Since then, INR has been universally accepted as the method for monitoring bleeding risk for patients receiving Vitamin K antagonist (VKA). From there, the INR was derived to achieve standardization and calibration when comparing PTs from different laboratories. The test is responsive to detecting coagulation factors X, VII, V, fibrinogen (II), and prothrombin (I). Quick developed the PT to investigate the coagulopathy associated with obstructive jaundice. In addition to procoagulation factors, anticoagulant factors such as anti-thrombin, protein C, and protein S are also synthesized by the liver 2. The liver is responsible for synthesizing 11 of the 13 blood coagulation factors, including fibrinogen (I), prothrombin (II), and factor V, VII, IX, X, XII, and XIII. Liver failure is characterized by defective hepatic synthesis of clotting factors and thrombocytopenia. To date, there is no defined protocol for clinicians to follow regarding treatment and evaluation of the pre-transplant liver failure patient population. However, coagulation test may only have limited predictive value for bleeding tendency. Standard laboratory workup includes obtaining a complete blood count, liver function tests, and coagulation panel including bleeding time, prothrombin time (PT)/international normalized ratio (INR), PT test, and platelet count. The current practice is to have access to the patient’s recent laboratory studies to predict bleeding complications. Other causes of liver diseases include alcohol abuse, drug abuse, and biliary obstruction. Therefore, many individuals with HBV or HCV are unaware that they are carriers resulting in silent infections until developing cirrhosis, end-stage liver disease, or hepatocellular carcinoma. However, majority of acute infections are asymptomatic or only cause mild symptoms. Acute illness can be characterized by nausea, malaise, abdominal pain, and jaundice. According to the 2016 Centers for Disease Control and Prevention viral Hepatitis Surveillance Report, 850,000–2.2 million persons are estimated to be infected with HBV and 2.7–3.9 million individuals are chronically infected with HCV in the United States. Liver disease has many forms, but is most commonly attributed to chronic infections such as hepatitis B virus (HBV), hepatitis C virus (HCV), and cirrhosis. Thus, persistent bleeding is a common concern in patients with chronic liver disorders that require surgical dental procedures. Liver diseases have been recognized as having underlying coagulopathy disorders as the liver is responsible for creating majority of the clotting factors required for body to maintain normal hemostasis. As health-care providers, it is paramount that we understand the risks associated with treating this patient population as well as formulating guidelines to help provide treatment safely. In today’s practice, it is not uncommon to encounter patients with liver diseases in dental clinics for routine care or for dental clearance before liver transplant surgery. This supports the belief that pre-operative INR testing is not a dependable marker to assess bleeding risk in patients with chronic liver diseases who are not taking Vitamin K antagonist anticoagulants. In the present study, there was no significant difference between the INR of patients with liver diseases or abnormal liver function tests and normal INR value. The range for the INR values was 0.7 ( n = 1) to 1.7 ( n = 1). The compiled INR for the 187 patients (M/F = 122/65) with mean age of 47 years (range: 22–77) was 1.126, with a median and mode of 1.1. Patients who were taking anticoagulants were excluded from the data pool. Materials and Methods:įrom July 2008 to January 2019, the INR of 187 patients with liver diseases who underwent oral surgical procedures at the Department of Oral and Maxillofacial Surgery Clinic, University of Maryland School of Dentistry was collected and compared with normal value. The aim of this study was to evaluate the validity of international normalized ratio (INR) in patients with liver diseases or abnormal liver function tests as related to bleeding risk in dental procedures.
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