Anticoagulant, NSAID, and an extraction request
A 72-year-old man requests extraction of tooth #31 (8 mm pocket, mobility II, no swelling) and of #3 (fractured cusp). Medical history: atrial fibrillation on apixaban 5 mg twice daily, hypertension on lisinopril 20 mg, and osteoarthritis on naproxen 500 mg twice daily for 5 years. eGFR is 55 mL/min and today's blood pressure is 138/84 mmHg. He reports that a dental cleaning last year caused a "small bleed" that stopped with pressure. He asks whether he should stop his blood thinner "for a few days" and whether you can give him "something stronger than ibuprofen" for afterward.
1. Should apixaban be interrupted for these extractions? Justify your answer and list what else you would check before deciding.
Read the worked answer
No - do not interrupt for simple extractions. Current evidence (including the PAUSE study) shows that continuing a direct oral anticoagulant around minor dental procedures does not increase major bleeding, while interrupting exposes the patient to thromboembolic risk. Local hemostatic measures are the correct answer, not dose omission.
Before the appointment:
- Timing of the last dose - schedule 12–24 hours after it, when the peak effect has passed.
- Renal function: apixaban is renally cleared and an eGFR of 55 affects drug accumulation.
- Dose appropriateness: 5 mg twice daily is correct here - dose reduction requires two of three criteria (age ≥80, weight ≤60 kg, creatinine ≥1.5 mg/dL), and he meets none.
- Any concomitant antiplatelet, recent bleeding events, or liver disease.
- A recent INR is irrelevant for apixaban but useful to rule out other issues.
If the patient or physician insists on interruption, that decision belongs to the prescriber, and it should be documented along with the reason; do not advise it yourself.
2. What analgesic will you recommend and why? Identify the interactions you are trying to avoid.
Read the worked answer
Recommend acetaminophen, up to 3 g/day in divided doses (lower if hepatic risk factors are present), not an NSAID.
Two interactions to avoid:
- Naproxen + apixaban: additive bleeding risk, particularly gastrointestinal, plus antiplatelet effect. Continuing his chronic naproxen through an extraction is the main avoidable hazard here.
- Naproxen + lisinopril + eGFR 55: the "triple whammy" of NSAID, ACE inhibitor, and reduced renal function can precipitate acute kidney injury.
Practical steps: advise him to discuss stopping or substituting the chronic naproxen with his prescriber - this is a chronic osteoarthritis medication, not something a dentist should silently discontinue. Do not simply add a second NSAID or an opioid.
If acetaminophen is insufficient, a short course of a weak opioid can be considered, but with caution in an older adult; the better answer is often excellent local anesthesia, an atraumatic extraction, and reassurance that day-one pain is manageable. Note any codeine or tramadol interaction with his other medications before prescribing.
3. Describe your local hemostasis plan and post-operative instructions, and state when you would refer.
Read the worked answer
Intra-operative:
- Atraumatic extraction with periotomes and luxators to preserve bone and soft tissue; avoid a large flap and excessive lingual retraction.
- Local anesthetic with a vasoconstrictor; infiltrations rather than blocks where possible in the mandible to reduce the risk of a spreading hematoma.
- Suture the socket, place a collagen sponge if the socket is large, and apply firm gauze pressure for 20–30 minutes with the patient biting, not talking.
Adjunct: 4.8% tranexamic acid mouthwash, 10 mL rinsed for 2 minutes four times daily for 2 days, has good evidence for DOAC patients and avoids systemic effects.
Instructions: no rinsing, spitting, straws, smoking, alcohol, or vigorous exercise for 72 hours; soft diet; pressure with gauze if oozing recurs; contact the office if bleeding persists beyond 20 minutes of continuous pressure.
Refer to an oral surgeon or emergency department for bleeding that does not stop with two episodes of sustained pressure, expanding swelling, airway concern, or a patient who cannot apply pressure reliably. Do not keep repeating local measures in an uncontrolled, sedated, or frail patient.