Does Clopidogrel (Plavix) need to be discontinued prior to dental extraction?

From the Guidelines

Plavix (clopidogrel) typically does not need to be stopped before routine dental extractions, as the risk of serious bleeding complications is generally low and can be managed with local hemostatic measures. Patients should continue taking Plavix as prescribed by their physician who manages their cardiovascular care. The potential cardiovascular risks of stopping Plavix (increased risk of heart attack, stroke, or stent thrombosis) usually outweigh the risk of bleeding during dental work 1.

According to the most recent and highest quality study, dental procedures, including tooth extraction, can likely be performed at no or only minor risk of bleeding, and the incidence and severity of oral bleeding can be reduced with local measures during surgery, such as absorbable gelatin sponge and sutures 1.

Some key points to consider include:

• The risk of bleeding due to antiplatelet therapy varies from one invasive procedure to another, but most dental procedures are considered low risk 1.
• The co-administration of other drugs interfering with haemostasis or the presence of comorbidities increasing the risk of bleeding may necessitate the discontinuation of the P2Y12 inhibitor, but this should be decided on a case-by-case basis 1.
• Patients should inform both their dentist and cardiologist about all medications they're taking before any dental procedure, and the dentist and physician should communicate to develop a personalized approach, especially for complex extractions or patients with multiple risk factors 1.

It's essential for patients to be prepared for potentially more bleeding during and after the procedure and to follow post-extraction care instructions carefully. The decision to stop or continue Plavix should be made in consultation with the patient's healthcare team, taking into account individual patient factors, such as the complexity of the extraction, the patient's overall health status, and their specific risk for thrombotic events 1.

From the FDA Drug Label

5.3 Discontinuation of Clopidogrel Discontinuation of clopidogrel increases the risk of cardiovascular events. If clopidogrel must be temporarily discontinued (e.g., to treat bleeding or for surgery with a major risk of bleeding), restart it as soon as possible. When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved.

The FDA drug label recommends interrupting therapy with clopidogrel for five days prior to surgery with a major risk of bleeding, which may include dental extraction with a high risk of bleeding. However, it does not explicitly state that Plavix needs to be stopped for all dental extractions.

• The decision to stop Plavix should be made on a case-by-case basis, considering the risk of bleeding and the risk of cardiovascular events.
• It is essential to consult the patient's healthcare provider to determine the best course of action for dental extraction in patients taking Plavix 2.

From the Research

Plavix and Dental Extraction

• The need to stop Plavix (clopidogrel) before dental extraction is a topic of discussion among dental professionals and patients.
• Studies have investigated the risk of bleeding after tooth extraction in patients taking Plavix, with varying results.

Risk of Bleeding

• A study published in 2011 found that dental extractions may be safely performed in patients receiving single or dual antiplatelet therapy, including Plavix, when appropriate local hemostatic measures are taken 3.
• Another study published in 2016 found that using aspirin and Plavix simultaneously has no considerable effect on the risk of bleeding in patients having conventional forceps extraction of a single tooth 4.
• A 2017 study concluded that single and multiple dental extractions in patients receiving acetylsalicylic acid or clopidogrel, including Plavix, can be safely performed without discontinuation of the therapy with provided appropriate local haemostasis 5.

Safety of Uninterrupted Plavix Therapy

• A 2021 study found that patients on uninterrupted dual antiplatelet therapy, including Plavix, undergoing dental extractions had an increased risk of bleeding complications, but all bleeding episodes were controlled with local hemostatic measures 6.
• A 2017 case-crossover study found that dental extraction can be performed safely without withdrawal of aspirin or clopidogrel, including Plavix, with no significant difference in bleeding severity between sessions with and without antiplatelet therapy 7.

Clinical Implications

• The available evidence suggests that Plavix does not need to be stopped for dental extraction, as the risk of bleeding can be managed with local hemostatic measures.
• Dental professionals should consider the individual patient's risk factors and medical history when deciding whether to continue or discontinue Plavix therapy before dental extraction, and consult with the patient's physician or cardiologist if necessary 3, 4, 5, 6, 7.