Check Bleeding Disorder Information/Warning Card – patient name, type of disorder, severity, contact numer to Haematology/Haemophilia/Haemostasis/Thrombosis Centre

Stay in touch with the local Haematology Team

Be aware of the effect of new oral anticoagulants (SDCEP guidelines, Sept 2015)

Novel oral anticoagulants can be prescribed for the patients who have: artificial heart valve/prosthetic heart valve, previous deep vein thrombosis, pulmonary embolism, stroke, coronary heart disease, peripheral vascular disease

If single antiplatelet drug: aspirin or clopidogrel – carry on as usually with medications, local measures: pack and sutures

If dual antiplatelet therapy – drop one of them, either aspirin or clopidogrel 7 days before, local measures

If combined antocoagulant therapy of 3 differents meds (eg. Warfarin, aspirin, clopidogrel): ask advice from specialist haematologist

If patient on new oral anticoagulants and anticipated more challenging extraction – ask advice and told the patient to omit one dose the morning time before procedurę, ideally early morning appt., then xla and normal dose at evening time.

 

Tranexamic acid 5% or epsilon aminocapronic acid as topical haemostatic measures in the form of mouthwashes. Usually, prepared by hospital pharmacy. Currently, getting ‘less popular and ‘not recommended in primary care setting

Consider to use 5% tranexamic acid mouthwashes used four times a day for two days (not readily available in most primary care dental practices, off licence)

So called liquid bandage (adhesive oral agent based on cyanoarylates) can be very useful as a topical haemostatic agent following difficult extraction

Pre-operative medication prior to treatment for patients with inherited bleeding disorders: transexamic acid tablets, factor VIII infusion, desmopressin with transexamic acid intravenously.

Dental patients with haematological problems may demonstrate a higher incidence of localised osteitis/dry socket due to: loss of blood clot and acid pH of local haemostatic agent placment.

The most commonly prescribed and used anticoagulants are: aspirin, warfarin and clopidogrel.

Antibiotic clarithromycin (macrolide group) may interact with warfarin action

Degree ad severity of haemophilia does vary a lot. Some patient have to be treated in safe hospital setting, eg. in oral surgery department with a proper pot-operative monitoring

Patient with haemophilia may self administer Factor VIII (Refaco) 1 hour before invasive dental procedures

Different grades of Haemophilia A depending on factor VIII level (IU/ml): clotting factor levels from 0.05 iu/ml – 0.4 iu/ml are diagnosed as having mild haemophilia, 0.01 iu/ml – 0.05 iu/ml as moderate haemophilia and less than 0.01 iu/ml as severe haemophilia

The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4 (ie <4) is very small and the risk of thrombosis may be increased in patients in whom oral anticoagulants are temporarily discontinued. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental surgery including dental extractions.

INR can increase in patients taking a warfarin if their diet includes lots of green leafs: spinach, brocoli, rocket. Interaction betwen these vegts and warfarin action.

Often combined problems: patient on NOAC due to eg AF and also additional inherited problem. Eg. patient with Factor V leiden disease and on rivaroxaban . Secodn opinion from haematologist prior to invasive procedures, eg. anticipated difficult xla

The risk of bleeding in patients on oral anticoagulants undergoing dental surgery may be minimised by the use of oxidised cellulose (Surgicel) or collagen sponges and sutures.

Patients taking warfarin should not be prescribed non-selective NSAIDs and COX-2 inhibitors as analgesia following dental surgery.

Patient on NAOC eg. rivaroxaban – episodes of spontaneous, profound ‘mouth bleeding’ associated with periodontally involved teeth (ging trauma by mobile tooth)

Patient on NAOC eg. rivaroxaban – to skip a single morning dose prior to extractionn (SDCEP recommendation), get a second opinion from patient’s GP/specialist prior to procedure to make sure this is safe fot the patient.

Contact Haemophilia & Haemostasis/Thrombosis Centre for second advice for all severe and rare haematological conditions: haemophilia, factor VIII deficiency, etc.

Patient undergoing chemotherapy due to eg. leukemia, cancer treatment; problems: low platelet count, mucositis, gingivitis, solutions: to consult with haemathologist, to plan full dental treatment before any prolonged cycles of chemotherapy, to use antinflammatory spray (eg. difflam), to use artificial saliva spray/mouthwash, ultra soft toothbrush recommended and non-foaming toothpaste without sodium lauryl sulfate.

Be aware of rare haematological conditions: Factor V Leiden Thrombophilia, susceptiility to blood clotting, needs to take ACs.

HIV-positive immunologically stable patient may undergo invasive dental procedures (simple extractions) considering regular check for HIV-associated oral problems, CD4-cell count and viral load

Myelodysplasia – leukemia like symptoms, dental findings: swollen gingivae as higher risk of infection and bleeding (low level of platelets and white cells). OH, caries and plaque control, to advocate ChX rinse, mild clotting aids like Vit K can be viable option. Extractions are best avoided. If necessary: risk assessment re: may need additional haemostatic measures and/or AB prophylaxis pre-operatively. If patient is about to start bisphosphonates – consider xla’s of any teeth with poor long term prognosis now. If chemotherapy – to consult with haematologist.

If patient undergoing chemotherapy – mandatory to check blood test results. Options: to ask patient bring the most recent results, to request from patient’s GP or to request from Oncology Department (eg. via fax)

Main problem associated with chemotherapy: low platelet count and risk of excessive bleeding following extraction.

Severe cirrhosis related to chronic alcoholism often results in a decreased level of platelets and risk of post-op bleeding. Request the full blood count  prior to any invasive procedures.

Do not underestimate anaemia !, special attention in terminally ill patients with cancer : low haemoglobin, low haematocrit, low red blood cells level, increased RWD. Are there any guidelines helping dental practitioners to sefely manage a patient with anaemia? According to Fragiskos D. (Oral Surgery book): ‘… severe hemorrhage duee to a tooth extraction or any other surgical procedure in the oral cavity results in aggraviation of the anaemia , possibly endangering the patient’s life.” and “….preventative measures are necessary for patients  with a history anaemia and who need to have a tooh extracted: hematocrit and hemoglobin levels must be s near normal as possible and the consultation with the patient’s haematologist are often necessary…”

Is patient with anaemia prone to excessive bleeding and/or delayed wound healing after extraction? Some of the opinions from dentists (ResearchGate forum):

“Anemia results in the reduction in the oxygen carrying capacity of blood that may be caused by reduced hemoglobin content or reduced number of RBCs. Since red blood cells and hemoglobin have no particular role to play in bleeding, anemia, unless accompanied by a reduction in the number or dysfunction of platelets, should not add to the risk of post-surgical hemorrhage. Aplastic anemia may be associated with excessive bleeding since the production of all blood cells including platelets are affected”

” ….as anemia is reduction of oxygen capacity of blood throughout the tissue and organs, so the normal process of wound healing would affected that give chance to bleeding and infection. ….ling could be definitely affected since oxygenation will be below expected levels. ….to my knowledge, there are no reports that have examined the extent of such an effect” ……Any delay in healing could certainly increase the chance of infection, however, to my knowledge changes in the healing process and infection can not cause bleeding. Since both the immediate stopping of  bleeding by the temporary platelet plug and the irreversible clot formation with the help of clotting factors occur before inflammation cascade completes. Healing will only begin later..”

“…based on my personal experience , I did not find any relation between them….we have been hearing that there is limited level of hemoglobin in which a surgery should be performed or avoided. Was this consideration based on scientific evidence or mythology ?…

“… Anemia is a very common condition in India due to various nutritional, infectious and inflammatory conditions and often it can be very severe. I know that severe anemia with HB levels below 7g/dL is considered a contraindication for any surgical procedure and in emergencies patients receive blood transfusions. As to the reason, at low  Hb levels  anaesthesia and maintenance of oxygen saturation without causing increased cardiac stress becomes difficult…”

“…red blood cells in the blood flow, platelets tend to swim in the middle of the vessel, rather than closer to the vessel wall (where you´ll normally find the damage, and von Willebrand factor bound to phospholipids or collagen). A hematokrit over 30% is improving this situation, as red blood cells seem to sort of push platelets to the vessel wall. So, to a smaller but sometimes significant extent, anemia might contribute to bleeding…”

“…My understanding has been that the initial aggregation of platelets is caused by the transient vasoconstriction after injury and amplified or enhanced by the release of factors after that. arbitrary as it may be, a hematocrit of 30% translates roughly to 10g/dL of Hb or mild anemia. So far have not come across any cases with increased bleeding time at that level or even with hemoglobin as low as 7g/dL. At what Hb level have you found the increased risk of bleeding?…”

Excellent SDCEP Scottish guidelines: “Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs”

 

Chronic alcohol dependence and severe liver disease

Severe pain associated with grossly decayed molar teeth which require extraction. Patient hospitalized due to severe liver dysfunction.  Thrombocytopenia, < 30k /ml. Patient already on antibiotic for 48 hours (C0-amoxiclav). No clear second opion from hospital haematologist and decision about extraction down to dentist discretion. Platelets and blood transfusion already started. Wait for new blood test results.

Comment: interestingly, according to the study carried out by Group 7 Oral Medicine (Workshop, Gothenburg, 28 Sept, 2018) even if platelet count is < 50k /ml , for the less invasive procedures, low risk of bleeding, minor complications, there is no need to provide a transfusion i! the local measures are sufficient!.

Terminal liver cancer

Periodontally involved maxillary molar, exteremelly mobile, which requires extraction. Patient c/o: constant discomfort and eating difficulties. Severe liver dysfunction due to malignant tumor.  Current platelets level about 120k /ml, second opion from GP – no contraindications to go ahead with xla. Local measures: Haemocolagene, cross matress suture, POI.