Bleeding & clotting disorders

BLEEDING AND CLOTTING DISORDERSLec.3

Dental management required for patients with bleeding disorders depends on both the type and severity of the dental procedure and the type and severity of the bleeding disorder.

Dental management required for patients with bleeding disorders

Careful history
• Description of bleeding, epistaxis, hematoma formation
associated with trauma, dental procedure or surgery
• liver Ds
• Family history of bleeding
Assessment of the coagulopathy and delivery of appropriate therapy prior to dental procedures is best accomplished in consultation with a hematologist.

Evaluation of Bleeding disorders

When medical management is unable to restore platelet counts to above the level of 50,000/mm3, platelet transfusions may be required prior to dental extractions or other oral surgical procedures.

Platelet Disorders

Chemotherapy-associated oral hemorrhage, most frequently related to thrombocytopenia, are best managed by transfusions of platelet.

transfusion recommendations generally aim for replacement of missing coagulation factors to levels of 50 to 100% This provides greater assurance of hemorrhage control.
Hemophilias A and B and von willebrand’s disease

Surgical treatment, including a simple dental extraction, must be planned to minimize the risk of bleeding, excessive bruising, or hematoma formation.

If multiple extractions are required, only one or two teeth should be extracted at the first appointment to ensure that hemostasis can be achieved.
Surgery

Consider whether to use antibiotics following a dental extraction. This is controversial, but there are a number of reports suggesting that their use may prevent a late bleed, which is thought to be due to infection. However, if a patient has an infection before dental treatment, it should be treated with antibiotics.

Have the patient rinse with chlorhexidine mouthwash for 2 minutes before the administration of the local anesthetic.

Suture the socket if the gingival margins do not oppose well.

Resorbable and non-resorbable sutures may be used .The only problem with non-resorbable sutures is the need for a post-operative visit and the possibility of bleeding when the suture is removed.

Use local hemostatic measures if indicated, These include

pressure
suture
hemostatic irrigant
absorbable gelatin sponge containing a thrombin solution
gauze-soaked and/or mouth rinses with fibrin or tranexamic acid (TXA)
Bone wax


The patient must be given detailed postoperative instructions:
• No mouth rinsing for 24 hours
• No smoking for 24 hours
• Soft diet for 24 hours
• Prescribed medication must be taken as instructed
• Analgesia should be prescribed for use if required


• Salt-water mouthwashes (1 teaspoon of salt in a glass of warm water) should be used four times a day, starting the day after the extraction for 7 days
• Antibacterial mouthwash may be used
• Emergency contact details must be given to the patient in case of problem.

Dental pain can usually be controlled with a minor analgesic such as paracetamol . Aspirin should not be used due to its inhibitory affect on platelet aggregation. The use of any non-steroidal anti-inflammatory drug (NSAID) must be discussed beforehand with the patient's hematologist because of their effect on platelet aggregation.
Anesthesia and pain management

There are no restrictions regarding the type of local anesthetic agent used although those with vasoconstrictors may provide additional local hemostasis. A buccal infiltration can be used without any factor replacement. It will anesthetize all the upper teeth and lower anterior and premolar teeth.

The mandibular molar teeth are usually treated using the inferior alveolar nerve block. This should only be given after raising clotting factor levels by appropriate replacement therapy, as there is a risk of bleeding and formation of hematoma in the retromolar or pterygoid space. The intraligamental technique should be considered instead of the mandibular block.

A lingual infiltration also requires appropriate factor replacement since the injection is into an area with a rich plexus of blood vessels and the needle is not adjacent to bone. There is a risk of a significant airway obstruction in the event a bleeding.