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ORIGINAL RESEARCH Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 1  |  Page : 22-25
The effect of ibuprofen on bleeding during periodontal surgery

1 Department of Periodontics, Raja Rajeshwari Dental College and Hospital, Bangalore, Karnataka, India
2 PMNM Dental College and Hospital, Bagalkot, Karnataka, India

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Date of Submission05-Jan-2007
Date of Decision29-Jun-2007
Date of Acceptance06-Jul-2007


Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used medications for both medical and dental ailments. These drugs have been shown to increase bleeding during surgeries, which may prompt practitioners to discontinue their use before surgical procedures. The aim of the present study is to assess the effect of a common NSAID, ibuprofen, on bleeding during periodontal surgery.
Materials and Methods: The study group consisted of 10 patients who were scheduled to undergo periodontal surgery of similar type, complexity, and duration. Each subject acted as control as well as case group. The case group consisted of 10 surgeries in which patients were administered ibuprofen prior to surgery, whereas ibuprofen was not administered in control group. Bleeding time was measured at first visit and prior to first and second surgeries. The volume of blood loss during each surgery was measured by subtracting the amount of water used for irrigation from the total volume of fluid collected in the portable aspirator at the end of the surgery.
Results: The result showed a statistically significant ( P < 0.05) increase in intraoperative bleeding during periodontal surgery when ibuprofen was preadministered. In addition, there was statistically significant ( P < 0.05) increase in bleeding time.
Conclusion: Ibuprofen taken prior to periodontal surgery increases intraoperative bleeding and should be administered cautiously before periodontal surgeries.

Keywords: Adverse effect, bleeding, ibuprofen, NSAID, pain control, periodontal surgery

How to cite this article:
Shiva Prasad B M, Vijaya M, Reddy SB, Patil SR, Kalburgi NB. The effect of ibuprofen on bleeding during periodontal surgery. Indian J Dent Res 2008;19:22-5

How to cite this URL:
Shiva Prasad B M, Vijaya M, Reddy SB, Patil SR, Kalburgi NB. The effect of ibuprofen on bleeding during periodontal surgery. Indian J Dent Res [serial online] 2008 [cited 2023 Feb 6];19:22-5. Available from:
In recent years, there has been an increased prevalence of conditions like heart diseases and arthritis. Majority of these patients are on nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are known to inhibit inflammatory processes related to the cyclooxygenase pathway and reduce the synthesis of prostaglandin, thromboxane and prostacyclin, and are generally used in dentistry for the reduction of post-operative pain and inflammation.

Many medical and dental practitioners are prompted to discontinue the use of NSAIDs before any surgical procedure due to the fear of uncontrolled bleeding associated with these drugs. The interruption of NSAID therapy may result in increased pain associated with inflammation of the joints, and the interruption of aspirin therapy may cause increased risk of thromboembolism, myocardial infarction, and cerebrovascular accident. Therefore, there is a concern to determine the actual effect of NSAIDs on bleeding during various surgeries, including periodontal surgery. Published reports of medical and surgical literature have shown numerous studies correlating the use of NSAIDs and the amount of bleeding during surgeries; whereas studies regarding the effect of NSAIDs during periodontal surgery is meager.

The approved indications for the use of ibuprofen include the symptomatic treatment of rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, and acute gouty arthritis. Ibuprofen is used as an analgesic for acute tendonitis, bursitis, primary dysmenorrhea, before and after tooth extraction, periodontal surgery, etc.

To date, there are very limited studies [1] regarding the effect of ibuprofen on intraoperative bleeding during periodontal surgery, in which temporary discontinuation of ibuprofen prior to surgery to decrease the risk of increased bleeding during periodontal surgery was recommended.

The present study aims to determine the effect of ibuprofen on intraoperative bleeding during periodontal surgery when applied with a prophylactic approach.

   Materials and Methods Top

A controlled, single-blind study was designed with 10 patients who visited the Department of Periodontics to determine the effect of ibuprofen on bleeding during periodontal surgery. The study was conducted with informed consent of patients and ethical clearance from ethical clearance committee of the institution.

The study comprised of 10 patients who acted as both experimental and control groups. The experimental group was administered with ibuprofen prior to surgery, whereas the control group was not.

Inclusion criteria

  1. Systemically healthy patients, who were not on any medications affecting the platelet function (e.g., warfarin, heparin, penicillin, dextran and aspirin).
  2. Age older than 18 years.
  3. The sites selected for periodontal surgery were of same type, complexity and were in same arch but in different quadrants.
  4. Ability to perform each surgery on separate visits, but at the same time of the day.
  5. Patients who were not pregnant.
  6. No medical history of gastric or peptic ulcers and drug allergy for NSAIDs.

The following steps were undertaken in each subject:

  1. Administration of 400 mg ibuprofen tablet 9, 5 and 1 h before either of the surgeries.
  2. Patients were instructed not to inform the surgeon for which surgery he/she had taken the tablet.
  3. Bleeding time and papillary bleeding index (PBI) scores were recorded.
  4. 1.8 ml of 2% lidocaine with 1:80,000 epinephrine was administered prior to surgery.
  5. Modified Widman flap surgery was performed in afternoon for all patients by the same operator.
  6. Patients were asked which surgery was more painful using visual analog scale.
  7. The time allotted for each surgery was 60 ± 15 min.

The surgeries performed were divided into experimental and control groups. The experimental group consisted of 10 surgeries in which the patients were administered ibuprofen prior to surgery, whereas the control group comprised the same number of surgeries in which ibuprofen was not administered.

Papillary bleeding index

PBI score (Saxter and Muhleman) was recorded prior to each surgery. The index discriminates four different grades of bleeding intensities subsequent to careful probing along the mesial and distal aspects of gingival sulcus of the tooth (in the papillary region). After 30 s when a quadrant has been completely probed, the intensity of bleeding was scored in four grades as follows: grade 0 = no bleeding; grade 1 = a single bleeding point is observed; grade 2 = a fine line of blood or several bleeding points become visible at the gingival margin; grade 3 = the interdental triangle becomes more or less filled with blood; grade 4 = profuse bleeding immediately after probing. Blood fled into the area to cover portions of the tooth or gingiva. The sum of the recorded scores gave the bleeding value. The PBI was calculated by dividing the bleeding value by the total number of papilla examined.

Bleeding time test (Duke's method)

A puncture was made at the finger tip. With the help of a stop watch, the time taken from the onset of bleeding to the arrest of bleeding was noted.

Collection of blood during surgery

The volume of water in the bottle used for irrigation during surgery was recorded before and after surgery. During the surgery, all the water and blood was collected into a graduated beaker using a portable aspirator. The total volume of blood was calculated by subtracting the volume of water used during surgery from the total volume of fluid aspirated. Any saliva generated during the procedure was considered negligible since the patient served as his/her own control; moreover, all the surgeries were performed at the same time of the day to minimize change in the rate of salivary flow due to circadian rhythm. Each of the scheduled surgeries performed within the same subject matched for complexity and duration. The surgery performed was modified Widman flap surgery.

Following the collection of data, the test group and control group were statistically analyzed. Paired ' t ' test was used to determine the significance of differences to a confidence level of 0.05.

   Results Top

Bleeding time results from 10 subjects prior to periodontal surgery with and without preadministered ibuprofen are reviewed in [Table - 1]. The mean bleeding time for patients who took ibuprofen was 2.25 min, whereas in those who had not taken ibuprofen, it was 1.7 min. The difference in mean bleeding times between the control and experimental groups is statistically significant ( P < 0.05).

The volume of blood loss in patients with and without ibuprofen is summarized in [Table - 2]. The result showed an increase in intraoperative bleeding when ibuprofen was taken prior to surgery. The average total volume of blood loss for the 10 patients with preadministered ibuprofen was 15 ml during periodontal surgery, whereas it was 11.6 ml in patients without preadministered ibuprofen. The increase in blood loss with ibuprofen intake was small, but statistically significant ( P < 0.05).

In patients with and without preadministered ibuprofen, the PBI scores did not show statistical significance in relation to bleeding time at base line. All the subjects reported lesser pain when they took ibuprofen prior to surgery.

   Discussion Top

Ibuprofen is a propionic acid derivative. It is rapidly absorbed and reaches peak plasma levels within 1-2 h after an oral dose and has a half life of 1.6 to 2.5 h. It is excreted mainly in the urine. The recommended single dose is 200-600 mg with a daily intake not exceeding 2,400 mg 2 .

The toxic effects of ibuprofen include gastrointestinal discomfort such as thrombocytopenia, dyspepsia, abdominal pain, nausea, and vomiting. [2],[3],[4] Ibuprofen is a potent inhibitor of prostaglandin biosynthesis, thus accounting for its pharmacological properties of reduction in alveolar bone resorption and also decrease in pain. [5] Several studies have demonstrated the analgesic efficacy of NSAIDs. [6],[7],[8],[9] NSAIDs prevent the formation of thromboxane A 2 (TXA 2 ), which is a potent activator of platelet aggregation. [10] Ibuprofen is an active inhibitor of collagen-induced platelet aggregation, which plays an important role in the formation of platelet plug during primary hemostasis following an injury.

The results of this study suggest that bleeding during periodontal surgery increases when ibuprofen is at peak plasma concentration prior to surgery.

The factors that influence bleeding during surgery are gender, hormones, type, duration, anatomical location of the surgery, time the surgery was performed, and general health of the patient.

The present study was a single-masked, case-control study that eliminated many of the confounders by each subject acting as both the control and case group. The two surgeries performed were of the same type (modified Widman flap) and duration, in the same arch (maxilla), at the same time of the day (afternoon), and by the same operator. The quantity of local anesthetic with epinephrine used for each surgery was also standardized. The reason for selected dosage regimen was to achieve peak plasma concentration and maximum drug activity during periodontal surgical procedure.

In the present study, there was a small but statistically significant increase in blood loss during periodontal surgery in subjects who were administered ibuprofen prior to surgery. Papillary bleeding scores for the quadrant scheduled for surgery showed similar scores with or without preoperative ibuprofen intake and no correlation with bleeding time.

Further, a small but statistically significant increase in the bleeding time from mean of 1.7-2.25 min was observed. Bleeding time for both the groups remained in the normal range. This finding is in concurrence with previous findings that ibuprofen may prolong bleeding time, but not beyond the upper limit of normal. [11] The papillary bleeding score showed no correlation with bleeding time in patients with or without administration of ibuprofen before periodontal surgery, which is in concurrence with the present study. [12]

Ardekian et al. conducted a study to determine the effect of low-dose aspirin therapy on intraoperative and postoperative bleeding in patients undergoing tooth extraction and concluded that aspirin therapy need not necessarily be stopped prior to oral surgery. [13]

Preoperative NSAID (Ketorolac) administration would result in excessive intraoperative bleeding in 14% of patients. Bleeding time in patients remained within normal limits. [14] In a previous study, the authors observed that only two of seven patients with protracted bleeding time experienced increased bleeding during operation. [15] Some authors demonstrated no increase in blood loss during thoracic surgery in 14 patients with prolonged bleeding time. [16] In one study, the authors examined the relationship between bleeding time and blood loss during hip surgery. They concluded that there was no significant increase in blood loss, even in the presence of aspirin, in patients with increased bleeding time. [17] Taking these data into consideration, it can be concluded that bleeding time may not be always a predictable criterion for volume of blood loss during surgery.

There is good evidence of gain in clinical attachment up to 12 weeks, reduction in probing depth, and inflammation (bleeding on probing) for 6 weeks on administration of ibuprofen. The administration of 600 mg ibuprofen either immediately before or after periodontal surgery significantly delays the onset of pain. [7]

   Conclusion Top

The present study illustrates a statistically significant increase in intraoperative bleeding during periodontal surgery in patients with preadministered ibuprofen. Increase in bleeding time was noted but within normal limits, and all the patients reported lesser pain and more comfort when ibuprofen was taken prior to surgery. Beneficial effects of ibuprofen, including being a good anti-inflammatory and analgesic, decreased alveolar bone resorption, and enhanced healing, outweigh its adverse effect of minimal increase in bleeding during periodontal surgery. Considering the favorable and undesirable effects of ibuprofen, the authors conclude that temporary discontinuation of ibuprofen prior to periodontal surgery is not mandatory. Further studies are required to know whether it would be appropriate to discontinue the drug compromising its favorable effects in different types of periodontal surgeries.

   References Top

1.Braganza A, Bissada N, Hatch, Ficara A. The effect of non-steriodal anti-inflammatory drugs on bleeding during periodontal surgery. J Periodontol 2005;76:1154-60.  Back to cited text no. 1    
2.Cooper SA, Engel J, Ladov M. Relative efficacy of an ibuprofen-codeine combination. Clin Pharmacol Ther 1980;27:249.  Back to cited text no. 2    
3.Cooper SA, Needle SE, Druger GO. Comparative analgesic potency of aspirin and ibuprofen. J Oral Surg 1977;35:898-903.  Back to cited text no. 3    
4.Winter J, Bass E, Recant B. Analgesic activity of ibuprofen (Motrin) in post operative surgical pain. Oral Surg Oral Med Oral Pathol 1978;45:159-66.  Back to cited text no. 4    
5.Goldhaber P, Rabadjija L, Beyer WR, Korhnauser A. Bone resorption in tissue culture and its relevance to periodontal disease. J Am Dent Assoc 1973;87:1027-33.  Back to cited text no. 5    
6.O'Brien TP, Roszkowski MT, Wolff LF, Hinrichs JE, Hargreaves KM. Effect of a non-streroidal anti-inflammatory drug on tissue levels of immunoreactive prostaglandin E2, immunoreactive leukotriene and pain after periodontal surgery. J Periodontol 1996;67:1307-16.  Back to cited text no. 6  [PUBMED]  
7.Vogel RI, Desjardins PJ, Major Kendal VO. Comparison of presurgical and immediate post surgical ibuprofen on post-operative periodontal pain. J Periodontol 1992;63:914-8.  Back to cited text no. 7    
8.Gallardo F, Rossi S. Analgesic efficacy of flurbiprofen as compared to acetaminophen and placebo after periodontal surgery. J Periodontol 1990;61:224-6.  Back to cited text no. 8    
9.Trombelli L, Schincaglia GP, Zangari F, Scapoli C, Calura G. Effect of pretreatment with ketorolac tromethamine on post-operative pain following periodontal surgery. J Clin Periodontol 1996;23:128-32.  Back to cited text no. 9  [PUBMED]  
10.Insel PA. Analgesic-antipyretic and anti-inflammatory agents and drugs employed in the treatment of gout. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, editors. The Pharmacological basis of therapeutics. 9th ed. McGraw-Hill: USA; 1996. p. 623.  Back to cited text no. 10    
11.McIntyre BA, Philip RB, Wood MJ. Effect of ibuprofen on platelet functions in normal subjects and haemophiliac patients. Clin Pharmacol Ther 1978;245:616-21.  Back to cited text no. 11    
12.Veronica WK, Bissada NF. Clinical evaluation of systemic doxycycline and ibuprofen administration as an adjunctive treatment for adult periodontitis. J Periodontol 1998;69:772-6.  Back to cited text no. 12    
13.Ardekian L, Gaspar R, Peled M, Brener B, Laufer D. Does low dose aspirin therapy complicate oral surgical procedures? J Am Dent Assoc 2000;131:331-5.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Splinter WM, Rhine EJ, Roberts DW, Reid CW, McNeill HB. Preoperative ketorolac increases bleeding after tonsillectomy in children. Can J Anaesth 1996;43:560-3.  Back to cited text no. 14    
15.Eika C, Havig I, Godal HC. The value of preoperative haemostatic screening. Scand J Haematol 1978;21:349-54.  Back to cited text no. 15    
16.Ramsey G, Arvan DA, Stewart S, Blumberg N. Do preoperative laboratory tests predict blood transfusion needs in cardiac operations? J Thorac Cardiovasc Surg 1983;85:564-9.  Back to cited text no. 16  [PUBMED]  
17.Amrein PC, Ellman L, Harris WH. Aspirin-induced prolongation of bleeding time and perioperative blood loss. JAMA 1981;245:1825-8.  Back to cited text no. 17  [PUBMED]  

Correspondence Address:
B M Shiva Prasad
Department of Periodontics, Raja Rajeshwari Dental College and Hospital, Bangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9290.38927

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