Anticoagulants and antiplatelet drugs before an extraction: what the ADA and SDCEP say about interrupting therapy

What it says#

The ADA's oral health topic page is the American summary, and its key point is one sentence: there is strong evidence for the older medications, warfarin and the antiplatelet agents, and limited evidence for the newer direct-acting oral anticoagulants, that for most patients it is not necessary to alter anticoagulation or antiplatelet therapy prior to dental intervention. Its own two-row table reduces it further. Typical patient: no need to discontinue medication, use local measures to control bleeding. Patients with higher risk of bleeding: any suggested modification to the medication regimen prior to dental surgery should be done in consultation with and on advice of the patient's physician.

The drugs the page covers are named there: the anticoagulant warfarin (Coumadin); the antiplatelet agents clopidogrel (Plavix), ticlopidine (Ticlid), prasugrel (Effient), ticagrelor (Brilinta) and aspirin; and the direct-acting oral anticoagulants dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis) and edoxaban (Savaysa). The local measures it names are mechanical pressure, hemostatic agents such as Gelfoam or Surgicel, suturing, and antifibrinolytics such as tranexamic acid.

On warfarin, the ADA reports three findings. A 2009 systematic review and meta-analysis found no increased risk of bleeding from continuing regular doses compared with discontinuing or modifying the dose for single and multiple tooth extraction. A 2015 systematic review of extractions in patients receiving warfarin determined that patients whose INR was in therapeutic range, which it gives as 3.0 or less, could continue their regular regimen. A 2016 Clinical Practice Statement from the American Academy of Oral Medicine determined that moderately invasive oral surgery, defined as uncomplicated tooth extraction, is safe with an INR of 3.5, with some experts stating that it is safe up to 4.0. The page also notes the American Academy of Neurology's recommendation that patients taking aspirin or warfarin for stroke prevention and undergoing dental procedures continue taking their medications.

On direct oral anticoagulants, the page is candid about the evidence: there is no direct evidence from prospective trials comparing periprocedural management strategies in dental patients, and the 2019 Manfredi systematic review and meta-analysis included 21 papers with no randomized controlled trials and found no discernable important differences in postoperative bleeding between continuing and discontinuing, with the caveat that the low quality of evidence and small numbers mean the result should be read with caution. A 2015 European Heart Rhythm Association consensus guideline, as the ADA summarizes it, suggests that extraction of 1 to 3 teeth, periodontal surgery, abscess incision and implant positioning do not necessarily require discontinuation. Where a patient is at higher risk, the ADA's summary offers three options to be considered in consultation with the physician: postponing the timing of the daily dose until after the procedure, timing the intervention as late as possible after the last dose, or temporarily interrupting drug therapy for 24 to 48 hours.

On antiplatelet therapy, both single and dual, the direction is the same and firmer. The page cites the consensus opinion of the American Heart Association, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the American College of Surgeons and the ADA: providers concerned about bleeding should contact the patient's cardiologist before discontinuing antiplatelet medications, and given the importance of these drugs after stent implantation in minimizing stent thrombosis, they should not be discontinued prematurely. A 2020 systematic review and meta-analysis found clinically similar bleeding rates after minor oral surgery across dual therapy, single agent and no antiplatelet therapy, all managed with local measures and with no fatal events, and concluded that interrupting dual antiplatelet therapy before minor oral surgery was not advised.

For the operational numbers the ADA does not give, the clearest published source is Scottish. SDCEP's Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs, second edition, March 2022, is guidance for Scotland whose development process is NICE accredited, and it words its recommendations with their strength and certainty attached. For warfarin, acenocoumarol or phenindione: check the INR, ideally no more than 24 hours before the procedure, up to 72 hours if the patient is stably anticoagulated; if the INR is below 4, treat without interrupting medication, a strong recommendation on low certainty evidence; if the INR is 4 or above, delay invasive treatment or refer if urgent. For the direct oral anticoagulants apixaban, dabigatran, rivaroxaban and edoxaban: for low bleeding risk procedures, treat without interrupting medication; for higher bleeding risk procedures, advise the patient to miss or delay the morning dose before treatment, both conditional recommendations on very low certainty evidence. Its dose schedule table for higher risk procedures reads: apixaban or dabigatran, taken twice a day, miss the morning dose and take the post-treatment dose at the usual time in the evening; rivaroxaban or edoxaban taken once a day in the morning, delay the morning dose and take it 4 hours after hemostasis has been achieved; rivaroxaban or edoxaban taken once a day in the evening, no change, usual evening time. A footnote applies to all of them: as long as no earlier than 4 hours after hemostasis has been achieved, with the usual schedule resuming thereafter. For aspirin alone, and for clopidogrel, dipyridamole, prasugrel or ticagrelor as single or dual therapy, the recommendation is to treat without interrupting medication, strong recommendations on low certainty evidence, with the note for the dual and non-aspirin agents to expect prolonged bleeding, limit the initial treatment area and strongly consider suturing and packing.

Who it applies to#

Any patient on one of these drugs who is having a procedure likely to cause bleeding, which SDCEP's Table 1 defines rather than leaving to judgment. Unlikely to bleed: infiltration, intraligamentary or mental nerve block anesthesia, basic periodontal examination, supragingival scaling, supragingival restorations, orthograde endodontics, impressions, orthodontic adjustments. Likely to bleed, low risk: inferior dental block and other regional blocks, simple extractions of 1 to 3 teeth with a restricted wound, incision and drainage of intra-oral swellings, six-point periodontal charting, root surface debridement, subgingival restorations. Likely to bleed, higher risk: complex or adjacent extractions causing a large wound, more than 3 extractions at once, flap-raising procedures including surgical extractions, periodontal surgery, preprosthetic surgery, periradicular surgery, crown lengthening and implant surgery, gingival recontouring, and biopsies.

Three groups are outside the conversation entirely: SDCEP says do not interrupt therapy for patients with prosthetic metal heart valves or coronary stents, for patients who have had a pulmonary embolism or deep vein thrombosis in the last three months, or for patients on anticoagulant therapy for cardioversion. And SDCEP is Scottish guidance; the INR thresholds and dose timings above are its words for its jurisdiction, reported here because the ADA page does not publish equivalents.

What changed#

The direction of travel over twenty years has been away from interruption. The ADA's own reference list includes a 2003 JADA paper titled the lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment, and a 2018 JADA paper titled the mythology of anticoagulation therapy interruption for dental surgery. What is new since roughly 2015 is the direct oral anticoagulants, and the honest position on them, stated by both sources, is that the evidence is limited and low certainty rather than absent or negative. SDCEP's second edition in March 2022 replaced its first, restructured around bleeding risk categories, and the ADA page was last updated September 28, 2022.

Where the source is#

The link under the title is the ADA's Oral Anticoagulant and Antiplatelet Medications and Dental Procedures page, free on ada.org, prepared by its Research Services and Scientific Information group and last updated September 28, 2022; it carries the ADA's standard disclaimer that oral health topic content does not establish a standard of care. SDCEP's guidance and its quick reference guide are free PDFs from sdcep.org.uk, which also publishes the patient leaflet and the fillable pre-treatment instruction sheets for warfarin and for DOACs; SDCEP permits copying for non-commercial educational purposes and within NHS Scotland. Every number above, every drug name and every threshold is copied from one of those two sources and attributed to it in the text. Nothing here is a protocol for a particular patient; the treating dentist and the patient's physician or prescribing clinician make that decision together.