Uncontrolled bleeding during tooth extraction from an undiagnosed arteriovenous malformation.

Arteriovenous malformations (AVMs) are rare congenital disorders of vascular morphogenesis. These lesions are characterised by high vascular flow with risk of severe bleeding from accidental trauma or surgical manipulation. Although infrequent, potentially life-threatening and fatal oral bleeding has been reported during extraction of tooth associated with AVM. This paper presents a case of uncontrolled bleeding in an adult female patient undergoing mandibular anterior tooth extraction. The bleeding was related to undiagnosed soft tissue AVM in gingivobuccal space. Management of the case with review of previously reported similar cases is presented.

Angina bullosa haemorrhagica: a systematic review and proposal for diagnostic criteria.

The aim of this study was to perform a critical review of published data on the epidemiological, aetiological, clinical, histological, biological, and therapeutic characteristics of patients with angina bullosa haemorrhagica (ABH). A literature search was conducted in the PubMed, Science Direct, Web of Science, and Cochrane Library databases. All publications fulfilling the selection criteria were included in the eligibility assessment according to the PRISMA statement. The full texts of 54 retrieved articles were screened. Forty articles published between 1985 and 2016 describing 225 cases of ABH were finally selected. The mean age of the patients was 55.4 years; the male to female ratio was 0.7. The predominant localization was the palate (66%). A third of patients had no medical history. When specified, a triggering event or promoting factor was frequently found (82%). Biological tests were normal. A biopsy was performed on 35% of the patients. Treatment was symptomatic with a favourable outcome. Recurrences were frequent (62%). In conclusion, ABH is poorly documented and only by studies of low-level evidence. This review did not allow any aetiopathogenic association to be made with a general pathology or treatment. On the basis of this systematic review of the literature, diagnostic criteria aiming to improve the care of patients presenting with ABH are proposed.

Does Achievement of Hemostasis After Pulp Exposure Provide an Accurate Assessment of Pulp Inflammation?

PURPOSE: The purpose of this study was to determine in primary molars with carious exposures whether hemostasis at the exposure site and pulp orifice reflected inflammatory status of the pulp at the canal orifice based on cytokine levels. METHODS: Forty mandibular primary molars with deep caries were included in the study. Teeth were divided into two groups: group A had teeth where hemostasis at the exposure site was achieved within five minutes, and group B had teeth where hemostasis at the exposure site could not be achieved within five minutes. Blood samples were harvested from the exposure sites and canal orifices. Cytokine levels for IL-1ß, IL-2, IL-6, IL-8, IL-10, TNF-α, and PGE2 were measured using ELISA for all sample sites. RESULTS: The IL-6 levels at the exposure sites were found to be significantly higher in group A when compared to group B, but there was no statistically significant differences in any of the cytokine levels at the canal orifices between the two groups. CONCLUSIONS: Controlling bleeding at the exposure site or canal orifices does not provide accurate assessment of inflammation at the canal orifice and may be misleading for diagnosing vital pulp treatment in primary teeth with a carious pulp exposure.

Dental treatment in the era of new anti-thrombotic agents.

BACKGROUND: In recent years, there have been dramatic changes in anti-thrombotic treatment as a result of new anti-thrombotic agents, as well as changes in the indications for their use. As a consequence, dentists are encountering larger numbers of patients who are undergoing anti-thrombotic treatment and who have increased risk for bleeding. The current paper aims to review the literature regarding up-to-date anti-thrombotic treatment and provide information regarding their implications on dentistry. METHODS: An online search was performed of the literature published between 2000 and 2016. Articles dealing with evidence-based clinical guidelines for anti-thrombotic treatments, as well as literature reporting the use of anti-thrombotic medications were included. The manuscripts were screened according to their relevance to dentistry as well as their treatment protocol guidelines. RESULTS: In total, 5,539 publications were identified: 56 of 554 evidence-based clinical guidelines were found that dealt with treatment protocols with anti-thrombotic agents; and 132 of 5,539 articles describe direct anti-thrombotic medications. CLINICAL IMPLICATIONS: Dental treatment includes a risk for bleeding. As a result of the increasing number of patients taking new-generation anti-thrombotic drugs, dentists must be up to date regarding the implications of such drugs on dental treatment as well as the practical means to achieve haemostasis.

Oral surgery in patients under antithrombotic therapy: perioperative bleeding as a significant risk factor for postoperative hemorrhage.

: To investigate perioperative and postoperative bleeding, complications in patients under therapy with anticoagulant or antiplatelet drugs submitted to oral surgery. To evaluate the risk of bleeding and safety for dental surgery, a retrospective chart review was performed. Medical and dental records of patients taking oral antithrombotic drugs undergoing dental surgery between 2010 and 2015 were reviewed. Results were statistically analyzed using Fisher's exact test, t test or the χ test. One hundred and seventy-nine patients underwent 293 surgical procedures. A total of eight cases of perioperative and 12 episodes of postoperative bleeding were documented. The complications were generally managed with local measures and did not require hospitalization. We found significant association of postoperative hemorrhage with increased perioperative bleeding (P = 0.043) and combination of anticoagulant and antiplatelet therapy (P < 0.001). The chance of postoperative hemorrhage for procedures with increased perioperative bleeding is 8.8 times bigger than procedures without perioperative bleeding. Dental surgery in patients under antithrombotic therapy might be carried out without altering the regimen because of low risk of perioperative and postoperative bleeding. However, patients with increased perioperative bleeding should be closely followed up because of postoperative complications risk.

Unplanned readmission following transoral robotic surgery.

OBJECTIVES: To determine the rate of unplanned readmission after transoral robotic surgery (TORS), and to determine which patient or surgical factors increase the likelihood of readmission. MATERIALS AND METHODS: Retrospective chart review of all patients who underwent TORS for squamous cell carcinoma at our institution from March 2010 through July 2016. Primary outcome was unplanned readmission to the hospital within 30 days of discharge. Univariable and multivariable logistic regression were performed to identify risk factors for unplanned readmission. RESULTS: 297 patients met eligibility criteria. 23 patients (7.7%) had unplanned readmissions within 30 days. Most common reasons for readmission were oropharyngeal bleed (n = 13) and pain/dehydration (n = 10). Average time to unplanned readmission was 6.52 days (range 0-25 days). Discharge on clopidogrel was the only variable independently associated with an increased risk of 30-day unplanned readmission on multivariable analysis with an OR = 6.85 (95% CI 1.59-26.36). Unplanned return to the operating room during initial hospitalization (OR = 7.55, 95% CI 1.26-38.50) and discharge on clopidogrel (OR = 10.45, 95% CI 1.06-82.69) were associated with increased risk of postoperative bleeding. Bilateral neck dissection (OR = 5.17, 95% CI 1.15-23.08) was associated with significantly increased odds of unplanned readmission secondary to pain and dehydration. CONCLUSION: Unplanned readmission following TORS occurs in a small but significant number of patients. Oropharyngeal bleeding and dehydration were the most common reasons for unplanned readmission following TORS.

High-flow paediatric mandibular arteriovenous malformations: case reports and a review of current management.

High-flow vascular malformations in the paediatric population are potentially life-threatening and are challenging to treat. This paper describes the management of three cases of mandibular arteriovenous malformations and reviews the contemporary management options for these serious lesions.

Lupus anticoagulant hypoprothrombinemia syndrome associated with severe thrombocytopenia in a child.

Lupus anticoagulant hypoprothrombinemia syndrome (LAHPS) comprises lupus anticoagulant, acquired hypoprothrombinemia, and often mild thrombocytopenia or normal platelets. It is usually associated with autoimmunity or postviral illness. We describe a case of a 10-year-old boy with oral bleeding and severe thrombocytopenia initially suggestive of immune thrombocytopenia. Secondary to bleeding, evaluation demonstrated prolonged coagulation tests and subsequently revealed the presence of lupus anticoagulant and hypoprothrombinemia, along with marked autoimmunity, suggestive of LAHPS. He was treated with intravenous immunoglobulin and hydroxychloroquine. This case report and discussion highlight the diagnostic and therapeutic challenges associated with LAHPS and coincident severe thrombocytopenia.

Contemporary management of carotid blowout syndrome utilizing endovascular techniques.

OBJECTIVES/HYPOTHESIS: To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS). STUDY DESIGNS: Retrospective chart review. METHODS: Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied. RESULTS: Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable. CONCLUSIONS: The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist. LEVEL OF EVIDENCE: 4. Laryngoscope, 2016 127:383-390, 2017.

Oral surgery in liver transplant candidates: a retrospective study on delayed bleeding and other complications.

OBJECTIVE: Untreated dental infections pose a threat for immunocompromised liver transplant (LT) recipients. Therefore, pretransplant dental evaluations are recommended. However, risk of bleeding should be considered among patients with end-stage liver disease, and prophylactic blood transfusions may be used to prevent bleeding. We performed a retrospective study of the incidence of and risk factors for oral surgery-related bleeding in candidates for LT and hypothesized that complications may occur despite preoperative and perioperative hemostatic actions. STUDY DESIGN: One hundred thirty-four patients who had tooth extractions performed by oral and maxillofacial surgeons before LT were studied. The primary endpoint was bleeding between 24 hours and 2 weeks after extraction. Bleeding risk was analyzed by preoperative platelet (PLT) count and international normalized ratio (INR). Invasiveness of procedures, severity of liver disease, PLT, INR, prophylactic transfusions of PLT, fresh frozen plasma, and tranexamic acid (TA) were included in univariate and multivariate logistic regression analyses to further assess risk. RESULTS: Twelve patients exhibited minor bleeding; four despite PLT >100 × 10(9)/L and INR <1.5. Increased bleeding associated with INR and prophylactic transfusions by univariate analysis; by multivariate analyses, prophylactic TA (odds ratio [OR] = 8.0; 95% confidence interval [CI] 1.7-37.0), and PLT (OR = 8.3; 95% CI 1.1-62.7) remained significant. CONCLUSIONS: Most extractions were safe, but prophylactic transfusions did not ensure adequate hemostasis. Local hemostatic measures and close follow-up are warranted.

The Occurrence Rate and Diameter of Arteries Traveling Near the Mandible and an Assessment of the Relative Hemorrhage Risk in Implant Surgery.

BACKGROUND: Bleeding in the floor of the mouth during implant surgery is attributed to arterial injuries in the sublingual space. PURPOSE: This study aimed to assess the relative hemorrhage risk during implant surgery. MATERIALS AND METHODS: We investigated the occurrence rate and diameter of submental and sublingual arteries with special reference to their relationship with the course patterns of these arteries using 26 human cadavers. RESULTS: Three types of arteries were distinguished: main duct (MD), mucoperiosteal branches (MB), and cortical branches (CB). The occurrence rate of MB and CB was significantly high at the central incisor region in the upper part of the mylohyoid muscle, whereas the diameter of the MB and CB was significantly smaller than the occurrence rate of MD at the incisor regions. The occurrence rate of MD in the submental artery was significantly higher at the lateral incisor, canine, and premolar regions in the lower parts, whereas the occurrence rate of MD was significantly lower at the second and third molars in the upper parts. CONCLUSION: The susceptibility of the submental artery to injury is suggested at the incisors, canine, premolars, and first molar regions during implant surgery.

Massive oral bleeding after full-mouth extraction in a patient with B-cell lymphocytic leukemia/small lymphocytic lymphoma reversed with recombinant activated factor VII.

BACKGROUND AND OVERVIEW: Full-mouth extraction can be associated with intraoral bleeding, which usually is controlled with local hemostatic measures. Recombinant activated factor VII (rFVIIa) occasionally is used to stop bleeding in a variety of off-label indications, with the main argument curtailing its use being thrombotic events. The authors describe the use of rFVIIa for bleeding after full-mouth extraction in a patient with undiagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma. CASE DESCRIPTION: A 72-year-old man underwent full-mouth extraction (18 teeth). The next day, the patient experienced massive oral bleeding. The authors administered tranexamic acid, aminocaproic acid, and a total of 12 units of packed red blood cells in addition to local hemostatic measures without control of bleeding. On postoperative day 10, the authors administered 5,000 micrograms of rFVIIa, and within 2 hours oral the bleeding ceased. The authors performed flow cytometry and diagnosed B-cell lymphocytic leukemia/small lymphocytic lymphoma. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Unexplained massive oral bleeding despite adequate local hemostatic measures should prompt further investigations for underlying bleeding or coagulation disorders. The authors describe the successful use of rFVIIa in massive oral bleeding. Further studies are mandatory to study the effectiveness of this drug for this off-label indication.