Should Plavix (clopidogrel) or aspirin be held for a dental cleaning?

Should Plavix or Aspirin Be Held for Dental Cleaning?

Neither Plavix (clopidogrel) nor aspirin should be discontinued for dental cleaning or any routine dental procedure, including tooth extractions. The risk of catastrophic thrombotic events from stopping these medications far exceeds the minimal and easily manageable bleeding risk associated with dental procedures. 1, 2

Evidence Supporting Continuation

Thrombotic Risk of Discontinuation is Life-Threatening

• Premature discontinuation of antiplatelet therapy markedly increases the risk of stent thrombosis, which frequently leads to myocardial infarction and death. 1, 2
• In patients who underwent surgery within 90 days of bare-metal stent implantation and had thienopyridine therapy discontinued, 6 of 7 patients 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. 2
• The risk of cardiovascular events increases 3-4 days after discontinuation of antithrombotic therapy. 3

Bleeding Risk is Minimal and Manageable

• There are no well-documented cases of clinically significant bleeding after dental procedures, including multiple dental extractions, in patients taking clopidogrel alone or combined with aspirin. 1, 2
• A prospective randomized study of single tooth extractions showed no statistically significant difference in postoperative bleeding between aspirin users and placebo. 1
• The overall frequency of postoperative bleeding in patients on dual antiplatelet therapy is only 8.3%, with all cases being controllable with local measures. 4
• Patients taking aspirin and clopidogrel simultaneously have no considerable effect on bleeding risk during conventional forceps extraction. 5

Guideline Recommendations

The American Heart Association, American College of Cardiology, and American Dental Association jointly recommend continuing antiplatelet therapy for all dental procedures. 1, 6, 2

• There is little or no indication to interrupt antiplatelet drugs for dental procedures, including teeth cleaning and tooth extractions. 1
• The American College of Cardiology specifically recommends continuing aspirin without interruption for all dental procedures. 6
• Professional guidelines emphasize that the thrombotic risk of discontinuation far outweighs the minimal bleeding risk. 6, 2

Local Hemostatic Measures

Bleeding control should be achieved through local hemostatic measures rather than medication discontinuation:

• Place absorbable gelatin sponge in extraction socket. 1, 2
• Suture extraction sites when needed. 1, 2
• Use local anesthesia with vasoconstrictor. 6
• Apply tranexamic acid mouth rinse. 6
• Pack socket with absorbable hemostatic material. 6

These measures are highly effective and make bleeding complications rare and easily manageable. 1

Special Considerations for Patients with Coronary Stents

For patients with coronary stents, continuation of dual antiplatelet therapy is absolutely critical:

• The FDA label for clopidogrel explicitly warns that discontinuation increases the risk of cardiovascular events and states that clopidogrel should be restarted as soon as possible if temporarily discontinued. 7
• When clopidogrel must be temporarily discontinued for surgery with major bleeding risk, it should be interrupted for five days prior and resumed as soon as hemostasis is achieved. 7
• However, dental procedures do not qualify as "surgery with major bleeding risk" and therefore do not warrant discontinuation. 1, 6, 2

Postoperative Analgesia

• Use acetaminophen (paracetamol) as first-line analgesia after dental procedures in patients on antiplatelet therapy. 6
• Avoid NSAIDs in patients on dual antiplatelet therapy. 6
• COX-2 inhibitors (coxibs) have less effect on platelet function and may be used if necessary. 6

Common Pitfall to Avoid

The most dangerous error is routinely instructing patients to stop "blood thinners" before dental procedures without distinguishing between warfarin and antiplatelet agents, and without evaluating the rationale for the therapy. 1 Many healthcare providers inappropriately discontinue these medications due to misguided concerns about excessive bleeding, when in reality dental bleeding is easily accessible, visible, and controllable with straightforward local measures. 2