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Sepsis: Recognition and the First Hour Chest Pain: Suspected Acute Coronary Syndrome Acute Ischaemic Stroke Avulsed Permanent Incisor Extraction in a Patient Taking Warfarin Diagnosing Pulpitis

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Extraction in a Patient Taking Warfarin

A 28-year-old male attends the Hospital Dental Department complaining of severe pain from his lower left first molar (36). He reports a mechanical mitral valve replacement five years ago and takes warfarin 5mg daily. The 36 is non-restorable. His latest INR, checked yesterday, was 3.2. His medical team has advised against stopping warfarin.You plan to extract the 36. What local haemostatic measures would you prepare for, and why?

Your reasoning

His INR of 3.2 was checked yesterday and is below 4, so I would go ahead without stopping warfarin. In the socket I would place an oxidised cellulose dressing and close with resorbable sutures, then bite on damp gauze for 20 minutes. Tranexamic acid 5% mouthwash for 2 days

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4/5score

“You demonstrated a good understanding of managing this patient, with appropriate planning for local haemostatic measures and post-operative care.”

What You Got Right

An INR of 3.2, checked yesterday, is within the acceptable range for a single extraction without altering warfarin.
Warfarin should not be stopped, in line with the medical team's advice and current guidelines.
Tranexamic acid 5% mouthwash is a recommended adjunct for reducing post-operative bleeding.

Model Answer

Confirm the INR is within the safe range for a single extraction without altering warfarin.
Extract as atraumatically as possible to minimise tissue damage and bleeding.

SourcesSDCEP: Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs

Viva Questions

What specific advice would you give the patient about the tranexamic acid mouthwash, including how to use it and for how long?
If, despite your local haemostatic measures, the patient has persistent bleeding at home, what would be your immediate advice and next steps?

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