Does a patient on Plavix (clopidogrel) and Aspirin (ASA) need to stop taking these medications when getting a dental crown?

No, Do Not Stop Plavix and Aspirin for a Dental Crown

For a patient on dual antiplatelet therapy (Plavix and aspirin) undergoing dental crown placement, continue both medications without interruption. 1

Evidence-Based Recommendation

The 2022 American College of Chest Physicians (ACCP) guidelines provide clear direction for this clinical scenario:

• Continue antiplatelet therapy for minor dental procedures rather than stopping medications 7-10 days before the procedure 1
• This recommendation applies to both single antiplatelet agents (ASA or P2Y12 inhibitors like clopidogrel) and dual antiplatelet therapy 1
• The evidence shows no increase in major bleeding with continuation of antiplatelet drugs during minor dental procedures 1

Risk-Benefit Analysis

Bleeding Risk is Minimal

• Small randomized trials and cohort studies (totaling <100 patients) demonstrate no increase in major bleeding with ASA continuation during dental procedures 1
• One 43-patient retrospective study specifically evaluated patients on combined ASA and clopidogrel and found zero bleeding episodes with continuation of dual antiplatelet therapy 1
• A 2016 study of 64 patients taking aspirin 80mg and clopidogrel 75mg after coronary stenting showed no significant difference in bleeding immediately or 30 minutes post-extraction, with no uncontrolled bleeds or emergency referrals at 48 hours 2

Thrombotic Risk is Substantial

• Stopping antiplatelet therapy increases cardiovascular event risk within 3-4 days of discontinuation 3
• The FDA label for clopidogrel explicitly warns that discontinuation increases the risk of cardiovascular events 4
• In patients with recent coronary stents, interrupting dual antiplatelet therapy can lead to catastrophic stent thrombosis 1

Practical Management Strategy

For Dual Antiplatelet Therapy Patients:

Option 1 (Preferred): Continue both ASA and clopidogrel throughout the procedure 1

Option 2 (Alternative): If there is exceptional concern about bleeding risk, the ACCP guidelines note that patients on dual antiplatelet therapy can continue ASA and interrupt the P2Y12 inhibitor (Plavix) 1

Local Hemostatic Measures:

• Optimize local hemostasis with appropriate techniques 1
• Use gelatine sponge, suturing, or compression as needed 5
• Minor bleeding (if it occurs) is typically managed successfully with local measures alone 2, 5

Critical Caveats

When to Consult the Prescribing Physician:

• Recent coronary stent placement (especially within 6 months for drug-eluting stents or 6 weeks for bare-metal stents) requires careful consideration 1
• The FDA label states that healthcare providers should talk to the prescribing physician before any surgery or invasive procedure 4
• However, this consultation should focus on confirming the indication for dual antiplatelet therapy, not routinely stopping medications 1

Timing Considerations if Interruption is Absolutely Required:

• If clopidogrel must be stopped (which should be rare for a crown procedure), the FDA label recommends interruption at least 5 days before surgery to avoid excessive bleeding 4
• Restart clopidogrel as soon as hemostasis is achieved 4

Common Pitfall to Avoid

Do not reflexively stop antiplatelet medications for routine dental procedures. The outdated practice of discontinuing these medications stems from overestimating bleeding risk and underestimating thrombotic risk 3. A 2017 study concluded that single and multiple dental extractions can be safely performed without discontinuation of therapy when appropriate local hemostasis is provided 5.

The evidence consistently demonstrates that the cardiovascular risk of stopping these medications far outweighs the minimal bleeding risk of continuing them for minor dental procedures like crown placement 1, 2, 3.