Management of dental extractions in patients on warfarin and antiplatelet therapy

Planning dental extractions for Taiwanese patients on antithrombotic therapy remains controversial. This study aimed to examine management of dental extraction in patients on warfarin and antiplatelet therapy.

Subjects comprised 1331 patients, with (1) 60 on warfarin with intentional normalized ratio (INR) below 4.0 (warfarin continued: 28 patients/33 occasions; warfarin stopped and switched to heparin under hospitalization: 32 patients/37 occasions); (2) 183 on antiplatelet therapy (aspirin: 125 patients/185 occasions; clopidogrel: 42 patients/65 occasions; dual therapy: 16 patients/24 occasions); and (3) a control group of 1088 patients/1472 occasions without any antithrombotic therapy. The patient's clinico-demographic parameters, warfarin effectiveness (dose and INR levels) and antiplatelet therapy, number and type of dental extraction and incidence of postoperative bleeding were investigated.

Incidence of postoperative bleeding in the warfarinized group (warfarin continued: 9.1%; warfarin stopped: 8.1%) was higher than in the antiplatelet group (aspirin: 1.1%; clopidogrel: 3.1%; dual antiplatelet: 4.2%), and the control group (0.7%), but these differences were not significant and unrelated to INR or number and type of dental extraction. Postoperative hemorrhage was managed successfully by repacking with Gelfoam impregnated with tranexamic acid powder in most patients.

The study indicated that there is no need to interrupt warfarin (INR<4.0) and antiplatelet therapy before dental extractions in Taiwanese patients. A sufficient hemostasis could be obtained using local measures. This approach can save these individuals from becoming exposed to the risk of thromboembolism and the inconvenience of bridging anticoagulation with heparin.