SAFE indicates that it is safe to proceed in a routine manner (local factors such as periodontal/gingival inflammation can increase the severity of bleeding; the clinician should consider all factors when making a risk assessment.)  

INSUFF. RES./ LOCAL MEASURES indicates that there is insufficient research to draw a conclusion.  In many instances the procedure can be performed with judicious use of local measures (sutures, oxidized cellulose, microfibrillar collagen, topical thrombin and/or tranexamic acid.)

NOT ADVISED indicates that it is probably not safe to proceed at the current INR level.  Refer to the anticoagulation clinic or physician managing the patient's warfarin therapy.

Reference: Herman WW, Konzelman JL, Sutley SH.  Current Perspectives on Dental patients Receiving Coumarin Anticoagulant Therapy.  JADA 1997;128(3):327-35.  Table 2 on page 329.  Copyright © 1997 American Dental Association. Adapted 2002 with permission of ADA Publishing, a Division of ADA Business Enterprises, Inc.

* It seems unlikely that there would be any additional risk of bleeding at an INR <1.5 since people who have never taken warfarin can have an INR as high as 1.2. 

EDITOR'S NOTE:  CAREFULLY CONSIDER THE EFFECT THAT STOPPING WARFARIN THERAPY FOR EVEN A FEW DAYS CAN HAVE ON THE PATIENT.  A MODERATE AMOUNT OF BLEEDING IS A MINOR INCONVENIENCE COMPARED WITH A PARALYZING STROKE OR DEATH.  

  The problem of having a dental procedure done while a person is taking warfarin 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 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.  This article will try to allay that fear in the perspective of current warfarin 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 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.  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 for dental surgery is not based on scientific fact, but is a myth.

  Evans et al reported on a randomized trial in which 52 patients stopped warfarin two days before a dental extraction and 57 patients continued warfarin throughout the extraction period.  The difference between bleeding rates were statistically insignificant.  The authors concluded that continuing warfarin when the INR was less than 4.1 caused no increase in clinically significant bleeding.  

  On a personal note, I took part in 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 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 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 or later years.

  There is some controversy about how long, if at all, that warfarin 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 for longer than two days, particularly without obtaining INR results is probably indefensible.  Likewise, there is no valid reason to stop warfarin 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 far outweighs any risk of having the teeth cleaned while fully anticoagulated.

  The official package inserts for warfarin products now recommend against stopping warfarin for procedures where applications of local measures such applying thrombin, microcellulose etc are likely to stop bleeding.  Getting the INR to the lower portion of the recommended range and testing the INR just before a procedure are also recommended.

  A mouthwash made from tranexamic 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.

  In my opinion, if your dentist wants to hold warfarin for longer than two days to do a simple procedure, you would be wise to ask for a referral to a more experienced dentist.

  A dentist who has a problem with a patient whose warfarin is held is going to be in an indefensible position in a lawsuit.  "I've always done it that way" or "I checked with the physician" will no longer be a successful defense.

It comes down to this - Every day people survive gunshot wounds.  If your dentist thinks that you are going to lose more blood from the procedure than a gunshot wound; find another dentist who has better technique.

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

Evans IL et al. Can warfarin be continued during dental extraction?  Results of a randomized controlled trial.  Br J Oral Maxillofac Surg. 2002;40:248-252.

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