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Bleeding Disorders Shalu Rai et al

severely inflamed tissues, initial treatment with chlorhexidine Conclusion
mouthwashes and gross debridement is recommended to Dentists are facing an ever-increasing number of
reduce tissue inflammation before deep scaling. Factor conditions — inherited, acquired and drug-related —
replacement may be required before extensive periodontal associated with abnormal hemostatic function. These
surgery and use of nerve blocks. Periodontal packing materials raise the possibility of excessive blood loss, poor
and custom vinyl mouthguards (stents) are used to aid in wound healing and infection. The dentist must
hemostasis and protect the surgical site, but these can be maintain clear and open communication with the
dislodged by severe hemorrhage or subperiosteal hematoma patient and his physician or hematologist. This will
formation. Antifibrinolytic agents may be incorporated into ensure that the dentist obtains complete information on
periodontal dressings for enhanced effect. Post-treatment the severity and control of the patient’s condition and
antifibrinolytic mouthwashes are usually effective in advice on management of the patient before and after
1,7
controlling protracted bleeding. surgery.

Restorative and Endodontic Procedures References:
General restorative procedures do not pose a significant risk of 1. Patton LL. Bleeding and clotting disorders. In: Burket’s oral
bleeding. Care should be taken to avoid injuring the gingiva medicine: diagnosis and treatment. 10th ed. Hamilton (ON):
BC Decker; 2003. p. 454–77.
while placing rubber dam clamps, matrices and wedges. A
2. Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management
rubber dam should be used to prevent laceration of soft tissues
considerations for the patient with an acquired coagulopathy.
by the cutting instruments. Saliva ejectors and high-speed Part 1: Coagulopathies from systemic disease. Br Dent J 2003;
suction can injure the mucosa in the floor of the mouth and 195(8):439–45.
cause hematoma or ecchymosis; thus, they should be used 3. Meechan JG, Greenwood M. General medicine and surgery for
carefully. Endodontic therapy is preferred over extraction dental practitioners Part 9: haematology and patients with
whenever possible in these patients. Endodontic therapy does bleeding problems. Br Dent J 2003; 195(6):305–10.
4. Webster WP, McMillan CW, Lucas ON, and others. Dental
not usually pose any significant risk of bleeding and can be
management of the bleeder patient. A comparative review of
performed routinely. Endodontic surgical procedures may
replacement therapy. In: Ala F, Denson LW, editors.
require factor replacement therapy. 1,7 Hemophilia. Amsterdam: Excerpta Medica; 1973. p. 33–7.
5. Golla K, Epstein JB, Cabay RJ. Liver disease: current
Prosthodontic Procedures perspectives on medical and dental management. Oral Surg
These procedures do not usually involve a considerable risk of Oral Med Oral Pathol Oral Radiol Endod 2004; 98(5):516–21.
bleeding. Trauma should be minimized by careful post- 6. Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management
insertion adjustments. Oral tissue should be handled delicately considerations for the patient with an acquired coagulopathy.
Part 2: Coagulopathies from drugs. Br Dent J 2003;
during the various clinical stages of prosthesis fabrication to
195(9):495–501.
reduce the risk of ecchymosis. Careful adjustment of prostheses 7. Gupta A, Ebstein JB. Bleeding Disorders of Importance in
is needed to reduce trauma to soft tissue. 1,7,10 Dental Care and Related Patient Management. JCDA 2007;
73; 1:77-83
Orthodontic Procedures 8. Bogdan CJ, Strauss M, Ratnoff OD. Airway obstruction in
Orthodontic therapy can be carried out without bleeding hemophilia (factor VIII deficiency): a 28-year institutional
complications, although care should be taken that appliances review. Laryngoscope 1994; 104(7):789–94.
9. Rackoz M, Mazar A, Varon D, Spierer S, Blinder D,
do not impinge on soft tissues and emphasis should be put on
Martinowitz U. Dental extractions in patients with bleeding
excellent, atraumatic oral hygiene measures. 7
disorders. The use of fibrin glue. Oral Surg Oral Med Oral
Pathol 1993; 75(3):280–2.
Patients on anticoagulants 10,11 10. Webster WP, Roberts HR, Penick GD. Dental care of patients
Management of the dental patient on anticoagulant therapy with hereditary disorders of blood coagulation. In: Rantoff OD,
involves consideration of the degree of anticoagulation editor. Treatment of hemorrhagic disorders. New York: Harper
achieved as gauged by PT/INR. Prothrombin time was & Row; 1968. p. 93–110.
11. Wahl MJ. Myths of dental surgery in patients receiving
conventionally used to monitor degree of anticoagulation.
anticoagulant therapy. J Am Dent Assoc 2000; 131(1):77–81.
Prothrombin ratio of 2 to 2.5( therapeutic range). Generally
higher INRs result in higher bleeding risk from surgical
Address for correspondence:
procedures. No surgical treatment recommended INR> 3.5-4
Dr Shalu Rai
without coumarin dose modification. Minor surgical
Prof and Head, Oral Medicine and Rdaiology
procedures; INR< 3.5-4 without coumarin dose modification.
IDST Dental College, Modinagar
Extensive flap surgery or multiple bony extraction requires
INR<1.5

Journal of Oral Sign 2011, Vol 3, No 2 (May-Aug)