A patient on warfarin presents for tooth extraction. What perioperative considerations are essential?

• A. Perform the extraction as planned with no changes to medication.
• B. Avoid local hemostatic measures to prevent clotting.
• C. Check INR and coordinate with the patient’s physician, avoid unnecessary bridging, use local hemostasis, minimize trauma, consider tranexamic acid mouthwash and post-procedural monitoring.
• D. Prescribe antibiotics for all patients regardless of signs.

Answer: (C)

Balancing bleeding risk with thrombosis risk during a dental extraction for a patient on warfarin requires a careful, coordinated approach. The essential steps start with checking the patient’s INR to know how anticoagulated they are and then coordinating with the prescribing physician about whether any adjustment or bridging is needed. In most cases for a straightforward extraction, unnecessary bridging is avoided because it can increase both bleeding risk and thromboembolic complications.

Plan around effective local hemostasis and minimize trauma during the procedure. This means using an atraumatic extraction technique, achieving secure socket closure with sutures as needed, and applying local hemostatic measures such as absorbable hemostatic agents or reliable compression. Incorporating tranexamic acid mouthwash can further stabilize clots by reducing fibrinolysis, which helps limit post-extraction bleeding in patients on anticoagulants.

Post-procedure, monitor for signs of prolonged bleeding and provide clear instructions on care and when to seek help. Avoid NSAIDs that can impair hemostasis, and manage pain with appropriate alternatives. Antibiotics are not routinely prescribed for all patients unless there are specific infection risks or guidelines warrant them.

This approach directly targets safe bleeding control while preserving effective anticoagulation, which is why it’s the best choice in this scenario.