Post-Extraction Bleeding in a Patient on Warfarin and Antiplatelets
A 70-year-old man attends for extraction of a grossly carious lower right second molar with a periapical abscess. He takes warfarin for atrial fibrillation, aspirin 75 mg, and has stable angina. His last INR is 3.4, measured 3 days ago, and his target range is 2.0 to 3.0. He has had no recent bleeding episodes. Blood pressure is 148/88 mmHg. The tooth is grade II mobile with suppuration. He is anxious and asks whether he should stop his warfarin for a week before the extraction.
1. How do you manage his anticoagulation and the immediate extraction decision?
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Do not advise stopping warfarin; the INR of 3.4 is above his target range, so the priority is to contact his anticoagulation clinic or physician to review the dose and arrange a repeat INR before any elective extraction. An INR above the therapeutic range increases bleeding risk, and a value within range, ideally near 2.5 or below, is generally acceptable for simple extraction with local measures. Stopping warfarin for a week would expose him to thromboembolic stroke risk and is inappropriate without specialist advice. Aspirin should be continued because stopping it increases cardiovascular risk. Because there is suppuration and mobility, the tooth is infected and may need urgent drainage or antibiotics first. I would defer elective extraction until the INR is optimised, control infection, and document the discussion with his physician.
2. Describe the local haemostatic plan and the advice you would give if the extraction proceeds.
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Use an atraumatic technique with a local anaesthetic containing a vasoconstrictor, avoiding inferior alveolar nerve block if possible because of the risk of a deep haematoma, or use it cautiously. After extraction, place a haemostatic agent such as oxidised cellulose or a collagen plug, suture the socket, and apply pressure with a gauze pack for 10 to 15 minutes. Consider tranexamic acid mouthwash four times daily for 2 to 3 days as an adjunct. Give written advice: bite on gauze if bleeding recurs, avoid rinsing, spitting, smoking, hot drinks, and strenuous exercise for 24 hours, and use paracetamol rather than NSAIDs because of his cardiovascular history. Provide an emergency contact and advise attendance if bleeding persists beyond 20 minutes or he feels unwell. Arrange follow-up and communicate the plan to his physician.