How to identify and safely manage patients at risk of bleeding during dental treatment

Question 1

What should I take into account when assessing the risk of bleeding?

Answer 1

Dental procedures required
Patient factors (systemic disease)
Medications

Question 2

How do I know what dental procedures will cause bleeding?

Answer 2

SDcep

-management of dental patients taking anticoagulants or antiplatelet drugs

Question 3

Dental procedures that are unlikely to cause bleeding

Answer 3

LA by infiltration, intra-ligamental, mental block
LA by IBD or other regional block
BPE
Supra-gingival scaling
Simple restorative treatment
Impressions
Ortho fitting/ adjustment

Question 4

Dental procedures likely to cause bleeding

Low risk of complications

Answer 4

Simple extractions (1-3 teeth)
Incision and drainage of a swelling
Detailed 6-point charting
RSD/ sub-gingival scaling
Direct/ Indirect restorations with sub-gingival margins

Question 5

Dental procedures likely to cause bleeding

High risk of complications

Answer 5

Complex extractions; adjacent teeth, +3
Flap raising procedures
Biopsies
Gingival recontouring

Question 6

General principles of safe treatment planning

Answer 6

Prevention of dental disease
Talk to patient or carer
Careful liaison with other HCP
-individual pt care GP
-hospital consultants
-haemophilia nursing teams
Plan apt times (morning so time to sort out if problems, treat early in week)
Only proceed if adequate access to emergency care
Defer care?
-if pt on short term treatment
Careful technique
Assess bleeding as you go along and stop if unexpected bleeding occurs
Clear written POI of who to contact (24hrs) and what to do if there is a problem
Not confident? Seek advice and plan carefully

Question 7

Prevention of dental disease

Answer 7

Encourage regular attendance
Agree oral care plan with pt
Written pt info
Encourage excellent oral hygiene
High F toothpaste
Application of fluoride varnish (etc.)

Question 8

Talk to pt or carer

Answer 8

Thorough medical history taking with regular updates and questioning of changes at each apt
Looking up in BNF of unfamiliar medications
Seeking confirmation of medical history and current medication from GP before treatment in poor historians (seek pt consent)

Question 9

Careful technique

Answer 9

Use aspirating syringes
Administer LA slowly and atraumatically
Avoid use of ID blocks where possible
Consider use of articaine for mandibular infiltrations in adults
-never use articaine for ID blocks and care with mental blocks!
Treat tissues as atraumatically as possible

Question 10

Extra precautions to consider for those at higher risk

Answer 10

Limit to single extraction at a time
Sub-gingival scaling 3 teeth then assess before continuing
Stage treatment over separate visits
Locals measures, pack and suture
BUT pts can develop inhibitors to some Factor replacements, and many Factor replacement therapies v expensive

Question 11

Patients at risk

Answer 11

MEDICAL FACTORS/ SYSTEMIC DISEASE
Chronic renal failure
Liver disease (alcohol dependence, chronic viral hepatitis, autoimmune hepatitis, primary biliary cirrhosis)
Haematological malignancy or myelodysplastic disorder
Previous or current chemotherapy
Advanced heart failure, prosthetic heart valves, coronary stents
Inherited bleeding disorders including haemophilia or von Willebrand’s disease
Idiopathic thrombocytopenia purpura

Question 12

Chronic renal failure: > bleeding due to

Answer 12

associated platelet dysfunction

Question 13

Liver disease: > bleeding due to

Answer 13

< production of coagulation factors

< in platelet number and function due to bone marrow toxicity

Question 14

Haematological malignancy or myelodysplastic disorder: > bleeding due to

Answer 14

Impaired coagulation or platelet function (even in remission)

Question 15

Previous or current chemotherapy: > bleeding due to

Answer 15

Pancytopenia including < platelet numbers

Question 16

Advanced heart failure, prosthetic heart valves, coronary stents: > bleeding due to

Answer 16

Resulting liver failure

Question 17

Inherited bleeding disorders including haemophilia or von Willebrand’s disease: > bleeding risk due to

Answer 17

Defective or < levels of coagulation factors

Question 18

Idiopathic thrombocytopenia purpura: > bleeding due to

Answer 18

< platelet numbers

Question 19

What should I be looking out for?

Answer 19

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

Question 20

Can I request any tests to see if bleeding is more likely?

Answer 20

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

Question 21

Which drugs might increase the risk of bleeding?

Answer 21

Anti-platelet (single or combination therapy)
-aspirin, clopidogrel
Cytotoxic drugs associated with bone marrow suppression
-leflunamide, hydrochloroquine, infliximab, adalimumab, enteracept, 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

Question 22

What are the options for treatment?

Answer 22

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 e.g. NSAIDS and SSRIs

Question 23

Medicine history

Answer 23

What medicines are you taking?
-prescribed and non prescribed (over the counter)
-herbal and complimentary medicines (eg St Johns Wort, garlic, Gingko biloba)
How long will you be taking them for?
-short term or long term
What medical conditions do you have?
What happens if you cut yourself?

Question 24

Local measures

Answer 24

Horizontal mattress sutures
Use haemostatic packing material eg oxidised cellulose, collagen sponge
Warm, wet absorbent gauze to put pressure directly on the site of extraction

Question 25

Tranexamic acid

Answer 25

Anti-fibrinolytic agent that inhibits breakdown of fibrin clots -blocks binding of plasminogen & plasmin to fibrin therefore preventing fibrinolysis -can be used in anti-coagulated dental pts as local haemostatic agent in the form of a mouthwash Tranexamic acid 500mg tablets or 5% (500mg/5ml) mouthrinse may be indicated for short term use for haemorrhage or risk of haemorrhage in those with > fibrinolysis or fibrinogenolysis -often prescribed as 5% (500mg/5ml) mouthrinse in pts with acquired and inherited clotting disorders, and for pts on anti-coagulants

Question 26

How is tranexamic acid used in dentistry?

Answer 26

Use qds, start 5-10 mins post extraction Rinse with 5mls 5% soln and hold for 2 mins, then spit Continue for 5 days Can be used to soak in absorbent gauze, to provide additional p to extraction site May be prescribed in pts at risk of haemorrhage as a rinse and swallow, (hold near extraction site and swallow) Avoid drinking for 1 hour post-rinse

Question 27

Why don't we use tranexamic acid mouthwash routinely?

Answer 27

Should not be used routinely in primary dental care In primary dental practice it 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 < postop bleeding compared to placebo mouthwash When used in combination with local haemostatic measures and suturing, it provides little additional < in postop bleeding

Question 28

Inherited bleeding disorders

Answer 28

``` Haemophilia A X-linked Haemophilia B X-linked -severity Normal FVIII level 50-150% -<1% severe -1-5% moderate ->5% mild Von Willebrand disease autosomal dominant Autosomal recessive Deficiency of fibrinogen, FII, FV, FVII, FX, FXI, FXIII ```

Question 29

Severe haemophilia - clinical features - dental treatment

Answer 29

Frequent spontaneous bleeds Enhanced preventative advice & treatment with GDP/ community dentist Should have all dental treatments except prosthetics carried out in hospital setting with specialist dental unit, unless prior arrangements made with haemophilia centre and GDP/ community dental practice

Question 30

Moderate haemophilia - clinical features - dental treatment

Answer 30

May have spontaneous bleeds Enhanced preventative advice and treatment with GDP/ community dentist Manage as for severe haemophilia

Question 31

Mild haemophilia - clinical features - dental treatment

Answer 31

Bleed after trauma or surgery Enhanced preventative advice and treatment with GDP/ community dentist Do not require all treatments carried out at hospital; should be seen every 2 years by specialist dental team at haemophilia centre -close liason between dentist and haemophilia centre necessary; some procedures may require prophylactic cover and this will be arranged and provided by haemophilia unit

Question 32

Carrier of haemophilia: dental treatment

Answer 32

If factor level <50% carriers should be treated as mild haemophilia

Question 33

Von Willebrand disease

Answer 33

Commonest inherited bleeding disorder Affects up to 1% of population Type 1, 2, 3 In general, milder bleeding disorder than haemophilia Clotting factor PLUS platelet abnormality Sites of bleeding: Bruising, cuts, gums, epistaxis, menorrhagia, post operative, post trauma

Question 34

What is desmopressin (DDAVP)

Answer 34

Synthetic replacement for vasopressin (hormone that < urine production) -may be taken nasally, IV, or oral or sublingual tablet Stimulates release of endogenous FVIII and VWF from stores in pts with mild haemophilia A and VWD (iv or intra-nasal) Prescribed by haematologist

Question 35

Platelet disorders: decreased production

Answer 35

``` Congenital -Fanconi's -Alport's -May Hegglin -Bernard Soulier -Wiscott Aldrich Acquired -B12/ folate deficiency -myelodysplasia -aplastic anaemia -sepsis -drugs: antiplatelet/ NSAIDs -uraemia -alcohol ```

Question 36

Platelet disorders: increased destruction

Answer 36

``` Idiopathic Thrombocytopenic Purpura ITP Thrombotic Thrombocytopenic Purpura Haemolytic Uraemic Syndrome Disseminated Intravascular Coagulation Antiphospholipid Syndrome Post Transfusion Purpura HIV/ Hepatitis Hypersplenism ```

Question 37

Platelet disorders: platelet function

Answer 37

Glanzmanns thrombasthenia | Platelet storage pool disease

Question 38

Platelet disorders

Answer 38

``` Decreased production -congenital -acquired Increased destruction Platelet function ```

Question 39

How can I treat pt with platelet disorders?

Answer 39

Careful liaison with haematology team to clarify the severity of each individuals disease, agree on most appropriate treatment location, primary or secondary care, and whether cover is necessary for individual dental treatment depending on likelihood of bleeding risk

Question 40

How can I treat pt with inherited bleeding disorders?

Answer 40

Careful liaison with haematology team to clarify the severity of each individuals disease, agree on most appropriate treatment location, primary or secondary care, and whether cover is necessary for individual dental treatment depending on likelihood of bleeding risk Always follow general principles of safe practice as above and special precautions as advised

Question 41

Vasculature bleeding disorders

Answer 41

``` Inherited -hereditary haemorrhagic telangiectasia -Ehlers-Danlos syndrome (vascular type) Acquired -senile purpura -scurvy (Vitamin C deficiency) -steroid purpura ```

Question 42

Pts on drugs that increase risk of bleeding

Answer 42

Anti-platelet drugs Vitamin K antagonists (VKAs) Warfarin

Question 43

Normal platelet levels

Answer 43

Normal platelet levels 140-350 x 10^9 / litre Thombocytopenia can aggravate surgical or traumatic bleeding <20 spontaneous bleeding >80 haemostatic

Question 44

Anti-platelet drugs

Answer 44

Impair primary haemostasis by interfering with platelet aggregation, reversibly or irreversibly - Clopidogrel (Plavix) - Aspirin - Dipyradimole (Persantin) - Ticagrelor (Brilique) - Prasugrel (Efient)

Question 45

Anti-platelet drugs and bleeding

Answer 45

> bleeding time, clopidogrel more than aspirin Dual anti-platelets > bleeding time by more (45-60 mins for aspirin and clopidogrel together) No clear data for prasugrel or ticagrelor Ask what happens when they have a cut

Question 46

Bleeding risk from drugs and how to manage

Answer 46

No available test to check the bleeding risk Dental procedures unlikely to cause bleeding continue without adjusting dose -apply general advice for managing bleeding risk, principles of safe treatment, use local measures routinely Pts on aspirin alone and dental procedures likely to cause bleeding continue without adjusting dose -apply principles of 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 Single anti-platelet other than aspirin or a dual antiplatelet with treatment likely to cause bleeding be aware bleeding may be prolonged (up to an hour), so plan accordingly -apply principles of 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 Other anti-platelet combinations consult with specialist before proceeding if procedure likely to cause bleeding

Question 47

Vitamin K antagonists (VKAs)

Answer 47

Inhibit the production or activity of factors required for the coagulation cascade Impair secondary haemostasis Warfarin (Marevan), widely used for prophylaxis of venous thrombo-embolism (VTE) Acenocoumarol (Sinthrome) Phenidione (Dindevan)

Question 48

Warfarin

Answer 48

Multiple drug and dietary interactions Variation in patient response to the drug Needs careful monitoring INR (International Normalised ratio) is 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 INR used also for the less common VKAs

Question 49

How do I check an INR?

Answer 49

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 Pts usually know their ‘target’ level and carry an INR card from their GP/practice nurse/haematology practitioner In reality, try and check all patients’ INR the day before (as you may not know if the INR is stable or unstable) Coaguchek machines in CCDH, many CDS clinics, and most GP surgeries Machines need regular calibration for accuracy

Question 50

INR less than 4

Answer 50

Dental procedures unlikely to cause bleeding continue without adjusting dose. -apply principles of safe treatment, use local measures routinely Dental procedures likely to cause bleeding (low or high risk) with stable INR check INR at least 72 hours beforehand -apply principles of safe treatment, use local measures routinely Dental procedures likely to cause bleeding (low or high risk) with unstable INR check INR 24 hours beforehand -apply principles of safe treatment, use local measures routinely Principles of 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

Question 51

INR more than 4

Answer 51

Refer back to medical practitioner for advice before proceeding Do not stop medication yourself If providing urgent care, remember warfarin interacts with many antibiotics (erythromycin, fluconazole, metronidazole) which can > the bleeding risk to pt Seek advice

Question 52

Low molecular weight heparins

Answer 52

``` Usually administered SC 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) ```

Question 53

How to treat those on low molecular weight heparins

Answer 53

Lack of clinical evidence so difficult to apply simple principles However -if dental treatment unlikely to cause bleeding Apply principles of safe treatment, use local measures routinely -if dental treatment likely to cause bleeding consult with patients GP or specialist to assess bleeding risk

Question 54

New oral anti-coagulants (NOACs)

Answer 54

Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) dabigatran is a direct thrombin inhibitor acting at the final step of the coagulation process preventing fibrinogen to fibrin -rivaroxaban and apixaban inhibit a different clotting factor

Question 55

Advantages of NOACs

Answer 55

``` As effective as warfarin Fast onset Fixed doses No blood tests Less drug interactions Lower risk of major bleeds > risk of GI bleeding BUT no antidote ```

Question 56

How to treat pts on NOACs

Answer 56

``` INR not a suitable test No trial data at all yet No clinical experience yet No Guidelines yet SCDEP Management of Patients who are taking Anticoagulants and Anitplatelet medication drugs and require dental treatment ```

Question 57

How to treat pts on NOACs: if dental procedure is unlikely to cause bleeding

Answer 57

Continue without interrupting NOACs

Question 58

How to treat pts on NOACs: if dental procedure is likely to cause bleeding with a low risk of complications

Answer 58

continue as normal but treat first thing in the morning, limit to single extraction or 3 teeth for sub-gingival scaling, local measures, pack and suture

Question 59

How to treat pts on NOACs: if dental procedure is likely to cause bleeding with a higher risk of complications

Answer 59

miss or delay (4 hours post treatment) the morning dose of dabigatran, rivaroxaban or apixaban and wait 4 hours at least before starting next dose of medication. Also treat first thing in the morning, limit to single extraction or 3 teeth for sub-gingival scaling, local measures, pack and suture