Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy

1. JOURNAL
PRESENTATION
PRESENTED BY:
DR.KAMINI DADSENA

2. ASSESSMENT OF THE RISK OF
HAEMORRHAGE AND ITS CONTROL
FOLLOWING MINOR ORAL SURGICAL
PROCEDURES IN PATIENTS ON ANTI-PLATELET
THERAPY: A prospective study
Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil
Vidyanagar, Nerul, Navi Mumbai, India
Int. J. Oral Maxillofac. Surg. 2014; 43: 99–106

3. ABSTRACT
Controversy exists concerning the suspension
or maintenance of anti-platelet drugs before
elective surgical procedures. Authors assessed
the association of the risk of prolonged
postoperative bleeding with anti-platelet
therapy by type of minor surgical procedure
and the association between anti-platelet
therapy and the level of hemostatic measures
required.

4. THE CURRENT STUDY WAS
UNDERTAKEN IN ORDER TO
ASSESS:
(1) the association between anti-platelet therapy
and prolonged postoperative bleeding;
(2) the association between prolonged
postoperative bleeding and the type of minor
surgical procedure performed; and
 (3) the association between anti-platelet therapy
and the level of hemostatic measures required.

5. MATERIALS AND METHODS

6. SAMPLE SIZE:
1121 patients were included in this study
Males- 686 and Females- 435
Group A (aspirin)-310 patients
Group B (clopidogrel)- 97 patients
Group C (aspirin and clopidogrel)- 139 patients
Group D (control group)- 575 healthy
individuals.

7. INCLUSION CRITERIA:
patients on single and dual anti-platelet
therapy, with a normal blood count and
coagulation profile.
Age - 40 to 75 years.

8. EXCLUSION CRITERIA:
uncontrolled diabetes/hypertension
Endocrine disorders
pregnant women.
Patients on concurrent therapies such as the birth
control pill, hormone replacement therapy, and
anticoagulants were also excluded.

11. Preoperative haematological investigations
comprising a complete blood count and
coagulation profile were performed for all patients.
The patient’s cardiologist/physician, who had
advised discontinuation of antiplatelet therapy,
received a written explanation of the nature of the
procedure to be carried out and assurance of
hemostasis being achieved in the chair.
Written consent to carry out the surgery without
stopping the antiplatelet therapy was received.

12. Following surgery, a pressure pack was applied
for 30 min.
Suturing was done using a simple interrupted
technique with 3-0 mersilk.
Patients were kept under observation for a
further 30 min with the pressure pack in place
after completion of the procedure.
Prolonged bleeding was defined as uncontrolled
bleeding that continued in spite of the pressure
pack given for 30 min postsurgery.

13. If bleeding persisted, it was controlled with
various local hemostatic measures. such as
pressure pack
suturing (simple interrupted technique)
local hemostatic agents like gel foam
surgical diathermy.

14. The local hemostatic measures were
categorized into five levels based on the
commonly followed sequence of their use to
achieve hemostasis in minor oral surgical
procedures:
 level 1, pressure pack;
 level 2, suturing;
 level 3, local hemostatic agent and suturing;
level 4, surgical diathermy;
 level 5, platelet transfusion.

15. For patients who bled during the postoperative
period, a pressure pack was applied and suturing
was done when indicated.
 In certain procedures (multiple extractions and
surgical extractions) prolonged postoperative
bleeding was controlled with gel foam and
resuturing was done.
In certain biopsy cases, Surgical diathermy was
chosen as a measure to control ongoing bleeding
when other local hemostatic measures failed.
Paracetamol was prescribed as the postoperative
analgesic to prevent interaction with the anti-
platelet drugs.

16. Patients were discharged with strict
postoperative instructions and were advised to
report any excess bleeding immediately.
Follow-up was completed after 24, 48, and 72 h
and at 1 week (when the sutures were removed).
All patients were given the contact number of
the surgeon so that they could report any
episode of bleeding. In the absence of any call,
the surgeon contacted the patient in the
evening.

17. STATISTICAL ANALYSIS
 Cramer’s V test was used to assess any possible
association between anti-platelet therapy and the risk of
prolonged postoperative bleeding; statistical significance
was set at the 0.05 level.
 The odds ratio was also used to assess any association
between the risk of prolonged bleeding and the type of
minor surgical procedure performed.
 Fisher’s exact test was performed to examine the
significance of the association between
single/dual/control classification of the patient and the
level of hemostatic measures used to control bleeding.

18. RESULTS:

19. ASSOCIATION BETWEEN ANTI-PLATELET
THERAPY AND THE RISK OF PROLONGED
POSTOPERATIVE BLEEDING
The results of the Cramer’s V test associated with the cross table were
statistically significant (P < 0.05). However the magnitude of Cramer’s V,
at 0.13, indicates a weak relationship between the two variables: anti-
platelet therapy and immediate post-operative bleeding.

20. The results of the Cramer’s V test associated with the cross table
were not statistically significant (P = 0.60). Thus, no relationship
was found between anti-platelet therapy and bleeding in the 24-h
postoperative period.

21. Compared to controls, the risk of prolonged bleeding in the immediate
postoperative period was significantly higher in patients on dual therapy,
followed by clopidogrel and aspirin.
All odds ratios were nonsignificant for the 24-h postoperative period, i.e.
there was no significant difference in the risk of prolonged bleeding on
comparing these groups for this time period.

22. ASSOCIATION BETWEEN THE RISK OF
PROLONGED BLEEDING AND THE TYPE OF
MINOR SURGICAL PROCEDURE PERFORMED
The odds ratio values for all the procedures were non-significant both in
the immediate postoperative period and in the 24-h postoperative period.
Hence, the risk of prolonged bleeding was determined to be independent
of the type of minor oral surgical procedure performed

23. ASSOCIATION BETWEEN ANTI-PLATELET
THERAPY AND THE LEVEL OF HEMOSTATIC
MEASURES REQUIRED

24. The majority of patients, bleeding was controlled with the
pressure pack alone (n = 20), followed by suturing (n = 13).
5 patients required the use of gel foam and
4 required the use of diathermy

25. The results of fisher’s exact test to assess the association between anti-platelet therapy and
the level of hemostatic measures required (table 10; stratified as level 1 and level >1)
showed a statistically significant association between dual ther- apy and more than level 1
hemostatic measures when compared to the control group (P = 0.004)

26. The other results were non-significant. When assessing the same association
with the levels stratified as level 2 and level >2 hemostatic measures (table 11),
the results were statistically significant for dual therapy when compared to the
control group (P = 0.035). The other results were non-significant.

27. DISCUSSION:
 Several studies have advocated stopping aspirin therapy
either 7–10 days 11– 15 or 24–48 h 16,17 before elective surgery
because of the fear of excessive bleeding intraoperatively and
during the following 24–48 h.
 Vaclavik J et al have reported that the risk of cardiovascular
events increases three-fold after aspirin withdrawal.18
 Wahl and Howell 19 were conclude that the risk of
haemorrhage after dental surgery may be greatly outweighed
by the risk of thromboembolism after withdrawal of anti-
thrombotic therapy.
 A study by Collet et al. reported that patients for whom
aspirin was recently discontinued developed acute coronary
syndrome (ACS).20

28.  Biondi-Zoccai et al have reported cardiovascular event
rates of 2.3–6% after discontinuing aspirin therapy.
risk of developing major cardiovascular events after
aspirin withdrawal has also been reported to be three
times higher than in those who continue aspirin
21
 Anti-platelet therapy withdrawal in stent patients is
extremely risky and can lead to the development of
stent thrombosis, with a 57-fold increase in the risk
this event with clopidogrel withdrawal and a 10-fold
increase in the risk with aspirin withdrawal. 22
 In patients with a recently implanted stent, anti-
therapy withdrawal in the perioperative period has
found to represent an average mortality rate of 20–
40%.22–24

29.  In this study the percentage of patients in the study
group experiencing prolonged immediate
postoperative bleeding was greatest for those on dual
therapy, followed by those on clopidogrel and then
those on aspirin.
 Cramer’s V results for the immediate post-operative
period showed a statistically significant value but a
weak relationship, which infers that anti-platelet therapy
is not the sole cause of postoperative bleeding.
 Bleeding within the 24-h postopera-tive period was
found to be independent of anti-platelet therapy.

30.  Factors other than anti-platelet therapy may aggravate
postoperative bleeding may include:
1. acute inflammation, periodontitis, and pericoronitis.
2. Leftover granulation tissue.
3. Accidental contact with the inferior alveolar canal
4. Excessive tension during closure led to the opening of
sutures and prolonged bleeding.
5. Stress-induced hypertension
6. Giant cell lesions,
7. pyogenic granuloma, and
8. inflammatory lesions of the tongue and floor of the
mouth caused prolonged bleeding

31. OTHER OBSERVATIONS MADE DURING
THIS RESEARCH WERE:
 (1) careful curettage and debridement should be
done whenever granulation tissue is present, as this
could be the cause of bleeding postoperatively;
 (2) firm pressure should be maintained for 30 min
and after that check for bleeding. If haemorrhage is
evident, then either suturing or a local hemostatic
agent along with suturing is advised;
 (3) the patient should be observed for the next 30
min at a minimum;

32.  (4) in cases of biopsy, where excessive bleeding is
anticipated, surgical diathermy should be kept on
standby. It may be easier and faster to use
diathermy than other local hemostatic measures in
such circumstances; and
 (5) surgeons should personally consult the
patient’s physician and discuss the nature of the
procedure to be performed and its safety with
continued anti-platelet therapy. The dental
fraternity should be urged to discuss treatment
with the patient’s physician so that the patient is
not deprived of the benefit of anti-platelet therapy

33. STERNGTH OF THE STUDY:
Strengths of this study include the large
sample size and the variety of minor oral
surgical procedures performed.
Another advantage is that authors compared
the study group to healthy individuals and
found similar episodes of bleeding, all of
which could be controlled with local
hemostatic measures.

34. LIMITATION OF THE STUDY
A limitation of the study is that the platelet
aggregation test was not used as it is expensive
and also because its predictive power is not well
documented.
Further, the intraoperative bleeding was not
quantified to estimate and compare the blood
loss amongst the study and control groups.

35. SUMMARY OF THE STUDY:
 (1) the risk of prolonged postoperative bleeding is
independent of the type of minor surgical
procedure performed;
 (2) patients on dual therapy are at the greatest risk
of prolonged postoperative bleeding;
 (3) pro-longed bleeding in patients on single drug
anti-platelet therapy can be managed in a similar
fashion to healthy individuals, with a pressure pack
as the first line of control wherever possible;

36.  (4) patients on dual therapy require higher levels of
hemostatic measures, thus suturing should be the
first line of control to arrest bleeding. This leaves
patients with an additional factor of safety; and
 (5) no patient required a blood transfusion. Hence
there is no need to expose the patient to the risk of
thromboembolism, cerebrovascular accidents, or
myocardial or renal infarction by discontinuing anti-
platelet therapy before minor oral surgical
procedures, which could cost the patient his or her
life.

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42. THANK YOU