Strategies for managing anticoagulated patients requiring dental extractions: an exercise in evidence-based clinical practice.
Evidence-based clinical practice requires the development and refinement of literature searching, appraisal skills, and clinical experience. Answering clinical questions using evidence-based methods can be time-intensive, but as one becomes more familiar with the methods, it becomes a fairly straightforward process. For example, it took less than an hour to complete the initial steps of this exercise and arrive at an initial recommendation for Ms. J. Oftentimes, the clinician does not have an hour to find an answer. Fortunately, there are more and more resources available that summarize reviews of clinical questions, so individual practitioners can rapidly access the information they need. Recently, I saw a patient who presented with a preauricular mass. During the visit, a pathologist performed a fine needle aspiration (FNA) to obtain a specimen for diagnosis. Much to our surprise, the FNA results suggested a diagnosis of melanoma. Not being a melanoma expert, I signed on to the computer, went to Up To Date, searched using the keyword "melanoma," and found the information I needed in under a minute. Before the patient left our office, he was scheduled for all the tests and imaging studies needed to maximize his initial appointment with the melanoma specialist. Central to evidence-based clinical practice is the explicit enumeration and balancing of risks and benefits. Evidence is never enough for making clinical decisions. We need to integrate our clinical values and preferences with the patient's values and preferences to render compassionate, informed treatment decisions.
Dodson
Thomas B
TB
Massachusetts General Hospital, Boston, MA, USA.
D000925:Anticoagulants / Q000627:therapeutic use*; D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D017742:Dental Care for Chronically Ill / Q000379:methods*; D019317:Evidence-Based Medicine; D006801:Humans; D033181:Information Dissemination; D019934:International Normalized Ratio; D006472:Oral Hemorrhage / Q000517:prevention & control; D019106:Postoperative Hemorrhage / Q000517:prevention & control; D012196:Review Literature as Topic; D014081:Tooth Extraction; D014148:Tranexamic Acid / Q000627:therapeutic use
D000925:Anticoagulants; D000933:Antifibrinolytic Agents; D014148:Tranexamic Acid