From the Guidelines
Dental prophylaxis after drug-eluting stents is generally not indicated, and the primary concern should be the management of dual antiplatelet therapy to prevent stent thrombosis. The American Heart Association and American College of Cardiology do not recommend routine antibiotic prophylaxis for patients with coronary stents undergoing dental procedures 1. However, timing of dental procedures after stent placement is crucial. For patients with drug-eluting stents (DES), it's advisable to delay elective dental procedures for at least 6 months after stent placement when possible, as this is the period of highest risk for stent thrombosis 1. If dental work is necessary sooner, the benefits should outweigh the risks of stent thrombosis.
Some key points to consider include:
- Patients with DES should continue their dual antiplatelet therapy (typically aspirin plus a P2Y12 inhibitor like clopidogrel) without interruption for dental procedures, as premature discontinuation significantly increases the risk of stent thrombosis 1.
- Minor bleeding during dental procedures can usually be managed with local hemostatic measures.
- For patients with both DES and other conditions that independently warrant antibiotic prophylaxis (such as prosthetic heart valves or previous infective endocarditis), prophylaxis should be provided according to those specific guidelines 1.
- The management of antithrombotic therapy is critical in the perioperative period, and guidelines suggest deferring surgery 6 weeks after bare-metal stent placement and 6 months after drug-eluting stent placement whenever possible 1.
Overall, the focus should be on balancing the risks of stent thrombosis with the need for dental procedures, and managing dual antiplatelet therapy appropriately to minimize these risks.
From the Research
Dental Prophylaxis after Drug Eluting Stents
- The optimal duration of dual antiplatelet therapy (DAPT) after drug-eluting stent (DES) implantation is still debated, with studies suggesting that short DAPT duration may be sufficient 2.
- Dental extractions can be carried out safely without stopping multiple antiplatelet agents in patients with coronary stenting, with minimal risk of excessive bleeding 3.
- The use of P2Y12 inhibitor monotherapy after DAPT may reduce bleeding risk while maintaining anti-ischemic efficacy 4, 5.
- A network meta-analysis suggests that P2Y12 inhibitor monotherapy may be associated with a lower risk of myocardial infarction compared to aspirin monotherapy after DAPT discontinuation 6.
Key Findings
- Short DAPT duration (≤ 3 months) followed by single antiplatelet therapy (SAPT) with a P2Y12 inhibitor may be a viable option for patients undergoing PCI with second-generation DES 2, 5.
- P2Y12 inhibitor monotherapy may be preferred over aspirin monotherapy after DAPT discontinuation due to its potentially lower risk of myocardial infarction 6.
- Dental procedures, including extractions, can be performed safely in patients with coronary stenting without stopping antiplatelet agents, with proper wound management and follow-up 3.
Implications for Dental Prophylaxis
- Patients with drug-eluting stents can undergo dental procedures, including prophylaxis, without stopping antiplatelet agents, but with careful consideration of bleeding risk and proper management 3.
- The choice of antiplatelet monotherapy after DAPT discontinuation may impact the risk of myocardial infarction and bleeding, with P2Y12 inhibitor monotherapy potentially being a better option 6.