Practice Considerations for Dental Professionals

The most important risk reduction strategy implemented by dental professionals is the completion of a comprehensive health history for every patient on a regular basis. The review of systems allows for the discovery of systemic conditions that alter bleeding, or that require the use of drugs that alter bleeding. Systemic causes of bleeding include liver disease, kidney disease, chronic alcoholism, bone marrow suppression, blood dyscrasias, Vitamin K deficiency, and inherited coagulopathies.127,128 As most clotting factors are formed by the liver, liver disease can greatly affect bleeding tendencies. Dental patients may present with liver disease caused by a variety of conditions, most commonly alcoholism, cirrhosis, and/or infections, such as hepatitis.

Intestinal bacteria continually produce Vitamin K, thus, a deficiency is rarely seen in a normal person due to an absence of Vitamin K from the diet. Exceptions are those with gastrointestinal diseases that result in poor fat absorption, as Vitamin K is fat-soluble and is absorbed into the blood along with dietary fats. One of the most common causes of Vitamin K deficiency is failure of the liver to secrete bile into the gastrointestinal tract, as lack of bile prevents fat digestion and absorption, thus reducing Vitamin K absorption as well.26

Dental professionals should remember to question patients about recent illnesses, changes in health behaviors, or modifications to their diets. Intestinal viruses that cause vomiting or diarrhea, changes in the intake of green leafy vegetables, or the use of medications can dramatically alter the patient’s response to warfarin. Fluctuations in the patient’s INR may be seen for several days, even weeks, following illness, dietary, or medication changes. It is essential to ask all patients taking warfarin about the results of their most recent INR. A follow-up with the patient’s physician may be warranted.

At every appointment, patients should provide a list of all of the medications and herbs that they take, including dosing schedules. This medication list should be documented in the treatment record at every appointment. Follow-up questioning of the patient is conducted as a component of the comprehensive health history to ensure that this list is accurate and complete. It is important to note that many patients think of some herbs as merely popular cooking ingredients (eg, garlic and ginger) and/or that these plant-derived substances are all natural, and must therefore be “safe” health products for ingestion. For this reason, patients must often be prompted to disclose the use of herbal medications. Remember that many herbal preparations contain multiple herbs within one supplement and that patients may not always know what herbs they are consuming in these products. While clearly herbs provide substantive and beneficial health properties, consuming herbs on a regular basis from either supplement use or cooking can potentially alter bleeding.

It is imperative that dental professionals have access to a good drug reference guide, either as a chairside reference text or in the form of an electronic database, to assist with completing an accurate medication list. Many popular dental drug resources also contain information on herbal medications, although dental professionals may find it helpful to also have a resource that is strictly devoted to herbal supplements. Resources provide valuable information about drug dosing, common side effects, drug interactions, and precautions for treating patients using these medications. Dental professionals should look up all medications that a patient is taking prior to prescribing other medications to ensure safety and compatibility. Text versions of reference guides should be replaced on an annual basis, as the field continuously evolves and changes. The advantages to electronic databases include speed of access to and the immediate availability of a vast quantity of information, and access to the most current drug data. Suggested resources for dental professionals are listed at the end of this paper.

Dental professionals should also observe their patients for physical manifestations of bleeding complications. Signs of altered bleeding may include excessive or diffuse bruising, petechial hemorrhaging, prolonged bleeding following dental procedures, and spontaneous gingival bleeding. Patients may report bruising easily or noticing an increase in bleeding with toothbrushing and flossing. Bruising is frequently observed in elderly patients taking antiplatelet and anticoagulant medications, who also demonstrate epithelial thinning as a normal part of aging. Clinical signs from observation and symptoms described by the patient should be documented in the treatment record.

Whenever there is doubt as to the patient’s safety and/or the stability of his current medical status, the patient’s physician should be contacted. The dental professional must be prepared to discuss the nature of the concern and proposed dental treatment with associated or potential risks, then request any information needed to safely proceed with treatment. Results from recent, relevant laboratory tests should be obtained for the treatment record. Copies of any test results ordered by the dentist that are required prior to initiating dental treatment should be forwarded to the patient’s physician as needed. Conversations with the patient’s physician must be documented in the treatment record.

As previously discussed, few anticoagulant and antiplatelet medications require discontinuation prior to routine dental treatment. Exceptions have been previously noted elsewhere in this paper. However, discontinuation may be required prior to invasive dental surgery. Herbal supplements should always be discontinued prior to any type of surgery, including dental surgery. Different herbs possess specific safety windows that range from 24 hours (ephedra) to 7 days to 14 days (garlic and ginseng) prior to undergoing surgery.20 Patients taking herbal supplements that possess anticoagulant and/or antiplatelet properties should be advised to discontinue use at least 2 weeks prior to having a surgical procedure until more is definitively known about the potential for bleeding complications.6,29 This 2 week to 3 week safety window is suggested by the American Society of Anesthesiologists (ASA).20 It is important to note that the safety window also takes into account other herbal side effects that may increase surgical risk, such as the ability to recover from general anesthesia. A discussion of these and other effects is beyond the scope of this paper. The reader is referred to Ang-Lee et al (2001) for a detailed discussion of these considerations

Despite careful planning and precautions, the potential for an unexpected bleeding event always exists for patients taking these medications. Therefore, it is essential that dental professionals have access to local hemostatic agents for use in the operatory. There are a variety of pharmacologic agents that are available for this purpose; however, a complete discussion about these products is beyond the scope of this paper. The reader is referred to Burrell and Glick (2003) for a review of hemostatic agents used in dentistry.129 Invasive procedures should be performed with as minimal trauma to the tissues as possible. Careful post-surgical monitoring is advised.6

To determine whether increased gingival bleeding is caused by a medication side effect, or is a manifestation of gingival disease, a thorough oral examination should be performed at each visit. Patients should be taught proper oral hygiene techniques to decrease etiologic bacteria that cause gingival inflammation. Manual plaque removal may be improved through the use of power-assisted toothbrushes, floss aids, and oral irrigators. Chemotherapeutic agents that exhibit antimicrobial properties are useful adjuncts to kill residual organisms that brushing and flossing may leave behind. Broad- spectrum antimicrobial agents, such as chlorhexidine, essential oil mouthrinse, and triclosan toothpaste, have demonstrated efficacy in reducing supragingival plaque and gingivitis, and resultant gingival bleeding. Improving oral hygiene reduces gingival inflammation, thus eliminating the primary etiologic factor for gingival bleeding. It is important to teach patients that gingival bleeding is not “normal,” as so many patients mistakenly believe, so that gingival bleeding as a complication of medication therapy can be quickly and accurately identified.

Dental hygienists possess an important role in educating patients about bleeding effects that may affect the oral cavity and the provision of oral health care services. Patients should be taught about the importance of accurately reporting their medication and herbal use, compliance with their medication regimens, and routine monitoring with blood tests as prescribed by their physicians. Patient education may also include dispelling myths about the need to discontinue medication use prior to undergoing routine oral care. Many patients discontinue their medications on their own, without consulting their physicians or dental professionals, because they are worried about a bleeding complication. It is important to educate patients about how bleeding is adequately managed in the oral health care setting, provide reassurance, and how, if needed, their medications should be discontinued.