**6. Perioperative bleeding risk associated periodontal procedures**

#### **6.1 Bleeding risk of periodontal procedures**

The perioperative bleeding risk depends on the extent and invasiveness of the periodontal therapeutic approach. A low bleeding risk has been mentioned for most periodontal interventions such as subgingival instrumentation, conventional surgeries (debridement flaps and regenerative or resective interventions), dental implants placement, or tooth extraction [8]. The bleeding associated with these interventions

*Periodontitis and Heart Disease: Current Perspectives on the Associative Relationships… DOI: http://dx.doi.org/10.5772/intechopen.102669*

could be controlled through local haemostatic measures. On the other hand, a moderate bleeding risk is considered for autogenous bone augmentation procedures including block bone harvesting and sinus floor elevation or interventions associated with secondary intention healing such as free gingival graft placement [71, 72]. The frequencies for low and moderate bleeding associated with periodontal therapies have been reported to be less than 1% and between 2 and 5%, respectively [8].

#### **6.2 Patients undergoing antiplatelet and anticoagulant therapy**

Single antiplatelet therapy such as acetylsalicylic acid (aspirin), clopidogrel, ticlopidine or ticagrelor did not increased the frequency of bleeding events as compared with control patients [73, 74].

Dual antiplatelet therapy usually using the combination of aspirin and clopidogrel may induce a certain risk for post-operative bleeding, which may be managed with local haemostatic approaches [75, 76].

The discontinuation of single or dual antiplatelet therapy before any kind of periodontal approach including dental implant placement is not recommended by current evidence [8].

"Current American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, European Society of Cardiology, American College of Chest Physicians Evidence-Based Clinical Practice (AHA/ACC/SCAI/ ACS/ADA/ESC/ACCP) guidelines on perioperative management of antithrombotic therapy do not suggest discontinuation of anti-platelet therapy for low bleeding risk procedures" [77–79].

No increased risk of bleeding has been associated with oral vitamin K antagonistanticoagulant therapy (warfarine, cumarine) in patients receiving dental extraction, minor dental procedures or dental implant placement when compared to patients discontinuing anticoagulant therapy [80, 81]. However, in comparison with non-vitamin K patients, a higher post-operative bleeding risk in patients continuing vitamin K antagonist-anticoagulant therapy and suffering from minor or higher-risk dental procedures have been reported, although post-operative bleeding could be effectively controlled with local haemostatic agents [80, 82, 83].

As for novel/direct anticoagulants such as apixaban, rivaroxaban, betrixaban, edoxaban, and dabigatran, it seems that the interruption of these drugs is not necessary for most dental-periodontal therapies, due to a low incidence of bleeding events associated with these drugs and which can be successfully managed with local haemostatic measures [84–86]. As a positive advancement in the field, a neutralizing agent (idarucizumab) has been developed for dabigatran. However, a higher incidence of delayed bleeding (2 days and later) has been reported in patients not discontinuing novel/direct anticoagulants in comparison with healthy persons [87]. Although, it has been widely used in the past, especially in the era of anti-vitamin K anticoagulants, the low molecular weight heparins (LMWH) bridging strategy should be avoided in patients treated with novel oral anticoagulants (NOAC) as it increases the risk of bleeding, with no benefit on the risk of cardioembolic events. It is reserved for patients with mechanical valve prostheses at high thrombotic risk [88].

However, in CVD patients receiving complex antithrombotic medication a strict communication with cardiologist is mandatory.
