Hemostasis in Dentistry

204 Pages·2018·4.57 MB·English

by  Richard P. Szumita, Paul M. Szumita

Hemostasis in
Dentistry
Richard P. Szumita
Paul M. Szumita
Editors
123
Hemostasis in Dentistry
Richard P. Szumita • Paul M. Szumita
Editors
Hemostasis in Dentistry
Editors
Richard P. Szumita Paul M. Szumita
Department of Dentistry Department of Pharmacy Services
St. Joseph’s Regional Medical Center Brigham and Women’s Hospital
Department of Dentistry Department of Pharmacy Services
Paterson, NJ Boston, MA
USA USA
ISBN 978-3-319-71239-0 ISBN 978-3-319-71240-6 (eBook)
https://doi.org/10.1007/978-3-319-71240-6
Library of Congress Control Number: 2018950141
© Springer International Publishing AG, part of Springer Nature 2018
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Contents
Part I Review of Hemostasis
1 Local Tissues in Hemostasis and Platelet Review . . . . . . . . . . . . . . 3
Tiffany Kuang and Richard P. Szumita
2 Coagulation Enzymes Review and Review of Hemostasis:
Putting It All Together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Richard P. Szumita
Part II Pathophysiology and Pharmacotherapy of Hemostasis in
Dentistry
3 Review of von Willebrand Disease and Perioperative
Management in Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Richard P. Szumita
4 Review of Hemophilia A and B and Perioperative
Management in Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Pooja Gangwani and Ryan Richards
5 Review of Thrombocytopenia and Perioperative
Management in Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Hani F. Braidy
6 Review of Liver Disease and Perioperative
Management in Dentistry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Hillel Ephros and Ilya L. Garibyan
7 Malignancy and Hemostasis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Matthew Idle, Scott Claiborne, Ketan Patel, and
Deepak Kademani
8 Stratifying Thromboembolic Risk: Why Is
Your Patient on Antithrombotic Medications? . . . . . . . . . . . . . . . 73
Benjamin Hohlfelder
9 Review of Antiplatelet Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Jeremy R. DeGrado and Kevin E. Anger
v
vi Contents
10 R eview of Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
David P. Reardon and Christopher Zemaitis
11 P harmacologic Reversal Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
James F. Gilmore, Michael J. Schontz, and
Kenneth E. Lupi Jr.
Part III Management of the Dental Patient on
Antithrombotic Therapy
12 P erioperative Management of Dental Patients
on Antiplatelet Medications � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 125
Michael J. Wahl
13 P erioperative Management of Patients on
Anticoagulant Medications: General Principles in
Medicine and Surgery � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 143
Jessica Rimsans and Katelyn W. Sylvester
14 P erioperative Management of Dental Patients
on Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Michael J. Wahl
15 L ocal Techniques and Pharmacologic Agents
for Management of Bleeding in Dentistry. . . . . . . . . . . . . . . . . . . 187
Richard P. Szumita and Paul M. Szumita
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Introduction
Understanding hemostasis is essential for the safe management of patients
undergoing dental treatment. The dental literature has consistently reviewed
topics in hemostasis, particularly in management of patients with pathology
of hemostasis and on medications altering hemostasis. The literature has
detailed time-tested protocols to help with decision-making in the periopera-
tive period. With this literature support and clinical experience, dental clini-
cians, along with their physician colleague input when appropriate, have been
proficient in safely managing patients with disorders of hemostasis.
However, two major categories of changes related to hemostasis have sur-
faced in the recent past. First, evolution of the understanding of hemostasis,
the pathology of hemostasis, and medical advances relating to hemostasis
continue to occur. Second, the number of medications—especially oral medi-
cations—impacting upon hemostasis has been increasing rapidly. These addi-
tional medications are not simply clones of medications that we have all
gained clinical experience in managing—but newer classes of medications
with different pharmacodynamics and varying indications for clinical use.
The “time-tested” clinical guidelines for which clinicians have relied may no
longer be appropriate for the newer classes of medications now being pre-
scribed. In order to safely manage patients, clinicians need to be familiar with
important steps in the hemostatic process and with how the newer drugs
impact hemostasis.
To standardize the information presented throughout this book, a few criti-
cal terms are reviewed. Antithrombotic medications refer to any medications
that cause an effect on the formation and/or maintenance of a thrombus or
clot. Antithrombotic medications include anticoagulants, antiplatelet, and
fibrinolytic medications. Anticoagulants refer to medications reducing the
formation of fibrin from fibrinogen. Antiplatelet medications affect formation
of a platelet plug. Fibrinolytic mediations are “clot” busters used in the hos-
pital environment for the emergency treatment of thromboembolic diseases—
ischemic stroke, myocardial infarction, and acute pulmonary embolism [1].
Patients taking anticoagulant and antiplatelet agents are commonly present-
ing for dental care, and therefore, their review is a primary focus of this work.
Since fibrinolytics are not encountered in dental practice, the discussion of
these agents will be limited.
vii
viii Introduction
Antithrombotics
Antiplatelet
Anticoagulants Fibrinolytics
medications

Although there are slight variations in the definition of hemostasis, a clini-
cal definition that seems apropos for the climate in which we practice is
reflected in the following: Hemostasis is the physiologic system of competent
blood vessels, endothelial cells, platelets, and numerous plasma proteins that
act in a finely controlled manner to preserve blood vessel integrity and pre-
vent pathologic hemorrhage or thrombosis [2]. While surgical disciplines
(including dentistry) strive to prevent excessive hemorrhage during and fol-
lowing procedures, medicine and pharmacology are increasing the number of
medications used to alter hemostasis in order to decrease the morbidity and
mortality associated with inappropriate thrombus formation. Dental clini-
cians should be familiar with contemporary treatment recommendations.
In this book, the physiology and pathophysiology of hemostasis will be
reviewed with emphasis on updated topics. The physiology of hemostasis is
complex. The review provided herein is intended to be of sufficient depth to
allow students, residents, and practicing clinicians in dentistry and the dental
specialties a thorough understanding of the updated models of hemostasis
and the essential steps and reactions responsible for cessation of bleeding
and prevention of excessive thrombus formation. A limited number of patho-
logic alterations in hemostasis will be reviewed in order to contrast normal
physiology. This work will highlight pharmacologic agents that affect hemo-
stasis with emphasis on the expanding number and role of direct oral anti-
thrombotics which will be increasingly prevalent in dental practice. Finally,
evidence-based guidelines are presented to assist the clinician in delivering
safe dental treatment.
References
1. Hamilton R. Tarascon pocket pharmacopoeia: 2015. Burlington, MA:
Jones & Bartlett Publishing; 2015.
2. Macik BG. Hemostasis. In: Moylan JA, editor. Surgical critical care. St.
Louis: Mosby-Year Book, Inc.; 1994. P. 697–718.
Paterson, NJ, USA Paul M. Szumita
Boston, MA, USA Richard P. Szumita
Part I
Review of Hemostasis
1
Local Tissues in Hemostasis
and Platelet Review
Tiffany Kuang and Richard P. Szumita
Abstract thrombosis. With vessel injury, the e ndothelium
Hemostasis is a complex physiologic state able and subendothelial tissues are responsible for
to change rapidly depending on the needs of initiating the explosion of pro-hemostatic
the organism. The hemostatic system broadly responses culminating in clotting and cessation
consists of three essential elements: local (vas- of bleeding.
cular) tissues, platelets, and biochemical fac- The second component of hemostasis, the
tors. In health, these three elements maintain a platelet, also fluctuates from neutral to pro-
state of neutrality (or mild antithrombosis) to thrombotic states. With hemorrhage, platelets
prevent pathologic intravascular clotting. become the essential mediators that anchor the
When needed to stop hemorrhage at a site of procoagulant reactions to the site of vascular
injury, the hemostatic system rapidly allows injury, leading to local thrombus formation
for a powerful prothrombotic response at the and the cessation of bleeding.
site of injury while maintaining neutrality This chapter reviews the fundamental
throughout the remainder of the organism. physiology and pathophysiology of local tis-
Maintaining the appropriate state of hemo- sues and platelets in hemostasis. This knowl-
stasis begins with the very tissues in which the edge is essential for understanding diseases
blood circulates—blood vessels. Endothelium, and management of patients with bleeding
which lines the vessels, and subendothelial disorders attributed to local tissues and plate-
structures are physiologically active in hemosta- lets and the pharmacology of current and
sis. When uninjured and in a non-pathologic developing antiplatelet medications.
state, the endothelium allows blood to remain in
a fluid state, preventing pathologic intravascular
Hemostasis is a complex physiologic process that
T. Kuang (*) involves an intricate balance between the pro-
Oral and Maxillofacial Surgery Resident, St. Joseph’s
thrombotic activity of platelets, enzymes, and
University Medical Center, Paterson, NJ, USA
coagulation factors and the antithrombotic activity
R. P. Szumita
of the fibrinolytic system and coagulation inhibi-
Department of Dentistry/Oral and Maxillofacial
tors. A critical component of this balance is the
Surgery, St. Joseph’s University Medical Center,
Paterson, NJ, USA very tissues in which the blood circulates—blood
vessels, endothelium, which lines the vasculature,
Private Practice, Little Falls, NJ, USA
e-mail: [email protected] and subendothelial structures. When uninjured
© Springer International Publishing AG, part of Springer Nature 2018 3
R. P. Szumita, P. M. Szumita (eds.), Hemostasis in Dentistry, https://doi.org/10.1007/978-3-319-71240-6_1