Bleeding Disorders: Characterization, Dental Considerations and Management

Meghan Sullivan Walsh March 1, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Bleeding Disorders: Characterization, Dental Considerations and Management

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Bleeding Disorders: Characterization, Dental Considerations and Management

Authors: Sara Israles, MD, FRCPC; Nora Schwetz, RN, BSc; Ron Boyar, RM, DMD, MSc; Archie McNicol, BSc, PhD

Journal: JCDA

Volume (number), Year, Page #’s; 72:9, 2006, pages 827-827L

Major Topic: Current knowledge of bleeding abnormalities, dental precautions and hemostatic measures.

Overview of Method of Research: Current review of literature and author’s recommendations

Findings: Many dental procedures such as extractions and periodontal surgery are associated with post-operative bleeding. A small but significant percentage of the population suffer from an increased risk of bleeding. This risk of bleeding and impaired wound healing may be due to an inherited disorder or deficiency or even a defect secondary to medication or an underlying disease.

I

nherited Coagulation Disorders:

Von Willebrand Disease: Most common inherited bleeding disorder (1%). Easy bruising, epistaxis, menorhagia and bleeding. Divided into three types. Type 1 most common 80%, autosomal dominant. Type 1 and 2 will respond well to desmopressin acetate treatment with an onset of reaction at 30-60 minutes. Type 3 may need vWD replacement.

Hemophilia: Inherited x-chromosome-linked bleeding disorder caused by Factor VIII or Factor IX deficiency. Easy bruising, spontaneous muscle and joint hemorrhage and excessive bleeding. Treatment is IV replacement of VIII or IX pre and post operative.

Rare Coagulation Factor Deficiencies: Deficiencies of fibrinogen, prothrombin and Factor V, VII, X and XIII are only 1 in 0.5-1 million. Patients may require coagulation factor replacement prior to surgery.

Acquired Coagulation Abnormalities:

Patients on long term anticoagulation therapy such as Warfarin and Heparin are at an increased risk of bleeding with trauma and surgery.

Warfarin: A vitamin K antagonist. Monitored by INR. (Therapeutic range 2.0-3.0 for most patients)

Heparin: Accelerated inhibition of the serine proteases Factors IIa and Xa. Therapeutic half life is short (1 hour) and is maintained by IV bolus. Monitored by PTT.

Platelet Disorders: Broadly characterized as defects of number (Thrombocytopenia)

Thrombocytopenias: When blood platelet levels fall below normal. Characterized as mild, moderate or severe. Two categories: Inherited and acquired. Acquired is then divided into immune such as ITP or immune thrombocytopenic purpura and nonimmune which are secondary to drug toxicity. Chemo can also cause thrombocytopenias. Chemo patients should have platelets evaluated immediately before dental procedures.

Adhesion Defects: Bernard Soulier syndrome (BSS) is an autosomal recessive disorder caused by genetic defects. Characterized by giant platelets and thrombocytopenia. Symptoms include mucosal bleeding, easy bruising and surgical bleeding.

Aggregation Defects: Glazmann thrombasthenia (GT) is an autosomal recessive disorder caused by a defect in a protein. Signs occur early in life which include easy bruising, epistaxis and prolonged bleeding from minor injuries. Management includes platelet transfusion and the use of recombinant Factor VIIa.

Granule Defect: Gray platelet syndrome is an autosomal recessive condition characterized by large platelets and reduced alpha granules. Patients have mucotaneous bleeding and mild thrombocytopenia. Dense granule deficiency can be found in Hermansky-Pudlak and Chediak-Higashi syndrome. These syndromes are associated with pigment abnormality and albinism.

Drug induced Platelet Defects: Prescribed and OTC drugs can affects platelet number and function. Heparin induced Thrombocytopenia is the most common. Many drugs also affects platelet activity. Most common is aspirin which acetylates COX and creates an antithrombotic effect that can last for several days. On 827g is a list of common drugs which can have effects on platelets for review.

Management:

Most important decision for management on these patients in a consultation with their physician and or hematologist. The decision for treatment will depend on their specific diagnosis, severity of the bleeding disorder and type of dental procedure. Some patients many require lab testing, factor replacement, or prophylaxis.

Antifibrinolytic Agents: Aminocaproic Acid and tranexamic acid are useful agents in preventing clot lysis.

Patients Receiving Antithrombotic Therapy: Most patients do not need to discontinue their medication. The risk of serious bleeding is minimal and may not outweigh the risk of these patients having a thromboembolitic event.

Key Points: Summary:

Dental Management of these patients must include careful assessment of the severity of the disorder as well as the type, location and extent of the intervention. The risk of intervention depends on the surgical site and the possibility for hemostasis control. The more limited the site for access to hemostasis such as deep spatial or cavity (e.g sinus) surgery, the more important systemic factors may become. Surgical location is equally as important. In addition, injection of local anesthetic poses a risk. Suggestions for surgery include minimizing trauma, avoiding flaps, choosing sites capable of packing and closing, striving for primary closure and removing granulation tissue. Adjuncts to hemostasis may include Gelfoam, Bleed-X, Tisseel, Cyklokapron, Electrocautery, Suturing and Amicar. Preformed Surgical splints are recommended. The most effective treatment of hemostasis will continue to be applying pressure to the site. Patients should always be informed of the risks of the procedures and plans for intervention.

Assessment of the Article: Great article describing many bleeding disorders I’ve never heard of. Most of these issues do not apply to our population of patients however, some of the syndromes mentioned and hemophilia we may see. Management of these patients is important and should always come with a physician’s consult prior to surgery.