Treatment Planning Considerations

Appropriate management for patients with bleeding disorders who require routine invasive dental procedures, including subgingival debridement (scaling and root planing), restorative procedures or simple surgical procedures, consists of the following:

    Step 1: Take accurate, comprehensive histories: personal, medical, dental and pharmacological. Perform a thorough extra and intraoral examination to identify lesions indicative of a bleeding disorder. When a known bleeding disorder is evident, understand the pathophysiology and its related impact on dental treatment. When an unknown bleeding disorder is suspected, refer the patient to his physician or a hematologist to establish a diagnosis. Definitive diagnosis of the bleeding/clotting disorder can be established by the physician or hematologist by ordering the “Prolonged Clotting Time Profile”11 laboratory tests.

    Step 2: Consult with the supervising physician to obtain additional information about the patient’s disorder or bleeding history. Continue to investigate and/or to obtain medical clearance to treat. Secondly, retrieve and evaluate the blood laboratory test results while scheduling the appointment within 24 hours of the results.

    Step 3: Develop an appropriate treatment plan: establish whether or not the invasive dental procedure will be carried out in the dental office or in a hospital-based dental facility. Possibly, prior to invasive treatment, consider blood and/or clotting factor replacement therapy for patients with hemophilia; and, patients with platelet disorders may require platelet transfusion therapy. In addition, other medical interventions may be required beyond infusion therapies for the respective disorders; for example, fibrinolytic defects, vascular defects or modification of anticoagulant therapy may require specialized medical care. When performing the invasive dental procedure recommendations include: minimize tissue trauma; consider hemostatic systems for predictable extensive bleeding during and after complex surgical procedures; consider alternative pain control techniques other than nerve-block anesthesia, especially for patients with coagulopathies; emphasize periodontal health to minimize gingival inflammation which can result in increased bleeding; and/or consider using a combination of local hemostatic systems to manage bleeding episodes. Specialty dental procedures (restorative, endodontic or surgical) can adhere to these fundamental guidelines in their approach to manage bleeding episodes, but most importantly, various invasive oral procedures carry a range of bleeding risk.2,17,24,25

When considering the management of a clinical bleed during various invasive dental procedures, hemostatic measures can include the following systemic or local applications: hemostatic irrigant; absorbable gelatin sponge containing a thrombin solution; gauze-soaked squares and/or mouthrinses with fibrin or tranexamic acid (TXA); aminocaproic acid (EACA); vasoconstrictors in local anesthetics; surgical techniques and sutures; ice packs; and/or a combination of these measures (Table 3).2,4,19,25,28

Table 3. Drug Products and Dental Procedures Used as Local Measures to Limit and Control Bleeding During Invasive Dental Procedures2,24
Brand Name Chemical Name Mechanism of Action Contradictions Disadvantages
Gauze 2” x 2” sterile gauze pads; place pressure on wound to close or apply finger pressure
Gelfoam Absorbable gelatin sponge material; provides stable 'scaffold' for clot formation Should not be used under epithelial incisions or flaps, inhibits healing
Surgical Oxidized regenerated cellulose; exerts physical effect rather than physiological
Bleed X Hemostatic product containing microporus poly-saccharide hemispheres (potato starch); dehydrates blood and accelerates clotting No known contraindications
Tisseel Fibrin sealant; adhesive action that binds fibrin to the clot Technique sensitive: requires special attention to preparation; reserved for complex procedures
Cykloapron Tranexamic acid Used in the form of a mouthwash after surgical procedures to inhibit postoperative bleeding; can be administered parenterally or as an 4.8% aqueous solution (4 times daily for 1 week)
Suturing Apposition of soft tissue
Amicar Aminocaproic acid Antifibrinolytic agent No longer available for topical use
Electrocautery Tool to slow intraoperative bleeding and interfere with postoperative episodes Use cautiously to avoid excessive tissue necrosis
Every drug or dental product is not without side effects/adverse events or drug interactions; dental provider must use dental drug reference prior to their use and/or consult with the patient's supervising physician.

Regarding patients on warfarin therapy, pharmacological evidence driven by a current, comprehensive literature review by investigators Patatanian and Fugate concluded the following outcomes regarding the use of hemostatic mouthwashes on patients with various INR target ranges: based on several small clinical studies, tranexamic acid and epsilon aminocaproic acid hemostatic mouthwashes are shown to be effective and safe in this selective population; although, TXA is “6–10 times more potent than EACA.”28 Neither hemostatic agent is prepared as a solution for local delivery; however, the pharmacist can prepare this hemostatic prescription as an aqueous preparation as indicated by the dental provider.28 Supporting this literature review is a Class I recommendation by Aframanian et al., based on a Level of Evidence A, by multiple randomized controlled trials. The use of a 2-day regimen of a 4.8% tranexamic acid mouthwash is helpful in achieving adequate clotting in patients on oral anticoagulation therapy after the simple oral surgical procedures.19

More importantly, when selecting a hemostatic therapy that achieves adequate hemostasis when performing invasive dental procedures on patients with bleeding disorders one must consider the following elements:

  • The specific bleeding disorder.
  • The need for a hemostatic agent and/or intervention.
  • The type of local and/or systemic hemostatic agent.
  • The need for a consultation with the patient's supervising physician to determine the need for coagulation factor replacement as indicated.
  • The severity of the bleeding disorder.
  • The specific invasive dental procedure that will induce a bleed intraoperatively and postoperatively.24