Haemostasis. Part 1: The management of post-extraction haemorrhage

Management of Cardiovascular Disease Patients with Periodontitis Requiring Dental Treatment - A KAP Study among Dental Students

Background

It is frequently observed that dental students require so many consents to manage medically compromised patients, especially cardiovascular patients with periodontitis requiring dental treatment.

Aims and Objectives

The present study aimed to assess the dental students' knowledge, attitudes, and practices regarding the management of cardiovascular disease (CVD) patients with periodontitis requiring dental treatment.

Material and Methods

The cross-sectional study was conducted among 611 dental undergraduate and postgraduate students (branches of Periodontology, Oral and Maxillofacial Surgery, Oral Medicine and Radiology, Endodontics, Prosthodontics, and Public Health and Dentistry) of central Gujrat. Self-administered structured questionnaires with 23 questions were distributed in pen-and-paper physical format. Statistical analysis for descriptive statistics like frequency, percentage, mean, standard deviation, confidence interval, one-way analysis of variance, post hoc test for multiple comparisons, Fisher's exact test, and Pearson's correlation has been done by MS Excel and STATA/IC-13.

Results

As per the post hoc test, both groups of students have significantly different knowledge (-4.20210*, P = 0.028) and their practices (0.68632, P = 0.968) but no significant difference between their attitudes (-6.22828, P = 0.089). According to the Pearson correlation test, a weak positive/no relationship between knowledge, attitudes, and practice is reported in both study groups. There is a weak positive relation between knowledge and attitudes (0.270) and between knowledge and practices (0.121), and a similar relationship between their attitudes and practices (0.172) was observed in both groups.

Conclusion

Correct knowledge, attitudes, and practices regarding dental management of CVD patients with periodontitis can reduce medical consent to improve the treatment quality of dental students.

Analysis of Risk Factors for Post-Extraction Bleeding and Study on Emergency Intervention Strategies

Objective

The objective of this investigation is to delineate the distributional attributes of factors correlated with post-tooth extraction bleeding and to scrutinize corresponding strategies for emergency prevention and intervention.

Methods

The chi-squared test and rank sum test were deployed to evaluate fluctuations in blood loss. Univariate and multivariate binary logistic regression methodologies were employed to compute the odds ratio (OR) and its associated 95% confidence interval (95% CI). Furthermore, we delved into the relationship between each contributing factor and blood loss. Concurrently, univariate and multivariate logistic regression techniques were utilized to probe the nexus between blood loss and treatment modalities.

Results

Following adjustments for pertinent factors, the outcomes of multivariate analyses unveiled an escalated susceptibility to bleeding among male patients and individuals aged 60 years or older. The adjusted OR values and their corresponding 95% CI were determined as follows: OR = 1.54 (95% CI: 1.34-1.77, P < 0.001), OR = 0.74 (95% CI: 0.59-0.91, P = 0.005), OR = 0.58 (95% CI: 0.42-0.80, P = 0.001). Additionally, the results of multivariate logistic regression analysis indicated that, in contrast to individuals experiencing minimal blood loss, the OR values associated with treatment modalities for patients encountering substantial blood loss, namely iodoform gauze strips, sutures, collagen, and compression, were noted as follows: OR = 220.80 (95% CI: 151.43-321.95, P < 0.001), OR = 69.40 (95% CI: 46.11-104.44, P < 0.001), OR = 52.78 (95% CI: 34.66-80.38, P < 0.001), OR = 12.85 (95% CI: 9.46-17.45, P < 0.001).

Conclusion

It is imperative to prioritize the scrutiny of risk factors associated with post-tooth extraction hemorrhage, with the aim of preemptively averting incidences of bleeding subsequent to tooth extraction. Moreover, it is paramount to offer expert and tailored emergency interventions designed to address diverse case scenarios.

A "Tie-Over" Hemostatic Approach in Emergency Department: An Alternative Option for Recurrent Episodes of Postoperative Intraoral Hemorrhage

Objective

This case series aimed to describe a hemostatic technique that has been applied in patients admitted to emergency department (ED) of a tertiary hospital due to recurrent episodes of intraoral hemorrhage (IOH) after various dentoalveolar operations. The "tie-over" approach involved the intraoral use of Xeroform® gauze (as compressive bolster dressing) and the oral rinsing with a liquid mixture of hemostatic agents.

Materials and Methods

Between February 1, 2014, and July 31, 2017, we retrospectively reviewed the medical data and records of patients in ED who chiefly complained about IOH. The inclusion criteria were cases secondary to dentoalveolar surgeries that have been exclusively treated by tie-over bolster approach. Data such as frequency and severity of hemorrhage episodes, pain, and discomfort were assessed pre- and postoperatively.

Results

The presented technique was applied in 23 patients, but 20 of them complied with follow-up evaluation. The mean age of those patients was 60.57 years (15-82 years) with a mean follow-up time of 5.05 days. Eighteen patients were taking antithrombotic medications, either per os (oral antiplatelets and anticoagulants-OAA group) or subcutaneously (heparin group). One patient from OAA group and 2 from heparin group experienced in total 4 bleeding events postoperatively. Three of those events were recorded as minimal (oozing) and did not last over 20 min. All the patients declared satisfaction about the non-bleeding oral status.

Conclusions

In addition to its compelling outcomes, we advocate that this approach conferred physiological benefits on patients who visited ED with symptoms of anxiety and malaise, secondary to multiple, lasting, or uncontrolled episodes of IOH related to extensive surgical trauma. The presence of the gauze intraorally was short-term and created minimal discomfort.

A Case of Congenital Mild Hemophilia Diagnosed After Wisdom Teeth Extraction

Hemophilia A is a recessive congenital deficiency of factor VIII that is characterized by normal bleeding time, normal prothrombin time, and prolonged activated partial thromboplastin time. In moderate and severe cases, abnormal bleeding is observed even after minor trauma, and the diagnosis is usually made by the age of 5-6 years, whereas in mild cases, abnormal bleeding is detected after major trauma or surgery. Herein, we present a case of hemophilia A that was discovered due to difficulties with hemostasis after tooth extraction.

A natural polyphenol-functionalized chitosan/gelatin sponge for accelerating hemostasis and infected wound healing

Natural polymers have been particularly appealing for constructing hemostatic materials/devices, but it is still desirable to develop new natural polymer-based biomaterials with balanced hemostatic and wound-healing performance. In this work, a natural polyphenol-functionalized chitosan/gelatin sponge (PCGS) was prepared by the lyophilization of a chitosan/gelatin mixture solution (under a self-foaming condition to prepare the CGS) and subsequent chemical cross-linking with procyanidin (PC). Compared with the original CGS, PCGS exhibited an enhanced liquid-absorption ability, reduced surface charges, and similar/low hemolysis rate. Benefiting from such a liquid-absorption ability (∼4000% for whole blood and normal saline) and moderate surface charges, PCGS exhibited high in vitro hemostatic property and promising hemostatic performance in an in vivo femoral-artery-injury model. In addition, PCGS possessed higher antioxidant property and slightly decreased antibacterial ability than CGS, owing to the incorporation of PC. The feasibility of PCGS for treating infected wounds was further confirmed in an in vivo infected-tooth-extraction model, as the typical complication of intractable tooth-extraction bleeding. The present work demonstrated a facile approach for developing multifunctional hemostatic materials through the flexible management of natural polymers and polyphenols.

A Biodegradable Flexible Micro/Nano-Structured Porous Hemostatic Dental Sponge

A biodegradable micro/nano-structured porous hemostatic gelatin-based sponge as a dentistry surgery foam was prepared using a freeze-drying method. In vitro function evaluation tests were performed to ensure its hemostatic effect. Biocompatibility tests were also performed to show the compatibility of the sponge on human fetal foreskin fibroblasts (HFFF2) cells and red blood cells (RBCs). Then, 10 patients who required the extraction of two teeth were selected, and after teeth extraction, for dressing, the produced sponge was placed in one of the extracavities while a commercial sponge was placed in the cavity in the other tooth as a control. The total weight of the absorbed blood in each group was compared. The results showed a porous structure with micrometric and nanometric pores, flexibility, a two-week range for degradation, and an ability to absorb blood 35 times its weight in vitro. The prepared sponge showed lower blood clotting times (BCTs) (243.33 ± 2.35 s) and a lower blood clotting index (BCI) (10.67 ± 0.004%) compared to two commercial sponges that displayed its ability for faster coagulation and good hemostatic function. It also had no toxic effects on the HFFF2 cells and RBCs. The clinical assessment showed a better ability of blood absorption for the produced sponge (p-value = 0.0015). The sponge is recommended for use in dental surgeries because of its outstanding abilities.

Uncontrollable bleeding after tooth extraction from asymptomatic mild hemophilia patients: two case reports

Background

Uncontrollable bleeding after tooth extraction usually occurs in patients with coagulation diseases, including hemophilia, von Willebrand’s disease, vitamin K deficiency, platelet deficiency, and taking anticoagulant drugs. Hemophilia A is an X-linked recessive disorder caused by insufficiency of coagulation factor VIII. Mild hemophilia, defined by factor level between 0.05 and 0.40 IU/mL, is characterized by uncontrollable hemorrhage after trauma or invasive operations. Some mild hemophiliacs may remain undiagnosed until late adulthood. Therefore, surgical management of these patients may be relatively neglected. These case reports describe two uncontrollable bleeding patients with unknown mild hemophilia A after tooth extraction.

Case presentation

This paper reports 2 cases of persistent bleeding after tooth extraction under local anesthesia which could not be completely stopped by routine treatments. Both of them denied prior illness and injury, allergies, anticoagulant medication history, systemic and family illness. The APTT and other coagulation screening tests of the two patients before surgery were normal. Finally, they were diagnosed with mild hemophilia A via coagulation factor assays. The patients acquired complete hemostasis by receiving coagulation factor supplement therapy in hematologic department.

Conclusion

Mild hemophilia is marked by subclinical, asymptomatic and even normal coagulation test results. The purpose of these case reports is to bring dental professionals’ attention that APTT test alone cannot be used to exclude mild hemophilia, and provide reasonable evaluation and treatment procedures of bleeding patients after tooth extraction.

Dental management of patients on anti-thrombotic agents

The number of geriatric patients seeking dental service is ever-rising because of increased life expectancy, also with problem of increased chronic medical conditions. One of them are patients on anti-thrombotic medication. Bleeding complication after minor oral surgery by anti-thrombotic agents is of concerns to dentists on dental management of these patients. Risk and benefit of the anti-thrombotic agents must be weighed before initiating dental procedures, which should be established as a treatment guideline. Purpose of the paper is to optimize the management of the dental patients on anti-thrombotic medication via standardization of treatment protocol of such a patient.

Interventions for treating post-extraction bleeding

BACKGROUND

Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. This is an update of a review published in June 2016.

OBJECTIVES

To assess the effects of interventions for treating different types of post-extraction bleeding.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 24 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 24 January 2018), Embase Ovid (1 May 2015 to 24 January 2018) and CINAHL EBSCO (1937 to 24 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. We searched the reference lists of relevant systematic reviews.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment.

DATA COLLECTION AND ANALYSIS

Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis.

MAIN RESULTS

We did not find any randomised controlled trial suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).

Knowledge, Attitude, and Perceived Confidence in the Management of Medical Emergencies in the Dental Office: A Survey among the Dental Students and Interns

Aims and Objectives

Many situations in the dental office can provoke medical emergencies. Lack of training and inability to overcome the medical emergencies can lead to serious consequences and legal actions. The aim of the study is to investigate and assess the knowledge, attitude, and perceived confidence of dental students and interns in the management of medical emergency.

Materials and Methods

A self-administered structured questionnaire was distributed to 153 of the undergraduate dental students and interns in Qassim province. Questionnaire consisted of nineteen questions pertaining to knowledge and awareness regarding syncope, cardiopulmonary resuscitation (CPR), intravenous drugs, measuring vital signs, and handling situation of aspiration of a foreign body, bleeding, and choking. Data were analyzed by Statistical Package for Social Sciences (SPSS) version 21.0.

Results

Fifty-seven percent was the response rate received from the questionnaire. Eighty-nine percent and 30% of the participants inquired about the medical history and vital signs before dental treatment, respectively. Only 37% of participants were confident to handle any medical emergency in the dental office. Seventy percent knew the correct location of chest compression and 67% were familiar about the right compression ventilation ratio showing significant difference between academic years and interns (P = 0.003). Females were significantly more aware about the management of bleeding after extraction than the males (65%, and 47%, respectively; P = 0.035). Thirty-five percent and 53% chose the correct management to relieve choking in responsive and unresponsive adult or child, respectively. A total of 28% of the participants reported syncope as the most common emergency situation.

Conclusion

Participants were lacking confidence in handling medical emergencies even though the majority of them inquired the medical history. Most of them have a good knowledge regarding CPR, but regarding airway obstruction, the knowledge was not at an acceptable level. Annual basic life support and emergency courses should be mandatory in dental teaching curriculum.

Management of a Life Threatening Bleeding Following Extraction of Deciduous Second Molar Related to a Capillary Haemangioma

Various forms of vascular lesion affect the head and neck region. The head and neck vascular lesions are classified into neoplasms and malformations. Neoplasm presents either as hemangioma or lymphangioma; neoplasm usually presents in young age compared with vascular malformation. A 9-year-old female patient presented to the outpatient clinic referred from the department of pedodontics after extraction of a right mandibular second deciduous molar. Extraction was done by dental GP in outpatient clinic. Massive bleeding followed the extraction. Bleeding was controlled by electrocoagulation of bleeding site and systemic and local application of antifibrinolytic agent. An intravenous line was placed to provide fluid replacement. Injection of intravenous cyklokapron was given to stabilize the blood clot. Selective embolization was performed 24 hours prior to surgical resection of lesion and the lesion was removed under general anesthesia followed by peripheral ostectomy of bone to remove any feeders. Different protocols are used to control life-threatening bleeding. Primary local measures such as Gelfoam packing, Tranexamic or Aminocaproic topical application, Surgicel application, Electrocautery, Bone wax, Ligation of External Carotid or Common Carotid Artery, or Selective Embolization of feeder vessel may be used to control the bleeding. Interventional radiographic blockage of feeder vessel currently shows high success rate in the management of life-threatening bleeding compared with previous techniques.

Clinical applications of ferric sulfate in dentistry: A narrative review

Ferric sulfate (FS) has been commonly used as a local hemostatic agent for more than three decades in dentistry. Even though the hemostatic mechanism of FS is questioned, it seems that agglutination of blood proteins occurs due to the reaction of blood with ferric and sulfate ions in acidic pH. FS has gained widespread importance as a pulpotomy medicament in contemporary dentistry; nevertheless, it has several applications in different fields of dentistry which was paid little attention. Hence, the purpose of this paper is to review the various applications of FS in dentistry, along with restorative dentistry and endodontics.

Interventions for treating post-extraction bleeding

BACKGROUND

Post-extraction bleeding (PEB) is a recognised, frequently encountered complication in dental practice, which is defined as bleeding that continues beyond 8 to 12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0% to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue haematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced). There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes.

OBJECTIVES

To assess the effects of interventions for treating different types of post-extraction bleeding.

SEARCH METHODS

We searched the following electronic databases: The Cochrane Oral Health Group Trials Register (to 22 March 2016); The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2016, Issue 2); MEDLINE via OVID (1946 to 22 March 2016); CINAHL via EBSCO (1937 to 22 March 2016). Due to the ongoing Cochrane project to search EMBASE and add retrieved clinical trials to CENTRAL, we searched only the last 11 months of EMBASE via OVID (1 May 2015 to 22 March 2016). We placed no further restrictions on the language or date of publication. We searched the US National Institutes of Health Trials Register (http://clinicaltrials.gov), and the WHO Clinical Trials Registry Platform for ongoing trials (http://apps.who.int/trialsearch/default.aspx). We also checked the reference lists of excluded trials.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) that evaluated any intervention for treating PEB, with male or female participants of any age, regardless of type of teeth (anterior or posterior, mandibular or maxillary). Trials could compare one type of intervention with another, with placebo, or with no treatment.

DATA COLLECTION AND ANALYSIS

Three pairs of review authors independently screened search records. We obtained full papers for potentially relevant trials. If data had been extracted, we would have followed the methods described in the Cochrane Handbook for Systematic Reviews of Interventions for the statistical analysis.

MAIN RESULTS

We did not find any randomised controlled trial suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

We were unable to identify any reports of randomised controlled trials that evaluated the effects of different interventions for the treatment of post-extraction bleeding. In view of the lack of reliable evidence on this topic, clinicians must use their clinical experience to determine the most appropriate means of treating this condition, depending on patient-related factors. There is a need for well designed and appropriately conducted clinical trials on this topic, which conform to the CONSORT statement (www.consort-statement.org/).