For a patient on Plavix (clopidogrel) and ASA (acetylsalicylic acid), how long before and after a dental procedure should they stop and then initiate these medications?

Management of Antiplatelet Therapy for Dental Procedures

For patients on Plavix (clopidogrel) and ASA (acetylsalicylic acid), antiplatelet therapy should be continued throughout dental procedures without interruption, 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

Recommendations for Antiplatelet Management

Before Dental Procedure:

• Continue ASA without interruption for all dental procedures 1, 2
• Continue clopidogrel without interruption for minor dental procedures 1, 2
• For patients on dual antiplatelet therapy (DAPT), the American College of Chest Physicians recommends continuing both medications during minor dental procedures 2

During Dental Procedure:

• Implement local hemostatic measures:
  • Absorbable gelatin sponge
  • Suturing when appropriate
  • Local pressure application
  • Tranexamic acid mouthwash 2

After Dental Procedure:

• Resume normal dosing immediately (no interruption needed)
• For ASA, maximal antiplatelet effect occurs within minutes of administration 1
• For clopidogrel, if it had been interrupted (which is not recommended), note that at maintenance dose (75 mg/day), it takes 5-10 days to attain maximal platelet function inhibition 1

Evidence Supporting Continued Therapy

Multiple studies demonstrate that the risk of significant bleeding during dental procedures in patients on antiplatelet therapy is minimal:

• Small randomized trials and cohort studies show no increase in major bleeding with ASA continuation during dental procedures 1
• A retrospective cohort study of 29 patients receiving combined ASA and clopidogrel found no bleeding episodes with continuation of dual antiplatelet therapy during dental procedures 1
• A 2018 case-and-crossover study showed no difference in bleeding severity between patients who continued versus those who stopped antiplatelet drugs before dental implant surgery 3
• A 2008 study demonstrated that patients continuing antiplatelet therapy had no episodes of prolonged or significant bleeding from extraction sites 4

Risks of Discontinuation

Discontinuing antiplatelet therapy increases the risk of thrombotic events:

• Premature discontinuation of antiplatelet therapy significantly increases the risk of stent thrombosis, which can lead to myocardial infarction and death 2
• Clopidogrel discontinuation increases the risk of cardiovascular events 5
• The FDA label for clopidogrel warns that discontinuation increases the risk of cardiovascular events and recommends restarting as soon as possible if temporarily discontinued 5

Important Considerations

• Platelet function recovery: After interruption of clopidogrel or ASA, 10-14% of normal platelet function is restored each day, with a complete platelet pool replenishment taking 7-10 days 1
• Bleeding management: If bleeding occurs, it can typically be managed with local hemostatic measures 2
• Consultation: For extensive oral surgery, consultation with a cardiologist is recommended before any changes to antiplatelet therapy, especially for patients with high-risk factors for stent thrombosis 2

Common Pitfalls to Avoid

• Routinely discontinuing antiplatelet therapy before dental procedures
• Failing to distinguish between antiplatelet agents and anticoagulants
• Recommending NSAIDs for post-procedure pain in patients taking aspirin 2
• Stopping therapy without considering the high risk of thrombotic events, which can be life-threatening

The evidence strongly supports continuing antiplatelet therapy during dental procedures, with appropriate local hemostatic measures to manage any minor bleeding that may occur.