Should Plavix (clopidogrel) be held prior to a dental extraction?

Management of Plavix (Clopidogrel) Prior to Dental Extraction

Plavix (clopidogrel) should NOT be discontinued prior to routine dental extraction, as the thrombotic risk of stopping antiplatelet therapy far exceeds the bleeding risk from the procedure itself. 1, 2, 3

Evidence-Based Rationale

Bleeding Risk is Minimal with Continued Therapy

• Multiple prospective studies demonstrate that dental extractions can be safely performed in patients continuing clopidogrel 75 mg daily without increased risk of uncontrolled bleeding 2, 3
• A study of 62 patients on clopidogrel showed no significant difference in bleeding rates between those who continued versus discontinued the medication 72 hours before extraction 3
• Another study of 64 patients taking dual antiplatelet therapy (aspirin 80 mg + clopidogrel 75 mg) after coronary stent placement showed no uncontrolled bleeds or emergency referrals during 48 hours post-extraction 2
• Local hemostatic measures (gelatin sponge, suturing, compression) effectively control any minor bleeding that occurs 2, 3

Thrombotic Risk is Substantial with Discontinuation

• The FDA label explicitly warns that discontinuation of clopidogrel increases the risk of cardiovascular events and states: "When possible, interrupt therapy with clopidogrel for five days prior to such surgery. Resume clopidogrel as soon as hemostasis is achieved." 1
• However, this guidance applies to "surgery with a major risk of bleeding," which does not include routine dental extraction 1
• Premature withdrawal of antiplatelet agents is associated with a 10% risk of all vascular events 4
• Following drug-eluting stent implantation, withdrawal is associated with stent thrombosis and potentially fatal consequences 4

Clinical Management Algorithm

For Standard Dental Extractions (1-3 teeth)

• Continue clopidogrel without interruption 2, 3
• Use local hemostatic measures: gelatin sponge placement in extraction socket and/or suturing 2, 3
• Schedule extraction earlier in the day to allow monitoring 3
• Provide clear post-operative instructions about applying pressure with gauze if minor oozing occurs 2

High-Risk Cardiac Patients Requiring Special Consideration

Do NOT stop clopidogrel in patients with:

• Drug-eluting stent placed within the prior 12 months 5, 4
• Bare metal stent placed within the prior 4 weeks 5
• Recent acute coronary syndrome (within 12 months) 5
• History of stent thrombosis 4

For these patients, cardiology consultation before stopping clopidogrel is essential if considering discontinuation for any reason 6, 7

When Clopidogrel Discontinuation Might Be Considered

The only dental scenarios where discontinuation could be justified are:

• Extensive maxillofacial surgery with anticipated major blood loss 8
• Surgery in closed spaces where even minor bleeding could cause serious complications 5, 8

Even in these cases, the decision requires:

• Cardiology consultation to assess thrombotic risk 6, 7
• Minimum 5-day discontinuation period if approved 5, 1
• Resumption within 12-24 hours post-operatively once hemostasis achieved 1, 8

Common Pitfalls to Avoid

• Never stop clopidogrel without consulting the prescribing cardiologist, especially in patients with recent coronary stents 6, 7
• Do not use heparin or low-molecular-weight heparin as "bridging therapy" - this does not protect against coronary or stent thrombosis and may increase bleeding risk 8
• Discontinuing clopidogrel less than 5 days before surgery is ineffective - clopidogrel causes irreversible platelet inhibition for 7-10 days, and restoration of adequate platelet function requires at least 5 days 5, 1
• Do not assume all dental procedures require stopping antiplatelet therapy - this outdated practice increases cardiovascular morbidity and mortality 8, 4

Post-Extraction Monitoring

• Most bleeding occurs within the first 30 minutes and is controlled with local measures 2, 3
• Instruct patients to apply gauze compression for 30-45 minutes if oozing occurs 2
• Mild bleeding in the first 24 hours is rare (occurred in only 1 patient in a study of 68 patients on aspirin) and responds to simple compression 3
• No major hemorrhages requiring emergency intervention or more than local hemostasis have been reported in recent studies 2, 3