CLINICAL SOCIETY MEETING

MAY 2024 ASSESSMENT OF POST

EXTRACTION BLEEDING
AMONG PATIENTS ON
UNINTERRUPTED SINGLE
ANTIPLATELET DRUG
THERAPY- A PROSPECTIVE
STUDY

• Guided by Dr Uma Magesh, Dr Nalini Sailaja I

 INTRODUCTION
• Antiplatelet drugs are used for secondary prevention of cardiac and
cerebrovascular disease.
• Low dose aspirin and clopidogrel are the most commonly prescribed
antiplatelet drugs.
• It is common for physicians and dentists to stop a patient’s antiplatelet
therapy for 3-7 days, before dental extraction to avoid the risk of bleeding.
• However, the interruption of antiplatelet therapy is associated with
progressive recovery of platelet function and potential risk of rebound
thrombotic arterial events.
OBJECTIVES

• To Assess the post-extraction bleeding among patients on the uninterrupted single

antiplatelet drug during tooth extraction.

• To Assess the post extraction bleeding among patients who discontinued the
antiplatelet drug 3 days prior to tooth extraction.

• And to compare the post extraction bleeding among both the group
PATIENTS WILL BE CATAGORIZED INTO

1 STUDY GROUP 2 CONTROL GROUP

patients who continued the
patients who
single antiplatelet drug
discontinued the
{Aspirin 75mg / Clopidogrel
75mg}during tooth extraction. antiplatelet drug 3 days
prior to tooth extraction.
 SAMPLE SIZE CALCULATION

30 TEST SAMPLE SIZE WAS CALCULATED TO BE 58 WITH 30 IN

TEST GROUP AND 28 IN CONTROL GROUP ASSUMING
ALPHA ERROR AT 0.05 AND POWER OF THE STUDY AT
90% USING G POWER SOFTWARE
28 CONTROL
METHODOLOGY
INCLUSION CRITERIA

• Patients referred to the department of oral and Maxillofacial Surgery who

are under single antiplatelet therapy( Aspirin 75mg/day or Clopidogrel
75mg/day),
• who require extraction of single multirooted tooth will be included into
the study.
• Patients under the age group of 35-65 years are included
METHADOLOGY
EXCLUSION CRITERIA
• Patients who are taking dual antiplatelet drug or other
anticoagulant, any anti inflammatory drugs.
• Patients with hematologic, renal and liver diseases, alcoholism.
• Patients having grade II,III mobile tooth or impacted tooth are
not included.
METHADOLOGY

• All the participants are recruited only after getting a fitness

certificate from their cardiologist.Bleeding time of all the
patients will be checked prior to extraction. Patients under
normal bleeding time are selected. Vitals are recorded prior to
the procedure.
INFORMED CONSENT FORM
 METHADOLOGY
Assessment of variables
Bleeding was assessed postoperatively by bleeding scale
• Grade 0: Very low (almost no bleeding).
• Grade 1: Low (minor bleeding from the socket that often stops on its own or when pressure is
given).
• Grade 2: Normal. (Clinically significant).
• Grade 3: High. (After clot has substantially formed, bleeding occurs).
• Grade 4: Very high (profuse bleeding that was uncontrollable by sutures or topical hemostatic
medications).
 METHADOLOGY

Any incidence of bleeding will be controlled by local haemostatic measures as required. Patients
will be evaluated in the department of oral and maxillofacial surgery after 24 hours, 72 hours and
5 days postextraction.
IMAGES

Preoperative Post-op Immediately After Extraction

IMAGES

Half An Hour After Extraction Tranexamic Acid Tranexamic Acid Loaded In A Gauze
IMAGES

Socket Compression With Gauze Containing Tranexamic Acid Two Hours After Extraction
 RESULT
There is a significant difference in preoperative bleeding time in control (mean BT = 87.86 sec) and study group (mean BT =175.67 sec),
Table.1.

Group N Mean Std. Deviation p value

Control 28 87.86 13.154 0.000

Test 30 175.67 26.869

RESULT
There is a significant difference in bleeding time immediately after extraction (p value <0.001), Table 2

Immediate P
Control Test
Post ext bleeding value

0 18 0

1 9 19 <0.001

2 1 11
RESULT
There is a significant difference in bleeding time 30min after extraction (p value = 0.005)

Immediate P
Control Test
Post ext bleeding value

0 25 17

0.005

1 3 13
RESULT
There is no significant bleeding in 2 hours , 24hr, 72 hr and 5th day after extraction

2hour after extraction

Immediate
Control Test
Post ext bleeding

0 28 30
RESULT
There is no significant bleeding in 2 hours , 24hr, 72 hr and 5th day after extraction
Ist day *Group

1st P
Control Test
day value

0 28 26

0.065

1 0 4
RESULT
There is no significant bleeding in 2 hours , 24hr, 72 hr and 5th day after extraction
3rd day * Group

P
3rd day Control Test
value

0 28 29

0.330

1 0 1
RESULT
There is no significant bleeding in 2 hours , 24hr, 72 hr and 5th day after extraction
5th day

5th
Control Test
day

0 28 30

All the incidence of bleeding are very well managed by placing tranexamic acid impregnated gauze
DISCUSSION
Coronary events that occured after aspirin withdrawal was found to
be 4% of all coronary events hospitalized
(Ferrari et al ,collet et al.)
DISCUSSION
Rapid withdrawal of aspirin may cause abnormally high levels of blood
markers reflecting an increase of thromboxane A2 which have
hazardous effects in patients with cardiovascular disease ( Beving et al ,
Mcdonald et al )
DISCUSSION
The average time between aspirin withdrawal and the manifestation
of acute coronary syndrome is 8 to 11 days .
Hence withdrawal of antiplatelet drug is a risk factor for recurrent
thrombotic events.
In patients under antiplatelet therapy, the formation of platelet plug is
delayed so there is risk of increased bleeding time but soon the
unaffected platelets and coagulation cascade take over to plug the
defect.
DISCUSSION
There was significant difference in postextraction bleeding between
the groups immediately after extraction and 30 minutes after
extraction.(3 in control group and 13 in test group) This postoperative
bleeding event was very well controlled with local application of 1ml
of 100 mg tranexamic acid soaked gauze
DISCUSSION
In the present study, none of the patients in both the group had
postextraction bleeding after 2 hours.
The difference in bleeding status between the two groups after
24hours and 72 hours were not significant.
No patients in the controls or test group developed late hemorrhagic
complications
DISCUSSION

Limitations of study:

Study is restricted to patients on

single antiplatelet therapy.
Only single multirooted tooth extractions were
carried out.
Other antiplatelet drug like prasugrel , ticlopidine were not included.
DISCUSSION

Recommendations:

Further studies have to be carried out by including patients taking dual

antiplatelet drug therapy, patients requiring multiple extractions and also
antiplatelet drugs like prasugrel , ticlopidine were to be included.
TAKE HOME MESSAGE
• This study elicited no progressive or secondary bleeding in patients
with antiplatelet therapy during simple dental extraction.

• So there is no need to stop antiplatelet therapy. The local hemostatic

measure can very well control all incidences of bleeding (1ml TXA
imprenated guaze is enough)