Bleeding Disorders of Importance in Dental Care and Related Patient Management

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center -Providence

Article title: Bleeding Disorders of Importance in Dental Care and Related Patient Management

Author(s): Gupta et al.

Journal: JCDA

Year. Volume (number). Page #’s: 2007. 73(1). 77-83a.

Major topic: Bleeding Disorders

Purpose:
Review common bleeding disorders and their effects on the delivery of oral health care.

Background:
Clinically significant bleeding episode:
-continues beyond 12 hours
-causes the patient to either call or return to the dental practitioner or seek medical/emergency care
-results in the development of a hematoma or ecchymosis
-requires blood support
A detailed medical, familial and drug history should be obtained. When a bleeding disorder is suspected, the physician should be consulted and labs should be taken including blood counts and clotting studies.
-bleeding time: norm 2-7min
-partial thromboplastin time (PTT): tests intrinsic coag pathway. Norm range 25 +/- 10 sec
-international normalized ratio (INR): to test extrinsic pathway. Norm 1.0
-platelet count: norm range 150,000-450,000/µL

Types of Bleeding Disorders:

I. Coagulation factor deficiencies:
A. Congenital
1. Hemophilia A- deficiency of clotting factor VIII. Inherited X-linked recessive trait found in males. Depending on the level of factor VIII available, different severities of hemophilia ranging from mild to severe are seen. Management may include increasing/replacing factor VIII or inhibiting fibrinolysis.
2. Hemophilia B- factor IX deficiency managed with replacement therapy with inactivated factor IX or prothrombin complex.
3. von Willebrand’s disease- most common hereditary coagulation disorder. Classified into type I or type IV and vary in severity. Desmopressin (DDAVP) or factor VIII replacements are used to treat this condition.
4. other rare deficiencies- renal failure and uremia, hepatic failure and bone marrow failure can all result in coagulation defects
B. Acquired
1. Liver disease
2. Vitamin K deficiency, warfarin use
3. Disseminated intravascular coagulation

II. Platelet disorders:
A. Thrombocytopenia: minimum platelet level 50,000/µL before dental surgical procedures. If below this level, replacement therapy can be carried out 30 minutes prior to treatment.
1. immune-mediated- idiopathic, drug-induced, collagen vascular disease, sarcoidosis
2. non-immune mediated- disseminated intravascular coagulation, microangiopathic hemolytic anemia, leukemia, and myelofibrosis
B. Qualitative disorders
1. congenital- Glanzmann thrombasthenia (defect in aggregation, requiring platelet infusion before surgery) and von Willebrand’s disease
2. acquired- drug induced, liver disease and alcoholism

III. Vascular disorders: rare and usually associated with bleeding confined within skin or mucosa. Treated with laser ablation, embolization or coagulation.
A. Scurvy
B. Purpura
C. Hereditary hemorrhagic telangiectasia
D. Cushing syndrome
E. Ehlers-Danlos syndrome

IV. Fibrinolytic defects: may occur in patients on medical therapy and those with coagulation syndromes where fibrin is consumed.
A. Streptokinase therapy
B. Disseminated intravascular coagulation

Systemic Management of bleeding disorders:
Principal agents include platelets, fresh frozen plasma, cryoprecipitate, factor VIII concentrate, factor IX concentrate, desmopressin, Epsilon-aminocaproic acid and tranexamic acid. (See chart for full details).

Oral Findings:
Platelet deficiencies can cause petechiae or ecchymosis, spontaneous gingival bleeding and brown deposits on surfaces of the teeth due to chronic bleeding. This may be in addition to gingival hyperplasia as in cases of leukemia. Hemarthrosis of the TMJ is uncommon.
Because of the lack of oral hygiene and regular professional dental care out of fear of bleeding complications, caries and periodontal diseases tend to be more prevalent in patients with bleeding disorders.

Dental Management:

Dental Management depends largely on the severity of the condition as well as the invasiveness of the procedure. The patient’s physician should be contacted before any invasive treatment is performed.

Nerve block injections are contraindicated unless no alternative and proper prophylaxis has been provided. Because the anesthetic is placed in a highly vascularized region, hematoma formation is possible which can lead to swelling, pain, dysphasia, respiratory obstruction and even death. Anesthetic with vasoconstrictor should be used as should other forms of sedation such as diazepam, N2O or even GA when applicable.

When oral surgery procedures are to be performed, factors should be between 50% to 100% of normal levels and in patients with hemophilia, additional postoperative factor maintenance may be needed. Local hemostatic agents, pressure, surgical packs or stents and sutures may also be needed to aid in hemostasis. Caution should be used with vasoconstrictors due to the risk of rebound vasodilation.

Drugs affecting bleeding mechanisms such as ASA and NSAIDS do not usually pose a problem before surgery, but if ASA is to be withdrawn it should be done at least 10 days prior to surgery. Of course the patient’s physician should be consulted and the risk-benefit ratio should be discussed. A patient taking warfarin can be safely treated with an INR reading of <3.0, but should be referred to a physician if it is higher than that. Penicillins, erythromycin, metronidazole, tetracyclines and miconazole may also have potentiating effects on warfarin.

It is very important for patients with bleeding problems to maintain periodontal health as hyperemic soft tissues are at a greater risk of bleeding. Periodontal issues also warrant extractions which can lead to complications. Perio probing, supragingival scaling and polishing can be performed with no risk of significant bleeding while deep scaling and root planning may require replacement therapy. When tissue is severely inflamed, chlorhexadine rinse and gross debridement are indicated to reduce inflammation prior to scaling and root planning. Perio dressings and stents may be needed to aid in hemostasis.

General restorative, prosthodontic and orthodontic treatments do not pose risk for significant bleeding, however, care should be taken not to lacerate or injure soft tissue. A rubber dam is preferred to protect soft tissue, but clamps and suctions should be used carefully. Endodontic procedures are preferred over extractions.

Assessment of Article:
This was a nice article FULL of information. Although the review of bleeding disorders was a bit detailed and over my head, the dental management section was interesting and full of applicable information I was previously unaware of. Good review for boards I’m sure.