From the Christiana Care Health System (Dr Wahl); the University Hospitals Case Medical Center (Dr Pinto); and the Section of Oral Medicine, University of Connecticut Health Center (Dr Lalla).
Correspondence to: Michael J. Wahl, DDS, 2003 Concord Pike, Wilmington, DE 19803; e-mail: WahlDentistry@aol.com
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
When performing dental surgery in patients receiving warfarin for anticoagulation, clinicians must weigh the risk of bleeding complications in continuous anticoagulation vs that of thromboembolic complications with anticoagulation interruption. Multiple studies have shown that dental surgery (including extractions) can be performed safely at therapeutic international normalized ratio (INR) levels (INR ≤ 3.5) with local hemostatic measures. Of the few cases needing more than local hemostatic measures (eg, vitamin K injection and/or fresh frozen plasma), most involved higher than therapeutic INR levels, and none was fatal. On the other hand, there have been many documented cases of serious thromboembolic complications (including deaths) after anticoagulation interruption for medical/dental procedures.
The American College of Chest Physicians issued statements in 2001, 2004, and 2008 recommending continuing anticoagulation for dental procedures. In a supplement to CHEST (February 2012), the American College of Chest Physicians statement by Douketis et al1 provided two options for minor dental procedures (including extractions and root canal treatments): continuing warfarin with coadministration of an oral prohemostatic agent or stopping warfarin 2 to 3 days before the procedure. This latter option was described as partial interruption of anticoagulant therapy, resulting in an INR of 1.6 to 1.9 on the day of the procedure. However, INR levels resulting from warfarin dose alterations can vary widely, and it may take a few days to get back to therapeutic INR levels after restarting warfarin.
Four prospective studies were cited in support of the option for partial interruption. In each of the four studies cited, dental surgery in patients who were taking anticoagulants was compared with dental surgery in patients whose anticoagulation was reduced or interrupted.2-5 Although there were no embolic complications in any of these patients, there were also no bleeding complications requiring more than local measures for hemostasis. The incidence of bleeding was the same in both the anticoagulation continuation and interruption groups in each study, and the authors of each of the four studies concluded that anticoagulation should not be interrupted for dental surgery.
In summary, local hemostatic measures are almost always sufficient for dental surgery in patients on warfarin, with no long-term sequelae. In contrast, thromboembolic events occurring in patients with warfarin interruption are much more likely to result in permanent disability or death. We, therefore, respectfully suggest that the option for alteration of warfarin therapy should be eliminated for minor dental procedures (including extractions) and reserved only for the most invasive oral surgical procedures in which a significant amount of blood loss is anticipated (eg, orthognathic surgery).
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