The surgical treatment of 3 cases of dental pa-tients at high hemorrhagic risk is described: a man with Von
Willehrand disease and 2 women, 1 with platelet deficiency with cirrhosis of the
fiver and the other with autoimmune idiopathic thrombocytopenic purpura. The
patients were hospitalized in order to monitor these cases in cooperation with
the University Hematology Center.
Dental patients with congenital or acquired blood diseases are difficult to
treat for the dentist even when they must un-dergo simple surgical events. Every
oral treatment is a serious problem for these patients: dental extractions or
osseous toilette, in fact, need a good hemostasis. Neverthless, the use of well
codified ther-apeutic protocols allows the dentist to oper-ate with safety.
Patients with bleeding-risk needing oral surgical procedures were identified
from the records of the Oral Surgery Unit, Department of Dentistry and
Stomatology, University of Bari.
Three cases were found out: a man with Von Willebrand disease and 2 women; 1 of
these had platelets deficiency with cirrhosis of the liver and the other,
instead, had autoim-mu ne idiopathic thrombocytopenic purpura. All patients were
submitted to personal treatment.
They were hospitalised in order to carry out a correct monitoring. In the case
with Von Willebrand disease, we have used DDAVP instead of the tradi-tional
substitutive therapy for the deficient factor.
1-deamino-8-D-arginine-vaso-pressin or desmopressin is a synthetic analog of the
antidiuretic hormone that causes a quick increase of FVIII/VWF through its
re-lease from the vascular endothelium. We have used topical antifibrinolytic
agents such as tranexamic acid in 4.8% water solu-tion, to prevent and treat
hemorrhagic events. Tranexamix acid in association with DDAVP counterbalances
the high fibrinolyt-ic salivary activity and the increase of the fib-rinolytic
activity caused by DDAVP.
Tranexamic acid in 4.8% water
solution is used before oral surgery to wash the operat-ing area and during the
operation before su-turing. After the operation patients have to execute
mouth-rinsing with 10 ml of tranexamic acid solution, 4 times a day for 2
minutes for 7 clays.
If bleeding does not stop, we
could exe-cute a local compression with tranexamic acid imbibed gauzes.
This protocol can be used for most part of the oral extractions. Nevertheless,
we must carefully evaluate the hemorrhagic risk considering many fac-tors such
as: ? Number and type of extraction.
Our first patient was a 20 years old, with autoimmune idiopathic
tluximbocytopenic purpura. She had impaction of the third molar (3.8). The
evaluation of the hemochrome showed platelet deficiency: 60 000/mm2.
Coagulation, instead, was normal, showing the following values of PT, PIT,
International Normalized Ratio (INR) and fibrinogen: ?PT: 1.00; ? 1.01; ? INR:
1; ? Fibrinogen: 263 mg/cll. We made an intravenous infusion of 4 vials of
tanexamic acid diluted in 500 ml of physiologic so-lution 1 h before the
operation, 4 Ilirther vials during the operation and other 4 after 24 h. Then,
by troncular anesthesia without vasocon-strictor, we made an incision and
decollement of a mucoperiosteal flap to remove the impacted 3.8. Then, after a
careful osseous toilette, a tamponade with Surgicel and suture with Vicryl 2.00
were made. The following antibiotic and analgesic postextrac-
live therapy was given to the patient: Cefazoline and Ketoprofene in intravenous
The second patient was a 40-year-old woman, with hepatic cirrhosis (waiting
for liver trans-plantation) and under therapy with: lactulose, furosemide,
fitomenadione, canrenoate and albumin. The immoral examination showed the
presence of multiple osteitic foci, For this reason the patient un-derwent our
treatment. Laboratory examinations showed a remarkable prolongation of the
coagulation time, ascribable to the liver disease with the following values: ?
PT: 3.78: ? PIT: 2,82; ? INR: 4.31: ? Fibrinogen: 62 mg/dl.
The patient underwent 20 ml/g p.c. fresh frozen plasma infusion before and after
the operation: then, by local anesthesia, we performed the extraction of
necrotic roots of 3.4 and 4.5, osseous toilette. tam-ponade with Surgicel and
suture with Vicryl 2.00. Postextractive therapy consisted of 2 vials of
tranex-antic acid in a glass of water for oral rinses 4 times a clay.
The last patient was a 55-year-old nan. with Von Willebrand disease and
chronic myeloid leukemia, under therapy with sulxotaneous Interferon (3 000 000
ILI a day). He had multiple osteitic foci. The platelet count. about 294/inin2,
was good. PT PIT and fibrinogen were respectively: 0.99. 2.2(1 and 461 mg/d1.
About 30 min before the operation, a subcuta-neous infusion of a 20 mg vial of
DDAVP was made and then, by local anesthesia, the extraction of necrot-ic roots
of 4.1 and 4.2, osseous toilette, tamponade with Surgicel and suture with Vicryl
were performed. Postextraction therapy was: intravenous vials of Cefazoline 11
g) twice a clay and cutaneous vials of tranexamic acid 6 times a clay.
Dental patients often give a medical history suggesting the possibility of a
congenital co-agulopathy or due to drugs with a risk for prolonged bleeding
during and following an invasive procedure. We can distinguish platelet
deficiency and platelet pathology.
Platelet deficiency (number of
platelet <100 000/mm) could be related to: deficiency of production
(involutional myelopathy, neo-plastic medullary process), altered Mantra-
non process of stem cells, increased platelet destruction (during increased
spleen func-tionality or increased spleen dimension), in-fections (German
measles), autoimmunity re-lated to neonatal purpura, drug-associated
thrombocytopenic purpur2ts, and idiopathic thromhocytopenic purpura. Platelet
pathology, instead, is character-ized by a normal number of platelets but an
irregular functionality of them. It is present in Von Willebrand disease,
Bernard Soulier syndrome, hemophilia, throm-hoastenia and Storage pool
There are, then, coagulation
disorders con-nected with the the oral anticoagulant treat-ment (OAT). Patients
with cardiac diseases are submit-ted to OAT to decrease the levels of hemat-ic
coagulability in order to to prevent throm-bosis.-.8 The level of
anticoagulability is measured by the prothrombin time (PT), which repre-sents
the necessary time for the coagulation of the citrate plasma after the addition
of cal-cium and thromboplastin; so it is sensitive to the reduction of bctors
II. VII and IX of the coagulation cascade.
The most used oral anticoagulants
are war-farin sodium (coumadin) and acenocoumarol (Sintrom), both synthetic
derivative of di-coumarol and antagonists of vitamin K: they stop the
y?carboxylation of glutamic residues of prothrombin and factors VII , IX and
The resulting molecules are
incomplete and so inactive for the coagulation. In 1983 the WHO has suggested to
use the International Normalized Ratio (INR) for mea-suring the therapeutic
level of warfarin. The higher is the INR level, the higher is the lev-el of
anticoagulation. If patients on OAT have to undergo oral surgery , we can decide
to continue, stop or substitute the therapy.
OAT is stopped IL IS when the
patient shows a remarkable prolongation of PT and PTT time: the suspension is
executed 2 days before the operation. Therapy begins again the clay after the
operation. If there is hemonitage during the opera-tion, a phial of vitamin K or
a fresh plasma transfusion can be administered to the patient.
The suspension of therapy reduces the in-cidence of bleeding during and after
the op-eration and makes hemostasis easy, but is dangerous for the patient’s
life. The substitution of OAT, instead , is made with drugs chacterized by a
shorter plasma life so to obtain a quick control of coagula-tion values.
In these cases the most used drug
for pa-tients with high 1NR values is heparin. Actually. it is possible to
continue the an-ticoagulant therapy,17-21 in association with local methods of
hemostasis like suture with insertion of fibrin sponges, Tabotamp, oxi-dized
cellulose, fibrin glue or laser coagu-lant.
On the basis of these protocols,
we could operate on patients with INR values from 2.5 to 4.0, while in 1984 the
American Dental Association (ADA) recommended to operate on patients with 1NR
values 2.23 Anyway, there are no stringent criteria that can be used in the
management of antico-agulatecl patients needing dental extractions. Multiple
factors need to be considered when determining when to extract teeth in an
anticoagulated patient. These factors, which include the level of
anticoagulation and risk of the procedures, must be evaluated on a case-by-case
Howewer. specific medical history
infor-mation and the proper use of laboratory tests is the first step to
identify patients who may be prone to oral bleeding.23-30 In this way, the
clinician could evaluate the coagulation conditions of the patient and so
formulate a personal protocol of therapy. Local fibrinolysis has been considered
a significant pathogenetic factor in the devel-opment of bleeding complications
after oral surgery in patients with coagulation disor-ders. We have observed
that local antifibrinolytic therapy with tranexamic acid significantly re-duces
the incidence of bleeding during and after oral surgery.
The effect of the
antifibrinolytic treatment in oral surgery may be explained by the pres-ence of
activators of fibrinolysis and the ab-sence of physiologic inhibitors of
fibrinolysis in saliva.
Tranexamic acid binds to
lysine-biriding sites on plasminogen and plasmin. This mechanism blocks the
binding of plas-mM to fibrin, thus acting as a potent inhibitor of fibrinolysis.
The concentration of tranexamic acid in saliva after mouth rinsing 4 times a day
is sufficient to reduce the amount of lysed fib-rin so that the incidence of
postoperative bleeding complications are significantly re-duced. We have used
tranexamic acid for intra-venous infusions, oral rinses and cutaneous infusions
in associaiton with DDAVP in the case of Von Willebrand disease. In no cases a
considerable bleeding has been observed. Therefore, in order to obtain a
successful surgical result a good hemostasis through meticulous suturing and
oxidized cellulose is recommended.
The hemorrliagic emergencies are a serious trouble in dentistry. Nevertheless,
through th progress of the scientific knowledge on heinostasis and through the
collaboration with hematological centers, a safe approach to the patient with
coagulation disorders is now possible. It is preferable to treat hemorrhagic
risk patients in hospital so that to face with safe-ty possible hemmorrhagic
events during and after the operation.
Keywords: Blood disease –
Mouth, surgery – Bleeding.
F. INCHINGOLO, V. CRINCOLI, C. DI PALMA, A.M. INCHINGOLO