Quality Resource Guide

Dental Care for Patients with Bleeding Disorders 3rd Edition

www.metdental.com

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

independently 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.

The most likely bleeding-risk scenario the

general dentist will encounter is the patient being

medically managed to reduce thromboembolic

risk.

Contemporary

guidance

generally

recommends against the routine interruption or

reduction of antithrombotic medication when such

a patient requires a minor surgical procedure

in the dental setting. The preponderance of

evidence

reveals that properly prescribed

antithrombotic medication results in manageable

bleeding risk following “minor dental surgery”,

while reduction of antithrombotic medication

leads to an increased risk for a potentially fatal

thromboembolic event.

3,4,6-8

While the definition of

a “minor surgical procedure” is debatable, it may

be defined as the simple extraction of ≤3 teeth;

crown and bridge procedures; and scaling or

periodontal surgery initially restricted to a limited

area to allow assessment of bleeding.

6,9-10

The Patient on Antiplatelet

Medication (Asprin, or Asprin &

Clopidogrel)

Low dose aspirin (81-325 mg/day) is commonly

prescribed for a patient as a first line agent to

reduce risk of stroke or heart attack. Aspirin

acts to irreversibly reduce platelet activation

aggregation. Another anitplatelet drug such as

clopidogrel (Plavix®) is added to the regimen

to further reduce platelet activity.

Available

research indicates the increased bleeding risk

associated with a limited surgical intervention in

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)

Promotes clot formation (topical thrombin should not

be used with collagen and cellulose products due to

inactivation from pH factors).

ε-Aminocaproic acid (Amicar

)

A rinse that inhibits plasminogen activation.

Tranexamic acid (Cyklokapron

)

A rinse that inhibits plasminogen activation.

Table 2 - Common Laboratory Tests to Assess Hemostasis

Test

Purpose

Normal Range

aPTT

Evaluate intrinsic 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