Quality Resource Guide –

Dental Care for Patients with Bleeding Disorders 2nd Edition

www.metdental.com

Page 3

Any patient presenting with an equivocal history

or clinical signs and symptoms suggestive of

undiagnosed, or poorly controlled, bleeding disorder

requires further medical evaluation to establish a

diagnosis.

While an experienced dental practitioner

may choose to order basic laboratory testing

(Table 2) to assess bleeding risk status (e.g.

activated partial thromboplastin time (aPTT),

prothrombin time (PT), thrombin time (TT), platelet

count), most dentists will refer the patient to their

physician for further evaluation and diagnosis. Once

the specific hematologic impairment is identified, it

must be documented in the patient’s chart.

In spite of obtaining a noncontributory medical

history and noting no abnormalities on clinical

examination, direct observation of excessive

bleeding during or after a dental procedure may

represent the first and only clue for the presence

of a patient’s underlying hematologic impairment.

Suggested Management

Guidelines

stablishment of a diagnosis allows the

dentist to develop a plan tailored to address

the dental needs of the individual patient.

Such a plan must not only consider the extent of

surgical therapy needed, but also the patient’s overall

medical status and the clinical experience of the

dentist.

1,3-5

For infrequently encountered scenarios

such as an inherited disorder, a medical consultation

is warranted to determine the patient’s current status

and his/her ability to tolerate the anticipated dental

care in either a general practice or specialist setting.

The dentist should clearly describe in the consult

the anticipated bleeding associated with necessary

dental care (“restore tooth #2 with no anticipated

mucosal incisions or tearing – no, or minimal,

bleeding anticipated”, “simple extraction of two (2)

teeth with primary soft tissue closure following the

procedure – moderate, locally controllable bleeding

anticipated”). In general, a patient determined to

have extensive surgical needs, labile hemostatic

profiles, or the need for treatment modifications not

routinely available in the dental office setting warrant

referral to a practitioner with expertise in managing

such cases (Oral and Maxillofacial Surgeon, Hospital

Dentist or Oral Medicine clinician).

General therapeutic principles recommended when

treating any patient with a hematologic impairment

include:

1. judiciously administering local anesthesia;

2. employing meticulous surgical technique;

3. removing granulation tissue that could mediate

continued bleeding;

4. accomplishing primary soft tissue closure when

possible;

5. using

adjunctive

hemostatic

agents

when

appropriate (see Table 3), and;

6. follow-up contact to ensure no complications.

Postoperative instructions should be clearly

explained and given in written form to the patient

and/or their caregiver to ensure that activities

that may increase the risk of clot disruption

(sucking through a straw, sucking candy, smoking,

rinsing, strenuous activity) are avoided. The use

of any medication that may adversely affect the

underlying hematologic condition, such as aspirin

and NSAIDs, is to be avoided.

1,5,6

Patients with a

hematologic impairment should be scheduled early

in the day, and early in the week, since immediate

complications occur within hours following a

procedure and delayed complications usually occur

within a couple days following a procedure. The

dental practitioner should never adjust the dosage

of any medically prescribed medication (aspirin,

NSAID, warfarin, etc.) intended to affect the

patient’s hemostatic profile. Such adjustments are

under the purview of the managing physician.

Table 2 - Common Laboratory Tests to Assess Hemostasis

Test

Purpose

Normal Range

aPTT

Evaluate instrinsic and common pathways of coagulation

25-30 seconds

Evaluate extrinsic and common pathways of coagulation

11-15 seconds

Evaluate the level and function of fibrinogen

9-13 seconds

Platelet count

Measure of number of platelets

140,000-400,000/uL

Table 3 - Adjunctive Hemostatic Agents

Agent

Purpose

Gauze

For direct pressure.

Absorbable gelatin sponge

(Gelfoam

)

Serves as a scaffolding to help stabilize clot. Recommend

stabilization with suture or splint.

Chitosan

(HemCon

Dental Dressing)

Provides a physical barrier to protect wound bed, dissolves

in 48 hours.

Absorbable collagen (Instat

)

Can be cut or shaped, similar benefit as gelatin sponge.

Microfibrillar collagen hemostat

(Avitene™ Flour, Avitene™ Ultrafoam™)

Attracts platelets and triggers aggregation to promote

platelet plug formation.

Absorbable collagen dressing

(CollaTape

, CollaPlug

CollaCote

)

Sutured over the wound or placed under stent.

Resorbable oxidized cellulose

(Surgicel

, others)

Swells on contact with blood to increase pressure in socket

to enhance hemostasis.

Topical thrombin (Thrombostat™,

Thrombin-JMI

, others)

Topical thrombin should not be used with collagen and

cellulose products due to inactivation from pH alterations.

ε-Aminocaproic acid (Amicar

)

A rinse that inhibits plasminogen activation.

Tranexamic acid (Cyklokapron

)

A rinse that inhibits plasminogen activation.