Protocol for the management of oral surgery patients on warfarin utilizing a Point-of-Care In-Office international normalized ratio monitoring device

Purpose: This study was performed to assess the utility and safety of an In-Office INR Monitoring Device and present a safe and efficient protocol for the management of patients on oral anticoagulants and/or antithrombolytics requiring routine office oral and maxillofacial surgery. Patients and Methods: Sixty-one patients requiring “minor” oral and maxillofacial surgery being treated chronically with oral anticoagulation (warfarin) were entered into the study and compared in 2 groups. The control group (n = 29) was managed by discontinuing warfarin and any anti-platelet medication(s) prior to surgery. In the study group (n = 30), the decision to continue or withhold warfarin was determined by a protocol in which patients are 1) stratified based on risk for thromboembolism, and 2) classified as requiring “major” or “minor” surgery. Procedures categorized as “minor” surgery included dental extraction(s), dental implants, soft tissue and bone biopsies, and preprosthetic bone surgery, and incision and drainage. Warfarin and antiplatelet medication were not withheld in these patients, and a Point-of-Care In-Office INR Monitoring Device was used to obtain INR levels on the day of consultation and surgery. Local measures including removal of granulation tissue, packing, suturing, etc. were utilized for hemostasis. Results: The 30 patients in the study group maintained on warfarin readily achieved hemostasis using intraoperative local measures. The mean INR measured by the In-Office INR Monitoring Device was 2.36 with a range from 1.3 to 3.2. Study group patients underwent a total of 131 separate procedures including 108 dental extractions (impactions), placement of dental implants, preprosthetic bony surgery, bone cyst removal, soft tissue biopsies, facial skin cancer repair, and incision and drainage. One patient (3%) required “minor” intervention with removal of a “liver clot” on postop day 2 with repacking and suturing. The 29 patients in the control group discontinued off of war farin underwent a total of 99 procedures. One patient (3%) also required a “minor” intervention (repacking of extraction site). There were no “major” complications in either group. Conclusions: This study supports previous studies that minor oral surgery procedures can be safely performed while maintaining patients on warfarin minimizing the risk of a potentially devastating thromboembolic event. When deciding whether or not to withhold warfarin, this study supports the use of the proposed protocol based on 1) risk stratification for thromboembolism, 2) the need for “minor” versus “major” surgery, 3) and utilization of an In-Office INR Monitoring Device. An In-Office Point-of-Care INR measuring device can be a very effective tool to safely simplify and make the perioperative management of the anticoagulated patient more efficient for the patient and oral and maxillo facial surgeon.

Minimally invasive approach for improving aesthetic in a patient with tetracycline-stained teeth by bleaching:A clinical evaluation

Objective:To compare 16% carbamide peroxide(CP)with a higher concentration of hydrogen peroxide(HP)for bleaching teeth in office or at-home to erase tetracycline stains on teeth.Materials and methods:In a randomized,self-controlled clinical trial,we assigned eligible subjects to group A with 40% HP compared with 16% CP or group B with 45% CP compared with 16% CP on the split maxillary arch and followed the manufacturers’instructions.Tooth color changes were measured with vita 3D-bleached guide and colorimeter at baseline and three-time assessment.Tooth sensitive intensity was evaluated using numeric rating scales,and oral soft and hard tissue examination was recorded.Patient satisfaction survey was conducted at the last tooth color evaluation.Results:There were 20 subjects enrolled.The color changes by the end of the study were A1(40% HP)=8.22,A2(16% CP)=8.20,B1(45% CP)=11.27,B2(16% CP)=8.26 respectively.All groups experienced significant shade reductions by bleaching,the 45% CP group had significantly greatest color changes compared with the other groups(p=0.03).For tooth sensitivity evaluation,significant differences were observed in 40% HP group(p=0.01),but with mild level.None patients suffered oral soft or hard tissue abnormalities before and after treatment.Patients were more in favor of using 45% CP according to the questionnaire results.Conclusion:The 3 whitening agents were effective and safe for the whitening of tetracycline-stained teeth,the 45% CP agent had quicker whitening efficacy with low tooth sensitivity and positive feedback.Clinical significance:45% of high-concentration CP whitener by at-home using,brought faster and superior efficacy to bleaching tetracycline-stained teeth while had the equal intensity of tooth sensitivity.