What are the recommendations for holding antiplatelet therapy in a patient with a history of stent placement on aspirin and Plavix undergoing a dental procedure?

Management of Antiplatelet Therapy for Dental Procedures in Patients with Coronary Stents

For patients with coronary stents undergoing dental procedures, dual antiplatelet therapy (aspirin and clopidogrel/Plavix) should be maintained without interruption to prevent the catastrophic risk of stent thrombosis. 1

Risk Assessment Framework

Stent-Related Factors

• Time since stent placement:
  • Drug-eluting stents (DES): Highest risk within first 12 months 1
  • Bare-metal stents: Highest risk within first 30-45 days 1
• Risk factors for stent thrombosis:
  • Multiple stents
  • Long stents
  • Bifurcation stents
  • History of stent thrombosis
  • Incomplete revascularization
  • Diabetes
  • Low ejection fraction 1

Procedure-Related Bleeding Risk

• Dental procedures are considered low bleeding risk and can be safely performed without interruption of antiplatelet therapy 1, 2
• Local hemostatic measures are highly effective in controlling bleeding during dental procedures 1

Recommendations for Dental Procedures

1. Continue both aspirin AND clopidogrel (Plavix) during dental procedures 1

   • This includes tooth extractions and other invasive dental procedures
   • Research shows dental extractions can be performed safely without stopping multiple antiplatelet agents 2

2. Use local hemostatic measures to control bleeding:

   • Absorbable gelatin sponge
   • Sutures
   • Local pressure 1

3. Do NOT stop antiplatelet therapy for dental procedures:

   • Premature discontinuation significantly increases risk of stent thrombosis, which can lead to myocardial infarction and/or death 1
   • There are no well-documented cases of clinically significant bleeding after dental procedures in patients on dual antiplatelet therapy 1

Important Considerations

• Consult with cardiologist before any changes to antiplatelet therapy:

  • Patients should be instructed to contact their cardiologist before stopping any antiplatelet therapy, even if instructed by another healthcare provider 1

• Avoid NSAIDs for post-procedure pain management:

  • Ibuprofen can attenuate the protective effects of aspirin 3
  • Consider alternative pain management strategies

• Risk-benefit analysis:

  • The risk of stent thrombosis (potentially fatal) far outweighs the risk of bleeding during dental procedures (typically manageable with local measures) 1

Common Pitfalls to Avoid

1. Routine discontinuation of "blood thinners" before dental procedures is a dangerous practice 1

2. Failing to distinguish between antiplatelet agents and anticoagulants when making decisions about perioperative management 1

3. Substituting antiplatelet therapy with heparin or other anticoagulants - there is no evidence supporting this practice and it may increase bleeding risk 1

4. Assuming all procedures carry the same bleeding risk - dental procedures specifically have been shown to have manageable bleeding risk even with continued dual antiplatelet therapy 1, 2

5. Recommending ibuprofen for post-procedure pain in patients taking aspirin - this interaction can reduce aspirin's cardioprotective effects 3

By maintaining dual antiplatelet therapy during dental procedures and using appropriate local hemostatic measures, the risk of serious bleeding complications is minimal while the critical protection against stent thrombosis is preserved.