Antiplatelet drugs are most commonly applied as part of chronic primary or secondary prevention of complications associated with atherosclerosis of coronary or peripheral arteries. The use of aspirin, clopidogrel and other similar drugs is linked with a risk of prolonged bleeding following dental surgeries [9, 23]. The current study is based on a retrospective analysis focusing on 153 patients, some subjected to dual antiplatelet therapy, who had to have teeth extracted due to existing pocket infections of dental nature. The related problems are not only encountered by dental practitioners but also by family doctors or cardiology specialists consulted in regard to patients’ eligibility for surgery . In the case of patients on chronic antiplatelet therapy who are eligible for tooth extraction, medical practitioners always face a dilemma whether or not to discontinue antiplatelet therapy . As emphasised by numerous researchers, discontinuation of antiplatelet therapy may lead to serious consequences such as thromboembolism affecting coronary or cerebral arteries, which according to statistics in 25% of cases end with death, while 40% of such episodes may lead to permanent disability. Papanicolaou et al. described a serious case of ST-Elevation Myocardial Infarction (STEMI) associated with cardiogenic shock following discontinuation of DAPT prior to tooth removal, and with heparin bridging which proved to be ineffective and increased a risk of perioperative thrombosis. It has been pointed out in the related literature that in the cases where antiplatelet therapy is not discontinued, dental surgery or tooth extraction may lead to prolonged postoperative bleeding which is difficult to stop [21, 25]. As mentioned in the introduction, a medical professional must make decisions based on his/her knowledge and clinical experience, tailored to the needs of a specific patient. However, it is always necessary to assess the risk of systemic thromboembolic complications due to discontinued therapy, and the likelihood of bleeding which can be stopped using available local haemostatic agents [26, 27].
In the current study it was hypothesised that local dressing can safely be applied to wounds resulting from tooth extraction, with no need to discontinue antiplatelet therapy, and the treatment may reduce prolonged and secondary bleeding following extraction [22, 28, 29]. Analysis of the author’s own materials show that in the group of 153 patients subjected to the procedure, secondary bleeding following the procedure was observed in eight patients accounting for 4.9% of the total group. In patients using dual therapy bleeding occurred on the second day, at a rate of 4.1%, and in the group of patients using primary prevention there were slightly more cases of bleeding, accounting for 7% of the subjects. Statistical analysis did not identify significant differences in the incidence of post-extraction bleeding relative to the primary or secondary therapy applied . A review of Polish literature showed there are no articles focusing on tooth extraction and dental surgeries performed in patients using dual antiplatelet therapy. Because of its retrospective nature, the current study does not compare cases of continued and discontinued antiplatelet therapy prior to the procedure, i.e. there is no control group. The small number and low rate of cases of prolonged bleeding show that the procedure may be safely performed with no need to discontinue the medication. This outcome is associated with the fact that adequate local treatment was applied. Similar conclusions were reported by authors of experimental control studies [30, 31].
In many studies and illustrative articles, the authors emphasise the important role of local treatments applied to post-extraction wounds; the options available include a variety of local haemostatic agents, e.g. gelatine sponges, collagen sponges, oxidised cellulose, tissue adhesives, and a variety of splints and stoppers made of acrylate mass . The options applied for years applied in Maxillofacial Surgery Centre at the Clinical Hospital of the University of Rzeszow include local haemostatic agents, i.e. Tissucol and Beriplast tissue adhesives; cellulose-based agents, as well as freeze-dried fibrin and collagen sealants TachoComb and TachoSil [17, 22].
The observations presented here are consistent with the findings reported by Bajkin et al. who performed tooth extractions without a risk of bleeding and without changing the algorithm of antiplatelet therapy (no interruption of the therapy); they only applied local haemostatic agents . Owattanapanich et al. presented data related to efficacy and effectiveness of tranexamic acid in treatment and prevention of post-extraction bleeding in patients using anticoagulant drugs . Napenas et al., based on a review of 15 studies meeting eligibility criteria, assessed the risk of bleeding after dental surgeries performed in patients subject to anti-aggregation therapy and they did not identify a higher risk of clinical complications following tooth extraction in patients using single or dual antiplatelet therapy . A study by Patel et al. demonstrated that dental procedures performed in patients taking antiplatelet drugs are linked with a low risk of post-extraction bleeding; therefore, there is no need to discontinue the antiplatelet therapy .
The current observations support opinions presented by many researchers claiming that it is not necessary to discontinue antiplatelet therapy in connection with tooth extraction, providing that adequate and safe topical dressing is applied to the post-extraction wound. As described in the current study, TachoSil fibrin-collagen patches in our opinion effectively stopped bleeding. Likewise, a study by Lu et al. taking into account a large group of 1271 patients subject to antiplatelet therapy, taking either ASA or clopidogrel (SAPT) or both agents (DAPT), demonstrated that there is no need to discontinue antiplatelet therapy prior to scheduled tooth extraction .
The presented material, intended mainly for general practitioners: dentists, family doctors, cardiologists, proves that tooth extraction using the TachoSil fibrin-collagen dressing for wounds after tooth extraction in patients after myocardial infarction, acute coronary syndromes and other cardiological diseases requiring the use of DAPT antiplatelet treatment, in accordance with the recommendations of the American and European Cardiac Societies, can be safely performed without discontinuing anti-aggregation treatment and achieving normal local haemostasis.
Many years of observations of the authors show that surgical-dental procedures, including tooth extraction, in patients who are undergoing long-term antiplatelet treatment should be performed by a team of experienced doctors with substantive preparation and knowledge of the treatment of coagulation disorders in patients qualified for surgery in the field of dental surgery. The authors believe that knowledge of the guidelines does not limit individual decisions made in relation to a given patient, after a thorough history and physical examination. Future studies should include the study of patients who did not receive platelet anti-aggregation treatment, which will allow for comparison of both study groups and allow for a broader understanding of the topic.