Dental Extraction in Patients on Acitrom (Acenocoumarol)
Continue acenocoumarol without interruption and perform the dental extraction using local hemostatic measures 1.
Pre-Procedure Assessment
Check the INR within 24-72 hours before the procedure to ensure it is within therapeutic range (typically 2.0-3.0). Do not stop the acenocoumarol 1, 2. The 2022 CHEST guidelines specifically recommend continuing vitamin K antagonists (VKAs) like acenocoumarol for dental procedures rather than interrupting therapy, as the bleeding risk is low and manageable with local measures, while stopping anticoagulation increases thromboembolic risk 1.
Key Laboratory Requirements:
- INR should be ≤3.0-4.0 for safe extraction 2, 3
- If INR is within therapeutic range, proceed with extraction
- No need for heparin bridging or other anticoagulant adjustments
Intra-Procedure Hemostatic Protocol
Apply local hemostatic measures at the extraction site 1, 2, 3:
- Gelatin sponge placement in the socket
- Suturing the extraction site (silk sutures are effective)
- Tranexamic acid mouthwash (10 mL of 5% solution):
- Give immediately before the procedure
- Continue 2-3 times daily for 1-2 days post-procedure 1
- Alternative: Fibrin glue or other topical hemostatic agents 3, 4
The evidence shows that simple measures like gelatin sponge and sutures alone are sufficient in most cases 3. Multiple studies demonstrate that continuing VKAs with local hemostatic measures results in only ~5-8.6% minor bleeding complications, all self-limiting and manageable without hospitalization 2, 3.
Post-Procedure Management
- Gauze soaked in tranexamic acid for immediate post-extraction compression
- Continue tranexamic acid mouthwash for 1-2 days
- Patient should avoid vigorous rinsing for 24 hours
- Do not alter acenocoumarol dosing post-procedure
Important Caveats
Risk stratification matters: The bleeding risk increases with:
- Multiple tooth extractions (vs. single tooth)
- Poor gingival health
- Complex surgical extractions
For high-risk scenarios (multiple extractions, extensive surgery), consider partial VKA interruption for 2-3 days pre-procedure as an alternative, though this is generally not necessary for routine single extractions 1.
What NOT to Do
- Do not stop acenocoumarol for 5-6 days pre-procedure (outdated practice that increases thrombotic risk)
- Do not use heparin bridging for dental extractions (unnecessary and increases bleeding risk)
- Do not proceed if INR >4.0 without medical consultation
Evidence Quality Note
The 2022 CHEST perioperative guidelines 1 represent the highest quality evidence, synthesizing multiple randomized trials and meta-analyses. These guidelines supersede older practices of routine VKA interruption. Studies consistently show that VKA continuation with local measures results in <5% minor bleeding, with zero major bleeding events or thromboembolic complications 2, 3.
The fitness clearance should state: "Patient cleared for dental extraction while continuing acenocoumarol. Recent INR [value] on [date] is within therapeutic range. Recommend local hemostatic measures including sutures, gelatin sponge, and tranexamic acid mouthwash."