Dental Management Of Patient With Dual Antiplatelet Therapy

Objective:Recently,more patients are asked to take antiplatelet agents to prevent and treat various ischemic cardio-cerebrovascular conditions,mainly for primary and secondary prevention of venous thrombosis and pulmonary embolism.The general antiplatelet agents,such as aspirin,clopidogrel,ticlopidine,and dipyridamole,could inhibit platelets aggregation through various mechanisms.These drugs are given individually as monotherapy,and sometimes combined as dual therapy,due to their different pharmacological mechanism.Dual antiplatelet therapy,Aspirin most combined with clopidogrel,mainly is used to prevent thrombosis.However,the postoperative bleeding risk of the patients in DAPT could significantly increase.The dental management of patients with antithrombotic therapy has always been a controversial problem.Therefore,clinicians must find a balance between the risk of postoperative bleeding with DAPT and thrombotic risk without DAPT.In order to solve this controversy,this article reviewed the present literature on this topic,and conducted the Meta-analysis,while treating patients in DAPT undergoing oral minor surgical procedures.Based on the results of the Meta-analysis,the decision analysis was carried out,to further weigh the pros and cons of the higher postoperative bleeding risk with continuation of DAPT and the higher embolization risk after stopping DAPT.So as to make more accurate evidence-based advice.Methods:Referencing to the method of evidence-based medicine,the Meta-analysis,on the dental management of patients in DAPT,was conducted,and obtained relevant therapeutic verdict.Decision tree model was established,on the basis of Meta-analysis that was used to define the probability of each branch of decision tree.The above work was done independently by the two researchers.Results:Finally,3 randomized controlled trials(RCTs)and 8 clinical controlled trials(CCTs)was included.The quantitative results indicated that the risk of postoperative bleeding with continuing DAPT experienced significantly increase(RR = 3.35,P =0.0005,95%CI=[1.69,6.63];I2 = 0%,P = 0.70).The rate of postoperative bleeding in DAPT continuation group(3.03%,15/495),and the rate of DAPT discontinuation group was 0.75%(21/2807).The decision analysis tended to continue DAPT,which resulted in an optimal EUV of 0.96 utility,1.05%greater than the discontinuation of DAPT.The results of sensitivity analysis showed that the DAPT strategy tended to be continued,when the QALYs of postoperative bleeding were higher than 0.3 utility.Conclusions:generally speaking,there was statistically significant correlation between whether discontinue DAPT and the risk of postoperative bleeding complications after tooth extractions,but it is extremely rare that additional measures or systemic coagulation therapy was still needed,with perfect local hemostasis after tooth extraction.Contrarily,the more severe embolic,even life-threatening complications occasionally occur.Therefore,we should not exaggerate the risk of bleeding after tooth extraction in DAPT.We should minimize trauma and improve postoperative hemostasis measures to reduce bleeding risk.