Warfarin, a Stale INR and Two Teeth to Extract

No - do not extract today.

Three things point the same way:

1. The INR is above the usual elective ceiling. Most guidelines permit simple extractions at an INR of roughly 3.5 or below (some accept up to 4.0 for single simple extractions), but 3.4 sits at or above the conservative threshold and is not a comfortable value for two surgical sites in one visit.
2. The value is five days old. Anticoagulation fluctuates with diet, illness and new drugs. A safe decision needs an INR drawn within 24–72 hours of the appointment.
3. There is no urgency. A draining sinus and recurrent pericoronitis are infections that can be managed short-term with local measures and, if needed, antibiotics; they are not indications for proceeding against a bleeding risk. His travel in three weeks is a reason to move quickly, not to skip the check.

Plan instead: telephone the anticoagulation clinic or prescriber, request a current INR, and rebook within the week. Do not stop or reduce warfarin yourself - that is the prescriber's decision and carries thromboembolic risk. Continue aspirin. Also address the BP: 148/88 is not a barrier to extraction but should be rechecked and followed up, since uncontrolled hypertension adds to bleeding risk and is a marker of cardiovascular risk.

Pre-operative

• Morning appointment, early in the week, so a bleeding problem can be managed while services are open.
• Confirm no new medications (particularly NSAIDs, SSRIs, azole antifungals or macrolides, which can raise INR).
• Consider tranexamic acid 4.8% mouthwash to be used post-operatively (10 mL, four times daily for two days, not swallowed).

Operative

• Local anaesthetic with vasoconstrictor is acceptable at this INR; a buccal infiltration plus, where needed, a block is not contraindicated when the INR is in range.
• Minimise trauma: periotomes, controlled force, no excessive curettage, remove sharp bony edges.
• Achieve primary closure with sutures, then apply a pressure pack for at least 10–20 minutes.
• Consider doing one tooth per visit if either site is likely to be surgically difficult.

Post-operative

• Paracetamol, not NSAIDs.
• No rinsing, spitting, smoking or hot drinks for 24 hours; soft diet.
• Written instructions and a contact number; warn that oozing is normal but prolonged bleeding or a swelling that enlarges is not.
• Review if bleeding persists beyond simple pressure measures, and know the local pathway for reversal (vitamin K, prothrombin complex) in the rare severe case.

The dental principles stay the same; the risk calculus shifts decisively towards not disturbing anticoagulation.

• A mechanical mitral valve carries a high thrombotic risk if anticoagulation is interrupted, so any suggestion of stopping or bridging warfarin must come from the cardiologist or anticoagulation service, not from the dentist.
• He is on dual therapy (warfarin plus aspirin), which increases bleeding risk, so a current INR and a coordinated plan are even more important. Simple extractions can still often be done in primary care at an in-range INR with local haemostatic measures.
• If the INR is high or labile, or if surgical difficulty is anticipated, arrange the procedure in a setting with access to reversal agents and medical support, and liaise directly with the managing physician.
• Document the conversation and give the patient clear, written post-operative instructions, because the consequences of both bleeding and thromboembolism are serious.