Should I stop my patient's warfarin prior to a dental procedure?
Henry I. Bussey, Pharm.D., FCCP, FAHA
Because dental procedures pose the risk of bleeding complications for patients on warfarin, some clinicians will opt to have a patient hold his/her warfarin prior to a dental procedure. In our clinic, we do not require patients to stop warfarin prior to dental procedures such as extractions or surgery. Instead, patients are given an aminocaproic acid (brand name Amicar) solution and instructed to hold 10 ml of the Amicar solution in the area of the dental procedure for two minutes just before the dental procedure and every 1 to 2 hours following the procedure until all of the solution is gone. We advise patients not to "swish" as doing so may dislodge a clot. We also advise patients not to do anything that might create negative pressure in the mouth such as sucking on a straw, candy, etc. since this too may dislodge the clot.
We mix the Amicar solution in our clinic on the day of the dental procedure for stability and sterility reasons. We use the 5 gram vial for injection and dilute it with sterile water to a total volume of 100 ml. Amicar is also available in tablet form and as a non-sterile liquid but these often are hard to find and expensive.
While Amicar may be the easiest and most affordable solution to this problem in the United States, tranexamic acid is used for this same purpose in some other countries. Both Amicar and Tranexamic acid are fibrinolytic inhibitors.
As a side note, the Amicar solution may also be useful for patients who experience gingival oozing or bleeding gums, although improved oral hygiene may combat those problems without the Amicar.
This issue is discussed in the current recommendations from the American College of Chest Physicians Consensus Conference on Antithrombotic and Thrombolytic Therapy (Ansell J, et al. Chest 2004; 1216: 204s-233s.) - specifically in the 2nd column on page 214s. Original reports of this practice can be found at Sindet-Pedersen, S, et al. N Engl J Med 1989; 324:840-843 and Sute JC, et al. J Oral Maxillofacial Surg 1996; 54:27-32. In our own clinic we have collected a series of patients managed with Amicar as well as survey responses from their dentist as to their satisfaction with this approach. While there have been almost no bleeding problems with this approach and the survey results are overwhelmingly favorable, I must admit that these data have not been published.