Clopidogrel Should NOT Be Discontinued Before Routine Tooth Extraction
Continue clopidogrel through routine tooth extraction and manage bleeding with local hemostatic measures only. Multiple high-quality 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" including tooth extractions 1.
Evidence-Based Rationale
Guideline Consensus on Dental Procedures
The AHA/ACC/American Dental Association joint science advisory specifically addresses dental extractions, stating that "there are no well-documented cases of clinically significant bleeding after dental procedures, including multiple dental extractions" in patients on clopidogrel 1.
These procedures can be performed "at no or only minor risk of bleeding" because oral bleeding is easily controlled with local measures (absorbable gelatin sponge, sutures) and bleeding rarely occurs once an initial clot forms 1.
The FDA label for clopidogrel states to "interrupt therapy for five days prior to surgery with a major risk of bleeding"—notably, routine dental extraction does not meet this threshold 2.
Critical Safety Concern: Stent Thrombosis Risk
Discontinuing clopidogrel creates catastrophic thrombotic risk that far exceeds any bleeding risk from tooth extraction:
In patients with coronary stents who stopped thienopyridines before surgery, 6 of 7 deaths occurred "in a manner suggestive of stent thrombosis" 1.
For drug-eluting stents placed within 12 months or bare-metal stents within 6 weeks, clopidogrel must never be stopped without cardiology consultation due to extreme risk of myocardial infarction and death 1.
Even beyond the critical stent period, premature discontinuation increases cardiovascular events 2.
Clinical Trial Evidence Supports Continuation
A 2015 prospective study of 160 patients on antiplatelet therapy (including 43 on dual therapy with aspirin plus clopidogrel) found only 1 bleeding event among 110 teeth extracted in the dual therapy group, which was mild and easily controlled 3.
A 2016 retrospective cohort of 183 patients on antiplatelet therapy (including 16 on dual therapy) undergoing 548 dental extractions found no significant difference in bleeding compared to controls (1.8% vs 0.7%, p=NS), and all bleeding was managed with local measures 4.
A 2016 study of 64 patients on aspirin plus clopidogrel after coronary stent placement found no uncontrolled bleeding or emergency referrals within 48 hours of tooth extraction 5.
A 2017 study of 62 patients on clopidogrel found no statistically significant difference in bleeding between those who continued versus stopped the medication 6.
Practical Management Algorithm
Pre-Extraction Assessment
Identify if patient has a coronary stent:
For patients without recent stents on clopidogrel for other indications (stroke, peripheral arterial disease):
- Continue clopidogrel through extraction 1
Intraoperative Hemostasis
- Use absorbable gelatin sponge (Gelfoam) in extraction socket 1, 3, 4
- Place sutures to approximate wound edges 1
- Apply direct pressure with gauze for 30 minutes 6, 5
- Consider tranexamic acid-soaked gauze for additional hemostasis 4
Post-Extraction Monitoring
- Instruct patient to bite on gauze for 30-60 minutes 6, 5
- Advise soft diet and avoid rinsing vigorously for 24 hours 6
- Provide emergency contact information if bleeding persists beyond 12 hours 3
Common Pitfalls to Avoid
Never confuse antiplatelet agents with warfarin—many practitioners incorrectly instruct patients to stop all "blood thinners" without distinguishing between these fundamentally different drug classes 1.
Never stop clopidogrel without consulting the prescribing cardiologist, especially in stent patients where discontinuation can be fatal 1.
Do not limit extractions based on antiplatelet therapy—studies show safe extraction of up to 3 teeth per visit 6 and even multiple extractions 1, 3.
Recognize that mild oozing in the first 30 minutes is normal and expected—this does not constitute a bleeding complication and responds to local pressure 6, 5.
When Clopidogrel Discontinuation Might Be Considered
Only for major surgery with bleeding in closed spaces (intracranial surgery, spinal canal procedures, CABG) should 5-7 day discontinuation be considered 1, 2—and even then, aspirin should be continued and clopidogrel restarted within 24-72 hours postoperatively 1.
Routine tooth extraction does not meet this threshold and the 2022 CHEST guidelines on perioperative antithrombotic management do not classify dental procedures as requiring antiplatelet interruption 1.