Introduction
Management of perioperative bleeding consists of many steps such as finding the people who are at risk, considering medication, use of hemostatic measures, use of topical solutions, scheduling treatment, and limiting the surgical site. Bleeding can be controlled in clinical or dental hospital settings as well by the simple use of both mechanical as well as pharmacologic local hemostatic measures. Read the article to know the significant management of high-risk patients prone to bleeding by your dentist.
Why Is Hemostasis Essential in Dentistry?
It is important for the dental surgeon to always manage dental perioperative bleeding in the clinical or hospital setting. This is not only just to gain a clear visual or an unobstructed view of the dental surgical field, but it also is important to achieve blood clot control or adequate hemostasis, for ensuring the dental procedure does not have any possibilities of post-operative stress, complications, or discomfort to the patients again.
Although many dental procedures are usually performed even when the patients are taking anticoagulant or antithrombotic medications, precautions must be taken by the maxillofacial surgeon or dentist to minimize perioperative bleeding. It is important for dental operators to primarily understand the concept in hemostasis that irrespective of whether the dental procedures they are performing are invasive or not, the patients on these blood-related medications would still be at a higher risk of bleeding. Irrespective of the invasiveness of the dental procedure in question, it is important to prevent any possible bleeding risks that oral surgeries can pose as a challenge to the dentist.
What Are the Different Types of Procedures and Risk Factors?
Complete dental clinical routine examination or dental checkup would first give your dentist or the surgeon a clear idea or a picture of what procedures would need to be performed on the patient. Secondly, your dentist will then need to prioritize low-risk or high-risk procedures in the patient who may be taking systemic anticoagulant or antithrombotic medications.
Low-risk procedures in dentistry range from routine scaling or cleaning of your teeth plaque and calculus deposits involve mild to major restorations that do not usually involve any gingival or soft tissue manipulation, extractions of mobile teeth, that are usually not surgically complex and involve extracting less than three teeth in a single sitting, obtaining soft tissue biopsies, root canal therapies or endodontic procedures, simple dental implant placement, fabrication of fixed and removable dentures, crowns and bridges, etc., are all the low-risk procedures even in these patients which do not usually involve any physician consent to be before the procedure nor do they warrant alteration in anticoagulant medications. The values should ideally be in the therapeutic range in patients under Warfarin therapies.
High-risk dental procedures with more bleeding risk are periodontal surgeries, surgical extractions or multiple extractions in a single sitting, that is more than three teeth, osteoplasty (is a procedure done for reshaping and repairing bones), multiple dental implants, etc., which may require the physician's consent prior to the dentist performing these in the hospital setting.
How Oral Bleeding Can Be Controlled?
Most patients who would be taking antithrombotic drugs and who cannot skip these medications even for the course of a day would need more local pressure to be applied by the dentist at the surgical site or at the blood loss site. This is usually done by your dentist effectively with gauze compression, which is one of the manual ways to achieve hemostasis.
In spite of the manual gauze compression technique, if further measures are still indicated for following in suspected patients prone to increased bleeding, then the dentist or oral surgeon can adopt the techniques of suturing, electrocautery, use of a local anesthetic that should contain the vasoconstrictor epinephrine, use of styptic agents, use of oxidized cellulose, use of absorbable sponges or even the use of bone wax to exert the material effects of hemostasis, as employed by the dentist to control blood loss effectively.
The manually recommended gauze pressure technique is such that pressure is applied to the extraction socket or the bleeding area in the patient's oral cavity. The dentist would apply consistent pressure with the gauze at the site in question and ask the patient to bite down on it for as long as up to one hour in high-risk bleeding cases to achieve hemostasis.
One more effective alternative suggested by dental researchers in the manual clotting methods for dental surgery is to place a tea bag in the extraction site or socket and the patient can bite on it for as long as 30 to 40 minutes; the rationale of using tea bags in dental clotting is that tannic acid present in regular tea would be an effective local vasoconstrictor compound that would tend to clot blood faster, and prevent intraoperative bleeding.
What Are the Post-operative Instructions and Management?
Patients should be hence given very clear instructions by the dental surgeon, also highlighting the clear need for physician consent in case of a detailed blood-related history, prior to dental management itself.
Once the dental surgery is performed, post-operative instructions such as the application of pressure, ice, drinking liquids without a straw, avoiding any kind of vigorous rinsing, spitting, sucking, or chewing at the surgical site of the oral cavity need to be avoided. Pressure application with gauze or rinsing mildly for three days postoperatively with a gentle antiseptic mouth rinse composed of essential oils or chlorhexidine gluconate, rinsing with lukewarm salt water multiple times in a day, etc are some of the instructions to be narrated clearly by the dentist to prevent possible postoperative complications and swelling in the surgical region of the mouth.
Interdisciplinary collaboration with the physician can definitely help regarding patients in treatment regimens with anticoagulants like Warfarin, antiplatelet agents such as Ticagrelor, Ticlopidine, Prasugrel, Clopidogrel, Aspirin, new age direct oral anticoagulant agents (DOACs) such as Dabigatran, Rivaroxaban, Apixaban, and Edoxaban with instructions to be given by the physician in whether to alter these drugs or not during the day of dental appointments to prevent any bleeding risks. Usually, these drugs should not be altered before routine dental procedures to pose a low bleeding risk.
Conclusion
Patients who are taking oral anticoagulants and who have a medical history of being on coexisting morbidities impacting their hemostasis, for instance, chronic liver disease, renal disease, or thrombocytopenia (platelet count in the blood is less), certainly require physician consent before dental procedures as these conditions may pose complex challenges both during the course and post-operatively after the procedure, making the patients prone to a definitive greater risk of bleeding.
Eliciting the patient’s current medication as well as medical history, preoperative assessment protocols, and guidelines prior to dental procedures are hence an imperative part of achieving hemostasis or effective blood loss control during any dental surgical procedure.
