What are the requirements for medical clearance for tooth extraction in an adult with bleeding disorders and/or cardiovascular disease on anticoagulants?

Medical Clearance for Tooth Extraction

For patients requiring tooth extraction, medical clearance should document bleeding risk stratification, anticoagulation/antiplatelet management plan, cardiac conditions requiring endocarditis prophylaxis, and any history of bone-modifying agents or head/neck radiation.

Essential Components of Medical Clearance Documentation

1. Bleeding Risk Assessment

Classify the extraction procedure by bleeding risk:

• Simple extraction (1-3 teeth): Low bleeding risk (0-2% major bleeding in 2 days) 1
• Multiple extractions (≥4 teeth) or procedure >45 minutes: High bleeding risk (2-4% major bleeding in 2 days) 1

2. Anticoagulation Management

For Patients on Warfarin (VKA)

Continue warfarin for dental extractions with local hemostatic measures 2, 1:

• Verify INR ≤4.0 within 24-72 hours before procedure 2
• Use tranexamic acid mouthwash, absorbable hemostatic packing, and sutures 1
• Do not interrupt warfarin for simple extractions 2, 1
• For multiple extractions in high thrombotic risk patients (mechanical mitral valve, recent stroke <3 months, CHA2DS2-VASc ≥7), consider case-by-case evaluation but generally continue warfarin 2

For Patients on Direct Oral Anticoagulants (DOACs)

Timing of last DOAC dose depends on renal function and bleeding risk 2:

For simple extractions (low bleeding risk):

• CrCl >80 mL/min: Last dose ≥24 hours before procedure 2
• CrCl 50-79 mL/min: Dabigatran ≥36 hours; Factor Xa inhibitors ≥24 hours 2
• CrCl 30-49 mL/min: Dabigatran ≥48 hours; Factor Xa inhibitors ≥24 hours 2

For multiple extractions (high bleeding risk):

• CrCl >80 mL/min: Dabigatran ≥48 hours; Factor Xa inhibitors ≥48 hours 2
• CrCl 50-79 mL/min: Dabigatran ≥72 hours; Factor Xa inhibitors ≥48 hours 2
• CrCl 30-49 mL/min: Dabigatran ≥96 hours; Factor Xa inhibitors ≥48 hours 2

Resume DOAC ≥24 hours post-procedure for low bleeding risk, 48-72 hours for high bleeding risk 2

No bridging with heparin is recommended 2

3. Antiplatelet Management

Continue all antiplatelet agents without interruption 3:

• Aspirin: Continue for all dental procedures 3
• Clopidogrel/Ticagrelor: Continue without interruption—premature discontinuation dramatically increases stent thrombosis risk leading to MI or death 3
• Use local hemostatic measures (vasoconstrictor, tranexamic acid rinse, absorbable packing, sutures) 1, 3

4. Cardiac Conditions Requiring Endocarditis Prophylaxis

Document if patient requires antibiotic prophylaxis 3:

Prophylaxis indicated for:

• Prosthetic cardiac valves 3
• Previous infective endocarditis 3
• Unrepaired or palliated cyanotic congenital heart disease 3
• Completely repaired congenital heart disease with prosthetic materials (first 6 months only) 3
• Repaired congenital heart disease with residual defects at prosthetic sites 3

Standard prophylaxis: Amoxicillin 2g PO 30-60 minutes before procedure (or clindamycin 600mg if penicillin allergic) 3

5. Bone-Modifying Agents and Radiation History

Document any history of bisphosphonates, denosumab, or antiangiogenic therapy 3:

• Communicate medication-related osteonecrosis of jaw (MRONJ) risk to dentist 3
• For patients on oncologic doses: insufficient evidence mandates discontinuation before extraction 3
• Ideally, high-risk teeth should be extracted ≥2 weeks before initiating bone-modifying agents 3

Document history of head/neck radiation 3:

• Osteoradionecrosis risk requires special consideration 2, 3
• Teeth within radiation field with poor prognosis should be extracted ≥2 weeks before radiation 3
• High-risk teeth include: moderate-severe periodontal disease, periapical disease, severe caries, partially erupted third molars 2, 3

6. Bleeding Disorders and Liver Disease

For patients with cirrhosis 3:

• No routine blood product administration needed before dental extractions 3
• Bleeding risk is low if INR <2.50 and platelets >30 × 10⁹/L 3

For hemophilia patients 4:

• Tranexamic acid 10 mg/kg IV immediately before extraction 4
• Continue 10 mg/kg IV 3-4 times daily for 2-8 days post-extraction 4
• Coordinate with hematology for factor replacement as needed 4

7. Postoperative Pain Management

Specify analgesic recommendations 3:

• First-line: Acetaminophen for all patients 3
• Avoid NSAIDs in patients on dual antiplatelet therapy 1, 3
• Coxibs have less platelet effect if NSAIDs necessary 1

Critical Pitfalls to Avoid

• Never discontinue antiplatelet therapy for dental procedures—thromboembolic risk far exceeds bleeding risk 1, 3
• Do not bridge warfarin with heparin for dental extractions—increases bleeding without reducing thrombosis 2
• Do not assume normal PT/aPTT excludes DOAC effect—specific anti-Xa or anti-IIa assays needed if timing uncertain 2
• Verify recent creatinine before calculating DOAC interruption timing—renal function determines clearance 2
• Document concomitant P-glycoprotein inhibitors (amiodarone, dronedarone, verapamil)—may require additional 24-hour DOAC interruption 2

Sample Medical Clearance Template

Patient cleared for tooth extraction with the following considerations:

1. Bleeding risk: [Low/High] based on [number of teeth, procedure duration]
2. Anticoagulation: [Continue warfarin with INR check / Hold DOAC × ___ hours based on CrCl ___ / Continue antiplatelet agents]
3. Endocarditis prophylaxis: [Required: Amoxicillin 2g PO / Not required]
4. Bone-modifying agents: [None / History of ___ - MRONJ precautions]
5. Radiation history: [None / Prior head/neck RT - osteoradionecrosis risk]
6. Hemostatic plan: Local measures (vasoconstrictor, tranexamic acid rinse, packing, sutures)
7. Postoperative analgesia: Acetaminophen; avoid NSAIDs if on antiplatelet therapy
8. DOAC resumption: ≥24-72 hours post-procedure based on bleeding risk