Dental implications for the management in patients with systemic disease - 1

Question 1

What’s the process of haemostasis?

Answer 1

•Injury and tissue damage
•Vascular response
•Platelet adhesion and aggregation
•Unstable platelet clot
•Coagulation factor cascade
•Fibrin (nat. anti-coag. controlled by
fibrinolysis)
•STABLE CLOT

• Vascular response —Vasoconstriction
• Platelet response :- VWF (Von Willebrand factor) +
platelet + fibrinogen ~ unstable platelet clot
• Fibrin (clotting cascade) gives stability to clot

Question 3

What are the different types of coagulation defects?

Answer 3

Genetic:
• Haemophilia A,B,C, Von Willebrands
Acquired:
• Drugs: Warfarin, Heparin, Enoxaparin, Rivaroxaban,
Dabigatran, antiplatelet drugs
• Liver disease
• Vitamin K deficiency
• DIC (disseminated intravascular coag.)
• Massive blood transfusion

Question 4

What is haemophilia A?

Answer 4

• Factor VIII deficient
Mild 5-40%
Moderate 2-5 %
Severe 0-1%
• Dental extractions and surgery are dangerous for
haemophiliacs

Question 5

What is haemophilia B?

Answer 5

• Factor IX deficient
• Very similar to Haemophilia A but factor IX given instead of
factor VIII
• Factor IX has a longer half life so can be given daily

Question 6

What is haemophilia C?

Answer 6

• Factor XI deficient
• Rapid fibrinolysis
• FFP, Factor XI plus tranexamic acid

Question 7

What is vonWillebrands disease?

Answer 7

types 1(mild), 2, 3 (most symptomatic) & Pseudo VWD (platelet
type)
• Similar to mild Haemophilia A
• Factor VIII infusion for more major procedures
DDAVP (Desmopressin) and oral tranexamic acid suitable for
more minor procedures

Question 9

What is warfarin?

Answer 9

• Requires Active and regular monitoring via INR
• Warfarin usually takes 2-4 days to become effective
• Warfarin impairs synthesis of Vit. K dependent coagulant
factors (II,VII,IX,X) in the liver

Question 10

How can you get acquired coagulation defects?

Answer 10

• Indications:- oral anticoagulation (short term)
• Prophylaxis to prevent DVT
• Myocardial infarction (3 months)
• Established DVT (3 months)
• Xenograft cardiac valves ( 3 Months)
• Pulmonary embolism (3-6 months)
• C.A.B.G. (2 months)

•Oral anticoagulation (long term)
•Recurrent venous thromboembolism
•Rheumatic heart disease and atrial
fibrillation
•Cardiac prosthetic valve replacement and
arterial grafts

Potentiation of Warfarin: • Decreased synthesis of Vit.K dependent clotting factors
• Anti-platelet drugs
• Potentiating factors :- Antibiotics
-Miconazole oral gel
-Aspirin and NSAID’s

Question 11

What are the different INR’s for the different acquired coagulation defects?

Answer 11

• INR = Prothombin time (test)/PT (control)
• Normal 1
• DVT, PE, AF 2.5
• Recurrent DVT 3.5
• Recurrent PE 3.5
• Mechanical heart valves 3.5
• INR needs to be checked on the day of or no longer than 24-36 hrs prior to procedure (NPSA guidelines)
• Local measures need to be effective in regard to suturing and packing of wound with haemostatic agents
• Keep any procedure as “atraumatic” to the local tissues as possible

Question 12

Some drug interactions?

Answer 12

• *Amoxicillin:**
• Anecdotal reports advise vigilance
• Single 3 gram dose not seen as a problem
• *Metronidazole:**
• Should be avoided / (warfarin reduced by half)
• *Erythromycin:**
• Unpredictable affects only certain patients
• *NSAID’s:**
• Caution advised due to increased bleeding & GI bleeds
• *Daktarin Oral gel:**
• Well described interaction
• INR of 20 reported resulting in death

Question 13

How can the INR be altered before surgery (but not for routine dental procedures)?

Answer 13

INR can be altered if surgery planned by:
• Stopping 48 hrs prior to procedure
• Reducing warfarin by 50% for 48 hrs.
• “Patient may be compromised by reducing warfarin”
• INR may be altered/raised by administration of antibiotic course,
antifungals

Question 14

What are the new anticoagulants?

Answer 14

• Dabigatran etexilate (Pradaxa):
Direct thrombin inhibitor
• Apixaban (Eliquis):
Inhibitor of activated factor X
• Rivaroxaban (Xarelto):
Inhibitor of activated factor X

Question 15

What are some antiplatelet medications?

Answer 15

• Low-dose aspirin (75-300mg daily)
• Clopidogrel
• Ticlopidine

• Dipyridamole

Question 16

What do aspirin, clopidogrel & ticlopidine do?

Answer 16

• Inhibit platelet aggregation to blood vessel walls.
• Last for the life of the platelets (7-10 days)

Question 17

What does dipyridamole do?

Answer 17

• The effect is reversible acts directly on enzyme in platelets and vessel cell walls.

Question 18

What are some non-steroidal antiinflammatory drugs?

Answer 18

•Ibuprofen / Diclofenac:
-Reversible effect once the drug is cleared
-Platelet function is restored.
•NSAID’s:
-Are not used clinically for their antiplatelet
activity

Question 19

What should you be careful of with all the coagulation disorders?

Answer 19

• Regional blocks or injections in floor of mouth may cause
haemorrhage to track through tissue planes causing potential
airway obstruction
• Factor VIII supplements must be given if there is any
likelihood of oral trauma. Immediately prior to procedure(^
50-75%)
• Avoid intramuscular injections

Question 20

What is the normal bleeding time?

Answer 20

2-10 mins. Longer in women than in men.

Question 21

What are some coagulation defects?

Answer 21

• Liver disease (leads to loss of the clotting factors produced by the liver)
• Hepatocellular failure (leads to loss of the clotting factors produced by the liver)
• Vit. K deficincy
• Increased fibrinolysis
• Thrombocytopenia

Question 22

What is the clotting cascade?

Answer 22

Question 23

What is thrombocytopenia?

Answer 23

Lower than average platelet count. Normal platelet count is 150,000-400,000 platelets per microlitre of blood.

If platelet count below 100,000 some patients may experience symptoms such as bleeding often nosebleeds, and/or bleeding gums. Some women may have heavier or longer periods or breakthrough bleeding. Bruising, particularly purpura in the forearms, the difference is the bruises are caused from the inside. Petechia (pinpoint hemorrhages on skin and mucous membranes), which can be seen on feet and legs. Post op bleeding.

Question 25

How do you manage thrombocytopenia?

Answer 25

• Autoimmune treat with steroids or splenectomy
• Leukaemia, aplastic anaemia, treat with platelet transfusion
• Important to get a full blood count prior to any invasive
procedure
• Use local measures

Question 26

How can endocarditis be prevented?

Answer 26

• Not solely prophylactic but also requires adequate treatment of infection of bacteraemia and fungaemia
• Prompt removal of colonised devices / teeth
• Management of chronic conditions that can lead to repeated infection

Question 27

What’s the endocarditis prophylaxis for
dental procedures?

Answer 27

• Good optimised oral hygeine
• Access to high-quality dental care
• Referral for dental assessment
• Treatment ideally at least 14 days before surgery to allow mucosal healing
• Emergency valve surgery
• Remedial treatment with definitive procedures 3 months post surgery

Question 28

What antibiotic prophylaxis can be given to prevent endocarditis?

Answer 28

• Corsodyl mouthwash (chlorhexidine 0.2%) 10ml rinse at least 2 mins approx 2 mins pre-op

-Amoxyxillin 3g orally one hour pre-op
or
1gm IV 15 mins pre-op

-If alergic to amoxyxillin give clindamycin

Question 29

What are the dental aspects of diabetes mellitus?

Answer 29

• Periodontal disease
• Candidosis
• Lichenoid reaction with oral hypoglycaemics
• Sialosis +/- Xerostomia
• Hypoglycaemia

Question 30

What to do if patient becomes hypoglycaemic?

Answer 30

Conscious patient:
• 10g sugar ( 2 heaped teaspoons) as sweetened
drink
• Hypostop gel
Unconscious patient:
• Hypostop gel
• 50ml 20-50% dextrose IV
• 1mg Glucagon IM/SC

Question 31

What is primary hypothyroidism?

Answer 31

Question 32

What is secondary hypothyroidism?

Answer 32

Question 33

What is tertiary hypothyroidism?

Answer 33

Question 34

What should you do if your patient has hypothyroidism?

Answer 34

• Avoid sedatives and opoid analgesics (codeine) & GA as may ppt. myxoedema, coma
• Be aware of the risk of anaemia and ischaemic heart disease
• Be aware that other autoimmune diseases may be present (Sjogren’s)

Question 35

What should you be aware of if your patient has hyperthyroidism?

Answer 35

• Risk of adrenaline containing LA (theoretical)
• Sympathetic overactivity may lead to faint
• Benzodiazepines may potentiate antithyroid drugs
• Carbimazole may cause agranulocytosis