Do I need to bridge warfarin (anticoagulant) for dental surgery?

From the Guidelines

You do not need to bridge warfarin for routine dental procedures, including extractions, as long as your INR is within the therapeutic range. In most cases, it's recommended to continue your regular warfarin dosage while maintaining your INR in the therapeutic range of 2.0-3.0 for most conditions or 2.5-3.5 for mechanical heart valves 1. Before your dental procedure, you should have your INR checked within 24-72 hours to ensure it's within the appropriate range. For minor bleeding control during and after the procedure, local measures such as pressure, sutures, gelatin sponges, or tranexamic acid mouthwash may be used 1. The risks of thromboembolic events from interrupting warfarin therapy typically outweigh the risks of bleeding during dental procedures when the INR is in the therapeutic range. However, for extensive oral surgeries or if you have additional bleeding risk factors, your healthcare provider and dentist should collaborate on an individualized plan. Some key points to consider include:

• The type of dental procedure: minor procedures such as tooth extractions, endodontic, and minor reconstructive procedures can usually be done without interrupting warfarin therapy 1.
• The patient's thromboembolic risk: patients with mechanical heart valves or other high-risk conditions may require more careful management 1.
• The use of local hemostatic measures: tranexamic acid mouthwash or other local measures can be used to control minor bleeding during and after the procedure 1. Always inform your dentist about your warfarin use and consult with the physician who manages your anticoagulation before any dental procedure.

From the FDA Drug Label

The management of patients who undergo dental and surgical procedures requires close liaison between attending physicians, surgeons and dentists. PT/INR determination is recommended just prior to any dental or surgical procedure. In patients undergoing minimal invasive procedures who must be anticoagulated prior to, during, or immediately following these procedures, adjusting the dosage of warfarin sodium tablets to maintain the PT/INR at the low end of the therapeutic range may safely allow for continued anticoagulation Some dental or surgical procedures may necessitate the interruption of warfarin sodium tablets therapy When discontinuing warfarin sodium tablets even for a short period of time, the benefits and risks should be strongly considered.

The decision to bridge warfarin for dental surgery depends on the type of procedure and the patient's individual risk factors.

• For minimal invasive procedures, adjusting the warfarin dosage to maintain the PT/INR at the low end of the therapeutic range may be sufficient.
• For other procedures, warfarin therapy may need to be interrupted, and the benefits and risks of doing so should be carefully considered 2. Bridging with another anticoagulant may be necessary in some cases, but this is not explicitly stated in the label.

From the Research

Warfarin Management for Dental Surgery

• The need to bridge warfarin for dental surgery is a topic of ongoing debate, with various studies providing insights into the risks and benefits of continuing or discontinuing warfarin therapy during dental procedures 3, 4, 5, 6, 7.
• A randomized controlled trial published in 2002 found that continuing warfarin during dental extractions may lead to an increase in minor post-extraction bleeding, but no significant increase in clinically important bleeding was observed 3.
• Another study published in 2011 compared the effects of warfarin and heparin on bleeding caused by dental extraction and found that dental extraction in patients receiving warfarin with an international normalized ratio (INR) from 1 to 4 could be carried out without a significant risk of bleeding and without altering the anticoagulant regimen 4.
• A systematic review published in 2007 provided evidence-based recommendations for the management of dental patients taking common hemostasis-altering medications, including warfarin, and suggested that warfarin therapy need not be modified or discontinued for simple dental extractions in patients with an INR below or equal to 3.5 5.
• A study published in 2020 found that warfarin use does not increase the risk of post-extraction bleeding and can therefore be continued during tooth extraction 6.
• Additionally, a study published in 2009 demonstrated that implantation of cardiac rhythm devices without interruption of oral anticoagulation compared with perioperative bridging with low-molecular weight heparin is a safe and effective approach, with a lower risk of significant pocket hematoma 7.

Key Considerations

• The decision to bridge warfarin for dental surgery should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type of dental procedure being performed 3, 4, 5, 6, 7.
• The use of local hemostatic agents and careful monitoring of the patient's INR and bleeding status can help minimize the risk of bleeding complications during dental surgery 4, 5.
• Patients with an INR greater than 3.5 may require dose adjustment or alternative anticoagulation strategies to minimize the risk of bleeding complications 5.