When to hold warfarin (anticoagulant) for dental procedures?

Management of Warfarin for Dental Procedures

For minor dental procedures, warfarin therapy should be continued without interruption as this approach does not significantly increase bleeding risk compared to discontinuing or modifying the warfarin dose. 1

Risk Stratification Approach

Low Bleeding Risk Procedures (Most Dental Procedures)

• Continue warfarin therapy at the regular dose without interruption 1
• Check INR prior to the procedure to ensure it is within therapeutic range (ideally 2.0-3.0) 2
• Consider using local hemostatic measures such as tranexamic acid mouthwash if available 3

High Bleeding Risk Dental Procedures

• For more extensive dental surgery with higher bleeding risk, consider temporary warfarin dose adjustment rather than complete discontinuation 4
• If interruption is deemed necessary, stop warfarin 5 days before the procedure 5
• Check INR prior to the procedure to ensure it is <1.5 5
• Resume warfarin 12-24 hours after the procedure when adequate hemostasis is achieved 4

Patient Risk Stratification for Thromboembolic Events

High Thromboembolic Risk Patients

• Patients with mechanical heart valves (especially older caged ball or caged disc valves) 2
• Recent thromboembolic event (<3 months) 5
• Atrial fibrillation with previous stroke history 2
• Management: If warfarin must be interrupted, consider bridging with therapeutic-dose LMWH starting 2 days after stopping warfarin, with the last dose given at least 24 hours before the procedure 5

Low Thromboembolic Risk Patients

• Atrial fibrillation without history of stroke 2
• Venous thromboembolism >3 months ago 5
• Bileaflet mechanical heart valve in aortic position 2
• Management: Brief interruption of warfarin therapy (≤5 days) without bridging is associated with a low risk of thromboembolism (0.7%) 6

Evidence-Based Recommendations

• Studies show that continuing warfarin therapy during minor dental procedures does not significantly increase the risk of clinically significant bleeding (RR 0.71; 95% CI 0.39-1.28) 1
• If warfarin must be temporarily discontinued, a 2-day suspension results in a mean decrease in INR by approximately 1.0 unit, with most patients returning to therapeutic range within 7 days after resumption 3
• The calculated average time spent at subtherapeutic INR (below 2.0) with a 2-day suspension is approximately 28 hours, minimizing thromboembolic risk 3

Common Pitfalls to Avoid

• Unnecessary discontinuation of warfarin for minor dental procedures, which increases thromboembolic risk without significantly reducing bleeding risk 1, 7
• Inappropriate use of bridging therapy with LMWH for low-risk patients undergoing minor dental procedures, which increases costs and may increase bleeding risk without providing significant benefit 7
• Failing to check INR before the procedure to confirm it is within an acceptable range 5
• Not coordinating care between the dentist and the physician managing the patient's anticoagulation 8

Practical Approach

1. Assess the bleeding risk of the specific dental procedure
2. Evaluate the patient's thromboembolic risk
3. For most routine dental procedures, maintain regular warfarin dosing
4. Use local hemostatic measures as needed
5. Only consider warfarin interruption for extensive oral surgery with high bleeding risk
6. If interruption is necessary, minimize the time off warfarin and consider bridging only for high thromboembolic risk patients