Minor Oral Surgery Service Referral Guidelines for Lancashire



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Allocation criteria relating to other complex needs


It is expected that the majority of patients who receive routine dental care in the primary care setting who have complex histories associated with their ability to communicate, ability to access oral care, have oral health risk factors, or who have legal and ethical barriers to care, could be managed in accordance the criteria outlined in above. Patients who in the opinion of the referring practitioner have exceptional circumstances or who receive care provided by the Salaried Primary Dental Care Service because of complex needs, requiring minor oral surgical procedures, may need to be allocated to secondary care. These referrals will be subject to individual case assessment prior to allocation.


Appendix 3 – Bisphosphonate Guidance


Management of Patients Receiving Treatment with Bisphosphonates
The following is a summation of the advice from various health agencies.
Extract from The Drug Safety Update Volume 3, Issue 4 November 2009. Medicines and Healthcare products Regulatory Agency (MHRA)
Individual bisphosphonates have different indications, and are used for: prophylaxis and treatment of osteoporosis; treatment of Paget’s disease; and as part of some cancer regimens, particularly for metastatic bone cancer and multiple myeloma.
Advice for healthcare professionals:


  • The risk of developing Bisphosphonate-Related Osteonecrosis of the Jaw (BRONJ) taking oral bisphosphonates seems to be low. The risk of BRONJ is substantially greater for patients receiving intravenous bisphosphonates for cancer indications than for patients receiving oral bisphosphonates for osteoporosis or Paget’s disease




  • There is clear evidence to suggest bisphosphonate-specific and indication-specific risk factors such as potency (highest for zoledronate); route of administration (eg, intravenous ibandronte, pamidronate, and zoledronate); and cumulative dose. The evidence base is less robust for other proposed risk factors (eg, duration and type of malignant disease, concomitant treatment, smoking, and comorbid conditions). However, healthcare professionals should consider these risk factors when evaluating an individual’s risk of developing BRONJ




  • A history of dental disease—including invasive dental procedures, dental trauma, periodontal disease, and poorly fitting dentures—is associated with an increased risk of BRONJ


Risk minimisation


  • All patients with cancer should have a dental check-up before bisphosphonate treatment. All other patients who start bisphosphonates should have a dental examination only if they have poor dental status




  • During bisphosphonate treatment, patients should maintain good oral hygiene, receive routine dental check-ups, and report any oral symptoms such as dental mobility, pain, or swelling


In the Drug Safety Update Volume 1, Issue 3 October 2007 MHRA it states:


  • Dental examination, with appropriate preventive dentistry, should be considered before bisphosphonate treatment in patients with concomitant risk factors (eg, cancer, chemotherapy, corticosteroids, and poor oral hygiene)




  • During bisphosphonate treatment, patients with concomitant risk factors should avoid invasive dental procedures if possible. For patients who develop osteonecrosis of the jaw during bisphosphonate treatment, dental surgery may exacerbate the condition


Advice from the North West Medicines Information Service: The Dental Management of Patients on Bisphosphonates includes:


  • Stopping the bisphosphonate prior to the procedure is not advocated. Bisphosphonates are laid down in the bone and take many years to be eliminated.




  • Routine prophylactic and/or postoperative antibiotic therapy is NOT recommended. There is NO evidence available that antibiotic prophylaxis reduces the incidence of osteonecrosis of the jaw following extractions or oral surgical procedures.




  • Patients should be reviewed 3-4 weeks after the procedure to ensure that the socket/surgical site has healed. Patients should be advised that if any postoperative problems (pain or unpleasant smell or taste in the mouth) develop sooner they should return to see the dentist before the planned appointment. If healing has not taken place after 4 weeks osteonecrosis of the jaw should be suspected and the patient referred to secondary care.

The following is based on the Best Practice Guidance : Osteonecrosis associated with Bisphosphonate usage. Circular Reference: HSC (SQSD) 54/09 Department of Health, Social Services and Public Safety (Northern Ireland)


ADVICE



COMMENTS

Full oral examination and medical history to include questions on bisphosphonate therapy.


When taking medical history ensure that patient is asked about any IV bisphosphonate medication as well as concomitant risk factors which include:


Local; poor oral hygiene, periodontal disease, dental caries, smoking

Systemic; cancer, chemotherapy, corticosteroids
As well as obvious dental problems such as caries, unsalvageable teeth and periodontal disease, patients with dentures should be checked for any potential areas of mucosal trauma.
Ideally assessment should be done before IV bisphosphonate therapy commences, but where not possible assessment should be done in parallel with commencement of therapy or within 6 months of commencement for IV patients.
For patients on oral bisphosphonates routine dental check ups and treatment should be completed as soon as is reasonably practicable.

Complete all necessary treatment; eliminate potential sites of infection.


Ideally complete all invasive procedures and treat oral infections and periodontal disease before drug therapy commences.


Unsalvageable teeth should be removed. Dentures should be adjusted as required. If treatment cannot be completed before drug therapy, then it may be carried out in parallel with the commencement of drug therapy and within 6 months of commencement for IV patients.
For patients on oral bisphosphonates, treatment should be completed as soon as is reasonably practicable.

Be familiar with the generic and proprietary names of the commonly prescribed bisphosphonate medicines in

the UK.

Refer to the BNF




Advice to Dentists for management of patients prior to prescription of bisphosphonates

Advice to dentists for management of patients who are currently on bisphosphonate therapy


ADVICE


COMMENTS

For patients on any bisphosphonate therapy, focus on preventive care and reinforce good oral hygiene regimen and dietary advice.


Regular check ups and radiological review as appropriate.

Advice on twice daily toothbrushing with fluoride toothpaste and inter-dental cleaning as appropriate.


For susceptible patients Use appropriate preventative measures as described in the “Oral Health Toolkit”. For Example:



Where possible, avoid dento-aveolar surgery in patients, on IV bisphosphonate therapy.


Review dentures regularly if applicable.

For non-restorable teeth, decoronation and endodontic treatment of remaining roots is the preferred option.


Procedures to be avoided if possible including extractions, implant placement, periapical surgery, and periodontal surgery

For patients on IV bisphosphonates who require dental extractions or other invasive dental procedures, refer to oral surgery specialist in secondary care.



Advice of oral surgeons/oral maxillo-facial surgeons to be followed which may include antibiotic cover.


For patients on oral bisphosphonates who are asymptomatic and require extractions, then extractions can be carried out in most cases in primary care.



Informed consent from patient.
Consultant oral surgeons or oral-maxillo facial surgeons may be approached for advice before commencing treatment. If infection is present, systemic antibiotics may be required.
Stopping the bisphosphonate prior to the procedure is not advocated.
Routine prophylactic and/or postoperative antibiotic therapy is not recommended unless specifically directed by secondary care.
The following regimen is advised:

  • Chlorhexidine mouthwash before and after extractions

  • Atraumatic extraction technique

  • Careful post operative follow up until

  • socket healed

  • Avoid significant bone removal

For patients who smoke, provide smoking cessation advice at least in the peri-operative phase



If BRONJ suspected, refer to oral surgery specialist in secondary care.

Signs of BRONJ include exposed, necrotic bone in maxilla or mandible that has persisted for more than 8 weeks in a patient who was receiving or had been exposed to a bisphosphonate drug and where there has been no history of radiation therapy to the jaws.
Patients may be asymptomatic or may exhibit pain due to secondary infection.

The guidance is based on the referral guidance drawn up in consultation with the Oral and Maxillofacial Surgery Department East Lancashire Hospitals Trust and East Lancashire LDC.



Bisphosphonates Currently Prescribed in the UK


Drug name

Trade name

Route of

administration

Nitrogen containing*

Disodium etidronate


Didronel


Didronel PMO (with

calcium carbonate)




Oral

No

Tiludronic acid




Skelid

Oral

No

Sodium clodronate




Bonefos Loron

Oral/IV

No

Disodium


Pamidronate


Aredia Dry Powder

IV

Yes

Alendronic acid


Fosamax


Fosamax Once Weekly Fosavance (with colecalciferol)


Oral

Yes

Risedronate sodium


Actonel


Actonel Once a Week


Oral

Yes

Ibandronic acid



Bondronat

Bonviva


Oral/IV

Yes

Zoledronic acid


Aclasta (lower dose for osteoporosis & Pagets disease)

Zometa ( higher dose for malignant disease)


IV

Yes

* Nitrogen containing preparations are more potent and are retained longer in skeletal tissue




Appendix 4 – Anticoagulation Therapy Guidance

DENTAL MANAGEMENT OF PATIENTS TAKING ORAL ANTI-COAGULANT DRUGS

Anti-coagulant therapy produces an increased risk of bleeding. The common anti-coagulant is the coumarin, warfarin – a vitamin K antagonist (VKA).


In the last five years there has been an introduction of new oral anti-coagulant drugs (NOAC) eg.Dibagitran, Rivaroxaban and Apixaban which in some cases have replaced Warfarin.
In addition there are an increasing number of patients on Anti-platelet therapy e.g. Clopidogrel+/- Aspirin.
Many dental procedures do not involve a significant risk of bleeding and therefore no special measures are required when treating patients who take an oral coagulant drug. These procedures are:


  • Simple restorative treatment

  • Supra gingival scaling

  • Local anaesthesia by buccal infiltration, intraligamentary or mental block

  • Impressions and other prosthetic procedures

  • Crown and bridge preparations

Procedures which carry a risk of significant bleeding and for which the dentist needs to consider the management of the patient in relation to their anti-coagulant therapy are:




  • Local anaesthesia by inferior alveolar or other regional nerve blocks or lingual or floor of mouth infiltrations

  • Sub gingival scaling and root surface instrumentation

  • Extractions

  • Oral surgery

  • Periodontal surgery

  • Biopsies

  • Incision and drainage of swellings



GENERAL GUIDANCE


  • Morning appointments, earlier in the week allow any post op. bleeding to be dealt with in the working day and before the weekend.

  • Local anaesthetic solutions containing a vasoconstrictor should be used unless rarely contraindicated on other medical grounds. An aspirating syringe must be used for all local anaesthetic injections.

  • For sub-gingival scaling, a small area should be scaled first, to assess the amount of bleeding, before instrumentation of larger areas is carried out. It may be necessary to complete a full mouth scaling over several visits.

  • Extractions should be restricted to a maximum of three to four teeth per visit in a maximum of two quadrants

  • All extractions should be completed as atraumatically as possible (using luxators/periotomes)

  • Sockets should be gently packed with a haemostat and sutured with resorbable sutures at the time of the extraction.





MANAGEMENT OF WARFARINISED PATIENTS
The vast majority of patients on Warfarin will have an INR of 2.0 to 3.0 and should be able to undergo routine dental extractions/minor oral surgery without stopping their warfarin. Extractions should be able to be safely carried out in the following circumstances:

  • Where the INR is less than or equal to 4

  • If local haemostatic measures are taken (packing, sutures). Warfarin should not be stopped but the INR should be checked within 24 hours of the planned procedure (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 greater than 4.


NEW ORAL ANTI-COAGULANTS (NOAC)
The main drugs in this classification that you will come across include:

DABIGATRAN (Pradaxa) Direct thrombin inhibitor (factor IIa) BD

RIVAROXABAN (Xarelto) Direct Factor Xa inhibitor OD

APIXABAN (Eliquis) Direct Factory Xa inhibitor BD


Their primary use is for the treatment of atrial fibrillation (AF) or because of recent or recurrent pulmonary embolus (PE).Occasionally used for 2 to 6 weeks following elective knee and hip replacement surgery.

The maximum coagulant effect is achieved 2 hours after ingestion.

They have a half life of approximately 12 hours and so the clotting status returns to normal within 24 hours if the drug is discontinued.

There is no routine blood test monitoring required for NOAC (INR is not sensitive to the anti-coagulant effect) and there is no drug that can counteract their activity (unlike Warfarin).

When managing patients taking a NOAC, you must assess the balance between the risk of bleeding and the risk of a thrombotic event if the drug is stopped.
DENTAL MANAGEMENT FOR NOAC



  • For patients on short courses of anti-coagulant, delay elective treatment until patient is recovered.

  • If other concerns exist for any patient e.g. social or medical, consider referral even if treatment seems straightforward.



LOW RISK
I.e. less than or equal to 3 - 4 simple extractions in up to 2 quadrants / simple oral surgery (e.g. incision of abscess, periodontal surgery, positioning of implants, simple oral surgery)


  • Do not stop NOAC

  • Carry out procedure with least possible trauma

  • Treat with local haemostatic measures (example oxidised cellulose or collagen sponges and sutures)

  • Allow patient to leave only when bleeding has stopped.


HIGHER RISK
I.e. Greater than 3 - 4 teeth in more than 2 quadrants/difficult oral surgery - Refer to Oral and Maxillofacial Surgery in secondary care.

GUIDE LINES ON ANTI-PLATELET THERAPY

Management of patients taking Clopidogrel/ Ticagrelor/ Prasugrel plus /- Aspirin.



Clopidogrel is given for a number of reasons but most commonly after PCI (percutaneous coronary intervention, coronary stent placement or to patients who have recently had a MI). There has been some evidence to suggest that Clopidogrel should be stopped prior to surgery if patients are also taking Aspirin as well.
If however there is a stent in situ the risk of stopping Clopidogrel and Aspirin are very high and therefore the drug should continue for six weeks after a bare metal stent and twelve months after a drug eluting stent.
Stopping anti-platelet therapy increases the risk of a stroke or myocardial infarction occurring – patients are more at risk of permanent disability or death if they stop anti-platelet medication prior to a surgical procedure than if they continue it. Bleeding complications while inconvenient do not carry the same risk as thromboembolic complications. It is therefore advisable to continue an anti-platelet drug and to take appropriate haemostatic measures. There is unfortunately very little evidence published regarding the risk of bleeding associated with dual anti-platelet drugs (Clopidogrel/ Ticagrelor/ Prasugrel + Aspirin) but it seems sensible to follow the above NOAC guidelines.

COMBINATION THERAPY of NOAC and ANTI-PLATELET DRUGS
With the increasing use of NOAC, patients are often on both NOAC and anti- platelet therapy ( Aspirin, Clopidogrel, Ticagrelor, Prasugrel, Dipyridamole). This may significantly increase the risk of bleeding in this group of patients. If they require a procedure that carries that risk, they should be referred to Oral and Maxillofacial Surgery in secondary care.


POST OPERATIVE MANAGEMENT/CARE INSTRUCTIONS FOR EXTRACTIONS AND SURGERY
The patient should be advised to rest for four hours post operatively, should avoid eating and drinking for that time to allow the clot to stabilise and local anaesthetic to wear off. The patient should be given the standard post operative advice verbally and in writing. Appropriate telephone contact details should be issued to the patient in writing and the patient should know how to obtain advice and/or help both in and out of hours if bleeding occurs.
In addition the following advice regarding analgesics should be given:


  • For post-operative pain control paracetamol is the safest pain killer. Non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen, and voltarol should be avoided.

  • If paracetamol alone is not sufficient to manage pain, dihydrocodeine may be an appropriate alternative if not contraindicated. Otherwise, the patient should consult their doctor for advice on pain relief.


PATIENTS UNSUITABLE FOR DENTAL MANAGEMENT IN PRIMARY CARE
Patients who have a INR greater than 4 or who have a very erratic INR should not undergo any form of dental procedure other than those from the safe list previously mentioned without consultation with the clinician who is responsible for maintaining their anti-coagulation. The anti-coagulant dose may be adjusted prior to the procedure at the discretion of this clinician or elective dental procedures which are at risk of significant bleeding may need to be referred.
The following medical problems may affect coagulation and clotting:

  • liver impairment and/or alcoholism

  • renal failure

  • Thrombocytopenia, haemophilia or other disorder of haemostasis

  • current course of cytotoxic medication


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