Warfarin Institute of America
DEDICATED TO YOUR HEALTH SINCE 2000
DENTAL PROCEDURES WHILE ON WARFARIN (Coumadin, Jantoven)
The problem of having a dental procedure done while a person is taking warfarin (Coumadin, Jantoven) is one of the most frequent that arises. I believe that much of the fear that dentists have about doing procedures on these patients is due to pre-1990 information. Prior to that time, the International Normalized Ratio (INR) system of monitoring warfarin (Coumadin, Jantoven) therapy was not used. Then, it was common to maintain the Prothrombin Time (PT) at 1.5 to 2.5 times control. We now know that, with some of the relatively insensitive materials that were used to measure the PT in that era, 2.5 times control resulted in an INR of greater than 8. When you consider that we now typically keep the INR somewhere between 2.0 and 3.5 it is no wonder that people bled. It is also little wonder that dentists trained prior to 1990 have a fear of warfarin (Coumadin, Jantoven). This article will try to allay that fear in the perspective of current warfarin (Coumadin, Jantoven) therapy.
There were three excellent articles published during the year 2000 from which I will draw much of my material. A.G. Mask, Jr. in the journal Periodontology unequivocally states, "Anticoagulation with coumadin (sic) is not a contraindication to dental procedures."
Russo et al reported on their procedures in Clinical and Applied Thrombosis/Hemostasis. The article is titled Simple and Safe Method to Prepare Patients with Prosthetic Heart Valves for Surgical Dental Procedures. Since 1994, they have been using a two-day withdrawal regimen, for patients with INRs between 2.0 and 4.5. All patients had mechanical heart valves and were preparing for dental surgery. Their study involved 104 patients undergoing molar tooth extractions, gingival or alveolar operations. By the end of 1998, there were a total of 123 procedures done. The procedures were done as scheduled if the INR was below 3.4 on the day of the procedure. During the week following dental surgery, there were no major bleeding complications. Minor bleeding (gingival) was experienced by only two patients. The first patient had an INR of 2.3 and bled for four hours. Local pressure was the only treatment. The second patient had an INR of 3.4 and bled for 12 hours. This patient was treated with tranexamic acid mouthwash and reduction of warfarin (Coumadin, Jantoven) dosage. (see below) The authors state that they believe that their policy is sufficient, safe and simple.
M. J. Wahl in the January 2000 edition of the Journal of The American Dental Association published a study of 950 people who had 2,400 dental procedures done. None of these people stopped their warfarin (Coumadin, Jantoven). There were only 12 incidents (about 1% of the time) where anything more than holding a pad with slight pressure was required to stop bleeding. In these 12 incidents, only 3 times was the INR at or below the therapeutic level. The author concludes that stopping warfarin (Coumadin, Jantoven) for dental surgery is not based on scientific fact, but is a myth.
On a personal note, I was recently asked to be part of the defense in a lawsuit against a dentist who had a patient suffer a stroke in his dental chair. The dentist had told the patient to stop the warfarin (Coumadin, Jantoven) for two days, but did not check the INR. The plaintiff had a dental professor who gave a deposition that he considered it malpractice to stop warfarin (Coumadin, Jantoven) without conferring with the physician or ordering an INR test to determine the patient's level of anticoagulation. The plaintiff dropped the lawsuit after I pointed out that the incident had occurred in 1999 and that the article by Wahl appeared in the January 2000 edition of the Journal of the American Dental Association. What was news in 2000 cannot be considered malpractice in 1999. However, this defense would no longer suffice in 2001.
There is some controversy about how long, if at all, that warfarin (Coumadin, Jantoven) should be stopped for a dental procedure. Two days is probably sufficient and could be defended on the basis of one these journal articles. However, even this is not without some risk. The dentist should be certain that an INR is done before the dental extraction and that the results of this test are understood before proceeding. Stopping warfarin (Coumadin, Jantoven) for longer than two days, particularly without obtaining INR results is probably indefensible. Likewise, there is no valid reason to stop warfarin (Coumadin, Jantoven) for a simple cleaning of the teeth. I had a patient who had a broken bridge. Minutes before he had the dental work done, his INR was 3,0. A laser was used to cut away some of the gum tissue. The patient, "reported no bleeding whatsoever." The risk of stroke or death posed by stopping warfarin (Coumadin, Jantoven) far outweighs any risk of having the teeth cleaned while fully anticoagulated.
A mouthwash of tranexemic acid can also be used. For more information, click here.
I have also exchanges e-mails with Mary Aubertin, DMD from the University of Texas Health Sciences Center at San Antonio on this topic.
Mr. Lodwick: I am interested in your experience. Have you done procedures on patients with INRs in the 2 to 3 range, and if so have you had any problems other than oozing blood for 12 hours or so?
Dr. Aubertin: We generally follow the current thinking and do not alter the patient's Coumadin if their INR is within the therapeutic range. I have done extractions on other patients and placed Gel-foam or Surgicel and had no problems with excessive oozing or bleeding
References:
Mask AG Jr. Medical management of the patient with cardiovascular disease. Periodontol 2000;23:136-41.
Russo G et al. Simple and Safe Method to Prepare Patients with Prosthetic Heart Valves for Surgical Procedures. Clin Appl Thrombosis/Hemostasis 2000;6:90-93.
Wahl MJ. Myths of Dental Surgery in Patients Receiving Anticoagulant Therapy. J Am Dental Assoc 2000 Jan;131(1):77-81.
Sindet-Pedersen S, Ramstrom G, Bernvil S, Blomback M.
Hemostatic effect of tranexamic acid mouthwash in anticoagulant-treated
patients undergoing oral surgery. N Engl J Med 1989 Mar 30;320(13):840-3
Mr. Lodwick has a presentation available for dental groups on this topic. Please e-mail him for more details.
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Last updated December 26, 2006