Management of primary hemostasis disorders in odontostomatology

Management of primary hemostasis disorders in odontostomatology

I/ Introduction:

The risk of bleeding is the main risk that dental surgeons may face. This risk can therefore be a source of very serious or even fatal complications after certain dental practices.

The act in odontostomatology must therefore be thought out and carried out well in order to avoid numerous risks for patients, including haemorrhagic risks which could endanger their lives.

II/ Physiological reminders:

1. Hemostasis: Hemostasis refers to all the physiological mechanisms that keep the blood in a fluid state, thus aiming to spontaneously stop hemorrhage and prevent thrombosis.
2. Primary hemostasis: 

Vascular time: immediate transient reflex vasoconstriction of injured small vessels leading to a decrease in circulating blood flow

• Platelet time:

. Platelet adhesion: to the subendothelium via the GPIB thanks to the FVW which forms a bridge between the platelet and the subendothelium

. Activation of platelets: by contraction and change of morphology and release of  

  factors (ADP, serotonin, calcium, etc.)

. Platelet aggregation: thanks to secreted substances, binding of fibrin to GPIIB and 

  GPIIIA , platelets aggregate together and form the white thrombus or platelet plug.

3. Coagulation or secondary hemostasis: see coagulation course

III/ Clinical manifestations of primary hemostasis disorders:

1. Skin hemorrhages:

• Petechiae  : punctiform elements of red coloration, not fading when     

                   glass pressure

• Bruise: blue spots of varying size and shape
• Vibices: petechiae arranged in linear streaks

2. Mucosal hemorrhages:

      Epistaxis, gingivorrhagia, menometrorrhagia in women, Endo-oral blisters: to look for  

      systematically because their presence constitutes an element of gravity

3. Visceral hemorrhages:  hemoptysis, hematemesis, hematuria. They are exceptional and  

are only seen in very severe thrombocytopenia

4. Retinal hemorrhages: Visualized by the fundus, they are serious because they involve  

game functional prognosis (blindness)

5. Cerebromeningeal hemorrhages  which should be systematically sought in the event of  

retinal hemorrhages, they are serious because they are life-threatening

IV/ Exploration of primary hemostasis

1. Interrogation: will look for:

• A known personal or familial hereditary bleeding syndrome: Willbrand disease
• A history of bleeding, personal or family
•  Systemic diseases: liver cirrhosis,…
• Taking medication

2. Clinical examination:

• Look for a hematoma, a perioral or perijugal facial bruise – A wound, a scratch, a reflection of trauma
• Look for petechiae, a sign of capillary fragility, hemorrhage following dental extraction, gingival bleeding, spontaneous or occurring after brushing or microtrauma.
•  Look for the nature of this bleeding, in a sheet or in a jet

      If a recent extraction has been carried out, ensure that the alveolus is empty and check the quality  

      blood clot

3. Biological examinations

A- Exploration of primary hemostasis:

• Platelet count:

•  Normal rate: 150000-400000/µl
•    < 50000/mm3: we are talking about severe thrombocytopenia with high hemorrhagic risk
• < 20000/mm3: cutaneous and mucosal hemorrhages are almost constant
•  50000-100000/mm3: the risk of bleeding is low
• Beyond 100000/µl there is no risk of purpura

      . Bleeding time (BT):

•  2 to 4min (Duke) 
•  5 to 8min (Ivy incision)

V/Primary hemostasis disorders:

Primary hemostasis disorders are classified into two categories:

1. Primary hemostasis abnormality due to platelet damage
2. Primary hemostasis abnormality due to vascular damage

A- Disorders related to platelet disorders:

1- Thrombocytopenia:

•    It is the decrease in the number of platelets below 150,000/mm3.
•    The risk is classified according to the degree of thrombocytopenia (see chapter on exploration of hemostasis)
• Etiological diagnosis:
•  Central thrombocytopenia: the disorder is located at the level of the marrow: medullary aplasia,  

 Acute leukemia, Metastases

•  Peripheral thrombocytopenia: platelets are produced normally but destroyed in the blood, the number of megakaryocytes in the bone marrow in this case is normal or increased and may be:

  a-Immunological: 

– Primary (idiopathic) immunological thrombocytopenia

             – Immunological thrombocytopenia secondary to autoimmune diseases

   b-Infectious:

• Viral thrombocytopenia: mumps, measles, chickenpox, MNI, hepatitis, HIV
• Bacterial thrombocytopenia: malaria, toxoplasmosis 

 c- Drug-induced thrombocytopenia

 d- Thrombocytopenia due to consumption: CIVD

2- Thrombopathies: 

•   Due to an abnormality of platelet functions which affect one or more stages of the   

  platelet plug formation, despite normal platelet count

•   Etiological diagnosis: 

1. Constitutional thrombopathies:  

• Are frequent and can be responsible for severe hemorrhagic syndromes

a- Jean Bernard Soulier syndrome: due to an adhesion anomaly and characterized by cutaneous, mucous membrane and sometimes visceral hemorrhages which begin very early in life.

     b-Glanzmann’s thrombobasthenia: due to abnormal aggregation, hemorrhages in this 

     cases are cutaneous, mucous and visceral; their severity and frequency tend to decrease  

     with age

                 c-Granule abnormality: Empty pool disease due to a deficiency of dense granules

     d- Thrombopathies related to an abnormality of storage of dense granules: 

         d1- Hermansky-Pudiak syndrome 

         d2- Wiskott-Aldrich syndrome 

                      d3- Chediak-Higashi syndrome 

2. Acquired thrombopathies: due to certain drugs, myeloproliferative syndromes, dysglobulinemia and refractory anemia
3. Willebrand disease: “pseudohemophilia”:

•  It is due to a qualitative and quantitative anomaly of the Willebrand factor.
•  TS increased 
•  Normal platelet count
•  Prolonged TCA (linked to decreased factor VIII) 
•  Decreased factor VIIIc.

B- Disorders related to vascular alterations: 

1. Senile purpura: This is a pathology of the elderly subject resulting in blue spots in areas exposed to the sun, linked to degeneration of the collagen fibers of the vessels.
2.  Rheumatoid purpura: This is a childhood disease characterized by purpuric skin lesions of an allergic type generally associated with abdominal pain and fever.
3. Rendu-Osler disease:  This is a hereditary condition characterized by telangiectasias  

hereditary

VI/ CAT in odontostomatology:

In any case, clinical assessment of the risk of bleeding can only be carried out through close collaboration between the hematologist and the dental surgeon . 

1. Acquired thrombocytopenias are a large group of pathologies. The best way to manage thrombocytopenia is to know its etiology; Some acquired thrombocytopenias require special management (chemotherapy and leukemia). (In case of emergency, it is always possible to implement local hemostasis techniques and perform a platelet transfusion if necessary. 
2. Thrombopathies: Platelet transfusion Protocol to be defined with the hematologist Local hemostasis++, it is recommended to contact the treating physician or the hematologist because these pathologies are not very widespread and little known. It is the hematologist who will be best able to provide us with information
3. Von Willebrand disease  : There is currently no official consensus for the oral management of this condition; there are no procedures for assessing the bleeding risk associated with the disease. The final management decision (administration of replacement therapy or not) belongs to the hematologist. 

VII / Conclusion:

Severe hemostasis disorders are most often diagnosed early in life due to their serious and early manifestations (hemarthroses, hematomas, etc.), while moderate and minor disorders have less equivocal manifestations and their diagnosis may occur late following a traumatic accident or after a simple dental extraction. 

This is why the surgeon must be able to recognize the clinical signs of a possible hemorrhagic pathology. When he suspects the existence of a hemostasis disorder, he must refer his patient to a hematologist,

 When the patient requires oral care, the difficulty for the dental surgeon is to assess the severity of the risk of bleeding. Given the complexity of the mechanisms of the primary hemostasis and coagulation processes, biological tests do not allow this risk to be ideally assessed. This is why the oral care of these patients must be multidisciplinary, 

Dental crowns are used to restore the shape and function of a damaged tooth.
Bruxism, or teeth grinding, can cause premature wear and often requires wearing a retainer at night.
Dental abscesses are painful infections that require prompt treatment to avoid complications. Gum grafting is a surgical procedure that can treat gum recession. Dentists use composite materials for fillings because they match the natural color of the teeth.
A diet high in sugar increases the risk of developing tooth decay.
Pediatric dental care is essential to establish good hygiene habits from an early age.
 

Management of primary hemostasis disorders in odontostomatology