TriangleOMS Newsletter

Patients who are maintained on anticoagulants (Coumadin) are commonly seen in dental practice. The degree of anticoagulation is dependent primarily upon the severity of the underlying medical condition, but the underlying concern is always thrombosis. The most common indication for anticoagulation is atrial fibrillation however other conditions such as deep vein thrombosis, stroke, and heart attack may also require treatment.

The commonly held idea that anticoagulants must be discontinued prior to routine dental treatments – or even surgery - has been challenged in the literature. In fact, it would seem - when considering risk to benefit analysis associated with this old strategy there actually may be greater risks both clinically and medicolegally. Interestly enough, it is surprising the degree to which our medical colleagues lack information about this altered approach.

The literature is replete with articles demonstating the safety of a graduated approach to dental treatment in this group of patients. While this medium does not allow for a complete discussion of this topic, it has been our experience that even minor surgical procedures may be undertaken without altering anticoagulation. The literature has various recommendations, however, our approach has been that limited procedures (single tooth removal, implant placement, etc) may be undertaken when patient’s INR (International Normalized Ratio) – or anticoagulation index – is between 2.0 and 4.0. Certainly, routine dental care - dental prophylaxis, restorative, endodontic, and periodontal procedures - should be performed without significant risk of untoward bleeding.

We have safely used this algorithm with hundreds of patients. It has been our experience that post operative bleeding rarely becomes problematic – and if so may be controlled with local measures (application of pressure, use of hemostatic materials i.e. Surgicel). For further information or advise, please contact the office or visit our Referral Resources page on the web.

A recent investigation uncovered illegal human tissue procurement practices between funeral homes and Biomedical Tissue Services, LTD (BTS) of Ft. Lee, NJ. Both hard and soft tissues were procured during the period of early 2004 to September 2005. The tissue recovered from donors may have not met FDA eligibility requirements and may have not been properly screened for infectious diseases.

While no adverse reactions related to the implantation of these tissues is known and the overall risk of infection is thought to be low, nevertheless recipients may be at increased risk of infection. Therefore, the FDA and CDC have recommended that implanting doctors should notify their patients that may have received tissue from one of the above processors and offer to provide patients with access to appropriate infectious disease testing (HIV, Hep B/C, and syphilis). Any infectious disease related to a tissue transplant from any of these processing firms should contact the FDA’s Med Watch (www.fda.gov/medwatch).

While we do use mineralized/demineralized human bone for grafting, our commercial sources have not utilized any of the noted tissue processors associated with BTS.

If you have controlled substances in your office you need to beware of a few common pitfalls. Firstly, you must maintain a running inventory of all controlled substances. Secondly, every 2 years you must take a physical inventory of all controlled substances per DEA rules; records for Schedule II (CII) controlled substances must be kept separately; C3 – C5 must be readily retrievable from ordinary professional and business records. All controlled substance records must be kept for 2 years and there is no requirement to submit copies to the DEA.

Should you have substances which are out-of-date, they must properly be disposed. While you are under no obligation to do so, the NC Board of Pharmacy does have a controlled substance disposal team which will remove your expired stock and provide you with a disposition receipt.

One further consideration is that unlike the NC Medical Board, the NC Dental Practice Act nor it’s Rules has no provision for the dispensing of any (controlled or non-controlled) prescription legend medication in office.

Disciplinary actions by the NC Board of Dental Examiners due to controlled substance violations are one of the most frequent actions taken against dentists in NC. Accounting for controlled substances in a manner similar to accounting for office revenue/expenses will give you the best defense in the event an investigator from the NC Board of Dental Examiners, NC Board of Pharmacy – or even worse – the DEA, decides to pay you a visit and audit your controlled substance logs. Be prepared! Lastly as a related point, avoid the common pitfall of prescribing controlled substances for your immediate family or office staff. If you must however, make sure you have proper documentation (clinical chart, notes, diagnostic information, tests) and only prescribe appropriate quantities.

In many ways, communications between health care providers via an electronic medium (i.e. email) is so much more efficient than attempting to do so by telephone. While certain situations may mandate a phone conversation, many situations can be dealt with by conferring by email. It certainly avoids the common pitfalls of playing “phone tag” and allows one the ability to respond to an inquiry or concern within the framework of what best fits a schedule or work day.

However, concerns over the security of email communications should be considered. Probably the most important fact to consider is that sending email directly from an email client (Outlook, Outlook Express, Thunderbird, etc) without optional encryption means a communication can be received and monitored along many points in the path from sender to receiver. For example, in the US Government’s attempt to thwart terrorism, it has instituted “CARNIVORE” – a node on the internet which funnels every email sent within the US thru it’s probe.

Some doctors make it common practice to attach to their email communications a notice of privacy and/or disclaimer. However, this will not prevent unwanted eyes from prying into intendedly private communications. Encryption is what is really required.

There are varying email utilities which will encrypt email – however they can be tedious and impractical to implement – because both sender and receiver require a key to encrypt and decrypt the message respectively.

A very simple – and free – solution is to use Hushmail (www.hushmail.com). It provides seamless email encryption allowing only the intended receiver to decrypt the message.

What’s New

UNC UPDATE IN GENERAL PRACTICE 2006 – Dr. Lambert has been invited to give a presentation at the annual UNC UPDATE IN GENERAL PRACTICE on June 2, 2006. The presentation will be entitled “Contemporary Management of Anticoagulation in the Dental Patient”. We hope you’ll have the opportunity to attend.

Got a quick question? Get a cyber-curbside consult via AOL Instant Messenger, username DMLDDSPA!

We support our partners in practice. We exist to serve you and your patients. We appreciate the opportunity to participate in your patients care.


	TriangleOMS Newsletter David M. Lambert, DDS, PA
April 2006 Volume 1, Number 2
In This Issue · Management of Anticoagulated Dental Patients · Invasion of the Body Snatchers – Revisited… · Controlling Controlled Substances · Secure email · What’s New Triangle OMS Referral Resource Site A website to support our referring partners Tainted Tissue FDA Advisory Find out more about the FDA advisory regarding contaminated human tissue distributed by BTS FDA MedWatch Report a case to the FDA CNN Article – Body Parts Scandel Could Be Growing CNN reports initial extent of body parts scandel may be underestimated Controlling Controlled Substances Secure Email? Hushmail Find out more about securing your patient-related email communications Check This Out! Triangle OMS Referral Resource Site A website to support our referring partners Contact Us www.TriangleOMS.com dmldds@TriangleOMS.com AOL IM: DMLDDSPA	Management of Anticoagulated Dental Patients Patients who are maintained on anticoagulants (Coumadin) are commonly seen in dental practice. The degree of anticoagulation is dependent primarily upon the severity of the underlying medical condition, but the underlying concern is always thrombosis. The most common indication for anticoagulation is atrial fibrillation however other conditions such as deep vein thrombosis, stroke, and heart attack may also require treatment. The commonly held idea that anticoagulants must be discontinued prior to routine dental treatments – or even surgery - has been challenged in the literature. In fact, it would seem - when considering risk to benefit analysis associated with this old strategy there actually may be greater risks both clinically and medicolegally. Interestly enough, it is surprising the degree to which our medical colleagues lack information about this altered approach. The literature is replete with articles demonstating the safety of a graduated approach to dental treatment in this group of patients. While this medium does not allow for a complete discussion of this topic, it has been our experience that even minor surgical procedures may be undertaken without altering anticoagulation. The literature has various recommendations, however, our approach has been that limited procedures (single tooth removal, implant placement, etc) may be undertaken when patient’s INR (International Normalized Ratio) – or anticoagulation index – is between 2.0 and 4.0. Certainly, routine dental care - dental prophylaxis, restorative, endodontic, and periodontal procedures - should be performed without significant risk of untoward bleeding. We have safely used this algorithm with hundreds of patients. It has been our experience that post operative bleeding rarely becomes problematic – and if so may be controlled with local measures (application of pressure, use of hemostatic materials i.e. Surgicel). For further information or advise, please contact the office or visit our Referral Resources page on the web. Invasion Of The Body Snatchers… A recent investigation uncovered illegal human tissue procurement practices between funeral homes and Biomedical Tissue Services, LTD (BTS) of Ft. Lee, NJ. Both hard and soft tissues were procured during the period of early 2004 to September 2005. The tissue recovered from donors may have not met FDA eligibility requirements and may have not been properly screened for infectious diseases. The following tissue processors received tissues from BTS: · Lifecell Corporation – makers of Alloderm · Lost Mountain Tissue Bank · Blood and Tissue Center · Tutogen Medical, Inc · Regeneration Technologies, Inc While no adverse reactions related to the implantation of these tissues is known and the overall risk of infection is thought to be low, nevertheless recipients may be at increased risk of infection. Therefore, the FDA and CDC have recommended that implanting doctors should notify their patients that may have received tissue from one of the above processors and offer to provide patients with access to appropriate infectious disease testing (HIV, Hep B/C, and syphilis). Any infectious disease related to a tissue transplant from any of these processing firms should contact the FDA’s Med Watch (www.fda.gov/medwatch). While we do use mineralized/demineralized human bone for grafting, our commercial sources have not utilized any of the noted tissue processors associated with BTS. Controlling Controlled Substances If you have controlled substances in your office you need to beware of a few common pitfalls. Firstly, you must maintain a running inventory of *all* controlled substances. Secondly, every 2 years you must take a physical inventory of all controlled substances per DEA rules; records for Schedule II (CII) controlled substances must be kept separately; C3 – C5 must be readily retrievable from ordinary professional and business records. All controlled substance records must be kept for 2 years and there is no requirement to submit copies to the DEA. Should you have substances which are out-of-date, they must properly be disposed. While you are under no obligation to do so, the NC Board of Pharmacy does have a controlled substance disposal team which will remove your expired stock and provide you with a disposition receipt. One further consideration is that unlike the NC Medical Board, the NC Dental Practice Act nor it’s Rules has no provision for the dispensing of *any* (controlled or non-controlled) prescription legend medication in office. Disciplinary actions by the NC Board of Dental Examiners due to controlled substance violations are one of the most frequent actions taken against dentists in NC. Accounting for controlled substances in a manner similar to accounting for office revenue/expenses will give you the best defense in the event an investigator from the NC Board of Dental Examiners, NC Board of Pharmacy – or even worse – the DEA, decides to pay you a visit and audit your controlled substance logs. Be prepared! Lastly as a related point, avoid the common pitfall of prescribing controlled substances for your immediate family or office staff. If you must however, make sure you have proper documentation (clinical chart, notes, diagnostic information, tests) and only prescribe appropriate quantities. Secure Email? In many ways, communications between health care providers via an electronic medium (i.e. email) is so much more efficient than attempting to do so by telephone. While certain situations may mandate a phone conversation, many situations can be dealt with by conferring by email. It certainly avoids the common pitfalls of playing “phone tag” and allows one the ability to respond to an inquiry or concern within the framework of what best fits a schedule or work day. However, concerns over the security of email communications should be considered. Probably the most important fact to consider is that sending email directly from an email client (Outlook, Outlook Express, Thunderbird, etc) without optional encryption means a communication can be received and monitored along many points in the path from sender to receiver. For example, in the US Government’s attempt to thwart terrorism, it has instituted “CARNIVORE” – a node on the internet which funnels every email sent within the US thru it’s probe. Some doctors make it common practice to attach to their email communications a notice of privacy and/or disclaimer. However, this will not prevent unwanted eyes from prying into intendedly private communications. Encryption is what is really required. There are varying email utilities which will encrypt email – however they can be tedious and impractical to implement – because both sender and receiver require a key to encrypt and decrypt the message respectively. A very simple – and free – solution is to use Hushmail (www.hushmail.com). It provides seamless email encryption allowing only the intended receiver to decrypt the message. Pretty good privacy! What’s New UNC UPDATE IN GENERAL PRACTICE 2006 – Dr. Lambert has been invited to give a presentation at the annual UNC UPDATE IN GENERAL PRACTICE on June 2, 2006. The presentation will be entitled “Contemporary Management of Anticoagulation in the Dental Patient”. We hope you’ll have the opportunity to attend. Got a quick question? Get a cyber-curbside consult via AOL Instant Messenger, username DMLDDSPA! We support our partners in practice. We exist to serve you and your patients. We appreciate the opportunity to participate in your patients care.

TriangleOMS Newsletter

April 2006 Volume 1, Number 2

In This Issue

· Management of Anticoagulated Dental Patients

· Invasion of the Body Snatchers – Revisited…

· Controlling Controlled Substances

· Secure email

· What’s New

Tainted Tissue

Controlling Controlled Substances

Secure Email?

Check This Out!

Contact Us

Management of Anticoagulated Dental Patients

Invasion Of The Body Snatchers…

Controlling Controlled Substances

Secure Email?

What’s New