Antiplatelet drugs

Refer to Section 8 of the full guidance.

Key recommendations:

For a patient who is taking single or dual antiplatelet drugs, treat without interrupting their antiplatelet medication.
(Strong recommendation; low certainty evidence) [unchanged 2022]

This recommendation is based on the available evidence and extensive clinical experience. The risk of post-operative bleeding is likely to be higher for dental patients on dual antiplatelet therapy than for those on single antiplatelet therapy or none. However, the reported incidence of bleeding complications is low with events controllable using local haemostatic measures.

This is considered a strong recommendation because of emphasis placed on the potential risk of a serious adverse thromboembolic event if antiplatelet treatment is interrupted.

For dental treatment that is likely to cause bleeding, with either a low or higher risk of bleeding complications (see Bleeding risks for dental procedures):

  • Treat the patient according to the general advice for managing bleeding risk, without interrupting their antiplatelet medication.

In addition:

If the patient is taking aspirin alone

  • Consider limiting the initial treatment area (e.g. perform a single extraction or limit root surface debridement to 3 teeth, then assess bleeding before continuing).
  • For procedures with a higher risk of post-operative bleeding complications (see Bleeding risks for dental procedures), consider carrying out the treatments in a staged manner, where possible, over separate visits.
  • Use local haemostatic measures to achieve haemostasis.

If the patient is taking another single antiplatelet drug or dual antiplatelet drugs

  • Be aware that bleeding may be prolonged (up to an hour). This should be taken into account when planning treatment time.
  • Limit the initial treatment area (e.g. perform a single extraction or limit root surface debridement to 3 teeth, then assess bleeding before continuing).
  • For procedures with a higher risk of post-operative bleeding complications (see Bleeding risks for dental procedures), consider carrying out the treatments in a staged manner, where possible, over separate visits.
  • Use local haemostatic measures to achieve haemostasis. Strongly consider suturing and packing, taking into account all relevant patient factors (see Haemostatic measures).

Patients taking antiplatelet medications tend to have prolonged bleeding times. This should be taken into consideration when planning dental treatments likely to cause bleeding, to ensure that sufficient time is available to achieve and monitor haemostasis.

Patients on dual antiplatelet therapies may have a higher risk of prolonged bleeding compared to those on a single antiplatelet drug and should be managed accordingly.

  • The most commonly encountered antiplatelet combination is aspirin with clopidogrel (for acute coronary syndrome)
  • Dipyridamole with aspirin after a stroke or transient ischaemic attack (TIA) is less commonly prescribed, as clopidogrel monotherapy is considered to be more effective and better tolerated
  • The newer antiplatelet drugs prasugrel (Efient) and ticagrelor (Brilique) are only prescribed in combination with aspirin and are currently only licensed for patients with acute coronary syndrome. Although evidence relating to bleeding risks with prasugrel and ticagrelor in the context of dental procedures is very limited, the risk of surgical bleeding complications is considered to be higher for prasugrel or ticagrelor compared to clopidogrel

Discontinuation of single or dual antiplatelet therapy has been associated with an increased risk of adverse thromboembolic events. Patients with a coronary artery stent will be prescribed dual antiplatelet therapy for up to 12 months. It is extremely important that this treatment is not stopped prematurely or interrupted without prior discussion and written advice from the patient’s cardiologist because of the risk of major adverse cardiac events.