How long before a dental extraction should a patient stop taking aspirin (acetylsalicylic acid) and Plavix (clopidogrel), who has been on Dual Antiplatelet Therapy (DAPT) for over 1 month?

From the Guidelines

For patients on Dual Antiplatelet Therapy (DAPT) with aspirin and Plavix (clopidogrel) for over 1 month, it is generally recommended not to discontinue these medications prior to dental extractions. The current standard approach is to continue both medications without interruption. Stopping these medications can significantly increase the risk of serious cardiovascular events, particularly for patients with recent stent placement or acute coronary syndrome. The bleeding risk during dental extractions can typically be managed with local hemostatic measures such as pressure, gelatin sponges, tranexamic acid rinses, or sutures. If bleeding concerns are significant, consultation with the patient's cardiologist is essential before considering any medication changes. The cardiologist may recommend modification of the regimen only in cases where bleeding risk is deemed to outweigh thrombotic risk. For patients who absolutely require antiplatelet interruption, aspirin is usually continued while Plavix might be stopped 5 days before the procedure, but this approach should only be taken after specialist consultation and with a clear plan for medication resumption, typically within 24 hours after bleeding is controlled, as suggested by studies such as 1 and 1.

Some key points to consider include:

• The risk of bleeding during dental extractions can be managed with local measures, reducing the need to stop antiplatelet therapy 1.
• The decision to stop antiplatelet therapy should be made on a case-by-case basis, considering the individual's risk of thrombotic events versus bleeding risk 1.
• Recent guidelines suggest continuing antiplatelet drugs for minor procedures, including dental, dermatologic, or ophthalmologic procedures, to minimize the risk of cardiovascular events 1.

Overall, the management of antiplatelet therapy in patients undergoing dental extractions should prioritize minimizing the risk of cardiovascular events while managing bleeding risks appropriately.

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 patient should stop taking Plavix (clopidogrel) for 5 days before a dental extraction. However, the label does not provide information on when to stop aspirin. Therefore, a conservative clinical decision would be to consult additional resources for guidance on managing aspirin therapy before dental extraction. 2

From the Research

Dental Extraction and Antiplatelet Therapy

• The decision to stop aspirin and Plavix (clopidogrel) before a dental extraction in patients who have been on Dual Antiplatelet Therapy (DAPT) for over 1 month should be based on the risk of bleeding versus the risk of thrombotic events 3, 4.
• Studies have shown that continuing antiplatelet therapy during dental extractions does not significantly increase the risk of major bleeding complications, and local hemostatic measures can effectively control bleeding 3, 4, 5.
• A meta-analysis found that the use of double antiplatelet therapy (DAPT) was associated with an increased risk of bleeding events, but the overall event incidence was still relatively low (1.59%) 6.

Management of Antiplatelet Therapy

• The American Dental Association and other organizations recommend that antiplatelet therapy should not be interrupted for routine dental procedures, including tooth extractions, due to the risk of thrombotic events 3, 4, 5.
• Patients on DAPT can undergo dental extractions safely without discontinuing their therapy, as long as appropriate local hemostasis is provided 4.
• The use of tranexamic acid mouthwash has been studied as a potential method to reduce bleeding after dental extraction in patients on non-vitamin K oral anticoagulants, but its effectiveness in patients on antiplatelet therapy is still being researched 7.

Bleeding Risk and Antiplatelet Therapy

• The frequency of postoperative bleeding in patients taking aspirin, clopidogrel, ticagrelor, and dual antiplatelet therapy has been found to be relatively low (3.2-8.3%) 5.
• Bleeding complications can be managed with local hemostatic measures, and none of the patients in the studied populations experienced prolonged bleeding 3, 4, 5.
• The risk of bleeding should be weighed against the risk of thrombotic events, and the decision to stop antiplatelet therapy should be made on a case-by-case basis, taking into account the patient's medical history and the type of procedure being performed 3, 4.