ABSTRACT 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.
Cite this paper
Hatzis, G. (2013) Protocol for the management of oral surgery patients on warfarin utilizing a Point-of-Care In-Office international normalized ratio monitoring device. Open Journal of Stomatology, 3, 255-267. doi: 10.4236/ojst.2013.34044.
 Todd, D.W. (2005) Evidence to support an individualized approach to modification of oral anticoagulant therapy for ambulatory oral surgery. Journal of Oral and Maxillofacial Surgery, 63, 536. doi:10.1016/j.joms.2004.12.008
 Beirne, O.R. (2005) Evidence to continue oral anticoagulant therapy for ambulatory oral surgery. Journal of Oral and Maxillofacial Surgery, 63, 540.
 Douketis, J.D., Berger, P.B., Dunn, A.S., et al. (2008) The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest, 133, 299S.
 Lim, W., Wang, M., Crowther, M. and Douketis, J. (2007) The management of anticoagulated patients requiring dental extraction: A cross-sectional survery of oral and maxillofacial surgeons and hematologists. Journal of Thrombosis and Haemostasis, 5, 2157.
 Troulis, M.J., Head, T.W. and Leclerc, J.R. (1998) Dental extractions in patients on an oral anticoagulant: A survey of practices in North America. Journal of Oral and Maxillofacial Surgery, 56, 914.
 Ward, B.B. and Smith, M.H. (2007) Dentoalveolar procedures for the anticoagulated patient: Literature recommendations versus current practice. Journal of Oral and Maxillofacial Surgery, 65, 1454.
 Mehra, P., Cottrell, D.A., Bestgen, S.C., et al. (2000) Management of heparin therapy in the high-risk, chronically anticoagulated, oral surgery patient: A review and proposed nomogram. Journal of Oral and Maxillofacial Surgery, 58, 198. doi:10.1016/S0278-2391(00)90339-2
 Aframian, D.J., Lalla, R.V. and Peterson, D.E. (2007) Management of dental patients taking common hemostatsisaltering medications. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 103, s45.
 Douketis, J.D., Johnson, J.A. and Turpie, A.G. (2004) Low-Molecular-Weight Heparin as bridging anticoagulation during interruption of warfarin: Assessment of a standardized periprocedural anticoagulation regimen. Archives of Internal Medicine, 164, 1319.
 Todd, D.W. and Roman, A. (2001) Outpatient use of low-molecular weight heparin in an anticoagulated patient requiring oral surgery: Case report. Journal of Oral and Maxillofacial Surgery, 59, 1090.
 Jaffer, A.K., Ahmed, M., Brotman, D.J., et al. (2005) Low-molecular-weight heparins as periprocedural anti-coagulation for patients on long-term warfarin therapy: A standardized bridging therapy protocol. Journal of Thrombosis and Thrombolysis, 20, 11.
 Bajkin, B.V., Popovic, S.L. and Selakovic, S.D. (2009) Randomized, prospective trial comparing bridging therapy using low-molecular-weight heparin with maintenance of oral anticoagulation during extraction of teeth. Journal of Oral and Maxillofacial Surgery, 67, 990.
 Bailey, B.M. and Fordyce, A.M. (1983) Complications of dental extractions in patients receiving warfarin anticoagulant therapy. A controlled clinical trial. British Dental Journal, 155, 308. doi:10.1038/sj.bdj.4805221
 Carter, G., Goss, A., Lloyd, J. and Tocchetti, R. (2003) Tranexamic acid mouthwash versus autologous fibrin glue in patients taking warfarin undergoing dental extrac- tions: A randomized prospective clinical study. Journal of Oral and Maxillofacial Surgery, 61, 1432.
 Valle, A.D., Sammartino, G., Marenzi, G., et al. (2003) Prevention of post-operative bleeding in patients undergoing oral surgery: Use of plateletrich plasma gel. Journal of Oral and Maxillofacial Surgery, 61, 1275.
 Souto, J.C., Oliver, A., Zuazu-Juasoro, I., et al. (1996) Oral surgery in anticoagulated patients without reducing the dose of oral anticoagulant: A prospective randomized study. Journal of Oral and Maxillofacial Surgery, 54, 27.
 Pototski, M. and Amenábar, J.M. (2007) Dental man- agement of patients receiving anticoagulation or anti-platelet treatment. Journal of Oral Science, 49, 253-258.
 Nematullah, A., Alabousi, A., Blanas, N., Douketis, J.D. and Sutherland, S.E. (2009) Dental surgery for patients on anticoagulant therapy with warfarin: A systematic review and metaanalysis. Journal of the Canadian Dental Association, 75, 41.
 Beirne, O.R. and Koehler, J.R. (1996) Surgical management of patients on warfarin sodium. Journal of Oral and Maxillofacial Surgery, 54, 1115.
 Campbell, J.H., Alvarado, F. and Murray, R.A. (2000) Anticoagulation and minor oral surgery: Should the anti- coagulation regimen be altered? Journal of Oral and Maxillofacial Surgery, 58, 131.
 Jeske, A.H. and Suchko, G.D. (2003) Lack of a scientific basis for routine discontinuation of oral anticoagulation therapy before dental treatment. The Journal of the American Dental Association, 134, 1492.
 Morimoto, Y., Niwa, H. and Minematsu, K. (2008) Hemostatic management of tooth extractions in patients on oral antithrombotic therapy. Journal of Oral and Maxillofacial Surgery, 66, 51.
 Ferrieri, G.B., Castiglioni, S., Carmagnola, D., Cargnel, M., Strohmenger, L. and Abati, S. (2007) Oral surgery in patients on anticoagulant treatment without therapy interruption. Journal of Oral and Maxillofacial Surgery, 65, 1149. doi:10.1016/j.joms.2006.11.015
 Wahl, M.J. (2000) Myths of dental surgery in patients receiving anticoagulant therapy. The Journal of the American Dental Association, 131, 77.
 Brennan, M.T., Hong, C., Furney, S.L., Fox, P.C., et al. (2008) Utility of an International Normalized Ratio testing device in a hospital-based dental practice. The Journal of the American Dental Association, 139, 697.
 Hirsh, J., Fuser, V., Ansell, J., et al. (2003) American Heart Association/American College of Cardiology Foundation Guide to warfarin therapy. Circulation, 107, 1692.
 Blinder, D., Manor, Y., Martinowitz, U. and Taicher, S. (2001) Dental extractions in patients maintained on oral anticoagulant therapy: Comparison of INR value with occurrence of postoperative bleeding. International Journal of Oral and Maxillofacial Surgery, 30, 518.
 Zanon, E., Martinelli, F., Bacce, C., et al. (2003) Safety of dental extraction among consecutive patients on oral anticoagulant treatment managed using a specific dental management protocol. Blood Coagulation & Fibrinolysis, 14, 27. doi:10.1097/00001721-200301000-00006
 Evans, I.L., Sayer, M.S., Gibbons, A.J., et al. (2002) Can warfarin be continued during dental extractions? Results of a randomized controlled trial. British Journal of Oral and Maxillofacial Surgery, 40, 248.
 Blinder, D., Manor, Y., Martinowitz, U., Taicher, S. and Hashomer, T. (1999) Dental extractions in patients maintained on continued oral anticoagulant: Comparison of local hemostatic modalities. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 88, 137.
 Morimoto, Y., Niwa, H. and Minematsu, K. (2009) Hemostatic management for periodontal treatments in patients on oral antithrombotic therapy: A retrospective study. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 108, 889.
 Salam, S., Yusuf, H. and Milosevic, A. (2007) Bleeding after dental extractions in patients taking warfarin. British Journal of Oral and Maxillofacial Surgery, 45, 463.
 Sacco, R., Sacco, M., Carpenedo, M. and Moia, M. (2006) Oral surgery in patients on oral anticoagulant therapy: A randomized comparison of different INR targets. Journal of Thrombosis and Haemostasis, 4, 688.
 Al-Mubarak, S., Rass, M.A., Alsuwyed, A., et al. (2006) Thromboembolic risk and bleeding in patients maintaining or stopping oral anticoagulant therapy during dental extraction. Journal of Thrombosis and Haemostasis, 4, 689. doi:10.1111/j.1538-7836.2006.01825.x
 Scully, C. and Wolff, A. (2002) Oral surgery in patients on anticoagulant therapy. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 94, 57.
 Jaffer, A.K., Brontman, D.J. and Chukwumerije, N. (2003) When patients on warfarin need surgery. Cleveland Clinic Journal of Medicine, 70, 973-984.
 Billingsley, E.M. and Maloney, M.E. (1997) Intraoperative and postoperative bleeding problems in patients taking warfarin, aspirin, and nonsteroidal anti-nflammatory agents. Dermatologic Surgery, 23, 381-383.
 Partridge, C.G., Campbell, J.H. and Alvarado, F. (2008) The effect of plateletaltering medications on bleeding from minor oral surgery procedures. Journal of Oral and Maxillofacial Surgery, 66, 93-97.
 Wysowski, D.K., Nourjah, P. and Swartz, L. (2007) Bleeding complications with warfarin use: A prevalent adverse effect resulting in regulatory action. Archives of Internal Medicine, 167, 1414-1419.
 Holbrook, A.M., Pereira, J.A., Labiris, R., McDonald, H., et al. (2005) Systematic overview of warfarin and its drug and food interactions. Archives of Internal Medicine, 165, 1095-1106. doi:10.1001/archinte.165.10.1095
 Jowett, S., Stirling, B., Isabelle, M., David, B., et al. (2008) A multinational investigation of time and traveling costs in attending anticoagulation clinics. Value in Health, 11, 207-212. doi:10.1111/j.1524-4733.2007.00253.x
 Heneghan, C., et al. (2006) Self-monitoring of oral anti- coagulation: A systematic review and meta-analysis. The Lancet, 367, 404-411.
 Christensen, T.D., Maegaard, M., S?rensen, H.T., Hjortdal, V.E. and Hasenkam, J.M. (2007) Selfversus conventional management of oral anticoagulant therapy: Effects on INR variability and coumarin dose in a randomized controlled trial. American Journal of Cardiovascular Drugs, 7, 191-197.
 Christensen, T.D., Maegaard, M., S?rensen, H.T., Hjortdal, V.E. and Hasenkam, J.M. (2006) Self-management versus conventional management of oral anticoagulant therapy: A randomized, controlled trial. European Journal of Internal Medicine, 17, 260-266.
 Christensen, T.D., Johnsen, S.P., Hjortdal, V.E. and Hasenkam, J.M. (2007) Self-management of oral anticoagulant therapy: A systematic review and metaanalysis. International Journal of Cardiology, 118, 54-61.
 Kitchen, D.P., Kitchen, S., Jennings, I., Woods, T., et al. (2008) Quality assessment in point-of-care coagulation testing. Semin Thromb Hermost, 34, 647-653.
 Du Breuil, A.L. and Umland, E.M. (2007) Outpatient management of anticoagulation therapy. American Fam- ily Physician, 75, 1031-1042.
 Van den Besselaar, A.M. (2001) Accuracy, precision, and quality control for point-of-care testing of oral anticoagulation. Journal of Thrombosis and Thrombolysis, 12, 35-40. doi:10.1023/A:1012734426811
 Kruse-Loesler, B., Kelker, M. and Kleinheinz, J. (2005) Comparison of laboratory and immediate diagnosis of coagulation for patients under oral anticoagulation ther- apy before dental surgery. Head & Face Medicine, 1, 12.
 Wahl, M.J. (1998) Dental surgery in anticoagulated pa- tients. Archives of Internal Medicine, 158, 1610-1616.
 Pettinger, T.K. and Owens, C.T. (2007) Use of low-molecular-weight heparin during dental extractions in a medicaid population. Journal of Managed Care Pharmacy, 13, 53-58.
 Larson, B.J., Zumberg, M.S. and Kitchens, C.S. (2005) A feasibility study of continuing dose-reduced warfarin for invasive procedures in patients with high thromboembolic risk. Chest Journal, 127, 922-927.
 DeClerck, D., Vinckier, F. and Vermylen, J. (1992) Influence of anticoagulation on blood loss following dental extraction. Journal of Dental Research, 71, 387-390.
 Carter, G. and Goss, A. (2003) Transexamic acid mouth-wash—A prospective randomized study of a 2-day regimen vs. 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions. International Journal of Oral and Maxillofacial Surgery, 32, 504.
 Bodner, L., Weinstein, J.M. and Baumgarten, A.K. (1998) Efficacy of fibrin sealant in patients on various levels of oral anticoagulant undergoing oral surgery. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 86, 421.
 Halfpenny, W., Fraser, J.S. and Adlam, D.M. (2001) Comparison of 2 haemostatic agents for the prevention of postextraction hemorrhage in patients on anticoagulants. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, 92, 257.
 Malden, N.J., Santini, A., Mather, C.I. and Gardner, A. (2007) Minor oral surgery and interference with anticoagulation in patients taking warfarin: A retrospective study. British Journal of Oral and Maxillofacial Surgery, 45, 645.
 Assael, L.A. (2003) Hemostasis is a shared responsibility. Journal of Oral and Maxillofacial Surgery, 61,1377.