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Oral Surgery & Warfarin

The risk of significant bleeding in patients on Warfarin is low.

Patients on Warfarin might bleed more than normal but bleeding is easily treated with ‘local measures’ (packing the tooth-socket with material that aids blood-clotting and stitching of the tooth socket).

Warfarin should NOT be discontinued in the majority of patients requiring dental extractions and biopsies unless instructed otherwise by their Anticoagulant Clinic.

There is an increased risk of thrombosis in patients who have temporarily stopped taking their Warfarin (the risk is small but potentially fatal). Bleeding complications, while inconvenient, do not carry the same risks as thrombo-embolic complications (that can lead to permanent disability or death).

Ideally, the INR should be checked within 36 hours of the procedure. If the INR is below 4.0, then the procedure can go ahead.

How Should Post-Operative Pain Be Managed?

Patients should follow the advice of their Anticoagulant Clinic with regard to the choice of painkillers for short-term, mild to moderate pain.

Generally, Paracetamol is considered the safest simple painkiller for patients taking Warfarin and it may be taken in normal doses if pain control is needed and no contra-indication exists.

Patients should not to take Aspirin, Aspirin-containing compound preparations or Non-Steroidal Anti-Inflammatory Drugs e.g. Ibuprofen, which are considered less safe than Paracetamol in patients taking Warfarin.

Patients requiring a course of antibiotics post-operatively should be vigilant for any signs of increased bleeding.

Treatment Algorithm for Warfarinised Patients (British Dental Journal 2003)
Treatment Algorithm for Warfarinised Patients (British Dental Journal 2003)
List of Drugs that Interact with Warfarin
List of Drugs that Interact with Warfarin

Useful Articles & Websites

Scottish Dental Clinical Effectiveness Programme

North West Medicines Information Centre 2001. Surgical Management Of The Primary Care Dental Patient On Warfarin

British Dental Journal 2003. Dental management considerations for the patient with an acquired coagulopathy. Part 2. Coagulopathies from Drugs

Austral Dental J 2003. Current Concepts of the Management of Dental Extractions for Patients taking Warfarin

BDJ 2003. Antibacterial Prescribing & Warfarin. A Review

BDJ 2003. Dental Management Considerations for the Patient with an Acquired Coagulopathy. Part 2. Coagulopathies from Drugs

JADA 2003. Lack of a Scientific Basis for Routine Discontinuation of Oral Anticoagulation Therapy before Dental Treatment

Dental Update 2004. Management of Dental Patients on Warfarin Therapy in a Primary Care Setting

Australian Family Physician 2006. Remove the tooth, but don’t stop the warfarin

American Academy of Oral Medicine 2007. Patient Information Sheet. Blood Thinners Dental Care

J Oral Sciences 2007. Dental Management of patients recieving anti-coagulation or anti-platelet treatment

Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007. Management of Dental Patients taking Common Hemostasis-Altering Medications

Evidence-Based Dentistry 2008. Guidelines for the Management of Patients who are taking Oral Anticoagulants & who require Dental Surgery

JCDA 2009. Dental Surgery for Patients on Anticoagulant Therapy with Warfarin – A Systematic Review & Meta-Analysis

Evidence-Based Dentistry 2009. Continuing Warfarin Therapy does not Increased Risk of Bleeding for Patients undergoing Minor Dental Procedures

NHS National Patient Safety Agency 2009. Managing Patients who are taking Warfarin & undergoing Dental Treatment

JOMS 2011. Comparison of the Effects of Warfarin & Heparin on Bleeding Caused by Dental Extraction. A Clinical Study

JOMS 2011. Delayed Complications of Tooth Extraction in Patients Taking Warfarin, Antibiotics and Other Medications

JOMS 2011. Risk Factors Affecting Postoperative Hemorrhage After Tooth Extraction in Patients Receiving Oral Antithrombotic Therapy

Dental Update 2012. An Interesting Potential Reaction to Warfarin

Dental Update 2012. Bleeding Disorders seen in the Dental Practice

Dental Update 2012. Management of Bleeding Disorders in the Dental Practice – Managing Patients on Anticoagulants

BJOMS 2012. Safety of local anaesthesia in dental patients taking oral anticoagulants. Is it still controversial?

Dent Update 2013. Special Care Dentistry Part 2. Dental Management of Patients with Drug Related Acquired Bleeding Disorders

Clin Cos & Invest Dent 2014. Dental Extraction in Patients on Warfarin Treatment

Dent Update 2016. Warfarin and Drug Interactions – Prescribing Vigilance

JOMS 2016. Postoperative Bleeding Following Dental Extractions in Patients Anticoagulated With Warfarin

BMJ Open 2017. Risks of Post-Extraction Bleeding after Receiving Direct Oral Anticoagulants or Warfarin – A Retrospective Cohort Study

Cardiology Research & Practice 2019. Anticoagulation Use prior to Common Dental Procedures – A Systematic Review