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Application of INSTAT hemostat in the control of gingival hemorrhage in the patient with thrombocytopenia
Application of INSTAT hemostat in the control of gingival hemorrhage in the patient with thrombocytopenia A case report James G. Green, DDS,a and Timothy DEPARTMENT MEDICAL
OF PATHOLOGY, CENTER,
COLLEGE
M. Durham,
DIAGNOSIS,
AND
DDS,b Omaha and Lincoln, Neb.
RADIOLOGY,
UNIVERSITY
OF NEBRASKA
OF DENTISTRY
Gingival bleeding in the patient with thrombocytopenia can be a difficult management problem. Primary therapy with platelet transfusions may not be sufficient to control the hemorrhage and adjunctive local therapy may be required. Currently, few local management techniques can effectively control this problen. INSTAT collagen absorbable hemostat can be used as a local adjunct with platelet transfusions and has certain application advantages over topical thrombin and microfibrillar collagen. Two successful techniques of INSTAT application to control gingival hemorrhage in a patient with severe thrombocytopenia in leukemic relapse are described. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:27-30)
T hrombocytopenia, number of circulating
an abnormal reduction in the platelets, is a manifestation of an underlying disease process. Platelet deficiencies may be due to decreased platelet production, decreased platelet survival, sequestration, or dilution.’ Thrombocytopenic gingival hemorrhage commonly occurs in patients with leukemia or patients undergoing myelosuppressive chemotherapy.2s 3 The primary management of gingival hemorrhage in the patient with thrombocytopenia is platelet transfusions, and approximately 90% of these hemorrhagic episodes can be controlled with this treatment.4 In those cases which do not respond entirely to platelet therapy, local measures are required. This article reports the successful use of INSTAT* collagen absorbable hemostat (Fig. 1) to control gingival hemorrhage in a patient with severe thrombocytopenia in leukemic relapse. CASEREPORT
A 65year-old white man with acute myelogenous leukemia in relapse reported to the emergency room with a comaAssociate Professor and Director, General Practice Program, Omaha. bAssistant Professor and Director, Advanced Education Dentistry Program, Lincoln. 7/12/15714 *INSTAT Johnson
(collagen absorbable hemostat) & Johnson Patient Care, Inc.
Residency in General
is a trademark
of
plaint of spontaneous and persistent gingival hemorrhage for the previous 2 days. Clinical and laboratory examination by the emergency room physician revealed steady bleeding from the gingival sulci of the entire right mandibular quadrant and a platelet count less than 3000/mm3. The patient was given 10 units of platelets, which elevated his count to 15,000/mm3, and was instructed to report to the hematology/oncology clinic the next morning. The patient, still hemorrhaging from the right mandibular quadrant reported to the clinic. A complete blood cell count revealed a white blood cell count of 32,200/mm3 with 92% blasts, 1% myelocytes, 1% monocytes, and 6% lymphocytes. The hemoglobin was 10.0 gm/dl, and the hematocrit was 29.3%. The red blood cell count was 3.57 million/mm3 and the platelet count was 8000/mm3. Administration of 1 unit of irradiated packed red cells and 10 units of platelets failed to control the gingival bleeding, and the dental service was consulted to provide local adjunctive therapy. Oral examination revealed generalized heavy plaque and calculus associated with the mandibular dentition and hemorrhage from the gingival sulci of the mandibular right quadrant. Attempts to control the bleeding with topical thrombin and pressure were unsuccessful. A 3 X 4 inch sponge of INSTAT collagen absorbable hemostat was obtained and cut to the appropriate size. After small lengthwise incisions were made, the hemostat was draped over the teeth like a rubber dam. The hemostatic agent was flossed interproximally with black silk suture and ligated around each tooth at the gingival margin (Fig. 2, A and B). Within 5 minutes after placement, thegingival hemorrhage stopped. The patient was instructed to avoid vigorous rinsing, eat a soft diet, and return if the bleeding recurred. At the follow27
28 Green and Durham
ORAl
SL!R(i
ORAl.
MED
ORAL
PAI-HOL
.lanuary
1991
Fig. 1. INSTAT hemostatin its individual sterilepacks. Both 1 X 2 inch and 3 X 4 inch sizesare shown.
up examination,the dressingwasintact around the gingival margins and no hemorrhagehad redeveloped.On removalof the hemostat,a thin gelatinouslayer that wasnot adherentto the gingiva waspresent.Removalof this layer did not reinitiate bleeding.The patient wasinstructed to gently clean the teeth with wet cotton ballsand placedon 0.12%chlorhexidinegluconate(Peridex*) rinses. The physicianwas informed of the patient’s poor oral hygieneand the needfor dental prophylaxis to reducethe possibilityof future spontaneous hemorrhage.Becauseof severethrombocytopeniaand lack of functional granulocytes, hospitalization for dental treatment with platelet transfusionsand prophylactic antibiotic coveragewasrecommended.The patient wasgiven 10 units of plateletson the eveningof his admission.An additional 20 units of plateletsalongwith ampicillin and gentamicinwasadministered immediately before his dental appointment. The pretreatment therapy elevatedthe platelet count to only 8000/mm3.An alginate impressionwasobtained,poured, and trimmed. A vacuformed mouthguardwasfabricated while the dental prophylaxis was completed.The anticipatedpostoperativehemorrhagewascontrolledby application of the hemostatwithin the mouthguard(Fig. 3, A and B). The hemostaticdressingwasmaintainedin the mouth overnight and removedthe next morning.No further hemorrhagewasnoted,andthe patient wasdischargedfrom the hospital.After his discharge,the patient had severaladditional episodesof spontaneousgingival hemorrhagethat were adequatelycontrolled with platelet transfusionsand application of the hemostat. DISCUSSION
Although platelet transfusions are the primary therapy for gingival hemorrhage in the patient with thrombocytopenia, they may not be sufficient in all cases to control hemorrhage. Microfibrillar collagen or topical thrombin applied with pressure can be used to complement but not replace systemic measures.5 *Peridex (chlorhexidine & Gamble.
gluconate
rinse)
is a trademark
of Procter
2. A, Small incisionsare madein INSTAT hemostat, and it is placed over teeth similar to application of rubber dam. B, INSTAT hemostatis flossedthrough contact areaswith suture material and ligated around each tooth to compress hemostaticagentagainstgingival tissues. Fig.
However, these local adjuncts have not been uniformly successful. This may be due to the following problems: multifocal bleeding points; difficulty in applying and maintaining the topical agent at the bleeding sites; and dispersion of the hemostatic agent by blood, saliva, and oral movement. Avitene* microfibrillar collagen hemostat is purified bovine collagen prepared as either a loose powder or a compact nonwoven web form.6 It must be applied with dry, smooth forceps or sprinkled over the bleeding area. If the forceps become wet, the hemostatic agent will adhere to the instrument and make application difficult. Microfibrillar collagen will also adhere to wet gloves. If there is constant hemorrhaging, washing of saliva, or abrasive oral movements, the powder form can be easily dispersed from the bleeding site. The web form falls apart when wet and cannot be ligated or sutured. If pressure is required, compression with gauze must be used. This may be cumbersome for the practitioner and uncomfortable *Avitene (microfibrillar collagen Alcon (Puerto Rico) Inc.
hemostat)
is a trademark
of
Volume 71 Number 1
INSTAT
for the patient. When multiple bleeding points are present, these problems are compounded. Topical thrombin can also be used in some oral clinical situations; however, its use for treating gingival hemorrhage has several limitations. With persistent bleeding from multiple sites, proper tissue preparation and direct application is difficult. Failure of the thrombin to reach the tissue surface may allow for continued bleeding beneath an apparent clot. The use of manual pressure with gauze to assist in hemostasis may be necessary. This may be cumbersome for the practitioner and uncomfortable for the patient. In addition, the clot can adhere to or form within the gauze, and movement or removal may reinitiate bleeding. Unless protected, the clot may be disrupted by oral movements. It was our experience that INSTAT hemostat provided several advantages over microfibrillar collagen and topical thrombin in the treatment of gingival hemorrhage. INSTAT hemostat is purified and lyophilized bovine collagen prepared as a lightly crosslinked spongelike pad. It can be cut and easily shaped, and maintains its structural integrity when soaked with blood or saliva. Because of these physical properties, it can be used to control bleeding over large surface areas or at sites not easily visualized or accessible. INSTAT hemostat adheres to bleeding surfaces when wet but does not stick to instruments, gloves, or sponges.’ Since INSTAT hemostat is lightly cross-linked, it can be sutured or ligated over the bleeding areas to prevent displacement by oral movements. When it is properly ligated at the cervical margins of the teeth, consistent pressure can be maintained on marginal and interproximal gingival tissues. Application within a mouthguard also prevents displacement and provides pressure. After hemostasis is achieved, INSTAT hemostat is easily removed without reinitiation of bleeding. Although INSTAT hemostat has many attractive features, some clinical problems can be encountered. When wet, INSTAT hemostat does not adhere to the smooth surfaces of teeth and can be difficult to maintain in the appropriate location for interproximal placement with ligatures. This problem can be minimized by placing dry INSTAT hemostat over the teeth, securing the most anterior ligature first, and working sequentially toward the most distal tooth. The mouthguard did not provide pressure equal to that produced by the use of ligatures; therefore hemostasis requires a slightly longer period of time. CONCLUSION
Gingival bleeding in the patient with thrombocytopenia can be a difficult management problem. Primary therapy with platelet transfusions may not be
application for controlling gingival hemorrhage 29
Fig. 3. A, Internally relieved O.lS-inch vacuformed mouthguard is lined with moistened INSTAT hemostat. B, Mouthguard is seated to compress hemostatic agent against gingival tissues.
sufficient to control the hemorrhage and adjunctive local therapies may be necessary. This article has presented two successful techniques of INSTAT hemostat application to control gingival hemorrhage in a patient with severe thrombocytopenia in leukemic relapse. This case demonstrates that INSTAT hemostat has the following advantages over microfibrillar collagen and topical thrombin: (1) control of hemorrhage at multiple bleeding sites, (2) ease of placement in areas difficult to access or visualize, (3) resistance to displacement by blood, saliva, and oral movements, (4) direct contact with the bleeding sites by ligature or suture, (5) application with pressure, and (6) removal without reinitiation of bleeding. REFERENCES
1. Marcus AJ. Hemorrhagic disorders: abnormalities of platelet and vascular function. In: Wyngaarden JB, Smith LH Jr, eds. Textbook of medicine. Philadelphia: WB Saunders Co, 1985:1028-40. 2. Gaydos LA, Freireich EJ, Mantel N. The quantitative relation between platelet count and hemorrhage in patients with acute leukemia. N Engl J Med 1962;266:905-9. 3. Stafford R, Sonis S, Lockhart P, Sonis A. Oral pathoses as di-
30
Green and Durham agnostic
indicators
PATHOL
1980;50:
in leukemia.
ORAL
SURG
ORAL
MED
ORAL
134-9.
4. Freireich EJ, Kliman A, Gaydos LA, Mantel N, Frei E III. Response to repeated platelet transfusion from the same donor. Ann Intern Med 1963;59:277-87. 5. Dreizen S, McCredie KB, Keating MJ. Chemotherapy-associated oral hemorrhages in adults with acute leukemia. ORAL SURG
ORAL
MED
ORAL
PATHOL
6. Alcon Inc. Avitene (microfibrillar Physician’s desk reference. Oradell, Co Inc. 1988:589.
1984;57:494-8.
collagen hemostat). In: NJ: Medical Economics
7. Department of Clinical Research, Johnson & Johnson Products, Inc. Clinical experience with lnstat collagen absorbable hemostat, a summary. New Brunswick, NJ: Johnson & Johnson Products, Inc, 1986. Reprint requests to: Timothy M. Durham, DDS UNMC College of Dentistry 40th and Holdregc Lincoln, NE 68583
OF PATHOLOGY, CENTER,
COLLEGE
M. Durham,
DIAGNOSIS,
AND
DDS,b Omaha and Lincoln, Neb.
RADIOLOGY,
UNIVERSITY
OF NEBRASKA
OF DENTISTRY
Gingival bleeding in the patient with thrombocytopenia can be a difficult management problem. Primary therapy with platelet transfusions may not be sufficient to control the hemorrhage and adjunctive local therapy may be required. Currently, few local management techniques can effectively control this problen. INSTAT collagen absorbable hemostat can be used as a local adjunct with platelet transfusions and has certain application advantages over topical thrombin and microfibrillar collagen. Two successful techniques of INSTAT application to control gingival hemorrhage in a patient with severe thrombocytopenia in leukemic relapse are described. (ORAL SURC ORAL MED ORAL PATHOL 1991;71:27-30)
T hrombocytopenia, number of circulating
an abnormal reduction in the platelets, is a manifestation of an underlying disease process. Platelet deficiencies may be due to decreased platelet production, decreased platelet survival, sequestration, or dilution.’ Thrombocytopenic gingival hemorrhage commonly occurs in patients with leukemia or patients undergoing myelosuppressive chemotherapy.2s 3 The primary management of gingival hemorrhage in the patient with thrombocytopenia is platelet transfusions, and approximately 90% of these hemorrhagic episodes can be controlled with this treatment.4 In those cases which do not respond entirely to platelet therapy, local measures are required. This article reports the successful use of INSTAT* collagen absorbable hemostat (Fig. 1) to control gingival hemorrhage in a patient with severe thrombocytopenia in leukemic relapse. CASEREPORT
A 65year-old white man with acute myelogenous leukemia in relapse reported to the emergency room with a comaAssociate Professor and Director, General Practice Program, Omaha. bAssistant Professor and Director, Advanced Education Dentistry Program, Lincoln. 7/12/15714 *INSTAT Johnson
(collagen absorbable hemostat) & Johnson Patient Care, Inc.
Residency in General
is a trademark
of
plaint of spontaneous and persistent gingival hemorrhage for the previous 2 days. Clinical and laboratory examination by the emergency room physician revealed steady bleeding from the gingival sulci of the entire right mandibular quadrant and a platelet count less than 3000/mm3. The patient was given 10 units of platelets, which elevated his count to 15,000/mm3, and was instructed to report to the hematology/oncology clinic the next morning. The patient, still hemorrhaging from the right mandibular quadrant reported to the clinic. A complete blood cell count revealed a white blood cell count of 32,200/mm3 with 92% blasts, 1% myelocytes, 1% monocytes, and 6% lymphocytes. The hemoglobin was 10.0 gm/dl, and the hematocrit was 29.3%. The red blood cell count was 3.57 million/mm3 and the platelet count was 8000/mm3. Administration of 1 unit of irradiated packed red cells and 10 units of platelets failed to control the gingival bleeding, and the dental service was consulted to provide local adjunctive therapy. Oral examination revealed generalized heavy plaque and calculus associated with the mandibular dentition and hemorrhage from the gingival sulci of the mandibular right quadrant. Attempts to control the bleeding with topical thrombin and pressure were unsuccessful. A 3 X 4 inch sponge of INSTAT collagen absorbable hemostat was obtained and cut to the appropriate size. After small lengthwise incisions were made, the hemostat was draped over the teeth like a rubber dam. The hemostatic agent was flossed interproximally with black silk suture and ligated around each tooth at the gingival margin (Fig. 2, A and B). Within 5 minutes after placement, thegingival hemorrhage stopped. The patient was instructed to avoid vigorous rinsing, eat a soft diet, and return if the bleeding recurred. At the follow27
28 Green and Durham
ORAl
SL!R(i
ORAl.
MED
ORAL
PAI-HOL
.lanuary
1991
Fig. 1. INSTAT hemostatin its individual sterilepacks. Both 1 X 2 inch and 3 X 4 inch sizesare shown.
up examination,the dressingwasintact around the gingival margins and no hemorrhagehad redeveloped.On removalof the hemostat,a thin gelatinouslayer that wasnot adherentto the gingiva waspresent.Removalof this layer did not reinitiate bleeding.The patient wasinstructed to gently clean the teeth with wet cotton ballsand placedon 0.12%chlorhexidinegluconate(Peridex*) rinses. The physicianwas informed of the patient’s poor oral hygieneand the needfor dental prophylaxis to reducethe possibilityof future spontaneous hemorrhage.Becauseof severethrombocytopeniaand lack of functional granulocytes, hospitalization for dental treatment with platelet transfusionsand prophylactic antibiotic coveragewasrecommended.The patient wasgiven 10 units of plateletson the eveningof his admission.An additional 20 units of plateletsalongwith ampicillin and gentamicinwasadministered immediately before his dental appointment. The pretreatment therapy elevatedthe platelet count to only 8000/mm3.An alginate impressionwasobtained,poured, and trimmed. A vacuformed mouthguardwasfabricated while the dental prophylaxis was completed.The anticipatedpostoperativehemorrhagewascontrolledby application of the hemostatwithin the mouthguard(Fig. 3, A and B). The hemostaticdressingwasmaintainedin the mouth overnight and removedthe next morning.No further hemorrhagewasnoted,andthe patient wasdischargedfrom the hospital.After his discharge,the patient had severaladditional episodesof spontaneousgingival hemorrhagethat were adequatelycontrolled with platelet transfusionsand application of the hemostat. DISCUSSION
Although platelet transfusions are the primary therapy for gingival hemorrhage in the patient with thrombocytopenia, they may not be sufficient in all cases to control hemorrhage. Microfibrillar collagen or topical thrombin applied with pressure can be used to complement but not replace systemic measures.5 *Peridex (chlorhexidine & Gamble.
gluconate
rinse)
is a trademark
of Procter
2. A, Small incisionsare madein INSTAT hemostat, and it is placed over teeth similar to application of rubber dam. B, INSTAT hemostatis flossedthrough contact areaswith suture material and ligated around each tooth to compress hemostaticagentagainstgingival tissues. Fig.
However, these local adjuncts have not been uniformly successful. This may be due to the following problems: multifocal bleeding points; difficulty in applying and maintaining the topical agent at the bleeding sites; and dispersion of the hemostatic agent by blood, saliva, and oral movement. Avitene* microfibrillar collagen hemostat is purified bovine collagen prepared as either a loose powder or a compact nonwoven web form.6 It must be applied with dry, smooth forceps or sprinkled over the bleeding area. If the forceps become wet, the hemostatic agent will adhere to the instrument and make application difficult. Microfibrillar collagen will also adhere to wet gloves. If there is constant hemorrhaging, washing of saliva, or abrasive oral movements, the powder form can be easily dispersed from the bleeding site. The web form falls apart when wet and cannot be ligated or sutured. If pressure is required, compression with gauze must be used. This may be cumbersome for the practitioner and uncomfortable *Avitene (microfibrillar collagen Alcon (Puerto Rico) Inc.
hemostat)
is a trademark
of
Volume 71 Number 1
INSTAT
for the patient. When multiple bleeding points are present, these problems are compounded. Topical thrombin can also be used in some oral clinical situations; however, its use for treating gingival hemorrhage has several limitations. With persistent bleeding from multiple sites, proper tissue preparation and direct application is difficult. Failure of the thrombin to reach the tissue surface may allow for continued bleeding beneath an apparent clot. The use of manual pressure with gauze to assist in hemostasis may be necessary. This may be cumbersome for the practitioner and uncomfortable for the patient. In addition, the clot can adhere to or form within the gauze, and movement or removal may reinitiate bleeding. Unless protected, the clot may be disrupted by oral movements. It was our experience that INSTAT hemostat provided several advantages over microfibrillar collagen and topical thrombin in the treatment of gingival hemorrhage. INSTAT hemostat is purified and lyophilized bovine collagen prepared as a lightly crosslinked spongelike pad. It can be cut and easily shaped, and maintains its structural integrity when soaked with blood or saliva. Because of these physical properties, it can be used to control bleeding over large surface areas or at sites not easily visualized or accessible. INSTAT hemostat adheres to bleeding surfaces when wet but does not stick to instruments, gloves, or sponges.’ Since INSTAT hemostat is lightly cross-linked, it can be sutured or ligated over the bleeding areas to prevent displacement by oral movements. When it is properly ligated at the cervical margins of the teeth, consistent pressure can be maintained on marginal and interproximal gingival tissues. Application within a mouthguard also prevents displacement and provides pressure. After hemostasis is achieved, INSTAT hemostat is easily removed without reinitiation of bleeding. Although INSTAT hemostat has many attractive features, some clinical problems can be encountered. When wet, INSTAT hemostat does not adhere to the smooth surfaces of teeth and can be difficult to maintain in the appropriate location for interproximal placement with ligatures. This problem can be minimized by placing dry INSTAT hemostat over the teeth, securing the most anterior ligature first, and working sequentially toward the most distal tooth. The mouthguard did not provide pressure equal to that produced by the use of ligatures; therefore hemostasis requires a slightly longer period of time. CONCLUSION
Gingival bleeding in the patient with thrombocytopenia can be a difficult management problem. Primary therapy with platelet transfusions may not be
application for controlling gingival hemorrhage 29
Fig. 3. A, Internally relieved O.lS-inch vacuformed mouthguard is lined with moistened INSTAT hemostat. B, Mouthguard is seated to compress hemostatic agent against gingival tissues.
sufficient to control the hemorrhage and adjunctive local therapies may be necessary. This article has presented two successful techniques of INSTAT hemostat application to control gingival hemorrhage in a patient with severe thrombocytopenia in leukemic relapse. This case demonstrates that INSTAT hemostat has the following advantages over microfibrillar collagen and topical thrombin: (1) control of hemorrhage at multiple bleeding sites, (2) ease of placement in areas difficult to access or visualize, (3) resistance to displacement by blood, saliva, and oral movements, (4) direct contact with the bleeding sites by ligature or suture, (5) application with pressure, and (6) removal without reinitiation of bleeding. REFERENCES
1. Marcus AJ. Hemorrhagic disorders: abnormalities of platelet and vascular function. In: Wyngaarden JB, Smith LH Jr, eds. Textbook of medicine. Philadelphia: WB Saunders Co, 1985:1028-40. 2. Gaydos LA, Freireich EJ, Mantel N. The quantitative relation between platelet count and hemorrhage in patients with acute leukemia. N Engl J Med 1962;266:905-9. 3. Stafford R, Sonis S, Lockhart P, Sonis A. Oral pathoses as di-
30
Green and Durham agnostic
indicators
PATHOL
1980;50:
in leukemia.
ORAL
SURG
ORAL
MED
ORAL
134-9.
4. Freireich EJ, Kliman A, Gaydos LA, Mantel N, Frei E III. Response to repeated platelet transfusion from the same donor. Ann Intern Med 1963;59:277-87. 5. Dreizen S, McCredie KB, Keating MJ. Chemotherapy-associated oral hemorrhages in adults with acute leukemia. ORAL SURG
ORAL
MED
ORAL
PATHOL
6. Alcon Inc. Avitene (microfibrillar Physician’s desk reference. Oradell, Co Inc. 1988:589.
1984;57:494-8.
collagen hemostat). In: NJ: Medical Economics
7. Department of Clinical Research, Johnson & Johnson Products, Inc. Clinical experience with lnstat collagen absorbable hemostat, a summary. New Brunswick, NJ: Johnson & Johnson Products, Inc, 1986. Reprint requests to: Timothy M. Durham, DDS UNMC College of Dentistry 40th and Holdregc Lincoln, NE 68583