Bleed or die? A bloody simple decision

Abstract

Thank you for an interesting article in the December 2010 issue.1Balevi B. Should warfarin be discontinued before a dental extraction: A decision-tree analysis.Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010; 110: 691-697Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar But Dr. Balevi makes a fatal error when he asserts that those who recommend continuing warfarin for dental extractions do so “despite the fact that there has been no reported case of a dental extraction causing a cardiovascular accident (CVA) in a patient whose warfarin was temporarily discontinued.” In fact, there have been at least 5 patients who suffered 4 fatal embolic complications and 2 nonfatal embolic complications shortly after having their warfarin therapy withdrawn for dental procedures.2Akbarian M. Austen W.G. Yurchak P.M. Scannell J.G. Thromboembolic complications of prosthetic cardiac valves.Circulation. 1968; 37: 826-831Crossref PubMed Scopus (95) Google Scholar, 3Behrman S.J. Wright I.S. Dental surgery during continuous anticoagulant therapy.J Am Dent Assoc. 1961; 62: 172-180Abstract Full Text PDF PubMed Scopus (23) Google Scholar, 4Marshall J. Rebound phenomena after anticoagulant therapy in cerebrovascular disease.Circulation. 1963; 28: 329-332Crossref PubMed Scopus (39) Google Scholar, 5Ogiuchi H. Ando T. Tanaka M. et al.Clinical reports on dental extraction from patients undergoing oral anticoagulant therapy.Bull Tokyo Dent. Coll. 1985; 26: 205-212PubMed Google Scholar, 6Tulloch J. Wright I.S. Long-term anticoagulant therapy: further experiences.Circulation. 1954; 9: 823-834Crossref PubMed Google Scholar On the other hand, Dr. Balevi is correct that there has never been a published case of death from a bleeding complication after a dental extraction in an anticoagulated patient. When considering withdrawing anticoagulation for a dental extraction, the small risk of a possibly fatal embolic complication has been shown to exceed the smaller risk of a (nonfatal) bleeding complication in patients undergoing continuous warfarin therapy at or even slightly above therapeutic levels.7Bacci C. et al.Management of dental extraction in patients undergoing anticoagulant treatment Results from a large, multicentre, prospective, case-control study.Thromb Haemost. 2010; 104: 972-975Crossref PubMed Scopus (71) Google Scholar, 8Wahl M.J. Dental surgery in anticoagulated patients.Arch Intern Med. 1998; 158: 1610-1616Crossref PubMed Scopus (294) Google Scholar, 9Wahl M.J. Myths of dental surgery in patients receiving anticoagulant therapy.J Am Dent Assoc. 2000; 131: 77-81Crossref PubMed Scopus (143) Google Scholar The choice in the decision tree is bloody simple: should the anticoagulated dental patient possibly bleed slightly (from continuing anticoagulation) or possibly die (from an embolic complication from anticoagulation withdrawal). The decision should be to continue therapeutic anticoagulation in dental patients undergoing extraction. Should warfarin be discontinued before a dental extraction? A decision-tree analysisOral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and EndodonticsVol. 110Issue 6PreviewThe aim of this study was to determine if warfarin should be withdrawn before a single tooth extraction on a patient with a prosthetic heart valve. Full-Text PDF Should warfarin be discontinued before a dental extraction?Oral Surgery, Oral Medicine, Oral Pathology and Oral RadiologyVol. 113Issue 2PreviewI appreciate the interest in my article1 and Dr Miller's thoughtful comments. For the sake of concision and clarity, I am responding to all of them in one letter. Full-Text PDF