Audit of referrals of patients on oral antithrombotic therapy to a hospital oral surgery service for simple tooth extractions

Abstract

Objective

To assess the proportion of patients referred to a hospital oral surgery department for procedures that could have been managed in primary care.

Method

This cross-sectional audit included 41 outpatients on oral antithrombotic therapy who were referred to the University Hospital Dubrava in Zagreb, Croatia, for simple tooth extraction(s). Information about additional factors that may affect the complexity of the intervention was collected using a questionnaire. Any instructions regarding patients’ antithrombotic therapy regimens were also recorded. An oral surgeon evaluated whether each surgical procedure could have been safely performed in primary care.

Results

The oral surgeon estimated that in 75.6% (31/41) of the cases, the indicated extractions could have been safely managed in primary care, provided the clinician had relevant training and confidence. Instructions to discontinue antithrombotic therapy prior to the procedure were frequently encountered and, in most cases, issued by the patients’ dentists.

Conclusion

The findings of this study support the need for more comprehensive studies on the quality, appropriateness and underlying reasons for referrals to oral surgery departments. Such research would provide evidence to guide the development and implementation of measures aimed to enhance dentists’ clinical skills, self-confidence, and interdisciplinary collaboration, ultimately improving patient care.

Keywords

antithrombotic therapy health care delivery oral surgery patient referral patient safety tooth extraction

Introduction

In Croatia, diagnostic and therapeutic procedures that fall into the scope of oral surgery may be provided by general dental practitioners or by specialists working either within the public health care system (under the contract with the Croatian Health Insurance Fund) or in a purely private practice. General dental practitioners are usually the first professionals that patients visit for their oral health needs. Dentists may then treat the patient or, depending on the patients’ needs and thereby their best interest, appropriately and timely refer the patient for speciality care.^1,2

Primary care-based general dental practitioners are expected to provide routine oral surgery care. In this way, patients obtain health service with minimal discomfort and without additional costs. Specialist services (expertise) should be reserved primarily for more complex cases and surgical procedures, conditions that need to be addressed in the hospital, etc. However, in Croatia, as in other countries,^3–5 patients may be referred to specialists for procedures that could have been managed in primary health care. If unjustified, referrals create inconvenience, especially for older patients, additional costs of transportation and/or accommodation, cause delay in patients’ treatment, especially if the coordination between providers is inefficient and important information is missing, influence patients’ satisfaction with the health care system, pose unnecessary workload on specialists, lengthen waiting lists, etc.^6–8

Several studies have previously analyzed the frequency of different types of diagnoses and treatments provided in oral surgery departments of Croatian hospitals.^9–11 In their retrospective study, Jokić et al.¹¹ reported that the most common ambulatory procedure at the Department of Oral and Maxillofacial Surgery, University Hospital Dubrava, in 2011 was tooth extraction. The authors emphasized that extractions and intraoral incisions could be performed by primary care dentists and suggested that enhancing the training of dentists and dental students may help reduce the number of referrals to oral surgeons.

The most prevalent reasons for (unnecessary) referrals have not been explored among Croatian dentists, but would likely include those reported by Coulthard et al.:¹² anticipated surgical difficulty, medical history issues, need for a second opinion, lack of appropriate facilities or staff, insufficient experience in oral surgery, and/or mere unwillingness to undertake surgical procedures. Dentist’s decision to shift health care provision to secondary and tertiary facilities may also be influenced by the patients themselves and by factors related to the organization and financing of health services such as payment of primary care physicians by the capitation-fee model.¹³ Similar barriers to performing surgical interventions within primary dental care, including also litigation concerns, were reported more recently by Lewis et al.¹⁴ Tzartzas et al.¹⁵ conducted a qualitative study among general medical practitioners to gain more accurate understanding on how doctors decide to refer their patients to specialists. The authors noted that the decision-making process involves multiple factors, not only medical/clinical, as decisions regarding patients’ management may challenge one’s self-esteem, introduce concerns regarding one’s professional recognition and reputation, influence relationship with colleagues and patients and other personal factors.

The issue of referring patients to oral surgery specialists for procedures that could be managed in primary dental care, such as simple tooth extractions, has been recognized in the ‘Strategy for the Development of Dental Care’ of the Croatian Dental Chamber.¹⁶ It is listed as a challenge for the discipline in both the current (2017–2025) and previous (2009–2015) version of the document. This descriptive study was thus based on the long-standing observation that oral surgery departments of university hospitals in Zagreb (University Hospital Centre Zagreb and University Hospital Dubrava) admit patients whose referrals are not always justified. The present study focused on patients referred to the Oral Surgery Clinic of the University Hospital Dubrava who (a) required simple tooth extraction(s) and (b) were receiving oral antithrombotic therapy. The necessity of referral was evaluated by a single oral surgeon, taking into account all relevant patient data. The aim of the study was to determine the proportion of patients referred to the oral surgery department for procedures that could have been managed in primary care.

Methods

The study was designed as a preliminary cross-sectional study. Patients using any kind of oral antithrombotic therapy referred for uncomplicated tooth extraction(s) met eligibility criteria. The extraction of the tooth or tooth remnant was considered simple if the characteristics of the tooth/root (its morphology and position) allowed for the extraction to be performed using basic surgical equipment (elevators and/or forceps) and competence (skill).

A convenience sample of patients was recruited from June until November 2022 at the University Hospital Dubrava Department of Oral and Maxillofacial Surgery. Recruitment was not performed systematically but intermittently, with ad-hoc random selection of some, but not all, eligible patients during routine clinical workflow. Relevant patient information (sex, age, travelling distance from the hospital, general health status, medication use, drug allergies, and level of dental anxiety/fear) was recorded using a questionnaire. Some of these factors – such as medical conditions, social issues, anxiety, or disability – may increase the complexity of an otherwise simple procedure. It was also recorded whether patients had been instructed to modify their antithrombotic therapy regimen prior to elective tooth extraction. A single oral surgeon assessed all patients at the time of recruitment and, taking all relevant data into account, evaluated whether the procedure could have been safely performed in primary care.

Ethical considerations

The study was reviewed and approved by the Ethics committee of the University of Zagreb School of Dental Medicine (05-PA-30-VII-4/2022) and by the Ethics Committee of the University Hospital Dubrava (2022/0905-04). All procedures were conducted in accordance with the Declaration of Helsinki. All participants signed the informed consent form.

Results

A total of 41 patients were included in the study. Sex and age distribution of the sample is presented in Table 1.

Table 1.

Demographic characteristics of the sample.

		Age structure (years)
Sex	Number of patients (%)	Minimum	Maximum	Median	Q1	Q3
Male	24 (58.5)	34	87	69	62.3	74.3
Female	17 (41.5)	49	87	68	59	80
Total	41 (100)	34	87	68	60	77

Table 2 shows descriptive statistics of the sample discriminated on the basis of patients’ antithrombotic therapy regimen. Monotherapy with an antiplatelet drug refers to acetylsalicylic acid in all cases but one (the one exception being clopidogrel). Dual therapy with two antiplatelet drugs refers to acetylsalicylic acid + clopidogrel in all cases but one (the one exception being acetylsalicylic acid + ticagrelor). Dabigatran was a prescribed direct oral anticoagulant (DOAC) in three cases and the other two patients were receiving rivaroxaban or apixaban. Most commonly used antithrombotic agent in our sample was acetylsalicylic acid.

Table 2.

Distribution of patients (N = 41) according to antithrombotic therapy regimen with the number and proportion of patients advised to temporarily stop antithrombotic therapy and those assessed eligible for primary care management.

Group of patients according to the prescribed antithrombotic therapy	Number (% of the total sample size) of patients in a group	Number (% of the group size) of patients to whom it was suggested to discontinue antithrombotic therapy 1–3 days prior to the dental procedure	Number (% of the group size) of cases for which the oral surgeon, considering patients’ clinical findings and medical history, estimated that the extraction could have been performed safely in primary dental care given that the clinician has relevant training and self-confidence
Monotherapy with an antiplatelet drug	20 (48.8)	11 (55)	16 (80)
Dual therapy with two antiplatelet drugs	5 (12.2)	1 (20) (patient was advised to discontinue acetylsalicylic acid only)	3 (60)
Warfarin	9 (21.9)	5 (55.5)	8 (88.9)
Warfarin + antiplatelet drug	2 (4.9)	0	0
Direct oral anticoagulant	5 (12.2)	3 (60)	4 (80)

Table 2 also presents the number of patients who were advised to stop their antithrombotic therapy 1–3 days prior to dental procedure. In most cases, this instruction was issued by the patient’s dentist. In the case of one patient who was taking warfarin, the suggestion was given following dentist’s consultation with the vascular surgeon. In one case of dabigatran and warfarin usage, the suggestion to omit therapy prior to dental procedure was given by general medical practitioner and a nephrologist, respectively. In addition, three patients (one using acetylsalicylic acid and two using DOAC) made the decision to omit their morning (daily) dose of the drug by themselves.

The oral surgeon estimated that in 31 patients (75.6%) the procedure could have been safely managed in primary dental care, assuming adequate training and confidence of the clinician. Wilson score interval was used to estimate proportion confidence interval: 95% CI [0.61, 0.86]. Table 2 presents distribution of these patients in relation to the type of their antithrombotic therapy.

Most patients (82.9%) lived within an hour travelling distance (by car or by public transportation) from Dubrava Hospital.

More than half of the patients (56.1%) admitted dental anxiety and/or fear and nearly 35% of them stated that the anxiety/fear prevents them from going to the dentist unless there is no way to avoid it.

Four patients (9.7%) reported allergy to penicillin.

Table 3 presents the number of teeth and/or retained roots planned for extraction, the number of patients with an X-ray at visit, and the number of patients with failed extraction attempt in primary care.

Table 3.

Number of teeth and/or retained roots designated for extraction in patients grouped according to their antithrombotic therapy regimen, number of patients with an X-ray at visit, and number of unsuccessful tooth extraction attempts in primary care.

	Number of teeth and/or retained roots designated for extraction
Group of patients according to the prescribed antithrombotic therapy	Range	Mean⁺⁄₋SD	Number (% of the group size) of patients with a dental X-ray at visit	Number (% of the group size) of patients referred to oral surgery due to unsuccessful tooth extraction attempt in primary dental care
Monotherapy with an antiplatelet drug	1–4	1.8⁺⁄₋1.1	9 (45)	1 (5)
Dual therapy with two antiplatelet drugs	1–4	2.2⁺⁄₋1.3	3 (60)	1 (20)
Warfarin	1–7	2⁺⁄₋1.9	3 (33.3)	0
Warfarin + antiplatelet drug	2–4	3⁺⁄₋1.4	1 (50)	0
Direct oral anticoagulant	1–3	1.6⁺⁄₋0.9	4 (80)	0

Three patients did not have a dental X-ray at visit because they forgot it. Eight patients (19.5%) had their third molar as one of or the only tooth indicated for extraction.

Discussion

The results of this small observational study confirm that general dental practitioners refer patients to Oral Surgery Department of the University Hospital Dubrava for simple (uncomplicated) tooth extraction(s). The study cannot reveal dentists’ reasons for the referrals but it is reasonable to assume that those reported by other authors^12–15 might be applicable here as well. Dentists’ insufficient experience in clinical decision-making and/or surgical technique may result in false anticipation of a difficult extraction, failed extraction or unwillingness to engage in surgical procedures at all, particularly in older patients with more complex medical histories.

It could be hypothesized that the absence of a dental X-ray (noted in half of our study sample) may, at least in some cases, reflect dentists’ reluctance to undertake surgical procedures. This assumption is supported by the fact that radiographs enable assessment of tooth and root morphology, and help clinicians in evaluating the extraction complexity (i.e. help them predict the difficulty of extraction).

For young dentists, it can be assumed that COVID crisis (lockdowns) left its mark on their skills and self-confidence by disrupting the course of their clinical education and training.^17,18

All patients included in this study were using some kind of antithrombotic therapy. As these agents interfere with normal haemostatic processes, patient assessment necessarily includes estimation of risk for heavier and/or prolonged intra- and postoperative bleeding. The finding that almost half of the patients were advised to discontinue antithrombotic therapy 1–3 days prior to dental procedure suggests that concerns about bleeding complications likely played a significant role in the dentists’ decisions to refer patients to the oral surgery clinic. Fear of complications was likely stronger when multiple teeth and/or retained roots were to be extracted. Indeed, several patients reported that their dentist referred them to the hospital due to ongoing antithrombotic therapy.

Both shorter and longer distances between the primary dental care provider and the hospital could endorse the decision to refer. At greater distances, dentists may prefer referral to ensure that the patient has timely access to care should complications arise during the procedure. When travelling distance is relatively short – as in this study, where most patients lived within an hour of Dubrava Hospital – referral may be perceived as enhancing patient safety while posing only a minor inconvenience.

Considering previous literature reports as well as personal experience of oral surgery specialists in our university hospital departments, the above described results are not unexpected. They confirm what has been acknowledged and addressed in the ‘Strategy for the Development of Dental Care’ of the Croatian Dental Chamber. Unfortunately, presented data cannot provide insight into the proportion of unnecessary referrals within the overall workload of oral surgery specialists at Dubrava Hospital. Addressing this would require a comprehensive study involving all Department specialists and, ideally, the evaluation of all admitted patients during a defined monitoring period. Such a study would also require standardized assessment criteria as clinicians differ in their professional experience and may judge the complexity of the patient’s condition, difficulty of the procedure, and the associated risks differently. In the present study, only one surgeon evaluated the necessity of referral in order to minimize variation in clinical decision-making.

The results of this study may provide support to the propositions of the Croatian Dental Chamber for the development of this discipline. As stated in the document, it should be more clearly defined which surgical procedures should be managed in primary dental care. If patients are referred to hospital outpatient clinics for such procedures, additional information justifying the referral could be requested. The document also suggests preparation of algorithms and protocols for specific surgical procedures, continuing education of specialists as well as general practitioners in the domain of oral surgery, and adequate coverage of the territory with secondary health care services, particularly specialists under the contract with the Croatian Health Insurance Fund. However, negative demographic trends burdening Croatia – depopulation and ageing of the domicile population – present important challenges in achieving goals regarding organization of the health care sector and ensuring sustainability of the Croatia’s health insurance system.^13,19 With decreasing number of the young, replacement of the retiring working force, especially in rural areas, islands and small towns, becomes more difficult even if the interest of the youth for health care professions is high. Ageing of the population also warrants greater appreciation of gerontology and gerodontology in dental education and in establishing professionals’ role as oral health care advocates (as promoters of healthy ageing).^20,21

Patients on antithrombotic therapy are also predominantly of older age. Our study is in line with this expectation as the median age of our sample was 68 years. Antithrombotic therapy is an important modifier of patients’ condition and may justify referral to oral surgery department even for simple procedures to ensure patients’ safety. However, such therapy does not in itself warrant referral. Bleeding risk is dependent on multiple factors and needs to be assessed for each patient individually. Besides the type of antithrombotic drug(s), bleeding risk will depend on patient-specific factors (including comorbidities and/or use of other medications or supplements affecting haemostasis), history of haemorrhage after trauma or medical interventions, and the nature of the planned dental procedure.²²

According to current guidelines, most routine surgical procedures in patients taking warfarin may be safely performed without interrupting anticoagulation therapy if the INR is within the therapeutic range and local haemostatic measures are used.²³ Discontinuation of therapy may put the patient into higher risk of thromboembolic complications that outweigh potential bleeding complications related to the procedure.²⁴ Discontinuation of DOAC therapy is also not indicated for dental procedures with minimal bleeding risk, but the procedure should be timed to coincide with the drug’s lowest blood concentration.²⁵ Guidelines regarding monotherapy with acetylsalicylic acid suggest that most dental procedures may be safely performed without interrupting the therapy.²⁶ Yet, 55% of our participants were advised to stop taking it 1–3 days prior to the procedure.

Despite existing guidelines, other authors have also reported uncertainty regarding the management of antithrombotic therapy in patients undergoing invasive dental procedures, including preference for discontinuing therapy prior to dental treatment.^27–29 Frequently encountered recommendation to discontinue antithrombotic therapy before simple tooth extraction suggests the need to strengthen education of students and general dental practitioners in this area. Dentists should not interrupt patient’s therapy on their own as this could compromise its protective effect, particularly in the presence of other factors that interfere with treatment efficacy, such as inadequate adherence to the medication schedule, missed doses, drug interactions, and other.

Inappropriate suggestions regarding management of antithrombotic therapy prior to dental procedures may also be given by general physicians or prescribing specialists.²⁷ Our study also confirms this. This finding reinforces the role of dentists as contributors in reaching the most appropriate decision in any particular case. Thereby, both the guidelines issued by professional and scientific societies for managing this group of patients, as well as dentists’ personal experience in evaluating the complexity and risks of invasive procedures in daily practice, play an important role in guiding their decision-making and consultations with other medical professionals to improve patient care.

Fear of bleeding complications likely contributed to referral decisions in our study sample. However, dentists also refer healthy, non-medicated patients to oral surgeons for simple tooth extractions. Although general dental practitioners are expected to manage such cases within primary care, referrals also have an important positive side. Patients referred to university hospitals for simple extractions are suitable cases for clinical training, particularly at the undergraduate level. When such patients also present with complex medical histories and/or antithrombotic therapy, students gain the opportunity to conduct a comprehensive assessment of the patient’s condition and associated risks, communicate and collaborate with colleagues from other medical fields, and provide treatment and manage possible complications (like expected or unexpected increased haemorrhage) in a safe, supervised learning environment.

The first limitation of this study is its small sample size. Nevertheless, the finding of a high proportion of patients referred to specialists for procedures that could have been managed in primary care suggests that this issue continues to be an important health service issue and supports the need for further research. Similar, but larger, department-based study could address other limitations of the present study such as nonsystematic patient recruitment. In addition to quantifying the institutional burden of unnecessary referrals, a department-based study could distinguish between referrals of otherwise healthy versus medically compromised patients and evaluate the influence of inter-rater variability on referral audits.

Our study could not reveal specific reasons why patients were referred to the Department of Oral Surgery at Dubrava Hospital. Detecting most common reasons for referrals from general dental practitioners to specialists for simple surgical procedures, gathering information regarding perioperative management of patients on antithrombotic therapy in primary care (where most extractions take place), gaining insight into the scope and (perceived) quality of interprofessional collaboration, as well as other aspects of daily practice would provide valuable guidance for improving education both at the undergraduate and postgraduate level. Studies conducted both in Croatia and in other countries that evaluated students’ perceptions of their knowledge and skills in oral surgery^30–35 support the need for continuous refinement of dental curricula, clinical training, assessment methods, and other aspects of dental education to better prepare young dentists for independent practice.

Conclusions

The results of this study confirm that patients are being referred to Oral Surgery Department of University Hospital Dubrava for procedures that could be provided in primary care. Referral decisions appear to be influenced by patients’ age, medical history and/or perceived risk of bleeding complications in relation to dentists’ self-assessed surgical skills and confidence. These findings support previously proposed strategies for the development of the discipline. Enabling general dental practitioners to make independent clinical decisions, confidently provide therapy and identify cases that require professional consultations and interdisciplinary approach may be seen as prerequisites for successful implementation of local and national strategic measures aimed at improving health care availability, accessibility and quality, and overall efficiency and effectiveness of the health care system.

Footnotes

Acknowledgements

We thank the patients who participated in this study for their contribution.

Ethical considerations

Consent to participate

All procedures were conducted in accordance with the Declaration of Helsinki. All participants signed the informed consent form.

Author contributions

LV, MBV, and IS contributed to the study conception and design. IS, MBV, EZ, and BP were engaged in data acquisition. All authors contributed to the analysis and interpretation of data. The first draft of the manuscript was written by LV and other authors revised it critically for important intellectual content. All authors read and approved the final version of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data from this research are available from the corresponding author upon reasonable request.*

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