Basic and patient-oriented research
Dentoalveolar Procedures for the Anticoagulated Patient: Literature Recommendations Versus Current Practice

https://doi.org/10.1016/j.joms.2007.03.003Get rights and content

Purpose

To evaluate the current practice of oral and maxillofacial surgeons in Michigan regarding perioperative warfarin therapy and dentoalveolar surgery in defined procedure risk groups.

Materials and Methods

Surveys were distributed to all surgeons (n = 188) registered with the Michigan Society of Oral and Maxillofacial Surgeons. Low/moderate/high surgery risk groups were defined based on retrospective data accumulated for procedures on pretransplant liver failure patients. We requested the surgeon’s maximum tolerated International Normalized Ratio (INR) for each risk group. In addition, surgeons were asked if their routine practice for each group included continuation or discontinuation of therapeutic warfarin perioperatively.

Results

A 72.6% response rate was achieved. The average maximum INR cutoff values for the various risk groups were: low, 2.68; moderate, 2.28; and high, 2.01. Routine discontinuation of warfarin occurred in these groups 23.6%, 48.8%, and 70.5%, respectively. Using a paired t test, these results showed statistically significant differences in patient management practices (P < .001) between the low, moderate, and high risk groupings.

Conclusion

Lack of uniformity exists regarding warfarin therapy and dentoalveolar surgery. No studies to date involve significant numbers of moderate/high risk procedures to provide evidence-based support of safety with maintenance of therapeutic INR. For moderate or high risk procedures, the majority of surgeons prefer warfarin discontinuation with minimally therapeutic or subtherapeutic levels, a practice that secondarily increases risk for thromboembolism. Based on these preliminary data, we believe a prospective trial to elucidate stronger management guidelines for both the moderate and high risk surgery population is indicated.

Section snippets

Sample

A survey questionnaire was distributed twice to all 188 OMFS registered with the Michigan Society of OMFS in July 2005. Anonymous prepaid postage return envelopes were provided. The surveys were numbered for the sole purpose of preventing duplication of data entry. The individual respondents were never identified with their answers.

Survey

A 2-part questionnaire was developed to allow for simple data acquisition. The questions were as follows:

  • 1)

    Please indicate the maximal INR you would tolerate for

Results

All 188 surgeon members of the Michigan Society of OMFS received an initial mailing followed by a duplicate second mailing 2 weeks later. Fifteen of the surgeons were excluded because of retirement or incorrect address. One hundred twenty-seven surveys were returned for data collection for an overall response rate of 72.8%; however, 4 surveys were excluded. Three because of incomplete information, and 1 respondent returned both surveys with the same information.

Mean maximal INR values for low,

Discussion

In patients requiring anticoagulation, INR values are maintained within a therapeutic range set forth by recommendations provided by various anticoagulation committees. An INR range between 2.0 to 3.0 is deemed appropriate for patients at risk for arterial and venous thrombosis.48, 49, 50, 51, 52, 53, 54, 89 An INR range from 2.5 to either 3.5 or 4.0 is advocated for mechanical heart valves by American Heart Association/American College of Cardiology48, 49 and European Society of

Acknowledgment

The authors thank Dr Joseph Helman for his guidance, and the Michigan Society of Oral and Maxillofacial Surgeons for their support.

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