Tooth Extraction After Heart Surgery

A clinician presents a dilemma to the DOCS Education faculty: a patient has a badly abscessed tooth and has already been on antibiotics for over a week. The tooth needs to be pulled, but the patient has recently suffered a heart attack and is on blood thinners. How should the clinician proceed to give the patient the care he needs?

A DOCS Education Member inquires:

I have a 46-year-old male patient who needs a tooth removed. He recently had a heart attack, resulting in the placement of a stent in late July. He is taking Brilinta® 90 mg per day and has been on antibiotics for an abscessed and periodontally involved tooth for over a week. We want to remove the tooth as soon as we can, but have been unable to receive a response from his cardiologist after many attempts. He does not have a primary care provider. We researched the medication online and found conflicting information about whether we can safely remove the tooth while on the thinner. We called his cardiologist again, and the receptionist informed us that the patient cannot be off the blood thinner for at least a year after heart surgery, and this is all she can tell us. Please advise.

Dr. Jerome Wellbrock, DOCS Education faculty member, responds:

Brilinta is similar to Plavix® in that it is used post-heart attack and/or stent placement. It is usually taken for 12 months in combination with aspirin therapy. The patient should not be taken off of either medication for dental surgery.

Considering that this patient has experienced a heart attack and received a stent placement so recently, most dental treatment should be delayed for six months. This is due to cardiac irritability and the increased risk of a secondary cardiac event. If you absolutely must do this single extraction, then I recommend the patient stays on his anti-coagulants, and during the operation, use local hemostatic control measures and limited amounts of local anesthetic with vaso-constrictor.

Dr. Anthony S. Feck, DOCS Education Dean of Faculty, adds:

Here is the information from Lexicomp® pertaining to your question:

"Premature discontinuation of combination antiplatelet therapy (ie, dual antiplatelet therapy) strongly increases the risk of a catastrophic event of stent thrombosis leading to myocardial infarction and/or death," so says a science advisory issued in January 2007 from the American Heart Association in collaboration with the American Dental Association and other professional healthcare organizations. The advisory stresses a 12-month therapy of dual antiplatelet therapy after placement of a drug-eluting stent in order to prevent thrombosis at the stent site. Any elective surgery should be postponed for 1 year after stent implantation, and if surgery must be performed, consideration should be given to continuing the antiplatelet therapy during the perioperative period in high-risk patients with drug-eluting stents."

Before I would treat this patient with an invasive procedure, I would confirm that it is a true emergency, and I would insist on hearing back from the patient's cardiologist, if for nothing else, medico-legal reasons. I would leave the patient on all of his meds, including the anticoagulation therapy, and manage the bleeding locally with atraumatic technique, pressure and primary closure.