Anticoagulants and antiplatelets before dental extraction
- Drugs
Most patients on blood thinners can have teeth out safely without stopping them, using local measures. Stopping them risks a stroke or clot.
What it is
The risk of a thromboembolic event from interrupting anticoagulants or antiplatelets usually outweighs the risk of dental bleeding, which can be controlled locally. For warfarin, guidelines generally advise checking the INR shortly before the procedure and proceeding without interruption if it is within the therapeutic range agreed by local protocol. For direct oral anticoagulants (apixaban, rivaroxaban, edoxaban, dabigatran), many protocols allow treatment without interruption for low-risk procedures and advise timing the procedure away from peak levels or omitting a single dose for higher-risk procedures, as agreed with the prescriber. Antiplatelets, including dual therapy after a coronary stent, are continued.
What to know
- Do not stop anticoagulants or antiplatelets for routine extractions without the prescriber.
- Warfarin: check INR close to the procedure; refer to the prescriber if it is above the agreed limit.
- Local haemostasis: sutures, haemostatic packing, tranexamic acid mouthwash, pressure.
- Plan treatment early in the day and early in the week so bleeding can be managed.
- Interactions: metronidazole and azole antifungals (including miconazole oral gel) markedly raise the INR; NSAIDs increase bleeding risk.
Risks and precautions
- Stopping dual antiplatelet therapy early after a coronary stent can cause stent thrombosis and death.
- Miconazole oral gel can cause dangerous INR rises and bleeding in people on warfarin; regulators have warned against the combination, so avoid it.
- Use paracetamol rather than NSAIDs for pain after the extraction in anticoagulated patients.
Next step / Initial management
- Continue antithrombotics; plan with the dentist local haemostatic measures and, for warfarin, an INR check before the procedure.
- INR above the agreed limit, extensive surgery or additional bleeding risk factors: refer to or consult the prescriber before the procedure.
- Avoid prescribing metronidazole or azoles to warfarin users without INR monitoring; prefer paracetamol for pain.
- Bleeding that does not stop: refer to the dentist or emergency department as for post-extraction bleeding.
Test yourself
Think of the answer, then tap the question to see it.
Should warfarin be stopped routinely before a simple extraction?
No; check the INR and proceed with local haemostatic measures if it is within the agreed range.
Which commonly prescribed dental drugs can raise the INR in patients on warfarin?
Metronidazole and azole antifungals, including miconazole oral gel.
Why must dual antiplatelet therapy after a recent coronary stent not be stopped for dental work?
Because stopping it risks stent thrombosis, myocardial infarction and death.
Connections
Educational content; it does not replace assessment by a dentist or doctor and is not a clinical instruction. For facial or neck swelling with difficulty swallowing or breathing, a knocked-out tooth or bleeding that will not stop, go to an emergency department at once.
Sources: Oral Surgery, Extraction of Teeth (StatPearls Publishing (NCBI Bookshelf), 2023); Warfarin (MedlinePlus, US National Library of Medicine, 2026); Bleeding Disorders (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.