ORAL HEALTH EVIDENCE-BASED PRACTICE PROGRAM
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Title Preoperative Discontinuation of Warfarin for Dental Surgery Not Indicated for Most Patients
Clinical Question In patients being treated with warfarin, should anticoagulant treatment routinely be interrupted before undergoing dental extractions or is local hemostasis an adequate method to reduce risk of excessive bleeding?
Clinical Bottom Line Patients being therapeutically anti-coagulated with warfarin (at an International Normalized Ratio (INR) of less than 4), can undergo dental extractions without discontinuation of anticoagulant therapy considering proper local hemostatic measures are used.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 21196857Rodriguez-Cabrera/2011Anticoagulated PatientsSystematic review of randomized trials
Key resultsCompilation of a sample of 1194 patients from the articles selected. All of the patients were prescribed on long-term anticoagulant treatment. The anticoagulant treatment was not suspended in any of the cases and the INR value was maintained within therapeutic ranges. Of the sample, 83 patients presented a certain degree of bleeding; in 77 of such cases, the bleeding was controlled with local hemostasis, whereas 6 patients required their dose of oral anticoagulants to be adjusted.
#2) 19239742Nematullah/2009 Patients on Warfarin TherapyMeta-Analysis
Key resultsContinuing the regular dose of warfarin therapy does not confer an increased risk of bleeding compared with discontinuing or modifying the warfarin dose for patients undergoing minor dental procedures.
#3) 14649397Carter/2003Patients taking Warfarin requiring ExtractionsSystematic review of randomized trials
Key resultsPatients therapeutically anti-coagulated with warfarin can be treated without interruption of their warfarin regimen provided appropriate local measures are used.
#4) 21196857Wahl/1998Patients on Oral Anticoagulant therapy requiring oral surgerySystematic review of randomized trials
Key resultsAlthough there is a theoretical risk of hemorrhage after dental surgery in patients who are at therapeutic levels of anti-coagulation, the risk appears to be minimal, the bleeding usually can be easily treated with local measures, and this risk may be greatly outweighed by the risk of thromboembolism after withdrawal of anticoagulant therapy.
Evidence Search PubMed Search; “Warfarin/therapeutic use” MeSH, “Tooth extraction” MeSH, “Postoperative Hemorrhage” MeSH
Comments on
The Evidence
Numerous research articles detail clinical trials for the management of anti-coagulated patients needing dental extractions. The articles selected represent a review of multiple clinical trails and research available reach a literature-supported conclusion.
Applicability Applicable to providers managing patients on warfarin needing dental extractions.
Specialty/Discipline (Oral Medicine/Pathology/Radiology) (General Dentistry) (Oral Surgery) (Periodontics)
Keywords Anticoagulation, Warfarin, Dental extractions, Local hemostasis
ID# 2600
Date of submission: 11/06/2013spacer
E-mail amana.farrkh@ucdenver.edu
Author Amana Farrkh
Co-author(s)
Co-author(s) e-mail
Faculty mentor/Co-author Thomas Borris, DDS
Faculty mentor/Co-author e-mail thomas.borris@ucdenver.edu
Basic Science Rationale
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