Assessment should include a systematic approach of collecting, organizing, and evaluating all patient data. Data must be retrieved from the personal, medical and dental histories, the pharmacological history, laboratory testing, and inspection of the extra and intraoral structures. This subjective and objective evidence is vital to the development of a proper treatment plan and dental management of patients with bleeding disorders when performing invasive dental procedures. All of these required pieces of information are essential when considering the legal and ethical responsibilities health care providers must exercise when caring for their patients.
Examining the medical history questionnaire is the first step in identifying whether or not it includes questions regarding the suspect or history of bleeding disorders. Questions should include the following: the determination of a known history or a family history of a bleeding disorder, history of bleeding episodes related to a dental procedure, areas of petechiae, purpura and ecchymosis, easy brusing, frequent nose bleeds (epitaxis), blood in the urine (hematuria), clotting problems, bleeding in the joints (hemarthrosis), deep muscle hematomas, excessive menstrual bleeding, alcohol abuse problems, cirrhosis of the liver, and unusual bleeding following an injury or a surgical procedure.1,2,5,9 A verbal inquiry or follow-up approach can include who, what, where, when, why, or how questions. Such questions that pertain to bleeding disorders can include:
- What is the bleeding disorder?
- What is the etiology of the bleeding disorder?
- What are the hemorrhagic signs and symptoms? Location of the hemorrhagic signs and symptoms?
- What prescription medications, OTC dugs and/or supplements are being taken?
- What are the results of the blood laboratory tests?
- Who is the supervising physician, cardiologist or hematologist?
- When was the bleeding disorder diagnosed? (bleeding history and/or family history)
- What bleeding complications have been encountered?(specifically, spontaneous bleeding with injury or a prolonged bleed related to dental or medical surgeries)
- How is the bleed medically or dentally managed?
Included in the pharmacological history the dental provider should query the patient about prescription medications that cause bleeding tendencies, specifically anticoagulation therapy, antiplatelet or nonsteroidal anti-inflammatory drugs, or heparin therapy. Just as important, patients should be asked about taking over-the-counter drugs containing aspirin; and they should be questioned about supplements and herbs that may exacerbate the bleed when patients are taking anticoagulants.26 There are more than 200 over-the-counter aspirin-containing drugs available to individuals as well as multiple combinations of herbal therapies that can affect the hemostatic pathways.
Following the patient and clinical assessments, dental professionals should perform a thorough extraoral and intraoral examination to identify deviations from normal that are indicative of bleeding disorders. Long-standing history of clinical findings in patients with mild to severe bleeding disorders often result in petechiae, ecchymoses, spontaneous gingival bleeding, and hemorrhages into the soft tissues. The most common oral finding associated with bleeding disorders is petechiae, which present as purple or red, 1 to 2 mm spots that appear as a result of minute hemorrhages within the dermal layers. Their locations are most often on the mucosal surfaces.27 Ecchymoses, larger than petechiae, are flat, reddish blue or purplish discolorations of the skin or mucosa.27 These hemorrhagic lesions result from spontaneous leakage of blood into the surrounding tissues (extravasation). This severe bleeding results from trauma, including surgery, by underlying blood vessels or by fragility of the vessel walls.1 In severe disorders, gingival bleeding may spontaneously occur.
Based on the outcome of the patient’s histories and head and neck (extra- and intraoral) examination, positive findings relative to the suspicion of a bleeding disorder should warrant a physician consultation and a laboratory screening evaluation. Hence, a proper diagnosis can be made and optimal dental care can be provided.