essay 27 - extractions in medically compromised patients (disorders of blood and hematopoietic system). management

tooth extraction in patients with blood and hematopoietic disorders is complex due to risks such as?

• delete healing

• excessive bleeding

• increased susceptibility to infection

when doing tooth extraction in patients with blood and hematopoietic disorders, dental clinicians must

• take a thorough history

• perform relevant clinical and lab investigations

• consult the patient's physician before any invasive procedures

role of white blood cells in dental health - disorders of white blood cells

• primary defence against infections

• crucial for immune response

• abnormal WBC's → delayed healing, mucous alteration, infection and even fatal complications

types of WBC disorders

1. leukaemia: cut out of WBC's in bone marrow and blood

• acute leukaemia = the rapid accumulation of immature and functionless WBC's in bone marrow and blood

• chronic leukaemia = slower, more functional WBC production

2. lymphoma: cancel lymphoid tissues, present as tissue masses

• types = Hodgkin's disease, non Hodgkins lymphoma, burkitts lymphoma, multiple myeloma

List The types of dental management of leukemic patients

• detection

• referral

• Pre dental treatment consultation

• routine dental care

• emergency dental care

• surgical planning

prescribe dental management During detection in leukemic patients

• history and clinical exam

• lab = WBC count, differential count, blood smear, haemoglobin/ hematocrit, platelet count

describe dental management during referral of leukemic patients

• refer to physician for diagnose and treatment

describe dental management during pre dental treatment consultation of leukaemia patients

• assess current medical status

• Determine dental treatment plan based on patient's condition

describe dental management during routine dental care in leukemic patients

• avoid in patients with acute symptoms

• allow after disease is controlled

• invasive care considerations e.g scaling and surgical procedures:

— platelet count > 50,000 = proceed

— platelet count <40,000 = Require platelet replacement

— neutropenic patient → antibiotic prophylaxis needed

describe dental management during emergency dental care of leukemic patients

• ulcers = antibiotics, bland rinses, and antihistamines, orabase

• oral candidiasis: antifungals

• pain/infection: conservative management, antibiotic sensitivity test, strong analgesics

describe dental management during surgical planning for leukemic patients

• get platelet count and bleeding time on procedure day

• platelet replacement if thrombocytopenic and delay procedure until physician is consulted

• in Hodgkin's disease with splenectomy: prophylactic antibiotics recommended

• regimen: penicillin VK 2g, 1 hr before, and 500 mg x4/day for 1 week

what are bleeding disorders

• conditions that alter ability of blood vessels, platelets and coagulation factors to maintain homeostasis

what are the types of bleeding disorders

• Inherited

• acquired

list and describe the inherited and acquired bleeding disorders

1. inherited

• haemophilia A = factor VIII deficiency

• hemophilia B (christmas disease) = factor IX deficiency

• rare = deficiencies and other clotting factors

2. acquired

• result of diseases that affect vascular water integrity, platelets, coagulation factors, drugs, radiotherapy or chemotherapy

• the liver disease, DIC

• vitamin K deficiency

• drug induced (e.g anticoagulants, aspirin, NSAID's, alcohol)

dental management during assessment of patients with bleeding disorders

• no surgery without bleeding history assessment and lab tests

• refer to haematologists for diagnosis and tests are abnormal

simple management during medication considerations of patients with bleeding disorders

1. aspirin = even low doses impair platelets (thromboxane inhibition)

• if PFA-100 is moderately prolonged, minor surgery may proceed unless another bleeding disorder is present

• in emergencies with PFA-100, desmopressin (DDAVP) can be used to shorten bleeding time

• Elective = stop aspirin three days before, if approved

2. NSAID's = reversible COX inhibition

• bleeding risk enhanced with alcohol, anticoagulants, liver disease

• wait for three half lives of the drug to pass before preceding the surgery to allow normal platelet function to return

describe precautions needed when treating patients with haemophilia A (factor VIII) deficiency)

• requires haematologist consultation

• determine = severity, inhibitors, responder status, Need for hospitalisation

• avoid = the block, lingual infiltration, floor of mouth, intramuscular injections without factor replacement

• replacement therapy is required = periodontal surgery, extractions, flap surgeries, 3rd molar removal (prefer buccal approach)

• mild/moderate forms = may use desmopressin, EACA, tranexamic acid

• pain control = paracetamol ± codeine

• always monitor for allergic reactions to factor products