In cardiology, whether to discontinue blood thinners before surgical procedures depends on the individual patient. Discontinuing these medications increases the likelihood of clot formation and the risk of heart attack. Conversely, continuing them increases the risk of bleeding during the surgical intervention. Therefore, the final decision is determined by the balance between thrombosis and bleeding. In other words, the answer to the question, “Which is more likely to occur in this patient, or which outcome would cause more harm?” is the decisive factor. Regarding dental health, the consequences of a potential bleeding event in all procedures, including tooth extraction and implants, are not worse than cardiovascular complications. For this reason, the primary approach is not to discontinue blood thinners. That is to say; discontinuing Aspirin, clopidogrel, prasugrel, ticagrelor, warfarin and the new generation of drugs called NOACs (apixaban, dabigatran, edoxaban and rivaroxaban) before the procedure is not recommended. In summary, all dental procedures are performed while continuing these medications. Admittedly, the bleeding time in the gums will be prolonged; however, its clinical significance is less than that of cardiovascular complications. Solving gum bleeding is also not difficult. Applying prolonged pressure (tamponade) to the bleeding area or suturing will resolve the issue. The details are as follows (explained according to the active ingredient of the drug):
  • Aspirin, clopidogrel, prasugrel and ticagrelor: These drugs are vital, especially to prevent stents placed in heart vessels from being blocked by clots. These medications are taken at their routine hours, and the dental procedure is performed. The measurement called INR, checked in blood tests, is not related to the anticoagulant effect of these specific drugs.
  • Warfarin: INR is checked 3-4 days before the procedure. The goal is to detect very high INR levels (>3-3.5). If the INR is too high, the procedure is not recommended due to the risk of unnecessary bleeding. In this case, warfarin is discontinued, and the INR is rechecked after 2-3 days. If the INR is 2-2.5, the procedure is performed on the same day. An exception to this is patients with mechanical heart valves. Since the possibility of a prosthetic valve being blocked by a blood clot can be life-threatening, the procedure is usually performed within a higher INR range (INR 2-3.5), depending on the type of valve. There is a common but incorrect approach in daily practice: routinely discontinuing warfarin until INR <1.5 and temporarily starting injectable anticoagulants such as enoxaparin. Thanks to recent data, we now know that this approach increases the risk of clot formation and should no longer be routinely preferred. Exceptions where this approach may be applied are only high-risk surgeries such as brain, spinal cord, and retinal surgery. This is because, in these surgeries, if the operation is performed without lowering the INR and bleeding occurs, it can lead to very serious problems such as stroke and blindness.
  • Rivaroxaban and Edoxaban: These are medications taken once a day. The drug is taken at its routine hour the day before the procedure. The next day, the dental procedure is performed without taking the medication; the dose is taken a few hours after the procedure is finished (or if routinely taken in the evening, it is taken that same evening). Since whether the INR is low or high is unrelated to the anticoagulant effect of these drugs, INR is not used to monitor them; if it has been checked for some reason, no decision is made based on the resulting value.
  • Dabigatran and Apixaban: These are medications taken twice a day, in the morning and evening. The evening dose from the day before the procedure is taken at its routine hour. The procedure is performed the following morning, before the morning dose is taken. Thus, the procedure is carried out when the level of the drug given the previous evening—and therefore its anticoagulant effect—is at its lowest in the blood. The morning dose is delayed until a few hours after the procedure. The evening dose on the day of the procedure is taken again at its routine hour. INR is not used for monitoring these medications either.
References
  1. Halvorsen S, Mehilli J, Cassese S, et al. ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022 Oct 14;43(39):3826-3924.
  2. Steffel J, Collins R, Antz M, et al. EHRA Practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Europace. 2021 Oct 9;23(10):1612-1676.