Do you hold blood thinners, Prolia, or Ozempic before dental procedures?
Evidence-based hold times for Eliquis, Xarelto, warfarin, Prolia, Fosamax, and GLP-1s before extractions and implants — every threshold cited. Every recommendation below is taken from the cited source — nothing is estimated or interpolated.
62%
of dentists interrupt DOAC therapy before single-tooth extractions — even though guidance favors continuation [2021]
INR < 3.5
warfarin continuation threshold for uncomplicated extraction (up to 4.0 per some experts; some guidelines draw the line at 3.0) [2024]
1–3 teeth
extractions safely performed without holding a DOAC, per SDCEP guidance [2023]
24–48h
manufacturer hold window for moderate-to-high-risk invasive surgery: rivaroxaban and edoxaban 24h, apixaban 48h [2022]
The hold-or-continue table
The medication, the scenario you are facing, and what the evidence says to do — with the source for every line.
| Medication | Scenario | What the evidence says | Verdict | Source |
|---|---|---|---|---|
| Eliquis, Xarelto (DOACs) | Extraction of 1–3 teeth or other low-bleeding-risk procedure | Continue — do not hold. Schedule at the end of the dosing cycle or 12–24h after the last dose, with local haemostatic measures if bleeding occurs.Full clinical answer | Continue | 20232022 |
| Eliquis, Xarelto (DOACs) | Multiple extractions, flap-raising surgery, or biopsies (guideline approach) | Miss or delay the morning dose on the treatment day, per SDCEP. The Spanish Society expert approach schedules extraction at trough drug concentration and delays the next dose at least 4 hours after; restart the same day once haemostasis is achieved.Full clinical answer | Miss morning dose | 202320242022 |
| Eliquis, Xarelto (DOACs) | Moderate-to-high-risk invasive surgery (manufacturer labeling) | Manufacturer labeling — a distinct strategy from the missed-dose approach — advises discontinuing rivaroxaban and edoxaban 24 hours before and apixaban 48 hours before invasive or surgical procedures, restarting the same day. This is drug labeling, not a dental-society guideline.Full clinical answer | Hold 24–48h | 2022 |
| Heparin bridging | Should held anticoagulants be bridged? | No. Bridging is not required for perioperative DOAC management, and interruption with bridging may increase thrombotic and bleeding complications. | No bridging | 20262024 |
| Warfarin | Simple extraction, INR in therapeutic range | Continue regular dosing — continuation does not increase bleeding versus dose adjustment or discontinuation when INR is below 3.5 (up to 4.0 per some experts for uncomplicated extraction), using local haemostasis: sutures, collagen, or tranexamic acid. Check INR 72 hours before an invasive procedure.Full clinical answer | Continue | 20242021 |
| Warfarin | INR between 3.0 and 3.5, or four or more teeth to extract | Sources draw the line differently: the Spanish Society guideline advises physician contact once INR exceeds 3.0 or several teeth are involved, while continuation is documented safe below 3.5 (to 4.0 for uncomplicated cases). In this band — and for extractions of four or more teeth, where bleeding risk rises — involve the prescribing physician.Full clinical answer | Consult physician | 2024 |
| Aspirin, clopidogrel (antiplatelets) | Single or dual antiplatelet therapy | Continue for simple dental procedures. Never stop prematurely after a stent — defer elective care 6 weeks after a bare-metal stent and 6 months after a drug-eluting stent instead. | Continue | 2026 |
| Prolia (denosumab) | How long after an injection can you extract a tooth? | Proceed with a necessary extraction rather than retaining an odontogenic infection — MRONJ risk at osteoporosis dose is low. Where a suspension is being considered, AAOMS advises completing planned surgery 3–4 months after the last dose, when osteoclast inhibition is waning, and reinstituting 6–8 weeks postsurgery; a 2026 cohort study found every MRONJ case occurred when surgery was within 3 months of an injection. Discontinuing denosumab without follow-on antiresorptive therapy is not recommended.Full clinical answer | Time it 3–4 mo | 202220262021 |
| Fosamax (oral bisphosphonate) | Is a drug holiday needed before implants? | Routine holiday is not supported for MRONJ prevention at osteoporosis dose — AAOMS calls the benefit unsubstantiated — and oral antiresorptives are not a contraindication to implants. Only patients on therapy beyond four years with systemic risk factors warrant discussing a pause with the prescriber.Full clinical answer | No holiday | 202220212025 |
| Ozempic, GLP-1 agonists | Sedation or general anaesthesia fasting rules | Most patients continue the drug under risk-stratified guidance. Higher-risk patients may need a 24-hour liquid diet, anaesthetic-plan modification, or point-of-care gastric ultrasound. No specific holding interval is established — coordinate with the anaesthesia team.Full clinical answer | Coordinate | 2026 |
How to use this table
- The default is continuation: for most outpatient dental procedures the evidence favors continuing antithrombotics with local haemostatic measures — stopping causes more harm from thromboembolism than the bleeding it prevents.
- What changes the answer is the procedure, not the drug: low bleeding risk is 1–3 extractions; high risk is six or more extractions, flap-raising surgery, or multiple implant placement.
- Any modification should involve the prescribing physician — especially antiplatelets after stent placement, where premature discontinuation risks stent thrombosis.
How this brief was built
Each row states the cited source's own recommendation, population, and risk stratification. Where sources disagree — as they do for the warfarin INR threshold — the row shows the disagreement rather than averaging it. Every medication that has a full-length clinical answer on this site links to it from its row.
Cited sources
Where every recommendation comes from
The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review
BMC Oral Health · 2023 · Systematic review
Open the sourceDental Management Considerations for Patients with Cardiovascular Disease — A Narrative Review
Reviews in Cardiovascular Medicine · 2022 · Narrative review
Open the sourceClinical practice guideline of the Spanish Society of Oral Surgery for oral surgery in patients with coagulation disorders
Medicina Oral, Patología Oral y Cirugía Bucal · 2024 · Clinical guideline
Open the sourceBleeding Outcomes After Dental Extraction in Patients Under Direct-Acting Oral Anticoagulants vs. Vitamin K Antagonists: A Systematic Review and Meta-Analysis
Frontiers in Pharmacology · 2021 · Meta-analysis
Open the sourceInfluence of antiplatelet medication and anticoagulation therapy after dental extractions on hospitalization: a retrospective 10-year study
BMC Oral Health · 2024 · Retrospective cohort
Open the sourceThe Oral Cavity as a Window to Systemic Disease: Diagnostic Clues and Pre-treatment Dental Management for Interdisciplinary Trainees
Cureus · 2026 · Narrative review
Open the sourceAmerican Association of Oral and Maxillofacial Surgeons' Position Paper on Medication-Related Osteonecrosis of the Jaws—2022 Update
Journal of Oral and Maxillofacial Surgery · 2022 · Position paper
Open the sourceThe therapeutic window: timing dentoalveolar surgery to minimize MRONJ risk in denosumab-treated osteoporotic patients
JBMR Plus · 2026 · Retrospective cohort
Open the sourcePrevention and treatment of oral adverse effects of antiresorptive medications for osteoporosis
Archives of Endocrinology and Metabolism · 2021 · Guidance review
Open the sourceDental Implant Survival and Risk of Medication-Related Osteonecrosis in the Jaws
International Journal of Molecular Sciences · 2025 · Review
Open the sourceOral Health Implications of GLP-1 Receptor Agonists and Other Incretin-Based Therapies
Journal of Clinical Medicine · 2026 · Review
Open the source
Ask this against the live evidence.
This brief is a stored snapshot of the published literature. Run the search yourself for sources matched to your patient’s exact medication and procedure.
This brief was compiled from the published reviews, guidelines, and trials listed above. Recommendations reflect each source’s own populations and risk stratification.
Compiled on . Verify against current evidence and apply professional judgment before clinical use.