Pharmacology · patient case question
What is the appropriate management of his dual antiplatelet therapy for this extraction?
Patient case: Medication review before an extraction
Patient: Male, 66 years old
Chief complaint: “This broken tooth needs to come out.”
History: Coronary stent placed two years ago; on aspirin 81 mg and clopidogrel. Seasonal allergic rhinitis, takes cetirizine. Generalised anxiety, takes buspirone.
Findings: Non-restorable tooth #30. No swelling. Blood pressure 128/78 mmHg.
Show answer and explanation
Correct answer: C. Proceed with no modification to either drug
- A. Stopping both drugs compounds the same error. Any decision to alter antiplatelet therapy belongs to the prescribing cardiologist, not the dentist, and is reserved for major surgery.
- B. A coronary stent is not an indication for antibiotic prophylaxis under AHA guidelines. Prophylaxis covers prosthetic valves, previous endocarditis, specified congenital heart disease and transplant valvulopathy.
- C. CORRECT. Dual antiplatelet therapy is NOT interrupted for routine dental extractions. The bleeding is minor, predictable and controllable with local measures — pressure, sutures, oxidised cellulose or gelatin sponge, and tranexamic acid mouthwash if needed. Interrupting therapy in a patient with a coronary stent risks STENT THROMBOSIS, which carries substantial mortality. The risk calculus is not close.
- D. Stopping clopidogrel for five days would restore platelet function but exposes the patient to a catastrophic thrombotic risk for a problem that local haemostasis handles.
Note: Plan for local haemostasis in advance rather than reacting to bleeding. Schedule earlier in the day and earlier in the week so any problem can be reviewed.