What are the recommendations for holding warfarin (anticoagulant) before dental procedures?

Management of Warfarin for Dental Procedures

For most routine dental procedures, warfarin therapy should be continued without interruption, with appropriate local hemostatic measures used to control bleeding. 1, 2

Risk Stratification Approach

Low-Risk Dental Procedures

• Continue warfarin therapy without dose modification for routine dental procedures such as simple tooth extractions 1
• Check INR during the week before the procedure to ensure it is within therapeutic range (ideally ≤3.5) 1, 3
• If INR is within therapeutic range, continue with usual daily dose 4, 5
• If INR is above therapeutic range but <5, reduce daily warfarin dose until INR returns to therapeutic range 4, 5
• If INR >5, defer the procedure and contact the anticoagulation clinic for advice 4

High-Risk Dental Procedures

• For extensive oral surgery with higher bleeding risk in patients with low thrombotic risk, consider discontinuing warfarin 5 days before the procedure 6, 5
• Check INR prior to the procedure to ensure it is <1.5 6, 5
• Restart warfarin with usual daily dose on the evening of the procedure 6, 5
• Check INR one week later to ensure adequate anticoagulation 4, 5

High-Risk Dental Procedures in High Thrombotic Risk Patients

• For patients at high risk of thromboembolism (e.g., recent thromboembolic event <3 months), warfarin should be temporarily discontinued and substituted with LMWH 6, 5
• Stop warfarin 5 days before the procedure 4, 5
• Two days after stopping warfarin, commence daily therapeutic dose of LMWH 4, 5
• Administer the last dose of LMWH at least 24 hours prior to the procedure 4, 5
• Check INR prior to the procedure to ensure it is <1.5 4, 5
• Resume warfarin on the day of the procedure with usual daily dose 4, 5
• Restart LMWH the day after the procedure and continue until a satisfactory INR is achieved 4, 5

Evidence Supporting Continued Warfarin

• Research shows that simple tooth extraction in patients on warfarin can be performed safely without high risk of bleeding when INR is ≤3.5 3
• A randomized controlled trial found no significant difference in clinically important bleeding between patients who continued versus stopped warfarin for dental extractions 7
• Meta-analysis confirms that continuing regular warfarin dose does not confer increased risk of bleeding compared to discontinuing or modifying the dose for minor dental procedures 8
• The risk of thromboembolic events from interrupting anticoagulation typically outweighs the risk of bleeding during dental procedures 1

Local Hemostatic Measures

• For all patients on warfarin, advise that there is an increased risk of post-procedure bleeding compared to non-anticoagulated patients 4
• Use local hemostatic measures including:
  • Packing with hemostatic dressing 9
  • Suturing 9
  • Application of local pressure 9
  • 4.8% tranexamic acid mouthwash for 2 days post-procedure (beneficial after oral surgical procedures) 2

Common Pitfalls and Caveats

• Discontinuing warfarin for simple dental procedures can lead to unnecessary risk of thromboembolic events 1, 2
• Even with continued warfarin therapy, moderate bleeding may occur in approximately 11-26% of cases, but this is typically manageable with local measures 3, 7
• Patients with INR >3.5 may have higher risk of bleeding complications and should be evaluated on a case-by-case basis 3, 2
• Close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction 3
• When warfarin must be discontinued, minimize the time off the medication to reduce thrombotic risk 6

By following this algorithmic approach based on procedure risk and patient thrombotic risk, dental procedures can be performed safely while minimizing both bleeding and thrombotic complications.