Extractions on anti-coagulant medications:

Dealing with patients

by Dr Gerard Clausen

One of the common questions that practitioners are faced with is the correct protocol for dealing with patients on anti-coagulant medications when tooth extractions or other surgical procedures are required.

In the past it was often considered medication such as Warfarin should be stopped prior to surgery to minimise the risk of severe or uncontrolled bleeding. However, a more specific and tailored approach is now recommended and it is important that clinicians are aware of this.

The current approach is based on the INR (International Normal Ratio); the ratio of the patient’s prothrombin time to a standardised norm. For example an INR of 2.0 indicates a patient’s blood takes twice the normal time to clot.

The recommended approach is to request an INR test 24 hours prior to surgery. For patients with an INR between 2.2 and 4.0 it is recommended that a tranexamic acid mouthwash is used.

Further information about this is published in Therapeutic Guidelines; Oral and Dental Version 2. For patients with an INR less than 2.2, surgery can be undertaken without a tranexamic acid mouthwash but the patient should be given the mouthwash and appropriate instructions for home use if required.

For patients with an INR above 4, surgery should not proceed and further evaluation must be undertaken. In all cases the complete medical history should also be taken into account so that INR values are not looked at in isolation. A post-surgical review protocol is also indicated, with reviews at two days and again within fourteen days being recommended.

In summary a very significant part of a thorough medical history is to ascertain if the patient is on anti-coagulant therapy, particularly if oral surgical procedures are planned.

Decreasing or ceasing anti-coagulant medication is not recommended as this may precipitate other risks such as a thrombotic event. The current best practice is to request an INR test and treat based on the guidelines presented to minimise risk.

It is essential, especially in cases where the patient may have a more extensive medical history, for the treating dental practitioner to liaise with the patient’s general medical practitioner to manage the patient in parallel. It is not at all unusual for a dental patient to either forget, or not completely disclose their full range of medications or medical history in the belief that these are medical matters that are not significant within the confines of dental treatment. Frank discussion with the patient’s medical practitioner is a critical part of holistic treatment planning and should be considered mandatory in these cases.