Special care dentistry: part 1. Dental management of patients with inherited bleeding disorders.

UNLABELLED: The most common cause of excessive bleeding is idiopathic, but bleeding can also be caused by inherited or acquired conditions associated with vascular defects, platelet defects or coagulation disorders. This paper will cover inherited bleeding disorders. Every clinician will encounter a patient who complains of prolonged bleeding following certain procedures; most commonly dental extractions. In the majority of cases the cause is often a local one and can be managed using simple local measures. However, prolonged post-operative bleeding following dental treatment might be one of the first signs of a bleeding disorder in an undiagnosed patient, necessitating referral for further investigations. Some patients may present with an already confirmed diagnosis of a bleeding disorder, requiring appropriate treatment planning and dental management in an appropriate setting with haematological advice. This paper will provide guidance on how to achieve this. CLINICAL RELEVANCE: To update clinicians on the dental management of patients with inherited bleeding disorders and how to decide the most appropriate setting for the provision of dental care.

Bleeding disorders seen in the dental practice.

Dentists may encounter patients with various types of bleeding disorders in their daily practice. Initial recognition of such bleeding disorders and their possible systemic causes, as well as knowing when to refer those cases to secondary care, plays a crucial and important role in reducing potential complications and negative side-effects. This article will give an account of the most common bleeding disorders that dentists might find in their daily dental practice. This will be followed by another article that will cover the management of congenital and acquired disorders found in the dental practice.

Coeliac disease causing symptomatic hypocalcaemia, osteomalacia and coagulapathy.

A 36-year-old gentleman presented with 6 months of poor energy, tingling in fingers and weight loss with a change in bowel habit. He appeared cachectic and had clubbing, demineralisation of teeth, pectus carinatus, kyphosis, spinal tenderness, proximal muscle weakness and generalised muscle atrophy. Chvostek's and Trosseau's signs were positive. His haemoglobin (Hb) was 8.7 g/dl, MCV 64.7 fl with low iron. Calcium corrected was 1.30 nmol/l, parathyroid hormone 440.4 ng/l, vitamin D <12.5 nmol/l; INR was 2.7 with coagulation inhibitor studies negative. Radiographs of spine and pelvis commented on osteopenia with thoracic kyphosis and mild anterior wedging of thoracic vertebrae. Antitissue transglutaminase was 145 U/ml, and antiendomysial antibodies were positive. An oesophagogastroduodenoscopy was consistent with coeliac disease. A diagnosis of osteomalacia and coagulopathy secondary to coeliac disease was made. The hypocalcaemia was treated with calcium gluconate infusions with symptomatic relief. Coagulopathy was treated with vitamin K intravenously with normalisation of INR. Following treatment with coeliac diet, calcium slowly normalised.

Template bleeding time for preoperative screening in patients having orthognathic surgery.

Excessive blood loss is a serious but rare complication of orthognathic surgery. The aim of this study was to find out whether template bleeding time (TBT) could detect primary bleeding disorders in patients having orthognathic operations and how many false positive tests there were. We also examined the correlation between the perioperative bleeding rate and the result of preoperative TBT. Patients who had orthognathic operations at Karolinska University Hospital, Huddinge, from August 2001 to December 2006, were screened preoperatively by measuring TBT and the records of their operations were reviewed retrospectively. Prolonged TBT was recorded in 20 patients (13%), 19 female and 1 male (P=0.02). After further examination, 10 of these patients were found to have a primary disorder of haemostasis. No detectable reason for the prolonged TBT could be found in the others. There was no significant difference in perioperative bleeding rate between patients with prolonged and normal TBT or between TBT and perioperative bleeding rate. In conclusion, the routine use of preoperative TBT for haemostatic screening in orthognathic surgery cannot be recommended because of the large number of false positive results. There was no significant correlation between prolonged TBT and bleeding during orthognathic surgery.

[Principal symptoms in hemostasis disorders]. / Leitsymptome bei Hämostasedefekten.

In a retrospective study the results of laboratory investigations were correlated with actual or previous bleeding symptoms of 40 patients. In 22 patients, a defect of hemostasis was documented in the laboratory, whereas the bleeding disorder, suggested by severe hemorrhage, could not be classified in 3 additional patients. In the remaining 15 individuals, no abnormality could be detected by the available laboratory methods. In the group with a documented bleeding disorder, 13 of 22 patients had prolonged bleeding following dental extraction or other surgery of the oral cavity. Other bleeding symptoms were equally distributed among patients with and without a documented defect. 3 patients had a positive family history, i.e. relatives with a hemorrhagic tendency. In 6 patients, a correlation between bleeding and the ingestion of acetylsalicylic acid could be established, while in 4 it was probable. Hemorrhagic complications following oral surgery, particularly in combination with drugs known to interfere with platelet function and a positive family history, strongly suggest an abnormality of hemostasis. Among the 22 patients with a documented defect of hemostasis, only 6 were found who did not present at least one of these leading symptoms.

[The social hygieneic importance of the cooperation of internal medicine and stomatology]. / Die sozialhygienische Bedeutung der Zusammenarbeit zwischen Innerer Medizin und ZMK-Heilkunde.

The contents of this paper are divided into three parts: the first points to the health risk for the dentist and his patients which has only been recently recognised to its full extent and seriousness: the transmission of virus hepatitis during dental treatment. The second section tries to enrol the help of oral surgery to detect the large number of unrecognised cases of hypertension through the introduction of blood pressure measurement into dental practice. The subject of the third section is the problem patients and patient problems deriving from medical diseases which crop up almost daily in dental practice and which should lead to interdisciplinary consultation between oral surgery and internal medicine.