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Oral Anticoagulant and Antiplatelet Medications and Dental Procedures
Key Points
There is both a growing number of individuals prescribed anticoagulation or antiplatelet therapy, as well as medications for this purpose.
There is strong evidence for the older medications (i.e., warfarin, antiplatelet agents), as well as limited evidence for the newer direct-acting
oral anticoagulants medications that, for most patients, it is not necessary to alter anticoagulation or antiplatelet therapy prior to dental
intervention.
Drug Class Drug Names
Anticoagulant* warfarin (Coumadin®)
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clopidogrel (Plavix®)
ticlopidine (Ticlid®)
Antiplatelet agents* prasugrel (Effient®)
ticagrelor (Brilinta®)
aspirin
dabigatran (Pradaxa®)
rivaroxaban (Xarelto®)
Direct-acting oral anticoagulants**
apixaban (Eliquis®)
edoxaban (Savaysa® [Lixiana® in Europe, Japan, elsewhere])
* Strong evidence
** Limited evidence
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
Introduction
Oral anticoagulant and antiplatelet agents are prescribed for individuals who are at high risk for or who have had thromboembolic events (e
blood clots). These include patients who have experienced deep-vein thrombosis (DVT) or pulmonary embolism (PE) or who have nonvalvul
atrial fibrillation (NVAF), a cardiac arrhythmia that predisposes patients to clot formation. Oral anticoagulants include the vitamin K
antagonist warfarin (Coumadin®) and the newer direct-acting agents, including the direct thrombin inhibitor dabigatran (Pradaxa®) and th
factor Xa inhibitors apixaban (Eliquis®), rivaroxaban (Xarelto®), and edoxaban (Savaysa® [Lixiana® in the European Union, Japan, and others]
6 Oral antiplatelet agents include clopidogrel (Plavix®), ticlopidine (Ticlid®), prasugrel (Effient®), ticagrelor (Brilinta®), and/or aspirin.7 Advers
effects associated with these drugs can include prolonged bleeding or bruising.
Without the anticoagulant/antiplatelet medications, these patients are at higher risk for blood clot development, which could result in
thromboembolism, stroke, or myocardial infarction (MI). The serious risks of stopping or reducing these medication regimens need to be
balanced against the potential consequences of prolonged bleeding,8-12 which can be controlled with local measures such as mechanical
pressure, hemostatic agents (e.g., Gelfoam® or Surgicel®), suturing, and/or antifibrinolytics, such as tranexamic acid.13-20 The following
sections review the evidence on management of patients taking these drugs and undergoing dental procedures.
Evidence: Direct-Acting Oral Anticoagulants
Four direct-acting oral anticoagulants have been approved for marketing in the U.S. for use in patients to prevent or treat DVT and PE, or
reduce the risk of stroke and systemic embolism in patients with NVAF. These are dabigatran (Pradaxa®), apixaban (Eliquis®), rivaroxaban
(Xarelto®), and edoxaban (Savaysa® [Lixiana® in the European Union, Japan, and others]).1-4 These agents differ from traditional oral
anticoagulant therapy (i.e., warfarin) in that they are targeted in action; are given as fixed doses; have more predictable pharmacokinetics an
shorter half-lives; require little to no routine monitoring; and have fewer drug or food interactions.21
There is no direct evidence from prospective trials comparing different periprocedural management strategies for dental patients receiving
the target-specific oral anticoagulants and evaluating effects on patient outcomes. However, based on limited evidence as reviewed in the
following sections, in most cases, there is no need to alter the anticoagulation regimen prior to most dental interventions.18, 22-26
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A 2015 consensus guideline from the European Heart Rhythm Association27, 28 (updating a 2013 guideline29) suggests that interventions not
necessarily requiring discontinuation of the newer anticoagulants include extraction of 1 to 3 teeth; periodontal surgery; abscess incision; or
implant positioning.
A 2019 systematic review and meta-analysis on direct oral anticoagulant management for invasive oral procedures by Manfredi et al.30
included 21 papers in their review; no randomized, controlled trials were found. Six studies that were included in the meta-analysis reported
direct comparisons of continued versus discontinued direct oral anticoagulant therapy prior to dental procedures. The authors reported no
discernable important differences in postoperative bleeding events between people who continued versus discontinued direct oral
anticoagulation therapy; however, they cautioned that the results should be interpreted with caution because of the low quality of the
evidence and the small number of participants included in the studies.
A 2018 systematic review31 looked at the question of how to safely manage direct-acting oral anticoagulants in patients requiring dental
procedures with low-to-moderate risk of bleeding. Procedures that were defined as being low risk were administration of local anesthetic,
simple restorations, supragingival scaling, and single tooth extraction; procedures considered moderate risk were extractions of 2 to 4 teeth
and local gingival surgery of 5 or fewer teeth. Five papers were included in the review of evidence. Among patients receiving the direct-actin
anticoagulants and undergoing dental procedures associated with low-to-moderate bleeding risk, bleeding rates were low whether the
anticoagulant was continued or held periprocedurally. Bleeding that was documented was generally mild and controlled by local hemostati
measures.
Two narrative reviews published in 201513, 32 included suggestions regarding more conservative approaches that might be considered, such a
maximizing the time between the last dose of the anticoagulant and the dental intervention, especially in patients who may have higher ris
of bleeding or when there may be increased risk of perioperative bleeding.
Evidence: Warfarin and Antiplatelet Agents
Warfarin or antiplatelet agents such as clopidogrel (Plavix®), ticlopidine (Ticlid®), prasugrel (Effient®), ticagrelor (Brilinta®) and/or aspirin are
commonly used in patients who have experienced a DVT or PE, patients who have had an MI and/or who have undergone cardiac stent
placement, or in patients with NVAF.7 As reviewed in the following sections, there is general agreement based on strong evidence that
treatment regimens with these older anticoagulants/antiplatelet agents should not be altered before dental procedures.8, 14-16, 22, 25, 33-43
Warfarin
A 2009 systematic review and meta-analysis found no increased risk of bleeding associated with continuing regular doses of warfarin in
comparison with discontinuing or modifying the dose for patients undergoing single and multiple tooth extraction.33 In its most recent
statement, the American Academy of Neurology recommended that patients taking aspirin or warfarin for stroke prevention and undergoin
dental procedures continue taking their medications.35
A 2015 systematic review of management of dental extractions in patients receiving warfarin determined that patients whose International
Normalized Ratio (INR; a measure of warfarin's therapeutic index) was in therapeutic range (i.e., 3.0 or less) could continue their regular
warfarin regimen prior to the procedure.41 Based on a literature review, a 2016 Clinical Practice Statement from the American Academy of Or
Medicine determined that moderately invasive oral surgery (defined as "uncomplicated tooth extraction") is safe with an INR of 3.5, with som
experts stating that it is safe up to 4.0.17 A 2008 systematic review and meta-analysis by Oake et al.44 found that although the risks of
hemorrhage and thromboembolism are reduced at an INR range of 2 to 3, ratios moderately higher than this range appeared to be safe and
more effective than subtherapeutic ratios.
Single or Dual Antiplatelet Therapy
The American Heart Association, the American College of Cardiology, the Society for Cardiovascular Angiography and Interventions, the
American College of Surgeons, and the American Dental Association published a consensus opinion about drug-eluting stents and
antiplatelet therapy (e.g., aspirin, clopidogrel, ticlopidine).9, 10 The consensus opinion states that healthcare providers who perform invasive o
surgical procedures (e.g., dentists) and are concerned about periprocedural and postprocedural bleeding should contact the patient’s
cardiologist regarding the patient's antiplatelet regimen and discuss optimal patient management, before discontinuing the antiplatelet
medications. Given the importance of antiplatelet medications post-stent implantation in minimizing the risk of stent thrombosis, the
medications should not be discontinued prematurely.9, 10
A 2020 systematic review and meta-analysis45 evaluated the incidence of bleeding after minor oral surgery in patients on dual antiplatelet
therapy (aspirin plus another antiplatelet agent) compared with single-agent therapy or no antiplatelet therapy and found clinically similar
rates of bleeding across the three groups. When bleeding did occur, it was managed with local measures and no fatal events occurred. The
authors concluded that dual antiplatelet therapy interruption prior to minor oral surgery was not advised.
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A 2013 systematic review14 found no clinically significant increased risk of postoperative bleeding complications from invasive dental
procedures in patients on either single or dual antiplatelet therapy.
Other Patient Considerations
Some patients who are taking single or multiple anticoagulant medications may have additional co-morbid medical conditions or may be
receiving other treatments/medications that can increase the risk of prolonged bleeding after dental treatment, including liver impairment o
alcoholism; kidney failure; thrombocytopenia, hemophilia, or other hematologic disorders; or may be currently receiving a course of cytotoxic
medication (e.g., cancer chemotherapy). In these situations, dental practitioners may wish to consult the patient's physician to determine
whether care can safely be delivered in a primary care office.38, 39 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.13, 17, 37, 46
Summary
There is general agreement that in most cases, treatment regimens with older anticoagulants (e.g., warfarin) and antiplatelet agents (e.g.,
clopidogrel, ticlopidine, prasugrel, ticagrelor, and/or aspirin) should not be altered before dental procedures. The risks of stopping or reducing
these medication regimens (i.e., thromboembolism, stroke, MI) far outweigh the consequences of prolonged bleeding, which can be
controlled with local measures. In patients with comorbid medical conditions that can increase the risk of prolonged bleeding after dental
treatment or who are receiving other therapy that can increase bleeding risk, dental practitioners may wish to consult the patient's physicia
to determine whether care can safely be delivered in a primary care office. Any suggested modification to the medication regimen prior to
dental surgery should be done in consultation and on advice of the patient's physician.
On the basis of limited evidence, general consensus appears to be that in most patients who are receiving the newer direct-acting oral
anticoagulants (i.e., dabigatran, rivaroxaban, apixaban, or edoxaban) and undergoing dental interventions (in conjunction with usual local
measures to control bleeding), no change to the anticoagulant regimen is required. In patients deemed to be at higher risk of bleeding (e.g.,
patients with comorbid conditions or undergoing more extensive procedures associated with higher bleeding risk), consideration may be
given, in consultation with and on advice of the patient's physician, to postponing the timing of the daily dose of the anticoagulant until afte
the procedure; timing the dental intervention as late as possible after last dose of anticoagulant; or temporarily interrupting drug therapy fo
24 to 48 hours. Further research is needed to definitively establish periprocedural management strategies for these patients, especially thos
considered to be at higher risk of bleeding.
References
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10. Grines CL, Bonow RO, Casey DE, Jr., et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronar
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Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the
American College of Physicians. Circulation 2007;115(6):813-8.
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18. Kaplovitch E, Dounaevskaia V. Treatment in the dental practice of the patient receiving anticoagulation therapy. J Am Dent Assoc
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19. Ockerman A, Miclotte I, Vanhaverbeke M, et al. Local haemostatic measures after tooth removal in patients on antithrombotic therapy
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surgery. Int J Oral Maxillofac Surg 2016;45(5):618-30.
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25. Miller CS. A perspective on "The mythology of anticoagulation interruption for dental surgery". J Am Dent Assoc 2018;149(1):3-6.
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27. Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K
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29. Heidbuchel H, Verhamme P, Alings M, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants
in patients with non-valvular atrial fibrillation. Europace 2013;15(5):625-51.
30. Manfredi M, Dave B, Percudani D, et al. World workshop on oral medicine VII: Direct anticoagulant agents management for invasive or
procedures: A systematic review and meta-analysis. Oral Dis 2019;25 Suppl 1:157-73.
31. Lusk KA, Snoga JL, Benitez RM, Sarbacker GB. Management of Direct-Acting Oral Anticoagulants Surrounding Dental Procedures Wit
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33. Nematullah A, Alabousi A, Blanas N, Douketis JD, Sutherland SE. Dental surgery for patients on anticoagulant therapy with warfarin: a
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34. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest
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Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):299S-339S.
35. Armstrong MJ, Gronseth G, Anderson DC, et al. Summary of evidence-based guideline: periprocedural management of antithrombotic
medications in patients with ischemic cerebrovascular disease: report of the Guideline Development Subcommittee of the American
Academy of Neurology. Neurology 2013;80(22):2065-9.
36. van Diermen DE, Aartman IH, Baart JA, Hoogstraten J, van der Waal I. Dental management of patients using antithrombotic drugs:
critical appraisal of existing guidelines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107(5):616-24.
37. van Diermen DE, van der Waal I, Hoogstraten J. Management recommendations for invasive dental treatment in patients using oral
antithrombotic medication, including novel oral anticoagulants. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116(6):709-16.
38. Perry DJ, Noakes TJ, Helliwell PS, British Dental Society. Guidelines for the management of patients on oral anticoagulants requiring
dental surgery. Br Dent J 2007;203(7):389-93.
39. United Kingdom National Health Service. Surgical management of the primary care dental patient on antiplatelet medication.
National Electronic Library of Medicines: 2007. Accessed September 28, 2022.
40. Alaali Y, Barnes GD, Froehlich JB, Kaatz S. Management of oral anticoagulation in patients undergoing minor dental procedures. J Mic
Dent Assoc 2012;94(8):36-41.
41. Weltman NJ, Al-Attar Y, Cheung J, et al. Management of dental extractions in patients taking warfarin as anticoagulant treatment: A
systematic review. J Can Dent Assoc 2015;81:f20.
42. Dunn AS, Turpie AG. Perioperative management of patients receiving oral anticoagulants: a systematic review. Arch Intern Med
2003;163(8):901-8.
43. Madrid C, Sanz M. What influence do anticoagulants have on oral implant therapy? A systematic review. Clin Oral Implants Res 2009;2
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44. Oake N, Jennings A, Forster AJ, et al. Anticoagulation intensity and outcomes among patients prescribed oral anticoagulant therapy: a
systematic review and meta-analysis. Cmaj 2008;179(3):235-44.
45. Ockerman A, Bornstein MM, Leung YY, et al. Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a
systematic review and meta-analysis. Int J Oral Maxillofac Surg 2020;49(1):90-98.
46. Hupp WS. Cardiovascular Diseases. In: Patton LL, Glick M, editors. The ADA Practical Guide to Patients with Medical Conditions. 2nd ed
Hoboken, NJ: John Wiley & Sons, Inc.; 2016. p. 25-42.
ADA Resources
JADA for articles on anticoagulants and dental procedures
ADA Library Services
ADA Store: The ADA Practical Guide to Patients with Medical Conditions
Other Resources
U.S. Food & Drug Administration MedWatch Program. If a practitioner suspects a patient to have had an adverse drug reaction, they may
contact the FDA’s MedWatch program online or by calling 800-FDA-1088.
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Last Updated: September 28, 2022
Prepared by:
Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC.
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