Department of Oral & Maxillofacial Surgery

Gloucestershire Hospitals NHS Foundation Trust

Referral Guidelines September 2012 CONTENTS

Referral to the Department of Oral & Maxillofacial Surgery, 3-4 Gloucestershire Royal / Cheltenham General Hospitals

Referral Guidelines: 5

 Non-Third Molar Exodontia 6

 Third Molars 7

 Apical Surgery 8

 Guidelines for Management of patients on Oral 9 -19 Anticoagulants requiring surgery

 Routine Exodontia in Warfarinised Patients 20 - 21

2 Our ref: Department of Oral & Maxillofacial Surgery Gloucestershire Royal Hospital 13 September 2010 Great Western Road GLOUCESTER To All General Dental Practitioners & GL1 3NN General Medical Practitioners Tel: 08454 228509/8564/8566 Fax: 08454 228517

Private and Confidential

Dear Colleague

Re: Referrals to the Department of Oral and Maxillofacial Surgery, Gloucestershire Royal/Cheltenham General Hospitals

You will be aware of the recent closure of the Department of Oral and Maxillofacial Surgery to all dento-alveolar referrals. As previous documentation has explained, this was due to many reasons, a significant proportion of which related to inappropriate referrals. We believe that the Trust and PCT are soon to re-open the department to all referrals and we welcome this action. However, it is pertinent to raise the issue that very little has changed in terms of manpower/staffing levels in the Department of Oral and Maxillofacial Surgery since the decision was made to close to dento- alveolar referrals on 12 July 2010. If referral patterns continue as previously, then it is very likely we will arrive at the same situation again in a relatively short period of time. This is a scenario we would wish to avoid.

We therefore wish to reiterate that the Department of Oral and Maxillofacial Surgery is not able to offer a service for routine dental extractions, extractions for nervous/phobic patients, third molar removal where not indicated by NICE guidelines or routine apicectomy. The Community Dental Services provide a GA extraction service for paediatric dental extractions. In addition, we do not offer a service for routine dental extractions in patients receiving Warfarin where the INR is less than 4.0 (as per national guidelines). Furthermore, it is rare for the patient’s history to complicate extractions to such an extent that it needs to take place in a hospital setting

Where patients are referred for dento alveolar surgery, we would be grateful if all relevant x-rays could be enclosed with the referral letter to the Department. This will reduce the chances of any unnecessary radiation exposure to patients who are being assessed by us. If such radiographs do not exist, then a statement in the referral letter to this effect and the necessity for such radiographs being obtained within the hospital department would speed the patient pathway through our Department as we would be able to complete the necessary paperwork for radiographs in the hospital prior to the patient attending.

/continued

3 /continued

Re: Referrals to the Department of Oral and Maxillofacial Surgery, Gloucestershire Royal/Cheltenham General Hospitals

If you feel that a general anaesthetic is indicated for routine dental cases and the patient is genuinely phobic, then the Community Dental Services do provide a service for such patients and have access to general anaesthesia. However, it should be stressed that this is for patients with a genuine dental phobia and not those who are merely nervous of dental treatment. If there is no surgical indication for general anaesthesia, it is more appropriate to manage anxious patients under local anaesthesia as a staged procedure in primary care. A previous history of a difficult extraction is a less reliable indicator for surgical difficulty than accurate clinical and radiographic examination.

Most of these patients will have had a bad experience from poorly managed previous extractions.

The PCT Oral Surgery Service at Southgate Moorings, The Docks, Gloucester, GL1 2DB or the NHS Treatment Centres run by UK Specialist South West Limited on behalf of the NHS at Cirencester Hospital or Emmerson’s Green, Bristol are able to provide an oral surgery service for the more routine cases, and often with a speedier outcome.

Lastly, we would wish to advise colleagues in the primary care setting in respect to oral medicine referrals. We receive a significant number of ‘white patch’ referrals, with often very little clinical information. You will appreciate that without the clinical information these patients have to be treated as urgent referrals, and to this day they are a significant, and often, unnecessary burden on the service. A little more input in terms of clinical information would help the Department of Oral and Maxillofacial Surgery in assessing the urgency, or otherwise, with which these types of referrals need to be seen. A recent audit has suggested that 75%-80% of white patch referrals received in the department have proven to be simple traumatic keratosis with no clinical suspicion of malignancy. Your help would therefore be much appreciated in this matter.

Yours sincerely

Jeremy Farrier MBBch BDS FDSRCS(Ed) FRCS(Eng) FRCS(I) FRCS(OMFS) Consultant Oral and Maxillofacial Surgeon

C S Perkins FDS FFD FRCS Consultant Oral and Maxillofacial Surgeon

Daryl R P Godden Consultant Maxillofacial Surgeon

Gregor Knepil FRCS, MRCS, MFDS Consultant Oral & Maxillofacial Surgeon

4 Referral Guidelines

 Non-Third Molar Exodontia

 Third Molars

 Apical Surgery

 Guidelines for Management of patients on Oral Anticoagulants requiring surgery

 Routine Exodontia in Warfarinised Patients

5 REFERRAL GUIDELINES

NON-THIRD MOLAR EXODONTIA

The department does not provide a service for “routine” extractions in healthy patients, anxious patients, those with a history of difficult extractions or those with anticipated difficult extractions. If a surgical approach is obviously necessary (e.g. retained roots) then referral should be made.

Indications for referral include:

 Associated pathology that needs to be submitted for histological examination (e.g. cysts)

 Extractions from abnormal or diseased bone (e.g. patients who have received therapeutic doses of irradiation to the jaws)

 Surgical complexity such as a general anaesthetic may be indicated

If there is no surgical indication for general anaesthetic it is more appropriate to manage anxious patients under local anaesthesia as a staged procedure in primary care. A previous history of a difficult extraction is a less reliable indicator of surgical difficulty than accurate clinical and radiographic examination. Most of these patients will have had a bad experience from poorly managed previous extractions.

It is rare for a patient’s medical history to complicate the extraction to such an extent that it needs to take place within the hospital setting.

Please ensure that relevant radiographs accompany all requests so that we can help to avoid unnecessary radiation exposure to patients. These radiographs will be returned once treatment has been completed.

If you are referring a patient because they request treatment under general anaesthesia please ensure that the GDC guidelines with regard to risk counselling have been followed and that evidence of this is provided in your letter.

If a referral is made outside these guidelines please give the reasons why treatment cannot be undertaken in primary dental care.

THIRD MOLARS

The National Institute of Clinical Excellence (NICE) has published referral guidelines for third molars which are available at their website (www.nice.org.uk).

Patients will normally only be offered surgical removal of third molars if they fulfil these guidelines. Indications include:

 Multiple episodes of pericoronitis  Caries leading to pulpal exposure  Periodontal disease  Medical “prophylaxis” e.g. for cardiac surgery or endocarditis  Periapical pathology  Restorative considerations  Fractured tooth  Resorption or caries of adjacent teeth  Association with a mandibular fracture  Prior to orthognathic surgery  Association with a cyst or tumour

Anterior crowding, if it occurs in the absence of any of the above, is not an indication for third molar removal.

If you are referring a patient because they request treatment under general anaesthesia please ensure that the General Dental Council Guidelines with regard to risk counselling have been followed and that evidence of this is provided in your letter.

APICAL SURGERY

Prior to referral for apical surgery complete orthograde obturation of the root canal system must have taken place. Since there is good evidence to suggest that endodontic re-treatment has higher success rates than apical surgery patients will be advised to pursue a non-operative route if obturation is radiographically incomplete or short of the root apex.

In order to prevent recontamination and failure of apical surgery all patients should also have a satisfactory coronal seal.

The success rate of apical surgery on molar teeth is low and will not be routinely undertaken. Repeat apicectomy has a low success rate and will also not be routinely undertaken.

Referral may be appropriate in cases of peri-radicular disease in root filled teeth while orthograde endodontic therapy cannot be re-performed or has failed. Likewise patients may be offered surgery in cases of suspected root perforation, root fracture or where biopsy of peri-radicular tissue is required (e.g. cystic change suspected).

More comprehensive guidelines for referral for apicectomy are available at www.rcseng.ac.uk/fds/news/surgical-endodontics-guidelines-update

8 GUIDELINES FOR THE MANAGEMENT OF PATIENTS ON ORAL ANTICOAGULANTS REQUIRING DENTAL SURGERY

British Committee for Standards in Haematology

Address for correspondence: BCSH Secretary British Society for Haematology 100 White Lion Street London N1 9PF e-mail: [email protected]

Writing group: Perry DJ 1 , Nokes TJC 2 , Heliwell PS 3

Disclaimer While the advice and information in these guidelines is believed to be true and accurate at the time of going to press, neither the authors, the British Society for Haematology nor the publishers accept any legal responsibility for the content of these guidelines.

Date for guideline review September 2011

1 Addenbrookes Hospital, Hills Road, Cambridge, UK 2 Derriford Hospital NHS Trust, Plymouth, UK 3 National Patient Safety Agency (NPSA)

9 Introduction The guideline group was selected to be representative of UK based medical experts and patients representatives. MEDLINE and EMBASE were searched systematically for publications in English from 1950 – 2006 using the key words: dental, surgery, oral and anticoagulants. The writing group produced the draft guideline, which was subsequently revised by consensus by members of the Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology. The guideline was then reviewed by a sounding board of approximately 100 UK haematologists, the BCSH (British Committee for Standards in Haematology), the British Society for Haematology Committee, the British Dental Association (BDA), the National Patient Safety Agency (NPSA) and comments incorporated where appropriate. Criteria used to quote levels and grades of evidence are as outlined in appendix 3 of the Procedure for Guidelines Commissioned by the BCSH (http://www.bcshguidelines.com/process1.asp#App3).

The objective of this guideline is to provide healthcare professionals including primary care dental practitioners with clear guidance on the management of patients on oral anticoagulants requiring dental surgery. The guidance may not be appropriate in all cases and individual patient circumstances may dictate an alternative approach.

Summary of key recommendations 1. The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4 (i.e. <4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extraction (grade A level Ib).

2. Recommendations: For patients stably anticoagulated on Warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their anticoagulant regimen (grade C, level IV).

3. The risk of bleeding may be minimised by: a). The use of oxidised cellulose (Surgicel) or collagen sponges and sutures (grade B, level IIb). b). 5% tranexamic acid mouthwashes used four times a day for 2 days (grade A, level Ib). Tranexamic acid is not readily available in most primary care dental practices.

4. For patients who are stably anticoagulated on Warfarin, a check INR is recommended 72 hours prior to dental surgery (grade A, level Ib).

10 5. Patients taking Warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesia following dental surgery (grade B, level III).

1. The risk of bleeding in anticoagulated patients undergoing oral surgery Dental surgery in anticoagulated patients is common and historically their management has been controversial following early reports of major bleeding in such individuals (1). Many of the early reports of haemorrhage associated with dental surgery during this period predated the standardisation of oral anticoagulant control by means of the INR. In 1954, the American Heart Association recommended a therapeutic range for oral anticoagulant therapy of a prothrombin time ratio (PTR) of 2 – 2.5 using human brain reagents (2). Later, the use of less sensitive commercial thromboplastins was not accompanied by a change in the target PTR ratio. Clinicians, therefore, administered larger doses of oral anticoagulants to achieve the target ratio, resulting in an increased incidence of haemorrhage. The development and introduction of the INR did not take place until 1983 (3).

The risks of bleeding associated with dental extraction in individuals not receiving oral anticoagulants is approximately 1% [4, 5]. In a review of 10 studies of patients undergoing dental surgery and in whom oral anticoagulants were continued, 9% (89/990) had delayed postoperative bleeding and in 3.5% of cases this was classified as ‘serious’ i.e. not controlled by local measures (4). Other studies have reported the incidence of minor bleeding as higher and in some cases up to 50% (5). However, the interpretation and comparison of bleeding rates in patients undergoing oral surgery is difficult as rates for different procedures are not analysed separately, the definitions used to describe serious bleeding vary and surgery can involve the use of differing treatments to secure haemostasis.

2. What constitutes dental treatment? Many procedures performed in the primary care setting are relatively non-invasive and would not, therefore, require measurement of the INR. Such procedures would include prosthodontics [construction of dentures], scaling/polishing and some conservation work [fillings, crowns, bridges].

Potentially invasive procedures performed in primary care would include: • Endodontics [root canal treatment] • Local anaesthesia [infiltrations, inferior alveolar nerve block, mandibular blocks] • Extractions [single and multiple] • Minor oral surgery • Periodontal surgery • Biopsies • Sub-gingival scaling

11 3. Which patients on Warfarin should NOT have a surgical dental procedure in the primary care setting? • Patients on oral anticoagulants with co-existing medical problems e.g. liver disease, renal disease, thrombocytopenia or who are taking anti-platelet drugs. Such patients may have an increased risk of bleeding.

• Patients requiring surgical procedures not listed above. Such patients should be referred to a dental hospital or hospital-based oral and maxillofacial surgery department.

Surgical dentists in the primary care setting often have the skills to undertake any of the procedures listed above in the context of the anticoagulated patient. The skill and experience of the primary care dentist, together with the difficulty of the procedure all need consideration.

4. Is it safe to discontinue anticoagulants prior to dental surgery? 4.1. The risk of thrombosis if anticoagulants are discontinued. The risk of thrombosis associated with temporarily discontinuing anticoagulants prior to dental surgery is small but potentially fatal. In the review of Wahl, 5/493 (1%) patients undergoing 542 dental procedures and in whom anticoagulants were withdrawn specifically for surgery, had serious embolic complications of which 4 were fatal (6). The four deaths comprised: a fatal cerebral embolism 17 days after discontinuing Warfarin; 1 fatal myocardial infarction 19 days after interruption of therapy for 9 days; 1 fatal cerebral thromboembolism 5 days postoperatively and 1 patient died from a thromboembolism but no other data are available.

4.2. The risk of major bleeding in patients undergoing oral surgery if anticoagulants are continued Wahl reviewed 26 papers comprising 2014 dental surgical procedures in 774 patients receiving continuous Warfarin therapy, including 1694 patients undergoing single, multiple extractions and full mouth extractions (6). This meta-analysis included patients with an INR up to 4.0. Although some patients had minor oozing treated with local measures, more that 98% of patients receiving continuous anticoagulants had no serious bleeding problems. Many of the procedures were performed in patients with an INR above the present recommended therapeutic levels of anticoagulation. Twelve patients (<2%) had postoperative bleeding problems that were not controlled by local measures. Eight of these 12 episodes were associated with a supra-therapeutic INR at the time of the procedure or in the week after. Major bleeding was rare (4/2012, 0.2%) for patients with a therapeutic INR (<4) undergoing dental surgery. There were no deaths.

Five randomised studies have been published since this systematic review.

12 Devani et al (7) randomised 65 patients on continuous Warfarin therapy and undergoing 133 dental extractions to either stop Warfarin 2-3 days prior to surgery (32 patients) resulting in a reduction in mean INR from 2.6 to 1.6, or to continue anticoagulants with no dose alteration (32 patients) and a mean pre-operative INR of 2.7 (range 2.2-3.9). All patients received local measures (‘Surgicel’ packing and sutures) to control post-operative bleeding. None of the patients had any immediate postoperative bleeding and only 1 patient from each group had mild delayed haemorrhage, which was controlled with local measures.

Campbell et al randomised 25 patients to either discontinue Warfarin 72-96 hours prior to surgery (13 patients: mean INR 2.0: range 1.2-2.9) or to continue anticoagulants (12 patients: mean INR 2.0: range 1.1-3.0) (8). A further group of 10 individuals not receiving anticoagulants served to establish a baseline bleeding risk. No patient in any group had postoperative bleeding `sufficiently severe to require therapeutic intervention and there were no significant differences in blood loss between the three groups.

Evans randomised 109 patients on continuous oral anticoagulants requiring dental extractions to either continue Warfarin (57 patients) although if the INR was >4 on the day of surgery, the patient was withdrawn (9). The control group (52 patients) stopped taking Warfarin 2 days prior to surgery and if the INR was >2 on the day of the procedure this was subsequently rebooked for the following day. Tranexamic acid mouthwashes were not allowed. The mean INR for the group taking anticoagulants at the time of dental surgery was 2.5 (range 1.2-4.7) and for the group that discontinued anticoagulants 1.6 (range 1.2-2.3). The rate of bleeding was higher in the group continuing anticoagulation (15/57, 26%) than in the control group (7/52, 14%) but the difference was not significant.

Sacco et al (10) randomised 131 patients on anticoagulants requiring dental surgery - primarily dental extractions - to either reduce their Warfarin dose 72 hours prior to surgery to achieve an INR of 1.5-2 on the day of surgery or to continue anticoagulants with no alteration but this latter group received haemostatic agents at the time of surgery and tranexamic acid mouthwashes for the following 6 days. Bleeding sufficient to warrant additional haemostatic measures was observed in 15% of the first group (mean INR 1.77 ±0.26) and 9% of the second group (mean INR 2.89 ±0.42).

Al-Murbarak et al randomised 168 patients on Warfarin undergoing dental surgery to one of four groups: no socket suturing with or without discontinuation of Warfarin socket suturing with or without discontinuation of Warfarin, (groups 1-4 respectively)(5). The percentage of patients who bled following surgery was (12%) in the group whose Warfarin was stopped and who in addition had suturing of the socket (mean pre-operative INR of 1.79) compared to 36% in Group 4 with a mean pre-operative INR of 2.6 but whose Warfarin was continued and who did not receive suturing

13 of the sockets following extraction. However, this difference in bleeding was not clinically significant and no surgical intervention was necessary.

Recommendations: The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4, is low. The risk of thrombosis if anticoagulants are discontinued may be increased. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental treatment. An appreciation of the surgical skills of primary care dentists and the difficulty of surgery, particularly when INR levels approach 4, is also important when assessing the risk of bleeding. Individuals, in whom the INR is unstable, should be discussed with their anticoagulant management team (grade A level Ib).

5. Anticoagulants and prophylactic antibiotics. Patients undergoing dental surgery may be prescribed antibiotics to prevent endocarditis. Antibiotics prescribed commonly include amoxicillin, ampicillin, clindamycin and azithromycin (11). A single dose of an antibiotic is unlikely to have any significant effect upon the INR. Individuals who are prescribed more than a single dose of antibiotics should have the INR measured 2-3 days after starting treatment.

Recommendations: For patients stably anticoagulated on Warfarin (INR 2-4) and who are prescribed a single dose of antibiotics as prophylaxis against endocarditis, there is no necessity to alter their anticoagulants (grade C, level IV).

6. Local haemostatic measures. Tranexamic acid binds to plasminogen and inhibits subsequent lysis of fibrin. Orally administered tranexamic acid does not appear in saliva at detectable levels (12) but as a mouthwash, the concentration of tranexamic acid remains sufficiently high to inhibit fibrinolysis for hours but insignificant levels are detected in the plasma. In the UK, tranexamic acid mouthwashes are not readily available in the primary care setting and dentists cannot currently prescribe it. Four studies have evaluated the role of alternative treatments in patients undergoing dental extractions to secure haemostasis. However, in two of these studies tranexamic acid was also used to secure haemostasis.

Blinder et al (13) in a study of 150 patients undergoing dental extractions and without interruption of their anticoagulants, randomised patients to one of three groups: group 1 (50 patients mean INR 2.38) who were treated with gelatin sponges and sutures; group 2 (50 patients mean INR 2.7) who were treated with gelatin sponges sutures and tranexamic acid mouthwashes and group 3 (50 patients mean INR 2.19) who received fibrin glue, gelatin sponges and sutures. 13 patients (8.6%)

14 developed post-operative bleeding: 3 in group 1, 6 in group 2 and 4 in group 3. The use of gelatin sponges and sutures provided adequate haemostasis for dental extraction without interruption of anticoagulants. Tranexamic acid mouthwashes or fibrin glue offered no benefit over resorbable gelatin sponges plus suturing.

In a subsequent study of 249 patients undergoing 543 dental extractions without interruption of their anticoagulant therapy (14) patients were divided into 5 groups according to their INR at the time of surgery. Local haemostasis in all groups was achieved with gelatin sponges and silk sutures. Overall, 12% developed post-operative bleeding but the incidence of bleeding was not significantly different between group I (59 patients: mean INR 1.74) and group V (23 patients: mean INR 3.8).

In a study of 26 patients undergoing dental extraction with an INR of 2.0-4.2, the sockets were packed with a resorbable oxycellulose dressing (‘Surgicel’) and sutured with a resorbable suture [20]. A second group of patients (INR 2.1-4.1) received local packing of the sockets with a fibrin adhesive (‘Beriplast’). Only 1 patient in the second group had significant postoperative haemorrhage. The authors concluded that fibrin adhesive is as effective as oxycellulose dressing in preventing post-extraction haemorrhage in patients receiving oral anticoagulants.

In a Spanish study of 150 patients on oral anticoagulants undergoing dental extraction (229 sessions/367 dental extractions) and with an INR of 2-3 (145 cases 2-2.5; 84 cases 84 2.5-3) haemostasis was secured using haemostatic gauze and/or sutures or a local compression (15). In over 99% of cases the use of resorbable gelatine sponges plus sutures at the time of dental surgery was sufficient to achieve haemostasis and only 1 case of severe bleeding was observed. However, all patients received tranexamic acid mouthwashes every 6 hours for 2 days.

In 2003 Zanon and colleagues (16) reported the results of a prospective study of 250 anticoagulated patients with INR values between 1.8-5.0 and 265 patients who were not receiving anticoagulation undergoing dental surgery. In all groups receiving oral anticoagulants, local haemostasis was secured with oxidised cellulose and silk sutures plus local application of a tranexamic acid saturated gauze swab for 30-60 minutes following surgery. There was no difference in bleeding complications between the two groups (4/250 for the anticoagulated group and 3/250 in the control group). When the anticoagulated group was stratified according to INR (1.8-2, 2-3 and 3-4) bleeding complications were seen in 1.2%, 1.3% and 4.8% of patients respectively but this difference was not significantly different.

Five randomised trials have evaluated the role of tranexamic acid or other local haemostatic measures in patients undergoing oral surgery on continuous anticoagulant therapy.

15 In a study of 39 patients receiving oral anticoagulants for a cardiac valvular stenosis, a prosthetic heart valve or a vascular prosthesis, surgery was performed without a change in anticoagulation, but before suturing the operative field was irrigated in 19 patients with 10ml of a 4.8% solution of tranexamic acid and in 20 patients with placebo (17). Patients were instructed to rinse their mouths with 10ml of placebo or tranexamic acid for two minutes, four times a day for 7 days. The range of INRs was estimated at between 2.5-4.8. There was a statistically significant difference between the two groups with 8/20 (40%) patients in the placebo group having a total of 10 postoperative bleeds compared to only 1/19 (5%) patients in the tranexamic acid-treated group.

In a second study, 93 patients undergoing invasive dental surgery were randomized to either tranexamic acid mouthwashes (4.8% four times a day for 7 days) (44 patients) or placebo (45 patients) (18). Anticoagulants in this study were assessed by measuring plasma factor X levels and there were no differences in factor X levels between the two groups of patients. In the group that received placebo mouthwashes, 10 patients (22%) had bleeding problems requiring treatment but none in the tranexamic acid group, a difference that was statistically significant.

A further study randomised 49 patients (undergoing 152 dental extractions) to either tranexamic acid (4.8% four times a day for 7 days) (26 patients: mean INR 3.0 range 2.3-4.0) or autologous fibrin glue (23 patients: mean INR 3.1 range 2.1-4.0) (19). 2 cases of post-operative bleeding were noted in the group that received autologous fibrin glue but both cases had elevated INRs (5.9/7.9) at the time of surgery. Tranexamic acid was found to be a more cost-effective alternative.

In a study of 85 patients on Warfarin undergoing dental surgery randomised to tranexamic acid mouthwashes (2 minutes four times a day: mean INR 2.7) for either 2-days or 5-days (mean INR 2.8) (19). There were no significant differences in bleeding complications between the two groups.

Sacco et al (Sacco et al 2006) reported a significant difference in bleeding complications between a group of patients whose Warfarin dose was reduced 72 hours prior to surgery compared to those who Warfarin continued uninterrupted but who received tranexamic acid mouthwashes for 6 days. The rate of bleeding was 15% in the first group compared to 9% in the second group.

The current ACCP guidelines recommend the use of tranexamic acid mouthwashes (or epsilon amino caproic acid (EACA) mouthwashes) without interruption of anticoagulant therapy in anticoagulated patients undergoing dental surgery (20).

Recommendations: In patients undergoing dental extractions, bleeding may be minimised by: a). The use of oxidised cellulose (‘Surgicel’) or collagen sponges and sutures (grade B, level IIb).

16 b). 5% tranexamic acid mouthwashes used four times a day for 2 days (grade A, level Ib). Tranexamic acid is not readily available in the primary care dental setting.

7. When should the INR be measured before a dental procedure? In patients receiving long-term anticoagulant therapy and who are stably anticoagulated on Warfarin an INR check 72 hours prior to surgery is recommended. This allows sufficient time for dose modification if necessary to ensure a safe INR (2-4) on the day of dental surgery.

There is no need to check the INR for non-invasive dental procedures although scaling subgingivally will require an INR check.

The INR should also be checked if performing an inferior alveolar nerve block (IANB) as there is an anecdotal risk of haematoma and airway compromise. If needed, an IANB should be given cautiously, using an aspirating syringe, with an INR <3.0.

8. The use of anti-inflammatory drugs in patients receiving warfarin and undergoing dental surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) are avoided in patients receiving oral anticoagulants because of their anti-platelet action and the risk of over anticoagulation and haemorrhage. Cyclo oxygenase-2 (COX-2) selective inhibitors are perceived to be safer than conventional NSAIDs in patients receiving Warfarin and this has led to an increase in their use in such cases. However, there is accumulating data that COX-2 inhibitors can cause an increase in INR and recent studies highlighting that the risk of upper GI haemorrhage are similar in Warfarin users concomitantly taking either non-selective NSAIDs or COX-2 inhibitors.

Recommendations: Patients taking Warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesics following dental surgery (grade B, level IIb.)

Acknowledgments For their helpful comments and suggestions, we are grateful to:

Mr Andrew Brewer in the Department of Oral and Maxillofacial Surgery, Glasgow Royal Infirmary.

Pippa K Blacklock in the Department of Oral and Maxillofacial Surgery, Derriford Hospital, Plymouth. 17 References

1. Ziffer AM, Scopp IW, Beck J, Baum J, Berger AR. Profound bleeding after dental extractions during dicumarol therapy. N Engl J Med 1957;256(8):351-3.

2. Wright IS, Beck DF, Marple CD. Myocardial infarction and its treatment with anticoagulants; summary of findings in 1031 cases. Lancet 1954;266(6802):92-5.

3. Kirkwood TB. Calibration of reference thromboplastins and standardisation of the prothrombin time ratio. Thromb Haemost 1983;49(3):238-44.

4. Randall C. Surgical management of the primary care dental patient on warfarin. Dent Update 2005;32(7):414-6, 419-20, 423-4 passim.

5. Al-Mubarak S, Rass MA, Alsuwyed A, Alabdulaaly A, Ciancio S. Thromboembolic risk and bleeding in patients maintaining or stopping oral anticoagulant therapy during dental extraction. J Thromb Haemost 2006;4(3):689-91.

6. Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med 1998;158(15):1610-6.

7. Devani P, Lavery KM, Howell CJ. Dental extractions in patients on warfarin: is alteration of anticoagulant regime necessary? Br J Oral Maxillofac Surg 1998;36(2):107-11.

8. Campbell JH, Alvarado F, Murray RA. Anticoagulation and minor oral surgery: should the anticoagulation regimen be altered? J Oral Maxillofac Surg 2000;58(2):131-5; discussion 135-6.

9. Evans IL, Sayers MS, Gibbons AJ, Price G, Snooks H, Sugar AW. Can warfarin be continued during dental extraction? Results of a randomized controlled trial. Br J Oral Maxillofac Surg 2002;40(3):248-52.

10. Sacco R, Sacco M, Carpenedo M, Moia M. Oral surgery in patients on oral anticoagulant therapy: a randomized comparison of different INR targets. J Thromb Haemost 2006;4(3):688-9.

11. Gould FK, Elliott TS, Foweraker J, Fulford M, Perry JD, Roberts GJ, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006.

12. Sindet-Pedersen S. Distribution of tranexamic acid to plasma and saliva after oral administration and mouth rinsing: a pharmacokinetic study. J Clin Pharmacol 1987;27(12):1005-8.

13. Blinder D, Manor Y, Martinowitz U, Taicher S, Hashomer T. Dental extractions in patients maintained on continued oral anticoagulant: comparison of local hemostatic modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88(2):137-40. 18 14. Blinder D, Manor Y, Martinowitz U, Taicher S. Dental extractions in patients maintained on oral anticoagulant therapy: comparison of INR value with occurrence of postoperative bleeding. Int J Oral Maxillofac Surg 2001;30(6):518-21.

15. Vicente Barrero M, Knezevic M, Tapia Martin M, Viejo Llorente A, Orengo Valverde JC, Garcia Jimenez F, et al. Oral surgery in patients undergoing oral anticoagulant therapy. Med Oral 2002;7(1):63-6, 67-70.

16. Zanon E, Martinelli F, Bacci C, Cordioli G, Girolami A. Safety of dental extraction among consecutive patients on oral anticoagulant treatment managed using a specific dental management protocol. Blood Coagul Fibrinolysis 2003;14(1):27-30.

17. Sindet-Pedersen S, Ramstrom G, Bernvil S, Blomback M. Hemostatic effect of tranexamic acid mouthwash in anticoagulant-treated patients undergoing oral surgery. N Engl J Med 1989;320(13):840-3.

18. Ramstrom G, Sindet-Pedersen S, Hall G, Blomback M, Alander U. Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 1993;51(11):1211-6.

19. Carter G, Goss A. Tranexamic acid mouthwash--a prospective randomized study of a 2-day regimen vs 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions. Int J Oral Maxillofac Surg 2003;32(5):504-7.

20. Ansell J, Hirsh J, Poller L, Bussey H, Jacobson A, Hylek E. The pharmacology and management of the vitamin K antagonists: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004;126(3 Suppl):204S-233S.

ROUTINE EXODONTIA IN WARFARINISED PATIENTS

There has been recent guidance issued related to the removal of teeth in dental practice for patients who are on Warfarin. Patients should be managed according to these guidelines and not referred to hospital for “routine” extractions. The guidelines stipulate that extractions can safely be carried out in primary care in the following circumstances:

 Where the INR is less than 4.0  If the socket is packed and sutured  Warfarin should not be stopped but the INR must be checked within 24 hours of the planned extraction (patients can usually co-ordinate this themselves with either their doctor or anti-coagulant clinic).

Patients should be referred if other coagulopathies co-exist or if the INR is maintained at over 4 (the latter will be recorded in the patient’s anticoagulant book).

Extractions should be timed appropriately and ideally should take place at the beginning of the week (such that delayed re-bleeding problems can be managed during the working week) and in the morning (such that immediate re-bleeding problems can be managed during the working day).

These guidelines are available at www.dundee.ac.uk/tuith/static/info/warfarin.pdf and are summarised overleaf.

20 Management of routine exodontia in Warfarinised patients undergoing surgical procedures in primary care

Does the patient’s medical history include: 1. Liver impairment and / or alcoholism Yes 2. Renal failure Refer 3. Another haemostatic disorder 4. Concurrent cytotoxic medications

Yes If possible delay extractions Is the patient on a short course of Warfarin or surgical procedures until (< 6 months) the course has been completed No

Is the patient’s INR normally maintained over Yes 4.0 Refer

Obtain INR measured ideally within 24 hours (but not more than 72 hours) before the procedure

Does the patient have an INR of 4.0 or below No Refer

Use a local anaesthetic containing a vasoconstrictor giving infiltrations or intraligamentary injections where practical (if there is no alternative to a regional nerve block use an aspirating syringe)

Pack the socket with an absorbable haemostatic dressing (e.g. Surgicel, Haemacollagen, Spongostan) and suture the socket

If the patient requires concurrent endocarditis prophylaxis follow guidelines making note of potential drug interactions.

If the patient requires post-operative analgesia non-steroidal anti-inflammatory drugs should be avoided because of interactions.