What is the next best step for a patient with an aortic valve replacement on warfarin (anticoagulant) who needs a tooth extraction after breaking a tooth?

Management of Tooth Extraction in a Patient with Aortic Valve Replacement on Warfarin

For a patient with an aortic valve replacement on warfarin who requires tooth extraction due to a broken tooth, the tooth extraction can safely proceed without discontinuation of warfarin therapy as long as the INR is within therapeutic range (≤3.5). 1

Rationale for Continuing Warfarin During Dental Procedures

Evidence Supporting Continued Anticoagulation

• Simple dental extractions can be safely performed in patients on warfarin without discontinuation of therapy, provided that:

  • The INR is ≤3.5 on the day of extraction 1
  • Local hemostatic measures are available
  • Close follow-up is arranged

• Discontinuing warfarin for dental procedures in patients with mechanical heart valves creates unnecessary thromboembolic risk 2

• Research shows that continuing warfarin during tooth extraction results in only mild to moderate bleeding that can be managed with local measures 1, 3

Pre-Extraction Protocol

1. Check INR on the day of extraction

   • Ensure INR is within therapeutic range (2.0-3.5)
   • If INR >3.5, postpone extraction until INR is appropriately adjusted

2. Risk assessment

   • Mechanical aortic valve replacement patients are at high thrombotic risk if anticoagulation is interrupted 4
   • Simple tooth extraction is considered a low bleeding risk procedure 4

3. Preparation for procedure

   • Arrange for local hemostatic measures to be available
   • Consider tranexamic acid mouthwash for local application 4

Procedural Considerations

1. Local hemostatic measures

   • Use of absorbable gelatin or collagen sponges
   • Suturing of extraction site
   • Application of tranexamic acid mouthwash
   • Pressure application with gauze

2. Monitoring during procedure

   • Be prepared to address any immediate bleeding complications
   • Most bleeding is mild (oozing) and self-limiting 1

Post-Extraction Management

1. Immediate post-extraction care

   • Provide clear instructions on managing minor bleeding
   • Apply pressure with gauze for 30 minutes
   • Avoid rinsing, spitting, or using straws for 24 hours

2. Follow-up

   • Arrange for follow-up within 24-48 hours
   • Provide emergency contact information for bleeding complications
   • Instruct patient to return if bleeding persists despite pressure application

Potential Complications and Management

1. Bleeding complications

   • Mild bleeding (oozing) occurs in approximately 88.6% of cases but doesn't require intervention 1
   • Moderate bleeding requiring local measures occurs in about 11.4% of cases 1
   • Severe bleeding requiring hospitalization is rare when INR is ≤3.5 1

2. Management of post-extraction bleeding

   • Local pressure application
   • Additional suturing if needed
   • Application of hemostatic agents
   • Tranexamic acid mouthwash

Antibiotic Prophylaxis Considerations

• Patients with prosthetic heart valves require antibiotic prophylaxis for dental procedures per AHA/ACC guidelines 4
• Optimal dental hygiene and antibiotic prophylaxis are essential components of long-term management of patients with prosthetic valves 4

Conclusion

The evidence strongly supports continuing warfarin therapy for patients with aortic valve replacements undergoing tooth extraction, as the risk of thromboembolic events from discontinuing anticoagulation outweighs the risk of bleeding complications, which can be effectively managed with local measures. The key is ensuring the INR is within therapeutic range (≤3.5) and having appropriate local hemostatic measures available.