What medications need to be held before dental extraction?

Medications to Hold Before Dental Extraction

For most patients undergoing dental extraction, vitamin K antagonists (warfarin) should be continued with the addition of local pro-hemostatic agents like tranexamic acid mouthwash, rather than being discontinued. 1

Anticoagulants

Vitamin K Antagonists (Warfarin)

• Continue warfarin without interruption for dental extractions when INR is in therapeutic range (typically <4.0), using local hemostatic measures instead of drug discontinuation 1
• Co-administer tranexamic acid mouthwash (10 mL of 5% solution) immediately before the procedure and 2-3 times daily for 1-2 days post-procedure 1
• Additional local measures include extra sutures, gauze soaked in tranexamic acid, and topical hemostatic agents 1
• Exception: Consider interrupting warfarin for 2-3 days (partial interruption) only when multiple tooth extractions are planned or in patients with poor gingival health where considerable bleeding is expected 1
• Never use heparin bridging - this significantly increases bleeding risk without reducing thromboembolic events 1

Direct Oral Anticoagulants (DOACs/NOACs)

For rivaroxaban, apixaban, dabigatran, and edoxaban:

• Hold for 2-3 days before extraction in patients with normal renal function (CrCl >30 mL/min) 1
• Specific timing by regimen 1:
  • Twice-daily dosing: Last dose on the morning of the day before the procedure
  • Once-daily morning dosing: Last dose on the morning of the day before the procedure
  • Once-daily evening dosing: Last dose two days before the procedure
• Extended interruption for renal impairment: Add 24 hours for each 50% reduction in creatinine clearance, especially critical for dabigatran 1
• No bridging with heparin - this increases bleeding without benefit 1
• Resume at least 6 hours post-procedure if no active bleeding and adequate hemostasis achieved 1

Antiplatelet Agents

Aspirin and Clopidogrel

• Continue aspirin and clopidogrel without interruption for dental extractions 2, 3
• Use appropriate local hemostatic measures (gelatin sponge, suturing) to control bleeding 2
• Discontinuation increases thrombotic risk without meaningful reduction in bleeding complications 2, 3

Dietary Supplements (High-Risk for Bleeding)

Hold the following supplements 2 weeks before extraction 1:

• Garlic - inhibits platelet aggregation 1
• Ginkgo biloba - antiplatelet effects 1
• Ginseng - antiplatelet activity 1
• Fish oil/Omega-3 fatty acids - antiplatelet effects 1
• Vitamin E (high doses) - antiplatelet activity 1
• Saw palmetto - may increase bleeding risk 1
• Feverfew - inhibits platelet aggregation 1
• Dong quai - anticoagulant properties 1
• Horse chestnut - antiplatelet and antithrombin effects 1
• Kava - may potentiate anesthetics 1

Hold 48 hours before extraction 1:

• Glucosamine - aspirin-like effects on platelet aggregation and major interaction with warfarin 1

Special Population: Prior Head and Neck Radiation

For patients with history of head and neck radiation therapy (≥50 Gy to mandible/maxilla):

• Start pentoxifylline 400 mg twice daily AND tocopherol 1,000 IU once daily at least 1 week before extraction and continue for 4 weeks after (preferably until socket heals) 1
• Prescribe oral antibiotics before and after extraction to reduce osteoradionecrosis risk 1
• Contraindications to pentoxifylline/tocopherol: Active cancer, increased bleeding risk, severe renal disease (GFR <30), severe coronary disease, cirrhosis 1
• Consider alternatives to extraction (root canal, crown, filling) when possible in high-risk zones 1

Critical Pitfalls to Avoid

• Never bridge anticoagulated patients with heparin/LMWH - this dramatically increases bleeding without reducing thrombotic events 1
• Do not routinely discontinue warfarin - the thromboembolic risk outweighs the minor bleeding risk that can be managed locally 1, 4, 5
• Do not forget to adjust DOAC interruption for renal function - inadequate clearance time increases bleeding risk 1
• Do not ignore supplement use - many patients don't consider these "real medications" but they significantly affect bleeding 1