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HAEMATOLOGICAL DISEASE 303 > Dental Management of coagulopathies > Flashcards

Dental Management of coagulopathies Flashcards

1
Q

What to take into account when assessing the risk of bleeding?

A

Dental procedures required
Pt factors (systemic disease)
Meds

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2
Q

What precautions to consider for those at a higher risk of bleeding?

A

Limit to single extraction at a time
Subgingival scaling 3 teeth then assess before continuing
Stage treatment over separate visits
Local measures pack and suture

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3
Q

What to look out for in terms of bleeding risk?

A

Asymptomatic
Bruising >1cm spontaneous, minimal trauma
Purpura 3-10mm (purple red, non-blanching)
Petichae <3mm (pinpoint)
Bleeding gums (unrelated to poor oral hygiene)
Epistaxis
History of haematuria history
History of menorrhagia
History of peri-op bleeding surgery or dental treatment
Fatigue

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4
Q

Tests to see if bleeding is more likely?

A

Full blood count FBC (which includes platelet levels)
Clotting screen
INR

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5
Q

What drugs might increase the risk of bleeding?

A

Anti-platelet (single or combination therapy), aspirin, clopidogrel

Cytotoxic drugs associated with bone marrow suppression
leflunamide, hydrochloroquine, infliximab, adalimumab entaracept, penicillamine, gold, sulfasalazine

NSAID (impair platelet function)
ibuprofen, diclofenac, naproxen

SSRI anti-depressants
Citalopram

Immunosuppressants
methotrexate, azathioprine, mycophenolate

Drugs affecting nervous system
gabapentin may impair platelet function, carbamazepine may cause thrombocytopenia

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6
Q

Treatment options for pts at risk to bleeding?

A

Liaise with medical practitioner/consultant
Refer to secondary care if still unsure
Treat patient without stopping their medication
Limit treatment, treat in stages, delay or defer treatment
Use local measures (pack and suture)
Anticipate a longer bleeding time, plan accordingly
Don’t forget other drug interactions
eg NSAIDS and SSRIs

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7
Q

What procedures have a high risk of bleeding?

A 
Complex extractions
Adjacent teeth
Flap raising procedures
Biopsies
Gingival recontouring
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8
Q

How to ensure safe treatment planning?

A 
Prevent dental disease - regular attendance, encourage OH
Talk to pt - check med history
Ask their GP/consultant
Plan appointment times - morning so time to sort problems, early in week
Only proceed if access to emergency care
Defer care?
Careful technique
Assess bleeding as you go along
Clear written POI
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9
Q

What is meant by local measures?

A

Horizontal mattress sutures
Use haemostatic packing material e.g. collagen sponge
Warm, wet absorbent gauze to put pressure directly on site of extraction

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10
Q

What is tranexamic acid?

A

Anti-fibrinolytic agent = inhibits breakdown of fibrin clots = prevents fibrinolysis
Can be used in anti-coagulated pts as a haemostatic agent via mouthwash
500mg tablets or 5% m/w for short term use for those at risk of haemorrhage - acquired and inherited clotting disorders and those on anticoagulants

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11
Q

How is tranexamic acid used in dentistry?

A

Use qds, 5-10 mins post extraction
Rinse with 5mls of 5% soln and hold for 2 mins, then spit
Continue for 5 days
Can soak gauze in it
May be prescribed in pts at risk of haemorrhage as a rinse and shallow
Avoid drinking for 1hr post rinse

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12
Q

Why is tranexamic acid not used routinely?

A

M/w = expensive, difficult to obtain and no more benefit than other local haemostatic measures
In combo with local measures and suturing = tranexamic acid provides additional reduction in post op bleeding

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13
Q

How to treat pts with inherited bleeding disorders?

A

Work with haematology team to clarify the severity of the disease, agree on location and care

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14
Q

What is the most common inherited bleeding disorder? What is this?

A

von Willebrand disease = clotting factor plus platelet abnormality

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15
Q

Where are the sites of bleeding of von willebrand disease?

A

Bruising, cuts, gums, epistaxis, menorrhagia, post op and trauma

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16
Q

What is desmopressin (DDAVP)?

A

Synthetic replacement for vasopressin = reduces urine production
Nasally, IV, oral or sublingual tablet
Stimulates release of endogenous FVIII and VWF from stores in pts with mild haemophilia A and VWD

17
Q

What are the categories of platelet disorders? Give an example of each

A

Platelet func - glanzmanns thrombasthenia
Increased destruction - ITP

Decreased production:

  • Congenital = Alports
  • Acquired = B12/Folate def
18
Q

Examples of vascular bleeding disorders

A

Inherited

  • hereditary haemorrhagic telangiectasia
  • ehlers-danlos syndrome

acquired:

  • senile purpura
  • scurvy
  • steroid purpura
19
Q

What is the normal platelet level?

A

140-350 x 109/litre
<20 spontaneous bleeding
>80 haemostatic

20
Q

Examples of antiplatelet drugs, how do they work?

A 
Clopidogrel
aspirin
dipyradimole
ticagrelor
prasugrel
= impair primary haemostats by interfering with platelet aggregation
= increase bleeding time
(clopidogrel more than aspirin)
21
Q

What to do regarding dental treatment when pts are on aspirin?

A

If procedure causes bleeding = continue without adjusting dose
Apply safe treatment
Limit to single extraction
Sub-gingival scaling 3 teeth then assess before continuing
Treatment over separate visits
Pack and suture

22
Q

What to do if a pt is on a single anti-platelet other than aspirin or a dual antiplatelet having treatment likely to cause bleeding?

A

Bleeding may be prolonged
Apply safe treatment
Limit to single extraction, sub-gingival scaling 3 teeth then assess before continuing, staged treatment over separate visits, local measures pack and suture

23
Q

How do vitamin K antagonists work??

A

Inhibit the production or activity of factors required for the coagulation cascade
Impair secondary haemostasis

24
Q

Examples of vitamin K antagonists?

A

Warfarin (Marevan), widely used for prophylaxis of venous thrombo-embolism (VTE)
Acenocoumarol (Sinthrome)
Phenidione (Dindevan)

25
Q

What is INR?

A

= The time taken for a clot to form in a blood sample relative to a standard of 1
More than 1 is an increased bleeding time

26
Q

How to check an INR?

A

Stable INR history, can be assessed up to 72 hours before the dental procedure
Unstable INR must be assessed within 24 hours of the dental procedure

27
Q

What to do if the INR is less than 4?

A

Procedure unlikely to cause bleeding = continue without adjusting dose, local measures

Likely to cause bleeding with stable INR = check 72hrs before hand, local measures

Likely to bleed with unstable INR = check 24 hrs beforehand, local measures

28
Q

What to do if the INR is more than 4?

A

Refer back to medical practitioner for advice
Do not stop meds
Urgent care = remember warfarin interacts with antibiotics (metronidazole) = increase bleeding

29
Q

Features of low molecular weight heparin? Examples?

A

Usually administered subcutaneously by injection. Prevention of VTE in pregnancy, after valve replacement, VTE and cancer, spinal injury. Short onset of action, short half life

Dalteparin (Fragmin)
Enoxaparin (Clexane)
Tinzaparin (Innohep)

30
Q

How to treat pts on low molecular weight heparin?

A

Unlikely to cause bleeding = local measures

Likely bleeding = consult GP or specialist

31
Q

Examples of NOACs

A

Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)

32
Q

What is dabigatran? How does it work?

A

Direct thrombin inhibitor acting at the final step of the coagulation process preventing fibrinogen to fibrin

33
Q

Advantages of NOACs?

A 
As effective as warfarin
Fast onset
Fixed doses
No blood tests
Less drug interactions
Lower risk of major bleeds
Increased risk of GI bleeding
34
Q

Negatives fo NOACs?

A

No antidote

Expensinve

35
Q

How to treat pts on NOACs?

A

Unlikely to bleed = do not interrupt NOACs
Likely to cause bleeding with a low risk of complications = continue as normal but treat 1st thing in morning, single extraction, 3 teeth sub-gingival, local measures, pack and suture

Likely to bleed and higher risk of bleeding = miss or delay (4 hrs post treatment) the morning dose of dabigatran, rivaroxaban, apixaban and wait 4 hours before next dose of meds

HAEMATOLOGICAL DISEASE 303 (5 decks)

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