Vol. 114 No.

4 October 2012

Risk of postoperative bleeding after dental procedures in patients

on warfarin: a retrospective study
Catherine Hong, BDS, MS,a Joel J. Napenas, DDS,b Michael Brennan, DDS, MHS,c Scott Furney, MD,d and
Peter Lockhart, DDSe

Objectives. The purpose of this retrospective study was to investigate the frequency of bleeding complications after invasive
dental procedures in warfarinized patients and the possible risk factors.
Study Design. The CoaguChek System was used to obtain an in-office international normalized ratio (INR) value for 122
patients (240 appointments), of which the mean age was 57.0 ⫾ 15.9 years and 50% were males. Demographic and clinical
information were obtained retrospectively from dental and medical records.
Results. Five episodes (mean INR: 2.0 ⫾ 0.8) of persistent bleeding were identified; 4 were after extractions and 1 was after
implant placement. The frequency of bleeding was 4.8%, if only considering surgical procedures. Postoperative bleeding was
significantly higher (P ⬍ .05) in patients who were taking anti-thrombotic medications in addition to warfarin.
Conclusions. There is a low incidence of persistent bleeding after invasive dental procedures in warfarinized patients but the
risk appears to increase with the use of concomitant anti-thrombotic medications. (Oral Surg Oral Med Oral Pathol Oral
Radiol 2012;114:464-468)

Warfarin is an anticoagulant often prescribed to prevent
thromboembolic events. The need to modify or discon-
tinue the patient’s anticoagulant medication before an
invasive dental procedure is controversial, as noted
from the various proposed protocols in the literature.1,2
A physician’s decision to discontinue anticoagulation
therapy, is often based on his or her experiences with
general surgery procedures and the assumption that the
risk of bleeding is analogous to that of a dental proce-
dure. The literature is clear that clinically significant
bleeding in properly anticoagulated patients following
invasive dental procedures is a rare occurrence,3-5 with
fewer than 2% of bleeding events being uncontrolled by
local hemostatic measures alone.6
The international normalized ratio (INR) was devel-
oped by the World Health Organization as a means of
standardizing prothrombin time results among different
laboratories. It is now widely used to monitor oral
The abstract for this article was presented at the International Asso-
ciation of Dental Research—South East Asia Division in 2011.
a
Assistant Professor, Division of Orthodontics and Pediatric Den-
tistry, Faculty of Dentistry, National University of Singapore, Singa-
pore.
b
Director, General Practice Residency, Department of Oral Medicine,
Carolinas Medical Center.
c
Oral Medicine Residency and Associate Chair, Department of Oral
Medicine, Carolinas Medical Center.
d
Chair, Department of Internal Medicine, Carolinas Medical Center.
e
Chair, Department of Oral Medicine, Carolinas Medical Center,
Charlotte, NC.
Received for publication Feb 8, 2012; returned for revision Apr 25,
2012; accepted for publication Apr 30, 2012.
© 2012 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2012.04.017
anticoagulant therapy and dosage planning for patients
receiving warfarin. The INR for a healthy patient not on
warfarin is 1 and the therapeutic INR for those on
warfarin therapy typically ranges from 2 to 4, depend-
ing on the reason for anticoagulation. In the past de-
cade, it has become clear that routine discontinuation of
oral anticoagulant therapy for dental procedures is not
supported by the scientific literature, as it may put
patients at unnecessary medical risk for thromboem-
bolic events either from the cessation of anticoagulant
therapy or because of “rebound phenomenon.”7-10 Ako-
pov et al.9 found 14 cases of cardioembolic cerebral
infarction that occurred owing to the discontinuation of
warfarin for a medical procedure; all were found to be
potentially preventable as the planned procedure either
did not require discontinuation of warfarin, or in in-
stances when withdrawal was warranted, no bridging
therapy was instituted.
Currently, most guidelines indicate that patients with
an INR less than 3.5 can undergo minor oral surgery
(e.g., simple single extraction) without any adjustment
in anticoagulation (Level of Evidence: A).1 Some INR
guidelines allow for an upper safety limit of 4.08;
however, the proposed upper safety limit has not been
vigorously investigated and the risk of bleeding at these
limits is particularly unclear for the more invasive oral
surgical procedures.1
Most studies on this subject focus on bleeding com-
plications following dental extractions; however, given
the larger surface area involved with dental office hy-
giene procedures (e.g., gross debridement, scaling, and
root planning) by comparison with a single tooth
socket, hygiene procedures may carry similar or higher
risk of bleeding than extractions. Furthermore, achiev-

464
OOOO
Volume 114, Number 4
ing hemostasis after hygiene procedures may be more
difficult because of the large surface area involved.11
Few studies have also examined contributory systemic
factors that may potentiate bleeding in patients receiv-
ing warfarin therapy.
The purpose of this retrospective study was to inves-
tigate the frequency of postoperative bleeding compli-
cations after various dental procedures, and the possible
contributing risk factors in patients on warfarin.
MATERIAL AND METHODS
The CoaguChek System (Roche Diagnostics, Indianap-
olis, IN) was used to obtain an in-office INR value for
patients who presented to the dental clinic at a large
academic medical center for dental care and were
thought to be at risk for developing postoperative
bleeding. The in-office INR device was chosen for this
study because of the advantage of providing point-of-
care testing. Dental assistants and dental hygienists
performed an INR test on all patients taking warfarin
who had not had an INR within 24 hours of the dental
visit. The CoaguChek System runs an internal control
with each test strip, such that no result will be produced
if the control does not pass the testing. As part of our
routine clinical practice and quality assurance, dupli-
cate INR readings were taken for abnormally high
readings (INR ⬎3.5). For this study, we considered an
INR to be out of range if it was higher than 3.5.
Demographic and clinical information was taken
from dental records, inpatient medical records, and
electronic patient records for the 25 hospitals and out-
patient clinics in our hospital system. The information
collected also included concomitant medications re-
ported to interfere with coagulation (specifically aspi-
rin, clopidogrel, and nonsteroidal anti-inflammatory
medications), type of dental procedure performed, use
of local hemostatic agents at time of dental procedure,
pre- and postoperative blood products used, and [the
nature and duration of] postoperative bleeding. Docu-
mentation of postoperative bleeding was based on a
positive response to any of the following: (1) visit to
our dental clinic or one of the emergency departments
(that are either associated with the academic medical
center or other hospitals within the same health care
system) for postoperative bleeding within 2 weeks of
the procedure, (2) telephone call to our dental clinic
with a concern for postoperative bleeding within 2
weeks of the procedure, or (3) documentation of post-
operative bleeding in the dental chart at the postoper-
ative visit. This study (#12-05-17E) was reviewed and
approved by the institutional research board at our
hospital.
Descriptive data analyses, including mean, SD,
counts, and percentages, were determined. Pearson ␹2
ORIGINAL ARTICLE
Hong et al. 465
or Fisher exact tests were used for dichotomous vari-
ables and statistical significance was considered to be at
the P less than .05 level. The corresponding odds ratios
(OR) and their 95% confidence intervals (95% CI) were
also determined. All statistical analyses were per-
formed using the software Statistical Package for the
Social Sciences (SPSS; SPSS Inc., Chicago, IL) version
11.0.
RESULTS
Demographics
We identified 122 patients who had a total of 240 dental
appointments between June 2004 and June 2010 (Table I).
There were 61 males (50%) with a mean age of 57.0 ⫾
15.9 years (range: 21-92). Thirty-five patients (29%)
were on concomitant medications thought to potentiate
bleeding. In addition to warfarin, 16 patients were on
aspirin, 4 were on enoxaparin, 2 were on clopidogrel,
and 6 were taking nonsteroidal analgesic medications
on a regular basis. Seven patients were on multiple
antithrombotic medications (excluding warfarin); 2
were taking a combination of aspirin, cilastazol, and
nonsteroidal analgesic medication; 3 were on a combi-
nation of aspirin and clopidogrel; and 2 were on a
combination of aspirin and enoxaparin. Ten (8%) pa-
tients had medical history which could potentially af-
fect their risk for bleeding: kidney transplant candidates
(4), patients with end-stage renal disease requiring he-
modialysis (3), liver transplant recipient with end-stage
renal disease (1), cardiac transplant recipient (1), and
sickle cell anemia (1).
Visits and procedures
The average INR value for all appointments (n ⫽ 240)
was 2.4 ⫾ 1.2 (range: 0.8 to above 8, median: 2.2).
Over a period of 6 years, the dental treatments of these
patients were carried out by 31 operators. Placement of
2 implants and 248 extractions were performed in 105
appointments (mean INR: 2.0 ⫾ 0.7, range: 0.8-3.9,
median INR: 2.1). Multiple extractions were performed
in 41 (39%) appointments, with a mean of 4.3 ⫾ 3.5
teeth (range: 2-20) extracted per appointment. Local
hemostatic measures used for appointments included
gelatin compressed sponges (e.g., Gelfoam) and sutures
for 54 (51%) appointments; sutures only in 23 (22%)
appointments; cellulose (e.g., Surgicel) and sutures in 2
(2%) appointments; and sutures and topical thrombin in
1 (1%) appointment.
Dental treatment was deferred (n ⫽ 32) or modified
(n ⫽ 3) in 35 appointments total. The average INR
value for these 35 appointments was 4.0 ⫾ 1.7 (range:
0.9 to above 8, median: 4.0). The dental treatment for
26 appointments was deferred (n ⫽ 24) or modified
(n ⫽ 2) because of an elevated INR value that was
ORAL MEDICINE OOOO
466 Hong et al. October 2012

Table I. List of procedures by INR values considered to be too high for invasive dental procedures
No. of (mean INR: 4.8 ⫾ 1.3, range: 3.3 to above 8, median
INR appointments INR: 4.4). The treatment for the remaining 9 appoint-
⬍2.0 ments was deferred or modified for the following rea-
a. examination 7 sons: failure to take antibiotic prophylaxis (n ⫽ 3),
b. restorations 4 anxiety (n ⫽ 1), severe gagging (n ⫽ 1), uncooperative
c. denture-related procedures e.g., delivery, 1
adjustment
behavior after local anesthetic administration (n ⫽ 1),
d. root canal therapy 1 patient’s preference to check with physician regarding
e. hygiene 37 anticoagulant therapy (n ⫽ 1), referral to an oral and
Ultrasonic scaling/prophylaxis 36 maxillofacial surgeon because of significant subman-
Scaling/root planing (2 quad) 1 dibular swelling (n ⫽ 1), or high glucose level and
f. extraction 49
Single/multiple extractions 24/25
subtherapeutic INR level (n ⫽ 1). The mean INR value
g. bone spicule removal 1 for these 9 patients was 2.0 ⫾ 0.7 (range: 0.9-2.7).
h. alveoloplasty 1
i. soft tissue biopsy 1 Postoperative bleeding complications
j. implant placement 1
k. deferment/modification of treatment 5
Overall, there were 5 episodes (2%) of persistent bleed-
2.0-2.5 ing when considering all appointments (n ⫽ 240) (Ta-
a. examination 3 ble II). All bleeding episodes were documented in male
b. restorations 1 patients who underwent surgical procedures (extrac-
c. crown cementation 1 tions and implant placements) and thus the frequency of
d. denture-related procedures, e.g., 1
delivery, adjustment
persistent postoperative bleeding if recalculated to in-
e. hygiene: Ultrasonic scaling/prophylaxis 15 clude only surgical procedures was 4.8%. The average
f. extraction 30 INR value for these patients was 2.0 ⫾ 0.8 (range:
Single/multiple extractions 18/12 1.1-3.3, median: 1.9). Patient 1 presented to both the
g. soft tissue biopsy 1 emergency department and the dental clinic because of
h. deferment/modification of treatment 1
2.6-3.0
persistent bleeding after surgical extraction of a single
a. examination 3 tooth. Patient 4 required hospitalization to manage
b. restorations 3 postoperative bleeding. The INR value on the day of
c. root canal therapy 1 hospital admission was 5.9 for patient 4. Table II sum-
d. hygiene 12 marizes the hemostatic measures implemented on the
Ultrasonic scaling/prophylaxis 11
Scaling/root planing (2 quads) 1
day of the procedure and day of the postoperative visit.
e. extraction 17 The postoperative bleeding complication rate was
Single/multiple extractions 13/4 significantly higher (P ⬍ .05) in appointments where
f. bone spicule removal 1 patients were taking concomitant medications (in addi-
g. deferment/modification of treatment 3 tion to warfarin; 17%, 4 of 27) compared with those
3.1-3.5
a. examination 2
where patients were on warfarin only (1%, 1 of 78).
b. restorations 1 The odds ratio for bleeding in patients on concomitant
c. hygiene 9 medications was 13.31 (95% confidence interval: 1.4-
Ultrasonic scaling/prophylaxis 8 125.8).
Scaling/root planning (2 quads) 1
d. extraction 6
Single/multiple extractions 6/0 DISCUSSION
e. deferment/modification of treatment 3/1 The results of this retrospective study suggest that the
3.6-4.0 overall prevalence of persistent bleeding after dental
a. examination 1
procedures in patients on warfarin therapy is low (2%).
b. restorations, crown preparation 2/1
c. hygiene: Ultrasonic scaling/prophylaxis 2 Additionally, most complications experienced were
d. extraction 3 controlled with local hemostatic measures and rein-
Single/multiple extractions 2/1 forcement of home care instructions (Table II). How-
e. implant placement 1 ever, if only the patients who underwent surgical pro-
f. deferment of treatment 6
cedures were considered, the frequency increased to
⬎4.0
a. restorations 2 4.8%. In a review of 493 patients undergoing dental
b. deferment/modification of treatment 15 surgery where anticoagulants were discontinued, 1%
INR, International Normalized Ratio.
(n ⫽ 5) of the patients had serious embolic complica-
tions, of which 4 were fatal.6 Thus, in spite of the
higher incidence of post– dental procedure bleeding in
OOOO ORIGINAL ARTICLE
Volume 114, Number 4 Hong et al. 467

our cohort of patients compared with the thromboem-

Medications that

Aspirin (81 mg)

may potentiate
bolic events reported by Wahl et al.,6 the treatment

bleeding
complexity and consequences of a thromboembolic

Celebrex
Lovenox

Lovenox
event is generally considered to outweigh that of per-

None
sistent bleeding from a dental procedure. Balevi12 pre-
sented an interesting article on the application of quan-

Yes: admission (FFP Postliver transplant

medical history
Other relevant

DVT, deep vein thrombosis; ED, emergency department; ESRD, end-stage renal disease; FFP, fresh frozen plasma; G, gelfoam; I, incisor; M, molar; PM, premolar, S, sutures.
titative decision-tree analysis to the decision of whether

hemodialysis

hemodialysis
warfarin should be withdrawn before a single tooth
extraction in patients with a prosthetic cardiac valve.

ESRD,
ESRD,
Based on this analysis, withholding warfarin was only
None

None

None
found to be slightly more favorable (0.02 utile higher)
than the alternative option of continuing warfarin for a
postoperative visit)
ED visit because of

and vitamin K)
dental extraction. As such, the article concluded that
Yes (3 d after
bleeding

continuation of the patient’s warfarin protocol and us-

No

No

No

ing local adjunctive means of hemostasis was a viable

alternative for the minimally invasive single tooth ex-
traction.12 Based on the current literature6,12,13 and
findings from our study, we can report that simple
bleeding/hemostatic measures
Dental office visit because of

extractions with adequate local hemostatic measures

at this postoperative visit

and dental cleanings (ultrasonic scaling and prophy-

Y/25% aminocaproic acid

Y/reinforced home care

Y/reinforced home care

laxis) could be completed in patients with INR levels of

up to 4.0 and without other coagulopathies associated
Y/G and S placed

Y/referred to ED

with medication or disease.

instructions

instructions
suspension

In this study, all of the patients with bleeding com-

plications, had INR readings that were 3.3 or lower, a
level that is considered within the recommended range
for carrying out all but the most invasive of dental
History of bleeding treatment Procedure/hemostatic measures on

mandibular and maxilla I, M)/G

Single surgical extraction (maxilla

procedures. In addition, the 8 patients with INR read-

Implant placement (mandibular

ings above 3.3 (range: 3.3-3.9) in the study were able to

Multiple extraction (2 teeth:

Multiple extraction (5 teeth:

undergo extractions (n ⫽ 7) and implant placement

day of treatment

Single surgical extraction

(n ⫽ 1) without prolonged postoperative bleeding. Sim-

maxilla PM)/G and S

(mandibular M)/S

ilarly, another study reported that preoperative INR

values up to a mean of 3.8 did not appear to influence
the frequency of bleeding.14 The medical history of 4 of
PM)/S

5 patients with reported complications in our study

and S
M)/S

revealed that they were concomitantly using medica-

tions (e.g., aspirin or low molecular weight heparin,
INR on

such as Lovenox) or had significant medical history that

day
1.1

1.9

1.8

2.2

3.3
Table II. Patients with postoperative bleeding

could affect hemostasis. Although most patients taking

concomitant medications (in addition to warfarin) did
post dental treatment

Atrial fibrillation Yes (after scaling and

not have any complications after surgical procedures,

the complication rate of 17% (4 of 23) in appointments
root planning)

in which patients were on concomitant medications was

significantly higher compared with the rest of the ap-
pointments (1%, 1 of 82). This is not unexpected, as the
Previous history No

Atrial fibrillation No

No

No

increased risk of hemorrhagic events in patients who

are on concomitant warfarin and other antithrombotic
years warfarin therapy

cardiac valve
Indication for

therapy (e.g., antiplatelet agents, low weight molecular

heparin) has been reported in the medical literature.15,16
of DVT

Prosthetic
Dialysis

Of the 5 patients who had complications, hemostasis

was achieved with local measures in all but one (patient
4). This specific patient was taking aspirin, and also had
no./age,
Patient

1/58

2/72

3/63

4/67

5/58

a significant medical history (liver transplant recipient

with end-stage renal disease), which together may have
ORAL MEDICINE
468 Hong et al.
contributed to the bleeding episode and necessitated
systemic blood products. The complication rate, al-
though low in this study, the profile of the patients with
postoperative bleeding complications suggests that
other variables such as the intake of medications or
comorbidities that affect coagulation or platelet quality/
quantity is important in predicting the patient’s risk for
bleeding.
Because of the retrospective nature of this study,
information on the condition of the gingival health was
not captured, and we therefore cannot rule out the possi-
bility that this may be a confounding factor in the fre-
quency of bleeding. Other limitations include the variance
in operator experience when performing invasive proce-
dures, the lack of laboratory values (i.e., prothrombin
time, partial thromboplastic time, and qualitative and
quantitative platelet measures) and possible underestima-
tion of bleeding episodes owing to patients’ visits to dental
offices and emergency departments outside of the hospi-
tal’s health care system.
CONCLUSIONS
The overall frequency of persistent bleeding (2%) is
low when all dental procedures are considered for pa-
tients on warfarin therapy. If considering only dental
patients undergoing extractions and implant placement,
the frequency increases to 4.8%. The results suggest
that patients are at greater risk for postoperative bleed-
ing if concurrent medications are used that could affect
their ability to maintain a clot.
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Reprint requests:
Catherine Hong, BDS, MS
Assistant Professor
Division of Orthodontics and Pediatric Dentistry
Faculty of Dentistry
National University of Singapore
5 Lower Kent Ridge Road
Singapore 119074
denchhl@nus.edu.eg