What are the guidelines for managing patients with anticoagulant therapy who require oral surgical procedures?

Management of patients on anticoagulant therapy who require oral surgical procedures involves careful assessment of the balance between thromboembolic risk and bleeding risk. Pharmacological venous thromboembolism (VTE) prophylaxis with low molecular weight heparin (LMWH) for a minimum of 7 days should be considered for people undergoing oral or maxillofacial surgery whose risk of VTE outweighs their risk of bleeding. ¹ If the bleeding risk is high, mechanical VTE prophylaxis such as anti-embolism stockings or intermittent pneumatic compression should be used instead, continuing until the patient regains normal or anticipated mobility. ¹

For patients on vitamin K antagonists, perioperative bridging therapy decisions should be individualized, although there is limited evidence comparing LMWH with unfractionated heparin for bridging in this context. ³ It is important to assess anticoagulation control, for example by calculating time in therapeutic range (TTR) for vitamin K antagonists, and to optimize control before surgery. ²

Decisions to stop or continue anticoagulation should be based on reassessment of stroke and bleeding risk using validated tools (e.g., CHA2DS2-VASc and ORBIT scores) and patient preferences, rather than stopping anticoagulation solely because of surgery. ²

Intraoperatively, clear fluids may be allowed up to 2 hours before surgery to reduce postoperative symptoms, but specific guidance on oral anticoagulants around the time of surgery should be followed in consultation with the surgical and anticoagulation teams. ³