Anticoagulation & Bridge Therapy

Warfarin:

INR Monitoring: Assess the patient's INR before surgery. For most procedures, an INR of 2.0-3.0 is generally acceptable for lower bleeding risk surgeries. For higher bleeding risk surgeries, an INR closer to 1.5 may be targeted.
Discontinuation: Warfarin is typically stopped 5 days before surgery to allow for a decrease in the INR. If the INR is not at the desired level, vitamin K or fresh frozen plasma can be considered to rapidly reverse the anticoagulant effect.
Bridging Therapy: For high thrombotic risk patients with mechanical heart valves or prior thromboembolism, bridging with LMWH may be considered during the interruption of warfarin.

‍Direct Oral Anticoagulants (DOACs):

Renal Function Assessment: Consider renal function when deciding on the timing of DOAC discontinuation and reinitiation. Drugs like dabigatran, rivaroxaban, apixaban, and edoxaban have different half-lives influenced by renal function.
Timing of Discontinuation: For low bleeding risk surgeries, DOACs are generally stopped 24-72 hours before the procedure. For high bleeding risk surgeries, discontinuation is typically longer.
Reinitiation Post-surgery: Reinitiate DOACs postoperatively based on the patient's bleeding risk and the need for thromboprophylaxis. Ensure hemostasis is achieved before restarting anticoagulation.

‍Antiplatelet Agents (Aspirin, Clopidogrel):

Timing of Discontinuation: Aspirin is typically stopped 7-10 days before elective surgery. Clopidogrel cessation depends on the specific surgical bleeding risk, and its discontinuation timing can vary from 5 to 7 days before surgery.

‍Bridge Therapy:

High-Risk Patients: Patients at high thrombotic risk (e.g., those with mechanical heart valves) might need bridging therapy with LMWH or unfractionated heparin during the perioperative period when anticoagulants are temporarily stopped.

‍Postoperative Resumption:

Restarting Anticoagulation: The decision to restart anticoagulation post-surgery depends on achieving hemostasis, the patient's bleeding risk, and the risk of thrombosis. Generally, anticoagulation is resumed as soon as it is safe post-surgery.

‍Special Considerations:

Regional Anesthesia: Assess the risk of spinal/epidural hematomas for patients on anticoagulants, especially when planning regional anesthesia.

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Bridge Therapy

Indications:

‍Bridge therapy is considered for high-risk patients with mechanical heart valves, atrial fibrillation with high thromboembolic risk, recent thromboembolism, or other conditions requiring continuous anticoagulation.

‍Agents Used for Bridging:

Low Molecular Weight Heparin (LMWH): Enoxaparin, dalteparin, or fondaparinux are commonly used.
Unfractionated Heparin (UFH): Given intravenously or subcutaneously.

‍Timing of Bridge Therapy:

Stopping Oral Anticoagulants: Warfarin is stopped several days before surgery. DOACs are usually stopped 24-72 hours before the procedure.
Starting Bridge Therapy: Typically initiated when the oral anticoagulant is discontinued and continued until the perioperative period is over or until the patient can resume oral anticoagulants.

‍Bridge Therapy Dosage:

LMWH: Dosage is based on weight and renal function. For instance, enoxaparin might be dosed at 1 mg/kg every 12 hours or 1.5 mg/kg once daily.
UFH: Adjusted based on activated partial thromboplastin time (aPTT) monitoring.

‍Bridging and Postoperative Resumption:

Warfarin: Typically restarted 12-24 hours post-surgery if hemostasis is achieved and the risk of bleeding is acceptable.
DOACs: Often resumed within 24-48 hours post-surgery if hemostasis is achieved and the patient's bleeding risk allows.

‍Bridge Therapy Continuation:

Bridge therapy is usually continued until the oral anticoagulant reaches therapeutic levels.

‍Special Considerations for Bridging:

Renal Function: Adjustments in LMWH dosing are necessary in patients with renal impairment.
Monitoring and Dose Adjustment: Monitoring of anticoagulant activity might be needed during bridge therapy, especially for UFH, to prevent excessive anticoagulation.

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Anesthesia

Cumulative Anesthetic (Off Service Anesthesia+ OMFS) Experience:
general anesthesia/deep sedation for a minimum of 300 cases.
Must involve care for 50 patients younger than 13.
A minimum of 150 of the 300 cases must be ambulatory anesthetics for oral and maxillofacial surgery outside of the operating room.

Major Surgery

Final Year Requirement:
175 major oral and maxillofacial surgery procedures on adults and children, documented by at least a formal operative note.
For the above 175 procedures there must be at least 20 procedures in each category of surgery. Sufficient variety in each category, as specified below, must be provided.
The categories of major surgery are defined as: Trauma, Pathology, Orthognathic Surgery, Reconstructive and Cosmetic Surgery
Surgery performed by oral and maxillofacial surgery residents while rotating on or assisting with other services must not be counted toward this requirement
Surgical procedures performed during foreign rotations must not count toward fulfillment of the 175 major surgical procedures.

Research

Oral or poster presentations at scientific meetings aside from program curriculum
Submission for publication of abstracts, journal articles (particularly peer reviewed) or book chapters
Active participation in or completion of a research project (basic science or clinical) with mentoring

Certifications

ACLS maintained throughout residency
PALS- certified during residency
ATLS- certified during residency

Accepted Codes by Category:

Cleft

Alveolar

42205, 42210

Lip

40700, 40701, 40702, 40720, 40761, 42260

Palate

42200, 42215, 42220, 42225, 42226, 42227, 42235, 42950

Craniofacial

Osteotomies

21137, 21138, 21139, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21260, 21261, 21263, 21267, 21268, 21275, 61557, 61559

Esthetic

Augmentation/Reduction Surgery

21120, 21125, 21127, 21208, 21209, 21270

Chemodenervation

64612

Fillers

11950, 11951, 11952, 11954

Soft Tissue Facial Non-Surgical

15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 17004, 17106, 17107, 17108

Soft Tissue Facial Surgical

15819, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15876, 67900, 67901, 69300

Rhinoplasty

15760, 21235, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520

Infection

Major

10061, 10121, 10140, 10180, 40801, 41005, 41006, 41007, 41008, 41009, 41015, 41016, 41017, 41018, 42300, 42305, 42310, 42320, 42700, 42720, 42725

Minor

10060, 10120, 10160, 21501, 40800, 41000, 41800, 41805, 41806

Orthognathic

Genioplasty Osteotomies

21121, 21122, 21123

Mandibular Osteotomies

21193, 21194, 21195, 21196, 21198, 21199

Maxillary Osteotomies

21141, 21142, 21143, 21145, 21146, 21147, 21188, 21206

Pathology

Biopsies

11305, 11306, 11307, 11308, 11310, 11311, 11312, 11313, 20240, 20245, 21550, 40490, 40808, 41100, 41105, 41108, 42100,42400, 42405

Lesion Excision/Resection Bone Benign

20615, 21025, 21026, 21029, 21030, 21040, 21046, 21047, 21048, 21049, 21295, 21296, 41825, 41826, 41827, 41850

Lesion Excision/ Resection Malignant

11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641, 11642, 11643, 11644, 11646, 17270, 17272, 17273, 17274, 17276, 17280, 17281, 17282, 17283, 17284, 17286, 21015, 21034, 21044, 21045, 21557, 40500, 40510, 40520, 40530, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155

Lesion Excision/Resection Soft Tissue Extraoral/Benign

11420, 11421, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 17000, 17110, 21555, 42810, 42815

Lesion Excision/Resection Soft Tissue Intraoral/Benign

40810, 40812, 40814, 40816, 40820, 41110, 41112, 41113, 41114, 41116, 42104, 42106, 42107, 42120

Salivary Gland

42330, 42335, 42408, 42409, 42410, 42415, 42420, 42425, 42426, 42440, 42450

Sinus

30580, 31030, 31032

Preprosthetic

Implants

21244, 21245, 21246, 21248, 21249, D6010

Preprosthetic Surgery

40840, 40842, 40843, 40844, 40845, 41822, 41823, D4263

Preprosthetic Surgery Soft Tissue

40818, D4273, D4275, D4276, D4277, D4278

Reconstruction

Cartilage Grafting

20912, 21230

Major Bone Grafting Free Bone Grafting

20969, 20970, 20972, 21210, 21215

Microvascular

15757, 20955, 20956, 20957, 20962

Nerve Surgery

64716, 64732, 64734, 64736, 64738, 64742, 64885, 64886

Salivary Duct

42500, 42505, 42507, 42509, 42510, 42665

Soft Tissue Flap Local/Adjacent

14020, 14021, 14040, 14041, 14060, 14061

Soft Tissue Flap Regional/Nearby

15572, 15574, 15576, 15610, 15620, 15630, 15732, 40525, 40527

Soft Tissue Graft Free Skin Grafting

15120, 15121, 15220, 15221, 15240, 15241, 15260, 15261, 15770

Temporomandibular Joint

Arthroscopy

29800, 29804

Minimally Invasive

20605, 21480, 21485

Open Joint

21010, 21050, 21060, 21070, 21240, 21242, 21490

Reconstructive Autogenous

20910

Reconstructive Prothetic

21243

Tracheostomy

31600, 31601, 31603, 31605, 31610

Trauma

Dentoalveolar Trauma

21440, 21445, D7270

Mandible Fractures

21450, 21451, 21452, 21453, 21454, 21461, 21462, 21465, 21470

Midface/Upper Face Fractures, Frontal Sinus Fractures

21343, 21344

Midface/Upper Face Fractures, LeFort Fractures

21345, 21346, 21347, 21348, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436

Midface/Upper Face Fractures, Malar Fractures

21356, 21360, 21365, 21366

Midface/Upper Face Fractures, Nasal Fractures

21310, 21315, 21320, 21325, 21330, 21335, 21336, 21337, 30020

Midface/Upper Face Fractures, NOE Fractures

21338, 21339, 21340

Midface/Upper Face Fractures, Orbital Fractures

21280, 21282, 21385, 21386, 21387, 21390, 21395, 21400, 21401, 21406, 21407, 21408

Repair of Lacerations Extraoral

12001, 12002, 12004, 12005, 12006, 12007, 12011, 12013, 12014, 12015, 12016, 12017, 12018, 12031, 12032, 12034,12035, 12036, 12037, 12041, 12042, 12044, 12045, 12046, 12047, 12051, 12052, 12053, 12054, 12055, 12056, 12057, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 40650, 40652, 40654, 40830, 40831

Repair of Lacerations Intraoral

41250, 41251, 41252, 42180

Lidocaine (Xylocaine): - Maximum Dose without Epinephrine: 4.5 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine) - Toxicity: Symptoms of lidocaine toxicity may include dizziness, confusion, seizures, cardiovascular collapse, and cardiac arrest.

‍Bupivacaine (Marcaine): - Maximum Dose without Epinephrine: 2 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 3 mg/kg (with epinephrine) - Toxicity: Bupivacaine toxicity can cause significant cardiotoxicity, leading to cardiac arrhythmias, cardiac arrest, and central nervous system (CNS) effects such as seizures and dizziness.

‍Mepivacaine (Carbocaine): - Maximum Dose without Epinephrine: 4.5 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine) - Toxicity: Symptoms of mepivacaine toxicity are similar to other local anesthetics and may involve CNS and cardiovascular effects.

‍Procaine (Novocaine): - Maximum Dose without Epinephrine: 7 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: Not typically used with epinephrine - Toxicity: Procaine toxicity may present with symptoms similar to other local anesthetics but is less frequently used today due to its shorter duration and higher allergenic potential.

‍Articaine (Septocaine): - Maximum Dose without Epinephrine: 7 mg/kg (without epinephrine) - Maximum Dose with Epinephrine: 7 mg/kg (with epinephrine) - Toxicity: Articaine has a longer duration of action but can cause similar toxicity symptoms as other local anesthetics if administered excessively or if there's accidental intravascular injection.

Hypokalemia (Low Potassium Levels):

- Mild to Moderate Hypokalemia (3.0-3.5 mEq/L):

- Oral potassium supplementation: Potassium chloride tablets or liquid, 20-40 mEq orally per day in divided doses.

- Severe Hypokalemia (<3.0 mEq/L):

- IV potassium chloride: Start with 10-20 mEq/hour, under continuous cardiac monitoring.

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‍Hyperkalemia (High Potassium Levels):

- Mild Hyperkalemia (5.1-6.0 mEq/L):

- Dietary potassium restriction and discontinuation of potassium supplements.

- Severe Hyperkalemia (>6.0 mEq/L or with ECG changes):

- Calcium gluconate or calcium chloride IV to stabilize cardiac membranes.

- Insulin with glucose IV, beta-agonists (e.g., albuterol), or sodium bicarbonate to shift potassium into cells. - Loop diuretics or exchange resins (e.g., sodium polystyrene sulfonate) to enhance potassium removal.

Hypocalcemia (Low Calcium Levels):

- Mild Hypocalcemia (8.0-8.5 mg/dL):

- Oral calcium supplements: Calcium carbonate or calcium citrate, doses vary based on elemental calcium content.

- Severe Hypocalcemia (<8.0 mg/dL or symptomatic):

- IV calcium gluconate or calcium chloride, dosages depend on severity and symptoms.

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‍Hypercalcemia (High Calcium Levels):

- Mild Hypercalcemia (10.5-11.9 mg/dL):

- Hydration with IV saline and loop diuretics.

- Severe Hypercalcemia (>12 mg/dL or symptomatic):

- Bisphosphonates, calcitonin, or corticosteroids may be used for severe cases.

Hypomagnesemia (Low Magnesium Levels):

- Mild to Moderate Hypomagnesemia (1.2-1.8 mg/dL):

- Oral magnesium supplements: Magnesium oxide, magnesium citrate, or magnesium glycinate, dosages vary.

- Severe Hypomagnesemia (<1.2 mg/dL or symptomatic):

- IV magnesium sulfate, doses vary based on severity and response.

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‍Hypermagnesemia (High Magnesium Levels):

- Mild to Moderate Hypermagnesemia (2.5-3.0 mg/dL):

- Discontinuation of magnesium-containing medications.

- Severe Hypermagnesemia (>3.0 mg/dL or with symptoms):

- IV calcium gluconate for severe symptoms.

- Dialysis may be necessary in extreme cases.

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