LETTERS TO THE EDITOR J Oral Maxillofac Surg 73:1023-1026, 2015
THE NEW ORAL ANTICOAGULANTS IN ORAL AND MAXILLOFACIAL SURGERY To the Editor:—I read with interest the article, ‘‘Hemorrhagic Complications of Dental Extractions in 181 Patients Undergoing Double Antiplatelet Therapy’’ by Olmos-Carrasco et al (J Oral Maxillofac Surg 72:2100, 2014) about oral anticoagulant therapy in oral and maxillofacial surgery. Anticoagulation therapy is used in several conditions to prevent or treat thromboembolism. For the past decades, warfarin and acenocoumarol have been considered the mainstay of treatment. In recent years, some new oral anticoagulants have been developed. In October 2010, dabigatran was approved by the Food and Drug Administration (FDA). In November 2011, the FDA approved rivaroxaban, and in December 2012, the FDA approved apixaban.1 Edoxaban is the latest new oral anticoagulant developed.2,3 With the new oral anticoagulants, routine coagulation monitoring is not needed using the international normalized ratio (INR), because the INR is not normally affected by these drugs.4 The number of patients taking these new oral anticoagulants has been increasing. Patients taking new anticoagulants pose a challenge for the clinician. In the management of any patient receiving anticoagulation therapy, it is important to assess the risk of bleeding.5 As health professionals, we should all be familiar with the new oral anticoagulants. It is necessary that we understand the effect of these new drugs. We should also be aware of how and when to report adverse drug reactions. Protocols for the management of patients taking edoxaban and for cases of emergency bleeding must be developed in the future.
4. Vanden Daelen S, Peetermans M, Vanassche T, et al: Monitoring and reversal strategies for new oral anticoagulants. Expert Rev Cardiovasc Ther 28:1, 2014 5. Cocero N, Mozzati M, Ambrogio M, et al: Bleeding rate during oral surgery of oral anticoagulant therapy patients with associated systemic pathologic entities: A prospective study of more than 500 extractions. J Oral Maxillofac Surg 72: 858, 2014
http://dx.doi.org/10.1016/j.joms.2015.01.038
REPLY To the Editor:—We are in total agreement with Dr Curto. The number of patients prescribed new oral anticoagulants has been increasing, and it is necessary to assess the risk of hemorrhagic complications in patients treated with these new drugs. The purpose of our study was to estimate the frequency of hemorrhagic complications with dental extractions in patients receiving double antiplatelet therapy. This therapy was the combination of 100 mg/day of acetylsalicylic acid and a second antiplatelet agent (clopidogrel, ticlopidine, prasugrel, or ticagrelor). The most common association in our population (97.2% of our patients) was acetylsalicylic acid and clopidogrel. Additional research is needed to assess the frequency of hemorrhagic complications during invasive dental procedures in patients treated with the new oral anticoagulants.
ADRIAN CURTO, BDENT Salamanca, Spain
OLGA OLMOS-CARRASCO, MD, FP Madrid, Spain
http://dx.doi.org/10.1016/j.joms.2015.02.001
References 1. Davis C, Robertson C, Shivakumar S, Lee M: Implications of dabigatran, a direct thrombin inhibitor, for oral surgery practice. J Can Dent Assoc 79:d74, 2013 2. Kakkos SK, Kirkilesis GI, Tsolakis IA: Editor’s choice—Efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: A systematic review and meta-analysis of phase III trials. Eur J Vasc Endovasc Surg 48:565, 2014 3. Yin OQ, Tetsuya K, Miller R: Edoxaban population pharmacokinetics and exposure–response analysis in patients with non-valvular atrial fibrillation. Eur J Clin Pharmacol 70: 1339, 2014
BAD SPLIT: ANATOMIC OR TECHNICAL PROBLEM? To the Editor:—We are writing about the article ‘‘Relationship Between Mandibular Anatomy and the Occurrence of a Bad Split Upon Sagittal Split Osteotomy,’’ published in the December 2014 issue of the Journal.1 Their study found a correlation between bad splits and certain mandibular anatomy. When we read their report, we were surprised by the high incidence of bad splits. Almost 1 of every 3 patients experienced a bad splint—14 of 48 patients. Additionally, we were concerned regarding the severity of the bad
Letters to the Editor must be in reference to a specific article or editorial that has been published by the Journal. Letters must be submitted within 6 weeks of the article’s print publication or, for an online-only article, within 8 weeks of the date it first appeared online. Letters must be submitted electronically via the Elsevier Editorial System at http://ees.elsevier.com/ joms. Letters are subject to editing and those exceeding 500 words may be shortened or not accepted due to length. One photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in any issue or edition of the journal, in any form or medium.
1023
1024
LETTERS TO THE EDITOR
splits illustrated in Figures 1 and 2. These bad splits were catastrophic. For comparison, we reviewed our electronic database and found no bad splits in 209 patients (418 sides). Thus, although certain mandibular anatomy can increase the risk of a bad split, this complication will usually be avoidable. On reviewing the bad splits shown in the report (Figs 1, 2), we noted that the vertical osteotomies were incomplete and that the medial osteotomy was short. The purpose of our letter is to bring these observations to the authors’ attention, in the hope that our information will help them to reduce the incidence of bad splits. An ideal vertical osteotomy should extend to, and include, the inferior border of the mandible. If one were to see the lingual side of the mandible after the osteotomies have been completed, but before the segments have been separated, one should see a notch in the inferior border of the mandible. The through and through cut will ensure that the fracture produced by the separation of the osteotomy segments stays in the lingual cortex. The authors should also consider moving their vertical cut more anteriorly (between the first and second molars). Relocating the vertical osteotomy will increase the bone contact between the segments and the visibility of the inferior border, which is necessary to make a good osteotomy of the inferior border. Another recommendation is to extend the medial cut posteriorly. The authors stopped the cut 3 to 4 mm beyond the lingula. When the lingula is small, this measurement will take the cut to the middle of the nerve canal. A better landmark would be the posterior border of the ramus. We stop the medial cut 3 to 4 mm in front of it. When splitting the osteotomy, we recommend starting the separation at the inferior border of the mandible and then extending it backward. The force needed to split the mandible should be small. If the mandible is not separating easily, one should stop and check all the osteotomies for completion. Rarely, one will need to apply moderate force, never greater. This recommendation will help avoid catastrophic fractures. When the lateral and medial cortices of the ramus are fused, one should separate the cortices, as much as possible, before the split. This can be accomplished using a thin burr, a saw, or a Piezo. As before, one should begin the split anteriorly, at the inferior border, and then extend it backward. When one reaches the ramus, one might encounter resistance. When this happens, one should stop and expose the nerve to avoid it. Next, with a curved osteotome pointed medially, one should cut the lingual cortex behind the nerve. JAIME GATENO, DDS, MD FLAVIO FERRAZ, DDS DAVID ALFI, DDS, MD Houston, TX
Reference 1. Aarabi M, Tabrizi R, Hekmat M, et al: Relationship between mandibular anatomy and the occurrence of a bad split upon sagittal split osteotomy. J Oral Maxillofac Surg 72:2508, 2014
http://dx.doi.org/10.1016/j.joms.2015.01.040
REPLY To the Editor:—I read Drs Gateno, Ferraz, and Alfi comments on our report titled, ‘ Relationship Between Mandibular Anatomy and the Occurrence of a Bad Split Upon Sagittal Split Osteotomy.’’ We thank you for the good points on our report. The greater incidence of a bad split in our study might have resulted from the use of postoperative cone beam computed tomography scans. Many lingual bad splits will not be diagnosed from routine postoperative radiographs. The research was conducted in a training center (university hospital). The experience of the surgeons was not evaluated in our research, which might have been a limitation of our study. Also, the overall incidence of bad splits in our study was in the range of those reported by previous studies (14.6% compared with 0.21 to 22.72%).1 We have performed a study on the length of the medial cut (The manuscript has been accepted in the International Journal of Oral and Maxillofacial Surgery). We did not find any relationship between the medial cut length and the occurrence of a bad split. The same result was reported by Muto et al.2 I agree with Dr Gateno in locating the buccal cuts anteriorly (between the first and second molars). Several advantages can be gained by placing the buccal cut anteriorly, including better bone contact between the osteotomy segments and appropriate fixation using bicortical screws. Our study focused on finding a correlation between the anatomic parameters and the frequency of a bad split. Furthermore, the mentioned variables (surgeon experience, medial cut length, and buccal cut position) were the same for all participants. REZA TABRIZI, DMD Tehran, Iran
References 1. Chrcanovic BR, Freire-Maia B: Risk factors and prevention of bad splits during sagittal split osteotomy. Oral Maxillofac Surg 16:19, 2012 2. Muto T, Takahashi M, Akizuki K: Evaluation of the mandibular ramus fracture line after sagittal split ramus osteotomy using 3-dimensional computed tomography. J Oral Maxillofac Surg 70:e648, 2012
http://dx.doi.org/10.1016/j.joms.2015.02.012
RE: DR LASKIN’S PERSPECTIVE To the Editor:—I read Dr Laskin’s ‘‘Perspective’’ in the April issue of the Journal with great interest and thank him for addressing an insidious feature harming our profession, the dearth of women pursuing a career in oral and maxillofacial surgery. Most US dental schools matriculate a student body composed of approximately 50% women. However, fewer than 8% of the total oral-maxillofacial surgery (OMS) specialists—residents, practitioners, faculty, and American Board of Oral and Maxillofacial Surgery examiners—are women. Dr Laskin’s article masquerades as a female-friendly argument, but in fact, it makes a number of highly offensive assumptions. Dr Laskin contends that a considerable bias toward women existed previously and was perhaps justified. He then states that this is currently not true, because women have ‘‘proved’’ themselves. However, multiple publications have reported that gender bias in oral and maxillofacial surgery remains a factor contributing to the lack of women
THE NEW ORAL ANTICOAGULANTS IN ORAL AND MAXILLOFACIAL SURGERY To the Editor:—I read with interest the article, ‘‘Hemorrhagic Complications of Dental Extractions in 181 Patients Undergoing Double Antiplatelet Therapy’’ by Olmos-Carrasco et al (J Oral Maxillofac Surg 72:2100, 2014) about oral anticoagulant therapy in oral and maxillofacial surgery. Anticoagulation therapy is used in several conditions to prevent or treat thromboembolism. For the past decades, warfarin and acenocoumarol have been considered the mainstay of treatment. In recent years, some new oral anticoagulants have been developed. In October 2010, dabigatran was approved by the Food and Drug Administration (FDA). In November 2011, the FDA approved rivaroxaban, and in December 2012, the FDA approved apixaban.1 Edoxaban is the latest new oral anticoagulant developed.2,3 With the new oral anticoagulants, routine coagulation monitoring is not needed using the international normalized ratio (INR), because the INR is not normally affected by these drugs.4 The number of patients taking these new oral anticoagulants has been increasing. Patients taking new anticoagulants pose a challenge for the clinician. In the management of any patient receiving anticoagulation therapy, it is important to assess the risk of bleeding.5 As health professionals, we should all be familiar with the new oral anticoagulants. It is necessary that we understand the effect of these new drugs. We should also be aware of how and when to report adverse drug reactions. Protocols for the management of patients taking edoxaban and for cases of emergency bleeding must be developed in the future.
4. Vanden Daelen S, Peetermans M, Vanassche T, et al: Monitoring and reversal strategies for new oral anticoagulants. Expert Rev Cardiovasc Ther 28:1, 2014 5. Cocero N, Mozzati M, Ambrogio M, et al: Bleeding rate during oral surgery of oral anticoagulant therapy patients with associated systemic pathologic entities: A prospective study of more than 500 extractions. J Oral Maxillofac Surg 72: 858, 2014
http://dx.doi.org/10.1016/j.joms.2015.01.038
REPLY To the Editor:—We are in total agreement with Dr Curto. The number of patients prescribed new oral anticoagulants has been increasing, and it is necessary to assess the risk of hemorrhagic complications in patients treated with these new drugs. The purpose of our study was to estimate the frequency of hemorrhagic complications with dental extractions in patients receiving double antiplatelet therapy. This therapy was the combination of 100 mg/day of acetylsalicylic acid and a second antiplatelet agent (clopidogrel, ticlopidine, prasugrel, or ticagrelor). The most common association in our population (97.2% of our patients) was acetylsalicylic acid and clopidogrel. Additional research is needed to assess the frequency of hemorrhagic complications during invasive dental procedures in patients treated with the new oral anticoagulants.
ADRIAN CURTO, BDENT Salamanca, Spain
OLGA OLMOS-CARRASCO, MD, FP Madrid, Spain
http://dx.doi.org/10.1016/j.joms.2015.02.001
References 1. Davis C, Robertson C, Shivakumar S, Lee M: Implications of dabigatran, a direct thrombin inhibitor, for oral surgery practice. J Can Dent Assoc 79:d74, 2013 2. Kakkos SK, Kirkilesis GI, Tsolakis IA: Editor’s choice—Efficacy and safety of the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban in the treatment and secondary prevention of venous thromboembolism: A systematic review and meta-analysis of phase III trials. Eur J Vasc Endovasc Surg 48:565, 2014 3. Yin OQ, Tetsuya K, Miller R: Edoxaban population pharmacokinetics and exposure–response analysis in patients with non-valvular atrial fibrillation. Eur J Clin Pharmacol 70: 1339, 2014
BAD SPLIT: ANATOMIC OR TECHNICAL PROBLEM? To the Editor:—We are writing about the article ‘‘Relationship Between Mandibular Anatomy and the Occurrence of a Bad Split Upon Sagittal Split Osteotomy,’’ published in the December 2014 issue of the Journal.1 Their study found a correlation between bad splits and certain mandibular anatomy. When we read their report, we were surprised by the high incidence of bad splits. Almost 1 of every 3 patients experienced a bad splint—14 of 48 patients. Additionally, we were concerned regarding the severity of the bad
Letters to the Editor must be in reference to a specific article or editorial that has been published by the Journal. Letters must be submitted within 6 weeks of the article’s print publication or, for an online-only article, within 8 weeks of the date it first appeared online. Letters must be submitted electronically via the Elsevier Editorial System at http://ees.elsevier.com/ joms. Letters are subject to editing and those exceeding 500 words may be shortened or not accepted due to length. One photograph may accompany the letter if it is essential to understanding the subject. Letters should not duplicate similar material or material published elsewhere. There is no guarantee that any letter will be published. Prepublication proofs will not be provided. Submitting a Letter to the Editor constitutes the author’s permission for its publication in any issue or edition of the journal, in any form or medium.
1023
1024
LETTERS TO THE EDITOR
splits illustrated in Figures 1 and 2. These bad splits were catastrophic. For comparison, we reviewed our electronic database and found no bad splits in 209 patients (418 sides). Thus, although certain mandibular anatomy can increase the risk of a bad split, this complication will usually be avoidable. On reviewing the bad splits shown in the report (Figs 1, 2), we noted that the vertical osteotomies were incomplete and that the medial osteotomy was short. The purpose of our letter is to bring these observations to the authors’ attention, in the hope that our information will help them to reduce the incidence of bad splits. An ideal vertical osteotomy should extend to, and include, the inferior border of the mandible. If one were to see the lingual side of the mandible after the osteotomies have been completed, but before the segments have been separated, one should see a notch in the inferior border of the mandible. The through and through cut will ensure that the fracture produced by the separation of the osteotomy segments stays in the lingual cortex. The authors should also consider moving their vertical cut more anteriorly (between the first and second molars). Relocating the vertical osteotomy will increase the bone contact between the segments and the visibility of the inferior border, which is necessary to make a good osteotomy of the inferior border. Another recommendation is to extend the medial cut posteriorly. The authors stopped the cut 3 to 4 mm beyond the lingula. When the lingula is small, this measurement will take the cut to the middle of the nerve canal. A better landmark would be the posterior border of the ramus. We stop the medial cut 3 to 4 mm in front of it. When splitting the osteotomy, we recommend starting the separation at the inferior border of the mandible and then extending it backward. The force needed to split the mandible should be small. If the mandible is not separating easily, one should stop and check all the osteotomies for completion. Rarely, one will need to apply moderate force, never greater. This recommendation will help avoid catastrophic fractures. When the lateral and medial cortices of the ramus are fused, one should separate the cortices, as much as possible, before the split. This can be accomplished using a thin burr, a saw, or a Piezo. As before, one should begin the split anteriorly, at the inferior border, and then extend it backward. When one reaches the ramus, one might encounter resistance. When this happens, one should stop and expose the nerve to avoid it. Next, with a curved osteotome pointed medially, one should cut the lingual cortex behind the nerve. JAIME GATENO, DDS, MD FLAVIO FERRAZ, DDS DAVID ALFI, DDS, MD Houston, TX
Reference 1. Aarabi M, Tabrizi R, Hekmat M, et al: Relationship between mandibular anatomy and the occurrence of a bad split upon sagittal split osteotomy. J Oral Maxillofac Surg 72:2508, 2014
http://dx.doi.org/10.1016/j.joms.2015.01.040
REPLY To the Editor:—I read Drs Gateno, Ferraz, and Alfi comments on our report titled, ‘ Relationship Between Mandibular Anatomy and the Occurrence of a Bad Split Upon Sagittal Split Osteotomy.’’ We thank you for the good points on our report. The greater incidence of a bad split in our study might have resulted from the use of postoperative cone beam computed tomography scans. Many lingual bad splits will not be diagnosed from routine postoperative radiographs. The research was conducted in a training center (university hospital). The experience of the surgeons was not evaluated in our research, which might have been a limitation of our study. Also, the overall incidence of bad splits in our study was in the range of those reported by previous studies (14.6% compared with 0.21 to 22.72%).1 We have performed a study on the length of the medial cut (The manuscript has been accepted in the International Journal of Oral and Maxillofacial Surgery). We did not find any relationship between the medial cut length and the occurrence of a bad split. The same result was reported by Muto et al.2 I agree with Dr Gateno in locating the buccal cuts anteriorly (between the first and second molars). Several advantages can be gained by placing the buccal cut anteriorly, including better bone contact between the osteotomy segments and appropriate fixation using bicortical screws. Our study focused on finding a correlation between the anatomic parameters and the frequency of a bad split. Furthermore, the mentioned variables (surgeon experience, medial cut length, and buccal cut position) were the same for all participants. REZA TABRIZI, DMD Tehran, Iran
References 1. Chrcanovic BR, Freire-Maia B: Risk factors and prevention of bad splits during sagittal split osteotomy. Oral Maxillofac Surg 16:19, 2012 2. Muto T, Takahashi M, Akizuki K: Evaluation of the mandibular ramus fracture line after sagittal split ramus osteotomy using 3-dimensional computed tomography. J Oral Maxillofac Surg 70:e648, 2012
http://dx.doi.org/10.1016/j.joms.2015.02.012
RE: DR LASKIN’S PERSPECTIVE To the Editor:—I read Dr Laskin’s ‘‘Perspective’’ in the April issue of the Journal with great interest and thank him for addressing an insidious feature harming our profession, the dearth of women pursuing a career in oral and maxillofacial surgery. Most US dental schools matriculate a student body composed of approximately 50% women. However, fewer than 8% of the total oral-maxillofacial surgery (OMS) specialists—residents, practitioners, faculty, and American Board of Oral and Maxillofacial Surgery examiners—are women. Dr Laskin’s article masquerades as a female-friendly argument, but in fact, it makes a number of highly offensive assumptions. Dr Laskin contends that a considerable bias toward women existed previously and was perhaps justified. He then states that this is currently not true, because women have ‘‘proved’’ themselves. However, multiple publications have reported that gender bias in oral and maxillofacial surgery remains a factor contributing to the lack of women
