Q: Describe the dental management for a patient who has atrial fibrillation and is on warfarin. INR = 2.5 (Or something like that lah).

Answer from articles:

Introduction
The most common indications for long-term oral anticoagulation with warfarin are venous thromboembolism, mechanical cardiac valves and atrial fibrillation. When patients with these conditions need surgery, the perioperative management of their warfarin therapy poses a major problem. Withholding warfarin increases the risk of thromboembolism, particularly in the context of surgery which itself increases the thrombotic risk. To minimise the risk of perioperative thrombosis, alternate anticoagulation with heparin is often used. Perioperative anticoagulation is accompanied by an increased risk of postoperative bleeding. There is no consensus on the optimal approach to anticoagulation in the perioperative period. In each individual patient, rational decisions must be made after weighing up the haemorrhagic and thrombotic risks.

Dental surgery in the anticoagulated patient
Non-surgical dental procedures (professional cleanings, fillings, crowns, etc.) are not associated with a significant bleeding risk and can be performed safely while the INR is in the therapeutic range.

Traditionally, many dentists have withdrawn warfarin before some dental surgical procedures. Recent evidence, however, suggests that the recommended approach is not to discontinue warfarin. In the English language literature, there are reports of approximately 2014 dental surgical procedures including multiple and full mouth extractions, alveoectomies and surgical extractions in 774 patients taking warfarin. Less than 2% of these patients had serious bleeding problems, defined as bleeding uncontrolled by local measures. Another study compared postoperative bleeding following dental extractions in 106 patients on warfarin and 106 normal patients. It found no difference in the incidence or severity of bleeding.

In contrast, in 542 dental procedures in 493 patients in whom warfarin was withheld for the procedure, five (1.0% of patients; 0.9% of procedures) had serious embolic complications (including four deaths). Although suggestive, a direct cause and effect relationship between withholding warfarin and a thromboembolic event is unproven.

Approach to dental surgery
1. Check INR the day before the procedure to ensure it is within the therapeutic range for the patient. If above this, delay surgery until the INR is within the therapeutic range.

2. In the majority of cases, continue warfarin therapy throughout the dental procedure and postoperative period. This may need to be reassessed for multiple and complex dental extractions, particularly if infection is a concern, in which case an INR of under 1.6 may be desirable. Table 3 is an example of a patient information sheet for use in this situation.

3. Daily or alternate day monitoring of the INR may be required, especially if the patient is receiving antibiotics.

4. Judicious use of local measures to ensure adequate haemostasis e.g. packs soaked in 5% tranexamic acid placed over the extraction site.

5. In patients with excessive oozing, tranexamic acid mouthwash (10 mL of 5% solution) held in the mouth for two minutes is helpful when used six hourly for 3-5 days. Practically, this preparation may be difficult to obtain other than from major teaching hospital pharmacies.