07/31/09 Bleeding Tendancy: A Practical Approach in Dentistry

Resident: Adam J. Bottrill
Date: 31JUL09 Region: Providence
Article title: Bleeding Tendancy: A Practical Approach in Dentistry
Author(s): Garfunkel, Adi A DMD et al
Journal: Compendium
Volume #: 20 No. 9
Page #s: pp: 836-852
Year: 1999
Major topic: Bleeding disorders
Minor topic(s): Coagulation pathways
Type of Article: Topic review and summary
Main Purpose: Discussion of bleeding disorders and dental considerations
Overview of method of research: Topical summary
Findings: N/A
Key points in the article discussion: Normally, bleeding is not considered a major problem when treating patients with normal hemostatic systems. Use of anesthetic agents assists the process. Occasionally, pt’s will experience exaggerated bleeding because of a congenital or acquired hemostatic anomaly.

A. Hemostatic System:
1. Platelet aggregation (primary hemostasis)
a. hemostatic plug
b. vasoconstriction

2. Coagulation cascade (secondary hemostasis)
a. fibrin clot formation

3. Fibrinolysis
b. Note: human saliva contains plasminogen activator inhibitor. Possibly to control bleeding in the oral cavity.

B. Congenital hemorrhagic disorders:
1. hemophilia A (VIII), B (IX) are Dx at birth and not a surprise to the dentist after thorough med Hx.
2. factor XI def, VII def, von Willebrand disease may remain undetected until later in life.

C. Drugs:
1. Platelet aggregation inhibitors
a. aspirin: COX inhibitor, lasts the lifetime of the platelet increases bleeding time
b. NSAIDs: competitive COX inhibitors slightly increased bleeding time
c. ticlopidine: used in stroke patients
d. consider discontinuing NSAID’s and Aspirin at least 5 days prior to surgery and then renewing immediately after. Be especially careful with even moderate alcohol consumption
2. Antivitamin K agents
a. coumarins, dicoumarol, warfarin
b. pts with prosth heart valves or Hx of DVT or PE
b. interfere with factors II, VII, IX and X.
c. monitored by prothrombin time (PT)
d. when within normal INR (2.0-3.5) no need to stop before dental Tx.
3. Heparin etc.
a. tx of DVT or postsurgical thromboembolus prevention
b. LMW hep preserves antithrombotic effects but not anticoagulant effects. Associated with less bleeding.

D. Liver Disease:
1. Impaired production of fibrinogen, prothrombin, II, V, VII, IX, X and XI. Also, thrombocytopenia can result from portal hypertension-related splenomegaly.
2. Cirrhosis can cause increased fibrinolysis as a result of impaired clearance of plasminogen activator.

E. Dental Approach: We should be familiar with the more common blood coagulation tests.
1. Platelet count: Normal is 150-400. Less is thrombocytopenia, more is thrombocytosis. Both of these conditions are associated with increased bleeding tendancy.
2. Bleeding time: Normal is 2.5-8 minutes. Not significant indicator of post-surgical bleeding tendancy.
3. Activated partial thromboplastin time (aPTT): Normal is 25-36 seconds. Measures intrinsic and common coagulation pathways. Indicate deficiency in any of the following XII, kininogen, prekallikrein, XI (not of concern); VIII and IX (of concern).
4. Prothrombin time (PT): Normal is 11-14 seconds. Measures extrinsic and common pathway. Hi PT AND aPTT suggests deficiency in II, V or X (of concern). Hi PT with normal aPTT suggests deficiency in VII (of concern).
5. International normalized ratio (INR): Normal is 1.0-1.3. gives a standardized ratio so different labs can give similar results.

F. Applicable MHx concerns
1. Gingival bleeding with no apparent etiology
2. Petechiae and ecchymoses
3. Nasopharyngeal bleeding.
4. Cutaneous bleeding
5. Hx of post-extraction bleeding.
6. Hx of hematuria, rectal bleeding.
7. Hx of joint hematomas.
8. Prolonged bleeding in any surgical situation.
9. Previous blood transfusion.

G. Treatment: We face 3 types of pt; known, suspected, dx following tx. Adequate Hx , consultations and local measures differ depending on which one.
1. Local measures
a. pressure, sutures, gelfoam, cellulose, topical thrombin, microfibrillar collagen, fibrin glue, cyanoacrylate, thermal methods (cautery, laser, cryo), antifibrinolytic agents, epinephrine, intraligamentary anesthesia, systemic replacement of components, platelet transfusion, FFP, cryoprecipitate, factor VIII concentrate
2. Systemic use of pharmacological agents
a. antifibrinolytic agents, vasopressin,

Summary of conclusions: Dental treatment for pts with a bleeding tendancy/disorder requires a multidisciplinary approach. The article described multiple disorders and conditions along with their associated dental considerations and possible treatments.

Assessment of article: Though this article was very thorough, it was unorganized and jumbled.