MARCH 14 — The fields of pharmacology and dentistry have long been intertwined. Medications prescribed for heart conditions — such as aspirin and warfarin — were once considered red flags before a dental extraction. Traditionally, doctors advised patients to stop taking aspirin for a day or two before undergoing tooth removal due to concerns about excessive bleeding.
Aspirin, an antiplatelet drug, works by preventing platelets from clumping together (aggregation) by blocking an enzyme called cyclooxygenase-1 (COX-1). Platelets are essential for blood clot formation, which helps stop bleeding when an injury occurs. However, aspirin is lifesaving for patients at risk of stroke, a condition where a blood clot blocks blood supply to the brain. Patients taking aspirin bleed more easily and take longer to form blood clots than those who do not.
To put this into perspective, in a healthy person, a blood clot typically forms within 6 to 10 minutes. In someone on aspirin therapy, clotting time may be prolonged by about 3 extra minutes. While this increases the risk of post-extraction bleeding, it is often manageable with pressure, sutures, and local haemostatic agents.
Aspirin is sometimes prescribed alongside anticoagulants, which act at a different stage of blood clot formation. While aspirin affects platelets, anticoagulants target specific steps in the coagulation cascade—the chain of events that leads to clot formation.
One commonly used anticoagulant is warfarin. Unlike aspirin, warfarin requires frequent blood tests to measure International Normalized Ratio (INR) — a value that indicates how long it takes for blood to clot. A higher INR means a longer clotting time and an increased risk of bleeding. Warfarin is often prescribed to prevent stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE). In some cases, both aspirin and warfarin are prescribed together, such as for patients with atrial fibrillation and coronary artery disease.
For years, a clinical dilemma remained: Is it safer to stop aspirin before a dental procedure to prevent bleeding, or does stopping aspirin pose a greater risk of stroke?
The answer has become clearer. Aspirin is no longer routinely stopped for dental procedures, even for multiple extractions or minor oral surgeries like wisdom tooth removal. This is because managing a bleeding wound with local measures (pressure, sutures, clot-promoting agents) is far easier and safer than exposing a patient to a potentially life-threatening stroke.
Recent advances in pharmacology have led to the development of Direct Oral Anticoagulants (DOACs), which are now preferred over warfarin for stroke prevention in patients with atrial fibrillation. Unlike warfarin, which affects multiple steps in the coagulation cascade, DOACs selectively target a single clotting factor — making their effects more predictable and reducing the risk of uncontrolled bleeding.
With the introduction of DOACs, dosage modifications before dental procedures have changed. In many cases, no changes are needed, while some require a minor adjustment—such as taking the medication two hours after a stable clot has formed at the extraction site. However, recommendations vary by country and individual patient factors.
A final word: Always consult before stopping medication. Patients should never stop anticoagulants or antiplatelets on their own. Any decision regarding medication adjustments before a dental procedure should be made in consultation with both the prescribing doctor and the dentist. Stopping these drugs without medical advice can increase the risk of stroke, heart attack, or other serious complications.
With modern advancements in medicine and dentistry, patients on blood thinners can now undergo safe and effective dental treatments without unnecessary interruptions to their vital medications. The focus has shifted from stopping medication to careful management, ensuring both patient safety and treatment success.
* Dr Aisyah Ahmad Fisal is from the Department of Paediatric Dentistry and Orthodontics, while Dr Goh Yet Ching is from the Department of Oral and Maxillofacial Clinical Sciences, Faculty of Dentistry, Universiti Malaya.
**This is the personal opinion of the writer or publication and does not necessarily represent the views of Malay Mail.
