Urgent extraction in a patient on dual antiplatelet therapy three months after coronary stenting

They should be continued, and the relative's advice must be corrected clearly.

The dominant risk is stent thrombosis, not bleeding. A drug-eluting stent is at its most thrombogenic in the first six months, and this patient is at three months, the highest-risk window. Premature interruption of dual antiplatelet therapy in that period carries a mortality of roughly 20 to 30 percent when thrombosis occurs, and it can happen within days of stopping. Dental bleeding, by contrast, is a low-pressure, accessible, local problem that can be controlled with pressure, sutures and topical agents. Large series of dental extractions in patients on single or dual antiplatelet therapy show increased oozing but no clinically significant increase in major bleeding events, and no justification for stopping therapy.

So the correct decision is to continue aspirin and clopidogrel uninterrupted, use meticulous local haemostasis, and avoid aspirin-containing analgesics for post-operative pain. Any proposed change to antiplatelet therapy belongs to the cardiologist, not the dentist, and in a genuine emergency the cardiologist should be contacted rather than the drugs modified. The infection is urgent enough to treat today; delaying extraction for six months to satisfy a theoretical bleeding concern would risk sepsis and cardiac events alike.

This is a spreading buccal infection with trismus, so drainage and removal of the source take priority over antibiotics, which are only an adjunct.

• Drain through an intraoral incision in the fluctuant buccal swelling, place a drain if the cavity is large, and send pus for culture if the patient is systemically unwell or has had prior antibiotics.
• Extract the tooth at the same visit if access and anaesthesia allow. Trismus of 20 mm usually still permits an inferior alveolar block; a 2% lidocaine with 1:100,000 adrenaline cartridge is appropriate, and adrenaline does not create a bleeding problem in these patients. If the block fails, an intraligamentary supplement or a short general anaesthetic in hospital should be considered rather than repeated traumatic attempts.
• Prescribe amoxicillin-clavulanate 625 mg three times daily for five to seven days, with metronidazole added if there is significant anaerobe-associated swelling, and adjust for renal function. Prescribe paracetamol, not an aspirin-containing combination.
• Haemostasis: atraumatic extraction, socket compression with gauze for at least ten minutes, a figure-of-eight suture, and 5% tranexamic acid mouthwash 10 mL four times daily for five days, not swallowed.
• Safety-net: written instructions, an emergency contact, and review in 48 hours. If there is dysphagia, a raised floor of mouth, systemic upset or airway concern, admit for intravenous antibiotics and drainage under hospital care.

Persistent oozing on antiplatelet therapy is almost always local, so I work through local causes before considering systemic ones.

1. Reassess: check blood pressure, pulse and general condition, and inspect the socket and surrounding mucosa. Common culprits are a torn marginal vessel, retained granulation tissue, a fractured root or bone spicule, an excessively large flap, or the patient repeatedly removing and replacing the gauze.
2. Reapply firm pressure with gauze for a full 20 minutes without interruption, using gauze moistened with tranexamic acid solution. Ask the patient to sit upright and avoid rinsing, spitting, smoking and hot drinks.
3. Local measures: place an absorbable haemostatic agent such as oxidised cellulose or a collagen plug in the socket, suture the margins, and consider electrocautery for a discrete bleeding point. Repeat the tranexamic acid mouthwash regimen.
4. Review systemically only if local measures fail: full blood count, platelet count and coagulation screen, and a check for missed medication such as an NSAID or herbal supplement.

I escalate to oral and maxillofacial or emergency services if there is arterial spurting, a falling haemoglobin or signs of hypovolaemia, bleeding that persists after three local attempts over 12 to 24 hours, or any airway compromise from a haematoma or continued swelling. I would not stop the antiplatelet drugs to control local oozing, and I would document the cardiology discussion when it occurs.