How soon should I stop taking anticoagulants (blood thinners) before dental work?

Management of Blood Thinners Before Dental Work

For most dental procedures, you should continue your blood thinner without interruption, especially when using local hemostatic measures like tranexamic acid mouthwash. 1

Recommendations Based on Type of Blood Thinner

Vitamin K Antagonists (e.g., Warfarin)

• Continue warfarin for minor dental procedures (single or multiple tooth extractions, root canals) 1
• Use pro-hemostatic agents (tranexamic acid mouthwash) before and after the procedure 1
• Maintain INR ≤3.5 on the day of extraction for safe dental procedures 2

Direct Oral Anticoagulants (DOACs)

For minor dental procedures with low bleeding risk:

• Last dose should be taken the day before the procedure 1
  • For twice daily regimen: Take morning dose the day before procedure
  • For once daily morning regimen: Take dose the morning before procedure
  • For once daily evening regimen: Take dose two evenings before procedure

Procedure-Specific Guidance

Low Bleeding Risk Dental Procedures

• Single tooth extractions
• Simple dental cleaning
• Minor dental procedures
• Recommendation: Continue anticoagulation 1, 3
• Resume DOAC at least 6 hours after procedure if no bleeding complications 1

Higher Bleeding Risk Dental Procedures

• Multiple tooth extractions
• Procedures in patients with poor gingival health
• Recommendation: Consider partial interruption (2-3 days before) for warfarin 1
• For DOACs in high-risk procedures:
  • Rivaroxaban/apixaban/edoxaban: Stop 3 days before procedure 1
  • Dabigatran: Stop 4 days before if CrCl >50 mL/min; 5 days if CrCl 30-50 mL/min 1

Local Hemostatic Measures

• Tranexamic acid mouthwash (5% solution, 10mL)
  • Use just before procedure
  • Continue 2-3 times daily for 1-2 days after procedure 1
• Additional measures:
  • Extra sutures
  • Local pressure
  • Gauze soaked in tranexamic acid 1

Important Considerations

Risk Assessment

• Bleeding risk is typically low (approximately 5%) when continuing anticoagulants for dental procedures 1
• Most bleeding is self-limiting and manageable with local measures 1, 4
• Thromboembolic risk from stopping anticoagulants (0.95%) is approximately three times higher than bleeding risk when continuing therapeutic anticoagulation 4

Common Pitfalls to Avoid

1. Unnecessary discontinuation of anticoagulants increases thromboembolic risk 4, 5
2. Bridging with heparin is not recommended for routine dental procedures and may increase bleeding risk 1, 6
3. Over-concern about minor bleeding - most post-dental bleeding is manageable with local measures 1, 2

Special Situations

• For patients at very high thromboembolic risk (mechanical heart valves, recent stroke/TIA within 3 months), consult with the prescribing physician before any modification 7
• For emergency dental procedures, laboratory testing of anticoagulant levels may be needed 3

Remember that continuing anticoagulation therapy during dental procedures has been shown to be safe in multiple studies, and the risk of thromboembolic events from discontinuation typically outweighs the risk of significant bleeding 4, 5.