Should aspirin and Plavix (clopidogrel) be held for dental procedures?

Management of Antiplatelet Therapy During Dental Procedures

Aspirin and Plavix (clopidogrel) should NOT be discontinued for dental procedures. Local hemostatic measures are sufficient to control bleeding, and the risk of thrombotic events from discontinuation far outweighs the minimal bleeding risk 1.

Rationale for Continuing Antiplatelet Therapy

Premature discontinuation of antiplatelet therapy significantly increases the risk of stent thrombosis, which can lead to myocardial infarction and death. This risk is particularly high when both antiplatelet agents are discontinued simultaneously:

• Median time to coronary stent thrombosis is as short as 7 days with both drugs withheld 2
• Patients with coronary stents who discontinue antiplatelet therapy have up to a sevenfold increase in risk for death or acute cardiovascular events 2
• The risk of significant bleeding during dental procedures is minimal and can be effectively managed with local measures 2

Evidence Supporting Continued Therapy

The American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association jointly advise:

• There are no well-documented cases of clinically significant bleeding after dental procedures, including multiple dental extractions, in patients on antiplatelet therapy 2
• A prospective study of single tooth extractions comparing aspirin versus placebo failed to show statistically significant differences in postoperative bleeding 2
• Clinical studies have demonstrated acceptable rates of controllable postoperative bleeding (3.2% for aspirin, 4.5% for clopidogrel, and 8.3% for dual antiplatelet therapy) 3

Management of Bleeding Risk

Local hemostatic measures are highly effective in controlling bleeding during dental procedures:

• Absorbable gelatin sponge
• Suturing
• Local pressure application
• Tranexamic acid mouthwash

These measures can easily reduce the incidence and severity of oral bleeding during surgery, and bleeding is unlikely once an initial clot has formed 2.

Common Pitfalls to Avoid

1. Routine discontinuation of antiplatelet therapy - This practice is based on misguided concerns about excessive procedure-related bleeding 2
2. Failing to distinguish between antiplatelet agents and anticoagulants - These medications have different mechanisms and bleeding risks 1
3. Recommending NSAIDs for post-procedure pain in patients taking aspirin - This can increase bleeding risk 1
4. Discontinuing both antiplatelet agents simultaneously - This creates the highest risk for stent thrombosis 2

Special Considerations

For patients with drug-eluting coronary stents, the risk of stent thrombosis is highest within the first 12 months, while for bare-metal stents, the highest risk period is within the first 30-45 days 1.

If there is any concern about extensive oral surgery in high-risk patients (multiple stents, long stents, bifurcation stents, history of stent thrombosis, diabetes), consultation with the patient's cardiologist is recommended, but the default approach should be to continue antiplatelet therapy 1.

According to the FDA label for clopidogrel, discontinuation increases the risk of cardiovascular events, and if temporarily discontinued, it should be restarted as soon as possible 4.