Point of Care

The Point of Care section of JCDA answers everyday clinical questions by providing practical information that aims to be useful
at the point of patient care. The responses reflect the opinions of the contributors and do not purport to set forth standards of
care or clinical practice guidelines. Readers are encouraged to do more reading on the topics covered. This months responses were
provided by Dr. George Sndor from the University of Toronto and Drs. Pia Lpez-Jornet and Ambrosio Bermejo-Fenoll
from the University of Murcia. If you would like to submit or answer a question, contact editor-in-chief Dr. John OKeefe at
[email protected].

Question 1

Should routine dental care for patients with asthma be any different than that for healthy
patients?

Asthma is a serious global health problem, and its

prevalence, particularly among children, has increased
steadily over the past 2 decades1 because of continuing
pollution of the atmosphere. Therefore, dental practitioners
are likely to encounter patients with asthma in routine
ambulatory dental practice.

Patient History
Asthma is a disease of the small airways that is caused by
constriction of the bronchioles, which results in expiratory
wheezing. In a severe asthmatic attack, this wheezing can
worsen over a short period of time, causing trapping of air
and eventual respiratory failure. Most patients with asthma
are treated or managed over the long term with a sympathomimetic agent such as salbutamol. The key in the
management of asthmatic patients in the dental setting is to
take a proper history, which should help the dental practitioner to identify high-risk asthma patients.2
For a patient with known asthma, a history of recently
worsening asthmatic symptoms especially shortness of
breath must be taken seriously. If the clinical condition
has a crescendo type pattern or seems to be getting less
stable, then the dental practitioner must consult the
patients physician before embarking upon any elective
dental treatment.
Another worrisome sign of asthma is an increase in the
frequency of the patients visits to the emergency department for stabilization. Any such patient should be regarded
as having unstable asthma and should not undergo dental
treatment unless medical assessment has been arranged
beforehand. Some patients with asthma have a strong
history of seasonality. Such patients may be reactive to a
particular allergen, and hence their asthma may be worse in
the spring, summer or fall. Other patients have much more
severe exacerbations of their asthmatic symptoms in the
winter months because of sensitivity to cold. Elective dental
Journal of the Canadian Dental Association

treatments for these patients should not be scheduled

during high-risk months.
Patients who require the use of systemic steroids (e.g.,
prednisone tablets or parenteral corticosteroids) should be
regarded as higher-risk patients. In contrast, patients who
are treated with inhaled aerosolized corticosteroids are at
lower risk. In this respect, the inhaled steroid is like lowerrisk topical therapy (similar to a steroid-containing ointment or cream), whereas oral therapy is higher-risk systemic
therapy. If a patient is taking systemically administered
corticosteroids, his or her physician should be consulted
before treatment.
Patients who use inhaled corticosteroids may experience
oral and pharyngeal candidiasis or thrush. Dentists can
help in the management of these conditions by counselling
the patient to either rinse with or drink some water after
inhaler therapy. If the candidiasis becomes symptomatic or
clinically apparent, treatment with a nystatin-containing
mouth rinse is helpful.

Management of Asthmatic Patients

Patients with asthma should always be treated when
their condition is clinically the most stable. Patients should
be asked to bring their inhalers to the dental office3 so that
their own device is available if there is the need for inhaler
therapy during dental treatment.
Patients with severe asthma who routinely use long-term
systemic corticosteroids may be immunocompromised and
may benefit from antibiotic prophylaxis for dental surgical
treatment. C

References
1. Coke JM, Karaki DT. The asthma patient and dental management.
Gen Dent 2002; 50(6):5047.
2. Sollecito TP, Tino G. Asthma. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2001; 92(5):48590.
3. Steinbacher DM, Glick M. The dental patient with asthma. An update
and oral health considerations. J Am Dent Assoc 2001; 132(9):122939.
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Question 2

Do patients taking oral anticoagulants need to discontinue their medication before surgical
procedures?

This is probably the question that dentists most

commonly ask physicians today. In providing a response,
the physician must analyze the individual patients situation
carefully.

Indication for Anticoagulation

The first consideration is the reason for anticoagulation
in the particular patient. The many indications for anticoagulation include prevention and treatment of deep vein
thrombosis and pulmonary emboli. Patients with arrhythmias such as arterial fibrillation and those with mechanical
heart valves may take anticoagulants to prevent emboli to
the circulation of the central nervous system. Patients with
hypercoagulable states, such as those with malignant
tumours, may receive anticoagulants to prevent the complications of widespread clotting and consequent ischemia
distal to the clots.

Anticoagulant

dental office immediately after a dialysis treatment, he or

she may have some residual heparin circulating in the
blood, which could lead to prolongation of bleeding after
surgery. Therefore, surgical treatment for these patients
should be scheduled on the day after dialysis, to give time
for circulating heparin levels to fall. For any patient who is
receiving heparin anticoagulation, consultation with the
physician is recommended before any surgical treatment.

Risk of Clotting if Anticoagulants Are

Discontinued
The next consideration is the risk of clotting that may
arise if the anticoagulant is discontinued. This risk may be
difficult to determine. If a patient has had recurrent thromboembolic events, then the risk of a subsequent clot is
thought to be high. However, it is safest to assume that the
risk of clotting is elevated whenever anticoagulants are
discontinued, regardless of the patients history.

The next factor to consider is the agent being used as the

anticoagulant.

Risk of Hemorrhage if Anticoagulants Are Not

Discontinued

Warfarin

The final consideration is the risk of bleeding after

surgery if the anticoagulants are not discontinued. Many
specialists in internal medicine and hematology view
postoperative intraoral bleeding as so-called visible bleeding. They typically regard this form of bleeding as less
dangerous than silent bleeding, such as intra-abdominal,
intrathoracic or intracranial bleeding. The latter can have
disastrous consequences, even though it may go unnoticed.
However, postoperative bleeding from intraoral sources can
also be significant and life threatening, and these episodes
should not be taken lightly.
The decision whether to continue or discontinue
anticoagulants is always made by delicately balancing all
the foregoing factors.

The most common agent used for anticoagulation is

warfarin sodium (Coumadin). This medication affects the
extrinsic pathway of coagulation by inhibiting the synthesis of the vitamin-K-dependent clotting factors II, VII, IX
and X. In doing so, warfarin increases the prothrombin
time, expressed as the international normalized ratio
(INR). An INR value of 1.0 is normal, but the therapeutic
range or goal for anticoagulation is between 2.0 and 3.5.

Antiplatelet Medications
Antiplatelet medications, including acetylsalicylic acid
and nonsteroidal anti-inflammatory drugs, inhibit platelet
function, thereby increasing bleeding time. Although these
are important therapeutic agents for other purposes, they
are not typically used as anticoagulants. Their use was
discussed in a previous article in this journal.1

Heparins
Heparin and heparin-like medications decrease blood
clotting through their effect on the intrinsic pathway of
coagulation. This effect is demonstrated by laboratory tests
such as partial thromboplastin time. These medications are
most often given parenterally, and ambulatory patients in a
dental office setting are therefore unlikely to be receiving
them. The exception is patients undergoing long-term
hemodialysis, in whom heparin is used to prevent clotting
within the dialysis equipment. If such a patient goes to the
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Evidence-Based Literature
There is some evidenced-based literature to help guide
the dental practitioner in treating patients who are taking
anticoagulants. In one randomized controlled trial,2 the
109 study patients were taking warfarin and had an
INR within the normal therapeutic range. Of these
patients, 52 were assigned to the control group (warfarin
stopped 2 days before extraction) and 57 patients were
assigned to the intervention group (warfarin continued).
The incidence of bleeding complications in the intervention group was higher (15/57, 26%) than in the control
group (7/52, 13%) but this difference was not statistically
significant. The authors concluded that because of the risks
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associated with stopping warfarin, the practice of routinely
discontinuing this drug before dental extractions should be
reconsidered.
In a more elaborate trial,3 249 patients who underwent
a total of 543 dental extractions were divided into 5 groups
on the basis of INR value on the day of the procedure:
group 1, INR of 1.501.99; group 2, INR of 2.002.49;
group 3, INR of 2.502.99; group 4, INR of 3.003.49;
and group 5, INR greater than 3.49. Local hemostasis was
accomplished with a gelatin sponge and multiple silk
sutures. Of the 249 patients, 30 (12%) presented with
postoperative bleeding: 3 (5.0%) of the patients in group 1,
10 (12.8%) of those in group 2, 9 (15.2%) of those in
group 3, 5 (16.6%) of those in group 4 and 3 (13.0%) of
those in group 5. The incidence of postoperative bleeding
was not significantly different among the 5 groups, and
the value of the INR within the therapeutic range did
not appear to significantly influence the incidence of postoperative bleeding. The authors concluded that dental
extractions could be performed without modification of
oral anticoagulant treatment. Local hemostasis with gelatin
sponge and sutures appeared to be sufficient to prevent
postoperative bleeding in this study.

Management
Evidence-based clinical practice requires that individual
clinicians develop and refine their literature searching and
appraisal skills and document their clinical experience.4

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They must balance the evidence reported in the literature

with what they know from experience to be clinically safe.
Recommendations have been made with respect to dental
patients taking warfarin according to their INR values.5 For
patients whose INRs are within the therapeutic range (that
is, less than 3.5), the anticoagulants are not routinely
stopped and reliance is placed on local measures such as
removal of all granulation tissue and use of gelatin foam
sponge, oxycellulose packing of the extraction socket and
suturing. These measures are typically used for routine
extractions, but practitioners must be careful in adapting
them to other, more invasive surgical situations, such as
removal of impacted teeth or use of periodontal flaps,
where postoperative bleeding can be more problematic. C

References
1. Daniel NG, Goulet J, Bergeron M, Paquin P, Landry PE. Antiplatelet
drugs: is there a surgical risk? J Can Dent Assoc 2002; 68(11):6837.
2. 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):24852.
3. Blinder D, Manor Y, Martinowitz U, Taicher S. Dental extractions in
patients maintained on oral anticoagulant therapy: comparison of INR
value with occurrence of postoperative bleeding. Int J Oral Maxillofac
Surg 2001; 30(6):51821.
4. Dodson TB. Strategies for managing anticoagulated patients requiring
dental extractions: an exercise in evidence-based clinical practice.
J Mass Dent Soc 2002; 50(4):4450.
5. Troulis MJ, Head TW, Leclerc JR. What is the INR? J Can Dent Assoc
1996; 62(5):42830.

Should patients with seizure disorders continue to take their medications during routine dental
treatment?

Epilepsy is a seizure disorder that is a common symptom

of underlying neurologic disorders. A seizure disorder can
take a variety of forms,1 which are generally categorized as
focal or generalized. The seizures may be idiopathic or may
be due to central nervous system scarring after trauma, for
example. Seizures can also occur secondary to a brain
tumour or metabolic disturbance such as hypoglycemia.

Antiseizure Medications
Chronic seizures are managed by antiseizure medications. These drugs typically increase the seizure threshold.
Antiseizure medications include the following drugs:
benzodiazepines, barbiturates, valproic acid, phenytoin and
carbamazepine. All of these drugs require the maintenance
of a minimum therapeutic drug level to ensure efficacy,
which in turn requires patient compliance and adherence
to the prescribed dosing regimen.
Journal of the Canadian Dental Association

Dental practitioners should not ask patients to withhold

seizure medications before dental treatment. On the
contrary, patients should be encouraged to take any
antiseizure medication with a sip of water on the day of the
dental appointment, as usual. An interruption in the
stream of antiseizure medication can lead to falling drug
levels and an increase in the frequency of seizure activity
either during or following dental treatment.

Management of Seizures
If a seizure should occur during dental treatment, then
the protocols for neurologic emergencies demand that the
dentist stop all major procedures, remove all foreign objects
from the patients mouth, maintain the airway, and
monitor breathing and circulation. If there is no prior
history of seizures, a quick secondary survey should be
done to identify possible causes of the seizure.2 If the
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seizures become continuous then it is imperative that

someone in the dental office notify emergency medical
services.2
Both the underlying neurologic condition and its
medical management can affect oral health. Patients with
neurologic conditions may find it more physically difficult
to perform oral hygiene tasks. Some medications such
as phenytoin may induce gingival hyperplasia, which can
be worse if the patient has poor oral hygiene. Prevention
of oral disease and carefully planned dental treatment
are essential to the well-being of patients with seizure
disorders.1 C

Question 4

References
1. Fiske J, Boyle C. Epilepsy and oral care. Dent Update 2002;
29(4):1807.
2. Busschots GV, Milzman BI. Dental patients with neurologic and
psychiatric concerns. Dent Clin North Am 1999; 43(3):47183.

What is the most appropriate treatment for salivary mucoceles? Which is the best technique for
this treatment?

Mucocele is the most common disorder of the minor

salivary glands (2.5 per 1,000 population). These lesions
occur more frequently among children, adolescents and
young adults than among adults,1 and males and females
are affected equally.
Salivary mucoceles are variably sized mucosal swellings
with mucoid content. They are benign lesions, typically
induced by trauma, which contain saliva extravasated from
or retained within a duct. Extravasation is much more
common in mucoceles of the lower lip and often occurs
between the midline and the angle of the mouth, although
this process can also occur elsewhere.2,3 Clinically, the
mucocele appears as a translucent, circumscribed, painless,
soft, recurrent swelling of the mucosal lining. The lesions
usually occur singly; bilateral presentations are very rare.
After the initial trauma, the lesion decreases in size because
of saliva resorption; however, because mucus production
often continues, the lesion is characteristically dynamic,
with fluctuations in size. In most cases the diagnosis is
established on the basis of clinical findings, although histo-

Figure 1: Labial mucocele in a 12-year-old

girl. Note the well-delimited swelling with
an overlying mucosal layer of normal
appearance.

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The answers to questions 1 to 3 were provided by

Dr. George Sndor. Dr. Sndor is coordinator of oral
and maxillofacial surgery, The Hospital for Sick
Children and The Bloorview MacMillan Childrens
Centre, Toronto, Ontario, director of the graduate
program in oral and maxillofacial surgery, and associate professor,
University of Toronto. E-mail: [email protected].
The author has no declared financial interests.

July/August 2004, Vol. 70, No. 7

logical confirmation is required to confirm the diagnosis

and ensure proper identification of the implicated salivary
gland to allow its removal and thus to prevent recurrence.
The best treatment results are afforded by complete
surgical resection.4 Needle aspiration always results in
short-term recurrence or relapse. Cryosurgery and carbon
dioxide laser surgery have both been used to eliminate these
lesions, with good results.
A simple and fast technique for removing minor salivary
gland mucoceles is proposed. This method involves use of
the B forceps (a modification of the Chalazion forceps),4,5
which simplifies elimination of lower lip mucoceles.
The tips of the forceps are fenestrated to facilitate access
to the grasped tissue. The lesion to be removed appears
exposed in the window. Forceps compression induces a
fluid depletion effect, which allows surgical removal of the
lesion under local ischemic conditions. Furthermore, the
compression causes the sectioned portion (detached from
its peripheral connective attachments) to be propelled like a
plug of tissue, which thereby facilitates depth appraisal and

Figure 2: Positioning of the B forceps and

initiation of surgical removal.

Figure 3: Surgical removal of the mucocele.

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access to the base for adequate sectioning. The time

required for removal of the lesion is shortened by 50%. The
forceps guarantee visibility, hemostasis and access, since the
surgical field is free of blood and saliva (Figs. 1 to 3).
After resection, the margins are sutured with silk or
resorbable material; 3 or 4 stitches are sufficient. Careful
manipulation is required to avoid damaging the sample,
which is then immersed in fixative for later histologic study.
This approach offers several advantages. such as induction
of ischemia (which improves visibility and thus further
facilitates resection) and rapid removal, and the help of an
assistant is not required. C

Dr. Pia Lpez-Jornet is assistant professor of oral

medicine, University of Murcia, Murcia, Spain. Email: [email protected].

Dr. Ambrosio Bermejo-Fenoll is full professor of oral

medicine, University of Murcia, Murcia, Spain.

References
1. Eveson JW. Superficial mucoceles: pitfall in clinical and microscopic
diagnosis. Oral Surg Oral Med Oral Pathol 1988; 66(3):31826.
2. Bermejo A, Aguirre JM, Lopez P, Saez MR. Superficial mucocele:
report of 4 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1999; 88(4):46972.
3. Tran TA, Parlette HL 3rd. Surgical pearl: removal of large labial mucocele. J Am Acad Dermatol 1999; 40(5 Pt 1):7602.
4. Seoane J, Varela-Centelles PI, Diz-Dios P, Romero M. Use of chalazion
forceps to ease biopsy of minor salivary glands. Laryngoscope 2000;
110(3Pt 1):4867.
5. Szpirglas H, Giozza S, Agbo-Godeau Y, Le Charpetier Y. Biopsy of the
accessory salivary glands. 5 years experience. Rev Stomatol Chir Maxilofac
1994; 95(3):2046.

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