Should rivaroxaban (Xarelto) be stopped before a dental extraction?

Rivaroxaban Management for Dental Extraction

For simple dental extractions (1-3 teeth), rivaroxaban should NOT be stopped—continue the medication and perform the procedure with local hemostatic measures. 1

Evidence-Based Approach

For Low-Risk Dental Procedures (Simple Extractions)

Continue rivaroxaban without interruption for routine dental extractions involving 1-3 teeth. 1 The 2018 European Heart Rhythm Association guidelines explicitly classify dental extractions of 1-3 teeth as "minor bleeding risk" procedures that can be performed safely without stopping direct oral anticoagulants. 1

• Apply local hemostatic measures including tranexamic acid mouthwash (10 mL of 5% solution before procedure and 2-3 times daily for 1-2 days post-procedure), fibrin glue, topical hemostatic agents, and sutures. 1
• The American College of Chest Physicians found no significant increase in bleeding when continuing anticoagulation for minor dental procedures, with bleeding rates remaining low (approximately 5%) and self-limiting. 1
• Avoid NSAIDs in the perioperative period to minimize bleeding risk. 1

For Higher-Risk Dental Procedures (Multiple Extractions, Surgical Extractions)

If the procedure involves more than 3 teeth or surgical extractions, consider a modified approach:

• Skip only the morning dose on the day of the procedure (if taken once daily in morning, or skip the dose 12-24 hours before if taken in evening). 2, 3
• The FDA label states rivaroxaban should be stopped at least 24 hours before procedures to reduce bleeding risk when interruption is deemed necessary. 2
• Resume rivaroxaban as soon as adequate hemostasis is established post-procedure, noting the rapid onset of therapeutic effect (2-4 hours). 2, 4

Critical Timing Considerations

Rivaroxaban has a half-life of 7-11 hours (11-13 hours in elderly), with peak effect at 2-4 hours after dosing. 4 This pharmacokinetic profile supports:

• 24-hour interruption provides approximately 2-3 half-lives of clearance, reducing anticoagulant effect to approximately 25% of peak. 1
• For patients with renal impairment (CrCl 30-50 mL/min), consider extending interruption to 48 hours, as one-third of rivaroxaban is renally eliminated. 1, 4

What NOT to Do

Do NOT use bridging anticoagulation with heparin or low-molecular-weight heparin during rivaroxaban interruption for dental procedures. 5, 6 The American College of Cardiology explicitly recommends against bridging, as it increases hemorrhagic risk without reducing thrombotic events. 5

Post-Procedure Bleeding Management

• Early bleeding (within 24 hours) occurs at similar rates whether anticoagulation is continued or interrupted. 3
• Delayed bleeding (days 1-7) occurs more frequently in anticoagulated patients compared to controls. 3
• Patients should be counseled about increased delayed bleeding risk and provided with clear instructions for managing post-extraction oozing with local measures (gauze pressure, tranexamic acid rinses). 3

Special Populations

For pediatric patients on rivaroxaban, the 2025 ASH/ISTH guidelines recommend pausing treatment 24 hours before low-risk bleeding procedures, though this is extrapolated from adult data. 1