Hematologic and surgical management of the dental patient with plasminogen activator deficiency

Anticoagulation therapy is used to treat patients with a variety of hemostatic disorders in an attempt to prevent thrombus formation. A thorough understanding of the patient's medical history is essential before dental treatment that may require alteration of this anticoagulation therapy. Alteration of anticoagulation therapy should be undertaken only after consultation with the patient's physician because some patients are at greater risk than others for thrombus formation or hemorrhage. This case of a 29-year-old man with plasminogen activator deficiency illustrates how consultation can result in a coordinated treatment plan for medical and dental management formulated to help ensure safe surgical treatment for these medically compromised patients.     

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??Postpartum hemorrhage is a common complication after tooth extraction. Many systemic and local factors can cause bleeding after tooth extraction. Reasonable selection and application of local hemostatic material for filling extraction socket is a good way to reduce and prevent post-extraction bleeding??and reduce the suffering of patients. With the development of oral materials science??more and more hemostatic materials are used to treat and prevent bleeding after tooth extraction. All kinds of hemostatic materials for filling extraction socket have a certain hemostatic effect. In clinical operation??our treatment should be based on the situation of tooth socket bleeding and the patient's general and economic conditions. In order to help clinicians to choose and apply hemostatic material??we will introduce the commonly used hemostatic materials??and analyze the characteristics of commonly used tooth extraction hemostatic materials in this paper.     

Hemostasis in oral surgery

The control of hemorrhage is a key component for the clinician to understand before performing oral surgical procedures. Hemostasis may be obtained primarily by local hemostatic measures. If hemostasis is not achieved with this modality, various hemostatic agents exist, which may be used as adjuncts to obtain hemostasis. Preoperative, perioperative, and postoperative methodologies toward hemostasis in oral surgery have been presented.     

Endovascular therapy in the emergent management of intractable hemorrhage associated with head and neck neoplasms

Purpose To evaluate the feasibility, safety, and efficacy of endovascular interventions in the emergent management of life-threatening hemorrhage associated with head and neck neoplasm. Materials and methods Over the past 5 years, 4 patients were subjected to emergent angiography to identify the sources of intractable bleeding and to endovascular interventions in an attempt to stop bleeding and salvage patient life. Selective bilateral CCA, ICA, and ECA arteriographies were initiated to document the underlying pathology and transcatheter arterial embolization with various embolic agents and stent deployment were carried out for cessation of intractable bleeding. Results The overall technical success rate is 75% (3/4). Two patients with buccal carcinoma were successfully treated with gelatin sponge pledgets and polyvinyl alcohol particles embolizations. One patient with a bulky ruptured RICA pseudoaneurysm associated with neurofibromatosis was successfully embolized with a 2–4 mm fibered platinum coil. The remaining patient with a wide-neck LCCA pseudoaneurysm resulted from IAIC for left buccal carcinoma was treated with two superimposing Easy Wallstents in the distal LCCA-LICA followed by 10 platinum coils embolizations due to non-availability of stent-graft (Covered stent). Unfortunately, despite sluggish flow leading to the pseudoaneurysm appreciated on fluoroscopy, the fragile pseudoaneurysm ruptured approximately 8 minutes thereafter while waiting for complete thrombosis. With the stents in place at LCCA-LICA, the vascular surgeon was able to ligate the LCCA and LICA to exclude the psendoaneurysm. No complications were encountered in all patients. Conclusion Endovascular therapy with various embolic agents and stent deployments were feasible, safe, and efficacious in the acute management of intractable hemorrhage associated with head and neck neoplasms.     

Influence of Hemostatic Agents in the Prognosis of Periapical Surgery: A Randomized Study of Epinephrine versus Aluminum Chloride

Introduction

Several variables have been associated with a better prognosis of periapical surgery. The aim of this study was to evaluate the influence of 2 hemostatic agents on the prognosis of periapical surgery at 12 months.

Cardiovascular effects and efficacy of a hemostatic agent in periradicular surgery

The purpose of this study was to evaluate the hemostatic efficacy and systemic cardiovascular effects of CollaCote collagen sponges saturated with 2.25% racemic epinephrine during endodontic surgery. A total of 48 patients participated in the study. Patients received CollaCote-saline or CollaCote-epinephrine placed in the bony crypt, after which hemostatic efficacy was evaluated. Blood pressure and pulse rate was recorded before and after administration of the local anesthetic, after the application of the test solutions, and before the patient's dismissal. Results showed no significant difference in blood pressure or pulse rate between the experimental and control groups. In the CollaCote-saline group, five of six cases failed to achieve hemorrhage control. In the CollaCote-epinephrine group, 1 of 42 cases had no hemorrhage control. Two patients had slight but apparent intermittent bleeding. Complete hemostasis was achieved in 39 of 42 cases. In conclusion, the results suggest that CollaCote collagen sponges saturated with 2.25% racemic epinephrine provide excellent hemostasis with no evident changes in blood pressure or pulse rate.     

消炎性止血网在拔牙创止血中的临床应用

目的：评价S-105消炎性止血网在拔牙创止血中的效果。方法：将270例门急诊拔牙患者分三组进行拔牙创止血，记录5min后止血情况。第一组中实验者（100例）拔牙后直接放置止血网，对照者按常规处理；第二组因正畸原因需双侧拔牙（30例），实验侧拔牙创放置止血网，对照侧按常规处理；第三组因拔牙后出血（40例），在清理牙槽窝后放置止血网。结果：第一组中放置止血网止血成功率为92％，与对照组常规处理半小时后止血成功率相比无统计学差异。第二组实验侧拔牙创均完全止血，且无一例出现术后疼痛，对照侧有7例仍有出血，止血成功率为77％，4例出现术后疼痛。第三组止血成功率为77.5％。结论：消炎性止血网用于拔牙创止血，止血迅速，使用方便，效果良好。     

Major vascular complications of orthognathic surgery: hemorrhage associated with Le Fort I osteotomies

Major intraoperative or postoperative bleeding associated with Le Fort I osteotomies can be venous and/or arterial in nature. Arterial hemorrhage generally involves the maxillary artery and its terminal branches. Arterial hemorrhage tends to be more persistent and can be recurrent, which makes it more difficult to manage. Postoperative bleeding following Le Fort I osteotomies generally presents as epistaxis and usually occurs initially within the first 2 weeks following surgery. Treatment modalities that have been used to successfully arrest postoperative hemorrhage include anterior and/or posterior nasal packing; packing of the maxillary antrum; reoperating with clipping or electrocoagulation of bleeding vessels, or the use of topical hemostatic agents in the pterygomaxillary region; external carotid artery ligation; and selective embolization of the maxillary artery and its terminal branches.     

Dental management of anticoagulated patients.

Today's trend toward ambulatory medical care will bring more pharmacological problems into the dental office. While the dental management of patients taking oral anticoagulants is controversial, current research supports the contention that they can be safely treated on an outpatient basis. The use of the International Normalized Ratio (INR) has made better estimates of prothrombin time possible, and patients can be maintained in a narrow therapeutic range. Postoperative hemorrhage can be avoided or controlled with local hemostatic agents.     

Comprehensive dental care for children with bleeding disorders--a dentist's perspective.

Providing treatment to pediatric patients with bleeding disorders can present a challenge for the dentist. In the past, this group of patients may have avoided regular dental care, attending the dentist only in acute situations requiring immediate attention. Today, with the recent advances in medical management, patients with bleeding disorders can undergo comprehensive dental care. However, the dentist must have an understanding of the patient's specific coagulation defect, and use a team approach with the patient's physician and hematologist prior to undertaking any treatment. This paper reviews the key aspects of patient assessment and provides specific management protocols for all phases of dental treatment. Supported by a strong preventive program, the use of indicated replacement therapy where necessary, conservative treatment approaches, and the use of local hemostatic measures to control hemorrhage, most cases can be successfully managed. Thus, a valuable and once neglected service can be delivered in a safe and thorough manner.     

导管支架在涎腺疾病治疗中的应用

支架是一种管腔样结构,可植入人体内维持机体腔孔状器官的外形和腔隙。近10年来,支架这一新的技术在全身各系统都得到了广泛的应用,而支架在涎腺疾病中的使用起源于内镜技术的发展。支架植入导管是内镜手术诊治涎腺阻塞性疾病的一种方法,为了避免内镜术后狭窄而放置临时导管作为支架,起到暂时性扩张和冲洗作用。     

Management of dental patients with bleeding disorders: review and update

Management of the dental patient who has a bleeding disorder requires an understanding of the normal hemostatic system and the patient's specific coagulation defect. This patient group can receive quality comprehensive dental care, provided appropriate preoperative planning and evaluation with the patient's physician or hematologist is accomplished. Emphasis should be placed on providing appropriate replacement therapy before the dental procedure, selection of conservative treatment approaches, and use of local hemostatic measures to facilitate hemostasis.     

Glanzmann's thrombasthenia. Report of two oral surgical cases using a new microfibrillar collagen preparation and EACA for hemostasis.

Glanzmann's thromboasthenia is a rare congenital platelet disorder characterized by a prolonged bleeding time, a qualitative platelet defect, and severe hemorrhagic episodes. Patients with this disorder have been managed by administration of blood and blood components (most recently, platelet-rich plasma and platelet concentrates) to control hemorrhage resulting from trauma or surgical procedures. The two case reports presented here illustrate the use of a local hemostatic agent (microfibrillar bovine collagen, Avitene) and a systemic fibrinolytic inhibitor (epsilon aminocaproic acid, Amicar) to control postoperative hemorrhage secondary to elective extraction of teeth. The clinical results demonstrate excellent postoperative hemostasis and support recent in vitro observation of platelet adherence to the collagen preparation. This provides an alternate therapeutic modality in the management of patients with Glanzmann's disease and possibly other disorders of platelet function.     

Aluminum Chloride versus Electrocauterization in Periapical Surgery: A Randomized Controlled Trial

Introduction

The aim of this study was to evaluate the efficacy of 2 hemostatic agents in periapical surgery and its relationship with patient- and tooth-dependent variables.

Prevention of hemorrhagic complications after dental extractions into open heart surgery patients under anticoagulant therapy: the use of leukocyte- and platelet-rich fibrin

Leukocyte- and platelet-rich fibrin (L-PRF) is a biomaterial commonly used in periodontology and implant dentistry to improve healing and tissue regeneration, particularly as filling material in alveolar sockets to regenerate bone for optimal dental implant placement. The objective of this work was to evaluate the use of L-PRF as a safe filling and hemostatic material after dental extractions (or avulsions) for the prevention of hemorrhagic complications in heart surgery patients without modification of the anticoagulant oral therapy. Fifty heart surgery patients under oral anticoagulant therapy who needed dental extractions were selected for the study. Patients were treated with L-PRF clots placed into 168 postextraction sockets without modification of anticoagulant therapy (mean international normalized ratio = 3.16 ± 0.39). Only 2 patients reported hemorrhagic complications (4%), all of which resolved a few hours after the surgery by compression and hemostatic topical agents. Ten patients (20%) showed mild bleeding, which spontaneously resolved or was resolved by minimal compression less than 2 hours after surgery. No case of delayed bleeding was reported. The remaining 38 patients (76%) showed an adequate hemostasis after the dental extractions. In all cases, no alveolitis or painful events were reported, soft tissue healing was quick, and wound closure was always complete at the time of suture removal one week after surgery. The proposed protocol is a reliable therapeutic option to avoid significant bleeding after dental extractions without the suspension of the continuous oral anticoagulant therapy in heart surgery patients. Other applications of the hemostatic and healing properties of L-PRF should be investigated in oral implantology.     

The management of dental extractions in cases of thrombasthenia complicated by the development of isoantibodies to donor platelets.

Two cases of thrombasthenia, a rare hereditary disorder of platelet function, are presented. The oral surgical and dental management of these cases is discussed in the light of the development of isoantibodies to transfused platelets in one of the cases and in another case encountered. The problems of obtaining donor platelets matched for platelet and HL-A antigens are discussed. Emphasis is placed on the use of local hemostatic measures and antifibrinolytic agents in the management of hemorrhage in this disorder and the avoidance of platelet transfusions as far as possible. Conservative dentistry and early preventive dental advice are considered desirable in order to avoid extractions.     

Management of middle meningeal and superficial temporal artery hemorrhage from total temporomandibular joint replacement surgery with a gelatin-based hemostatic agent

Complications associated with temporomandibular joint (TMJ) replacement surgery may include injury to nerves, blood vessels, and otologic structures. Vascular injuries can be associated with trauma to the carotid artery and its terminal branches, the superficial temporal artery, and the internal maxillary artery. Suggested management to control hemorrhage has included uniand bipolar electrocautery, laser ablation, local anesthetics with vasoconstrictors, direct pressure, embolization, and ligation. In this case report, the iatrogenic injury to both the middle meningeal and superficial temporal arteries during total TMJ replacement surgery controlled by using a gelatin-based hemostatic agent is discussed.     

Assessment of the risk of haemorrhage and its control following minor oral surgical procedures in patients on anti-platelet therapy: a prospective study

Controversy exists concerning the suspension or maintenance of anti-platelet drugs before elective surgical procedures. We assessed the association of the risk of prolonged postoperative bleeding with anti-platelet therapy by type of minor surgical procedure and the association between anti-platelet therapy and the level of hemostatic measures required. Five hundred and forty-six patients were included in the study group: those on aspirin (n = 310), clopidogrel (n = 97), and aspirin + clopidogrel dual therapy (n = 139); the control group comprised 575 healthy individuals. Cramer's V test was significant (P < 0.05) but showed a weak association between anti-platelet therapy and prolonged immediate postoperative bleeding. Compared to controls, the odds ratio revealed that the risk of prolonged bleeding in the immediate postoperative period was significantly higher with dual therapy, followed by clopidogrel and aspirin. Prolonged bleeding occurred in 22 patients in the study group and 20 in the control group, and was successfully controlled with local hemostatic measures. Fisher's exact test showed a significant association between dual therapy and higher levels of hemostatic measures (P = 0.004; P = 0.035). Prolonged bleeding in patients on anti-platelet therapy was independent of the type of minor surgical procedure. The greatest risk of prolonged bleeding was found in patients on dual therapy; this required higher levels of hemostatic measures.     

穿透性颈部大血管伤的救治:附6例报道

目的:探讨穿透性颈部大血管伤的救治方法。方法:1999—2010年收治6例穿透性颈部大血管伤患者,损伤的重要血管结构中颈内动脉1例,颈内静脉2例,椎动脉5例。6例患者中,5例行手术探查,1例为外伤性椎动脉假性动脉瘤,采用覆膜支架介入治疗。结果:6例患者均获得成功救治,所有患者存活,止血彻底,无继发性出血,无因脑部供血不足产生的功能障碍;2例患者颈部伤口延期愈合,分泌物非脓性,细菌培养无致病菌。结论:开放性颈部大血管伤以手术探查止血为首要治疗手段,损伤血管首选吻合,闭合性血管损伤介入血管重建值得推荐,椎动脉损伤手术填塞止血是有效的止血措施。     

模板在种植义齿修复中的制作与应用

目的：探讨模板在种植体植入的位置和方向上的导向作用，以及计算影象诊断的变形率。方法：利用热压成型法和自凝塑胶涂布法等在IT1、Anthogyr和BLB种植系统种植体植入中应用。结果：种植体植入颌骨中的位置、方向和角度基本准确，修复效果满意。结论：模板对提高种植义齿修复的质量有重要意义。