Do you hold Plavix (clopidogrel) prior to dental extraction?

Management of Clopidogrel (Plavix) During Dental Extraction

Clopidogrel (Plavix) should NOT be discontinued prior to dental extractions, as the risk of thrombotic events from discontinuation far outweighs the minimal bleeding risk that can be effectively managed with local hemostatic measures. 1

Rationale for Continuing Antiplatelet Therapy

The American College of Chest Physicians strongly recommends continuing antiplatelet therapy during minor dental procedures 2. This recommendation is based on evidence showing:

• The risk of serious thrombotic events (including stent thrombosis, myocardial infarction, and death) from discontinuing antiplatelet therapy outweighs the minimal risk of bleeding during dental procedures
• Any bleeding that occurs can typically be managed effectively with local hemostatic measures
• Multiple studies have demonstrated that patients on antiplatelet therapy, including dual antiplatelet therapy, can safely undergo dental extractions without significant bleeding complications 3, 4

Evidence Supporting Continuation

Recent research provides strong support for continuing clopidogrel during dental extractions:

• A 2016 study found no significant differences in bleeding complications between patients taking both aspirin and clopidogrel and healthy controls during conventional tooth extractions 3
• A 2021 prospective study showed that while patients on dual antiplatelet therapy had a 7-fold increased risk of immediate bleeding, all bleeding episodes were successfully controlled with local hemostatic measures 4

Management Algorithm for Dental Extractions in Patients on Clopidogrel

1. Pre-procedure assessment:

   • Confirm indication for clopidogrel (particularly important for patients with coronary stents)
   • Determine time since stent placement (highest risk of stent thrombosis is within first 6-12 months)
   • Do NOT discontinue clopidogrel prior to dental extraction

2. During the procedure:

   • Use atraumatic extraction techniques
   • Consider limiting the number of teeth extracted in a single session
   • Have local hemostatic measures readily available

3. Local hemostatic measures to employ:

   • Absorbable gelatin sponge placement in extraction socket
   • Suturing of the extraction site
   • Application of pressure with gauze soaked in tranexamic acid
   • Tranexamic acid mouthwash (if available)

4. Post-procedure monitoring:

   • Apply pressure with gauze for at least 30-60 minutes
   • Monitor for bleeding for at least 30 minutes after extraction
   • Provide clear instructions on managing minor bleeding at home

Special Considerations

For patients on dual antiplatelet therapy (DAPT) following coronary stent placement:

• Never discontinue both antiplatelet agents due to high risk of stent thrombosis 2
• If absolutely necessary to modify therapy (which is rarely the case for dental extractions), continue aspirin and temporarily withhold clopidogrel only after consultation with the patient's cardiologist 2
• For patients with drug-eluting stents, early resumption of P2Y12 receptor inhibitor (clopidogrel) is critical, preferably within 5 days after any interruption 2

Common Pitfalls to Avoid

1. Discontinuing antiplatelet therapy without consulting the patient's cardiologist
2. Failing to distinguish between antiplatelet agents and anticoagulants (which have different management protocols)
3. Not having adequate local hemostatic measures available
4. Recommending NSAIDs for post-procedure pain management, which may increase bleeding risk in patients taking aspirin

In conclusion, the evidence strongly supports continuing clopidogrel during dental extractions, with appropriate local hemostatic measures in place to manage any bleeding that may occur.