Influence of Aspirin on Post Tooth Extraction Bleeding

Influence of Aspirin on Post Tooth inception BleedingABSTRACTAim The aim of the test was to evaluate the make of acetylsalicylic acid on post descent expel in a clinical setup.Materials and Method 200 Patients cured between 50 to 65 years, who were indicated for dental extraction was selected from outpatient department of Oral and Maxillofacial Surgery. All the patients were arbitrarily divided in acetylsalicylic acid go on root ( theme A) and aspirin discontinuing stem ( chemical group B). After checking all the vital signs extractions were carried out. Bleeding clock meter and clotting time was recorded for evaluation by chi lame Test.Results Chi Squ ar test asserted that the haemorrhage time increased (3.80.75) in Group B patients who proceed with the anti blood platelet therapy charm it decreased in Group A patients who discontinue aspirin. Similarly clotting time increased in group B patient and decreased in Group A patient. nevertheless in some(prenominal) the groups, bleeding and clotting time remained deep down customary curbs.Conclusion Assessing most of the dental and medical literature it can be concluded that there is absolutely no need to discontinue anti platelet therapy for some(prenominal) ambulatory dental procedure and even if practician wishes to discontinue, it should non be more than 3 days. This is also stated in the guidelines of American Heart Association.Keywords Anti platelet drugs, Aspirin, Bleeding time, Tooth extraction.INTRODUCTION health check practiti superstarrs commonly advice their patients who are on antiplatelet therapy to either stop or manipulate their medications preceding to running(a) procedures due to fear of excessive and uncontrolled bleeding. This is a proven fact that aspirin ca use of goods and servicess increased put on the line of intraoperative as wholesome as postoperative bleeding and also increased endangerment of thromboembolic events such(prenominal) as myocardial infraction and cerebrovascular accidents if the drug is continued1. Thrombotic and thromboembolic occlusions of roue vessels are the main cause of ischaemic events in heart, lungs and brain2. In miscue of blood vessel injury hemostatic mechanism is responsible for taenia the extravasation. in the first place hemostatic mechanism in characterized by two consecutive phases original and secondary. Primary mechanism arrests wee bleeding as a emergence of platelet plug formation3. Secondary hemostasis phase is mediated by complex cascade of clotting factors which helps in formation of fibrin clot4. In juvenile years lot of seek and progress choose been made in the field of antiplatelet agents and anticoagulants. These drugs have been utilized for the management of arterial thrombosis also2. Even though a number of antiplatelet and anticoagulant agents have been developed, aspirin and warfarin ashes the standard drug of choice5.Development of aspirin dates back to 1897 and is considered a s one of the safest and cheapest drug worldwide. A general practitioner Lawrence cowardly prescribed hapless dose aspirin (Baby Aspirin) to his 400 patients and none of them developed myocardial infraction6. This was in all probability the first time in medical history where aspirin was use to prevent myocardial infarction. Since then it has become the drug of choice for cardiologists.The antithrombotic ready of aspirin is mediated by irreversible inhibition of cyclooxygenase employment in platelets. Phospholipase-A2 acts on the cell membrane to release arachidonic acid on activation. Cyclooxygenase acts on arachidonic acid to produce thromboxane A2. Thromboxane A2 is a potent platelet stimulant head for the hillsing to degranulation of platelet and platelet aggregation. Aspirin inhibits cyclooxygenase enzyme and decreases the train of platelet stimulant thromboxane A2,5 thus increasing the bleeding time. This is the important resolve for a medical practitioner to stop aspir in 3 to 7 days precedent to any invasive mathematical process.The purpose of this carry was to investigate the influence of aspirin on post extraction bleeding.MATERIALS AND METHODThis study was conducted at the outpatient Department of Oral and Maxillofacial Surgery. Patients who were on aspirin therapy, aged between 50 to 65 years and who had to undergo tooth extraction were selected for the study. Patients on warfarin, non-steroidal anti-inflammatory drugs, heparin, steroids or suffering from blood disorders and diabetes were excluded from the study. Informed consent was obtained from the patients with the good committee clearance.Two hundred patients including both males and females whose teeth were indicated for extraction were include in the study. Patients were randomly divided into Group A and Group B of 100 patients each. Group A patients continued to receive aspirin preoperatively while Group B patients were asked to stop aspirin 7 days prior to extraction.Pre operati vely all the vital signs (Blood Pressure and Pulse) were measured. Bleeding time (White and lee(prenominal) technique) and clotting time (Ivys technique) was calculated. Extractions were carried out only if the in a higher place parameters were at bottom pattern range. After tooth was extracted presence or absence of bleeding and bleeding time was recorded. Analgesics and antibiotics were prescribed as needed for pain and infection control.Chi square test was used to evaluate the relative frequencies of patients in both groups. Differences of parametric variables were tested with analysis of variance.RESULTSAfter applying Chi square test, call up bleeding time was calculated as 2.10.52 minutes in the patients who discontinued baby aspirin (Group B) 7 days prior to extraction. Bleeding time of Group A patients who continued aspirin through the entire study was put in to be 3.80.75 minutes. This difference was statistically operative (p=0.002) Table 1. Although there is remark able increase in the bleeding time of Group A patients it should be noned that bleeding time of both the groups was within the normal limits. coagulation time of Group B patients was 3.80.75 and Group A was 4.70.74 which was also within the normal limits (Normal range according to Ivys Method 3 to 5 minutes).DISCUSSIONHistorically aspirin was used as an anti-inflammatory, painkiller and antipyretic drug for a short period of disease employment. Lawrence Craven in 1950 reported for the first time its long term use to prevent myocardial infarction6. He advocated a lower dose for antiplatelet action. Antiplatelet activity of aspirin occurs at doses ranging as low as 40 mg/day7 to 3208 mg daily. Doses above 320 mg/day decrease the feelingiveness of aspirin as antiplatelet agent due to inhibition of prostacyclin production9. but recent clinical trial indicates that clx mg/day is optimal for antiplatelet action10. In emergencies where imperative antithrombotic action is ask a loadi ng dose of three hundred mg is advocated9. Usually in United States daily dose of 81 mg, 160 mg or 325 mg are prescribed while in Europe and other countries daily dose of 75 mg, 150mg or 300 mg are prescribed10.Risk of continuing aspirin therapy prior to surgery is that, with the alteration of platelet function longer time period is required to stop the bleeding from a operative site. This is attributed to the alteration in primary winding hemostatic mechanism. Burger et al stated that, in patients on aspirin, the average risk of bleeding increases 1.5 folds. At the same time there is a risk in stopping the aspirin prior to surgery leading to a potential risk of rebound of thromboembolic vascular events. On stopping aspirin thromboxane A2 activity increases to a greater extent with decrease in fibrinolytic activity11. Ferrari et al showed the existence of biological platelet rebound phenomenon on interruption of aspirin therapy. This could create a prothrombotic state which may le ad to foreboding(a) thromboembolic events. well-nigh 20% of these episodes are fatal and another 40% can lead to permanent disability12.Practitioners who advocate the stoppage of aspirin have been debating among themselves regarding the time limit to stop aspirin. Literature wise the effect of aspirin on platelets is irreversible. The effect lasts for 7 to 10 days which is the life span of platelets13, 14. therefrom since early days it was recommended to stop aspirin 7 days prior to surgical procedure15-19. Sonksen et al in their study comprising of 52 healthy individuals showed that withdrawal of aspirin for more than 5 days was not recommended20. Wahl et al advocated that aspirin should be discontinued for 3 days only as after 3 days of interruption of aspirin, sufficient number of newer platelets would be beat in circulation for hemostasis21, 22.Now again the debate arises whether to stop aspirin therapy or not? Fear for uncontrolled bleeding encourages the practitioners to di scontinue the aspirin therapy. Few studies have shown that there is always an increased risk of bleeding in patients continuing aspirin23, 24. Hence few studies recommended stopping of aspirin therapy prior to surgical procedure17, 19, 25. However if the aspirin therapy is discontinued, there is increased risk of thromboembolic events which can be fatal but none of these have been reported in dental literature. Fijnheer et al in his article mentioned that there is scarcity of literature regarding dental surgeries involving patients on aspirin medication26. Little et al recommended that unless bleeding time is increased above 20 minutes aspirin affected platelets would not cause significant bleeding complication22. Similar claims were made by Sonksen et al and Gaspar et al20, 27.Canigral et al conducted a research involving surgical extraction in patients on antithrombotic therapy. In 92% cases bleeding halt within 10 minutes with pressure alone. This conduct was in accordance with the present study4. Gaspar et al advocated that ambulatory oral surgical procedures can be performed in patients without discontinuing the use of aspirin27. A recent recommendation from American Heart Association and American College of Cardiology is that, either continuing aspirin or clopidogrel therapy for minor oral surgical procedures in patients with coronary artery stents or delaying treatment until prescribed regimen will be complicated.The present study demonstrated that there was significant increase in the bleeding time in both the groups but in no case it was difficult to stop the bleeding. Although bleeding time increased in the Group A patients but it still remained within the normal range, regardless of whether patients continued or discontinued their aspirin therapy28, 29, 30. This result was similar to the study make by Canigral et al4. Valerin et al conducted a study with 17 patients randomized to aspirin and 19 to placebo and found no differences in bleeding ou tcomes for patients on aspirin. This decision suggested that there was no need to discontinue aspirin prior to any ambulatory oral surgical procedures31.Adchariyapetch compared the postoperative bleeding on subjects who stopped or continued taking the aspirin for seven days prior to extraction. The mean bleeding time in both the groups was in normal range. After the procedure there was no difficulty in achieving hemostasis. Therefore they concluded that surgical extraction did not require discontinuation of antiplatelet therapy32. Matocha in his study concluded that risk of bleeding after dental extraction is very minimal in the patients with aspirin therapy and did not exceed 0.2 to 2.3%33. stump spud et al concluded with a survey that 86% of the dental practitioners who cognizant the patient to stop antiplatelet drugs prior to dental extraction did so with the acknowledgment of the patients physician and found that the protocol followed by the physicians and dentists was not bas ed on the current recommendations and guidelines34.Napenas et al concluded that the risk of stopping antiplatelet therapy and predisposing the patient to thromboembolic events overweighed the minimal risk of bleeding from dental procedures. Similar results were found in the study done by Nielsen et al35. Wahl in a research study reported that in 950 patients receiving anticoagulation therapy, only 12 required (