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.

Hemophilia A

Department of Pediatric Dentistry

Lutheran Medical Center

Date: 07/24/2009

Article title: Hemophilia A

Author(s): Leon W. Hoyer M.D.

Journal: New England Journal of Medicine

Volume (number): Vol 330 No 1

Month, Year: 1994

Major topic: Hemophilia

Minor topics:

Type of Article: Review of Literature

Main Purpose: Review of Everything Hemophilia A

Overview of method of research: Review of Literature

Findings:

Hemophilia has a history of being a very destructive disease, but modern therapies have significantly improved the quality of life and the lifespan of those affected. Basically, it is the absence of clotting factor VIII or having a plasma concentrate of less than .04ug per milliliter plasma. Treatment is much more than the simple prescription of factor VII concentrates. A dental examination with plans for appropriate care is recommended as an essential part of any hemophilia patient's treatment.

Key points/Summary :

• Incidence approaches 20 per 100,000 male births.
• Although and X-linked disorder, it is supposed that up to 1/3 of cases come from random deletions and are not inherited.
• The gene that codes for factor VIII is at the tip of the long arm of the X chromosome, which can be missing or mutated.
• Factor VIII circulates in a non-covalent bond with von WIllenbrand factor, which enhances synthesis of the factor.
• Factor VIII is essential for rapid cleavage of factor X--if you want more clotting science, read it.
• Clinically, it is essential to distinguish between severe presentations and mild or moderate, the later perhaps never having a bleeding episode outside of surgery or severe trauma.
• Diagnosis of hemophilia should be suspected anytime there is abnormal bleeding in male patients. The diagnosis is determined by laboratory testing (which you can read about in the article)
• The clinical hallmarks are joint and muscle hemorrhages, easy bruising and prolonged and potentially fatal hemorrhage post surgery or trauma; but no excessive bleeding after minor cuts and abrasions.
• Hemarthroses are usually first noted when a child is learning to walk, which quickly leads to limitation of motion and mild discomfort. Within hours, it becomes severe pain, joint swelling and cutaneous warmth.
• Untreated the disease process leads to hemophilic arthropathy and can lead to permanent disability.
• Bleeding can happen in other locations also including intramuscular hematomas and closed space bleeding can lead to nerve paralysis and or airway constriction.
• In the past, 25% of deaths were attributed to intracranial bleeds. AIDS would take over this high percentage of deaths during the years of tainted transfusion.
• Factor VIII plasma replacement can be achieved using human donated plasma or synthetically derived alternatives.
• Patients with some factor VIII production can benefit from Desmopressin.
• Today--1994 that is--parents can use genetic testing and amniocentesis to determine the likelihood of transmission from mother to son.
• Care is constantly improving and the article suggested that perhaps stem-cell therapy could ultimately be a cure for the disease.

Assessment of article: A great review. This article was too in-depth for our uses and it would be nice to see an update to this (which I'm sure could be researched) and see where treatment is today. This is an interesting and significant disease. If you can get through the hard science without burning out there is a lot of good relevant information.