Anticoagulation and extraction

My position is that anticoagulation is not stopped for a dental extraction, and the dental reviews, with much of the recent guidance on minor procedures, support continuation: patients who continue warfarin or a direct oral anticoagulant bleed more in the chair, and more than people on no anticoagulant, but the reviews have not found a consistent excess of postoperative bleeding over patients who stopped, and the bleeding in the studies reviewed was overwhelmingly controlled with local measures, while the harm on the other side of the decision — a stroke, an embolism or a stent thrombosis — is rarer, remote from the mouth and often not reversible. The two risks differ in kind and not only in size, and that difference is the argument. Dual antiplatelet therapy raises bleeding after extraction compared with single therapy or none, but a meta-analysis of sixteen studies put the absolute excess in postoperative bleeding at about one percentage point, not statistically significant, and a 2007 science advisory co-issued by cardiology, surgical and dental bodies warns that stopping it prematurely after a coronary stent greatly increases the risk of stent thrombosis, infarction and death. The evidence is weakest exactly where the question is newest: a French prospective cohort found more bleeding with continued direct oral anticoagulants than with continued warfarin, and a large Korean cohort managed with a standardised planned interruption reported very low bleeding and no thromboembolic events, though without a comparison arm — so for these agents a brief, planned interruption is a defensible alternative to straight continuation, and the evidence does not yet separate the two.