Does Low-Dose Aspirin

Therapy Complicate Oral

Surgical Procedures?
Evan Blackwell
Jenna Cha
Andrew Peterson

Learning Objectives
1. Be able to understand mechanism of COX
2. Be able to understand mechanism of NSAIDs
3. Be able to state the effects & side effects of
Aspirin
4. Be able to reason your choice of action with
Aspirin drug holiday

Background
The fear of uncontrolled bleeding often prompts
medical practitioners to stop aspirin intake 7 to 10
days before any surgical procedure
WHY?
The platelet lifespan is approximately 8 to 9 days

Learning objective 1: COX?

Learning objective 1: COX?

Learning objective 1: COX?

Learning objective 1: COX?

COX-1 is also called as constitutive enzyme

because it is produced by a cell under all types of
physiological conditions. The amount at which
constitutive enzymes are produced remain
constant without regard of substrate
concentration and physiological demand.
On the other hand COX-2 is an inducible enzyme
as it is produced under certain specific conditions
like inflammation.

Learning objective 1: COX?

PGs, mostly by COX-1, are constitutively
expressed in almost all tissues; COX-2 appears to be
located in macrophages, leukocytes and fibroblasts.
Under normal physiologic conditions, PGs play an
essential homeostatic role in cytoprotection of gastric
mucosa, hemostasis, renal physiology, gestation, and
parturition
In platelets there is only COX-1exist (converts
arachidonic acid to TxA2)
COX-1 predominant in gastric mucosa (source of
cytoprotective PGs)
The production of PGs, (inducible COX-2 activity
>> COX-1) at sites of inflammation propagate pain,
fever

Learning objective 2: Mechanism

of NSAIDs
NSAIDs: Non-steroidal anti-inflammatory drugs
Usually used for treatment of acute or chronic
conditions for pain & inflammation
Aspirin, Ibuprofen, Naproxen, etc
Inhibits activity of both COX-1 and COX-2
COX-1 inhibition: can cause GI bleeding and ulcers
COX-2 inhibition: anti-inflammatory, analgesic and
antipyretic affects

Learning objective 2:
Mechanism of NSAIDs
Most NSAIDs nonselective COX inhibitors
Inhibit both COX 1 & COX 2
Inhibition is reversible

Aspirin
Irreversible inhibition
Non-selective
Weakly more selective for COX-1

Learning objective 2:
Mechanism of NSAIDs
Possess a long channel (COX-2 channel is wider than in
COX-1).
Non-selective NSAIDs enter channel (but not aspirin).
Block channels by binding with H-bonds to an arg half
of the way in.
This reversibly inhibits the COX by preventing
arachidonic acid from gaining access.
Selective COX-2 inhibitors generally more bulky
molecules - can enter and block the channel of COX-2,
but not that of COX-1.

Learning objective 3: Aspirin

2-(acetyloxy)benzoic acid
Aspirin, the only NSAID able to irreversibly inhibit
COX
Indicated for inhibition of platelet aggregation
By inhibiting action of Thromboxane A2

Used for:
Management of arterial thrombosis
Prevention of adverse cardiovascular disease

Salicylate
Aspirin acetylates COX (at ser530) and is, therefore,
irreversible.
Acetyl group is covalently attached to serine residue
in the active site of the COX enzyme.

Learning objective 3: Aspirin

Learning objective 3: Aspirin

effects

Analgesic (0.3-0.6 g/day): PG

Refers to the relief of pain by a mechanism other than
the reduction of inflammation (for example, headache);
produce a mild degree of analgesia which is much less
than the analgesia produced by opioid analgesics such as
morphine
Anti-inflammatory (3-5 g/day): PG
These drugs are used to treat inflammatory diseases and
injuries, and with larger doses - rheumatoid disorders
Antipyretic (0.3-0.6 g/day): PG
Reduce fever; lower elevated body temperature by their
action on the hypothalamus; normal body temperature is
not reduced
Antiplatelet (30-100 mg/day): Thromboxane
Inhibit platelet aggregation, prolong bleeding time; have
anticoagulant effects

Learning objective 3: Aspirin

Side effects
Gastrointestinal symptoms
CNS toxicity
Allergic reaction (urticaria, angioneurotic edema,
aspirin asthma, occasionally anaphylactic shock)
Salicylate reaction (CNS reaction)
Renal damage
Hematologic effects
Metabolic acidosis stimulates medullary
respiratory center respiratory alkalosis

Risks
Interruption of aspirin therapy may expose these
patients to the risk of developing
thromboembolism, myocardial infarction or
cerebrovascular accident

Purpose of the study

This study was initiated to measure the effect of
low-dose aspirin therapy on intraoperative and
postoperative bleeding in patients undergoing
oral surgery.
In addition, the authors compared the relationship
between clinical hemorrhagic complications and
the tested bleeding time

Low Dose Aspirin Regimens

Continuous low-dose aspirin regimens have
become popular in the last decease for treating
cardiovascular and peripheral vascular diseases,
patients are reluctant to stop their regular therapy
before undergoing surgical procedures

Fuster et al. Prog Cardiovasc Dis 1987

Materials and Methods

The study group was composed of 39 patients
Mean age: 62 +/- 13.2 years
Age Range: 39 to 89 years
15 women/24 men

All patients were receiving 100 mg of aspirin per

day on a long-term basis as a secondary
preventive drug for cardiovascular or peripheral
vascular diseases

M & M continued
Patients were randomly divided into an
experimental group and a control group
Patients in the control group continued aspirin
therapy
Patients in the experimental group stopped aspirin
therapy seven days before their extraction and
did not resume until the day after the procedure

Bleeding time
Bleeding time is a medical test done on someone
to assess their platelets function. It involves
making a patient bleed then timing how long it
takes for them to stop bleeding

Bleeding normally stops within 1 to 9

minutes.
** However, values may vary from lab to lab.

M&M
Surgical procedures were divided into three
categories
Simple extractions
Compound procedures
Complex procedures

Before all procedures, patients received only local

anesthetic (3% mepivacaine)

Intraoperative bleeding time

Measured by subtracting the volume of irrigation
fluid from the volume of blood accumulated in the
suction trap

Results
Discontinued aspirin therapy
1.8 +/- 0.47 minutes

Continued aspirin therapy

3.1 +/- 0.65 minutes

P value = 0.004
Statistically significant

But both groups were still within the normal

bleeding time range of 1 to 4.5 minutes

Results continued
In 33 of the 39 patients, intraoperative bleeding was
controlled with suturing, and local hemostasis with
direct packing of gauze
6 patients received 10% tranexamic acid, an
antifibrolytic agent that stabilizes the blood clot by
inhibiting plasmin, was added to the local packing
No episodes of uncontrolled bleeding reported during
the week after surgery

Discussion
Until the early 1980s, aspirin was used as an antiinflammatory, analgesic, and antipyretic drug for
a short period of time
Major side affects, mainly, gastrointestinal
irritation and ulcers

Controversy
With the increase use of low-dose aspirin, this has
presented dentists with the dilemma of whether
to advise patients to discontinue aspirin therapy
prior to surgical procedures.
Controversy currently exists in the literature

Conclusion
In contrast to other studies which involved high
dose aspirin therapy, their study was a
prospective study that examined the bleeding
tendency of patients receiving regular low dose
aspirin therapy.
They suggest there is no need to expose patients
to the risk thromboembolism, cerebrovascular
accident or myocardial infraction undergoing
dental extractions

Bottom Line
Patients should continue with low-dose aspirin
therapy prior to dental extractions during the
preoperative phase