Mngment of the dental pt w/ a Hematologic disorder

  1. If Significant Anemia, Systemic Manifestations Are Prominent And Only Emergency Dental Treatment Provided Until Patient Stable.
  2. Mild Anemia Not An Issue for Most
    Dental Procedures As Bleeding is Minimal
  3. Anemia - compensatory changes
    Easier Release of Oxygen From Hemoglobin

    Hyperdynamic Cardiovascular System
  4. Who Is The Dentist Concerned About??
    • Patients with Leukopenia
    • --Drug Induced
    • -Usually Early In Drug Treatment
    • -Most Commonly With AEDs

    • --Chemotherapy Induced
    • --Cyclic Neutropenia (alternating cycle of high and low neutrocyte count)

    • Leukemias and Lymphomas
    • --Dysfunctional WBCs
  5. What Is The Dentist Particularly Concerned About?
    oAbsolute Neutrophil Count

    oNeeded To Fight Bacterial Infection

    oNeutropenia < 1500 cells/μL

    • oRisk of Infection Significantly
    • Increased with Neutropenia  < 1000
    • cells/μL
  6. The Chemotherapy Patient
    oMust Determine Current Hematologic Status To Ensure Patient Can Safely Be Treated

    oLaboratory Studies Needed Prior To Treatment

    --RBC’s – Tolerate Stress of Procedure

    • --WBC’s – Infection
    • -Acute Osteomyelitis After Extraction?
    • -Antibiotic Prophylaxis

    --Platelets - Hemostasis
  7. At the time of chemotherapy, pt should be treated before or after diagnosis?
    before so that pt has optimal oral health when entering chemotherapy
  8. Can chemo pt be treated during chemotherapy?
  9. Test of Coagulation
    • aPTT - Partial Thromboplastin Time
    • Normal 25 – 35 sec
    • Measures Factors I, II, V, VIII, IX, X, XI, XII (Intrinsic)

    • PT - Prothrombin Time
    • Normal 12 – 14 sec
    • Measures Activity of Factors I, II, V, VII, X (Extrinsic)

    • INR - International Normalized Ratio Used 
    • Used to Compare PT From One Laboratory to Another
    • INR = Patient’s PT ÷ Mean Lab PT Adjusted by International Sensitivity Index
    • normal = 1.0
  10. Quantitative Platelet Testing
    • Platelet Count
    • Normal 150,000 – 300,000 cells/μL

    Thrombocytopenia < 100,000 cells/μL

    > 50,000 cells/μL Needed For Surgical Hemostasis

    < 20,000 cells/μL Can Cause Spontaneous Bleeding (crevices bleeding)

    Platelet Life Span 9 – 11 Days
  11. Qualitative Platelet Testing
    • PFA-100****
    • Tests Ability of Platelets to Aggregate to Collagen-Epinephrine and Collagen-ADP
    • Main Screening Test

    • Platelet Aggregometry
    • Tests Ability of Platelets to Aggregate With:
    • pADP, Collagen, Arachidonic Acid, or epinephrine

    • Ultegra
    • Tests Ability of Platelets to Bind Fibrinogen
  12. Platelet Concerns - thrombocutopenia and tx
    Decreased Formation → Marrow Aplasia, Marrow Neoplasia, Megaloblastic Anemia

    Increased Destruction → Drug Induced, Idiopathic Thrombocytopenia Purpura, Splenomegaly

    oTreatment: Platelet Transfusion One Unit/10kg Increases 5,000 – 10,000mm3
  13. Platelet Concerns – von Willebrand's disease
    1:1000 People; Male = Female

    Low Plasma vWF Impairs Platelet Adhesion

    Released From Endothelium and Platelets

    Type I, IIA, IIB, III (Increasing Order of Severity)

    Bleeding Persists Early In Surgery

    Frequently Diagnosed Following Dental Extraction
  14. Von Willebrand’s Disease: Dental Management
    • Coordinate with Hematologist To Administer Prior to Surgery
    • Mild = Stimate® - Desmopressin
    • (DDAVP)
    • 0.3 mcg/kg IV 30 min prior to procedure
    • Onset = 30 min; Duration Up To 3 Hours IV
    • Nasal Spray < 50kg = 150mcg; > 50kg = 300mcg

    • Moderate – Severe
    • Viral Inactivated Factor VIII-vWF
    • Humate-P**, Alphanate and Koate DVI

    • Cryoprecipitate (But Risk of Disease transmission)
    • 100 IU Of Factor VIII,  250 mg Fibrinogen,
    • 100 IU Vwf, Factor XIII, And Fibronectin

    Consider Antifibrinolytics
  15. Antifibrinolytics
    oInhibitors of Plasminogen Activators

    Epsilon Amino-carpoic Acid (Amicar®)**

    Tranexamic Acid (Cyklokapron®)

    • oAmicar Orally Administered Prior To
    • Surgery and Five Days Post-operatively

    oRinses of Tranexamic Acid
  16. Von Willebrand’s Disease: Dental Management
    • oConsult Hematologist
    • Know Onset and Duration Of Factor Used

    • oAspirin and NSAIDs Contraindicated
    • Acetaminophen & Opioids OK

    • oHave Coagulation Adjuncts Available
    • e.g., Gelfoam®, Avatine®, Surgicel®, ActCel®

    Primary Surgical Closure (no gap in between)
  17. Aspirin Therapy
    oIrreversibly Inhibits Cyclooxygenase Leading to Decrease in Thromboxane A2 Synthesis

    oPlatelet Dysfunction For Life of Platelet (10d)

    • oBleeding Time Prolonged
    • 9½ min (Range: 4 – 21 min) on Aspirin

    oNo Need To D/C For Oral Surgery Especially If Used For Secondary MI/Stroke/Stent protection

    • oMajor Surgery?
    • Orthognathic Surgery, Facial Cosmetic, ICBG, etc
  18. How long should you wait after taking aspirin to perform surgery?
    10 day
  19. should you discontinue aspirin for a surgery?
    no. pt might have MI or stroke or stent
  20. Plavix - indication
    • oIndicated for Secondary Prevention
    • Stroke, Post MI, *Post Coronary Stenting*
  21. Plavix - compare to aspirin (spontaneous bleeding)
    less than aspirin
  22. Plavix -oDental Management
    Do Not D/C For Routine Dentistry/Oral Surgery

    • Never D/C Post-Drug Eluting Stent (DES) < 1 Year
    • Cardiologist May Recommend D/C  > 3 mo. Post BMS

    *If* Cardiologist Recommend D/C, Generally Need At Least 6 Days
  23. Effient - indication, mngment and MofA
    • oIndicated for Secondary Prevention
    • Stroke, Post MI, *Post Coronary Stenting*

    Irreversible Antagonist of Platelet ADP Receptor

    oDental Management As For Plavix
  24. Hemophilia
    • oBecause Platelets Intact
    • --> Early Hemostasis May Occur
    • Bleeding Occurs Late

    oSymptoms: Hemarthrosis; GI Bleeding; Spontaneous Bleeding If Severe

    • oDental Concerns:
    • Deep IM Injections (IAN Block) (lacerate tissue - need good technique)

    • oManagement:
    • Factor Replacement & Antifibrinolytic
    • No Aspirin or NSAIDs
  25. Coumadin - common condition requiring coumadin
    • INR 2.0 – 2.5: Deep Vein Thrombosis (DVT), Post Pulmonary Embolus, A-Fib, Post
    • MI/CVA, Composite Aortic Valve

    INR 2.5 – 3.5: Prosthetic Mitral/Aortic Valve
  26. Coumadin: Dental  Management
    • oDetermine Medical Condition
    • More Risk w/o Coumadin vs. Bleeding Risk?

    • oConfirm PT/INR Level
    • Within 12 – 24 Hours Of Surgery

    oEvaluate For Type of Surgery/Infection

    • oDental Surgery/Injection/Single Tooth
    • Extraction OK with INR < 3
    • What About 3.5?  4??

    • oMultiple Tooth Extraction/Perio Surgery
    • MD Consult To Discuss INR ≤ 1.5 ?
    • MD Consult For Bridge Therapy With LMWH?
  27. Bridge Therapy With Lovenox
    oEnoxaparin (Lovenox) = LMWH Administered 1 -2/Day Subcutaneously

    oD/C Coumadin and Start Lovenox®

    oMonitor PT for Coumadin/PTT of Lovenox

    oStop Lovenox AM of Surgery

    oRestart Lovenox Post-Op with Coumadin

    oD/C Lovenox® When Coumadin Therapeutic
  28. Coumadin: Dental Management
    -Aides to Coagulation Process-
    oPressure Packs

    • oAgents to Promote Platelet Aggregation
    • Gelfoam® – Absorbable Gelatin Sponges
    • Avatine® - Microfibular Collagen
    • Surgicel® - Oxidized Methylcellulose
    •     Also Precipitates Fibrin
    • Hemcon®– Polysaccharide Chitosan
    • ActCel®– Collagen-like (From Cellulose)

    • oAgents to Promotes Coagulation
    • Thrombostat® – Thrombin
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Mngment of the dental pt w/ a Hematologic disorder
Mngment of the dental pt w/ a Hematologic disorder