Managing Dental Patients with
Medical Problems
Dayton W. Daberkow II MD
Leonard J. Chabert
Internal Medicine Residency Program Director
Houma, Louisiana
Diabetes
45 year old male with history of diabetes type 2 on Glargine (Lantus) 30 units
at bedtime and has a dental procedure in the morning. 20 minutes after the
procedure the patient tells the nurse he fells very weak, his right arm is weak
and his fingers are tingling. What do you recommend at this time?
1.
2.
3.
4.
Contact EMS to transfer to emergency room for a stroke work-up.
Make sure the patient is laying down and check on him in 30 minutes.
Check the blood glucose with a glucometer.
Give a rapidly absorbed form of 15 grams of a carbohydrate.
Diabetes
If the patient is unable to take anything by mouth, has an IV line
and his glucose is 30 you should:
1.
2.
3.
4.
Recheck the glucose in 20 minutes to make sure it is low before initiating
any treatment.
Administer 1 amp of D50 solution (25 to 50 mL of a 50% dextrose
solution).
Administer 1 amp of bicarbonate
Administer 5 mg of Glucagon
Diabetes
If the patient does not have an IV then do the following if
hypoglycemic:
1.
2.
3.
4.
Administer 1 mg of glucagon IM or SQ at any body site.
Administer 1 mg of epinephrine IM or SQ
Administer 1 amp of D50 under the tongue
Administer 1 mg of glucagon under the tongue
Management of hypoglycemia in the office
• Signs and symptoms: confusion, tremors, sweating, agitation,
anxiety, dizziness, tingling or numbness, and tachycardia.
Severe hypoglycemia may result in seizures or loss of
consciousness.
• Immediately check blood sugar with a glucometer.
• If no glucometer available assume HYPOGLYCEMIA with above
symptoms. Hyperglycemia can have some of these same
symptoms but hypoglycemia more dangerous.
Type 2 diabetes treated with oral
hypoglycemic agents
55 y/o female with history of diabetes type 2 will have a dental
procedure in the morning. She takes metformin twice a day. She
will be not eating breakfast before the procedure. You advise
her to do the following:
1. Take the morning dose of her metformin.
2. Hold morning dose of metformin, resume evening dose if
eating.
3. Hold morning dose of metformin and double the dose at
bedtime.
4. Hold both morning and evening dose of metformin.
Type 2 diabetes treated with oral
hypoglycemic agents
• Sulfonylureas increase the risk of hypoglycemia
• DPP-IV inhibitors (gliptins) and GLP-1 analogs (incretins) could
alter GI motility
• Metformin is contraindicated in conditions that increase the
risk of renal hypoperfusion, lactate accumulation and tissue
hypoxia
• Therefore, hold all oral hypoglycemic agents before
procedures that require morning fasting. If no fasting,
patient may take oral hypoglycemics with careful glucose
monitoring.
Type 1 or insulin treated type 2
diabetes
35 male with history of diabetes type 2 is scheduled for a dental
procedure the next day. He takes 25 units of Glargine (long
acting insulin) nightly and 6 units of Novolog (rapid acting) with
each meal. He will be NPO before the procedure. You
recommend:
1. Hold Glargine and Novolog and resume the evening after the
procedure.
2. Hold Glargine but begin and insulin infusion in the office.
3. Continue Glargine the night before procedure and give ½
dose of Novolog in the morning.
4. Continue Glargine the night before procedure and hold
Novolog until patient eating.
Type 1 or insulin treated type 2 diabetes
For minor morning procedures:
• Generally patients who use insulin can continue with their
subcutaneous insulin for procedures that are not long and
complex.
• If the patient has borderline hypoglycemia or "tight" control
of the fasting blood glucose, reduce the night time (supper or
HS) long or intermediate acting insulin on the night prior to
surgery to prevent hypoglycemia.
• Type 1 diabetes can develop ketoacidosis if they take no
insulin even they are NPO. Their basal metabolic needs when
fasting require at least ½ their usual insulin requirements.
• Hold short-acting insulin until eating.
Type 1 or insulin treated type 2 diabetes
For Procedures that are long or take place later in day where both
breakfast and lunch are missed:
•If insulin (both intermediate and short-acting insulin) taken only in morning,
give one-half their total morning insulin to provide basal insulin during the
procedure and prevent ketosis
•Hold short-acting insulin morning of procedure if also on long acting insulin.
•For patients who take insulin two or more times per day, give between onethird to one-half of the total morning dose (both intermediate and shortacting insulin) as intermediate acting insulin only
•Patients on continuous insulin infusion may continue with their usual basal
infusion rate. Start dextrose containing intravenous solution.
Biphosphonates and Dental Surgery
Osteonecrosis of Jaw (ONJ)
• Risk factors include invasive dental procedures (eg, tooth
extraction, dental implants, boney surgery); a diagnosis of
cancer, with concomitant chemotherapy or corticosteroids;
poor oral hygiene, ill-fitting dentures; and comorbid disorders
(anemia, coagulopathy, infection, pre-existing dental disease).
• Most cases after IV but some reports of oral therapy.
• Manufacturer recommends discontinuing bisphosphonates in
patients requiring invasive dental procedures. No real
evidence this prevents ONJ.
Blood Pressure Management
60 year-old-male with a history of hypertension is scheduled for a
dental procedure. His past history and physical examination are
unremarkable. He takes Verapamil 240 mg every day and his blood
pressure in the office was 130/80.
Which of the following is the best strategy for preoperative evaluation
1. Schedule an exercise stress test
2. Echocardiogram
3. Hold blood pressure pill before surgery
4. Take blood pressure pill AM of surgery
Blood Pressure Management
55 year-old-female with a history of hypertension is scheduled
for a dental procedure. Past history and PE are unremarkable.
She takes HCTZ 25 mg every AM and office blood pressure is
200/120.
Which of the following would be the best management?
1. Take HCTZ am of surgery and proceed to surgery.
2. Delay surgery and add another BP pill to get diastolic blood
pressure less than 110 mm Hg.
3. Delay surgery and increase dose of HCTZ to get diastolic
blood pressure less than 80.
Blood Pressure Management
• Elective surgery/procedures should be postponed in patients
with blood pressures above 170/110 mmHg
• Take all blood pressure pills with sip of water morning of
procedure
• Continue antihypertensive treatment throughout procedures,
especially drugs like Clonidine and Beta- blockers to avoid
severe post procedure hypertension.
Hypertensive Emergencies
• Repeat BP in both arms and again 10 minutes later and make
sure the cuff size is the appropriate size (bag length 80% of
limb circumference)
• For severe hypertension systolic BP > 200 or diastolic BP > 120
assess whether the elevated BP is causing target organ
damage
• Assess neurologic, cardiac, renal function and retinas
• Patients with evidence of target organ damage should be
admitted to an ICU with invasive monitoring and parenteral
antihypertensive therapy
• Don’t lower BP aggressively if there are focal neurological
signs; don’t allow diastolic BP to fall below 100 mm Hg
Endocarditis Prophylaxis
26 year-old-male with a history of mitral valve
prolapse with regurgitation
1. Amoxicillin 2.0 grams orally 1 hour before surgery (1997 AHA
guidelines)
2. No prophylaxis needed (2007 AHA guidelines)
3. Amoxicillin 1.0 gram orally 1 hour before surgery
4. Amoxicillin 1.0 gram orally 1 hour before and 1.0 gram after
surgery
Endocarditis Prophylaxis
65 year-old-male with a history of a prosthetic
mitral valve who’s jaw is broken and can’t
swallow.
1. No prophylaxis needed
2. Amoxicillin 2.0 grams orally 1 hour before surgery
3. Ampicillin 2.0 grams IM/IV 30 minutes before surgery
4. Ampicillin 2.0 grams IM/IV 3 hours before and 1 hour after
surgery
Endocarditis Prophylaxis
44 year-old-female with a previous history of
endocarditis who is allergic to penicillin
1. No prophylaxis needed
2. Cephalexin 500 mg 1 hour before surgery
3. Clindamycin 600 mg orally 1 hour before surgery
4. Azithromycin or Clarithromycin 500 mg orally 1 hour
before surgery
5. 2 or 3
6. 3 or 4
Endocarditis Prophylaxis
50 year-old-female with a history of hypertrophic
cardiomyopathy who is allergic to penicillin and can’t
swallow
1. No prophylaxis needed (2007 AHA guidelines)
2. Vancomycin 1.0 gram IV 1-2 hours, complete infusion before
surgery
3. Cephalexin 1.0 gram IV 30 minutes before surgery
4. Clindamycin 600 mg IV 30 minutes before surgery (1997 AHA
guidelines)
Cardiac Conditions Associated With
Endocarditis
Endocarditis Prophylaxis Recommended for
High-risk categories:
1. Prosthetic cardiac valves, including bioprosthetic and
homograft valves
2. Previous bacterial endocarditis
3. Complex cyanotic congenital heart disease (e.g.. Single
ventricle states, transposition of the great arteries,
tetralogy of Fallot)
4. Surgically constructed systemic pulmonary shunts or
conduits
5. Cardiac Transplant with new valvulopathy
Cardiac Conditions Associated With
Endocarditis
No Prophylaxis Recommended (2007 AHA Guidelines)
Moderate risk category:
Most other congenital cardiac malformations (other
than high-risk)
•
Acquired valvular dysfunction (e.g.. Rheumatic
heart disease AI, AS, MS, MI)
•
Hypertrophic cardiomyopathy
•
Mitral valve prolapse with valvular regurgitation
and/or thickened leaflets
•
Cardiac Stents first 30 days? Endothelialized
Endocarditis Prophylaxis Not
Recommended
Negligible-risk category (no greater risk than the general
population)
• Isolated secundum atrial septal defect
• Surgical repair of atrial septal defect, ventricular septal
defect, or patent ductus arteriosus (without residua beyond
6 months)
• Previous coronary artery bypass graft surgery
• Mitral valve prolapse without valvular regurgitation
• Physiologic, functional, or innocent heart murmurs
• Previous rheumatic fever without valvular dysfunction
• Cardiac pacemakers (intravascular and epicardial) and
implanted defibrillators
Dental Procedures and Endocarditis
Prophylaxis
Endocarditis Prophylaxis Recommended:
•Dental extractions
•Periodontal procedures including surgery, scaling and root planing,
probing, and recall maintenance
•Dental implant placement and reimplantation of avulsed teeth
•Endodontic (root canal) instrumentation or surgery only beyond the
apex
•Subgingival placement of antibiotic fibers or strips
•Initial placement of orthodontic bands but not brackets
•Intraligamentary local anesthetic injections
•Prophylactic cleaning of teeth or implants where bleeding is
anticipated
Prophylaxis recommended
• All dental procedures that involve
manipulation of gingival tissue or the
periapical region of teeth or perforation of the
oral mucosa.
• For patients only in the HIGH RISK category
Prophylactic Regimens for Dental, Oral,
Procedures
Situation
Standard general
prophylaxis
Agent
Amoxicillin
Regimen
Adults 2.0g; children 50
mg/kg orally 1 hr
before procedure
Unable to take oral meds
Ampicillin
Adults 2.0g intramuscular (IM)
or intravenously (IV);
children: 50 mg/kg IM
or IV within 30 min
before procedure
Prophylactic Regimens for Dental, Oral,
Procedures
Situation
Allergic to penicillin
Agent
Clindamycin
Regimen
Adults 600 mg;
children: 20 mg/kg
orally 1 hr before
procedure
Azithromycin,
Clarithromycin
Adults 500 mg;
children 15 mg/kg
orally 1 hr before
procedure
Prophylactic Regimens for Dental, Oral, Procedures
Situation
Allergic to penicillin
and unable to take
before procedure
Agent
Clindamycin
Regimen
Adults: 600 mg
IM/IV;
children
20 mg/kg IM
IV within 30
minutes
Endocarditis Prophylaxis
For patients having surgery, which of the following cases requires
Endocarditis prophylaxis: (yes/no)
1. 26F with a hx of MVP w/o regurgitation
2. 40F with a physiologic/innocent heart murmur
3. 60M with a hx Endocarditis
4. 55M who has a systolic murmur that increases with
valsalva and echocardiogram shows a thickened septum
5. 70F with a prosthetic aortic valve
6. 70F with a hx of CABG 2 months ago
7. 66M who had a cardiac pacemaker for SSS
8. 66M s/p repair of an atrial septal defect
Prosthetic Joints
• Prosthetic joints in > 2 years and no
immunocompromising states no antibiotic
prophylaxis.
• Prosthetic joints in < 2 years and
immunocompromised maybe antibiotic
prophylaxis.
Cardiac Conditions and Dental
Procedures
62-year-old man with history of CABG 3 years ago is
scheduled for a dental procedure. No other medical
problems and physical examination is unremarkable. What
historical information will best help you in managing this
patient?
1. No headaches or dizziness
2. No shortness of breath (SOB) while sleeping
3. No chest pain or SOB at rest
4. No chest pain or SOB after walking up a flight of stairs
Cardiac Conditions and Dental
Procedures
This same 62 year-old-man with a history of a CABG
had chest pain over the past month that occurred with
ambulation after one block and has been increasing in
severity, duration, and frequency over the past 1 week.
What is the best preoperative strategy?
1. Take nitroglycerin before dental procedure
2. Echocardiography
3. Proceed to dental procedure with no action
4. Cancel dental procedure and refer back to PCP or cardiologist
Cardiac Conditions and Dental
Procedures
A 38 male is scheduled for a dental procedure. His physical
examination revealed a jugular venous pressure of 8 cm, an S3
gallop, and bilateral crackles? He also says that he has had
progressive SOB over that past 3 weeks?
1. Proceed to dental procedure
2. Coronary angiogram to decrease risk
3. Delay surgery and medically manage until the CHF has
resolved
Cardiac Conditions and Dental
Procedures
55 year old female is scheduled for a dental procedure. She has
a history of atrial fibrillation on no anticoagulation. She has had
palpitations over past 2 weeks, is on metoprolol 25 mg twice a
day and office heart rate is 120. You recommend:
1. Cancel procedure and refer to PCP for management of her
atrial fibrillation and better heart rate control < 110
2. Proceed with procedure as long as heart rate < 130
3. Administer digoxin 0.25 mg in the office and have the patient
stay until heart rate < 90
Active Cardiac Conditions for which patients should
undergo evaluation and treatment before Non-cardiac
Surgery
1. Unstable Coronary Syndromes
Unstable or severe angina (CCS Class III or IV). Recent MI
(more than 7 d less than 1 month).
2. Decompensated HF
NYHA functional class IV; worsening or new-onset HF.
Congestive Heart Failure Systolic Dysfunction
Pharmacological Management
• Diuretic - Furosemide 20-80 mg per day (200 mg in CRI). Best to
give at 4-6 PM when volume status highest.
• Spironolactone 25-100 mg BID
• Angiotensin Converting Enzyme (ACE) inhibitor at bedtime
(captopril, enalapril). Titrate to the largest tolerated dose.
• Beta-Blockers with meals.
• Discontinue ACE inhibitors if the serum potassium is >5.5 meq per L
that cannot be reduced, sx hypotension, or hx of adverse reaction
• Hydralazine/isosorbide dinitrate is an alternative for ACE inhibitors
or ARB’s (Angiotensin II receptor blockers i.e. losartan)
• Digoxin
• Monitor electrolytes, control blood pressure
• Avoid NSAIDS and COX-2 inhibitors
Active Cardiac Conditions for which patients should
undergo evaluation and treatment before Non-cardiac
Surgery
3. Significant Arrhythmias
–
–
–
–
–
–
–
High grade AV block
Mobitz Type II AV block
3rd degree AV block
Symptomatic ventricular arrhythmias
Supraventricular arrhythmias (atrial fibrillation with
uncontrolled rate, HR greater 110 at rest)
Symptomatic bradycardia
Newly recognized ventricular tachycardia
Active Cardiac Conditions for which patients should
undergo evaluation and treatment before Non-cardiac
Surgery
4. Severe Valvular Disease:
Aortic Stenosis severe (mean pressure gradient > 40 mm
Hg, aortic valve area < 1.0 cm2, or symptomatic)
Mitral Stenosis Symptomatic (progressive dyspnea on
exertion, exertional presyncope, or HF)
Cardiac Risk for Non-cardiac Surgical
Procedures
Low (<1% cardiac risk)*
Dental procedures
Breast surgeries
Endoscopic procedures
Superficial procedures
Cataract operation
Ambulatory surgery
*combined incidence of cardiac death and nonfatal MI.
Noncardiac Surgery and medicines
Perioperative Statin therapy:
Protective effect on cardiac complications, therefore,
continue through surgery/procedure.
Alpha-2 Agonists:
Clonidine has minimal hemodynamic effects and
reduced postoperative mortality for up to 2 years.
Continue through surgery/procedure
Perioperative Calcium Channel Blockers:
Reduced ischemia and supraventricular tachycardia and
death and MI. Continue through surgery/procedure.
Lung Disease and Dental Procedures
A 25 year old male with history of asthma is scheduled for a
dental procedure. What questions are important to ask him to
assess the status of his asthma?
1.
2.
3.
4.
5.
6.
What medicines are you currently taking?
Do you have any pets in the house?
Have you had any of the following, cough, wheezing, shortness of
breath, chest pain over the past 2 weeks?
Did you get your flu shot this year?
1,2 and 4
1 and 3
Lung Disease and Dental Procedures
A 32 year old female with a history of Asthma is scheduled for a
dental procedure. She takes fluticasone/salmeterol (100/50) 1
puff twice a day and an albuterol inhaler 2 puffs as needed daily.
She has had to use her albuterol 4 times a day over the last week
because of a lingering cough. You recommend:
1. Advise to stop the albuterol since it is making her cough
worse.
2. Proceed with dental procedure since it will be less than 1
hour and no drugs will be used to affect her asthma
3. Send to ER immediately
4. Cancel procedure and refer to PCP to assess asthma
Lung Disease and Dental Procedures
Two weeks later this same 32 female is scheduled for her dental
procedure. Her PCP increased her fluticasone/salmeterol to
(200/50). She wants to get the procedure done and said the
cough is better but does get short of breath twice a day and has
had some chest pain. What test below would provide the most
information about the current state of her asthma?
1. Pulmonary function studies.
2. Chest X-ray
3. Peak flow meter reading in the office
4. Arterial blood gas
Lung Disease and Dental Procedures
Severe Persistent Asthma
•
•
•
•
Symptoms throughout the day
Nocturnal symptoms frequent
Nocturnal awakenings nightly
Need for short-acting beta agonists for symptom relief several
times per day
• Peak flow rate: < 60% predicted
Lung Disease and Dental Procedures
Severe Persistent Asthma
Treatment:
• Medium to High-dose Inhaled Corticosteroids (ICS) and
Long-acting Beta-2 agonist (LABA)
• Omalizumab an anti-IgE therapy may be considered if
there is objective evidence of allergies i.e. allergy skin
tests
• Oral corticosteroids as needed for severe symptoms
Lung Disease and Dental Procedures
Potential Risk Factors Asthma
Maximize control before any procedure/surgery
• No cough, SOB, wheezing
• Peak flow greater than 80% predicted or
personal best value
• Pulmonary Exam should be free of wheezes
Lung Disease and Dental Procedures
65 y/o M with history of COPD is scheduled for a dental
procedure. He takes ipratropium bromide inhaler 2 puffs
twice a day and a short-acting Beta-agonist 2 puffs twice
a day. He has a non-productive cough that has been
increasing the past 2 weeks. Lung exam reveals bilateral
wheezes.
Management before procedure:
a. Increase both inpratropium bromide and the shortacting beta-agonist
b. Begin antibiotics
c. Get pulmonary function tests prior to surgery
d. Perform procedure
Lung Disease and Dental Procedures
After 2 weeks of maximizing his inhalers by his PCP he still has a
non-productive cough and SOB that is worse than 4 weeks ago.
On lung exam he has bilateral wheezes that haven’t changed.
The chest x-ray shows no infiltrate/pneumonia.
Management:
a. Proceed to procedure/surgery
b. Begin Antibiotics
c. Steroids-Prednisone 40 mg in AM for 7-10 days
Lung Disease and Dental Procedures
55 y/o M with a history of COPD is scheduled for a dental
procedure. He takes ipratropium bromide 2 puffs twice a
day. Over the past 10 days he has had increasing SOB and a
cough with productive sputum. On exam he has bilateral
decreased breath sounds. What do you recommend?
a. Cancel procedure and follow-up with PCP and get pulmonary
function tests
b. Send to ER and get a stat EKG
c. Cancel procedure follow-up with PCP and get a Chest x-ray
d. Proceed to procedure
Lung Disease and Dental Procedures
The chest x-ray showed no infiltrates/pneumonia. What do you
think his PCP would be adding for further management before
the dental procedure?
a. Add short-acting beta-2 agonist
b. Prednisone 40 mg for 7 days
c. Continue ipratropium bromide inhaler
d. Antibiotics
e. All of the above
Lung Disease and Dental Procedures
COPD
• Patients with COPD have an increased risk of postop/procedure pulmonary complications depending on
severity
• Treat patients who do not have optimal reduction of
symptoms (cough, SOB) and optimal exercise capacity
before surgery
• Combinations of bronchodilators, physical therapy,
smoking cessation, antibiotics for exacerbations, and
corticosteroids will reduce the risk.
Lung Disease and Dental Procedures
COPD
• Antibiotics only for COPD exacerbations as defined by change
in character or amount of sputum production.
• Patients with continued symptoms despite bronchodilator
therapy may benefit from a 1-2 week
preoperative/preprocedure course of steroids.
Lung Disease and Dental Procedures
Preventing Pulmonary Complications
Pre-procedure:
1. Urge patient to stop smoking
2. Treat uncontrolled COPD or asthma before surgery
3. Delay procedure and administer antibiotics if a respiratory
infection is present
Lung Disease and Dental Procedures
Pre-procedure Evaluation
The history and physical examination are the most
important parts of the pre-procedure pulmonary
assessment
History
1. Cough
2. Dyspnea
3. Wheezing
4. Exercise Tolerance
Lung Disease and Dental Procedures
History:
5. Smoking history
6. Medications
7. History of pneumonias
8. DVT/PE with prior surgeries
9. Known pulmonary disease
COPD
Asthma
Restrictive disease
Sleep Apnea
Hepatic Disease and Dental
Procedures
Acute and chronic liver disease can significantly change
the patient’s ability to tolerate surgery and anesthesia.
Therefore, it is important to determine preoperatively if
hepatic functions have been disturbed. If so, the
severity of the functional impairment should be
assessed and steps undertaken to minimize the
operative/procedure risk. The functional disturbances
that can occur as the result of liver disease include:
Hepatic Disease and Dental
Procedures
1. Bleeding Problems
• Deficiency in the coagulation factors synthesized in the liver
(II, VII, IX, X) and fibrinogen.
• Thrombocytopenia secondary to an enlarged spleen or
alcoholic depression of the bone marrow.
• Portal hypertension causing esophageal varices which can
bleed.
2. Fluid and electrolyte disturbances
• Sodium retention, hypokalemia, hypocalcemia and
hypoalbuminemia.
• Edema, ascites and hepatorenal syndrome.
Hepatic Disease and Dental
Procedures
3. Malnutrition
•
Present in patients with significant liver disease due to anorexia,
poor intake and hypermetabolic state.
4. Immunocompromised
•
Host defenses that rely on immunoproteins synthesized by the liver
are impaired.
•
Increased risk of infection in patients with severe liver disease.
5. Central nervous system dysfunction
•
Hepatic encephalopathy. Events that occur perioperatively can
exacerbate hepatic encephalopathy which can include blood in the
GI tract.
Hepatic Disease and Dental
Procedures
History of Liver disease should be suspected if
the patient gives a history of significant or
chronic alcohol intake, illicit drug use, tattoos,
exposure to toxic materials, prior blood
transfusions, sexual promiscuity, family history
of liver disease or hepatitis, or jaundice.
Hepatic Disease and Dental
Procedures
• Physical Examination. A patient may have no
physical signs of liver disease. If active hepatitis
exists, the liver may be enlarged and tender. Cirrhotic
disease produces a small, hard, nontender liver.
• Other findings may include increased abdominal
girth, jaundice, palmar erythema, spider
telangiectases, splenomegaly, and gynecomastia or
testicular atrophy in men.
Hepatic Disease and Dental
Procedures
Laboratory Examination if liver disease is
suspected by history or by physical examination,
blood chemistries should be obtained. A history
of viral hepatitis or IV drug abuse is a definite
indication for serology testing.
Hepatic Disease and Dental
Procedures
• 40 y/o F is scheduled for surgery. History of a
blood transfusion in 1988. Past medical history is
unremarkable, her PE is normal and she has no
symptoms. The dentist orders a comprehensive
metabolic profile. The serum albumin, ALP, and
PT are all within normal limits but the AST and
ALT are elevated respectively at 150 normal (550) and 200 normal (5-55). No recent travel.
•
Hepatic Disease and Dental
Procedures
What other blood tests would you order?
a. None proceed to procedure
b. TSH, CBC and HBs Ag
c. HBs Ag, Anti-HCV
d. CBC and INR
g. HBs Ag, IgM anti-BHc, Anti-HCV, IgM anti HAV
Hepatic Disease and Dental
Procedures
Blood chemistry tests for liver disease
• Serum glutamic oxaloacetic transaminase, (SGOT),
(AST)
• Serum glutamic pyruvic transaminase (SGPT), (ALT)
• Gamma glutamyltranspeptidase (GGPT)
• Total bilirubin
• Alkaline phosphatase
• Total serum protein
• Serum albumin
• Prothrombin time/INR
Hepatic Disease and Dental
Procedures
Initial Hepatitis Serology:
• HBsAg
• IgM anti-BHc
• anti-HCV
• IgM anti-HAV (travel history, seafood)
Hepatic Disease and Dental
Procedures
The 40 y/o F comes back to your office 1 week
later and you inform her that the Hepatitis C
antibody is positive. May she proceed to with
her dental procedure?
Hepatic Disease and Dental
Procedures
An asymptomatic patient with mild elevations of
serum aminotransaminases (AST, ALT) that have
stabilized and have a normal total bilirubin, PT
time, and albumin should tolerate surgery.
Patient must follow up with a liver specialist and
avoid alcohol, and hepatotoxic drugs like
acetaminophen, NSAIDS, benzodiazepines, and
raw seafood.
Hepatic Disease and Dental
Procedures
Testing for Hepatitis C
• IV drug users
• People who received a blood transfusion before July
1992
• Long-term hemodialysis patients
• Health care workers who have had percutaneous
exposure to HCV-positive blood
• Those with abnormal liver enzyme tests
• Baby Boomers 1946-1964 (CDC 2012)
Hepatic Disease and Dental
Procedures
Others to consider testing for Hepatitis C:
• People who have received transplanted organs
• People who sniff illegal drugs
• Individuals who have undergone tattooing or body
piercing
• Those who have a sexual partner with Hepatitis C or
people with multiple sexual partners or have had
numerous STD’s
Hepatic Disease and Dental
Procedures
55 y/o M with a history of alcohol abuse is scheduled
for a dental procedure. No symptoms and his PE is
normal. AST 400 (5-50), ALT 100 (5-55), total bilirubin
1.8 (.2 - 1.3), PT 14 (control 15), albumin 4.0 (3.5 - 5.0)
Best management before surgery?
a. Fresh frozen plasma and proceed to surgery
b. Proceed directly to surgery
c. Abstain from alcohol 4-6 weeks prior to surgery
Hepatic Disease and Dental
Procedures
Alcoholic Liver Disease:
Alcohol leads to a state of relative deoxygenation around the
central veins of the liver, which may affect the metabolism of
drugs. Therefore, a period of abstinence is advised because of
the high surgical risk seen in active alcoholic hepatitis.
Acetaminophen must be used with caution because of the toxic
metabolites that can result in hepatic necrosis. Diazepam,
barbiturates should also be used cautiously.
Hepatic Disease and Dental
Procedures
Laboratory Examination
1. Liver Enzymes: If liver chemistries are elevated they should
be repeated in 48 hours to determine whether they reflect
hepatitis that is worsening or resolving. Dental procedures
should be deferred until the enzymes have normalized or
stabilized.
2. Total bilirubin > or = 4 mg/dl carries a high procedure risk.
3. Tests of Liver Synthetic Function: Patients with a serum
albumin = or < 3.5 gm/dl, and a PT prolonged three seconds
over control and resistant to Vitamin K administration have a
high procedure risk.
Hepatic Disease and Dental
Procedures
• A 42 y/o male with history of cirrhosis secondary to
Hepatitis C is scheduled for a dental procedure. He is alert,
oriented with no bleeding problems or other symptoms.
On PE he has no ascites or other physical signs of liver
disease. What laboratory values will help you in evaluating
his surgical risk?
• a. CBC
• b. Serum Albumin
• c. Potassium
• d. Total Bilirubin, PT
• e. a and b
• f. b and d
Hepatic Disease and Dental
Procedures
Table 1. Modified Child-Pugh Score
Albumin (g/dL)
Bilirubin (mg/dL)
Prothrombin Time
(Seconds prolonged) or
International Normalized
Ratio (INR)
Ascites
Encephalopathy
*Class A = 5-6 points
*Class B = 7-9 points
*Class C = 10-15 points
1
> 3.5
<2
<4
Points*
2
2.8-3.5
2-3
4-6
3
< 2.8
>3
>6
< 1.7
1.7-2.3
> 2.3
Absent
None
Slight-moderate Tense
Grade I-II
Grade III-IV
Hepatic Disease and Dental
Procedures
Patients with stable cirrhosis without signs of liver failure,
encephalopathy, poor nutritional status, uncontrolled ascites,
albumin < 3.5, and bilirubin > 3.0 can usually tolerate surgery.
There are no prospective studies to show better surgical
outcomes after preop interventions to improve liver function
but accepted guidelines are that:
Elective surgery is: (Dental Procedures as a guide)
• Tolerated in Child’s class A cirrhosis
• Permissible in Child’s class B cirrhosis (with preop
preparation, not hepatic resection or cardiac surgery)
• Contraindicated in Child’s class C cirrhosis
Hepatic Disease and Dental
Procedures
MELD Score
• For over 30 years, the principal predictor of operative risk
in patients with cirrhosis has been the Child's
classification, but newer studies suggest that the Model
for End-Stage Liver Disease (MELD) score may be
superior.
• MELD is a prospectively developed and validated chronic
liver disease severity scoring system that uses a patient's
laboratory values for serum bilirubin, serum creatinine,
and the international normalized ratio for prothrombin
time (INR) to predict survival.
Hepatic Disease and Dental
Procedures
In patients with chronic liver disease, an increasing
MELD score is associated with increasing severity of
hepatic dysfunction and risk of death.
MELD > 15 high surgical risk
MELD 10-15 moderate surgical risk
MELD < 10 lowest surgical risk
Hepatic Disease and Dental
Procedures
The 42 y/o male with a history of cirrhosis has an albumin 2.7,
total bilirubin 1.6 (.1-1.2) and normal AST and ALT but his
prothrombin time is 18 (control 10-12) or 6 seconds
prolonged. He is not anemic by his CBC.
Initial management prior to surgery:
a. Proceed to surgery
b. Type and cross 4 units and of packed red blood cells and
transfuse
c. Fresh frozen plasma 8 units
d. Vitamin K 10 mg SQ
e. Vitamin K 10 mg po
Hepatic Disease and Dental
Procedures
His platelet count is 60,000/mm3 (140-450,000) and his
PT doesn’t correct at all after 10 mg of vitamin K.
How would you correct his coagulopathy to decrease his
risk of bleeding?
a. Transfuse 6 units of platelets
b. FFP
c. Cryoprecipitate 10 units IV
d. DDAVP
e. Plasma exchange
Hepatic Disease and Dental
Procedures
Correction of Coagulation Deficiencies
PLATELETS
-Prophylactic platelet transfusions for counts <
50,000/mm3 for minor surgeries (liver biopsies). Major
surgeries < 100,000.
-Alcohol may directly suppress platelet production in
alcohol-related liver disease
Hepatic Disease and Dental
Procedures
Hypoprothombinemia (elevated PT)
Poor nutrition or malabsorption due to cholestasis may
cause Vitamin K deficiency.
-Vitamin K 10 mg 1-3 doses PO/SQ
Impaired hepatic synthetic function
-FFP
-Cryoprecipitate 10 U IV
-DDAVP IV
-Plasma Exchange
* Aim for a PT within 3 seconds of control
Hepatic Disease and Dental
Procedures
36 year-old-female is scheduled for a dental procedure. Four
weeks ago she had a viral illness in which her eyes turned yellow
and resolved after 1 week. She has no problems except for joint
aches in her hands, her physical exam is unremarkable.
What blood tests would you order?
a. AST, ALT, total bilirubin, PT
b. AST, ALT, CBC, thyroid test
c. HbsAg, IgM anti-BHc
d. Anti-HCV, IgM anti HAV
e. a, b, c
f. b, c, d
g. a, c, d
Hepatic Disease and Dental
Procedures
The 36-year-old female’s blood tests come back positive for
HBsAg and IgM anti-BHc and her AST is elevated at 450 and
her ALT is elevated at 658. All other tests including PT and
bilirubin were within normal limits.
What would be your next management:
a. Delay procedure until 1 month after liver enzymes have
returned to normal
b. Proceed to surgery and type and cross for 4 units of FFP.
c. Proceed to surgery since patient only has joint pain.
d. Perform a liver biopsy prior to surgery
Hepatic Disease and Dental
Procedures
Acute hepatitis: The presence of acute viral or
alcoholic hepatitis increases operative risk 10 %
and postop complications 11 %. Elective
surgery/procedure should be delayed until one
month after liver enzymes have returned to
normal.
Hepatic Disease and Dental
Procedures
Complications in Patients with Chronic Liver Disease after procedure:
Watch for:
• Hepatic Encephalopathy: Precipitating factors/post-op complications
include: GI bleeding, constipation, azotemia, hypokalemic alkalosis, sepsis,
hypoxia and use of CNS depressant drugs.
• Treat with restriction of protein 30 grams per day, enemas or cathartics to
cleanse the bowel, lactulose (an oral unabsorbable disaccharide) in a dose
needed to achieve mild diarrhea.
• Careful selection of medications used and adjustment of dosage, if
necessary.
• Bleeding.
• Prothrombin time and Bilirubin are probably the best measures of hepatic
function.
• Bilirubin can be expected to rise after: complicated surgery, multiple
transfusions, bleeding, or with systemic infections.
Hepatic Disease and Dental
Procedures
Summary of Key Points:
An asymptomatic patient with mild elevations of
serum aminotransferase levels should have a
work-up to look for the causes of liver disease
before elective surgery. This may include a liver
biopsy.
Hepatic Disease and Dental
Procedures
Procedures/Surgery is well tolerated in:
• Chronic persistent hepatitis (asymptomatic
mild chronic hepatitis)
• Mild, chronic active hepatitis (if the patient is
well compensated, has normal PT time,
bilirubin, and albumin)
• Child's class A or MELD <10 cirrhosis
Hepatic Disease and Dental
Procedures
Procedures/Surgery Permissable in:
Child's class B or MELD 10-15 cirrhosis (except
those undergoing extensive hepatic resection or
cardiac surgery) who have undergone thorough
preoperative preparation.
Hepatic Disease and Dental
Procedures
HIGH RISK PROCEDURE/SURGERY IN LIVER PATIENTS WITH THE
FOLLOWING:
• Severe chronic active hepatitis - elective surgery
contraindicated in symptomatic disease.
• Active alcoholic hepatitis - 6-12 weeks abstinence advised
(steroids ?).
• Obstructive jaundice - increased risk of renal failure, DIC,
stress ulceration, impaired wound healing, dehiscence.
• Acute or Fulminant Hepatitis of any cause - wait until
evidence of clinical improvement in the underlying disease
process to decrease risk.
• Childs Class C cirrhosis or MELD > 15 cirrhosis.
• Severe Coagulopathy.
Bleeding Disorders and Dental
Procedures
50 Year-old-male with no past medical history is scheduled
for a dental procedure. He’s had no bleeding problems and
his PE is unremarkable. His bleeding time is normal and
CBC is normal except for a platelet count of 70,000. What
would be the most appropriate management prior to
surgery?
1. Proceed with procedure and check platelets 2 hours
after completed
2. Transfuse 8 units of platelets to get count >100,000
3. Transfuse 4 units of platelets to get count >100,000
4. Delay elective procedure until cause is determined and
corrected
Bleeding Disorders and Dental
Procedures
Thrombocytopenia and Bleeding risk
• Risk of bleeding related to the cause of the
thrombocytopenia and patients associated conditions.
• Delay elective procedures until cause is determined and
corrected.
• Healthy patients like young women with ITP have lower
risk.
• Patients with Systemic illnesses: aplastic anemia,
chemotherapy induced are at higher risk.
• Highest risk is patients with other hemostatic defects like
liver disease and patients with sepsis and DIC.
Coagulation factors not working.
Bleeding Disorders and Dental
Procedures
Thrombocytopenia and Bleeding risk
• A normal platelet count > 150,000/µL isn’t necessary for
any procedure.
• >100,000 /µL is considered adequate
• >50,000 /µL adequate for minor surgeries
• Unless other conditions (liver disease, ASA use) are
present that can increase risk of bleeding, very few
platelets are required to provide adequate hemostasis.
• Avoid NSAIDS and Aspirin because they can impair
platelet function.
Bleeding Disorders and Dental
Procedures
Anticoagulation
60 year-old-female with a history of a mitral valve
replacement 5 years ago is scheduled for a dental
procedure. She has no complaints and her physical exam is
unremarkable. She takes 5 mg of coumadin per day. What
would be the most appropriate test to order?
1. CBC with platelets
2. PT/PTT and INR
3. Bleeding time
4. Liver profile
Bleeding Disorders and Dental
Procedures
Her lab work shows an INR of 3.0. What do you
recommend to manage her anticoagulation before surgery?
1.
2.
3.
4.
Withhold 4 scheduled doses of coumadin
Withhold 8 scheduled doses of coumadin
Withhold 6 scheduled dose of coumadin
Proceed to procedure without discontinuing coumadin
(with good local control)
Bleeding Disorders and Dental
Procedures
The INR is measured the day before dental procedure. What
would be the goal of the INR before proceeding to surgery?
1.
2.
3.
4.
INR 2.5-3.0
INR 4.0-6.0
INR 1.5-2.0
INR 1.0-1.5
Bleeding Disorders and Dental
Procedures
Since this patient has a mechanical valve and is at risk for a CVA,
when would you recommend the patient to take warfarin after
her dental procedure?
1.
2.
3.
4.
Immediately after surgery.
In 4-5 days.
In 1-2 days.
In 1 week.
Bleeding Disorders and Dental
Procedures
Anticoagulated Patients and Dental Procedures must
consider:
1. The individual patient (liver disease, history of CVA’s,
healthy?)
2. The reason for the anticoagulation
a.
b.
c.
Deep venous thrombosis
Atrial Fibrillation (history of CVA’s?)
Prosthetic Valve
3. Nature of the procedure (extraction, how much bleeding?)
Bleeding Disorders and Dental
Procedures
Mechanical heart valves or non-valvular atrial fibrillation
• Ideally, have the INR in the low therapeutic range before surgery,
but in practice difficult to do.
• Don’t normalize the INR because of CVA risk. The longer the
window of normalization without heparin the greater the risk of a
CVA.
• A-Fib: check INR, if in therapeutic range: 2-3, may proceed to
surgery with good local control . If supertherapeutic hold several
doses.
• Mech. Valve: check INR, if in therapeutic range: 2.5-3.5 may
proceed to surgery with good local control. Hold several doses if
supertherapeutic and recheck INR.
• Minor Surgery (extract teeth) with good local control, keep INR <
3.0
Bleeding Disorders and Dental
Procedures
Anticoagulation Review
• ASA continue but if needed stop 1 week before
procedure.
• Clopidogrel (Plavix-antiplatelet agent) continue but if
needed stop 1 week before procedure.
• Ticlopidine (Ticlid-platelet aggregation inhibitor) stop
10-14 days before surgery if needed.
• Stents (Bare-Metal): At least 1 month of Plavix/ASA.
Best 6-12 months.
• Drug-Eluting Stents need Plavix, ASA for 1 year.
Bleeding Disorders and Dental
Procedures
Dabigatran (Pradexa)
• Thrombin inhibitor taken twice a day.
• Normal renal function > 50 cc/min: Stop 1-2 days before
surgery.
• Abnormal renal function < 50 cc/min: Stop 3-4 days
before surgery.
• With good local control:
Continue or stop PM dose and AM dose day of
surgery.
Resume night of surgery. Works in 2-3 hours.
Bleeding Disorders and Dental
Procedures
62 year-old-male with a history of atrial fibrillation on 7.5
mg of coumadin every day is scheduled for a dental
procedure (extraction). His INR is 8 and he has no bleeding.
What would be the most appropriate management before
surgery?
1.
2.
3.
4.
5.
Withhold coumadin and wait till INR is 2.0-2.5
Administer Vitamin K 2.5 mg po
Administer Vitamin K 5.0 mg IV
1 and 2
1 and 3
Bleeding Disorders and Dental
Procedures
Two weeks after a dental extraction, the patient comes to your
office complaining of a nosebleed for 3 hours that won’t stop.
He is back on 7.5 mg of coumadin and you order a stat INR which
is 10. The best management for his bleeding would be the
following
1.
2.
3.
4.
5.
6.
Hold the next 6 doses of coumadin and check the INR in 6 days
Admit and administer Vitamin K 10 mg IVP (over 20-60 mins)
Admit and administer Vitamin K 5mg SQ
Admit and administer fresh frozen plasma (FFP) IV
1 and 2
2 and 4
Bleeding Disorders and Dental
Procedures
•
•
•
•
•
Reversing the Anticoagulant Effects of Warfarin
Risk of bleeding rises sharply when INR > 5.0
Reduce INR by withholding coumadin or (Vit. K or FFP if
needed emergently)
Vitamin K > 10 mg can lead to coumadin resistance
Vitamin K IV can cause anaphylactoid reactions so infuse
slowly
Vitamin K 1-2.5 mg po can reverse an INR 5-9 within 24 hours
in most patients
Bleeding Disorders and Dental
Procedures
Reversing the Anticoagulant Effects of Warfarin
• When the INR > 9.0, a larger dose is needed 5 mg of Vitamin K
po
• If serious or life-threatening bleeding is present, or if rapid
reversal of anticoagulation is required (eg, in preparation for
emergency surgery), warfarin should be stopped and 10 mg of
vitamin K1 administered by a slow intravenous infusion (eg,
over 20 to 60 minutes), supplemented by transfusions of fresh
frozen plasma (FFP, initial dose: 2 to 3 units; more as clinically
indicated)
Bleeding Disorders and Dental
Procedures
A 30 year-old-female is scheduled for a dental procedure.
She has a history of moderately heavy menses and a
prolonged bleeding time of 14 minutes. The rest of her lab
studies showed the following:
Platelet count 400,000 (150 - 450,000)
PT 10 sec (control 11)
PTT 55 sec (control 30)
Mixing studies corrected to 34s (control 30)
Factor VIII 25% (10-200% of normal)
Bleeding Disorders and Dental
Procedures
The patient’s diagnosis?
1. Hemophilia A
2. Hemophilia B
3. von Willebrands Disease
Management before surgery?
1. VWF Concentrates
2. Packed Red Blood Cells
3. DDAVP
4. 1 or 3
5. 1 or 2
Bleeding Disorders and Dental
Procedures
von Willebrands Disease
• VWD is characterized by mutations that lead to an
impairment in the synthesis or function of von
Willebrand factor (VWF). There are also acquired forms
of VWD.
• VWF is necessary for normal platelet adhesion and is
either deficient or defective
• Autosomal dominent mostly - Some types recessive. The
most common of the inherited bleeding disorders
• Prevalence of 1% with random lab screening but
symptomatic VWD 0.01 %
Bleeding Disorders and Dental
Procedures
von Willebrands Disease
• Von Willebrand factor (VWF) binds to platelets and
endothelial components, forming an adhesive bridge at
sites of endothelial injury.
• VWF also contributes to fibrin clot formation by acting as
a carrier protein for factor VIII, which has a greatly
shortened half-life unless it is bound to VWF.
• Type 1 most common form (75%); they produce an
inadequate amount of normal VW factor. Type 2 (4
subtypes) have defective VW factor and Type 3, the
rarest form, have virtually no VW factor
• Most cases are mild and are not screened for
Bleeding Disorders and Dental
Procedures
von Willebrands Disease
HISTORY of bleeding very important, tip offs include:
nosebleeds, copious bleeding from minor cuts or dental
work, easy bruising, excessive menstrual bleeding, or
family history of bleeding
5 Screening tests:
–
–
–
–
Plasma VWF antigen (VWF:Ag)
Plasma VWF activity (ristocetin cofactor activity, VWF:RCo)
Factor VIII activity (FVIII) and PTT
Bleeding Time or Platelet function analyzer (PFA)
Bleeding Disorders and Dental
Procedures
von Willebrands Disease
In Type I you usually see:
• Prolonged bleeding time or abnormal PFA
• Decreased factor VIII which is carried with VWF protein,
• prolonged PTT
• VWF:ag decreased
• VWF:activity decreased
Bleeding Disorders and Dental
Procedures
von Willebrands Disease Tx for Type I:
• Mild: DDAVP (desmopressin) nasal spray 2 hrs before
surgery. Weight >50 kg: 300 mcg (1 spray each nostril).
Weight <50kg: 150 mcg (1 spray in one nostril).
• DDAVP given IV: 0.3 mcg/kg in 50 cc Normal Saline over
20minutes 30 minutes before surgery.
• DDAVP may use 2-4 doses every 12 hours if needed.
• Minor Bleeding or Surgery: VWF Concentrates containing
all VWF multimers.
– Initial dose 60 ristocetin cofactor units followed by 40 units
every 12-48 hours to keep VWF level >30 IU/dl for 3-5 days.
Bleeding Disorders and Dental
Procedures
von Willebrands Disease Type II and III
Severe or anticipate Major Surgery or bleeding: VWF
Concentrates containing all VWF multimers.
• 40 to 60 international units/kg; repeated doses of 20 to
40 international units/kg should be given approximately
every 12 hours to maintain a level between 50 to 100
IU/dL of VWF ristocetin cofactor activity
• VWF ristocetin cofactor levels of 100 IU/dL activity be
maintained for 7 to 14 days
Bleeding Disorders and Dental
Procedures
von Willebrands Disease
Antifibrinolytic Agents:
1. Aminocaproic Acid: 50 mg/kg (maximum 5 gram dose)
4 times daily by mouth.
2. Tranexamic acid: 10 mg/kg 3 times daily IV.
Topical Agents:
1. Topical Thrombin.
2. Micronized collagen (Avitene), which is available in
strips for packing,
Bleeding Disorders and Dental
Procedures
65 year old female is scheduled for a dental procedure. No personal or
family history of bleeding problems. Her pre-operative PTT was 94s
(control 34)
Other laboratory studies:
Prothrombin time 12 sec (control 11)
Platlelet count 350,000 (150-400,000)
What other studies would you order to help assess her PTT?
1. Anemia panel
2. Mixing study (50-50 mix of patient and normal plasma) to see if
PTT gets corrected
3. Factor 8, 9, 11, 12
4. Von Willebrand Factor Antigen, ristocetin cofactor assay activity
Bleeding Disorders and Dental
Procedures
Laboratory studies:
Mixing study corrected the PTT
immediately
Factor 8,9, 11 activity wnl.
Factor 12 had 5% activity (60-139% of
normal)
Will this patient have any bleeding problems
during or after surgery?
Bleeding Disorders and Dental
Procedures
•
•
•
•
Factor XII Deficiency (Hageman)
Autosomal recessive
Lab findings: elevated PTT often greater than
100s
The PTT may be corrected with addition of
normal plasma
Despite a high PTT these patients do not have
bleeding problems even during major surgery or
trauma
Bleeding Disorders and Dental
Procedures
55 y/o/F with is scheduled for a dental procedure. No personal
or family history of bleeding problems. Her pre-operative PTT
was 100s (control 34). Labs revealed the following:
Mixing study corrected the PTT immediately
Factor 8,9, 12 activity wnl
Factor 11 had 5% activity (60-130% of normal)
Is this patient at risk for bleeding?
Bleeding Disorders and Dental
Procedures
Factor XI Deficiency
•
•
•
•
•
Rare autosomal recessive hereditary disorder
More common in the Japanese and Eastern European Jews
Lab findings: elevated PTT normal PT and BT
PTT is corrected with normal plasma
Individuals with partial FXI deficiency (ie, heterozygotes)
usually have FXI activity between 20 and 70 % of normal.
Those in the higher activity range can have a normal PTT.
• Low incidence of spontaneous bleeding but may bleed
excessively after surgery or trauma
Bleeding Disorders and Dental
Procedures
Factor XI Deficiency Treatment
• FFP (20cc/Kg loading dose and 10 cc/kg daily).
• Factor XI replacement therapy to raise the factor XI
level to between 30% to 45% of normal. Half-life is
long 4 - 5 days, therefore permitting 1 - 2 transfusions
per bleeding episode if minor.
• Tranexamic acid used as a 5 % mouthwash ,as tablets
in an oral dose of 1g or 25 mg/kg, or intravenously in a
dose of 10 mg/kg. Doses should be repeated every 6 to
8 hours for a total of 7 days, starting 12 hours before
surgery. Replacement therapy is not required.
Bleeding Disorders and Dental
Procedures
42 y/o F with a history of recurrent bleeding complications from
nosebleeds and once after a tooth was pulled. Her pre-op labs:
Bleeding time 5 min (<10 min)
Platelet Count 290,000 (150,000 - 300,000 per microliter)
PTT 32s (control 34)
PT 10s (control 11)
Her most likely diagnosis is:
1. Factor XII deficiency
2. Factor XI deficiency
3. Hemophilia A (factor VII deficiency)
4. Factor XIII deficiency
Bleeding Disorders and Dental
Procedures
•
•
•
•
•
Factor XIII deficiency
Autosomal recessive trait
Defective crosslinking of fibrin
Coagulation and bleeding tests are normal
Significant bleeding may occur after surgery
Replacement therapy with FFP (preferably virusinactivated), cryoprecipitate, or pasteurized
plasma concentrate prior to surgery to maintain
hemostasis
Bleeding Disorders and Dental
Procedures
A 22 year-old-male with a history of hemophilia A is
scheduled for a dental procedure. He has no
bleeding problems, his PTT is 65 sec and factor VIII
is 10%
What replacement therapy do you recommend to
decrease his risk of bleeding?
1. DDAVP or Aminocaproic acid
2. Cryoprecipitate
3. Factor VIII concentrate
4. FFP
Bleeding Disorders and Dental
Procedures
•
•
•
•
•
Hemophilia A (Factor VIII deficiency)
X-linked recessive, males usually affected but can
occur in females
Characterized by bleeding into soft tissues,
muscles and weight bearing joints
Mild disease, factor VIII >5%, infrequent bleeding,
unless surgery
Severe disease, factor VIII < 1%, bleed frequently
even without trauma
Prolonged PTT and all other tests normal
Bleeding Disorders and Dental
Procedures
Replacement Therapy: determined by severity and
anticipated bleeding
• Severe disease - transfuse factor VIII concentrate to
bring factor level to 100% prior to surgery. After the
initial dose maintain factor VIII above 50% for 10 - 14
days after surgery
• Moderate disease – factor VIII concentrate to get factor
VIII around 50%.
• Mild disease - DDAVP, Aminocaproic acid (Amicar),
Tranexamic acid
• Prior to surgery every patient should be screened for
the presence of an inhibitor to factor VIII
Bleeding Disorders and Dental
Procedures
A 17 year-old-boy with a family history of Hemophilia A is
scheduled for a dental procedure. He’s had no bleeding
problems and his PTT is normal at 30 sec (control 31).
What would be your preoperative management to
decrease his risk of bleeding. His CBC, bleeding time and
platelet count are within normal limits.
1. Check Factor 9 level
2. Check Factor 8 level
3. Proceed to surgery since PTT normal, no risk of
bleeding
4. Perform mixing studies
Bleeding Disorders and Dental
Procedures
The lab reports that the patients Factor VIII level is 20%
(normal is 60-100%). The appropriate management
before surgery to decrease his risk of bleeding is which
of the following?
1. Mild Hemophilia, treat with factor 8 concentrate
2. Mild Hemophilia but no bleeding risk because factor
8 >5%
3. Mild Hemophilia, treat with DDAVP or Aminocaproic
acid because he may still bleed
Bleeding Disorders and Dental
Procedures
A 27 year-old-male with a history of hemophilia B (factor 9 defy)
is scheduled for surgery. He has no bleeding problems his PTT is
80 and his factor IX is 1%. What replacement therapy do you
recommend to decrease his risk of bleeding?
1.
2.
3.
4.
DDAVP or Amicar
Cryoprecipitate
Factor IX concentrate
FFP
Bleeding Disorders and Dental
Procedures
Hemophilia B (Factor IX deficiency, Christmas disease)
• X-linked recessive
• Clinical features similar to Hemophilia A
• Prolonged PTT all other tests normal
• Factor assay used to determine: severity, distinguish
from factor VIII deficiency, and follow replacement
therapy
Replacement Therapy:
• Severe disease: Factor IX concentrate as in Hemophilia
A
• Moderate/mild disease: FFP
Bibliography
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patients with Liver disease. UpToDate. 2008; version 16.2.
• Friedman L. When patients with liver disease need surgery.
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• Ortiz J, Lane C. A Primary Care Approach, Hepatitis C.
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abstinence on poor postoperative outcome in alcohol
misusers: randomized control trial. BMJ. 1999; 318:1311-6.
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• National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3):
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management. UpToDate. Topic 547 Version 23.0. 2013
Bibliography
• Nadia A Khan, MD, MSc; William A Ghali, MD, MPH; Enrico Cagliero, MD.
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• Kearon C, Hirsh J. Management of anticoagulation before and
after elective surgery. New Engl Jour Med. 1997; 336: 1506 1511
• Weibert RT, et al. Correction of excessive anticoagulation with
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• Hirsh J. Reversing of the Anticoagulant Effects of Warfarin by
Vitamin K. Chest, 1998; 114:1505-1508
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• Rick M, Leung L, Landaw L. Treatment of von Willebrand disease.
UpToDate. 2012.
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Willebrand disease
UpToDate. 2012.