Oral Surgery & Blood Thinners

Is oral surgery safe when taking blood thinning medications?

Dear Doctor,
I am a 66 year old male and unfortunately need to have a few bad teeth removed. I am nervous because I am taking warfarin. Do you have any information or advice?

Dear Charles,
Your question raises two important topics: what does warfarin do and what are the consequences for tooth removal or any other oral surgical procedures. Let's take them one at a time — we'll paint these topics with a broad brush in order to give you some guidelines.

Warfarin as you probably know is a potent blood thinning medication and is used for a variety of medical conditions as an anti-coagulant — as the name implies to stop blood from clotting. It is usually given to people with an increased tendency for thrombosis (blood clot formation inside blood vessels) or to prevent of further clots in those who have had them before. It helps prevent the serious risk of heart attack and stroke that these clots can pose. Common conditions for which warfarin is used include atrial fibrillation (the heart's two upper chambers, fibrillate or beat out of normal rhythm); deep venous thrombosis (clotting in the deep leg veins) and pulmonary embolism (blood clots moving into the lungs). Anti-coagulant therapy may also be given as a preventive measure in patients who have artificial heart valves and on a short-term basis to those who have had surgeries, such as knee replacements.

For a person of any age, but especially as you get older your health status is important and needs to be evaluated carefully along with many other clinical or medical factors to make sure you are healthy enough to undergo surgery, even oral surgery for tooth removal.

It should also be pointed out that the commonly used drug aspirin is a potent blood thinner and many people forget or don't know to tell their doctors they are taking it before undergoing surgery.

Aspirin is a potent blood thinner; if you are taking it tell your doctor before undergoing surgery.

Now for the good news — warfarin treatment is not a contra-indication to having teeth removed or for that matter, having them replaced with dental implants. In other words one thing has nothing directly to do with the other. Indirectly though, surgery for anyone on blood thinners can be complicated because blood will not clot normally and it can be difficult to stop bleeding. However, tooth removal usually constitutes minor oral surgery, especially with a minimum of trauma or damage to tissues, in careful and experienced surgical hands.

The surgeon who assesses your condition should work with your medical doctor to determine the risk and monitor your warfarin dosage appropriately. The safety of maintaining, modifying or reducing your warfarin dosage to accommodate tooth extraction or any other minor oral surgery will depend on what condition you are taking it for, together with the particular type of surgery you need.

The traditional measure of blood clotting is something called the Pro-thrombin Time (PT) and the International Normalized Ratio (INR). It is quite conceivable that your medical doctor will reduce your dosage based on the PT/INR levels, which together with local measures (specially treating the surgical area) will ensure that you have sufficient ability to stop bleeding and heal well. The key is communication between your doctors and their experience and judgment. If it is not considered safe for you to stop warfarin completely, an INR of below 4 may be acceptable, between 2 and 3 is preferable, but these are guidelines only and require a discussion between your physician and surgeon.

For the surgical procedure related to tooth removal, your dental surgical specialist (oral surgeon or periodontist), or general dentist can take special precautions to help insure blood clotting and an uneventful healing time after the surgery. These include treatment of the surgical site with special haemostatic agents (haem – blood, stasis – still) which helps stabilize a blood clot, then carefully suturing (stitching) the gum tissues to reduce the surface area of the wound opening and putting tension on the wound edges to prevent the capillaries (tiny blood vessels) from bleeding excessively. It is also common practice today to place a bone graft into an extraction socket to prevent the otherwise inevitable shrinkage of your bone, especially important if you are contemplating implant tooth replacement. This will also reduce the volume of bleeding.

Anti-anxiety medication, good pain control and anti-inflammatory medication, together with rest and avoidance of vigorous activity will all help ensure a comfortable and safe recuperative period, necessary for the first few days. You will be able to resume warfarin (or aspirin for those who take it) almost immediately afterwards, under the direction of your doctors.

I sincerely hope you find this information helpful. Be sure to consult with both your physician and dentist or surgical specialist to allay your anxiety.