Management of Aspirin and Clopidogrel for Dental Extraction
Continue both aspirin and clopidogrel without interruption for dental extractions, as local hemostatic measures are highly effective and the thrombotic risk of discontinuation far outweighs the minimal bleeding risk.
Primary Recommendation
Do not discontinue antiplatelet therapy for dental procedures. Multiple authoritative guidelines from the American Heart Association, American College of Cardiology, and American Dental Association explicitly state there is "little or no indication to interrupt antiplatelet drugs for dental procedures" 1. Dental extractions, including multiple extractions, can be safely performed with local hemostatic measures such as absorbable gelatin sponges and sutures 1.
Evidence Supporting Continuation
Bleeding Risk is Minimal and Manageable
- No well-documented cases of clinically significant bleeding after dental procedures exist in patients taking thienopyridines (clopidogrel) alone or combined with aspirin 1
- A prospective randomized study of single tooth extractions showed no statistically significant difference in postoperative bleeding between aspirin users and placebo 1
- Research demonstrates that dental extractions in patients on aspirin or clopidogrel can be performed safely without discontinuation, with bleeding controlled by local measures 2
- Studies of patients on dual antiplatelet therapy (aspirin + clopidogrel) show postoperative bleeding rates of only 8.3%, all controllable with local measures 3
- A case-crossover study found no difference in bleeding severity whether aspirin or clopidogrel was continued or stopped 5 days prior to extraction 4
Thrombotic Risk of Discontinuation is Catastrophic
- Premature discontinuation of dual antiplatelet therapy markedly increases the risk of stent thrombosis, which frequently leads to myocardial infarction and/or death 1
- In patients who underwent surgery within 90 days of bare-metal stent implantation, 6 of 7 patients who had thienopyridine discontinued died in a manner suggestive of stent thrombosis 1
- The median time to coronary stent thrombosis can be as short as 7 days when both drugs are withheld compared with 122 days when only clopidogrel is withheld 1
Local Hemostatic Measures
Use these standard techniques to control any bleeding:
- Absorbable gelatin sponge placement in extraction socket 1
- Suturing of extraction site 1
- Compression with gauze for 30 minutes post-extraction 2
- Limit extractions to no more than 3 teeth per visit 2
These measures are highly effective, with bleeding typically occurring only in the first 30 minutes and easily managed 2.
Critical Distinction from Major Surgery
Dental procedures are fundamentally different from major surgery. While guidelines acknowledge that major noncardiac surgery may require discontinuation of clopidogrel (with aspirin continuation) due to increased bleeding risk 1, dental extractions fall into the category of minor procedures where:
- Bleeding is easily accessible and visible 1
- Local hemostatic control is straightforward 1
- Once an initial clot forms, bleeding is unlikely to recur 1
Common Pitfall to Avoid
Do not routinely instruct patients to stop "blood thinners" without distinguishing between warfarin and antiplatelet agents 1. Many healthcare providers inappropriately discontinue antiplatelet therapy due to misguided concerns about excessive bleeding, placing patients at catastrophic risk of stent thrombosis and myocardial infarction 1.
Special Consideration for Coronary Stents
If your patient has coronary stents (particularly drug-eluting stents placed within the past 6-12 months), the risk-benefit ratio overwhelmingly favors continuation of dual antiplatelet therapy 1. For these high-risk patients, maintaining aspirin during any procedure is the preferred option, and dental extractions represent minimal hemorrhagic risk 1.
Timing Considerations
- Aspirin: Continue without interruption 1
- Clopidogrel: Continue without interruption 1
- Dual therapy: Continue both agents without interruption 1, 3
The French guidelines classify dental procedures as having minor hemorrhagic risk, where intervention can proceed on both aspirin and clopidogrel 1.