By the BossCE Editorial Team.
Key Points
- For most patients on warfarin (INR below 4), single or dual antiplatelets, or prophylactic-dose low molecular weight heparin, current guidance is to treat without interrupting the medication [1].
- For direct oral anticoagulants (DOACs), low-risk procedures go ahead as normal; for higher-risk procedures the morning dose is missed (apixaban, dabigatran) or delayed (rivaroxaban, edoxaban) [1][3].
- Bleeding is managed with careful technique and local measures, not by stopping the drug. Serious bleeds are rare, and these drugs are prescribed to prevent thromboembolic events [1].
Why This Question Keeps Coming Up
A patient on an anticoagulant needs an extraction. The dentist calls the GP to ask whether to stop it, and the GP is unsure what the dentist plans to do. Both want to avoid a bleed, but stopping the drug is usually the riskier choice. The Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, updated in its second edition in 2022, gives clear, graded recommendations that work well for both professions [1]. This article sets out its approach and the supporting evidence.
The guidance notes that anticoagulants reduce thromboembolic events at the cost of a higher bleeding risk, and that serious bleeding after dental treatment is rare. In patients who continued oral anticoagulants, around 4% needed extra haemostatic measures after surgery, almost all of these were managed with local measures, and fewer than 0.1% needed hospital admission [1].
Step 1: Classify the Procedure
SDCEP groups dental procedures by their likelihood of post-operative bleeding [1]. The table is a guide only, and the clinician decides where a specific case sits.
| Bleeding risk | Examples |
|---|---|
| Unlikely to cause bleeding | Infiltration, intraligamentary or mental nerve block anaesthesia; basic or six-point periodontal examination; impressions and prosthetic work; orthodontic appliance adjustment |
| Low risk | Inferior dental or other regional blocks; supragingival scale and polish; restorations (including subgingival margins); orthograde endodontics; simple extraction of 1–3 teeth with a restricted wound; incision and drainage of intraoral swellings; root surface debridement |
| Higher risk | Complex extractions, adjacent extractions leaving a large wound, or more than 3 extractions at once; flap procedures (surgical extraction, periodontal, periradicular or implant surgery, crown lengthening); gingival recontouring; biopsies |
Step 2: Identify the Drug and Apply the Recommendation
Warfarin and Other Vitamin K Antagonists
Check the INR, ideally no more than 24 hours before the procedure; if the patient’s INR is stable, a check up to 72 hours before is acceptable. If the INR is below 4, treat without stopping warfarin. If it is 4 or above, delay invasive treatment, and refer urgent cases to secondary dental care [1].
Direct Oral Anticoagulants
For low-risk procedures, treat without interrupting the DOAC [1]. For higher-risk procedures, SDCEP advises the patient to miss the morning dose of apixaban or dabigatran (twice-daily drugs), or delay the morning dose of rivaroxaban or edoxaban (usually once daily) [3]. Restart advice is specific:
- Once-daily rivaroxaban or edoxaban: take the delayed dose 4 hours after haemostasis, then resume as usual the next morning [3].
- Twice-daily apixaban or dabigatran: take the evening dose at the usual time, provided it is no earlier than 4 hours after haemostasis [3].
- Patients who take rivaroxaban or edoxaban in the evening do not need to change their schedule before treatment [3].
The recommendation is graded conditional, based on very low-certainty evidence [1]. A systematic review of DOAC patients having simple extractions found that bleeding was mostly minor and immediate, and concluded that DOAC therapy did not need to be stopped or changed for simple extractions. It called for more research on surgical procedures [6].
Antiplatelet Drugs
Treat without interrupting single or dual antiplatelet therapy. Aspirin alone is unlikely to raise the post-operative bleeding risk compared with patients on no anticoagulant, and may not need suturing [1][2]. With other single agents or dual therapy, expect bleeding to last longer (up to an hour), and strongly consider suturing and packing [1].
Low Molecular Weight Heparin
First find out whether the patient is on a prophylactic or a treatment dose. Treat patients on a prophylactic dose without interruption. If the patient is on a treatment dose, or you are not sure, contact the prescriber [1].
Combinations and Other Risk Factors
If a patient takes an anticoagulant together with an antiplatelet, or has other conditions that raise bleeding risk, contact the prescribing clinician before invasive treatment [1]. The guidance lists conditions such as chronic renal failure, liver disease, haematological malignancy, recent chemotherapy or radiotherapy, advanced heart failure, inherited bleeding disorders and platelet disorders [1].
When Not to Interrupt Under Any Circumstances
Do not stop anticoagulant or antiplatelet therapy, unless the patient’s cardiologist gives direct written instruction, for patients with prosthetic metal heart valves or coronary stents, those who had a pulmonary embolism or deep vein thrombosis in the last three months, and those anticoagulated for cardioversion [4].
Step 3: Chairside Checklist
- Book treatment early in the day, and early in the week where possible, so bleeding can be monitored and managed [1].
- Limit the initial treatment area, and stage higher-risk work over several visits [1].
- Work as atraumatically as possible, and discharge only once haemostasis has been achieved [1].
- Have gauze, haemostatic packing (for example oxidised cellulose or collagen sponge, with a non-animal option) and a suture kit ready [2].
- Give written post-operative advice and emergency contact details [4].
- Recommend paracetamol, unless contraindicated, rather than NSAIDs such as ibuprofen, diclofenac or naproxen [4].
On tranexamic acid, SDCEP notes it reduces bleeding compared with placebo but may add little over other local measures. It does not advise primary care dentists to prescribe it, but if the patient’s doctor has prescribed it, use it alongside local measures [2].
Prescribing Interactions That Matter
If you prescribe an antibiotic for a patient on warfarin, warn them that the INR may rise, and tell the GP or anticoagulation service so they can consider extra INR monitoring. This should not stop you giving an antibiotic that is clinically indicated. Avoid miconazole in patients taking warfarin or acenocoumarol. Macrolides interact with DOACs; with edoxaban and erythromycin together, the prescriber needs to review the edoxaban dose [5].
What About Implants and Surgery?
For implant placement, a meta-analysis of seven studies found no significant increase in bleeding when oral anticoagulants were continued and local haemostatic measures were used. An indirect comparison suggested a greater bleeding tendency with vitamin K antagonists than with DOACs [7]. Evidence for more extensive surgery is still limited, so SDCEP’s staging and local-measure advice remains the safest approach [1][6].
A Note for GPs
When a dentist asks whether to stop an anticoagulant, the answer for most procedures is no. The most useful things you can provide are a recent INR for warfarin patients, the drug and dose regimen, the indication (particularly valves, stents, recent venous thromboembolism or cardioversion), and any other bleeding risk factors. Where dosing needs to change for a higher-risk procedure on a DOAC, the SDCEP schedule above is simple to follow.
Find the Guidance Quickly
Clinical practice guidelines for Malaysia, including those on antibiotic prophylaxis in oral surgery and on cardiovascular conditions, are in the BossCE Library. To check a specific case, ask BossCE AI: “A patient on apixaban needs a surgical extraction of a lower molar. Should the dose be changed, and when should it be restarted?”
References
- Scottish Dental Clinical Effectiveness Programme. Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs. Dental Clinical Guidance, 2nd edition. SDCEP; 2022. sdcep.org.uk (PDF)
- SDCEP Dental Companion. Managing Bleeding Risk: Haemostatic Measures. companion.sdcep.org.uk
- SDCEP Dental Companion. Direct Oral Anticoagulants: Higher Risk of Bleeding Complications. companion.sdcep.org.uk
- SDCEP Dental Companion. Managing Bleeding Risk: Clinical Practice Advice. companion.sdcep.org.uk
- SDCEP Dental Companion. Interactions With Drugs Prescribed by Dentists. companion.sdcep.org.uk
- López-Galindo M, Grau-Benítez M. Systematic review on the effects of the discontinuation of the anticoagulant therapy and the postoperative bleeding, in patients under new oral anticoagulants after dental extraction. J Clin Exp Dent. 2023. doi:10.4317/jced.60122
- Zou L, Hua L. Risk of bleeding with dental implant surgery in patients on anticoagulant or antiplatelet drugs: a systematic review and meta-analysis. Acta Odontol Scand. 2022. doi:10.1080/00016357.2022.2085324
This article is for qualified healthcare professionals and is not a substitute for clinical judgement or the full guideline. Check the current version of each source before applying it.