Management of Anticoagulation for Tooth Extraction in an Elderly Patient with Atrial Fibrillation
Continue warfarin without interruption for this tooth extraction, as the INR of 2.3 is within the safe therapeutic range for dental procedures, and the thromboembolic risk from stopping anticoagulation outweighs the minimal bleeding risk from a simple dental extraction. 1
Do NOT Stop Warfarin or Bridge with Enoxaparin
- For simple dental extractions, warfarin should be continued without interruption when the INR is between 2.0 and 3.0. 2, 1
- Stopping warfarin for 5 days and bridging with enoxaparin (Lovenox) is not indicated for dental procedures and actually increases bleeding risk unnecessarily while exposing the patient to stroke risk during the interruption period 2
- The annual thromboembolic risk in atrial fibrillation patients is approximately 5% per year, which translates to a 5-day risk of stroke during warfarin interruption that far exceeds the manageable risk of post-extraction bleeding 2
Why Continuing Warfarin is Safe for Dental Extraction
- An INR of 2.3 falls well within the therapeutic range of 2.0-3.0 and is considered safe for dental extractions with appropriate local hemostatic measures 1, 3
- Simple dental extractions are considered minor procedures where local hemostatic control (pressure, sutures, tranexamic acid rinses, oxidized cellulose packing) is highly effective even with therapeutic anticoagulation 1
- The risk of serious bleeding from dental extraction while on warfarin with INR 2.0-3.0 is minimal and easily managed with local measures, whereas stroke risk from stopping warfarin is potentially catastrophic 1, 3
Special Considerations for This Elderly Patient
- For patients over 85 years old, maintaining INR in the 2.0-3.0 range remains appropriate, as lowering the INR below 2.0 does not reduce bleeding risk but significantly increases stroke risk. 3
- The patient's history of falls does not change the recommendation to continue warfarin for this procedure, as the procedural bleeding risk remains minimal with local hemostatic measures 1
- Age 85+ does increase intracranial hemorrhage risk (adjusted OR 2.5), but this applies to spontaneous bleeding, not procedural bleeding that can be controlled locally 3
Coordination with the Dentist
Inform the dentist that the patient is anticoagulated with an INR of 2.3 and request they use local hemostatic measures including:
- Suturing the extraction site
- Applying pressure with gauze for 30 minutes post-extraction
- Using tranexamic acid mouth rinses (5% solution, 10 mL four times daily for 2 days)
- Packing the socket with oxidized cellulose or gelatin sponge if needed 1
Schedule the extraction earlier in the week (Monday-Wednesday) so that if delayed bleeding occurs, dental services are readily available 1
What NOT to Do (Common Pitfalls)
- Do not stop warfarin for 5 days - this creates a dangerous anticoagulation gap where stroke risk is highest 2, 1
- Do not bridge with enoxaparin - bridging therapy is reserved for high-risk procedures (major surgery, spinal procedures) and mechanical heart valves, not dental extractions 2, 4
- Do not target a lower INR - reducing INR below 2.0 provides no bleeding benefit for dental procedures but dramatically increases stroke risk (approximately 80% loss of stroke protection) 2, 3, 5
- Do not prescribe NSAIDs for post-extraction pain - use acetaminophen instead, as NSAIDs increase bleeding risk when combined with warfarin 1
Post-Procedure Monitoring
- Check INR 24-48 hours after the extraction only if there is persistent bleeding or other concerns, but routine INR monitoring is not required for uncomplicated extractions 1
- Instruct the patient to avoid vigorous rinsing, spitting, or using straws for 24 hours post-extraction to prevent clot dislodgement 1
- If delayed bleeding occurs (rare), apply local pressure with gauze soaked in tranexamic acid and contact the dentist; do not stop warfarin 1