A common question from patients and dentists is whether warfarin needs to be interrupted at times of dental procedures, such as cleaning or pulling of teeth or root canals. Medical publications and recommendations from the dental community outlining best management of patients on warfarin exist (ref 1-6). However, even though evidence suggests that stopping warfarin for low-risk dental procedures is not necessary, many dentists are hesitant to perform dental procedures if the patient is on warfarin.
Communication between the health care provider dealing with the patient’s warfarin management and the dentist is important to make a solid decision whether warfarin needs to be discontinued or not. This table (blog#3 table) (from ref 4) can be helpful in the communication process.
A study just published shows that many dental procedures can be safely done on warfarin. This was a large multicenter study to assess how often bleeding complications occur after dental extractions if patients remain on warfarin. 451patients on warfarin who required dental extractions were compared with a control group of 449 individuals not on warfarin also needing dental extractions. In the warfarin-treated group, warfarin therapy was continued unchanged, such that the patients had an INR (International Normalized Ratio) between 1.8 and 4.0 at the time of the dental procedure. Local measures were used to minimize bleeding at the time of extraction (i.e. fibrin sponges, silk sutures and gauzes saturated with tranexamic acid). Seven bleeding complications occurred in the warfarin group and four in the control group; the difference in the number of bleeding events between the two groups was not statistically significant. No post-operative late bleeds requiring hospitalization and/or blood transfusions were recorded.
The authors of the study conclude, that “dental extractions can be performed easily and safely in patients on warfarin without any modification of the ongoing warfarin therapy”.
Several medical guidelines from respect medical bodies exist:
- American College of Chest Physician (ACCP) guidelines (ref 2): In the patient undergoing minor dental procedures (single and multiple tooth extractions and root canal procedures) we recommend continuing warfarin therapy around the time of the procedure. It is reasonable to give oral (local) prohemostatic agents.
- British Committee for Standards in Haematology (BCSH) guideline (ref 3): The risk of significant bleeding in patients on oral anticoagulants and with a stable international normalized ratio (INR) in the therapeutic range 2-4 (i.e., <4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extraction”.
The study confirms what has been observed over the last few years: that many dental procedures can be safely done on warfarin. Warfarin interruption for dental cleaning, pulling of one or several teeth, or root canals is typically not needed. However, good local measures by the dentist (such as fibrin sponges, silk sutures and gauzes saturated with tranexamic acid) to minimize bleeding risk are prudent.
- Bacci C et al. Management of dental extraction in patients undergoing anticoagulant therapy. Thrombosis and Haemostasis 2010;104:972-975.
- Douketis J et al. Ther perioperative management of antithrombotic therapy. Chest 2008;133:299-399S.
- http://www.guidelines.gov/content.aspx?id=11998 - Perry DJ et al. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. British Committee for Standards in Haematology; 2007.
- Herman WW et al. Current perspectives on dental patients receiving coumarin anticoagulant therapy. Journal of the American Dental Association. 1997;128:327-335.
- Aframian DJ et al. Management of dental patients taking conmon hemostasis-altering medications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103(suppl 1):S45.e1-S34.e11).
- Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. Journal of the American Dental Association. 2000;131:77-81.
Disclosure: I have no financial conflict of interest relevant to this blog entry.
Last updated: June 22nd, 2011