LOW-DOSE ASPIRIN THERAPY

LETTERS time helps patients or the insurance companies? Why not eliminate radiographs altogether? It should not take very long for the companies to determine if we are compromising the integrity of the system. If, after working together with them, it is determined we have, then they can reinstitute the policy of sending radiographs. Any dollars lost would surely be offset by money not spent on personnel to handle the radiographs and forms in the first place. Richard H. Price, D.M.D. Newton Centre, Mass. LOW-DOSE ASPIRIN THERAPY

Relative to the article “Does Low-Dose Aspirin Therapy Complicate Oral Surgical Procedures?” by Dr. Leon Ardekian and colleagues in March JADA, I believe the authors have far too little evidence to reach the conclusion that “low-dose aspirin therapy should not be stopped before oral surgery.” Their study group of 39 patients is inadequate to suggest altering what has been accepted as the standard in managing patients who are on low-dose aspirin therapy. The most this study contributes is to consider the wisdom of discontinuing aspirin preceding surgery. Before changing a long-established practice, far more evidence should be at hand. As the authors point out, intravascular clotting is a serious concern, but this project, involving fewer than 40 patients divided into two groups, is only a clue as to what one might expect by continuing aspirin therapy while carrying out an oral 1398

surgical procedure. Can the authors assure the practitioners they are advising that their 40th patient would not have had a significant increase in bleeding time? In clinical terms, this hypothetical 40th patient might have had severe hemorrhaging. Granted that embolic formation is a dire event, can the authors assure us that measures to stop bleeding might not make the patient more vulnerable to clotting? Is uninterrupted lowdose aspirin therapy less risky than a few days of discontinuing the aspirin? These questions are of concern. However, to act on the authors’ proposition—to discontinue low-dose aspirin therapy prior to an oral surgical procedure, mindful of the slight amount of evidence they present—is an injustice to the patient and potentially dangerous. In my opinion, the only logical conclusion for this study is to suggest that further research is needed. It might be preferable not to interrupt lowdose aspirin therapy in anticipation of an oral surgical procedure, but that has yet to be proven. This is a legitimate issue, and the authors are correct to question the practice of discontinuing low-dose aspirin therapy. The answer, however, is not in the sparse evidence they presented. Martin Olin, D.M.D. Arlington, Mass. Author’s response: I agree with Dr. Olin that the study sample was relatively small. However, as mentioned repeatedly in the article, this is only a preliminary report and is the

first report checking the influence of stopping aspirin in patients undergoing oral surgery. Only in this way can we prove the efficiency of any treatment modality, even if this is a well-established treatment, as Dr. Olin mentioned. Every change must begin somewhere. This article is only the beginning. [In the future,] we hope to research a study group in the hundreds. Afterwards, we will publish our results. Regarding the risk of not stopping aspirin, we believe that the thromboembolic complications carry a higher morbidity rate than continuing the medication. Studies already have shown that in patients taking warfarin that bleeding control using local methods has no effect systemically on the patients (Gaspar R, Brenner B, Ardekian L, Peled M, Laufer D. Use of tranexamic acid mouthwash to prevent postoperative bleeding in oral surgery patients on oral anticoagulant medication. Quintessence Int 1997;28[6]:375-9; Sindet-Pedersen S, Ramstrom G, Bernvil S, Blomback M. Hemostatic effect of tranexamic acid mouthwash in anticoagulant-treated patients undergoing oral surgery. N Engl J Med 1989;320[13]:840-3). I would like to remind Dr. Olin that bleeding caused by aspirin is mainly intraoperative, and bleeding time is the only measurement for this. Since we found bleeding time within normal limits, we are certain that hemostasis will occur during the surgical procedure. In conclusion, we would like to thank Dr. Olin again for raising this question, but our dealing with this subject is very le-

JADA, Vol. 131, October 2000 Copyright ©1998-2001 American Dental Association. All rights reserved.