Dental Extractions on Anticoagulants: Continue vs Hold (Warfarin & DOACs)

Published September 6, 2025 · Dentistry

Short version: For simple dental extractions, continuation of anticoagulation with local hemostasis is often reasonable per many institutional policies. If an interruption is considered, base it on drug, procedure bleeding risk, and renal function (CrCl). For DOACs, do not bridge. For warfarin, follow INR governance and coordinate with dentistry.

How to think about continue vs hold

• Procedure risk & extent: Single-tooth/simple extractions with suturing and local measures usually bleed minimally; multi-tooth, surgical flaps, or complex cases raise risk.
• Anticoagulant class: Warfarin relies on INR governance; DOACs (apixaban, rivaroxaban, edoxaban, dabigatran) use hold windows scaled by bleeding risk and renal function.
• Renal function (CrCl): Lower CrCl increases exposure (especially dabigatran) and may warrant longer holds if interruption is chosen.
• Local hemostasis toolkit: atraumatic technique, sutures, pressure packs, topical TXA per policy, and clear post-op instructions.

Warfarin (Coumadin): when to continue vs hold

For minor dentistry (e.g., simple extractions), continuation of warfarin with local measures is often acceptable when the INR is therapeutic and the dentist is prepared for local hemostasis. If interruption is required for more extensive procedures, common approaches include:

• Stop 5 days before the planned procedure date.
• Check INR pre-procedure; aim for < 1.5 if an interruption is required for an invasive case.
• Bridging: Reserve for high or very-high thrombotic risk only and coordinate with Hematology. For renal impairment (<30 mL/min), UFH is preferred to therapeutic LMWH.
• Restart once hemostasis is secure; typically within 12–24 h for minor/low-risk dental procedures.

Need a personalized plan with timestamps? Use the AnticoagPlanner calculator and select the procedure risk, drug, and renal function to generate stop/restart instructions and governance lines.

DOACs (Eliquis, Xarelto, Pradaxa, Savaysa): practical approach

For simple extractions with robust local measures, many policies allow continuation of DOACs. If an interruption is chosen based on patient/procedure specifics:

• Short, conservative holds for low-risk dentistry; longer holds for higher-risk cases.
• Dabigatran needs longer holds at low CrCl (e.g., <50 mL/min); avoid neuraxial with severe impairment.
• Do not bridge DOACs. If very-high thrombotic risk is a concern, consult Hematology rather than auto-bridging.
• Restart after hemostasis is secure; for low-risk dental cases this is often the evening of or the day after, per local policy.

Coordinate with dentistry & give clear post-op instructions

• Share the plan (continue vs hold, timing, and restart) with the dentist/oral surgeon.
• Use a local hemostasis bundle (pressure, sutures, gauze, topical TXA per protocol).
• Provide post-op instructions on pressure application, diet, and whom to contact if bleeding persists.

Common scenarios (examples)

Simple extraction on warfarin with INR in range

Proceed with continuation, coordinate with dentistry for local measures. No routine bridging. If unexpected INR elevation is found, delay or correct according to local policy.

Simple extraction on apixaban (Eliquis) with normal renal function

Continuation is often reasonable. If a hold is chosen, keep the window short and avoid bridging. Restart after hemostasis is secure.

Complex multi-tooth extraction on dabigatran with reduced CrCl

Consider interruption with longer hold based on renal function, and schedule when support for close monitoring and local measures is available. Do not bridge. Restart later if hemostasis is tenuous.

FAQ

Can patients stay on blood thinners for a tooth extraction?

Often yes for simple cases with good local hemostasis, but confirm local policy and collaborate with the dentist. For higher-risk cases or complex oral surgery, an interruption plan may be appropriate.

What about neuraxial anesthesia for dental work?

Neuraxial techniques are uncommon in dental extractions. If neuraxial anesthesia or deep blocks are in play, follow neuraxial timing and catheter rules and avoid dosing while a catheter is in place.

When should anticoagulants be restarted after extraction?

After hemostasis is secure. For low-risk dental cases, this is often within 12–24 hours. High-risk procedures or ongoing oozing warrant a later restart. The calculator provides timing windows based on risk and drug class.

Sources

• MD Anderson. Peri-Procedure Anticoagulants, V8 (approved 07/15/2025) — core stop/restart frames; DOAC no-bridging governance; INR governance for warfarin.
• Institutional dental/oral surgery protocols for local hemostasis bundles (topical TXA usage varies by site) — confirm local policy.