Managing patients who are taking warfarin and undergoing dental treatment

in Primary Care

General guidelines If increased bleeding occurs then the

If patients on warfarin who require dental patient should be advised to contact Is the patient known to
surgery have an International Normalised their usual anticoagulant monitoring have liver impairment/
Ratio (INR) of below 3.5, they can usually service to arrange additional INR testing high alcohol intake,
receive their dental treatment in primary and dose review. significant renal impairment,
thrombocytopenia, YES
care without needing to stop their Metronidazole Refer to specialist services.
warfarin or adjust their dose. haemophilia or other
Metronidazole interacts with warfarin haemostasis disorders, are
The risk of thromoembolism after and should be avoided if possible. If it they receiving chemotherapy
temporary withdrawal of warfarin therapy cannot be avoided, the warfarin dose or taking more than one
outweighs the risk of oral bleeding may need to be reduced by a third to a antiplatelet drug?
following dental surgery. half, and re-adjusted again when
Patients on warfarin may bleed more than the antibiotic is discontinued. Patients NO
normal, but bleeding is usually controlled should be advised to contact their usual
with local measures. anticoagulant monitoring service to
Obtain an INR measured
arrange additional INR testing and dose
Drug interactions no more than 48 hours
review.
before the dental
The list of drug interactions in this
Analgesia procedure
guidance is not comprehensive and Refer to anticoagulation
practitioners are advised to check Non-steroidal anti-inflammatory service. Reschedule the
a source such as the BNF (www. drugs including ibuprofen, aspirin procedure when INR is less
medicinescomplete.com). However, and diclofenac should not be used as than 3.5. Refer to specialist
common drugs that dentists may analgesics in patients taking warfarin. Does the patient have an NO services for dental treatment
prescribe, which can cause interactions, INR of 3.5 or below? if INR remains above 4.0 or
are as follows: Dental surgery covered by this control is erratic.
advice includes: YES
Amoxicillin
Treatment where the INR does not need
There have been anecdotal reports to be checked: Consider the timing of Use a local For extractions,
that amoxicillin interacts with warfarin
the dental procedure. It is anaesthetic gently pack
causing increased prothrombin time
• Prosthodontics recommended treatment containing a the socket with
and/or bleeding, but documented cases
• Conservation takes place in the morning vasoconstrictor. an absorbable
are relatively rare. Patients requiring a
at the beginning of the Where possible haemostatic
course of amoxicillin should be advised • Endodontics
week when re-bleeding use an infiltration, dressing.
to be vigilant for any signs of increased • Hygiene Phase Therapy problems can be managed intraligamentary Drug therapy: if the patient
bleeding.
during the working day and or mental nerve Carefully suture requires analgesia, use
Erythromycin and other macrolide Treatment where the INR does need to working week. injection. If there the socket where paracetamol. Avoid non-
antibiotics (e.g. azithromycin) be checked (follow the diagram): It is advisable to extract one is no alternative possible. steroidal anti-inflammatories,
Macrolide antibiotics interact with or two teeth, especially for and an inferior for example, ibuprofen,
warfarin unpredictably and only in certain multi-rooted teeth. alveolar nerve aspirin and diclofenac.
• Extractions
individuals. Patients should be advised In a hospital setting, with block is used, the
• Minor oral surgery injection should
to be vigilant for any signs of increased appropriately trained staff,
bleeding. • Periodontal surgery be administered
it is possible to provide
routine treatment for slowly using
patients with an INR of 4.0 an aspirating
or less. technique.

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