Rare Case of Hemorrhagic Shock After Dental Extraction Highlights Risks in Patients on Dual Antithrombotic Therapy

Alexia Pouplin, Université de Lorraine, Faculté d'Odontologie, F-54500 Nancy, France, and colleagues detail the experience of a 71-year-old oncology patient who developed life-threatening bleeding episodes after the extraction of two teeth. The first episode occurred just one-day post-surgery, followed by a second bout a week later. Despite the presence of known bleeding risk factors such as advanced age, cancer treatment, and dual antithrombotic therapy (acetylsalicylate of DL-lysine and Tinzaparine), the intensity of the hemorrhage observed was found to be unusually severe and clinically unexplained.

Before the dental procedure, a biological assessment was conducted, and the surgical plan was reviewed and approved by a cardiologist to ensure patient safety. Nevertheless, the patient required red blood cell transfusions and underwent surgical wound revision to achieve hemostasis after the bleeding episodes.

The authors emphasize that while minor bleeding is a known risk in patients on anticoagulant or antiplatelet medications, the development of hemorrhagic shock remains exceedingly rare, particularly following a procedure as common as dental extraction. The report highlights a lack of standardized guidelines in oral surgery for managing patients receiving a combination of oral anticoagulants and antiplatelet drugs—an increasingly common scenario given the aging population and the rising prevalence of cardiovascular conditions and cancer.

Despite thorough evaluation, the researchers could not identify a definitive cause to fully explain the severity of the bleeding in this case. While the patient's comorbidities and medications undoubtedly increased the risk, the clinical team found no precedent in the literature describing such a dramatic presentation under similar conditions.

The case emphasizes the importance of proactive measures to control bleeding during surgery. However, as this case shows, even well-planned interventions may not fully prevent complications in high-risk individuals. Based on this experience, the authors advocate for extended postoperative observation, particularly over the first seven days, in patients with significant bleeding risk factors. This approach may help detect delayed bleeding episodes early and allow timely intervention.

The authors emphasized that although hemorrhagic shock following tooth extraction is an uncommon complication, the case stresses the importance of increased clinical vigilance, thorough interdisciplinary coordination, and prolonged postoperative monitoring in patients with complex medical profiles. They further noted that the case highlights a significant gap in existing clinical guidelines for managing oral surgical procedures in individuals receiving dual antithrombotic therapy.

Reference:

Pouplin, A., Pham Kormann, D., Dolivet, G., & Phulpin, B. (2025). Hemorrhagic shock after dental extractions in a patient with anticoagulant and antiplatelet therapy: A case report. International Journal of Surgery Case Reports, 131, 111375. https://doi.org/10.1016/j.ijscr.2025.111375