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www.nature.com/bdjopen ARTICLE OPEN The practices and beliefs of dental professionals regarding the management of patients taking anticoagulant and antiplatelet drugs 1,2✉ 2 2 2 2 2 Niamh Kelly , Laura Beaton , Jennifer Knights , Douglas Stirling , Michele West and Linda Young © Crown 2023 AIM: This study aimed to inform the implementation of the updated Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance, ‘Management of Dental Patients taking Anticoagulant or Antiplatelet Drugs’, and to determine training needs by investigating dental professionals’ current practice and beliefs regarding management of patients taking these medications. METHODS: Dental professionals were recruited via the NHS Education for Scotland Portal. The online questionnaire collected demographic information, data on current practice and information about beliefs regarding behaviours related to the management of patients on anticoagulant or antiplatelet medication. Quantitative data were analysed using SPSS and subjected to frequency calculations, t-tests, one-way ANOVA and linear regression. Qualitative data were collected via free text boxes and analysed using thematic analysis. RESULTS: One hundred and ﬁfty-seven participants responded to the questionnaire. The majority of respondents stated they were aware of the guidance and always based their practice on it. The majority of respondents always assessed the patient’s individual bleeding risk prior to dental procedures. Most respondents felt that they did not know how to appropriately manage patients taking low doses of low molecular weight heparins (LMWH), and only 38% of respondents always followed SDCEP guidance about direct oral anticoagulants (DOAC) medication and procedures with a low associated risk of bleeding. DISCUSSION: This study demonstrates a need for further educational support surrounding LMWHs and management of patients on DOAC medication. Time and remuneration represent barriers to guidance implementation in primary care. CONCLUSION: There is good awareness and adherence to the guidance in primary care settings, however training needs were identiﬁed to support implementation. BDJ Open (2023) 9:1 ; https://doi.org/10.1038/s41405-022-00127-3 INTRODUCTION been used for over 60 years, however in the last 8 years its use has Medical conditions such as atherosclerosis or cardiac arrhythmias decreased, due to the availability of DOACs . Although the use increase patients’ risk of thrombosis, resulting in potentially fatal of antiplatelet medication has remained relatively stable , the events such as cardiac arrest, stroke or pulmonary embolism . introduction of newer drugs, such as prasugrel and ticagrelor, has Antiplatelet and anticoagulant medication are prescribed to resulted in a greater variation in antiplatelet drugs that patients reduce this risk for patients with mechanical valve replacement, may be prescribed . Although less commonly used than oral cardiac stents, atrial ﬁbrillation, a history of stroke or cardiovas- anticoagulants or antiplatelet agents, parenteral anticoagulants cular incidents or arrhythmias [2–4]. However, the use of such as the low molecular weight heparins (LMWHs) may also be anticoagulant and antiplatelet medication increases bleeding risk; encountered. therefore, an assessment of bleeding risk prior to surgical Prescribing of anticoagulant and antiplatelet medication may procedures, such as those carried out in dentistry, is fundamental. continue to increase, as the prevalence of patients with The Scottish Dental Clinical Effectiveness Programme, (SDCEP) cardiovascular and chronic cerebrovascular illnesses continues to produced guidance in 2015 to provide support surrounding the rise, given an aging population. Therefore, dental professionals are management of dental treatment for patients on antiplatelet and likely to encounter these patients more frequently [10, 11]. anticoagulant medication. Since the publication of the 2015 guidance, Although anticoagulants such as warfarin and antiplatelet drugs the landscape of anticoagulant and antiplatelet use has changed. such as aspirin and clopidogrel have been widely used for a Anticoagulant medication is prescribed for approximately 1.25 number of years, with various dental guidelines relating to their million people per year in the UK , with the use of direct oral use [2, 12], less evidence-based guidance has been available for anticoagulant (DOAC) medication increasing from 16% in 2015 to DOACs such as apixaban, rivaroxaban, dabigatran and antiplate- 62% of all anticoagulant medication by 2019 . Warfarin has lets such as prasugrel and ticagrelor . 1 2 Dental Core Trainee, Dundee Dental Hospital and School, NHS Tayside, Dundee, UK. NHS Education for Scotland, Scotland, UK. email: email@example.com Received: 7 September 2022 Revised: 28 November 2022 Accepted: 2 December 2022 1234567890();,: N. Kelly et al. The 2015 SDCEP guidance ‘Management of Dental Patients recorded for the quantitative data, including current practice, beliefs and demographics. Taking Anticoagulants or Antiplatelet Drugs’ provides recommen- Statistical analysis was carried out using t-tests, one-way ANOVA and dations and clinical advice for managing dental patients taking Tukey post-hoc tests to explore the relationship between the behaviours anticoagulants or antiplatelet medication including the newer and demographic information. Statistical signiﬁcance was set at p < 0.001, drugs. Despite this, variation in clinical practice between general to account for multiple testing . Linear regression was used to explore dental practitioners, lack of conﬁdence and failure to follow an the relationships between the behaviours and the COM-B domains. In evidence-based approach in the management of these patients addition, demographic information (i.e., sex, professional role, age, has been reported . location, setting and years since qualiﬁed) was included in the regression SDCEP developed an update of its guidance, which was model to control for confounding factors. published in 2022, taking the changed drug prevalence and other Qualitative analysis of free-text responses was conducted using thematic developments into account. The guidance update includes the analysis. Thematic analysis is a method of qualitative data analysis, involving a six-step process: analysis of the data, generating initial codes, newest DOAC edoxaban, new recommendations for managing searching, reviewing and deﬁning themes, and producing a summary patients taking LMWH, and updated information to support report [17, 18]. Thematic analysis was carried out by 3 authors bleeding risk assessment. independently. Analysis was completed by NK, with support from LB and The aim of this paper is to detail work undertaken by TRiaDS JK; any disagreements regarding coding were discussed until consensus (Translation Research in a Dental Setting) to support the was reached. A six-point framework  was used to ensure validity and implementation of the updated SDCEP guidance through reproducibility of the process. determining barriers to compliance and identifying professional training needs. Dental professionals were recruited from a range Ethical considerations. Given that this project constituted part of the of clinical settings such as primary dental care, community dental process of SDCEP guidance production and implementation, ethical approval was not deemed necessary. Completion of the questionnaire services and hospital dentistry in Scotland, to highlight barriers to represented consent to take part. A participant information sheet was implementation in primary practice, to determine how this may be provided in the recruitment email outlining the purpose of the survey and addressed. advising that participation was voluntary. METHODS RESULTS Sample and design One hundred and ﬁfty-seven questionnaire responses were An online cross-sectional survey was used to gather data. NHS and private submitted. Seventy-ﬁve percent of respondents were female and dental practitioners, dental therapists, and dental hygienists in both the 25% were male. Fifty-one percent of participants were between 30 General Dental Service (GDS) and Public Dental Service (PDS) in Scotland were recruited via the NES Portal, an online tool used for course bookings/ and 50 years old. management administered by NHS Education for Scotland. Only those Seventy-four percent of respondents worked in the GDS, 22% who had previously opted in to receive marketing correspondence were worked in the PDS, and a small number of participants, 4%, included in the dissemination of the questionnaire. Vocational Dental worked in other settings such as military dental services, private Practitioners in Scotland were recruited through the Dental Vocational practice and hospital dental services. The majority of respondents Training Hub. (81%) worked in cities and towns, whilst 19% worked in remote and rural settings. Data collection Job roles included: principal dentists (15%), associate dentists The questionnaire was hosted in Questback, an online survey tool, and (53%), vocational dental practitioners (13%), and hygienists (1%). disseminated in December 2021. The survey was open to responses until Eighteen percent of participants worked in ‘other’ job roles as January 2022. Reminders to complete the survey were provided 2 weeks consultants, specialists, specialty dentists, civilian dental ofﬁcers, before the closing date. and clinical director roles (Table 1). Questionnaire development Prevalence The online questionnaire collected demographic information, data on Fifty-four percent (n = 84) reported that they usually saw current practice and information about beliefs regarding taking a patients taking antiplatelets weekly. Thirty-three percent medical history, assessing bleeding risks, managing patients taking (n = 52) reported they saw patients taking DOAC medication DOAC medication, managing patients taking warfarin or another vitamin weekly and 11% (17) saw patients taking vitamin K antagonists K antagonist (VKA), managing patients taking a LMWH, carrying out (VKA) weekly. Although 83% (n = 130) of dental professionals haemostatic packing and suturing and referrals to secondary care for patients taking anticoagulant or antiplatelet drugs. Free text boxes were always asked for a list of medications when completing a also provided, to allow respondents to explain their answers in more medical history form, only 59% (n = 93) reported that they detail. always asked speciﬁcally about the use of anticoagulant or The COM-B model  was used as a theoretical base to inform antiplatelet medications. questionnaire development. COM-B is a model used to understand LMWHs were less commonly encountered by respondents, with behaviour in the context in which it occurs . It investigates capability, 23% (n = 35) stating they never encountered patients on a LMWH opportunity, motivation, and behaviour, positing that for a behaviour to and 5% (n = 8) of respondents encountering patients on a LMWH occur, the person(s) involved in the behaviour must have the capability, at least once a week. A further 9% (n = 14) were unaware if opportunity and motivation to do it. The categories assessed are further patients they treated were taking a LMWH. subdivided into physical capability, psychological capability, physical opportunity, social opportunity, reﬂective motivation, and automatic motivation. Questions were developed for each behaviour, addressing Current Practice each of these subcategories. All participants who responded to this question (n = 156) were aware of the 2015 SDCEP guidance on the management of dental patients taking anticoagulant or antiplatelet medication, and 77% Data analysis Items comprising each COM-B domain were scored positively, summed (n = 121) of respondents answered that they always based their when appropriate and an average ‘domain score’ calculated for each practice upon the SDCEP guidance. respondent. Cronbach’s alpha and Spearman Brown tests were used to test For patients on antiplatelet or anticoagulant medication, 78% reliability for each domain and behaviour. An alpha score of 0.6 was (n = 123) of respondents always assessed individual bleeding risk considered satisfactory for reliability . Descriptive frequencies were BDJ Open (2023) 9:1 N. Kelly et al. medication when taking a medical history. Eighty-seven percent Table 1. Respondent demographics. (n = 137) agreed that they knew who to contact to get further information about patients’ medication, however only 50% Demographic n Percentage (%) (n = 79) agreed that it was straightforward to obtain the Sex Male 38 25% information. Seventy percent (n = 109) of participants agreed Female 115 75% that they had sufﬁcient time to ask patients about anticoagulant Prefer not to say 1 1% or antiplatelet use. Location Rural 30 19% Assessing bleeding risk Towns/Cities 127 81% Ninety percent (n = 142) of respondents agreed that they knew Age 20–29 32 21% how to assess the risk of bleeding complications associated with 30–39 37 25% required dental procedures and 71% (n = 111) felt that they had sufﬁcient time within routine appointments to assess a patient’s 40–49 40 27% individual risk of bleeding. Ninety-eight percent (n = 154) 50–59 36 24% of respondents felt that it was important to them to 60–69 6 4% assess patient’s individual risk of bleeding prior to dental Setting GDS 116 74% procedures. Regarding the COM-B model component of opportunity, PDS 34 22% respondents working in the PDS more frequently felt they had Other 6 4% sufﬁcient time to assess bleeding risk than respondents working in Job role Principal 24 15% the GDS (F = 8.52, p < 0.000) (Table 2). Associate 82 53% Managing patients taking DOACs VDP 20 13% Ninety percent (n = 141) of respondents felt that they understood Hygienist 2 1% how to manage patients taking DOAC medication and 91% Other 28 18% (n = 143) felt that they had the skills to do so. Seventy-seven GDS general dental services, PDS public dental services, VDP vocational percent (n = 120) of respondents felt it was straightforward to dental practitioner. obtain up-to-date information about DOACs. Seventy percent *Due to rounding of results, percentages may not equal 100%. (n = 110) of respondents felt comfortable advising patients to miss their morning dose of apixaban or dabigatran when appropriate and 69% (n = 108) felt comfortable advising patients prior to dental procedures, and 90% (n = 142) always assessed the to delay their morning dose of rivaroxaban or edoxaban when risk of bleeding complications associated with the required dental appropriate. procedure. Only 38% (n = 56) of respondents stated they always followed Managing Patients taking Warfarin or VKA SDCEP guidance to treat patients taking a DOAC without Ninety-two percent (n = 144) of respondents stated that they interrupting their medication regime for procedures with a low know when a patient’s INR should be checked before carrying out risk of bleeding complications. For procedures with a higher risk of a procedure which is likely to cause bleeding for patients with a bleeding associated, 48% (n = 73) of respondents always asked stable INR, and for those with an unstable INR (85%, n = 134). patients on apixaban or dabigatran to miss their morning dose Sixty-two percent (n = 98) felt that they could rely on patients to and 41% (n = 61) of respondents always advised patients on report their most recent INR accurately. Fifty-one percent (n = 80) rivaroxaban or edoxaban to delay their morning dose. felt it was straightforward to liaise with medical colleagues to For patients on warfarin or another VKA, 97% (n = 151) of conﬁrm a patient’s most recent INR before carrying out a respondents ensured the INR (International Normalised Ratio) had procedure likely to cause bleeding. Checking INR readings prior been checked within 72 hours of the procedure if stable, in to carrying out procedures likely to cause bleeding was routine accordance with SDCEP guidance and 82% (n = 129) checked no practice for 94% (n = 148) of respondents. more than 24 hours prior to the procedure if unstable, in Regarding the COM-B model component of opportunity, accordance with SDCEP guidance. respondents working in the PDS more frequently felt it was For patients on a LMWH requiring a dental procedure with a low straightforward to liaise with medical colleagues to conﬁrm INR associated risk of bleeding complications, 22% (n = 32) of readings, than respondents working in the GDS (F = 9.23, respondents always treated without interrupting their antic- p < 0.000). oagulant medication. Thirty-one percent (n = 49) of respondents always carried out packing and suturing for procedures likely to Managing patients taking a LMWH cause bleeding for patients taking anticoagulant or antiplatelet Forty-one percent (n = 64) of respondents felt that they knew how medication. Sixty-one percent (n = 96) of respondents stated that to appropriately manage patients taking low doses of LMWH and if they had concerns about safely treating a patient in primary felt conﬁdent to do so. Forty-two percent (n = 66) of respondents care, they would ﬁrst contact a colleague in secondary care to agreed that they could access timely advice from a patient’s discuss the most appropriate management, before making a prescribing clinician when deciding how to manage these referral. patients. There were no statistically signiﬁcant differences noted between respondents’ current practice behaviours and their Carrying out haemostatic packing and suturing demographic proﬁle. Ninety-one percent (n = 144) of respondents understood how to effectively carry out haemostatic packing and suturing and 64% (n = 99) felt they had sufﬁcient time to carry out packing and BELIEFS OF RESPONDENTS suturing during an appointment. Twelve percent (n = 17) felt Taking a medical History there was sufﬁcient remuneration from the SDR (Statement of All (n = 157) respondents agreed that they understood the Dental Remuneration) * to carry out packing and suturing in reasons for asking about anticoagulant or antiplatelet general practice. BDJ Open (2023) 9:1 N. Kelly et al. Table 2. ANOVA beliefs and age, setting, years qualiﬁed. Current Beliefs Mean Standard error F df p Tukey post- practice difference hoc p value Setting Sufﬁcient time to assess bleeding risk (14.4) 1.00 0.31 8.52 2, 152 <0.000 PDS vs GDS p = 0.004 Feeling it was straightforward to liaise with medical 1.35 0.34 9.23 2, 153 <0.000 PDS vs GDS colleagues to conﬁrm INR readings (19.3.4) p < 0.000 Time to carry out packing and suturing (23.3) 1.43 0.36 11.77 2, 152 <0.000 PDS vs GDS p < 0.00 2.40 0.76 11.77 2, 152 <0.000 PDS vs other p = 0.006 Remuneration for packing and suturing (23.4) 1.19 0.31 7.49 2, 149 0.001 PDS vs GDS p < 0.001 Time to liaise with colleagues in secondary care (25.3) 1.87 0.38 17.14 2, 153 <0.000 PDS vs GDS p = 0.000 3.04 0.82 17.14 2, 153 <0.000 Other vs GDS p = 0.001 Table 3. Regression analysis. Behaviour Signiﬁcant predictors R Fdf p Taking a medical history � Respondent’s intention to ask about current anticoagulant or antiplatelet 0.24 15.2 3 <0.00 use and medical conditions � Knowledge regarding who to contact for further information about antiplatelet or anticoagulant medication regimes Assessing bleeding risk � Capability 0.57 93.0 2 <0.00 � Importance they placed on assessing a patient’s individual risk of bleeding complications Managing patients � Motivation 0.14 22.3 1 <0.00 taking DOACs Carrying out packing and � Gender 0.20 11.4 3 <0.00 suturing � Capability � Number of years since qualiﬁcation Referring to secondary care � Capability 0.14 24.0 1 <0.00 Respondents working in the PDS more frequently felt they had There were no statistically signiﬁcant differences noted sufﬁcient time to carry out packing and suturing, than colleagues between respondents’ age, sex, location, number of years in the GDS, (F = 11.77, p < 0.000) and felt there was sufﬁcient qualiﬁed and beliefs. remuneration for packing and suturing from the SDR, (F = 7.49, p < 0.001). *The Statement of Dental Remuneration (SDR), is a document Regarding the COM-B model component of opportunity, produced by the Scottish Government, outlining NHS fees for respondents who worked in the PDS more frequently felt they provision of treatment in primary dental care settings. had the opportunity to carry out packing and suturing, than dental professionals working in the GDS (F = 11.77, p < 0.000) and other clinical settings (F = 11.77, p < 0.000). Linear regression Linear regression was carried out to explore the relationship Referrals to secondary care for patients taking anticoagulant between the clinical behaviours and the predictors posited by or antiplatelet drugs the COM-B model. Behaviours included taking a medical history, Ninety percent (n = 141) of respondents agreed that they assessing bleeding risk, managing patients taking DOACs, understood when it was appropriate to contact a colleague in managing patients taking warfarin or another vitamin K secondary care to discuss the most appropriate management for antagonist, managing patients taking a LMWH, carrying out the patient. Forty-four percent (n = 70) agreed they had sufﬁcient haemostatic packing and suturing and referrals to secondary time in primary care settings to contact colleagues in secondary care for patients taking anticoagulant or antiplatelet drugs care to discuss management. Ninety-ﬁve percent (n = 147) agreed (Table 3). it was important to them only to refer patients to secondary care if Independent variables included: demographic information (sex, there was a concern about safely managing patient care in age, location, setting, years qualiﬁed) and beliefs (capability, primary care settings. opportunity, and motivation), related to each behaviour. Regarding the COM-B component of opportunity, respondents working in PDS and other clinical settings more frequently felt Thematic analysis. A total of 126 free-text responses were they had sufﬁcient time to contact secondary care colleagues received: 28 responses related to taking a medical history, 10 (F = 17.14, p < 0.000), (F = 17.14, p < 0.000), than respondents responses related to assessing bleeding risk, 22 responses related working in the GDS. to DOACs, 14 responses related to warfarin, 17 responses related BDJ Open (2023) 9:1 N. Kelly et al. to LMWH, 26 responses related to packing and suturing, and 9 practice to assess bleeding risk in a 5 min exam appointment’.- responses related to referrals. (Specialist Practitioner) Analysis of free text responses highlighted a number of themes related to each of the behaviours: MANAGING PATIENTS TAKING DOACS TAKING A MEDICAL HISTORY Following SDCEP guidance GPs and other medical practitioners Several respondents stated they do not always follow the SDCEP Thematic analysis revealed that respondents experienced difﬁ- guidance for procedures deemed ‘low risk’, due to conﬂicting culty in corresponding with general medical practitioners (GMPs), advice from specialists, who have recommended patients miss to gain more information about the patient’s medical conditions morning doses of anticoagulant medication prior to any extrac- and medications. Gaining timely feedback and advice from GMPs tion, regardless of the associated bleeding risk, and are aware a was difﬁcult, and although respondents found secondary care number of their colleagues also adopt this management strategy. consultants and specialists more accessible, the process is time consuming, and response time is often slow. ‘I ﬁnd that most of my colleagues routinely miss the AM dose of apixaban when doing extractions, whether simple and 1–3 teeth ‘It is extremely difﬁcult if not impossible to get in touch with the or complex, contrary to what SDCEP seems to guide us so, I tend patient’s GP, they never get back to me, except Consultants. - to follow the consensus and also miss the AM dose for patients on (GDP Associate) DOACs needing an extraction whether low or high risk for bleeding’. - (Associate Dentist) Respondents expressed concerns about the lack of knowledge of most medical practitioners regarding dental procedures and Most respondents who left a comment noted that they lacked implications of anticoagulant or antiplatelet medication, suggesting conﬁdence to stop/alter medication doses without ﬁrst speaking that most medical colleagues do not feel comfortable providing to colleagues in secondary care settings, GPs or consulting the advice due to their own lack of education and training on this topic. SDCEP guidance. ‘How to communicate altering medications with medical As it is fairly uncommon for me to be planning surgery/ colleagues is a bit unclear - do we just tell them we’re doing extractions on such patients I would not want to rely on my this? ask their permission? Or ask their advice? I often get the recollection of the guidance & would refer to SDCEP guidance to response that they don’t know enough to advise or comment so guide my assessment & management strategies. - (Associate think prescribers also need education’. - (Dental Consultant). Dentist) Medical records The majority of general dental practitioners reported that they did MANAGING PATIENTS TAKING WARFARIN OR ANOTHER not have access to electronic medical records, clinical letters, VITAMIN K ANTAGONIST referrals and medication lists, making it difﬁcult to verify INR records medication prior to dental procedures. Dental professionals in Although in the majority of cases dental professionals are able to PDS and salaried dental services found it more straightforward to conﬁrm INR readings via patients’ INR recording books, sometimes check anticoagulation medication for patients due to access to they rely on the patient’s word that INR has been tested and is electronic care records. within correct values. Qualitative comments revealed that some respondents felt that medical colleagues sometimes underesti- ‘I think it would be sensible to allow GDPs the access to ECS mate the importance of timely INR checks prior to dental (Emergency Care Summary) at least to check meds’. - (Specialty treatment, and this can result in a delay with treatment. Dentist) ‘Access to INR checks can be difﬁcult and delay treatment’.- (Consultant Community Dental Services) SDCEP Guidance Clarity is often required from medical practitioners if patients’ drug regimens differ from recommendations provided by the SDCEP guidance. Dentists acknowledge clinical judgement is also MANAGING PATIENTS TAKING A LMWH required with use of the SDCEP guidance. Lack of knowledge and conﬁdence Respondents acknowledged the rarity of encountering patients ‘I do always need to clarify guidelines with SDCEP. Sometimes, the taking LMWHs and their lack of experience in managing these patient’s drug regimen may differ from that suggested in the patients. Further guidance would be welcomed by dental guidelines and then I struggle to know what to do’ - (Associate professionals, to aid management. Dentist) ‘I have not treated patients taking heparin, so I am unaware of the standard advice. I would however consult SDCEP guidance if required to do so, or seek advice from a special care dentist if it ASSESSING BLEEDING RISK did not provide the information required’. - (Associate Dentist) Time constraints Due to time constraints with appointments in general practice, it can be difﬁcult to assess bleeding risks associated with individual dental procedures and the individual risk to the patient. CARRYING OUT HAEMOSTATIC PACKING AND SUTURING Barriers to packing and suturing My role in PDS allows me to arrange long assessment A number of dental professionals raised concerns regarding the appointments - it would be difﬁcult for a GDP in high street lack of remuneration available from the NHS in general practice BDJ Open (2023) 9:1 N. Kelly et al. for packing and suturing. They highlighted the longer appoint- regimes should not be altered, due to the increased risk of ments required to provide this service and the knowledge and thromboembolic events . However, although 90% (n = 141) of skills required to complete packing and suturing. A number of respondents felt that they understood how to manage patients respondents also stated they would not carry out packing and taking DOAC medication, only 38% always follow SDCEP guidance suturing for all patients and base this decision on the individual advice not to interrupt DOAC medication regimes for procedures risk assessment of the planned procedure and patient. with a low associated risk of bleeding. The free text responses offer further insight, revealing that a number of respondents do ‘If I have identiﬁed a patient as having a bleeding risk, I make sure not always follow the SDCEP guidance for procedures deemed I book a longer appt to allow packing, suturing and haemostasis. ‘low risk’ due to conﬂicting advice from local specialists, who have The SDR does not remunerate adequately for this’. - (Associate recommended patients miss morning doses of DOAC medication Dentist) prior to any extractions, regardless of the associated bleeding risk. Respondents also stated they were aware that several colleagues also adopt this management strategy. The evidence supporting altering DOAC medications and REFERRALS TO SECONDARY CARE FOR PATIENTS TAKING altering medication regimes based on bleeding risk in the ANTICOAGULANT OR ANTIPLATELET DRUGS guidance document is limited, due to the low quality of some Referrals and advice studies and the paucity of evidence relating to dental procedures Dental professionals expressed difﬁculty in reaching dental with a higher risk of bleeding. The 2015 edition of the guidance practitioners and specialists in community dental services or acknowledged the lack of supporting evidence from dental hospital settings for advice and guidance. studies. This may contribute to lack of compliance with guidance recommendations surrounding DOACs and dental procedures as ‘Getting hold of colleagues in the hospitals quickly to discuss is noted in the qualitative data. Existing research and meta-analyses almost impossible’. (Associate Dentist) have also concluded that evidence regarding DOAC management in a dental setting is limited and studies are of low quality [20, 21]. Dental professionals in rural settings also expressed apprehen- Existing research also found that adherence to SDCEP guidance sion about carrying out complex procedures due to the distance was low regarding DOAC management, with compliance ranging away from secondary care settings, in case of complications. from 25–57% in one study. The study concluded that the complexity of guidance recommendations may contribute to ‘I would not feel comfortable doing a more complex procedure on non-compliance. The study ﬁndings also supported the guidance a patient on anticoagulants. Due to the distance from my recommendation for audit and regular staff education to improve practice to a dental hospital. I would usually refer them’.- compliance and staff knowledge . (Associate Dentist) Respondents highlighted a lack of conﬁdence, knowledge, experience, and skills in managing patients taking LMWH. This was evident from both quantitative and qualitative analysis. Free text responses acknowledged the rarity of encountering patients on DISCUSSION LMWH and the need to contact prescribing clinicians for advice. The SDCEP guidance on managing dental patients taking antic- Respondents highlighted that they would welcome further oagulants or antiplatelet drugs was updated in 2022, taking into guidance surrounding the dental management of patients taking consideration the increased prevalence of DOAC prescribing and LMWH. Only 41% (n = 64) of respondents felt that they knew how uncertainty about managing treatment for patients taking to appropriately manage patients taking low doses of LMWH and LMWHs. The updated guidance includes recommendations and felt conﬁdent to do so. The second edition of the SDCEP guidance advice for the newest DOAC, edoxaban, and the LMWHs, and  has been updated to include management advice for patients updated information to support bleeding risk assessment. on low prophylactic doses and higher doses of LMWH, to support In line with the TRiaDS framework  for supporting the dental professionals. development and implementation of SDCEP guidance, the Statistical analysis revealed that the only demographic variable purpose of this project was to investigate the current practice where there were signiﬁcant differences in beliefs was setting and beliefs of dental professionals surrounding the management (GDS, PDS, other). Regarding the COMB domain of opportunity, of dental patients taking anticoagulant and antiplatelet drugs. The dental professionals working in PDS had greater opportunity to results provide an overview of these before the updated guidance assess bleeding risk, carry out packing and suturing and liaise with was published and identify potential barriers to following the medical professionals, than colleagues in GDS. Time pressures, guidance recommendations in primary care settings. workload, and the environment of general medical practice  The results of the pre-publication survey highlighted that there can often result in barriers to implementation of evidence-based were discrepancies between current practice and practice practice, this is applicable in both general medical and dental recommended in the 2015 edition of the guidance. The results settings. Greater opportunities and support for dental profes- highlighted very good awareness (100% of respondents stated sionals in GDS are required to ensure guidance can be they were aware of the guidance), and good adherence (77% of implemented into general dental practice. Regarding the COM-B respondents stated they always base their practice on the component of opportunity, interventions which provide greater guidance). However, the results also highlighted potential areas ﬁnancial support and time made available in general dental that could be targeted for improvement. practice for dental professionals, would aid guidance implementa- Whilst the SDCEP guidance advises that dental professionals tion and behaviour change . should ask patients about their current or planned use of Thematic analysis of free text responses identiﬁed time, anticoagulants or antiplatelet drugs and other medications, when remuneration and access to electronic health records and patient taking or conﬁrming their medical history , only 59% of medication lists as barriers to guidance implementation and respondents (n = 93) always asked speciﬁcally about the use of adherence to SDCEP guidance. anticoagulant or antiplatelet medications. This suggests that These barriers to guidance implementation noted from free text further support related to taking a medical history is required. responses and discrepancies noted in current practice support the The SDCEP guidance also advises that for dental procedures notion that guidance publication alone is unlikely to result in with a low associated bleeding risk, anticoagulant medication desired changes in practice by healthcare professionals . BDJ Open (2023) 9:1 N. Kelly et al. Whilst barriers such as insufﬁcient time and remuneration cannot 4. Ruff C, Giugliano R, Braunwald E, Hoffman E, Deenadayalu N, Ezekowitz M, et al. Comparison of the efﬁcacy and safety of new oral anticoagulants with warfarin in be addressed by SDCEP, educational support could help address patients with atrial ﬁbrillation: a meta-analysis of randomised trials. 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[Internet] Paraschiv C, Esanu I, Ghiuru R, Manea P, Munteanu D, Gavrilescuet C. The ﬁndings of this project contribute to the current body of Dental implications of the new oral anticoagulants. 2015. Available from: http:// evidence surrounding dental professionals’ beliefs and current practice www.rjor.ro/wp-content/uploads/2015/12/ DENTAL_IMPLICATIONS_OF_THE_NEW_ORAL_ ANTICOAGULANTS.pdf. Accessed surrounding the dental management of patients on anticoagulant and 18 July 2022. antiplatelet drugs, highlighting potential barriers to guidance imple- 11. Green L, Tan J, Morris J, Alikhan R, Curry N, Everington T, et al. A three-year mentation in primary care. However, several limitations are recognised. prospective study of the presentation and clinical outcomes of major bleeding Whilst the use of questionnaires offers an objective means of collecting episodes associated with oral anticoagulant use in the UK (ORANGE study). information about respondents’ knowledge, beliefs and behaviour , Haematologica. 2018;103:738–45. there are often limitations with their use in research. The potential for 12. [Internet] Randall C. Surgical Management of the Primary Care Dental. Patient on response bias must be considered, as the dental professionals who Warfarin: North West Medicines Information Centre. 2007; Available from: submitted responses may be more engaged with the SDCEP guidance www.app.dundee.ac.uk/tuith/Static/info/warfarin.pdf. Accessed 18 July 2022. and make more regular use of it in their daily practice. Recall bias is a 13. Kelly N, Nic Íomhair A, Hill S, McKenna G, O’Carolan D, Cleary G, et al. Perceptions of General Dental Practitioners in Northern Ireland on the clinical management of further limitation that must be considered, in terms of the subjective patients taking Direct Oral Anticoagulants (DOACs). J Ir Dent Assoc. nature of respondents’ self-reported knowledge, motivation, opportu- 2021;67:340–5. nity and capability. The ﬁndings of the questionnaire may not be 14. Michie S, Atkins L, West R. The behaviour change wheel. [S.l.]: Silverback Pub- generalisable to the general population in the UK as respondents were lishing; 2014. recruited through the NES Portal and VDP training hub, and practice 15. Ursachi G, Horodnic I, Zait A. How reliable are measurement scales? External may differ between countries. factors with indirect inﬂuence on reliability estimators. Procedia Econ Financ. Future work will involve a post-publication questionnaire, to be 2015;20:679–86. disseminated to all dental professionals following publication of 16. Jafari M, Ansari-Pour N. Why, when and how to adjust your p values? Cell J. the second edition of the guidance. Further education and 2019;20:604–7. https://doi.org/10.22074/cellj.2019.5992. 17. Kiger M, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Med support could be provided, to support implementation of the Teach. 2020;42:846–54. guidance into primary care settings and to provide support, if the 18. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. post-publication questionnaire provides no evidence of a change 2006;3:77–101. in beliefs and current practice surrounding LMWH use and 19. Clarkson J, Ramsay C, Eccles M, Eldridge S, Grimshaw J, Johnston M, et al. The assessing bleeding risk. translation research in a dental setting (TRiaDS) programme protocol. Implement Sci. 2010;57:5. 20. Manfredi M, Dave B, Percudani D, Christoforou J, Karasneh J, Diz Dios P, et al. CONCLUSION World workshop on oral medicine VII: direct anticoagulant agents management In order to support the implementation of the updated SDCEP for invasive oral procedures: a systematic review and metaanalysis. Oral Dis. 2019;25:157–73. guidance, the aim of the project was to determine barriers to 21. Fortier K, Shroff D, Reebye U. Review: an overview and analysis of novel oral compliance and to identify training needs of dental professionals. anticoagulants and their dental implications. Gerodontology. 2018;35:7886. Analysis of the pre-publication questionnaire results concluded 22. Woolcombe S, Ball R, Patel J. Managing direct oral anticoagulants in accordance that there is very good awareness of the guidance in primary care with the Scottish Dental Clinical Effectiveness Programme guidance for patients settings, with good adherence to the advice and guidance undergoing dentoalveolar surgery. Br Dent J. 2022;232:547–54. suggested. 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Available from: https:// 26. Linnebur S, Ellis S, Astroth J. Educational practices regarding anticoagulation and www.sdcep.org.uk/published-guidance/anticoagulants-andantiplatelets/. Acces- dental procedures in U.S. Dental Schools. J Dent Educ. 2007;71:296–303. sed 18 July 2022. 27. Sapsford R. Survey research. London: SAGE Publications; 1999. 2. [Internet] Randall C, Surgical Management of the Primary Care Dental Patient on Antiplatelet Medication: North West Medicines Information Centre, 2010. Avail- able from www.app.dundee.ac.uk/tuith/Static/info/antiplatelet.pdf. Accessed 18 July 2022. ACKNOWLEDGEMENTS 3. Van EsN, Coppens M, Schulman S, Middeldorp S, Büller H. Direct oral antic- The authors would like to acknowledge the assistance of Tracy Frail and Anne Coats oagulants compared with vitamin K antagonists for acute venous thromboem- with the dissemination and administration of the questionnaire and to thank all of bolism: evidence from phase 3 trials. Blood. 2014;124:19681975. the dental professionals who responded. BDJ Open (2023) 9:1 N. Kelly et al. AUTHOR CONTRIBUTIONS ADDITIONAL INFORMATION All authors made substantial contributions to the preparation of the manuscript and Correspondence and requests for materials should be addressed to Niamh Kelly. approval was given prior to submission to the BDJ Open, by all authors. NK: conceptualisation, quantitative and qualitative data analysis, writing original draft Reprints and permission information is available at http://www.nature.com/reprints and revision of manuscript. LB, JK, LY, DS, MW: conceptualisation, reviewing and editing the manuscript. LB: quantitative and qualitative data analysis. JK: qualitative Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims data analysis. LY: quantitative data analysis. in published maps and institutional afﬁliations. Open Access This article is licensed under a Creative Commons COMPETING INTERESTS Attribution 4.0 International License, which permits use, sharing, The authors were part of the methodology team facilitating the development of the adaptation, distribution and reproduction in any medium or format, as long as you give 2nd edition of the SDCEP guidance ‘Management of Dental Patients on Antic- appropriate credit to the original author(s) and the source, provide a link to the Creative oagulant and Antiplatelet Drugs’ . The authors have no other conﬂict of interests to Commons license, and indicate if changes were made. The images or other third party declare. material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory ETHICS APPROVAL AND CONSENT TO PARTICIPATE regulation or exceeds the permitted use, you will need to obtain permission directly Given that this project constituted part of the process of SDCEP guidance production from the copyright holder. To view a copy of this license, visit http:// and implementation, ethical approval was not deemed necessary. Completion of the creativecommons.org/licenses/by/4.0/. questionnaire represented consent to take part. A participant information sheet was provided in the recruitment email outlining the purpose of the survey and advising that participation was voluntary. © Crown 2023 BDJ Open (2023) 9:1
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