Safety of Perioperative Anticoagulant Discontinuation in Cardiovascular Patients Undergoing Periodontal Therapy

Periodontists are encountering increasing number of cases in their practices where patients present with cardiovascular diseases. Patients with a history of myocardial infarction, ischaemic stroke, acute coronary syndrome or peripheral vascular disease are prescribed anticoagulant medications by cardiologists, such as aspirin, warfarin, clopidogrel, ticlopidine, prasugrel, dipyridamole, cilostazol or dabigatran- either as monotherapy or dual therapy, for prevention of further thromboembolic events during lifetime. As because these agents act by inhibiting platelet aggregation, they tend to prolong bleeding time. Concerns regarding excessive periprocedural bleeding in patients receiving such drugs have led to some clinicians recommending periprocedural discontinuation of anticoagulant therapy. However, several studies, including systematic reviews and meta-analyses, have proved that there is no significantly increased risk of bleeding associated with continuing anticoagulant therapy when compared with discontinuation or modification of the anticoagulant regimen. In fact, without the anticoagulant medication, these patients have been found to be at increased risk of thromboembolic events with potentially serious consequences. The accepted recommendation, therefore, is that the anticoagulant drug regimens should not be altered or discontinued prior to periodontal treatment procedures, as the risks associated with such discontinuation far outweigh the consequences of prolonged bleeding, which can be well controlled with local measures.