J Oral Maxillofac Surg

65:1149-1154, 2007

Oral Surgery in Patients on Anticoagulant

Treatment Without Therapy Interruption
Giovanni B. Ferrieri, MD, DMD,* Stefano Castiglioni, DDS,†
Daniela Carmagnola, DDS, PhD,‡ Marco Cargnel, DDS,§
Laura Strohmenger, MD, DMD,储 and Silvio Abati, MD, DMD¶

Purpose: Conflicting opinions exist in literature concerning the management of oral surgery in patients on
oral anticoagulants because no consensus on perioperative protocols is available, including precise guidelines
regarding the need for therapy modification or withdrawal. The aim of this study was to evaluate bleeding
complications associated with oral surgery performed on patients on oral anticoagulants without therapy
modification or withdrawal but following a standardized comprehensive perioperative management protocol.
Patients and Methods: Patients on oral anticoagulant therapy with warfarin and in need of oral surgery
underwent a thorough general and oral clinical evaluation to assess thromboembolic and bleeding risk; 255
subjects who, on the morning of surgery, had INR values ⱕ5.5 were included in the study. An atraumatic
surgical technique was carried out and all patients received postoperative careful instructions.
Results: Five cases (1.96%) of bleeding complication were observed in patients with moderate to high
thromboembolic and bleeding risk.
Conclusion: The findings from this study suggest that a comprehensive perioperative management
protocol for oral surgery in patients on oral anticoagulants including 1) thromboembolic and bleeding
risk assessment, 2) an atraumatic surgical technique, and 3) postoperative careful instructions, can lead
to safe and successful results with minimal complications.
© 2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:1149-1154, 2007

Cardiovascular conditions represent a main cause of
death in the world population and are related to an
increased risk for thromboembolic complications.
Patients affected by cardiovascular conditions may be
treated, when indicated, with warfarin (coumarin), a
drug that inhibits the process of hemostasis, therefore
leading to an increased tendency to bleed after trauma.1
Conflicting opinions exist in the literature concern-
ing the management of oral surgery in patients on oral
anticoagulants because general protocols have been
suggested,1,2 but no specific perioperative protocol is
Received from the Departments of Medicine, Surgery, and Den-
tistry, Università degli Studi di Milano, Milano, Italy.
*Clinical Professor.
†PhD Student.
‡Research Associate.
§Clinical Professor.
储Professor and Chairman.
¶Associate Professor.
Address correspondence and reprint requests to Dr Ferrieri:
Università degli Studi di Milano, Via Beldiletto 1/3, 20142 Milano,
Italy; e-mail: giovanni.ferrieri@unimi.it
© 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6506-0014$32.00/0
doi:10.1016/j.joms.2006.11.015
available based on randomized controlled studies.3
Nowadays, most authors seem to agree on the use-
lessness of modification or interruption of oral anti-
coagulants when performing oral surgery because a
decreased risk for excessive bleeding might be asso-
ciated with an increased risk for thromboembolic
complications.4
Some authors consider INR (international normal-
ized ratio) values less than 4 as safe concerning bleed-
ing complications in case of oral surgery, while they
suggest that oral surgery should be avoided with INR
values exceeding 5.5,6 Nevertheless, Blinder et al7
found no correlation between INR values and postop-
erative bleeding after teeth extractions in patients on
oral anticoagulants, even with INR values over 3.5.
Beirne,8 in a literature review, stated that interrupt-
ing warfarin for dentoalveolar surgery to decrease INR
values was not supported by clinical evidence be-
cause the risk for life-threatening postsurgical bleed-
ing consequences is extremely low. On the other
hand, Todd9 suggested oral anticoagulants modifica-
tion when performing oral surgery, according to the
entity of the cardiovascular condition and the oral
surgical intervention.
All authors agree on performing wound compres-
sion with wet gauzes and tight multiple suturing1 to

1149
1150
Table 1. CHARACTERISTICS OF THE SUBJECTS
INCLUDED IN THE STUDY
Gender
Age Groups Male Female
⬍40 3 1
40-49 8 4
50-59 16 11
60-69 59 36
70-79 41 49
⬎80 16 11
Total 143 112
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007.
control intra- and postsurgical bleeding. Some proto-
cols recommend the use of tranexamic acid irrigation
or mouth rinses after surgery, alone or with aids such
as fibrin glue and oxidized cellulose mesh,10,11 espe-
cially when INR values exceed 3.5 to 4.
The purpose of this study was to evaluate bleeding
complications associated with oral surgery performed
in patients on oral anticoagulants without therapy
modification or withdrawal but following a standard-
ized comprehensive perioperative management pro-
tocol including 1) thromboembolic and bleeding risk
assessment, 2) an atraumatic surgical technique, and
3) postoperative careful instructions.
Patients and Methods
Between November 2002 and June 2005 a total of
255 patients (mean age, 67.8 ⫾ 9.5; range, 27-89
years; Table 1) on anticoagulant therapy with warfarin
underwent oral surgery at the Day Hospital Unit of the
Dental Clinic, Department of Medicine, Surgery and
Dentistry, University of Milan, Italy.
Inclusion criteria for access to this study were
chronic treatment with warfarin and need for oral
surgery (including tooth extractions, biopsy, and im-
plant insertion). Patients were on anticoagulant treat-
ment because of their history of cardiovascular dis-
ease or thromboembolic events, or because they had
mechanical prosthetic heart valves and were referred
to our clinic by their private dentists or clinician in
charge.
On the first appointment, all subjects were investi-
gated concerning their general medical history and
stomatologic specific history. When systemic history
was uncertain, the patients’ clinician in charge was
interviewed to obtain complete health status informa-
tion. Further, all patients underwent clinical and ra-
diographic oral examination.
According to a classification suggested by Beirne,8
all patients included in the study were divided into 3
groups concerning the risk for thromboembolic
ORAL SURGERY AND ANTICOAGULANTS
events (low, moderate, or high risk). Atrial fibrillation
without stroke, cardiomyopathy without atrial fibril-
lation, venous thrombosis more than 6 months ear-
lier, and bileaflet aortic valve with less than 2 risk
Total factors for stroke were considered low risk condi-
4 tions. Bileaflet tilting disc aortic valve with ⱖ2 stroke
12 risk factors, chronic atrial fibrillation with ⱖ2 stroke
27 risk factors, and venous thrombosis less than 6
95 months earlier were considered moderate risk condi-
90 tions. Mechanical mitral valve, ball-cage valve replace-
27
255 ment, venous thrombosis less than 3 months earlier,
hypercoagulable state, atrial fibrillation with history
of stroke, acute myocardial infarction less than 3
months earlier and recent (1 month) stroke or tran-
sient ischemic attack were considered high risk con-
ditions (see Beirne8 for details).
Patients were then classified in a high or low sur-
gical risk group according to the type of intervention
for which they were scheduled (Table 2). Namely,
simple single extraction and multiple (up to 4 ele-
ments) simple extractions were considered low risk
interventions. Complicated extractions (requiring flap
elevation and/or ostectomy), multiple extractions of
more than 5 elements, soft tissue surgery (biopsies),
and implant insertion were considered high-risk inter-
ventions.
One week before surgery, each patient received
supragingival scaling and oral hygiene instructions
and were instructed to use 0.2% chlorexidine mouth
rinses twice daily for 7 days.
Surgery was performed according to a standardized
surgical protocol including a presurgical, an intra-
surgical, and a postsurgical phase, as detailed below.
PRESURGICAL PHASE
In the early morning, patients underwent blood
sample collection for INR evaluation.
Patients whose INR resulted higher than 5.5 were
referred to their clinician in charge for therapy adjust-
ment before rescheduling oral surgery.
All patients with INR less than 5.5 were connected
to a multiparametric monitor (Nelicor Puritan Bennet-
3930; Anthos, Imola, Italy) for evaluation of cardiac
Table 2. SURGICAL RISK CLASSIFICATION
ACCORDING TO INTERVENTION TYPE
Low Risk High Risk
Simple single extractions Complicate single extractions
Simple multiple (⬍4) Simple multiple (⬎5)
extractions extractions
Biopsies
Implant installation
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007.
FERRIERI ET AL
frequency, blood pressure, O2 saturation, and electro-
cardiography activity.
If systolic blood pressure was over 180 mmHg
and/or diastolic blood pressure was over 100 mmHg
after 3 measurements performed at 15-minute inter-
vals, the patient was referred to his/her clinician in
charge for therapy adjustment before rescheduling
the oral surgery.
According to guidelines from the American Heart
Association,12 patients at risk for developing endocar-
ditis were given 2 g amoxicillin or, if allergic, 500 mg
clarithromycin, 1 hour before surgery.
SURGICAL PHASE
Patients were asked to rinse their mouth with 10
mL 0.2% chlorexidine for 60 seconds.
Locoregional anesthesia was obtained using differ-
ent anesthetic solutions depending on the patients’
health status. Namely, infiltration was performed
with 3% chloridrate mepivacaine (Carbocaina 3%;
AstraZeneca, Basiglio, Italy) in patients affected by
unstable angina, recent (less than 6 months earlier)
myocardial infarction, recent coronary bypass (less
than 6 months earlier), poorly controlled angina,
poorly controlled hypertension, and congestive car-
diac failure.13 In all other cases, anesthesia was ob-
tained with 2% mepivacaine with 1:100,000 epineph-
rine (Carbocaina) or articaine with epinephrine
1:100,000 (Ubistesin; 3M ESPE, Segrate, Italy). When
possible, only papillary and intraligamentous infiltra-
tion were performed.
A surgical atraumatic technique aiming at soft tis-
sue and bone tissue preservation was carried out. Soft
tissues were carefully handled to minimize trauma.
Flap elevation, when required, was performed subpe-
riosteally and attention was paid to minimize flap
tension. Teeth were sectioned for removal when pos-
sible. When ostectomy was required, a minimal quan-
tity of bone tissue was removed to not completely
destroy the bone walls and thus help blood clot sta-
bilization. Particular attention was paid to removing
all granulation tissue by carefully curetting extraction
sites.
According to the extension of intraoperative hem-
orrhage, when light “regular” bleeding was observed,
the operated site was carefully sutured with non-
resorbable multiple sutures in order, whenever pos-
sible, to achieve primary wound repair and otherwise
to bring papillae and flaps near. Further, the site was
pressed for 30 minutes with gauze previously soaked
in saline.
When large intraoperative bleeding was observed,
the operated site was rinsed with 5 mL tranexamic
acid (Tranex 500 mg/5 mL; Lusofarmaco, Peschiera
Borromeo, Italy) and then sutured. Gauze was then
soaked with 5 mL tranexamic acid and was pressed on
1151
the wound for 30 minutes. Finally, gauzes soaked
with saline were used to press the wound for 30
minutes. The wound was checked again and if a stable
blood clot was obtained and maintained for the sub-
sequent 30 minutes, the patient was dismissed. If not,
new gauze soaked with tranexamic acid was used and
the cycle was repeated until a stable clot was ob-
tained. If a stable clot would not be achieved by local
measures, major bleeding was recorded and the site
would undergo wound surgical revision.
POSTSURGICAL PHASE
Patients were carefully instructed concerning post-
surgical care. For 24 hours following surgery they
were required to eat a liquid and cold diet and not to
rinse their mouth. In particular, all patients were
warned not to create oral vortexes with water or
mouthwashes, not to perform any suction activity and
not to “push” in the wound area with their tongue.
Home oral hygiene care was to be suspended in the
operated region for 24 hours. In case of oozing, pa-
tients were told to press the wound with gauze
soaked with tranexamic acid for 30 minutes. They
were recommended to get in contact with a doctor in
case of bleeding that would not significantly decrease
or stop by compression within 1 hour.
Further, 0.2% chlorexidine mouth rinses was pre-
scribed to be used starting from the second day after
surgery twice a day for 14 days.
In case of diabetes, ostectomy or large suppuration
of the treated sites, 1 g amoxicillin twice a day for 6
days was prescribed (clarithromycin 500 mg twice a
day for 6 days in case of amoxicillin allergy).
Postoperative pain management was achieved with
paracetamol tablets 500 mg twice a day for 3 days or
ibuprofen tablets 300 mg twice a day for 3 days.
Clinical control visits were carried out after 1, 3,
and 7 days. Suture removal was performed after 7
days.
Results
A total of 334 interventions were carried out on 255
patients (Table 3).
According to thromboembolic risk, 41 patients
were classified as low risk, 115 moderate risk, and 99
high risk. According to bleeding risk, 127 patients
(189 interventions) were classified as low risk and
128 (145 interventions) as high risk (Tables 4 and 5).
Blood values concerning preoperative INR were
comprised between 1.3 and 5.4 (average, 2.7 ⫾ 1.2)
and distributed, as illustrated in Table 6, according to
thromboembolic risk.
Out of 255 patients, 5 (1.96%) were referred for
bleeding complications (Table 7). Namely, 1 patient
was characterized by postsurgical major bleeding; 1
1152 ORAL SURGERY AND ANTICOAGULANTS

Table 3. PATIENTS’ DISTRIBUTION ACCORDING TO BLEEDING RISK AND INTERVENTION TYPE

Low Bleeding Risk High Bleeding Risk

Simple Single Simple Multiple Complicated Single Simple Multiple Implant
Extractions (⬍4) Extractions Extractions (⬎5) Extractions Biopsies Installation Total

Patients 41 86 68 44 13 3 255
Interventions 103 86 81 44 13 7 334
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Surg 2007.

patient started bleeding approximately 12 hours after Discussion

surgery; 1 about 16 hours after surgery; 1 after ap-
In the present study it was observed that by using
proximately 24 hours, and the last after 5 days. All
a standardized comprehensive perioperative manage-
subjects but the first, who underwent immediate
ment protocol including 1) thromboembolic and
wound revision, managed to control hemorrhage by
bleeding risk assessment, 2) an atraumatic surgical
pressing the wound area with gauze soaked with
technique, and 3) postoperative careful instructions,
tranexamic acid and did not need to seek help from a
oral surgery in subjects on oral anticoagulants is a safe
doctor. Nevertheless, 1 patient, namely the one who
procedure even with high INR values. In the sample
experienced bleeding 12 hours after surgery, was
population considered, only 5 (1.96%) patients
characterized at the 3-day control (but not after 24
showed bleeding complications. Such complications
hours) by the presence of submandibular, cervical,
occurred in patients who, before surgery, had been
and thoracic ecchymosis (Fig 1). Since at control visits
classified as moderate to high risk subjects for throm-
all sites showed continuous (although light) oozing,
boembolic or hemorrhagic events. Wound revision
the patients underwent new INR evaluation followed
and patient review of instructions appeared to be the
by wound revision including curettage and tight mul-
appropriate approach to the management of postsur-
tiple suturing. No further complications were ob-
gical complications.
served. When interviewed, 1 patient admitted that he
All patients were carefully investigated concerning
did not follow the instructions concerning cold and
their systemic and oral history and status, and this
soft diet and 2 subjects stated they rinsed their mouth
allowed for the identification and adjustment, when
with water on the same day of surgery.
possible and necessary, of detectable risk factors. Fur-
In 3 patients, 7 mandibular intraforaminal implants
ther, a precise classification concerning thromboem-
were inserted. No surgical or postsurgical complica-
bolic and hemorrhagic risk was possible.
tion was observed. The implants were loaded 6
In the present protocol, it was decided not to
months after placement and were functional and sur-
interrupt or replace oral anticoagulant therapy. This
rounded by healthy tissues after 18, 20, and 25
approach is supported by Dunn and Turpie3 and
months from insertion.
Beirne.8 Dunn and Turpie,3 in a systematic literature
An overall risk was calculated for each patient who
review, found 0.2% major bleeding complications fol-
reported postsurgical complications by crossing
lowing dental procedures in patients on oral antico-
thromboembolic and hemorrhagic risk (Table 8). It
agulants (4 out of 2,014). Further, evidence exists
was observed that 2 patients were characterized by
that, if INR values are within therapeutic range, oral
high thromboembolic and hemorrhagic risk, 2 by low
anticoagulation can be continued when performing
hemorrhagic and moderate or high thromboembolic
oral surgery because the risk for uncontrolled post-
risk, and 1 by high hemorrhagic and moderate throm-
surgical bleeding appears to be very low and does not
boembolic risk. No complications were observed in
justify increasing the risk for thromboembolic com-
patients who had been classified as low hemorrhagic
plications. Also, the appropriate therapeutic INR
and low thromboembolic risk subjects.

Table 5. PATIENTS’ AND INTERVENTIONS’

Table 4. PATIENTS’ DISTRIBUTION ACCORDING TO DISTRIBUTION ACCORDING TO BLEEDING RISK
THROMBOEMBOLIC RISK
Low High Total
Low Risk Moderate Risk High Risk Total
Patients 127 128 255
41 115 99 255 Interventions 189 145 334
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007. Surg 2007.
FERRIERI ET AL 1153

Table 6. AVERAGE INR VALUES ACCORDING TO

THROMBOEMBOLIC RISK GROUP

Low Risk Moderate Risk High Risk

Average INR 1.4 2.5 3.4

SD 1.1 1.3 1.2
Range 1.3-1.9 1.9-3.2 3.2-5.4
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007.

range in patients on oral anticoagulants is quite tough

to reach and maintain because it is very sensitive to
factors like diet and minor changes in tablet intake.1
Therefore, unless very invasive surgery is planned,
oral anticoagulant therapy interruption or temporary
replacement with heparin does not seem to be justi-
fied.
Various reports on oral surgery in patients on oral
anticoagulants consider INR values under 4 as safe
and recommend to not perform surgery with INR
over 5.5,6 In the present study, 14 patients with INR
values under 4 were included (up to 5.5). Such pa-
tients were classified as low risk subjects for both
thromboembolic and hemorrhagic events and did not
respond adequately to the analgesic therapy previ-
ously prescribed. Therefore, it was decided to pro- FIGURE 1. Submandibular, cervical, and thoracic eccymosis 3 days
ceed with dental extractions despite the high INR after oral surgery in a patient on anticoagulant therapy.
value. Actually, no complications were observed in Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
these patients because all subjects reporting postsur- Surg 2007.
gical bleeding had INR values ⱕ4. Blinder et al7 stud-
ied postsurgical bleeding following teeth extractions
in 249 patients on oral anticoagulants divided into 5 oral cavity. Namely, 1 week before surgery all patients
groups according to their INR values. These authors underwent oral hygiene care including gross suprag-
found no correlation between INR values and postop- ingival plaque and calculus removal. Further, all pa-
erative bleeding, even with INR values over 3.5. It tients were prescribed 2% chlorexidine mouth rinses
may be speculated that, rather than the INR value twice a day for 7 days.
alone, a thorough classification of the patient com- Concerning the specific surgical technique, an
prising the assessment of bleeding and thromboem- atraumatic approach was carried out following guide-
bolic risk can increase the predictability and safety of lines similar to those reported by Scully and Wolff1
oral surgery in subjects on oral anticoagulants. and Evans et al.14 Subperiosteal flaps were raised and
To set optimal conditions for getting limited intra- attention was paid to minimize flap tension. When
and postsurgical bleeding, in the presurgical phase an possible and indicated, teeth were sectioned for re-
effort was made to reduce the quantity of irritants and moval and if ostectomy was required, a minimal quan-
the degree of soft tissue inflammation present in the tity of bone tissue was removed. This protocol al-

Table 7. BLEEDING COMPLICATION DISTRIBUTION ACCORDING TO PATIENTS’ CHARACTERISTICS AND

INTERVENTION TYPE

Time of Complication Gender Age INR Type of Intervention Systemic Pathology

1 hour Male 60 2.8 Multiple extractions ⬎4 Mitral valve replacement

12 hours Male 57 2.9 Complicated extraction Atrial fibrillation, 4 coronary by-pass
16 hours Male 68 3.4 Multiple extractions ⬍4 Lung embolism, diabetes type I
24 hours Male 56 4.0 Multiple extractions ⬍4 Mitral valve replacement
5 days Female 77 2.6 Complicated extraction Mitral valve replacement
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac Surg 2007.
1154
Table 8. OVERALL RISK TREND ACCORDING TO
THROMBOEMBOLIC AND HEMORRHAGIC RISK
Thromboembolic
Risk
Low Moderate
Low 0 1
Hemorrhagic risk
High 0 1
Ferrieri et al. Oral Surgery and Anticoagulants. J Oral Maxillofac
Surg 2007.
lowed for preservation of the bone walls, thus helping
blood clot stabilization. Further, careful curetting of
the extraction sockets to remove all inflamed and
granulation tissue was considered a key point for
minimizing postsurgical bleeding. When, following
wound compression with gauzes soaked with saline
solution, simple oozing was observed, the operated
site was carefully sutured with nonresorbable multi-
ple sutures in order, whenever possible, to achieve
primary wound repair and otherwise to bring papillae
and flaps near. When a stable blood clot would not
form, gauze soaked with tranexamic acid was pressed
on the wound before suturing. This procedure failed
to result in a stable blood clot in only 1 case and major
bleeding was recorded. This approach is not in agree-
ment with some authors, who recommend standard
tranexamic acid irrigation of extraction sockets and
the use of, for example, fibrin glue, cellulose,11,14 or
gelatin sponges7 to help blood clot formation before
suturing. The findings from the present study suggest
that such measures are not necessary to prevent
bleeding complications in patients on oral anticoagu-
lants because compression with a gauze soaked in
saline or tranexamic acid normally appeared to be
adequate for reaching wound stabilization.
Different protocols also exist for postsurgical man-
agement of patients on oral anticoagulants. Some au-
thors suggest that mouth rinses with tranexamic acid
might be of help and should always be performed
postoperatively.10 In our protocol, nevertheless, we
intentionally avoided such recommendation because
we consider the risk for blood clot dissolution caused
by the vortexes produced by rinsing to be higher than
the advantage obtained by the use of tranexamic acid.
Home postsurgical compliance appears to be a key
issue for preventing bleeding complications in patients
on oral anticoagulants. Beyond standard postsurgical
information, patients should be specifically told to not
push with their tongue in the wound region, to not
perform any suction,1 and to not create vortexes in their
mouth. In the present study, 5 postsurgical hemorrhagic
complications occurred in 5 subjects, 2 of which were
characterized by high thromboembolic and hemor-
ORAL SURGERY AND ANTICOAGULANTS
rhagic risk. Although particular attention was paid to
conveying precise postsurgical instructions to the pa-
tients concerning home care, when interviewed 1 pa-
tient indicated that he did not follow the instructions
concerning cold and soft diet and 2 subjects stated they
High rinsed their mouth with water on the same day of
1 surgery. Once the wound was re-examined and the
patient was reminded of postsurgical instructions, no
2 further complications were observed.
Findings from the present study suggest that a com-
prehensive perioperative management protocol for
oral surgery in patients on oral anticoagulants, includ-
ing 1) thromboembolic and bleeding risk assessment,
2) an atraumatic surgical technique, and 3) postoper-
ative careful instructions, can lead to safe and success-
ful results with minimal complications even in sub-
jects with high INR. Preoperative risk assessment
rather than the INR value alone seems to be a key
factor for the safety and predictability of dental pro-
cedures in patients on oral anticoagulants.
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