Management of Clopidogrel for Dental Surgery
For most routine dental procedures including simple extractions (≤3 teeth), continue clopidogrel without interruption and use local hemostatic measures to control bleeding. 1, 2
Risk Stratification: Thrombotic vs. Bleeding Risk
The decision to continue or stop clopidogrel depends on both the complexity of the dental procedure and the patient's thrombotic risk profile.
Patient Thrombotic Risk Assessment
High thrombotic risk patients require cardiology consultation before any consideration of stopping clopidogrel: 3, 4
- Drug-eluting coronary stent placed within 12 months 3, 4
- Bare metal stent placed within 1 month 3, 4
- Recent acute coronary syndrome (within 6-12 months) 3, 4
- History of stent thrombosis 3
Low thrombotic risk patients (safer to discontinue if needed): 3, 4
- Coronary stents placed >12 months ago 4
- Stable ischemic heart disease without stents 3, 4
- Peripheral vascular disease 3, 4
Dental Procedure Bleeding Risk Classification
Low bleeding risk procedures (continue clopidogrel): 5, 6
- Simple dental cleaning and fillings 5
- Single or double tooth extractions 1, 2
- Routine restorative work 6
Higher bleeding risk procedures (consider stopping in low thrombotic risk patients only): 6
- Extraction of >3 teeth 6
- Open-flap periodontal surgery 6
- Surgical extractions 6
- Crown lengthening procedures 6
Evidence-Based Approach for Routine Dental Extractions
The strongest contemporary evidence supports continuing clopidogrel for most dental extractions. A propensity-matched study of 100 coronary stent patients on dual antiplatelet therapy undergoing dental extractions without stopping medications found only 2% excessive bleeding (lasting 4-5 hours), with no transfusions, rehospitalizations, or major cardiovascular events. 1 This was comparable to the control group not on antiplatelet therapy. 1
A randomized controlled trial of 62 patients on clopidogrel found no statistically significant difference in bleeding between those who continued versus stopped clopidogrel 72 hours before extraction. 2 All bleeding episodes were mild and controlled with local hemostatic measures. 2
When Discontinuation is Necessary
For high bleeding risk dental procedures in low thrombotic risk patients, stop clopidogrel 5 days before surgery. 3, 7, 8 This timing allows adequate platelet function recovery, as clopidogrel causes irreversible platelet inhibition for the entire 7-10 day platelet lifespan. 7, 8
For patients on dual antiplatelet therapy (clopidogrel + aspirin), continue aspirin if clopidogrel must be stopped. 3 This maintains some antiplatelet protection while reducing bleeding risk.
Resume clopidogrel within 24-48 hours after the procedure once hemostasis is achieved. 3, 8, 4
Local Hemostatic Measures (Essential for All Cases)
Implement aggressive local hemostatic techniques regardless of whether clopidogrel is continued: 1, 2
- Suture all extraction sites 1, 2
- Apply gelatin sponges or other hemostatic agents 2
- Use tranexamic acid mouthwash 7, 5
- Apply direct pressure with gauze 2
- Limit extractions to ≤3 teeth per visit 2
Critical Caveats and Pitfalls
Never stop clopidogrel without cardiology consultation in high thrombotic risk patients, even for complex dental procedures. 3, 4 The risk of stent thrombosis, myocardial infarction, or death far outweighs bleeding risk. 9 Cardiovascular events can occur 3-4 days after discontinuing antiplatelet therapy. 9
The outdated practice of routinely stopping clopidogrel before all dental procedures is not evidence-based and increases thrombotic risk. 5, 9 Most dental bleeding is manageable with local measures and does not constitute a medical emergency. 1, 2
For urgent/emergent dental procedures in high-risk patients, proceed with the procedure while continuing clopidogrel rather than delaying for medication washout. 5 The infection or pain from delayed treatment poses greater risk than manageable bleeding. 5