Haemostasis

Question 1

What would a risk assessment prior to a tooth extraction involve?

Answer 1

• careful planning
• thorough analysis of medical history

Question 2

What does the process of haemostasis involve?

Answer 2

• vasoconstriction
• platelet plug formation
• coagualation cascade/network

Question 3

Clot formation is a dynamic process. It involves a balance between what systems?

Answer 3

haemostatic and fibrinolytic systems

Question 4

When does fibrinolysis occur?

Answer 4

When the plasminogen precursor is activated and becomes plasmin

Plasmin is then able to digest the fibrin threads in the clot

Question 5

The majority of clotting factors are produced in the …

Answer 5

liver

Question 6

Platelets are produced in the …

Answer 6

red bone marrow

Question 7

Problems relating to clotting factors and platelets are either ________ or ________

Answer 7

acquired or congenital

Question 8

Give an example of a congenital clotting factor deficiency

Answer 8

Haemophilia A (factor VIII deficiency)

Question 9

State the 3 types of post extraction haemorrhages

Answer 9

• primary haemorrhage
• reactionary haemorrhage
• secondary haemorrhage

Question 10

What is a primary haemorrhage?

Answer 10

this is bleeding that occurs at the time of surgery

Question 11

What is reactionary haemorrhage?

Answer 11

this is bleeding that occurs 2-3 hours after the procedure as a result of cessation of vasoconstriction

Question 12

What is a secondary haemorrhage?

Answer 12

this is bleeding that occurs up to 14 days after the surgery.

Question 13

What is the most likely cause of a secondary haemorrhage?

Answer 13

infection

Question 14

Haemorrhages can also be classified according to the site affected. Give examples of such sites

Answer 14

• soft tissue
• bone
• vascular

Question 15

The use of haemostatic agents and equipment is not limited to managing post-extraction haemorrhages. Give examples of other invasive procedures where haemostatic agents/equipment are useful

Answer 15

• non surgical periodontal therapy
• periodontal surgery
• pulpotomy
• preparation of teeth for indirect restorations

Question 16

Briefly describe immediate post extraction management and why it is important

Answer 16

• once a tooth has been removed, pressure shoud be placed on the buccal and lingual/palatal sufaces of the alveolus around the socket- this is referred to as **digitalised pressure **
• this immediate bucco-lingual pressure reduces the dead space of the wound and is the first step to gain haemostasis

Question 17

What is the result of the extraction of a tooth via the intra-alveolar approach?

Answer 17

expansion of the alveolus aorund the roots of a tooth

Intra-alveolar extraction is a forceps extraction (not a surgical extraction!)

Question 18

Post-operatively, how would you manage an extraction site with an opposing edentulous area? Why would you go about it this way?

Answer 18

use finger pressure on the gauze for several minutes

this is because biting together following gauze placement may not apply enough firm pressure

Question 19

What is the duration of time for the formation of granulation tissue following an extraction?

Answer 19

24 hours

Question 20

Give examples of clotting factor deficiencies

Answer 20

• haemophilia A (factor VIII)
• haemophilia B (factor IX)
• Von willibrand disease
• vitamin K deficiency (Factor II, VII, IX, X)
• Acquired liver disease- hepatitis/ cirrhosis

Question 21

Platelet deficiencies such as thrombocytopenia can be either ________ or ___________

Answer 21

idiopathic
or
drug induced (antiplatelet therapy)

Question 22

Give examples of vascular anomalies that put patients at high risk of post extraction haemorrhage

Answer 22

• atriovenous malformation
• hereditary haemorrhagic telangiecstasia
• collagen disorders

Question 23

Failure to give a patient clear post operative instructions for the management of the socket can lead to ____________ haemorrhage

Answer 23

secondary

Question 24

Why is it important to provide a concise instruction leaftlet as well as verbal POI?

Answer 24

• patients may not be able to recall a long list of instruction following extraction

Question 25

Providing a leaflet without comprehensive verbal instructions is acceptable practice. True or fale

Answer 25

false

Question 26

What clinical scenarios is it acceptable for a clinician to give after care instructions at a previous appointment or pre-operatively?

Answer 26

patients having treatment under IV or inhalation sedation who may have their ability to retain information significantly reduced

Question 27

In the presence of infection, granulation tissue may form at the base of the socket. How does the presence of granulation tissue increase the risk of bleeding ?

Answer 27

* impairs clotting * granulation tissue (macrophage cytokines such as VEGF encourage angiogenesis as a result there is an abundance of fragile blood vessels - prone to haemorrhage)

Question 28

What size and shape of needle is useful for suturing intra-oral wounds

Answer 28

3.0 suture 1/2 circle curved needle

Question 29

How long does polygactin (vicryl) offer wound support?

Answer 29

7-10 days

Question 30

What is in a dental clinicians armanentarium for a post-extraction haemorrhage?

Answer 30

* sterile gauze (pressure pack) * suction * suture kit (needle holders, tissue forceps, suture material and needle) * haemostatic gauze * bone wax * astringent solution e.g. ferric sulphate * 5% tranexamic acid mouthwash * cautery * systemic monitoring equipment- blood pressure, heart rate, pulse oximeter

Question 31

Give examples of haemostatic agents that are available to a dental practitioner

Answer 31

* tranexamic acid * ferric sulphate * silver nitrate

Question 32

List the POI following a dental extraction

Answer 32

Do not: * rinse your mouth on the day of extraction as it may dislodge the clot * drink alcohol/hot drinks at least 24 hours; may increase blood pressure and induce hyperaemia * smoke or use tobacco products for at least 24 hours (causes vasoconstriction and can increase dry socket) * chew food for 4 hours, avoid hard foods as they may disturb clot * carry out physical activity (increased blood pressure Do: * sip lukewarm drinks carefully (helps avoid clot removal by washing out socket) * bite on gauze for 10 minutes if area bleeds, sitting upright * salt water rinces or CHX (0.2%) mouthwash after 24 hours. Continue regular mouthwash use over following weeks especially after meals * clean teeth as normal, avoiding area of surgery for 24 hours

Question 33

What are directions of use for 5% tranexamic acid mouthwash?

Answer 33

use as a rinse 4x daily for two days post-operatively to prevent fibrinolysis

Question 34

What are the first line management options for soft tissue haemorrhages ?

Answer 34

* sutures * haemostatic gauze

Question 35

Ferric sulphate is commonly used an ____________ solution in dentistry

Answer 35

astringent solution (15.5%)

Question 36

Give instances where ferric sulphate is commonly used

Answer 36

* gingival retraction techniques for impressions for crown and bridge work * haemostatic agent for pulpotomy

Question 37

In what form is silver nitrate available?

Answer 37

It is available in the form of pencil which contains 95% silver nitrate

Question 38

When are silver nitrate pencils made use of ? Give specific examples of such instances

Answer 38

to aid haemostasis in areas where suturing or finger pressure is not possible mucosal biopsy taken from hard palate or retromolar pad

Question 39

Silver nitrate is a powerful _______ agent

Answer 39

cauterizing agent burning flesh in order to control bleeding

Question 40

How is silver nitrate deactivated?

Answer 40

after a few minutes silver nitrate should be de-activated by genetly swabbing the area with saline solution to avoid damage to surrouding structures

Question 41

How can bleeding from within the socket be arrested in most cases?

Answer 41

it can be arrested by inserting a pack

Question 42

How can you manage a bony haemorrhage?

Answer 42

cancellous bone can be burnished with a flat plastic instrument or mitchells trimmer to help compress the bone in that area

Question 43

The use of haemostatic gauze/dressing along with the placement of suture is recommended for patients at high risk of post operative haemorrhage. Give examples of resorbable haemostatic dressing materials

Answer 43

* surgicel * haemocollagen * Gelfoam

Question 44

Surgicel is ...

Answer 44

oxidised regenerated cellulose

Question 45

Haemocollagen is a ________ sponge

Answer 45

collagen

Question 46

Gelfoam is a ________ sponge

Answer 46

gelatin

Question 47

Give examples of non-resorbable haemostatic dressing

Answer 47

Kaltostat

Question 48

What does bone wax consist of?

Answer 48

* beeswax * paraffin * softening agent

Question 49

What is the main use of bone wax?

Answer 49

it can be used to control bleeding in cancellous bone it is placed into spaces within the bone

Question 50

How does surgicel facilitate haemostasis ?

Answer 50

it forms a gelatinous mass upon saturation with blood which leads to the formation of a stable clot

Question 51

How does bone wax facilitate haemostasis?

Answer 51

the pressure provided facilitates haemostasis

Question 52

What are the caveats of bone wax usage?

Answer 52

* non-resorbable and thus the host may treat it as a foreign body * complete removal of bone wax is difficult and thus it often remains in situ

Question 53

Wax placement is often followed by ...

Answer 53

placement of haemostatic gauze and a suture to maintain pressure on the socket

Question 54

What type of haemorrhage causes the most distress to a patient?

Answer 54

vascular haemorrhage

Question 55

What sort of repair may be required for a large vessel haemorrhage?

Answer 55

ligation (tying up an artery)

Question 56

What sort of repair may be carried our for smaller vessels?

Answer 56

cauterization (burn)

Question 57

What is electrocautery?

Answer 57

this is the process of sealing the exposed end of a vessel with heat conduction

Question 58

When is systemic monitoring of particular importance?

Answer 58

when dealing with a secondary haemorrhage

Question 59

How should a patients blood pressure be monitored?

Answer 59

sphygmomanometer

Question 60

How is should patients heart rate be monitored?

Answer 60

* manually * pulse oximeter

Question 61

When should a patient be referred to A&E following an extraction? What treatment should these patient receive ?

Answer 61

* if it is not possible to arrest haemorrhage * With the following readings: * diastolic BP: consistently <60 in a short monitoring period * systolic BP: consistently <100 in a short monitoring period * heart rate raised- 100bpm - tachycardic they should receive fluid replacement as these are the signs of hypovolaemic shock

Question 62

What is the quickest route to successful management of a haemorrhage?

Answer 62

the correct diagnosis

Question 63

Outline the management of a vascular haemorrhage ?

Answer 63

* localise vessel * apply pressure * may require electrocautery or ligating * haemostatic gauze * suture

Question 64

Outline the management of a soft tissue haemorrhage ?

Answer 64

* haemostatic gauze * suture * chemical agents if appropriate

Question 65

Outline the management of a bony haemorrhage ?

Answer 65

* identify site of haemorrhage * place haemostatic gauze then suture * burnish if possible and or insert bone wax, pack and suture