Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

DEN303 - IHD > How to identify and safely manage patients at risk of bleeding during dental treatment > Flashcards

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

1
Q

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

A

Dental procedure required
Patient factors
Medications

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

How to know what will cause bleeding

A

www.sdcep.org.uk

management of patients taking anticoags or anti platelet medication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Dental procedures likely to cause bleeding

Low risk

High risk

A 
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

General principles

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

extra precautions for high risk

balance with

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Medical factors/systemic disease

A

Chronic renal failure
Liver disease
Haematological malignancy
Chemo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What to look out for

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Test request

A

FBCs
Clotting screen
INR

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Which drugs may increase bleeding risk

A

Warfarin
St John’s wort, garlic, gingko biloba

How long for

Which medical conditions

What happens when cut themselves

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Which drugs may increase risk - examples

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Local measures

A

Horizontal mattress suture
Haemostatic packing material
oxidised cellulose, collagen sponge
Warm, wet, absorbent gauze

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Options for Tx

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Tranexamic acid

What is it
Mechanism
Administration

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Use of tranexamic acid in dentistry

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Why is tranexamic acid not used routinely

A

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.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Inherited bleeding disorders

and how are they treated

A 
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 
	Others 
Autosomal recessive 
Deficiency of fibrinogen, FII, FV, FVII, FX, FXI, FXIII

Liaison with haematology team to clarify severity of each individuals disease
agree on most appropriate treatment location

17
Q

von Willebrand disease

Sites of bleeding

A

Most common bleeding disorder
Affects up to 1%
Type 1,2,3
Milder than haemophilia
Clotting factor and platelet abnormality
Bruising, cuts, gums, epistaxis, menorrhagia, post operative, post trauma

18
Q

How are people with haemophilia treated

What is it

A

Given desmopressin

Desmopressin is a synthetic replacement for vasopressin, the hormone that reduces urine production. It may be taken nasally, intravenously, or as an oral or sublingual tablet
DDAVP stimulates the release of endogenous FVIII and VWF from stores in patients with mild Haemophilia A and VWD (iv or intra-nasal)
Prescribed by haematologist

19
Q

Vascular bleeding disorders

A 
Inherited 
Hereditary Haemorrhagic Telangiectasia 
Ehlers-Danlos Syndrome (vascular type) 
Acquired 
Senile Purpura 
Scurvy (Vitamin C deficiency) 
Steroid Purpura
20
Q

Antiplatelet drugs - platelet levels

A

Normal is 140-350 x109
Thrombocytopenia
<20 spent bleeding
>80 haemostats

21
Q

Anti platelet drugs

NAMES
ROLE

A 
Impair primary haemostasis
Interfere with platelet aggregation 
Clopidogrel
Prasugrel
Aspirin

Increase bleeding time, clopidogrel more than aspirin
Dual anti-platelets increase 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

22
Q

Vitamin K antagonist
Mechanisms
Example

A

Inhibit the production/activity of factors required for coagulation cascade
Impair secondary haemostasis
Warfarin used for prophylaxis and VTE

23
Q

Warfarin

A

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

24
Q

Checking INR

A

Ideally 1

stable INR if not been >4 for 2 months

25
Q

INR <4

A

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

26
Q

INR more than 4

A

Refer back for advice

27
Q

Low molecular weight heparin

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

28
Q

NOACs
Examples
Mechanism

A

Rivaroxaban
Dabigatran 2x day
Apixaban 2x day

Dabigatran is direct thrombin inhibitor acting at final step of coagulation preventing fibrinogen to fibrin
R and A inhibit a different clotting factor

29
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
BUT no antidote
30
Q

How to treat

A

If the dental procedure is unlikely to cause bleeding continue without interrupting NOACs

If dental procedure likely to cause bleeding with a low risk of complications 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

If the dental procedure is likely to cause bleeding or there is a higher risk of bleeding complications, 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

DEN303 - IHD (58 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions