Dr Rahul VC Tiwari - Oral & Maxillofacial Surgery - SIBAR Institute of Dental Sciences, Gunutr, Andhra Pradesh. Oral surgery in liver transplant candidates: a retrospective study on delayed bleeding and other complications

1. 10/25/2016 8:31:03 AM RT/JC/1/OS IN LIVER TRANSPLANT 1

2. Oral surgery in liver transplant candidates:
a retrospective study on delayed bleeding
and other complications
2
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3. About the Journal
Journal Name: Oral Surgery, Oral Medicine,
Oral Pathology and Oral Radiology
Periodicity of journal: Monthly
• Editor in Chief: R Bryan Bell
• Publisher’s name: Thomas Reuters Ltd.
• ISSN NO Print : 0265 -539X
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4. About the Journal contd..
• Impact factor:
• Peer review:
• Indexation:
0.732
Yes
Pubmed, Google scholar, EBSCO
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5. • Date of publication: 1st May 2016
• Volume: 121
• Issue: 5
• Type of article: Research Article
• Page numbers: 490-495
• Received: 25 August 2015
• Accepted: 24 January 2016
About the Article
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9 months

6. About the Article contd..
• Author names :
• Institutional Attachments :
• Designations :
• Keywords :
Jaana helenius hietala
& its associates
Helinski, finland
Not Mentioned
Dental infections,
Heamorrhage,
Tooth extraction,
Liver cirrhosis
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7. • Study design : Mentioned.
• Common terms : Common terms were used.
Title :
Oral surgery in liver transplant candidates: a
retrospective study on delayed bleeding and other
complications
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8. Running Title:
Bleeding following oral surgery in liver
transplant candidates
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9. Abstract:
Informative : Yes
Balanced summary of what
was done and what was found:
Structured Abstract.
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10. Introduction:
Scientific background:
Approach:
Mentioned
Seminar approach
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11. 11
Guggenheimer et al 2003, Helenius heitala j et al 2013
Pre-transplant dental treatment is a prerequisite in many liver transplantation
pt.to prevent post-transplant infectious complications, such as bacteremia
and sepsis, which could be fatal in immunocompromised patients.
Helenius heitala j et al 2012, ward BB et al 2006
In particular, patients with chronic liver disease (CLD) have shown poor oral
health with a high prevalence of dental infections in pre-LT dental
evaluations. Patients with CLD also run a high risk of bleeding after oral
surgery, due to CLD-associated coagulopathy
Perdigao JP et al 2012, Stanca CM et al 2010
previous studies were limited by small cohorts (9 to 90 patients), and those
patients often had well-compensated CLD
Valerian 2007, Hong CH 2012
Earlier studies that specifically studied LT candidates, that is, patients with
advanced or end-stage liver disease, included only 23 to 36 patients.
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REVIEWOFLITERATURE

12. Objectives:
Untreated dental infections pose a threat for immunocompromised
liver transplant (LT) recipients.
Therefore, pretransplant dental evaluations are recommended.
However, risk of bleeding should be considered among patients with
end-stage liver disease and prophylactic blood transfusions may be
used to prevent bleeding.
We retrospectively studied the incidence of and risk factors for oral
surgery-related bleeding in candidates for LT and hypothesized that
complications may occur despite pre- and peri-operative hemostatic
actions.
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13.  Pre-specified
hypotheses :
Mentioned
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14. Study design:
One hundred thirty four patients who had tooth extractions
by oral and maxillofacial surgeons pre-LT
were studied.
The primary endpoint was bleeding between 24 h and 2
weeks post-extraction. Bleeding risk was analyzed by the
pre-operative platelet (PLT) count and INR.
Invasiveness of procedures, severity of liver disease, PLT,
INR, prophylactic transfusions of PLT, fresh frozen plasma,
and tranexamic acid (TA) were included in uni- and
multivariate logistic regression analysis to further assess
risk.
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15. Sampling technique:
Study design:
Setting Locations:
Relevant dates Periods
of recruitment:
Statistical analysis:
Statistical test:
Not mentioned
Retrospective study
Helsinki, Finland
2000-2006 (toto of 306- dental
evaluation 263 in that 134) = -129?
SPSS.ver.17
Chi-square,
Mann-Whitney test
Univariate logistic regression
Multivariable logistic regression
Materials and Methods
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16. Variables:
Dependent: bleeding incidence,
platelet level
Independent: tooth extractions
INR
MELD score
PPT
Age
Gender
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17. Results
Twelve patients exhibited minor bleeding; four
despite PLT>100x109/L and INR<1.5.
Increased bleeding associated with INR and
prophylactic transfusions by univariate analysis;
by multivariate analyses, prophylactic TA and PLT
remained significant.
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21. Discussion
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22. Given
Limitations:
Overall
interpretation of
results :
Generalizability:
Mentioned
Given.
Not Discussed.
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23. Observed Limitations
23
• Retrospective
• Only INR & Platelets were considered
• Results partly confirm the hypothesis
• No other complications are mentioned
• Only males
• No reason for age groups
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24. Bias:
Ethical clearance:
Funding:
Not mentioned
Institutional review board
approval from Helinski
Mentioned
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25. Conclusion is meaningful and is based on aim of the
study.i.e risk of bleeding is difficult to predict in
patients with cirrhosis but, on the other hand,
frequency of delayed bleeding is in general low.
Acknowledgement were not mentioned.
Recommendation were not mentioned.
Finally, results suggest that use of prophylactic blood
coagulation factors requires individual assessment.
CRITICAL APPRAISAL OF CONCLUSION
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26. Suggested Title:
26
Delayed bleeding in tooth extraction males
among 45-51 year old with liver transplant in
Helniski : A Restrospective study.
OR
Retrospective study of delayed bleeding after
tooth extraction in 45-50 year old age group
who underwent liver transplant in helinski.
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27. 23 references in total.
References accessed were : 14
References are in HARVARD .
Number of articles reflecting the study: 09
Reference before 2006: 10
Reference after 2006: 13
Introduction: 8 were cited
Materials and methods: NONE
Discussion: 15 were cited
CRITICAL APPRAISAL OF REFERENCES
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28. Statement of clinical relevance
INR and platelet count do not reliably predict bleeding after
tooth extractions in liver transplant candidates due to
rebalanced hemostasis.
Lisman T et al. 2010 . Rebalanced hemostasis in patients with liver
diseases: evidence and clinical consequences.
Hence, routine prophylactic replacement therapy may be
ineffective.
Alternatively, local hemostatic measures and close post-
operative follow-up by a skilled clinician are recommended.
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