Bleeding is often expected following invasive dental treatments, such as tooth extractions or implant placement. A piece of gauze on the wound is sometimes enough to manage bleeding, usually ceasing it within 10 minutes. Patients should stay away from hot and cold foods, exercise, and smoking, all to avoid post-operative bleeding, and unnecessary stress. However, for some patients, it isn’t so easy. Their care needs to be individualised to manage the risk and minimise bleeding as much as possible.
Bleeding disorders
Extensive bleeding during or after an operation can be a significant issue for haemostatic compromised patients. These conditions are often present from birth, disrupting the blood’s coagulation process and resulting in wounds that bleed for far longer than normal. This can potentially hinder the completion of treatment, as well as compromising the healing process of a wound. Patients that are susceptible to infection for longer periods for time could suffer both general health implications and the potential failure of their dental implant.
Two of the most common bleeding disorders include von Willebrand disease (VWD) and haemophilia. VWD is seen in up to one in every 100 people, whereas the two forms of haemophilia are rarer. Haemophilia A presents in one in every 10-20,000 people, and haemophilia B is one in every 30-60,000. Each of these conditions leads to easy bruising, potential spontaneous bleeding, and, most significantly, blood that takes longer to clot or doesn’t at all. Patients with these conditions have a reduced or non-existent level of specialised proteins that aid the coagulation of blood, referred to as clotting factors. Those with VWD have reduced ‘von Willebrand factor’; haemophilia A patients lack substantial levels of factor VIII; haemophilia B patients have a shortage of factor XI.
Individual considerations
Whenever planning treatment for a patient with a blood clotting disorder, it’s important to consider how their condition will impact the treatment and subsequent recovery. Invasive surgeries such as extractions, dental implants or periodontal surgery will require individualised care. Management of these patients requires collaboration with a haematologist, providing the highest level of knowledge available to minimise the risk to their health.
Consulting a patient’s designated haematologist can ensure the management of pre-operative procedures is comprehensive. Prior to all invasive surgeries, patients with inherited bleeding disorders should be advised to use appropriate clotting factor replacement therapy, aiming to reduce the risk of extensive bleeding. A patient’s haematologist can help manage the factor levels and replacements in relation to the planned surgery, to maximise safety throughout.
Anaesthesia is often a necessity to make treatment manageable and reduce pain for a patient. Patients with haemophilia are at a unique risk; inferior alveolar nerve blocks create the opportunity for bleeding into the surrounding muscles, potentially compromising the airways due to haematoma formation. Whilst clotting factor replacement minimises this risk, adjusting the administration site has also proved to be beneficial. Buccal infiltration is a minimally invasive technique and a comparable alternative to inferior alveolar nerve block injection. Whilst similarly effective, buccal infiltration may be preferred by patients due to its less invasive nature, combined with a lower risk of adverse events.
Managing bleeding
Clinicians should be appropriately prepared to immediately manage bleeding as it occurs, during or after a haemostatic compromised patient’s treatment. If bleeding occurs, early identification of the source is paramount. The application of a damp gauze will not be as immediately effective as when treating most other patients, but its use for at least 15 minutes, and in many cases longer, should be considered.
Utilising local haemostatic agents is essential for these patients. Absorbable sutures on the wound can effectively minimise the bleeding whilst preventing late bleeding at suture removal. A variety of measures, such as plugs and meshes, amongst others, are beneficial, and these should be chosen appropriately. Studies have found collagen-based items are the most effective, closely followed by gelatine and oxidised regenerated cellulose. Utilising multiple options at once, where appropriate, could be an overall beneficial solution to control post-operative bleeding.
Effective local haemostatic agents allow clinicians to be confident in their treatment, with a reliable solution at hand to manage post-operative bleeding. Consider using collacone, part of the biomaterials range from the Straumann Group, a haemostatic collagen plug that stabilises the blood coagulum to prevent postoperative bleeding events. Hydrophilic properties ensure collacone quickly absorbs blood, and its application with sutures allows for stable fixation in extraction sockets, ensuring food particles and bacteria cannot enter the vulnerable site.
Effectively tailoring care for haemostatic compromised patients is essential for reducing the risk of detrimental haemorrhages. By working with their haematologist to provide the safest level of care, clinicians ensure patients can access their necessary dental care whilst feeling in control of the risks their condition poses to treatment.
References available on request.
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