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UNIVERSIDADE FEDERAL DO CEARÁ
FACULDADE DE FARMÁCIA, ODONTOLOGIA E ENFERMAGEM
PROGRAMA DE PÓS-GRADUAÇÃO EM ODONTOLOGIA
JOÃO PAULO VELOSO PERDIGÃO
AVALIAÇÃO DO RISCO DE SANGRAMENTO PÓS-EXODONTIA EM PACIENTES
CANDIDATOS AO TRANSPLANTE DE FÍGADO.
FORTALEZA
2011
JOÃO PAULO VELOSO PERDIGÃO
AVALIAÇÃO DO RISCO DE SANGRAMENTO PÓS-EXODONTIA EM PACIENTES
CANDIDATOS AO TRANSPLANTE DE FÍGADO.
Dissertação submetida à Coordenação do
Programa de Pós-Graduação em Odontologia,
da Universidade Federal do Ceará, como
requisito parcial para obtenção do título de
Mestre em Odontologia.
Área de Concentração: Clínica Odontológica
Orientador: Prof. Dr. Fabrício Bitu Sousa
FORTALEZA
2011
JOÃO PAULO VELOSO PERDIGÃO
AVALIAÇÃO DO RISCO DE SANGRAMENTO PÓS-EXODONTIA EM PACIENTES
CANDIDATOS AO TRANSPLANTE DE FÍGADO.
Dissertação submetida à Coordenação do Programa de Pós-Graduação em
Odontologia, da Universidade Federal do Ceará, como requisito parcial para
obtenção do título de Mestre em Odontologia; Área de Concentração: Clínica
Odontológica.
Aprovada em 01/05/2011.
BANCA EXAMINADORA
_____________________________
Prof. Dr. Fabrício Bitu Sousa (Orientador)
Universidade Federal do Ceará – UFC
_____________________________
Prof. Dr. Eduardo Costa Studart Soares
Universidade Federal do Ceará – UFC
_____________________________
Profa. Dra. Karem López Ortega
Universidade de São Paulo
A Deus e àqueles que aguardam na fila por um transplante de órgão.
AGRADECIMENTOS
Ao meu pai, Ronaldo, minha mãe, Sandra, e irmãos, Rennan e Marcos (em
memória), pelo apoio e incentivo durante este desafio.
À minha avó, Celina, por todas as oportunidades dadas e pela família
maravilhosa que gerou.
Ao meu orientador, Prof. Fabrício Bitu, pelo conhecimento cientifico
dedicado, pelas oportunidades dadas, pela amizade, paciência, incentivo e
credibilidade dispensada ao longo deste convívio.
A todos os pacientes que participaram da pesquisa com a intenção de ajudar
na descoberta de novos conhecimentos, a fim de proporcionar um melhor
atendimento odontológico.
Aos professores, Profa. Ana Paula Negreiros, Prof. Eduardo Studart e
Prof. Mário Rogério Mota, por terem contribuído com críticas e sugestões que
enriqueceram muito a metodologia deste trabalho, e pelo conhecimento transmitido
durante os atendimentos na Clínica de Estomatologia.
Aos colegas, Rafael Lima Verde e Saulo Batista, que contribuíram com
idéias e hipóteses para a elaboração desse trabalho.
A todos os colegas do mestrado e aos colegas da estomatologia, Renata
Galvão, Isabela Pacheco, Diego Peres, Malena Freitas, Carolina Teófilo e Tácio
Bezerra.
A todos os acadêmicos do NEPE que auxiliaram os procedimentos cirúrgicos
e contribuíram para o desenvolvimento desta pesquisa.
À Prefeitura Municipal de Fortaleza e aos colegas de trabalho pelo apoio e por
terem possibilitado o meu afastamento parcial para realização do curso de Mestrado.
“Não cruze os braços diante de uma dificuldade,
pois o maior homem do mundo morreu de braços abertos.”
Bob Marley
RESUMO
O transplante hepático é o tratamento padrão para pacientes com cirrose hepática e
carcinoma hepatocelular. Dados do Registro Brasileiro de Transplantes (RBT)
demonstraram que o transplante hepático foi o segundo órgão sólido mais
transplantado em 2010. Para eliminar focos de infecção e reduzir o risco infeccioso
na fase pós-transplante, esses pacientes devem passar por uma avaliação
odontológica minuciosa para remoção dos focos de origem dental. No caso de
procedimentos odontológicos que gerem sangramento, o cirurgião-dentista deve dar
atenção especial para a hemostasia, devido, principalmente, à redução da síntese
hepática de fatores da coagulação e trombocitopenia. O objetivo deste estudo
prospectivo foi avaliar a incidência de hemorragia pós-operatória de exodontias em
pacientes na fila de espera por um transplante de fígado. Nesse estudo foram
incluídos 23 pacientes com idade média de 43,17 ± 14,62 anos com predominância
da raça branca (82,6%) e do sexo masculino (60,9%). Nos 23 pacientes, 84
exodontias simples foram realizadas em 35 procedimentos cirúrgicos. Os pacientes
foram divididos em dois grupos para comparação de duas medidas hemostáticas
locais após as exodontias: no grupo 1, aplicou-se pressão local com gaze embebida
em ácido tranexâmico, e no grupo 2, realizou-se a mesma conduta sem o uso do
referido ácido. Em todos os pacientes foram utilizadas a esponja de colágeno
reabsorvível e sutura em X como medida hemostática padrão. Os valores
encontrados para os exames hematológicos foram: hematócrito médio de 34,54 ±
5,84% (intervalo de 21,7% – 44,4%), plaquetometria variou de 31.000/mm3 a
160.000/mm3 e o índice médio encontrado para a razão internacional normatizada
(INR) foi 1,50 ± 0,39 (intervalo de 0,98 – 2,59). Sangramento pós-operatório ocorreu
apenas em um procedimento (2,9%) e a pressão local com gaze foi eficaz em parar
o episódio de hemorragia. Dessa forma, esse trabalho demonstra a possibilidade da
realização de exodontias em pacientes com cirrose hepática com valores de INR ≤
2,50 e plaquetometria ≥ 30.000/mm3 sem a necessidade de transfusão sanguínea e
que diante da ocorrência de intercorrências hemorrágicas, o uso de medidas
hemostáticas locais pode ser satisfatório.
Palavras-chave: Cirurgia Bucal. Extração Dentária. Transplante de Fígado.
Assistência Odontológica para Doentes Crônicos. Medicina Bucal.
ABSTRACT
Liver transplantation is the gold standard treatment for patients with cirrhosis and
hepatocellular carcinoma. The Brazilian Registry of Transplantation revealed that
liver transplantation was the second solid organ most transplanted in 2010. With the
purpose to eliminate foci of infection and reduce the risk of infection on the
postransplant stage, these patients should undergo dental treatment to the removal
of dental foci, with special care regarding the hemostasis impairment, mainly related
to a reduced hepatic synthesis of procoagulants factors and thrombocytopenia. The
aim of this prospective study was to evaluate the incidence of postoperative bleeding
after dental extraction in candidates for liver transplantation. In this study, 23 patients
were included with a mean age of 43.17 ± 14.62 years, with a higher prevalence of
whites (82.6%) and men (60.9%). In 23 patients, 84 simple extractions were
performed in 35 dental surgical procedures. Patients were divided in two groups to
compare two local hemostatic measures after tooth extraction: in group 1, local
pressure after sutures was applied with gauze soaked with tranexamic acid, and in
group 2, the same procedure without the tranexamic acid was performed. In all
subjects, absorbable hemostatic sponges and cross sutures were used as a standard
hemostatic measure. The main preoperative blood tests found were: mean
hematocrit of 34.54% (SD ± 5.84%, range 21.7% – 44.4%), platelets ranged from
31,000/mm3 to 160,000/mm3, mean international normalized ratio (INR) was 1.50
(SD ± 0.39; range 0.98 - 2.59). Postoperative bleeding occurred in only one
procedure (2.9%) and local pressure with gauze was effective to achieve hemostasis.
Thus, this paper demonstrates the possibility of performing tooth extractions in
patients with liver cirrhosis, with INR ≤ 2.50 and platelets ≥ 30,000/mm3, without the
need of blood transfusion, and in case of bleeding events, the use of local hemostatic
measures can be satisfactory.
Key-words: Oral Surgery. Tooth Extraction. Liver Transplantation. Dental Care for
Chronically Ill. Oral Medicine.
SUMÁRIO
1 INTRODUÇÃO GERAL ......................................................................... 9
2 PROPOSIÇÃO ...................................................................................... 15
3 CAPÍTULO ............................................................................................ 16
3.1 Capítulo 1: Postoperative bleeding after tooth extraction in the
pretransplant liver failure patient. …………………………………………... 17
4 CONCLUSÃO GERAL .......................................................................... 38
REFERÊNCIAS ............................................................................................. 39
ANEXOS ........................................................................................................ 43
9
1 INTRODUÇÃO GERAL
O transplante hepático é o tratamento padrão para pacientes com cirrose
hepática e carcinoma hepatocelular. Essas patologias possuem indicações
semelhantes para o transplante, indiferente da etiologia, que podem ser de origem
infecciosa (virais), tóxica ou imunológica, além das doenças biliares e obstrutivas.
Dessas, a cirrose hepática por vírus da Hepatite C e alcoolismo crônico são as
principais causas dos transplantes (GALLEGOS-OROZCO; VARGAS, 2009;
O’LEARY; LEPE; DAVIS, 2008).
De acordo com o Registro Brasileiro de Transplantes, 1.413 transplantes de
fígado foram realizados em 2010, representando 22,1% do total de transplantes de
órgãos sólidos, atrás somente do transplante de rins com 72,3%. O Estado do Ceará
foi responsável por 113 transplantes hepáticos em 2010, o segundo estado brasileiro
com maior número de transplantes realizados. A equipe do Hospital Universitário
Walter Cantídio foi a primeira equipe cadastrada no Estado do Ceará a realizar esse
transplante, sendo responsável por 91 transplantes realizados em 2010 (REGISTRO
BRASILEIRO DE TRANSPLANTES, 2010).
A infecção é uma das complicações mais freqüentes e preocupantes após o
transplante de fígado. Por esse motivo, os pacientes passam por avaliações em
várias especialidades médicas com o objetivo de eliminar focos de infecção. Boa
saúde bucal é essencial em pacientes antes e após o transplante, com o objetivo de
reduzir o risco de infecção sistêmica com origem na cavidade oral
(GUGGENHEIMER; MAYHER; EGHTESAD, 2005; SHEEHY et al.,1999; TENZA et
al., 2009).
Alguns estudos avaliaram a saúde oral de pacientes pré-transplante hepático
e encontraram higiene oral deficiente, doença periodontal avançada, cárie e lesões
periapicais (BARBERO et al., 1996; DÍAZ-ORTIZ et al.,2005; NIEDERHAGEN et al.,
2003; NOVACEK et al., 1995). Trabalhos demonstram que alcoólatras tendem a
negligenciar a higiene oral como resultado de causas sociais, psicológicas e efeitos
do abuso de álcool, o que leva a uma maior incidência de doenças de origem
dentária (NOVACEK et al., 1995; ROBB; SMITH, 1996). As necessidades de
procedimentos cirúrgicos relatadas na literatura variam entre 50% a 68% desses
pacientes (DÍAZ-ORTIZ et al.,2005; RUSTEMEYER; BREMERICH, 2007).
10
O diagnóstico e tratamento cirúrgico dos focos de infecção (e.g. periodontite,
cistos, dentes não-restauráveis ou abscessos) são recomendados na avaliação
odontológica pré-transplante hepático, apesar de esse protocolo ser até então
controverso. Idealmente, o objetivo dessas medidas para eliminar focos de sepse
nos maxilares é evitar uma infecção dentária pós-operatória durante a terapia
imunossupressora (GUGGENHEIMER; MAYHER; EGHTESAD, 2005). Em teoria,
pacientes imunossuprimidos possuem risco importante de infecção secundária de
vários órgãos via hematogênica (GUGGENHEIMER; EGHTESAD; STOCK, 2003).
Vários conceitos de tratamento têm sido descritos na literatura, mas não há um
protocolo uniforme, e a literatura ainda é falha em provar a relação do foco de
infecção nos maxilares de origem dentária e sepse pós-operatória após o
transplante (GUGGENHEIMER; EGHTESAD; STOCK, 2003; LITTLE; RHODUS,
1992).
Apesar de não existir nenhum protocolo baseado em evidência para
tratamento de focos de infecção de origem dental, os pacientes devem ser
orientados para remoção dos focos de infecção, antes do transplante de órgãos,
com objetivo de evitar complicações locais e sistêmicas pós-transplantes, como
documentados em casos individuais (GUGGENHEIMER; MAYHER; EGHTESAD,
2005; SHEEHY et al., 1999; SVIRSKY; SARAVIA, 1989).
O manejo odontológico de pacientes na fila de espera por um transplante
hepático, em sua maioria com cirrose, envolve algumas considerações como: o
metabolismo hepático imprevisível das drogas prescritas e administradas durante o
tratamento odontológico, maior susceptibilidade para infecções e desordens na
hemostasia, devido à trombocitopenia ou síntese hepática reduzida de fatores da
coagulação (FIRRIOLO, 2006). A remoção de raízes residuais pode causar eventos
hemorrágicos, infecções e/ou dificuldades na cicatrização pós-operatória (ADAM;
HOTI, 2009; THOMSON; LANGTON, 1996; WYKE, 1987).
As complicações hemorrágicas e dificuldades na cicatrização são relatadas
na literatura, variando entre 15,4% e 43% (NIEDERHAGEN et al., 2003;
PLACHETZKY et al., 1992 apud NOVACEK et al., 1995). A ocorrência de
sangramento pós-operatório após cirurgia oral em pacientes anticoagulados varia
entre 1,3% e 12% (BLINDER et al., 2001; WAHL, 2000), enquanto que em pacientes
saudáveis essa incidência não passa de 0,41% (ZANON et al., 2000). O risco maior
para complicações hemorrágicas é relatado em pacientes com cirrose hepática
11
causada pelos principais fatores etiológicos, o vírus da Hepatite C e alcoolismo
crônico (NIEDERHAGEN et al., 2003).
Devido a essas complicações, autores priorizam a exodontia de focos com
inflamação periapical e sintomatologia dolorosa, enquanto dentes retidos
assintomáticos, tratamentos endodônticos satisfatórios e dentes cariados, devem ser
preservados. Niederhagen et al. (2003) recomendam realizar somente as exodontias
necessárias e adiar procedimentos eletivos para após o transplante, devido à alta
taxa de complicações. Enquanto Little & Rhodus (1992) recomendam que pacientes
com doença periodontal avançada, dentes com cáries extensas, ou dentes com
doença periapical aguda ou crônica, em pacientes que demonstram pouco interesse
ou capacidade na preservação dos dentes, são melhores tratados com remoção de
todos os dentes e confecção de próteses totais.
O manejo das coagulopatias e plaquetopenias é realizado com medidas
hemostáticas sistêmicas e/ou locais, com o intuito de reduzir a incidência de
complicações hemorrágicas. Dentre as medidas sistêmicas estão as transfusões
com plasma fresco congelado e concentrado de plaquetas. Medidas hemostáticas
locais (e.g. pressão local com compressa de gaze, esponja de colágeno
reabsorvível, soluções locais antifibrinolíticas, sutura, cola de fibrina e cola de
cianoacrilato) também podem ser úteis em reduzir as complicações hemorrágicas
associadas a procedimentos odontológicos (FIRRIOLO, 2006; RAKOCZ et al.,
1993). Blinder et al. (1999) relataram que nenhuma medida hemostática local
demonstrou ser superior a outra e que seria indiferente a sua escolha.
Uma das medidas hemostáticas locais estudadas na literatura é a esponja de
colágeno reabsorvível, sutura e pressão local com compressa com gaze embebida
em ácido tranexâmico. As vantagens dessa medida local são suas propriedades
biodegradáveis, custo relativamente baixo, capacidade de ajudar na ativação da
cascata da coagulação e possibilidade de ser aplicada em superfícies úmidas
(CAMPBELL; ALVARADO; MURRAY, 2000; SAMUEL; ROBERTS; NIGAM, 1997). O
ácido tranexâmico é um potente inibidor da fibrinólise, ao inibir a ligação da fibrina à
plasmina, e pode ser administrado de forma sistêmica ou tópica. Esse agente
antifibrinolítico é um dos fármacos mais discutidos para pacientes com alterações na
coagulação sanguínea, com objetivo de reduzir o sangramento após exodontias
(BLINDER et al., 1999; BLINDER et al., 2001; CARTER; GOSS, 2003). A associação
do uso de agentes antifibrinolíticos com esponjas de colágeno reabsorvíveis tem
12
sido uma combinação comprovada em estudos recentes, pois o efeito inibidor da
fibrinólise com o efeito mecânico da presença da esponja no alvéolo tem se
mostrado eficaz na hemostasia após exodontias (RAMLI; RAHMAN, 2005; REICH et
al., 2009). O uso do ácido tranexâmico em bochechos ou embebido na gaze tem
sido comprovado como uma medida hemostática local isolada ou em conjunto com
outras medidas locais após exodontias em pacientes anticoagulados (BLINDER et
al., 1999; BLINDER et al., 2001; CARTER;GOSS, 2003; CARTER et al. 2003;
ZANON et al., 2003). Entretanto, Patatanian & Fugate (2006) relataram que o
bochecho de ácido tranexâmico apresenta pouco ou nenhum efeito em reduzir a
incidência de sangramento pós-operatório de exodontias em pacientes
anticoagulados.
Devido ao risco hemorrágico, a avaliação pré-operatória é mandatória para
garantir o sistema da coagulação satisfatório. Na avaliação pré-operatória deve-se
incluir o hemograma completo, tempo de protrombina (TP), razão normalizada
internacional (INR) e tempo parcial de tromboplastina ativada (TTPa) (DOUGLAS et
al., 1998).
Os pacientes com doença hepática podem apresentar anemia, redução na
produção de fatores da coagulação por disfunção na síntese hepática, depleção do
armazenamento de vitamina K devido à desnutrição ou absorção intestinal reduzida,
atividade fibrinolítica aumentada por deficiência de inibidores da fibrinólise e
trombocitopenia, devido ao seqüestro esplênico relacionado à hipertensão portal e
supressão na medula óssea induzida pelo álcool (O’LEARY; LEPE; DAVIS, 2009;
TRIPODI, 2009). Dessa maneira, caracteriza-se que a complexidade do defeito
hemostático nesses indivíduos é maior que em pacientes anticoagulados.
O hematócrito baixo, que representa um déficit na concentração de células
vermelhas no sangue e pode ser encontrado nesses pacientes, tem sido relacionado
ao aumento do tempo de sangramento, mesmo em pacientes com contagem normal
de plaquetas (ANAND; FEFFER, 1994; EUGSTER; REINHART, 2005; QUAKNINE-
ORLANDO et al. 1999; VALERI; KHURI; RAGNO, 2007). Escolar et al. (1988)
demonstraram que o agregado plaquetário é prejudicado quando o hematócrito é
reduzido a 20%, independente da contagem de plaquetas. Por outro lado, há outros
trabalhos relatando que a função plaquetária só é normalizada quando o hematócrito
é restabelecido por meio de transfusão a valores de 26% a 35% (FERNANDEZ et
al., 1985; MOIA et al., 1987; VALERI; KHURI; RAGNO, 2007).
13
Não há um protocolo único para a realização de procedimentos cirúrgicos em
pacientes com insuficiência hepática. Porém, alguns trabalhos procuram valores pré-
operatórios de referência para realizar as exodontias sem aumentar a incidência de
complicações hemorrágicas. A maioria dos autores realiza estudos em um modelo
de pacientes que fazem uso de anticoagulantes orais e não em pacientes com
insuficiência hepática. Medidas hemostáticas locais com gaze embebida com o
ácido tranexâmico ou bochecho com ácido tranexâmico, após exodontias, têm
eficácia em pacientes anticoagulados com INR menor que 4. Nesses estudos, os
poucos casos de hemorragia existentes estavam relacionados a dentes com
inflamação em tecidos moles e problemas periodontais, e as medidas hemostáticas
locais foram eficazes em parar o sangramento, sem a necessidade de internação
hospitalar ou transfusão sanguínea (BACCI et al., 2010; NEMATULLAH et al., 2009;
RODRIGUEZ-CABRERA et al., 2011). Al-Mubarak et al. (2007) foram além, e
relataram que exodontias simples sem suturas podem ser realizadas com segurança
em pacientes anticoagulados com INR ≤ 3,0.
Ziccardi et al. (1991) e Douglas et al. (1998), dois dos poucos autores que
revisaram protocolos para o manejo odontológico de pacientes com alterações
hepáticas, recomendam que em procedimentos invasivos ou cirúrgicos com TP e/ou
TTPa maior que 1,5 vezes do valor padrão ou INR igual ou maior que 3,0, deve-se
considerar administração de plasma fresco congelado, que provêm fatores II, V, VII,
IX, X, XI, XII e XIII. Já o Hospital Universitário da Universidade Federal de Santa
Catarina (2005) é mais cauteloso e recomenda a administração de plasma fresco
congelado quando o INR for maior que 1,8. Em relação à plaquetometria, Rose &
Kay (1983) foram os primeiros a recomendar a necessidade de transfusão com
concentrado de plaquetas, quando a plaquetometria for menor que 50.000/mm3, e
ainda são seguidos até a atualidade. Mais recentemente, Ward & Weideman (2006)
relataram uma incidência de hemorragia em apenas 6% dos pacientes pré-
transplante de fígado que realizaram exodontias simples, sem necessidade de
transfusão em pacientes com INR ≤ 4 e plaquetometria ≥ 50.000/mm3, e com
transfusão para pacientes com INR > 4 ou plaquetometria < 50.000/mm3.
Apesar da exposição acima de protocolos para avaliação pré-operatória,
Tripodi et al. (2007) tentaram reunir na literatura trabalhos que comprovassem a
capacidade do TP/INR em avaliar risco de sangramento, e concluíram que esses
testes apresentam falhas ao avaliar o risco hemorrágico em pacientes com doença
14
hepática. Segundo Tripodi et al. (2007), a deficiência de fatores anticoagulantes, que
também ocorre na doença hepática, pode balancear a deficiência de fatores
procoagulantes, demonstrado pelos resultados elevados de TP/INR, e não alterar o
processo hemostático nestes pacientes. Também ressaltaram que o TP não
apresentou relação com sangramentos gastrointestinais e risco de sangramento,
após biópsia de fígado em pacientes com doença hepática, baseada em evidência
científica em mais de 20 anos.
Desta maneira, avaliar o risco hemorrágico após exodontias em pacientes
com doença hepática é um desafio pela falta de estudos já realizados nessa área. O
presente estudo objetiva avaliar a incidência de sangramento pós-exodontia com
uso de medidas hemostáticas locais.
15
2 PROPOSIÇÃO
2.1 Objetivo Geral
Avaliar a incidência de sangramento pós-exodontia em pacientes pré-
transplante hepático que se submeteram à exodontia sem transfusão pré-
operatória para reposição de fator ou plaquetas.
2.2 Objetivos Específicos
Avaliar o efeito da compressão com gaze embebida em ácido tranexâmico no
controle do sangramento pós-exodontia em candidatos ao transplante
hepático.
Avaliar o efeito da compressão com gaze seca no controle do sangramento
pós-exodontia em candidatos ao transplante hepático.
Comparar o efeito da compressão com gaze seca e embebida em ácido
tranexâmico no controle do sangramento pós-exodontia em candidatos ao
transplante hepático.
Estabelecer valores mínimos de plaquetometria e INR, em que seja possível
controlar o sangramento pós-exodontia com medidas hemostáticas locais em
candidatos ao transplante hepático.
16
3 CAPÍTULO
Esta dissertação está baseada no Artigo 46 do Regimento Interno do
Programa de Pós-Graduação em Odontologia da Universidade Federal do Ceará,
que regulamenta o formato alternativo para dissertações de Mestrado e teses de
Doutorado e permite a inserção de artigos científicos de autoria ou co-autoria do
candidato (Anexo A). Por se tratar de pesquisa envolvendo seres humanos, o projeto
de pesquisa desse trabalho foi submetido à apreciação do Comitê de Ética em
Pesquisa do Hospital Universitário Walter Cantídio da Universidade Federal do
Ceará, tendo sido aprovado (Anexo B). Assim sendo, essa dissertação é composta
de um capítulo, contendo manuscrito a ser submetido para publicação em revista
científica, conforme descrito abaixo:
3.1 Capítulo 1:
“Postoperative bleeding after dental extraction in the liver pretransplant
patient.”
Perdigão JPV, Almeida PC, Sousa FB.
Esse manuscrito será submetido à publicação no periódico Journal of Oral and
Maxillofacial Surgery.
17
Title: Postoperative bleeding after dental extraction in the liver pretransplant
patient.
Short-title: Dental extraction in the liver pretransplant patient.
Keywords: Oral Surgery; Tooth Extraction; Liver Transplantation; Dental Care for
Chronically Ill; Oral Medicine.
Authors:
João Paulo Veloso Perdigão, DDS
Postgraduate Student, School of Dentistry, Federal University of Ceará, Brazil.
Paulo César de Almeida, PhD
Research Fellow, Associate Professor, Department of Health Sciences, School of
Statistics, State University of Ceará, Brazil.
Fabrício Bitu Sousa, DDS, PhD
Associate Professor, Coordinator of the Study Center in Special Care Dentistry,
Department of Stomatology, School of Dentistry, Federal University of Ceará, Brazil.
Address correspondence and reprint requests to Dr Sousa:
Rua Monsenhor Furtado, s/n (2nd floor)
Curso de Odontologia – Universidade Federal do Ceará
Programa de Pós-Graduação em Odontologia
Fortaleza/CE – Brasil CEP 60.430-350
Phone: +55 85 9921-7851
E-mail: [email protected]
18
Abstract
Purpose: The aim of this prospective study was to evaluate the incidence of
postoperative bleeding after dental extraction in candidates for liver transplantation.
Patients and Methods: A prospective cross-sectional observational study was
performed with individuals awaiting liver transplantation and referred for oral health
evaluation. All the subjects with dental foci that required extraction were considered
in this study. Patients were included in the analysis when the blood exams were
according to: platelet count ≥ 30,000/mm3 and INR ≤ 3.0. Absorbable hemostatic
sponges and cross sutures were used as a standard hemostatic measure. All tooth
extractions were performed without administration of blood products (platelet
concentrate, fresh frozen plasma).
Results: In 23 patients included in this study, 84 simple extractions were performed
in 35 dental surgical procedures. The main preoperative blood tests found were:
mean hematocrit of 34.54% (SD ± 5.84%, range 21.7% – 44.4%), platelets ranged
from 31,000/mm3 to 160,000/mm3, mean international normalized ratio (INR) was
1.50 (SD ± 0.39; range 0.98 - 2.59). Postoperative bleeding occurred in only one
procedure (2.9%) and local pressure with gauze was effective to achieve hemostasis.
Conclusion: This paper demonstrates the low bleeding risk of tooth extractions in
patients with liver cirrhosis, with INR ≤ 2.50 and platelets ≥ 30,000/mm3, without the
need of blood transfusion, and in case of bleeding events, the use of local hemostatic
measures can be satisfactory.
19
Introduction
Liver transplant is the gold standard therapy for patients with end-stage liver
disease, also known as cirrhosis. Chronic hepatitis C and alcohol induced liver
disease are the two main causes of cirrhosis in candidates for orthotopic liver
transplantation.1 According to the Global Observatory on Organ Donation and
Transplantation,2 liver transplantation is the second most transplanted organ and
20,300 liver transplants were performed worldwide in 2008, while Brazil ranked fourth
among the most active countries with respect to the total number of transplanted
organs. Meanwhile, the Brazilian Registry of Transplantation reported 1.413 liver
transplantations in 2010, which represents a rate increase of 5.9% in number of
procedures compared to the previous year. The state of Ceará, located in
Northeastern Brazil, is one of the main states in Brazil in which a large number of
transplants is performed.3 The rising number of solid organ transplants has reached
the point at which health care must be extended beyond immediate issues related to
transplantation procedures.4
Infection and rejection are the postoperative transplant complications of most
concern and common occurrence. For this reason, medical evaluation and treatment
of the foci of infection prior to organ transplantation are recommended. Despite of the
discussion in the literature about the role of oral infections in postransplant
complications, dental treatment for oral foci before transplantation is a good practice
in order to provide oral health to the patients along the immunosuppressive therapy
after the organ transplant.5-8
Niederhagen et al 6 and Rustemeyer & Bremerich 4 reported an incidence of
65% and 68.4%, respectively, of patients with liver disease requiring dental surgical
intervention for oral foci sanitation. As the general condition and coagulation status of
these patients may be compromised, especial attention must be driven when
considering any invasive procedure. Patients with liver disease may present anemia,
reduced hepatic synthesis of procoagulants factors, depletion of vitamin K stores,
increased fibrinolytic activity and thrombocytopenia due to hypertension-induced
splenic sequestration and/or alcohol-induced bone marrow suppression.9,10 For these
reason, preoperative evaluation with a complete blood count and platelet count,
prothrombin time (PT), international normalized ratio (INR) and partial thromboplastin
time (PTT) ratio is recommended.9,11 Most of the studies regarding bleeding risk after
20
tooth extraction are developed in patients in anticoagulant therapy. Recently, meta-
analytic studies have concluded that dental extraction in anticoagulated patients with
INR ≤ 4.0 have a low incidence of postoperative bleeding.12,13 However, as previously
characterized above, the complexity of hemostasis impairment in patients with liver
disease is higher than in those who are under anticoagulant therapy. The risk of
surgery in patients with severe coagulopathy and thrombocytopenia (defined as INR
> 1.5 and platelet count <50,000/mm3, respectively) is still uncertain.9 Ward &
Weideman 14 were the only authors until today to study postoperative bleeding after
dentoalveolar surgery in pretransplant liver failure patients demonstrating the
influence of INR and thrombocytopenia. In that retrospective study, after performing
at the maximum of 10 nonimpacted teeth extractions per dental visit, an incidence of
8% of postoperative bleeding was reported among the 25 procedures in the minimal
and moderate risk groups together. The authors recommended larger studies to
validate their results and to indentify other risk factors, and stated that only patients
requiring more 10 dental extractions are at high risk of experiencing prolonged
postoperative bleeding.14
In order to answer the lack of evidence-based science to guide the dentist in
the preoperative evaluation, a prospective study was developed with patients
awaiting liver transplantation and requiring sanitation of oral foci. The aim of this
study was to evaluate the incidence of postoperative bleeding after tooth extraction in
candidates for liver transplantation.
Patients and Methods
A prospective cross-sectional observational study was performed with 23
individuals awaiting liver transplantation and referred for oral health evaluation. All
patients were liver transplant candidates. Ethical approval was obtained from the
local Research Ethics Committee (REC protocol nº 025.03.10) and all of the
participants signed an informed consent form that included general information about
the study.
After a clinical and radiographic evaluation of the transplant candidates, all the
subjects with dental foci that required extraction were considered to this study. Dental
foci were defined as residual roots, teeth with unrestorable caries, periapical lesions,
advanced periodontal disease or marked mobility (grades 3 and 4). Standard exams
21
prescribed to all patients were: panoramic radiograph, complete blood count, PT, INR
and PTT ratio. The liver disease and the Model for End-stage Liver Disease (MELD)
score were recorded from the medical files. The blood samples for the study purpose
were collected within 24h before tooth extraction. Patients were included in the
analysis when the blood exams were according to the following values: platelet count
≥ 30,000/mm3 and INR ≤ 3.0. The preoperative blood tests were analyzed by an
independent examiner, so the surgeon did not know the blood values during the
procedure. In this study, all tooth extractions were performed without administration
of blood products (platelet concentrate, fresh frozen plasma). Antibiotics prophylaxis
was prescribed in patients with risk for spontaneous bacterial peritonitis, ascites or
neutropenia (<1,500/mm3). The protocol prescribed was according to Firriolo (2006):1
2 g of amoxicillin in addition to 500 mg of metronidazole 1 hour before the procedure.
Patients scheduled for dental extraction were randomly divided into two
groups: in group 1, local pressure after sutures was applied with gauze soaked with
250 mg/ 5 ml tranexamic acid (Transamin® Nikkho, Rio de Janeiro, RJ, Brazil) and in
group 2, the control, local pressure with gauze without tranexamic acid was used.
Local pressure was applied continuously for 5 minutes and repeated until hemostasis
was achieved. In both groups, standard procedures were performed with the use of
absorbable hemostatic sponges (Hemospon® Technew, Rio de Janeiro, RJ, Brazil)
introduced into the tooth socket until it was completed filled and a 3-0 silk cross
suture to keep the sponge in place. Extractions were performed under local
anesthesia with mepivacaine 2% epinephrine 1:100,000 (Mepivalem® AD Dentsply,
Catanduva, SP, Brazil). No more than three cartridges (5.4 ml) were used in each
procedure. The number of extractions per procedure was limited due to the
administration of 3 cartridges of the local anesthetic solution, and, in some
procedures, the extractions were performed in different quadrant sites.
All procedures were performed in an outpatient setting by one surgeon and the
surgical technique was restricted to simple extractions with the use of forceps and
elevators. None of the extractions required elevation of mucoperiosteal flaps,
osteotomy or odontosection. Teeth with acute inflammation, such as periodontal or
periapical abscess, were not considered in the analysis due to a possible
interference of the inflammation process on postoperative bleeding.
Regarding the postoperative prescription, nonsteroidal anti-inflammatory drugs
were not prescribed and acetaminophen 750 mg was efficient for pain control. Few
22
patients had medical contra-indications to acetaminophen, and, in these cases,
dipyrone 500 mg was prescribed according to medical recommendations. These
medications were only administrated in the event of postoperative pain, limited to 4
pills per day. This protocol for pain control was discussed and in agreement with the
liver transplant team.
Postoperative instructions sheets were given and the patients orientated to
apply local pressure with gauze for 20 minutes and contact the dentist in case of
bleeding. In the event of bleeding not controlled by the patient, local hemostatic
maneuvers with the replacement of the absorbable hemostatic sponge, re-suture and
local pressure with gauze were performed by the dentist in an outpatient setting. If
the previous measures did not stop the bleeding, the patient was submitted to
hospital admission and administration of blood components. Follow-up was
scheduled 1 week after surgery for suture removal and postoperative evaluation with
a questionnaire regarding postoperative bleeding, necessity of systemic hemostatic
measures and hospital admission.
Data are presented as the mean + SD. Differences between two groups were
compared using Student’s t or Mann-Whitney tests. Chi-square and likelihood ratio
tests were used between the categorical variables. The analyses were performed
using SPSS software (v. 17; SPSS Inc, Chicago, IL, USA). Differences exceeding a
95% confidence interval (p<0.05) were considered statistically significant.
Results
During 9 months of the study, 52 patients were referred to dental evaluation
and 33 subjects (63.5%) presented oral foci that required dental extractions. Among
the other 19 patients, 6 (11.5%) presented good oral health and 13 (25%) required
restorations and/or periodontal treatment regarding tooth scaling and root planning.
Only 26 patients were submitted to tooth extraction, because 4 patients did not return
to the dental appointment and 3 patients had the transplantation before the dental
visit. Other 3 patients were excluded from this study because: one subject presented
normal blood values that represented outliers in the statistical analysis; one subject
required blood transfusion before tooth extraction because the platelet count was
22,000/mm3 and the extraction was performed after administration of two units
platelet concentrate; and one subject presented medical complications not related to
23
the tooth extraction that did not allowed the postoperative evaluation after the dental
procedure.
The remaining 23 patients considered in this analysis, 14 men (60.9%) and 9
women (39.1%), were submitted to a total of 35 surgical procedures to removal of
dental foci. The patients were divided into two groups: 11 in group 1 and 12 patients
in group 2. The mean age of all patients was 43.17 years (standard deviation, SD ±
14.62; range 20 to 67 years). The mean MELD score was 16.26 (SD ± 3.95; range 9
to 23). No statistically significant difference was found between the groups
concerning the above cited characteristics. The most prevalent indication for liver
transplantation was liver cirrhosis (87%) caused by viral hepatitis (30.4%) and
alcohol consumption (26.1%). Other indications for liver transplantation were Wilson’s
disease (8.7%) and hepatocellular carcinoma (4.3%). In the 35 procedures, a total of
84 dental foci were removed with a mean of 2.4 teeth per procedure (SD ± 1.00;
range 1 to 4). The numbers of procedures between the groups were 15 in Group 1
and 20 in Group 2. Other comparisons between groups are listed in Table 1. The
mean hematocrit before the procedures was 34.54% (SD ± 5.84, range 21.7 to
44.4%), with 25.7% of the procedures performed with an hematocrit less than 30%.
The platelet count ranged from 31,000 to 160,000 platelets/mm3 (mean 67,888.57 ±
33,564.38 platelets/mm3), with 34.3% of the procedures performed with a platelet
count between 30,000 to 50,000 platelets/mm3. The mean INR was 1.5 (SD ± 0.39;
range 0.98 to 2.59), with only 3 procedures (8.6%) performed with an INR higher
than 2. The mean PTT ratio was 1.39 (SD ± 0.26; range 0.92 to 2.06) with only one
procedure (3.2%) performed with PTT ratio higher than 2. In four procedures, data
from PTT ratio was not available, but the remaining 31 were included in the analysis.
The Tables 2 and 3 show the number of procedures, preoperative blood exams ratios
and range between the groups. In all tooth extractions, hemostasis was guaranteed
with the use of absorbable hemostatic sponges, cross sutures and local pressure
with gauze. Time to hemostasis in 77.1% of the procedures took only 5 minutes of
local pressure. No statistically significant difference in the time to hemostasis was
found between the two groups (Table 4). The mean duration of each procedure, from
incision to suturing, was 16.25 minutes (SD ± 8.75 minutes). Statistically significant
difference between groups (P<0.05) was found in the hematocrit (P<0.001) and
platelet count (P=0.04) per patient; hematocrit (P=0.048) per procedure and the
hematocrit (P<0.001), platelet count (P=0.007) and INR (P=0.009) per extraction
24
between groups. However, these were not findings of relevance and, still, would not
interfere in the demonstration of a statistical significant difference in the use of
tranexamic acid in the gauze used to apply local pressure.
Postoperative bleeding occurred in one procedure (2.9%) in one patient
(4.3%) three days after the tooth extraction of a maxillary first molar. The
preoperative blood tests of this patient were INR 2.5 and platelet count of
50,000/mm3. Local pressure with gauze for 20 minutes applied by the dentist in the
ambulatory was an effective hemostatic measure.
Discussion
The prevalence of patients with liver disease requiring dental surgical
intervention for oral sanitation (63.5%), found in this study, may not be addressed as
a direct result of the liver disease and can be a reflection of the oral health status of
the general population in Brazil, with a DMFT index of 19.6 in the population aged
between 35 and 44 years living in Northeastern Brazil.15 However, this prevalence is
in agreement with other studies, with the same group of patients, in a developed
country like Germany, 65% and 68.4%.6,4 Anyway, the prevalence reported in this
paper demonstrates the need of surgical treatment for oral foci sanitation in patients
with liver disease.
The hematocrit level was recorded in order to assess if there was a relation
between low hematocrit levels and increased bleeding time even in patients with
normal platelet count as it was reported by previous studies.16-19 The literature
describes that hematocrit levels from lower than 20% to 35% may lead to a platelet
clot formation impairment independent of the platelet count.19-22 Besides the mean
hematocrit values in the present study did not varied much from normal values, with
only 25.7% of the procedures performed with an hematocrit lower than 30%, no
bleeding episode was occurred when the procedures was performed with lower
hematocrit values.
In the present study, only one patient experienced postoperative bleeding
representing an incidence of only 2.9% among the 35 procedures. Local pressure
with gauze as a local hemostatic measure in an outpatient setting was successful to
stop the bleeding and in none of the patients there was the need of blood
components administration and hospital admission. To date, to compare the
25
incidence of bleeding episodes in patients with similar systemic conditions is only
available with the study of Ward & Weideman.14 The incidence of bleeding found in
this study is lower than in the study of Ward & Weideman,14 who reported 7 (20%)
postoperative bleeding episodes from a total of 35 oral surgical interventions in liver
pretransplant patients. Among these 7 episodes of postoperative bleeding, only 1
(14.3%) procedure did not need the administration of platelets, fresh frozen plasma
or packed red blood cells. If there are considered only the “Minimal risk” and
“Moderate Risk” groups (procedures with fewer than 10 nonimpacted teeth extracted
or 1 bony impacted teeth removed) in that study, the incidence of postoperative
bleeding would still be higher, 2 (8%) procedures among 25 procedures with the
platelet count higher than 50,000/mm3 and INR less than 4.0. patients. If the
comparison is limited to the “Minimal Risk” group (maximum of 5 simple tooth
extractions), the incidence of postoperative bleeding in the present study would still
be lower than the incidence of bleeding of 6% in that group, where the procedures
were performed with platelet count higher than 50,000/mm3 and INR less than 4.0.
After all this comparison, even if the only postoperative bleeding episode was added
to the group of procedures with platelet count from 30,000/mm3 to 49,999/mm3, the
incidence would be 1 (7.7%) postoperative bleeding episode among 13 procedures
that were performed in that range, and it would still be an low incidence of
postoperative complications that could justify a dental intervention without the use of
blood components. In 1983, Rose & Kay 23 were the first to recommend the necessity
of administration of platelets when the platelet count was less than 50,000/mm3 and
that statement should be reviewed in order to indicate a rationally use of blood
transfusions. There are also other studies who reported higher incidences of bleeding
complications and healing impairment, ranging from 15.4% to 43%.6,24 In the present
study 8.6% of the procedures were performed with the INR higher than 2.0 and
34.3% with the platelet count between 30,000/mm3 and 49,999/mm3, this
demonstrates that it is most likely to find a low platelet count than higher INR values
in these subjects. And from the 26 patients that had preoperative blood exam
evaluations, only one patient (3.8%) needed blood transfusion. Then, the incidence
of patients that require blood transfusion with this protocol was low. Further
prospective studies could use the data from the present study and add to more
procedures, with the objective to understand if there are algorithms parameters
26
concerning coagulation blood values when evaluating the need of hospital admission
and blood transfusion in patients with liver disease to perform tooth extractions.
In the literature, there are a wide variety of studies that assess the risk of
bleeding in oral anticoagulated patients, including some recently meta-analytic
studies. However, the studies with that model of patients are not a reliable
comparison to understand the risk of bleeding in liver disease patients. The
difference in the patients with liver disease is that the impairment in the hemostasis
may be a reflection of anemia, decreased production of clotting factor because of
hepatic synthetic dysfunction, depletion of vitamin K stores due to malnutrition or
decreased intestinal absorption, increased fibrinolytic activity and/or
thrombocytopenia due to portal hypertension-induced splenic sequestration or
alcohol-induced bone marrow suppression.10,25 In this way, it is characterized that the
complexity of the hemostasis impairment in these patients is higher than in
anticoagulated patients. Even though, to date, the studies with a model of
anticoagulated patients are more studied in the literature and they represent the
closest model of hemostasis impairment that can be compared to patients with liver
disease. In anticoagulated patients, local hemostatic measures have proven to be
effective in patients with INR ≤ 4.0. In those studies, the few episodes of bleeding
have been related to teeth with soft tissue inflammation and periodontal diseases,
and the local hemostatic measures were effective to stop the bleeding without the
need of hospital admission or administration of blood components.12,13,26 In the
present study, there was not any statistical significant difference that could
demonstrate an advantage of using tranexamic acid solution in the gauze for local
pressure, what was already reported by several studies that failed to demonstrate
any statistical significant difference between different local hemostatic measures
regarding hemostasis.27-30 Al-Mubarak et al 31 went beyond and reported that simple
teeth extractions without sutures can be performed with safety in anticoagulated
patients with the INR ≤ 3.0. The association of antifibrinolytic agents with the use of
absorbable collagen sponge has a proved efficacy in recent studies, because of the
effect in the fibrinolysis inhibition with the mechanical effect of the collagen sponge in
the tooth socket has showed to be effective as a local hemostatic measure after
simple tooth extraction.32,33 Patatanian & Fugate 34 also reported no difference in the
hemostasis with the use of tranexamic acid rinses after tooth extraction in
27
anticoagulated patients. For this reasons, it can be said that the compression without
tranexamic acid can be used as it represents a lower income to the procedure.
Despite of some guidelines concerning INR values in the preoperative
evaluation, Tripodi et al 35 reported that INR have deficiencies in evaluating
impairments in the coagulation cascade as anticoagulant factors, not evaluated by
these tests, may also be reduced in the liver disease and can balance the deficiency
of procoagulant factors. According to Tripodi et al,35 alternative tests to predict
bleeding should be developed and a new international sensitivity index (ISI) for
commercial thromboplastin using plasma from patients with cirrhosis instead of
plasma from patients on oral anticoagulant therapy should be used. Tripodi et al 35
also suggested that the thrombin generation monitoring and thromboelastography
tests may be more reliable to assess the bleeding risk in liver disease patients.
Further studies with liver transplant patients should be encouraged to help the
practitioner to understand the limits of a surgical dental care intervention without the
administration of blood components and not increasing the risk of postoperative
bleeding. Still, it is recommended to perform these procedures in an outpatient
setting only if some medical on call services is available to perform emergency local
hemostatic measures or hospital admission for blood transfusion if needed.
In this study, there was no advantage of using gauze soaked with tranexamic
acid to achieve hemostasis compared to the simple compression with gauze without
the use of the mentioned solution. In this way, the set of local hemostatic measures
with absorbable collagen sponge, cross suture and local pressure with gauze were
effective to obtain hemostasis after tooth extraction in candidates for liver
transplantation.
Thus, this paper demonstrates the possibility of performing tooth extractions in
patients with liver cirrhosis, with INR ≤ 2.50 and platelets ≥ 30,000/mm3, without the
need of blood transfusion, and in case of bleeding events, the use of local hemostatic
measures can be satisfactory.
28
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34
Tables
Table 1. Number of procedures and extractions per patient in Group 1 and
Group 2.
All participants
(N=23)
mean ± SD
Group 1
(N=11)
mean ± SD
Group 2
(N=12)
mean ± SD
p
value1
Number of procedures 35 15 20
Procedure per patient 1.52 ± 0.94 1.36 ± 0.50 1.66 ± 1.23 0.921
range 1 – 5 1 – 2 1 – 5
Number of extractions 84 37 47 0.574
Extractions per patient 3.65 ± 3.15 3.36 ± 2.65 3.91 ± 3.65
range 1 – 15 1 – 8 1 – 15
Extraction per procedure 2.4 ± 1.00 2.46 ± 1.18 2.35 ± 0.87 0.841
range 1 – 4 1 – 4 1 – 4
(1) Mann-Whitney test.
35
Table 2. Hematocrit, platelet count, INR and PTT ratio values per procedures in
Group 1 and Group 2.
All
participants
(N=35)
mean ± SD
Group 1
(N=15)
mean ± SD
Group 2
(N=20)
mean ± SD
p value
Hematocrit (%) 34.54 ± 5.84 38.16 ± 4.54 31.82 – 5.28 <0.0011
range 21.7 – 44.4 28.3 – 44.4 21.7 – 42.1
Platelet count
(platelets/mm3) x10
3
68 ± 34 83 ± 40 57 ± 24 0.0402
range
(platelets/mm3) x10
3
31 – 160 31 – 160 31 – 124
INR* 1.5 ± 0.39 1.6 ± 0.35 1.43 ± 0.42 0.1921
range 0.98 – 2.59 1.19 – 2.59 0.98 – 2.5
PTT ratio** 1.39 ± 0.26 1.41 ± 0.27 1.38 ± 0.26 0.7301
range 0.92 – 2.06 0.92 – 1.83 0.99 – 2.06
Time to hemostasis
(minutes)
5 – 40 5 – 40 5 – 20 0.3002
* International Normalized Ratio (INR).
** Partial Thromboplastin Time (PTT). PTT ratio value was not available in 4 subjects
and mean ± SD were calculated with the values from 31 subjects.
(1) Student’s t test;
(2) Mann-Whitney test.
36
Table 3. Hematocrit, platelet count, INR and PTT ratio ranges per procedures/extraction in Group 1 and Group 2.
All participants Procedures Extractions
Procedures Extractions Group 1 Group 2
P value
1 Group 1 Group 2
P value
(N=35) n (%)
(N=84) n(%)
(N=15) n (%)
(N=20) n (%)
(N=37) n (%)
(N=47) n (%)
Hematocrit
0.0481
<0.0012
20% – 29% 9 (25.7) 22 (26.2) 1 (6.7) 8 (40) 2 (5.4) 20 (42.6)
≥ 30% 26 (74.3) 62 (73.8) 14 (93.4) 12 (60) 35 (94.6) 27 (57.4)
Platelet count (platelets/mm
3)
<0.2512
0.0072
30,000 – 49,999 12 (34.3) 29 (34.5) 3 (20) 9 (45) 7 (18.9) 22 (46.8)
50,000 – 79,999 11 (31.4) 22 (26.2) 5 (33.3) 6 (30) 9 (24.3) 13 (27.7)
80,000 – 149,999 10 (28.6) 26 (31) 5 (33.3) 5 (25) 14 (37.8) 12 (25.5)
≥ 150,000 2 (5.7) 7 (8.3) 2 (13.3) - 7 (18.9) -
INR*
0.1751
0.0091
2.01 – 3.00 3 (8.6) 8 (9.6) 1 (6.7) 2 (10) 3 (8.1) 5 (10.6)
1.41 – 2.00 14 (40) 37 (44) 9 (60) 5 (25) 23 (62.2) 14 (29.8)
≤ 1.40 18 (51.4) 39 (46.4) 5 (33.3) 13 (65) 11 (29.7) 28 (59.6)
PTT ratio**
0.3781
0.1702
1.41 – 2.00 15 (48.4) 34 (47.2) 8 (61.5) 7 (38.9) 18 (56.3) 16 (40)
≤ 1,4 16 (51.6) 38 (52.8) 5 (38.5) 11 (61.1) 14 (43.8) 24 (60)
* International Normalized Ratio (INR).
** Partial Thromboplastin Time (PTT). PTT ratio value was not available in 4 subjects and
mean ± SD were calculated with the values from 31 subjects.
(1) Likelihood ratio test;
(2) Chi-square test
37
Table 4. Time to hemostasis per procedure with local pressure in
Group 1 and Group 2.
All participants
(N=35)
n (%)
Group 1
(N=15)
n (%)
Group 2
(N=20)
n (%)
Time of local pressure
5 minutes 27 (77.1) 10 (66.7) 17 (85)
10 minutes 4 (11.4) 3 (20) 1 (5)
20 minutes 3 (8.6) 1 (6.7) 2 (10)
40 minutes 1 (2.9) 1 (6.7) 0 (0)
p = 0.280; Chi2 for linear trend.
38
4 CONCLUSÃO GERAL
Da avaliação dos resultados obtidos nesse trabalho, pode-se concluir que:
exodontias em pacientes com insuficiência hepática, apresentando INR ≤ 2,50
e plaquetometria ≥ 30.000/mm3, podem ser realizadas sem a necessidade de
transfusão sanguínea e que diante, da ocorrência de intercorrências
hemorrágicas, o uso de medidas hemostáticas locais pode ser satisfatório.
não houve vantagens quanto ao uso tópico do ácido tranexâmico para obter
hemostasia, em comparação com a aplicação de pressão local com gaze sem
o referido ácido. Dessa forma, o uso de um conjunto de medidas
hemostáticas locais com esponja de colágeno, sutura em X e pressão local
com gaze são eficazes para se atingir a hemostasia, após exodontias em
pacientes candidatos ao transplante de fígado.
39
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ANEXOS
44
ANEXO A
45
ANEXO B