Do I need to hold my blood thinner (anticoagulant) for a tooth extraction?

Management of Blood Thinners During Tooth Extraction

Blood thinners should NOT be discontinued for tooth extractions, as the risk of thromboembolism from discontinuation outweighs the minimal bleeding risk that can be effectively managed with local hemostatic measures. 1, 2

Evidence-Based Recommendations

For Patients on Warfarin:

• Continue warfarin therapy without interruption for dental extractions 2, 1
• Ensure INR is within therapeutic range (2.0-3.0) 1, 3
• For most dental extractions, an INR ≤3.5 is considered safe 4
• Use local hemostatic measures to control bleeding 2, 1

For Patients on Direct Oral Anticoagulants (DOACs):

• Continue DOAC therapy without interruption 1
• Consider timing the extraction at least 6-7 hours after the last DOAC dose to minimize bleeding risk 5

Local Hemostatic Measures

• Tranexamic acid mouthwash (5 mL, 5% solution) used before procedure and 2-3 times daily for 1-2 days after 2
• Absorbable gelatin sponge placement 2
• Suturing of extraction site 2, 1
• Local pressure application 1

Risk Assessment

Bleeding Risk

• Multiple studies show minimal risk of significant bleeding when continuing anticoagulants 6, 4, 7
• Most bleeding is mild (oozing) and can be managed with local measures 4
• Meta-analyses show no significant difference in bleeding risk between patients who continue vs. discontinue anticoagulants (risk ratio 1.31; 95% CI 0.79-2.14) 6

Thrombotic Risk

• Discontinuing anticoagulants increases risk of serious thromboembolic complications 7, 2
• Patients with mechanical heart valves, recent coronary stents, or high CHADS2 scores are at particularly high risk 1

Special Considerations

• For patients with multiple tooth extractions or poor gingival health, additional local hemostatic measures may be needed, but anticoagulation should still be continued 2
• For patients on dual antiplatelet therapy, both medications should be continued, with emphasis on local hemostatic measures 1, 8

Common Pitfalls to Avoid

• Discontinuing anticoagulants unnecessarily, which increases thromboembolism risk 2, 7
• Failing to distinguish between antiplatelet agents and anticoagulants 1
• Not using appropriate local hemostatic measures 2, 1
• Recommending NSAIDs for post-procedure pain in patients taking antiplatelet medications 1

The evidence strongly supports continuing blood thinners during tooth extractions, with appropriate local hemostatic measures to control bleeding. This approach minimizes the risk of serious thromboembolic events while maintaining a manageable bleeding risk.