Should anticoagulation be held for teeth extraction?

Management of Anticoagulation for Dental Extractions

For most patients undergoing dental extractions, anticoagulation should be continued without interruption, with appropriate local hemostatic measures used to control bleeding.

Risk Assessment and Decision Framework

Procedure Risk Classification

• Dental extractions are classified as minimal bleeding risk procedures 1, 2
• Single tooth extractions typically have lower bleeding risk than multiple extractions 1
• Root canal procedures are generally less hemorrhagic than extractions 2

Patient Risk Stratification

High Thromboembolism Risk

• Mechanical heart valves (especially older generation)
• Atrial fibrillation with recent stroke/TIA (<3 months)
• Recent VTE (<3 months)
• CHA₂DS₂-VASc score ≥7 or CHADS₂ score of 5-6 1

Low-to-Moderate Thromboembolism Risk

• Bileaflet mechanical AVR without other risk factors
• Atrial fibrillation without recent stroke/TIA
• VTE >3 months ago 1

Management Recommendations by Anticoagulant Type

Vitamin K Antagonists (e.g., Warfarin)

1. Continue VKA therapy at therapeutic levels (INR 2.0-3.0) during dental extractions 1, 2
2. Use local hemostatic measures including:
   • Tranexamic acid mouthwash (5-10 mL of 5% solution before procedure and 2-3 times daily for 1-2 days after) 1, 2
   • Local pressure, extra sutures, absorbable gelatin sponges, oxidized cellulose 2
3. Verify INR within 24 hours before the procedure 2
4. For INR >4: Consider delaying procedure until INR is within therapeutic range 2

Direct Oral Anticoagulants (DOACs)

1. Continue DOACs for dental extractions 1
2. No bridging with LMWH is recommended when temporarily stopping DOACs 1
3. For high bleeding risk dental procedures (multiple extractions with poor gingival health):
   • Consider taking the last DOAC dose the morning of the day before the procedure 1
   • Resume DOAC 24 hours after procedure if adequate hemostasis is achieved 1

Evidence Supporting Continuation of Anticoagulation

1. No significant difference in bleeding risk between patients continuing vs. discontinuing oral anticoagulant therapy during dental extractions (risk ratio 1.31; 95% CI 0.79-2.14) 3
2. Multiple randomized trials show no significant increase in clinically important bleeding when warfarin is continued 1, 2
3. Risk of thromboembolism from discontinuing anticoagulation outweighs the minimal bleeding risk that can be controlled with local measures 4
4. Self-limiting bleeding occurs in approximately 5% of cases, which can be easily managed with local measures 1, 2

Special Considerations

Patients with Very High Bleeding Risk

• For patients with multiple extractions or poor gingival health, partial interruption of warfarin for 2-3 days before the procedure (resulting in INR of 1.6-1.9) is an alternative approach 1, 2

Patients with Impaired Renal Function

• Use caution with DOACs and LMWH due to risk of accumulation and prolonged anticoagulant effect 5
• Avoid bridging with LMWH in these patients 5

Post-Procedure Care

1. Apply local pressure to control minor oozing
2. Continue tranexamic acid mouthwash 2-3 times daily for 1-2 days
3. Avoid hot foods/drinks for 24 hours 2
4. Monitor for delayed bleeding up to 7 days post-procedure 3

Common Pitfalls to Avoid

1. Unnecessary bridging with LMWH when stopping anticoagulation, which increases bleeding risk 1, 5
2. Failure to use local hemostatic measures like tranexamic acid mouthwash 2
3. Poor communication between healthcare providers regarding anticoagulation management plan 2
4. Stopping anticoagulation unnecessarily, which increases thromboembolism risk 4

By following these evidence-based recommendations, dental extractions can be performed safely in anticoagulated patients while minimizing both bleeding and thromboembolism risks.