Dentists should be familiar with clopidogrel, which is commonly used in combination with aspirin following placement of coronary stents to prevent coronary stent thrombosis. Clopidogrel may also be used in patients who are unable to take aspirin. Ticagrelor and prasugrel are new antiplatelet drugs that may be used as alternatives to clopidogrel.
All antiplatelet drugs place patients at an increased risk of bleeding following invasive dental procedures, especially dental extractions or dentoalveolar surgery. In patients who are receiving dual antiplatelet therapy following coronary artery stenting, premature discontinuation of the drugs can increase the risk of stent thrombosis, which may lead to acute myocardial infarction and death.1
Australian guidelines2 recommend that patients requiring dental extractions or dentoalveolar surgery should not cease antiplatelet therapy, either monotherapy with aspirin, or dual therapy where aspirin is combined with other antiplatelet drugs. Patients should be warned of the increased risk of prolonged bleeding and also bruising.
Local measures such as placement of haemostatic materials into sockets and suturing should be used. If patients stop these medicines without substitute anticoagulants or monitoring, there is a risk of significant cardiac events or cerebrovascular accident. Elective extractions or surgery are best delayed if possible, especially in patients taking dual antiplatelet therapy temporarily (usually 12 months following stent placement).
It is important that a thorough medical history, including a medication history, is obtained for all patients. This should be updated at each visit. For patients requiring dental extractions or dentoalveolar surgery, their antiplatelet medication should not be ceased.2 However, their treating physician should be made aware of the planned procedures. When a dentist lacks experience in the oral surgical management of patients on antiplatelet therapy, the patient should be referred to an oral and maxillofacial surgeon for specialist management.
Conflict of interest: none declared
- Grines CL, Casey DE Jr, Gardner TJ, Lockhart PB, Moliterno DJ, Bonow RO. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians. Circulation 2007;115:813-8 .
- Therapeutic guidelines:oral and dental. Version 2. Melbourne: Therapeutic Guidelines Limited; 2012. p. 138-40 .