure (Table 1).
The reason given for stopping the drug by all those in favor of this practice was fear of post-operative bleeding
Aspirin irreversibly interferes with platelet function, the effect lasting for the life time of the platelet, approximately 8-10 days.10 As little as 81 mg of aspirin is enough to effectively prevent platelet aggregation.11
Earlier case reports suggested oral bleeding on account of aspirin, however, it is not clear if they were directly related to aspirin or other actors.12 More recently a large number of prospective trials have been published to evaluate this effect of aspirin. Brennan MT et al, in the randomized, double blind placebo-controlled study to evaluate the impact of higher doses of aspirin (325mg/d) in persons requiring single tooth extraction found no significant differences for the primary haemostatic outcome of oral bleeding between the aspirin and placebo group and concluded that there was no indication for discontinuing aspirin for individuals requiring a single tooth extraction or similarly invasive dental procedures.13
A similar study published in The Saudi Dental Journal in 2009, on patients receiving 81 mg of ASA daily, showed similar outcomes in all patients taking ASA versus placebo regarding bleeding post-operatively after 2-5 days and concluded that patients on ASA could undergo tooth extraction without the risk of bleeding.14
Adchariyapetch compared the postoperative stoppage of bleeding in subjects who stopped or continued taking aspirin seven days before simple dental extraction. The mean bleeding time in both groups was normal before and after the procedure and the bleeding stopped in both groups within 30 minutes by biting the gauze, except for one patient who required a gauze biting time of between 31 to 60 minutes. They therefore concluded that simple tooth extraction of 1-3 teeth in patients taking low dose aspirin (< 100mg) could be done without the necessity of stopping aspirin.15 Krishnan et al also found no increased risk of prolonged or excessive postoperative bleeding in patients on long-term antiplatelet therapy and the bleeding
was stopped by applying pressure packing only.16 Napenas JJ et al found no difference between patients receiving single or even dual antiplatelat therapy for all variables, most notably the number of invasive procedural visits, total extractions and adjunctive haemostatic measures.17
In view of that and much more available literature data, which clearly and loudly speaks against practice of discontinuing ASA before tooth extractions; when we look at our study in which majority of our practitioners both working privately or in institutions, their tendency to stop ASA is unjustified. The risk of discontinuing or altering the dose of antiplatelat agents far overweigh the very low theoretical risk of postoperative oral bleeding, which even if it occurs, can easily be controlled by local haemostatic measures. This trend needs to be addressed clearly and loudly at all levels including Medical and Dental Teaching and public health awareness programs. If necessary this very common problem should especially be included in Medical and Dental curriculum at national level to stop this erroneous and dangerous practice of withholding low dose aspirin at the probable cost of impending lethal complications..
Majority of dental practitioners in Karachi still consider stopping low dose aspirin before tooth extractions; a practice which needs to be discouraged at all levels.
Authors would like to acknowledge the help extended in data collection by Dur-e-Aden, Ayesha Munaf, Moomal Ali, Momina Abbas and Zoya Rizwan, the students of 3rd year BDS, Fatima Jinnah Dental College, Karachi.
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