How long should Coumadin (warfarin) be held before and after a dental procedure?

Warfarin Management for Dental Procedures

For most dental procedures, do not stop warfarin—continue it without interruption as long as the INR is within therapeutic range (typically 2.0-3.5), and use local hemostatic measures to control bleeding. 1, 2, 3

Risk Stratification by Procedure Type

Low-Risk Dental Procedures (Continue Warfarin)

• Simple dental extractions, diagnostic procedures with or without biopsy, and routine dental work can be performed safely without stopping warfarin. 1, 4, 2
• Check INR within the week before the procedure to confirm it is within therapeutic range (typically 2.0-3.5). 1
• Studies demonstrate that simple tooth extraction can be performed safely with INR up to 3.5 without increased risk of severe bleeding. 4
• One prospective study showed 88.6% of patients had only mild oozing requiring no intervention, and 11.4% had moderate bleeding controlled with local measures when INR was ≤3.5. 4

High-Risk Dental Procedures (Consider Stopping Warfarin)

• For extensive oral surgery, multiple extractions, or procedures with high bleeding risk, stop warfarin 5 days before the procedure. 1, 5
• Verify INR <1.5 on the day before or morning of the procedure. 1
• Approximately 7% of patients still have INR >1.5 after 5 days of discontinuation, making verification mandatory. 1

Patient-Specific Risk Assessment

Low Thrombotic Risk Patients

• For patients with atrial fibrillation without prior stroke/TIA or CHADS₂ score <5, stop warfarin 5 days before high-risk procedures without bridging. 1, 5
• Resume warfarin at usual maintenance dose on the evening of or day after the procedure once hemostasis is adequate. 6, 1

High Thrombotic Risk Patients

For patients with mechanical heart valves (especially mitral position), recent stroke/TIA, CHADS₂ score ≥5, or recent VTE within 3 months, bridging anticoagulation is required if warfarin must be stopped. 7, 1, 5

Bridging Protocol for High-Risk Patients:

• Stop warfarin 48-72 hours before the procedure (for mechanical aortic valve with no risk factors) or 4-5 days before (for mechanical mitral valve or aortic valve with risk factors). 7, 5
• Start therapeutic-dose LMWH (100 U/kg every 12 hours) or unfractionated heparin (15,000 U every 12 hours subcutaneously) when INR falls below 2.0. 7, 5
• Stop heparin 4-6 hours before the procedure (for IV heparin) or give last dose 24 hours before (for LMWH). 7
• Restart heparin as early after surgery as bleeding stability allows. 7
• Continue bridging until INR is therapeutic for at least 48 hours after resuming warfarin. 6

Post-Procedure Management

• Resume warfarin at the usual maintenance dose on the evening of or day after the procedure once adequate hemostasis is achieved. 6, 1, 5
• Do not double the warfarin dose post-procedure, as this achieves therapeutic INR only 1-2 days faster but increases dosing complexity without proven benefit. 6
• For high bleeding risk procedures in bridged patients, delay LMWH restart for 48-72 hours post-procedure. 1
• Continue bridging anticoagulation until INR has been in therapeutic range for 2 consecutive days. 1

Local Hemostatic Measures

• Use local hemostatic agents (gelatin sponges, tranexamic acid rinses, sutures) for all dental extractions in anticoagulated patients. 2, 3
• These measures are effective in controlling bleeding and allow continuation of warfarin for most procedures. 2, 3

Critical Pitfalls to Avoid

• Do not routinely give vitamin K for INR 1.5-1.9 measured 1-2 days before the procedure, as this causes post-operative warfarin resistance without proven benefit. 6, 1
• Do not use heparin bridging for low-risk patients, as this increases bleeding risk up to 20% without reducing thrombotic events. 1
• Do not assume 5 days of warfarin discontinuation is always sufficient—always verify INR before the procedure. 1
• Avoid high-dose vitamin K (>2.5 mg) for routine reversal, as this creates a hypercoagulable state and makes re-anticoagulation difficult. 7, 5
• If emergency reversal is needed, fresh frozen plasma is preferable to high-dose vitamin K. 7

Special Considerations

• For mechanical mitral valves or any mechanical valve with risk factors, the thrombotic risk is substantially higher than for mechanical aortic valves alone, requiring more aggressive bridging strategies. 7
• Elderly patients (>75 years) may require lower warfarin doses and have higher bleeding risk, necessitating more frequent monitoring. 5
• The systematic review evidence consistently shows that continuing anticoagulation during dental procedures does not increase bleeding risk when INR is therapeutic, while stopping anticoagulation carries well-documented thromboembolic risk. 2, 3