KNOWLEDGE OF DENTISTS REGARDING MANAGEMENT OF ORALLY ANTICOAGULATED PATIENTS UNDERGOING DENTAL EXTRACTIONS.
Oral anticoagulation therapy (OAT) is prescribed for the prevention and treatment in patients with thromboembolic disorders. These inhibit blood clotting and, thus, pose problems in hemostasis, when patient has to undergo dental extractions.
This study aimed at determining dentists' knowledge, attitudes and clinical practices towards management of patients on oral anticoagulation therapy requiring dental extractions.
A survey with sections on demographics and knowledge of anticoagulation treatment, clinical practice, local haemostatic measures, and postoperative management was distributed among dentists. The target population consisted of 447 dentists, out of which 240 (68.5%) completed and returned their forms. Of the respondents, 88 were House officers (HOs), 70 Post graduate trainees (PGs) and 82 Private Dental Practitioners (PDPs), with experience range of 1-41 years.
This study identified a lack of knowledge among all groups of dentists with insignificant difference between them in Diagnosis (p value-0.940) and significant difference in Treatment Planning (p value-0.043) and Post-Operative Management sections (p value - 0.029).
This lack may have a negative effect on the dental care for the patient taking Oral Anticoagulants and special attention and efforts are needed to elevate the dentist knowledge in this field.
Key Words: Dentists' knowledge, Oral anticoagulation therapy, extractions, continuing dental education.
Thromboembolic disorders are among the major health problems leading to higher rates of morbidity and mortality. Effective prophylaxis and treatment with Oral anticoagulant therapy (OAT) in such conditions reduces the incidence or recurrence of thromboembolic events.1,2 Warfarin is the most commonly prescribed anticoagulant across the world and Pakistan is no exception.3 The newer oral anticoagulant agents, Dabigatran etexilate (Direct thrombin inhibitor), Rivaroxaban and Apixaban (Factor Xa inhibitors), are also available for certain types thromboembolic conditions.2,4,5 These drugs cause desired changes in coagulation for specific set of patients but can cause excessive bleeding preoperative and post operatively in the oral surgical procedures.1
Previously, cessation of OAT for few days was used as strategy to reduce postoperative bleeding but now, it is considered to be a potential risk factor for developing thromboembolism and causing unacceptable increase in morbidity and mortality.1,2,6
A dentist, therefore, should have an understanding of the haemostasis, thromboembolism and anticoagulant medications for better oral surgical management of the patients on OAT.1 The competency required to manage medically compromised patient is developed during undergraduate studies and further groomed during postgraduate training and continuing professional development programs that help in constant update of the knowledge.7,8,9 Studies on the dentists perception, knowledge and practices in management of these patients, conducted in Saudi Arabia (2015), Spain (2010) and America (2007) showed lack of updated knowledge among students and dentists.10,11,12 Although no comparative study evaluating knowledge or depth of problem among Pakistani dentists was found in the manual and electronic literature, similar studies showed dentists' inadequate knowledge and doing false practices while treating other medically compromised patients.13
The purpose of this study was to compare the knowledge among house officers (HOs), post graduate trainees (PGs) and private dental practitioners (PDPs). The knowledge base could highlight the adequacy of the current knowledge or otherwise of the current undergraduate curriculum and continuing dental education (CDE) about medical conditions as implemented by Pakistan Medical and Dental Council (PMDC).
This cross sectional study was designed as a prospective, questionnaire based survey. It was undertaken in April 2015 to August, 2015. Questionnaire was specially designed for this study and a pilot survey was conducted. It was discussed with and approved by the research consultants of Institutional Review Board of Fatima Memorial Hospital. It consisted of 4 sections. First section (Q1-4) inquired the attributes of the dentists, followed by section regarding checking knowledge of "Diagnosis" (Q5-Q8), "Treatment Planning" (Q9 and Q10) and "Post-operative Management" (Q11-Q13). The section of "Diagnosis" inquired about the dentists' major concerns while managing these patients as well as the theoretical knowledge about screening of different medical conditions associated with the use of OAT and identification of the newer oral anticoagulant agents. "Treatment planning" portion probed different management strategies used for these patients.
The "Post-operative management" section investigated the dentists' choice of local haemostatic agents, analgesics and antibiotics prescribed to patients on OAT. Data collected was entered and analysed in computer program SPSS version 20. The two portions, Diagnosis and Post-operative management, were checked manually and marked separately with a total of 14 and 6 marks respectively. The passing criteria were set at 75% (10.5 and 4.5 respectively) using standard setting Conjectural (Modified Angoff) Method.14 Negative marking was also done in Postoperative management section to further highlight the important areas of essential crucial applied knowledge, lack of which can lead to serious complications. The mean scores of each section were compared among postgraduate trainees, house offers and private practitioners and ANOVA test of significance was used.
Treatment planning portion is presented as frequencies and percentages of the right and wrong responses and significance was calculated using Chi-square test.
A total of 350 questionnaires were distributed and 240 were completed and returned (Response rate; 68.5%). Participants included 70 Postgraduate students (29.2%), 88 House Officers (36.7%) and 82 Private practitioners (34.2%). Of 240 participants, 145 (60.4%) were female and 95(39.6%) male. In "Diagnosis", the mean score of total dentist population was 8.94 (S.D+- 2.86) (63.85%). Dentists were found unfamiliar to the indications of OAT (see Fig 1), as well as the newer oral anticoagulants (see Fig 2). In "Treatment Planning", 33.3% of dentists were in favour of cessation of warfarin, while 10.4% preferred maintenance of OAT. In "Post-operative section", mean score was 3.99 (SD+- 1.03) (66.5%), <4.5 (75% of the total of 6). The choice of hemostatic agent also varied among dentists, with sutures found to be the most commonly used in patients taking OAT (see Fig 3).
This study identified lack of knowledge with insignificant difference among (HOs), PGs and PDPs in Diagnosis (p value: 0.940). PDPs significantly scored better in the treatment strategy (p value: 0.043) and post-operative management (p value: 0.029) (see Table 1).
TABLE 1: COMPARISON OF KNOWLEDGE AMONG DENTISTS
###Diagnosis Total = 14###Treatment strategy###Post-Operative Total = 6
This study was an attempt to emphasize on the precise knowledge for the adequate dental management of thromboembolic patients taking oral anticoagulant therapy. The study sample mainly consisted of dental graduates of around 29 years of age with experience ranging from 1 to 41 years and conducted in Lahore and Gujranwala. More than 65% (n=158) participants were either HOs or PGs, indicating current affiliation with dental training institution and existing practices carried out in dental schools.
This study showed that dentists had a relative lack of knowledge and thus inability to manage these patients during a minor oral surgical procedure. The respondents had a limited knowledge about diseases that require use of OAT. In Pakistani population the most common indications for warfarin are mechanical cardiac valves and valvular heart diseases, followed by atrial fibrillation.3 Most of dentists were well familiar with mechanical cardiac valves but unaware of the rest of indications . The lack of knowledge was also seen in the selection of screening test for OAT, as 14.45% dentists failed to identify INR as screening tool. A very small percentage of the dentists were able to identify the newer oral anticoagulants, which showed their unawareness to the current evolution in oral anticoagulation therapy.
Although 90.14% of the respondents claimed to know the current guidelines but the responses showed a serious lack of knowledge because only 105 (43.4%) dentists correctly identified one of the two strategies described in the old and new literature.1 Eighty (33.33%) participants were in the favour of the historical standard of treatment, that was to always stop the medication for a number of days. Only twenty five (10.4%) of respondents were in favour of maintaining OAT in extraction patients if all other factors are normal. Fortunately though, such preference was supported by a high percentage (75.4%) that would need to seek a specialist opinion or help for such a decision. This confusion was not limited to this population only, but also reported by Martinez-Beneyto et al, Shah AH et al and Linnebur et al in their studies as well.10,11,12
Current guidelines advocate the tailor made approach for the individual patients that aimed at balancing the thromboembolism and haemorrhage.1,2,15-23
Current study also showed that majority of dentists relied only on the traditional haemostatic agents. Their preferred haemostatic agents were sutures and gauze packs, whereas recent literature supports newer haemostatic agents e.g. Oral rinse with 4.8% tranexamic acid in these patients, for better and earlier hemostasis.1
Another area of lack of knowledge identified in this survey was the prescription of post-operative medications to avoid pain and infection. The lower scores in post-operative management section showed that majority of dentists did not know that non selective NSAIDs drugs interact with platelet aggregation by inhibiting COX1 enzyme, which may further enhance blood loss. Recent literature suggests use of analgesics without COX-1 inhibition potential in these patients, e.g. Paracetamol, Celecoxib, Codeine etc., because these do not interact with platelet function.1
The undergraduate curriculum is devised to make the dentists capable of managing these medically compromised patients. The dental graduates are expected to identify medical conditions that are associated with the use of OAT, order relevant screening tests to assess anticoagulation status and plan an invasive procedure to minimize the per operative and post-operative bleeding as well as thromboembolic risk of the patient. The dental curriculum in Pakistani universities suggests teaching physiology, pathology and pharmacology of clotting system in the first and second year of dental studies and application of this basic knowledge in Medicine, general surgery and Oral and Maxillofacial Surgery, taught in the third and final years.7 The lack of knowledge shown in this study can be improved by laying more emphasis on applied clinical pathology and medicine in the BDS curriculum.
It is also recommended that PMDC, College and Physicians and Surgeons, Pakistan and medical universities should devise comprehensive continuing dental education program and implement it immediately to fill those lacunas.
Short coming of the study was filling bias, which was taken care by negative marking and multiple options. Also this study was undertaken in dentists from two cities only, which may not have completely represented the whole dental population. These limitations suggest that this study must only be considered as a guide. This assessment can be improved by a multicentre study across the country.
This study can be used as a guideline for a multicenter research work in this area of knowledge. The results of that may used to suggest any changes in the curriculum of both the undergraduates and postgraduates. It also may helpful for designing the continuing dental education programs.
In this survey, it was observed that the dentists had a lack of knowledge regarding management of patients taking oral anticoagulant therapy. This lack may have a negative effect on patients' care in dental offices. Acquisition of applied knowledge of diseases and associated medications should be assessed at undergraduate level. Moreover with continuing advancements in disease management, continuing professional development of dental practitioners is required. The mandatory Continuing Dental Education (CDE) hours for the renewal of practicing license, implemented by the PMDC, is a good step towards meeting this goal.
1 Doonquah L, Mitchell AD. Oral surgery for patients on anticoagulant therapy: current thoughts on patient management. Dent Clin N Am 2012; 56: 25-41.
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5 Firriolo FJ, Hupp WS. Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients. Oral Surg Oral Med Oral Path Oral Radiol 2012; 113: 431-41.
6 Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med 1998; 158(15): 1610-16.
7 Curriculum of BDS [Internet]. 2010 [updated 2010 Aug 19]. Available from: www.pmdc.org.pk/LinkClick.aspx?fileticket=06HF%2Blta1uc%3D
8 Patel R, Batchelor P, Narain A, Merali F. The Impact of Continuing Professional Development in Dentistry. [Internet]. 2011 [Cited 2016 Aug 7]. Available from: www.fgdp.org.uk/_assets/pdf/ research/final%20impact%20of%20cpd%20on%20dentistry%20 novemver%202011.pdf
9 Guidelines for Continuing Medical Education /Continuing Dental Education: Pakistan Medical and Dental Council; 2014. Avaiable from: www.umdc.tuf.edu.pk/admin/PDF/PMDC%20 guidelines%20for%20CME.pdf
10 Shah AH, Khalil HS, Alshahrani FA, Khan SQ, AlQthani NR, Bukhari IA, et al. Knowledge of medical and dental practitioners towards dental management of patients on anticoagulant and/ or antiplatelet therapy. Saudi J Dent Res 2015; 6: 91-97.
11 Martinez-Beneyto Y, Lopez-Jornet P, Camacho-Alonso F, Gonzalez-Escribano M. Dental students' knowledge of and attitudes toward anticoagulation dental treatment: assessment of a one-day course at the University of Murcia, Spain. J Dent Educ 2012; 76(4): 495-500.
12 Linnebur S, Ellis SL, Astroth J. Educational practices regarding anticoagulation and dental procedures in US dental schools. J Dent Educ 2007; 71: 296-303.
13 Khan MA, Ahad B, Khan TA, Mufti AH, Khan TA. Knowledge of dentist about epilepsy and their attitude towards the dental treatment of epileptic patients. Pak Oral and Dent J. 2015; 35(3): 356-60.
14 Livingston SA, Zieky MJ. Passing Scores: A Manual for Setting Standards of Performance on Educational and Occupational Tests.[Internet].2015. Available at: www.ets.org/Media/Research/pdf/passing_scores.
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17 Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management considerations for the patient with and acquired coagulopathy. Part 2: coagulopathies from drugs. Br Dent J 2003; 195(9): 495-501.
18 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.
19 Pototsky M, Amenabar JM. Dental management of patients receiving anticoagulation or antiplatelet treatment. J Oral Sci 2007; 49(4): 253-8.
20 Todd DW. Anticoagulant therapy: consideration of modification in conjunction with minor surgery. J Oral Maxillofac Surg 2003; 61: 1117-18.
21 Romond KK, Miller CS, Henry RG. Dental management considerations for a patient taking dabigatran etexilate: a case report. Oral surgery, oral medicine, oral pathology and oral radiology. 2013 Sep 30; 116(3): 191-95.
22 Perry DJ, Noakes TJ, Helliwell PS. Guidelines for the management of patients on oral anticoagulants requiring dental surgery. Br Den J 2007; 203(7): 389-93.
23 Aframian DJ, Lalla RV, Peterson DE. Management of dental patients taking common hemostatis-altering medications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 103(45): 1-11.
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|Publication:||Pakistan Oral and Dental Journal|
|Date:||Dec 31, 2016|
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