Angina bullosa haemorrhagica-like lesions in pemphigus vulgaris.

BACKGROUND/OBJECTIVES: The aim of this study was to describe a previously unreported association of oral pemphigus vulgaris with short-lived blood-filled painless blisters resembling angina bullosa haemorrhagica (ABH). METHODS: A cross-sectional study of consecutive patients with Pemphigus vulgaris. All patients were examined for the presence of ABH-like lesions, and demographic, clinical and histopathological data were collected. Histopathological examination was performed when feasible. RESULTS: A total of 318 with pemphigus vulgaris were included (63.5% female, mean age: 46 years). ABH-like lesions were present in 82 (25.8%) patients, commonly observed in the buccal mucosa (47, 57.3%) followed by the palate (15, 18.3%). All patients had normal platelet counts with no evidence of bleeding diathesis. Biopsies of the ABH-like lesions showed suprabasal clefts in four of six samples. ABH-like lesions were significantly associated with partial remission of pemphigus vulgaris (47.5%, P = 0.002) and the use of intraoral steroids (P = 0.001, odds ratio: 5.9 [95% confidence interval: 2.5-13.6]). CONCLUSION: ABH-like lesions may represent a transient or abortive form of oral pemphigus vulgaris and tend to have a benign and self-limiting nature.

The effect of different hemostatic agents following dental extraction in patients under oral antithrombotic therapy: a network meta-analysis.

This network meta-analysis was done to thoroughly evaluate the available literature on the use of different hemostatic agents for dental extraction in patients under oral antithrombotic therapy, aiming to identify the agent with the best/worst performance in bleeding control. Considering that such patients have a higher risk of bleeding, choosing the right hemostatic is essential. Twenty-three randomized clinical trials articles were included after completing the literature search. Cyanoacrylate tissue adhesive showed a reduction in the odds of postoperative bleeding events compared with conventional methods (i.e., gauze/cotton pressure, sutures), with a tendency toward a statistical significance (OR 0.03, P = 0.051). Tranexamic acid was the only agent that demonstrated a significantly lower risk of developing postoperative bleeding events (OR 0.27, P = 0.007). Interestingly, chitosan dental dressing and collagen plug had the shortest time to reach hemostasis. However, they ranked last among all hemostatic agents, regarding bleeding events, revealing higher odds than conventional measures. Therefore, it is concluded that the use of cyanoacrylate tissue adhesive and tranexamic acid gives favorable results in reducing postoperative bleeding events following dental extractions. Although chitosan dental dressing and collagen exhibited a faster time to reach hemostasis, they led to a higher occurrence of bleeding events.

Successful management of bleeding after dental procedures with application of blood stopper: a single center prospective trial.

AIM: Ankaferd Blood Stopper (ABS), as an herbal complementary medicine, has been approved for the management of clinical hemorrhages in Turkey, including dental interventions. Basic, preclinical and clinical studies disclosed the settings of the topical hemostatic use of ABS. The aim of this study is therefore to assess the efficacy and safety of ABS as an antihemorrhagic agent in the bleedings associated with dental procedures in patients with normal and impaired hemostasis. MATERIALS AND METHODS: ABS has been topically applied by homogeneously spraying to the 113 patients during dental interventions within its on-label indications. A median of 0.5 ml (IQR:0.5-1 ml) ABS was administered after tooth extraction with prolonged hemorrhages. RESULTS: After the administration, bleeding stopped in less than 10 seconds in 59 (52.2%) patients, and below 22.5 seconds (IQR: 18, 8-30) in 54 patients (47.8%). A total of 141 procedures were performed in these 113 patients, and nearly 72.5 ml ABS was used with a total cost of 98 €. CONCLUSION: ABS as a new herbal medicine was found to be an effective method for controlling bleeding related to dental procedures. No patient had wound infection and the healing process appeared to be normal. Topical ABS could be useful for the local hemostasis and wound healing in periodontal surgeries. CLINICAL SIGNIFICANCE: In this prospective study ABS, for the first time, has demonstrated its potential for being an effective hemostatic agent for the management of bleedings due to dental procedures.

Manejo odontológico del paciente en tratamiento de anticoagulante oral sometido a cirugía oral: una revisión narrativa / Stomatological management of anticoagulated patients undergoing oral surgery: a narrative review

Resumen Los pacientes que se encuentran bajo tratamiento de anticoagulantes orales, presentan alteraciones en distintas etapas de la hemostasia, lo que conlleva a tener implicancias y consideraciones médico/quirúrgicas durante su atención. En la actualidad, no existe un consenso en relación con el manejo odontológico de estos pacientes que serán sometidos a procedimientos quirúrgicos, llevando a protocolos clínicos que siguen diversas posturas, como la de disminuir la ingesta farmacológica del anticoagulante, sustituir con heparina y la de mantener el tratamiento bajo control. Objetivo Establecer el manejo estomatológico del paciente que se encuentra en tratamiento de anticoagulante oral mediante una revisión profunda de la literatura Materiales y método Se realizó una búsqueda de revisión bibliográfica manualmente de artículos indexados a las bases de datos de PUBMED y EBSCO que correspondiesen a las palabras "cirugía bucal", "anticoagulantes", "atención dental" y "hemorragia oral". En cuanto a los criterios de inclusión, se consideraron revisiones bibliográficas, estudios observacionales, ensayos clínicos, guías, revisiones sistemáticas y metaanálisis publicados entre noviembre de 2005 y 2022, en idiomas inglés o español. Conclusiones Existen múltiples protocolos para la atención del paciente anticoagulado que será sometido bajo procedimiento de cirugía oral menor. Es importante considerar el anticoagulante utilizado, motivo, control de este, el procedimiento a realizar en el paciente y medidas hemostáticas tanto intra como postoperatorias por realizar, tras analizar lo anterior, se advierte que disminuir la ingesta del fármaco para realizar el procedimiento, puede ser más perjudicial al paciente como al clínico, por lo tanto se sugiere mantener el tratamiento antitrombótico y realizar un correcto manejo médico/quirúrgico.

Abstract Patients undertaking oral anticoagulant treatment may experience alterations in different stages of hemostasis, which lead to medical/surgical implications and considerations during their care. Currently, there is no consensus regarding the dental management of these patients, as they go through surgical procedures. This leads to clinical protocols that follow numerous approaches, such as reducing the pharmacological intake of the anticoagulant, replacing it with heparin, and maintaining the controlled treatment. Objective: To establish the stomatological management of the patient undergoing oral anticoagulant treatment through an in depth review of the literature. Materials and Method: A manual bibliographic review search of articles indexed to the PUBMED and EBSCO databases corresponding to the words "oral surgery", "oral bleeding", "anticoagulants" and "dental management" was performed. Regarding the inclusion criteria: bibliographic reviews, observational studies, clinical trials, guidelines, systematic reviews, and meta-analyses published between November 2005 and 2022, in English or Spanish, were considered. Conclusion: There are multiple protocols for the care of the anticoagulated patient who will undergo a minor oral surgery procedure. It is important to reflect on the anticoagulant used, the reason for it, its supervision, the surgical procedure that will be undertaken by the patient, and both intraoperative and postoperative hemostatic measures to be implemented. After analyzing the above, it is noted that reducing the intake of the drug to perform the surgical procedure may be harmful to the patient and to the clinician, therefore it is suggested to maintain the antithrombotic treatment and carry out a correct medical/surgical management.

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.

Is povidone-iodine a hemostyptic? A clinical study.

Povidone-iodine (PVP-I) is an antiseptic agent commonly used on intact skin in preparation for surgery and on open wounds. In oral surgery it is used for irrigating alveolar sockets following extraction. The present authors found by chance that irrigation of extraction sockets with povidone-iodine led to cessation of bleeding in patients without recurrence. Fifty patients were selected and divided equally into treatment and control groups. Povidone-iodine (1%, w/v) was used for irrigation of extraction sockets in the treatment group and saline was used in the control group. In the treatment group, 19 patients showed cessation of bleeding compared to only 5 in the control group. Povidone-iodine significantly (P<0.01) controlled bleeding as compared to saline. Iodine is corrosive due to its oxidizing potential while povidone is a thickening and granulating agent; together they may have a chemocauterizing effect that could be the reason for the cessation of bleeding. These results suggest that povidone-iodine may act as a hemostyptic as well as an antiseptic.

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.

Management of bleeding in a multi-transfused patient with positive HLA class I alloantibodies and thrombocytopenia associated with platelet dysfunction refractory to transfusion of cross-matched platelets.

Thrombocytopenia is a common condition in the critical care setting. Repetitive platelet transfusion might lead to formation of alloantibodies. HLA class I and human platelet antigen antibodies can lead to transfusion-refractory thrombocytopenia. Transfusion of cross-matched platelets often is effective in these patients. We report on the successful use of recombinant activated factor VII in an acute bleeding situation in a multi-transfused patient presenting with positive HLA class I alloantibody status and thrombocytopenia associated with platelet dysfunction refractory to even transfusion of cross-matched platelets. The 41-year-old female patient developed HLA class I antibodies during former episodes of massive transfusion. Her former medical history was empty concerning hemorrhagic events. During this specific bleeding episode the patient suffered from intractable profuse bleeding from the nasopharynx and oral cavity. Global coagulation tests were within the normal range. Platelet dysfunction was confirmed by PFA100. Initially the patient responded well to Desmopressin infusion, but after 36 h she became thrombocytopenic and refractory to even transfusion of cross-matched platelets. Recombinant activated factor VII was chosen as the last resort. Two identical boli of 160 microg/kg NovoSeven each were injected via a central line within an interval of 3 h. After the first injection bleeding was significantly reduced and vasopressor support discontinued. After the second bolus bleeding completely ceased and did not reoccur. We did not observe any side effects. The pluripotent hemostatic agent recombinant activated factor VII might be a new option in the treatment of hemorrhagic episodes in patients presenting with this rare disorder, especially when the patient is refractory to cross-matched platelets or matched platelets are not available.

A Stafne's cavity with unusual location in the mandibular anterior area.

The typical Stafne's cavity, located on the posterior portion of the mandible, is a relatively uncommon entity. However, when the defect is located in the anterior region of the mandible, it is quite rare, having thus far been described in only 36 cases in the scientific literature. Most of these defects appear in the fifth and sixth decades of life, are localized to the area of the canines and premolars, and have a predilection for males. The inferior dental canal, one of the anatomical-radiographic landmarks that aid in the diagnosis of Stafne's cavity in the posterior region, is rarely present anterior the mental foramen. For this reason, because of its more variable radiographic appearance compared to the posterior defect, its tendency to be superimposed over the apices of the teeth, and the rarity of its localisation to the anterior mandible, it is much more difficult to establish a definitive diagnosis of a Stafne's cavity in this location. It is therefore more likely that a diagnostic error can occur, especially early on. We present a new case in a 68-year-old male in which the diagnosis was serendipitous, and we review in particular the aetiology and pathogenesis, clinical aspects, and differential diagnoses for this condition.

Primary prevention of coronary arterial thrombosis with the factor Xa inhibitor rTAP in a canine electrolytic injury model.

The antithrombotic efficacies of the coagulation factor Xa inhibitor recombinant tick anticoagulant peptide (rTAP) and heparin were compared in a canine model of left circumflex (LCX) coronary artery electrolytic lesion. Intravenous infusions of saline (controls), rTAP (50 micrograms/kg/min continuous infusion) or heparin (200 U/kg bolus followed by 2 U/kg/min continuous infusion) were started 60 min prior to the initiation of LCX coronary artery electrolytic injury (150 microA continuous anodal current). All 6/6 saline-treated control animals developed occlusive thrombi at 49.8 +/- 13.6 min after the initiation of vessel injury, and possessed a residual thrombus mass of 20.7 +/- 3.3 mg. In the rTAP treatment group, 4/6 preparations developed occlusive thrombi, but with times to thrombosis delayed significantly compared to both the saline control as well as to the heparin treatment group (202.7 +/- 28.9 min; p < 0.01 to both saline and heparin groups). The remaining 2 rTAP-treated preparations remained patent despite the continued electrical stimulation of the coronary vessel for 5 h. Residual thrombus mass in the rTAP treatment group was reduced markedly compared to the saline control group (4.4 +/- 1.0 mg; p < 0.01). Heparin infusion resulted in a modest but statistically insignificant delay in occlusive LCX coronary artery thrombosis compared to saline controls, with all 6/6 heparin-treated preparations occluding at 79.7 +/- 16.5 min after the initiation of vessel injury. Residual thrombus mass in heparin-treated animals, however, was reduced compared to saline controls (9.4 +/- 1.4 mg; p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Recombinant activated factor VII combined with local measures in preventing bleeding from invasive dental procedures in patients with Glanzmann thrombasthenia.

Recombinant activated factor VII (rFVIIa), combined with local measures of fibrin glue and a celluloid splint, preventing bleeding from four invasive dental procedures is reported. A single dose of 180-200 micro g/kg was successfully used in three surgical removals of impacted teeth. Four doses of rFVIIa were required in another full mouth treatment of extraction, pulpotomy, filling and the stainless steel crowning of 13 teeth. The repeated dose of rFVIIa was given whenever the bleeding complication was visualized. It is cost-effective for preventing external bleeding. Additionally, an oral rinsing solution of tranexamic acid (25 mg/kg) was given three times a day for 7 days. In conclusion, rFVIIa has been shown to be an effective alternative to platelet concentrate in patients with Glanzmann thrombasthenia.

Variability of gingival bleeding in experimental gingivitis trials.

Gingival bleeding is a difficult parameter to assess in experimental trials. The Confirmed Bleeding Day was recently developed as a measurement for this purpose. It was observed that considerable variations existed between the measurements made in a pilot study and an experimental trial, and these variations were subjected to a statistical analysis. The reasons for the variations are discussed, and recommendations made for the design of experimental trials involving gingival bleeding.

Hemodynamic changes during dental extraction and post-extraction bleeding in patients with prosthetic heart valves.

Hemodynamic changes during dental extraction and postextraction bleeding were retrospectively evaluated in patients with prosthetic heart valves. It was found that the rate pressure product had a higher value in the period of anesthesia and during dental extraction. There was a tendency for a high RPP difference corresponding to an increased incidence of ECG changes, such as ST-T, QRS, P, and tachycardia. ECG changes were frequently observed high in procedures which required high doses of local anesthetic at one time or when multiple dental extractions were undertaken, whereas they seemed to have no positive relation to the number of heart valves replaced. Approximately 87% of the extractions were carried out under continuous anticoagulant therapy with a pretreatment coagulability level, of which 32% had bleeding during the first 24 h.

Vasopressin for bleeding from the head and neck.

Excessive bleeding from the head and neck sometimes presents a therapeutic problem. Ten patients with this type of haemorrhage have been treated with continous vasopressin infusion for 1-3 days. Haemostasis was quickly established in eight cases. No serious side effects were noted. Infusion of vasopressin has a rapid, beneficial effect on haemorrhage from branches of the external carotid artery.

Serious postextraction hemorrhage into the submandibular space: report of case.

A 47-year-old woman had a swelling in the floor of the mouth and in the submandibular area on the left side. About four hours earlier, a dentist had extracted the mandibular left second premolar and first molar. The rate and degree of the distension were alarming; the floor of the mouth was at a level with the incisal edges of the mandibular incisors. Five hours later, the floor of the mouth was elevated about 1 1/2 cm above the incisal edges of the teeth. Treatment of the patient and her unusual sensitivity to meperidine and promethazine that caused a depression into Cheyne-Stokes respiration and hypotension are described.

Post-extraction bleeding--an aid to diagnosis? Case report.

Haemophilia A, the most common of bleeding disorders is characterized by bruising and spontaneous bleeding into the joints but may remain undiagnosed if present in the mild form. A case is discussed where episodes of bruising and joint swelling as a child were misdiagnosed as rheumatic fever and the bleeding disorder was diagnosed following recurrent episodes of bleeding after extraction of an upper molar tooth.

Diagnosis and management of onyalai.

Onyalai is diagnosed by finding the combination of haemorrhagic blisters in the mouth and severe thrombocytopenia, and by excluding other possible causes of thrombocytopenia. Patients improve rapidly with appropriate therapy. Haemorrhagic shock should be corrected with intravenous fluid and blood transfusion. Corticosteroids should be given in large doses initially, then tapered off and stopped over a period of several weeks. Occasional patients may require more prolonged steroid therapy.

[Study on the antihemorrhagic action of aminaphtone]. / Studio sull'azione antiemorragica dell'Aminaftone.

This research is the continuation of a previous published paper. The blood losses occurring during multiple dental extractions under general anesthesia in pretreated patients (not with a recent new capillary protector) have been measured. The results obtained have been processed statistically and confirm the effectiveness of the product.