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Another view on the anticoagulated patient
LETTERS TO THE EDITOR J Oral Maxillofac Surg 60:342, 2002
THIRD MOLARS AND EATING DISORDERS
ANOTHER VIEW ON THE ANTICOAGULATED PATIENT
To the Editor:—The Discussion of our article, “The Role of Third Molar Surgery in the Exacerbation of Eating Disorders” ( J Oral Maxillofacial Surgery 59:1297, 2001) by Dr Ingersoll is correct in describing the survey as tantalizing and preliminary. However, Dr Ingersoll is in error when she questions the validity of the patients’ responses because “those enrolled in a residential or inpatient treatment program for eating disorders will include the most extreme cases.” We clearly stated, under Methods, that the study was performed in an outpatient psychiatric facility. These patients do not represent the “pathologically extreme” who are at greatest risk for relapse as stated by Dr Ingersoll. As they do not represent the most severe cases, they also do not experience the extreme cognitive distortions, delusions, strained logic, and recall bias suggested by the discussant. The 3 screening questions were included in a lengthy and comprehensive interview. The examiner did not stress dental procedures as a possible cause of the symptomatology; thus, it is unlikely that recall bias contaminated the results. We intended this to be a qualitative preliminary study, raising more questions than answers and prompting oral and maxillofacial surgeons to be sensitive to the needs of patients with a history of disordered eating. This was a survey, a sampling to determine if a relationship exists between eating disorders and third molar surgery. The data suggest that this is so. No comparison group was necessary, but does oral surgery create chronic eating problems (or any other psychopathology) in schizophrenia or bipolar disease? Does surgery, other than oral surgery, exacerbate eating disorders? Further studies are indicated. Nonetheless, in response to the data presented, we feel obligated to recommend that oral and maxillofacial surgeons act to prevent their procedures from becoming enabling factors in the exacerbation and progression of eating disorders.
To the Editor:—Let me take this opportunity to applaud JOMS for the publication of an article in the September 2001 issue on anticoagulation and oral surgery ( J Oral Maxillofac Surg 59:1090, 2001). This is certainly needed in terms of directing thoughts to a very controversial subject. In my position at St Francis Hospital, I have had extensive clinical experience in the subtleties of treatment planning for these “special” patients. St Francis is one of the largest centers for cardiovascular surgery in the country. Unfortunately, both the authors (Drs Todd and Roman), as well as the discussant (Dr Bierne) miss other vital and unrecognized points in offering their recommendations for treatment. A significant number of patients with the need for anticoagulation are both debilitated and noncompliant. As well, the tissue “tone” is often friable due to long-standing infections. These issues impact directly on establishing hemostasis. From my experience, the worst cases of postoperative bleeding (one even requiring multiple transfusions) have arisen more as a result of the overall condition of the patient, than from the choice of anticoagulation drug. In my years at St Francis, I have had the opportunity to deal with such patients on a daily basis, as opposed to simply reviewing the data of prior publications. This has led me to the conclusion that every patient must be assessed on a very individual basis and with particular attention to the “bigger” picture. The thrust of this article clearly misses the point. Hopefully our national organization (AAOMS) can direct more attention to this ever-increasing patient population. J. WILLIAM BRIDBORD, DDS Manhasset, NY
MARGO MAINE, PHD MORTON H. GOLDBERG, DMD, MD West Hartford, CT
doi:10.1053/joms.2002.31336
doi:10.1053/joms.2002.32035
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
342
THIRD MOLARS AND EATING DISORDERS
ANOTHER VIEW ON THE ANTICOAGULATED PATIENT
To the Editor:—The Discussion of our article, “The Role of Third Molar Surgery in the Exacerbation of Eating Disorders” ( J Oral Maxillofacial Surgery 59:1297, 2001) by Dr Ingersoll is correct in describing the survey as tantalizing and preliminary. However, Dr Ingersoll is in error when she questions the validity of the patients’ responses because “those enrolled in a residential or inpatient treatment program for eating disorders will include the most extreme cases.” We clearly stated, under Methods, that the study was performed in an outpatient psychiatric facility. These patients do not represent the “pathologically extreme” who are at greatest risk for relapse as stated by Dr Ingersoll. As they do not represent the most severe cases, they also do not experience the extreme cognitive distortions, delusions, strained logic, and recall bias suggested by the discussant. The 3 screening questions were included in a lengthy and comprehensive interview. The examiner did not stress dental procedures as a possible cause of the symptomatology; thus, it is unlikely that recall bias contaminated the results. We intended this to be a qualitative preliminary study, raising more questions than answers and prompting oral and maxillofacial surgeons to be sensitive to the needs of patients with a history of disordered eating. This was a survey, a sampling to determine if a relationship exists between eating disorders and third molar surgery. The data suggest that this is so. No comparison group was necessary, but does oral surgery create chronic eating problems (or any other psychopathology) in schizophrenia or bipolar disease? Does surgery, other than oral surgery, exacerbate eating disorders? Further studies are indicated. Nonetheless, in response to the data presented, we feel obligated to recommend that oral and maxillofacial surgeons act to prevent their procedures from becoming enabling factors in the exacerbation and progression of eating disorders.
To the Editor:—Let me take this opportunity to applaud JOMS for the publication of an article in the September 2001 issue on anticoagulation and oral surgery ( J Oral Maxillofac Surg 59:1090, 2001). This is certainly needed in terms of directing thoughts to a very controversial subject. In my position at St Francis Hospital, I have had extensive clinical experience in the subtleties of treatment planning for these “special” patients. St Francis is one of the largest centers for cardiovascular surgery in the country. Unfortunately, both the authors (Drs Todd and Roman), as well as the discussant (Dr Bierne) miss other vital and unrecognized points in offering their recommendations for treatment. A significant number of patients with the need for anticoagulation are both debilitated and noncompliant. As well, the tissue “tone” is often friable due to long-standing infections. These issues impact directly on establishing hemostasis. From my experience, the worst cases of postoperative bleeding (one even requiring multiple transfusions) have arisen more as a result of the overall condition of the patient, than from the choice of anticoagulation drug. In my years at St Francis, I have had the opportunity to deal with such patients on a daily basis, as opposed to simply reviewing the data of prior publications. This has led me to the conclusion that every patient must be assessed on a very individual basis and with particular attention to the “bigger” picture. The thrust of this article clearly misses the point. Hopefully our national organization (AAOMS) can direct more attention to this ever-increasing patient population. J. WILLIAM BRIDBORD, DDS Manhasset, NY
MARGO MAINE, PHD MORTON H. GOLDBERG, DMD, MD West Hartford, CT
doi:10.1053/joms.2002.31336
doi:10.1053/joms.2002.32035
Letters to the Editor are considered for publication (subject to editing and abridgment), provided they are submitted in 1 of 2 ways. If typewritten, they must be submitted in duplicate, signed by all authors, double-spaced, and should not exceed 40 typewritten lines of manuscript text (excluding references). You may also e-mail your Letters to the Editor to [email protected]. The same length limits apply. Letters should not duplicate similar material being submitted or published elsewhere. Letters to a recent Journal article must be received within 6 weeks of the article’s publication. Receipt of letters is not acknowledged and there is no guarantee that your letter will be published. We cannot provide prepublication proofs. Submitting the letter constitutes your permission for its publication in any current or subsequent issue or edition of the Journal, in any form or media, now known or hereafter developed.
342