The commonest question on a referral form is whether the patient should stop their anticoagulant. For simple dentoalveolar surgery the answer is usually no, and the reasoning is worth setting out because it is the opposite of what intuition suggests.
The asymmetry
Post-extraction bleeding in an anticoagulated patient is common, visible, and almost always controllable in the chair with packing, a haemostatic dressing and sutures. A thromboembolic event caused by interrupting anticoagulation is uncommon, invisible until it happens, and catastrophic. Those two risks are not comparable, and treating them as though they are is how a routine extraction becomes a stroke.
What we actually do
- Warfarin: check an INR within 24 hours (72 hours if stably controlled). If it is within the therapeutic range, proceed without interruption.
- Direct oral anticoagulants: for low-bleeding-risk procedures, continue. For higher-risk procedures, consider delaying the morning dose rather than omitting doses — decided with the prescriber, not unilaterally.
- Single or dual antiplatelet therapy: continue. Do not stop clopidogrel or aspirin for dental extractions.
- Local measures every time: atraumatic technique, oxidised cellulose or collagen in the socket, sutures, and tranexamic acid mouthwash where indicated.
- Book the appointment early in the day and early in the week, so that a bleed declares itself while we are still open.
Where the case is not simple — multiple extractions, a bony impaction, a graft, a patient with a mechanical valve or recent stent — the decision belongs to a conversation with the prescribing physician or cardiologist, and we will have it.
What we ask patients
- A complete drug list, including over-the-counter and supplements. Fish oil and high-dose vitamin E matter.
- Recent INR results if on warfarin.
- Any personal or family history of unusual bleeding.
- Liver disease, renal impairment, or a recent change of dose.
None of this is novel and none of it is controversial. It is written down here because the instruction to stop a blood thinner before a dental appointment is still given, and it is still, in most cases, the wrong instruction.