Cirugía Bucal

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British Journal of Oral and Maxillofacial Surgery (2002) 40, 248–252
© 2002 The British Association of Oral and Maxillofacial Surgeons
doi: 10.1054/bjom.2001.0773, available online at http://www.idealibrary.com on

BRITISH

Journal of
Oral and
Maxillofacial
Surgery

Can warfarin be continued during dental extraction? Results of
arandomized controlled trial
I. L. Evans,* M. S. Sayers,* A. J. Gibbons,* G. Price,* H. Snooks,† A. W. Sugar*
*Maxillofacial Unit, Morriston Hospital, Swansea, UK; †Mid and West Wales Research and Development
Support Unit, School of Postgraduate Studies in Medical and Health Care, University of Wales, Swansea, UK
SUMMARY. A randomized controlled trial was set up to investigate whether patients whowere taking warfarin
and had an International Normalised Ratio (INR) within the normal therapeutic range require cessation of
their anticoagulation drugs before dental extractions. Of 109 patients who completed the trial, 52 were allocated to the control group (warfarin stopped 2 days before extraction) and 57 patients were allocated to the
intervention group (warfarin continued). The incidenceof bleeding complications in the intervention group
was higher (15/57, 26%) than in the control group (7/52, 14%) but this difference was not significant. Two
patients in the study required hospital review for bleeding and all other episodes of bleeding were controlled by
patients at home. Continuing warfarin when the INR is :4.1 may lead to an increase in minor post-extraction
bleeding afterdental extractions but we found no evidence of an increase in clinically important bleeding.
As there are risks associated with stopping warfarin, the practice of routinely discontinuing it before dental
extractions should be reconsidered. © 2002 The British Association of Oral and Maxillofacial Surgeons

bacterial endocarditis may increase the effects of warfarin and the risk of bleeding.Indeed, several case
reports have been published of antibiotic-induced bleeding in patients who were taking warfarin after dental
procedures.11
Customary practice in the UK has been to stop warfarin treatment 2 days before extractions, to do an INR
on the day of operation and to proceed if the INR is
:2.1. Warfarin is started again later the same day.12
Several authors have suggested thatthe anticoagulant
regimen does not require alteration for dental extractions if the INR is :4.0.1,12–16 Additional measures that
can be taken to ensure haemostasis include packing
sockets with oxidized cellulose gauze and suturing all
sockets.1,12 Tranexamic acid has been used as a mouth
rinse to reduce haemorrhage further postoperatively.15,17
Because of the risks associated with eitherstopping or
continuing warfarin for dental extraction, general dental
and medical practitioners routinely refer patients who
are taking warfarin to maxillofacial units for this procedure. If patients could be treated without altering their
anticoagulant regimen, then it is possible that most
dental extractions could be done in general dental practice on the same day as regular INR bloodmonitoring.
This would often be more convenient and quicker for the
patient, cost-effective and would help to reduce hospital
waiting lists.

INTRODUCTION
Warfarin is the most commonly prescribed oral anticoagulant. At present over 300,000 people in the UK
are taking oral anticoagulants1 and the treatment is
underused in some conditions.2 With an ageing population in the UK and a greaterproportion of this population retaining their teeth, the number of patients taking
warfarin who require dental extractions is likely to
increase.
Therapeutic levels of warfarin are measured by the
International Normalised Ratio (INR). The British
Society of Haemotology has published guidelines on
anticoagulant control which recommend a maximum
target INR of 3.5, with a range of 3–4.3 For dental...