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Special care dentistry: part 2. dental management of patients with drug-related acquired bleeding disorders Najla Nizarali Sobia Rafique Dental Update 2024 40:9, 707-709.
Authors
NajlaNizarali
Specialist in Sedation and Special Care Dentistry, Department of Sedation and Special Care Dentistry, Floor 26 Tower Wing, Guy's Hospital, London Bridge, London SE1 9RT, UK
Consultant Special Care Dentistry, Department of Community Special Care Dentistry, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK
The first of this series of three articles discussed the dental management of patients with inherited bleeding disorders. This paper will discuss and outline the dental management of patients with acquired bleeding disorders that can result from drug therapy. These may be associated with vascular defects, platelet defects or coagulation defects.
In an age when people are living longer, and medical interventions are continually becoming more advanced, clinicians will need to be aware of systemic disorders and treatments that may cause complications in the dental setting. According to National Statistics,1 the UK population is projected to increase by 0.7% by 2016. This trend is shared with other European countries which also have ageing populations. The proportion of people aged over 65 is predicted to increase from 16% in 2006 to 22% in 2031.
Clinical Relevance: Being able to recognize which drugs may cause bleeding problems at an early stage will lead to good patient management, particularly in planning and delivering treatment following invasive procedures such as dental extractions. Whilst most patients can be successfully treated in general dental practice, the clinician may need to make a decision on whether or not to refer a patient to specialist services for all dental treatment, or to share care between primary care and specialist services for selected procedures.
Article
As discussed in part 1, primary haemostasis is achieved by a platelet plug occluding the wound after blood vessel damage, and is mediated by interactions between platelets, coagulation factors and the vessel wall. Bleeding disorders can therefore arise as a result of a defect in vessels, platelets or the coagulation pathway and can be congenital or acquired. This paper will concentrate on acquired bleeding disorders.
Several hours of minor post-operative bleeding following dental extractions may be of little concern and usually managed using post-operative local measures. Prolonged bleeding could be defined as that which:
Features that might be noticed during extra-oral examination include:
Special tests for patients with bleeding disorders have been discussed in part 1. For acquired bleeding disorders, the Prothrombin Time (PT) is particularly valuable, especially when investigating bleeding tendencies for patients on anticoagulant medication. It is derived from measures of prothrombin ratio and the International Normalized Ratio (INR), which measures the extrinsic pathway of coagulation. It is used to determine the clotting ability in patients on warfarin or patients with liver damage. The reference range of PT is usually 12–15 seconds. The normal range for INR is approximately 0.8–1.2. The PT measures factors II, V, VII and X as well as fibrinogen. It is used in conjunction with APTT.3
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