PDF: Postoperative Bleeding Following Dental Extractions in Patients Anticoagulated With Warfarin

The practicing dentist must frequently advise on the risks involved with dental extractions in the patient taking an anticoagulant.

This study assessed the risk of bleeding in a large heterogeneous cohort of patients on warfarin treated by practitioners in training (dental students and junior staff in a teaching hospital). 

Warfarin is the most common anticoagulant used in Australia, with more than 2.6 million prescriptions filled in 2014. Warfarin is used predominately for the prevention of life-threatening thromboembolic events, such as stroke and deep vein thrombosis, in at-risk patients. 

The clinical indications for warfarin therapy recorded for patients in this study are presented in Table 1.

It is a potent anticoagulant classed as a vitamin K antagonist that works by inhibiting vitamin K epoxide reductase, which in turn inhibits the recycling of vitamin K from its inactive to active form. 

This in turn interferes with the formation of vitamin K–dependent clotting factors II, VII, IX, and X and antithrombotic factors protein C and protein S. 

Suggestions on the approach to management of dental extractions in patients taking warfarin have varied considerably, from stopping the anticoagulant before extraction to continuing its use while using local hemostatic techniques. 

Ceasing warfarin with no bridging therapy has the risk of inducing a life-threatening thromboembolic event.

Garcia et al found that when withholding warfarin for even a short period in low- or moderate-risk patients, the risk of a thromboembolic event was as high as 0.7%. 

Because of this risk of thromboembolism and the low risk of perioperative and postoperative bleeding, it iswell accepted that ceasing warfarin before dental extraction is not recommended. 

However, in instances when the risk of bleeding remains a concern, the use of local hemostatic measures, such as tranexamic acid, fibrin glue, and oxidized cellulose, are indicated. 

The therapeutic effect of warfarin is measured as prothrombin time and communicated as the international normalized ratio (INR). 

Depending on the clinical indication for warfarin therapy, a different target INR range exists, with most patients targeting a value between 2 and 3. 

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