The Blood Thinner Warfarin and Oral Healthcare

It is quite common for individuals who have heart valve disease; heart attacks; deep vein clotting tendencies; strokes; heart valve replacements and kidney dialysis to be on anticoagulation (blood thinning) medication. Two of the commonly used anticoagulants are: (i) “warfarin” for long term treatment; and (ii) “heparin” for short term treatment. Warfarin is the more commonly used anticoagulant and is taken by mouth. Treatment with warfarin impairs clotting (when blood cells come together to stop bleeding). Therefore after a laceration (cut), someone who is taking warfarin, will take longer than normal to stop bleeding. The warfarin’s effect usually takes 8-12 hours to begin and persists for 3 days.

Bleeding in the mouth can be excessive, even in non-anticoagulated patients. Consequently, dental patients on warfarin have an increased risk of bleeding during surgical procedures and as such, if a surgical procedure is required, the dental healthcare professional

a. Will assess the effect of the warfarin on the blood by using a laboratory test called the International Normalized Ratio (INR). The average person, who is not on warfarin, has an INR of 1. The number climbs depending on the amount of warfarin a person is using and the effect it has on the body’s ability to stop bleeding. The larger the number, the more likely the individual is to keep bleeding after a cut, when compared to the average person.

b. Be cognizant of the reason why the individual is taking the anticoagulant; and

c. Consider the type of dental procedure to be performed. Surgery is the main oral healthcare hazard to a patient on warfarin and therefore options such as root canal therapy should always be considered.

Dental preventative care should be emphasized, in order to reduce the possible need for dental surgery (i.e. an extraction) because of a decayed tooth.

For any elective dental surgery, it is imperative for the dental patient to understand the potential for excessive bleeding ‘during’ and ‘after’ the surgery.

In addition, it is worth noting that there are certain systemic conditions that can increase the risk of excessive bleeding especially in patients taking warfarin such as, (i) vascular diseases; (ii) malignancies; and (iii) HIV infection.

All well trained dental healthcare professionals, will be aware of and take great care in choosing the most appropriate medications to be used during any dental treatment, for a patient taking warfarin. Care will also be taken in choosing any medications to be prescribed after any dental treatment. This type of protocol is followed, in order to reduce any possibility of excessive bleeding during or after the dental treatment.

Caution is taken not only in choosing and prescribing medication, but a prudent dentist will also use procedural techniques that reduce excessive bleeding during and after dental treatment. In addition, the INR value is used as an indicator of the tendency of a patient to bleed excessively during a dental surgery. The INR is a guideline to care and is checked on the day of the surgical procedure or 24 hours prior to the surgery. It is crucial that a patient taking anticoagulation medication has all excessive bleeding analyzed. Despite all of the above, it is not usually necessary to ask patients to stop taking their warfarin medication for any period of time before a primary care dental surgical procedure. The American Heart Association (AHA) usually suggests that patients take no wafarin for a short time before major surgeries.

The American Dental Association Council on Scientific Affairs (ADA/SCA) has determined that the AHA guidelines for patients undergoing major surgery are not applicable for patients having dentoalveolar surgery (e.g. extractions). It is therefore acceptable to allow persons having minor surgeries to continue to take their warfarin medication and to be closely monitored during the procedure.

Furthermore, the ADA/SCA, the British Dental Association and the Haemostasis and Thrombosis Task Force of the British Committee for Standards in Hematology have reviewed scientific literature and have concluded that warfarin therapy should NOT be stopped for patients having routine dentoalveolar surgery if the INR is less than or equal to 4. There are no scientific studies regarding non routine, more extensive surgeries (e.g. more than 6 extractions at one visit; removal of impacted teeth and tori (normal bone excessive growth) removal).

The dental healthcare professional will make a final decision concerning what is best for the patient and will adhere to all current protocols to ensure patient safety. If you are taking the blood thinner warfarin, please remember to tell your oral healthcare professional. The professional will use the information, to ensure that special precaution is taken when managing your mouth health and if necessary; your medical doctor will be consulted. This is to ensure the safest experience for you. Full disclosure of the medications you use is crucial and may be life saving.