How to identify and safely manage patients at risk of bleeding during dental treatment Flashcards
What should I take into account when assessing the risk of bleeding
Dental procedure required
Patient factors
Medications
How to know what will cause bleeding
www.sdcep.org.uk
management of patients taking anticoags or anti platelet medication
Dental procedures likely to cause bleeding
Low risk
High risk
Simple extractions Incision and draining of a swelling 6 point RSD/subgingival scaling Direct/indirect restorations with sub gingival margins
Complex extractions
Flap raising
Biopsies
Gingival recontouring
General principles
Prevention of dental disease
- encourage regular attendance
- agree oral care plan with patient
- written patient information
- encourage excellent OH
- high fluoride toothpaste
- f- varnish
Talk to patient/carer
- thorough medical history taking with regular updates
- look up unfamiliar meds in BNF
careful liaison
plan appt times
only proceed with adequate access
defer care
careful technique
assess bleeding as you go along
clear written POI
not confident - seek advice
extra precautions for high risk
balance with
Limit to single extraction at a time
Sub-gingival scaling 3 teeth then assess before continuing
Stage treatment over separate visits
Local measures pack and suture
Balance with
Budget
Medical factors/systemic disease
Chronic renal failure
Liver disease
Haematological malignancy
Chemo
What to look out for
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
Test request
FBCs
Clotting screen
INR
Which drugs may increase bleeding risk
Warfarin
St John’s wort, garlic, gingko biloba
How long for
Which medical conditions
What happens when cut themselves
Which drugs may increase risk - examples
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
Local measures
Horizontal mattress suture
Haemostatic packing material
oxidised cellulose, collagen sponge
Warm, wet, absorbent gauze
Options for Tx
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
Tranexamic acid
What is it
Mechanism
Administration
Anti-fibrinolytic agent
Inhibits breakdown of fibrin clots
Blocks binding of plasminogen and plasmin to fibrin
Fibrinolysis prevented
Used as local haemolytic agent in form of mouthwash
Tablets or 5% mouth rinse indicated for short term use for haemorrhage or risk of in those with increased fibrinolysis
Use of tranexamic acid in dentistry
Use qds, start 5-10 minutes post extraction
Rinse with 5mls of 5% solution and hold for 2 mins, then spit
Continue for 5 days
Can be used to soak in absorbent gauze, to provide additional pressure to extraction site
May be prescribed in patients at risk of haemorrhage as a rinse and swallow, (hold near extraction site and swallow)
Avoid drinking for 1 hour post-rinse
Why is tranexamic acid not used routinely
Tranexamic acid mouthwash should not be used routinely in primary dental care
Tranexamic acid mouthwash in primary dental practice is expensive, difficult to obtain and of no more benefit than other local haemostatic measures. When used alone with no local haemostatic dressing, tranexamic acid mouthwash reduces postoperative bleeding compared to placebo mouthwash.
When used in combination with local haemostatic measures and suturing, tranexamic acid mouthwash provides little additional reduction in postoperative bleeding.