Do patients need to stop Plavix (clopidogrel) for dental work?

Management of Plavix (Clopidogrel) for Dental Procedures

Patients on Plavix (clopidogrel) should continue their medication during dental procedures, as the risk of thrombotic events from discontinuation far outweighs the minimal bleeding risk that can be effectively managed with local hemostatic measures. 1, 2

Evidence-Based Recommendations

The American College of Chest Physicians (ACCP) provides clear guidance on this issue in their 2022 clinical practice guidelines:

• For patients receiving antiplatelet drugs (including P2Y12 inhibitors like Plavix) who are undergoing minor dental procedures, continuing the antiplatelet drug is recommended over stopping it before the procedure 1
• This recommendation is consistent across multiple professional societies including the American Heart Association, American College of Cardiology, and American Dental Association 2

Risks of Discontinuation vs. Bleeding Risk

Thrombotic Risk

• Premature discontinuation of antiplatelet therapy significantly increases the risk of stent thrombosis, myocardial infarction, and death 2
• This risk is particularly high for patients with recently placed coronary stents

Bleeding Risk

• Clinical studies demonstrate that the risk of significant bleeding during dental procedures in patients on antiplatelet therapy is minimal:
  • The overall frequency of postoperative bleeding in patients taking clopidogrel is approximately 4.5% 3
  • When bleeding does occur, it is typically mild and controllable with local measures 3, 4, 5
  • No major hemorrhages requiring more than local hemostasis have been reported in studies 5

Management Algorithm

1. Continue Plavix for all routine dental procedures

   • Including extractions, periodontal procedures, and endodontic treatments 2

2. For patients on dual antiplatelet therapy (DAPT):

   • Continue aspirin
   • Continue the P2Y12 inhibitor (Plavix) 1, 2
   • Note: The bleeding rate with dual antiplatelet therapy is slightly higher (8.3%) but still manageable with local measures 3

3. Employ local hemostatic measures as needed:

   • Absorbable gelatin sponge
   • Suturing
   • Local pressure application
   • Tranexamic acid mouthwash 2

4. Special considerations:

   • For extensive oral surgery, consultation with the patient's cardiologist is recommended 2
   • Patients with high-risk factors for stent thrombosis (multiple stents, long stents, bifurcation stents, history of stent thrombosis, diabetes) require extra caution about medication changes 2

Common Pitfalls to Avoid

1. Do not routinely discontinue antiplatelet therapy before dental procedures based on outdated concerns about bleeding 2

2. Avoid confusing antiplatelet agents with anticoagulants (which have different management protocols) 2

3. Do not recommend NSAIDs for post-procedure pain in patients taking aspirin as part of their antiplatelet regimen 2

4. Do not make medication changes without consulting the prescribing physician, especially for patients with recently placed coronary stents 2

The evidence consistently shows that the risk of thrombotic events from discontinuing Plavix outweighs the minimal and manageable bleeding risk during dental procedures. Multiple clinical studies and current guidelines strongly support continuing antiplatelet therapy during dental work.