Assessment of the Dental Students and Dental Practitioners Awareness about Bleeding Disorders across Saudi Arabia

Introduction: Bleeding disorders are a group of disorders which results from defective platlets functions or coagulation or both and it can be classified into platlets disorders, blood vessel disorders and coagulation factors disorders. Bleeding disorder patients undergoing dental procedures may need special management before dental procedure. Aim: To assess the awareness level of the dental students and practitioners in Saudi Arabia about the bleeding disorders. Materials and Methods: This cross-sectional study was conducted among 502 dental students and dentists in Saudi Arabia. This was a questionnaire based internet survey consisted of 331 clinical year dental students and 171 dentists. The questionnaire contained 15 questions. Results: The highest percentage of participants were from the Eastern Province (31.1%). Almost half of the participants were males (51.2%). The dentists represented (34.1%). Around (47.8%) of participants reported that they had encountered bleeding disorder patients before. Almost (50.8%) Original Research Article Alnaim et al.; JPRI, 33(60B): 2739-2744, 2021; Article no.JPRI.79739 2740 participants who encountered those patients said that they referred them to a physician for a consent. Six questions were used to assess the knowledge of the participants about the bleeding disorders based on the number of the correct answers. Only (1%) were able to answer all the questions correctly. Most of the participants (93.8%) said that they need to learn more about bleeding disorders. Conclusion: Majority of the dental students and general practitioners had poor knowledge of the management of bleeding disorder patients.We strongly recommend intensifying dental educational programs and more training is required in management of patients with medical complications.


INTRODUCTION
Bleeding disorders are a group of disorders that share the inability to form a proper blood clot [1]. Platelets play an important role in forming the blood clot if any injury occurs. Platelets accumulate at the site of injury to maintain the process of hemostasis [2]. Bleeding disorders can be classified into Platlets disorders such as thrombocytopenic purpura and vWD and coagulation factors disorders for example hemophilia. Also it can be classified into congenital such as Hemophilia, Von Willebrand disease (vWD) and acquired disorders such as Leukemia, thrombocytopenia due to infections or malnutrition, DIC and drugs [3]. Most bleeding disorders are caused by a defect in one or more factors of coagulation, including fibrinogen, prothrombin, Factors V, VIII, VII, X, XI, and factor XIII [2]. Some of these bleeding disorders have interactions with certain medications. Therefore, management should be done in a way which would decrease the bleeding [2]. Dental practioners level of awareness will affect the outcome of patients with bleeding disorders; as the dentists are the most important factor in treatment and management of patients [4]. The awareness of bleeding disorders plays an important role in minimizing potential complications which might arise while performing invasive dental procedures [5]. Dentist's knowledge about the management of different bleeding disorders and its types is necessary because for each disease the management approach could differ [2].
Bleeding disorder patients might require diagnostic tests prior to dental procedures in order to know if any changes are needed in the procedure [4]. Changes could be such as prescribing medications or giving the patient an anticoagulant prior to treatment or to do minimal invasive treatments only [4]. Many surgical procedures, such as tooth extraction, flap surgery and many periodontal procedures could cause bleeding [2]. Episodes of most dental bleedings are minor and do not require special precautions or treatment [4]. Local hemostatic measures provide effective results in most of the cases but are insufficient in patients with severe hemophilia A and vWD [6]. Accordingly, the consultation of the hematologist before treating bleeding disorder patients is essential.
Hemophilia A is a deficiency of factor VIII or antihemophilic factor [1]. Von Willebrand's disease is the most common hereditary coagulation disorder and is marked by deficiency in vWF [6]. Management for Hemophilia A and vWD in dental clinic consists of increasing factor VIII levels by giving the patient the factor as an infusion [6]. A successful case history should be taken including previous medical, family and dental history, past drug medications of the patients, is the best way to prevent complications [2]. During history-taking, any clinically relevant bleeding episodes need to be noted; for example 1) Prolonged bleeding after 12 hours; 2) bleeding in which patients requested or returned to or seek medical attention at the dental clinic; 3) bleeding which causes an ecchymosis or hematoma within soft tissue; 4) requires support for blood transfusions; and 5) history of nasal or oral hemorrhages [4]. Taking proper family history for bleeding disorders is necessary also as many bleeding disorders run in families [3].
International normalized ratio (INR) is the recommended test for patients taking vitamin K antagonists (VKA) [7]. It could also be used to assess the risk of bleeding or the coagulation status of the patients [7]. For normal patients who are not on anticoagulation, the INR is usually 1.0 [7]; Whereas patients who are on anticoagulant therapy such as Warfarin and Aspirin, the therapeutic INR ranges between 2.0 to 3.0 and it is the standard therapeutic target range (STTR) [8]. INR levels above 4.9 are considered critical values and increase the risk of bleeding [7].
Analgesics might be required for dental pain or abscess management, or for post-procedure pain relief [9]. In patients with bleeding disorders, aspirin and drugs containing aspirin should be avoided as the hemorrhagic risk might increase as a result of the inhibition of platelet function [9]. The use of non-steroidal anti-inflammatory medications could be helpful in managing dental pain, but their prescription should be discussed with the physician, because if administered preoperatively they could increase the risk of bleeding [9]. Safe substitutes are paracetamol and codeine-based preparations [9]. Hence, this study was conducted to assess the awareness level of the dental students and practitioners in Saudi Arabia about the bleeding disorders.

MATERIALS AND METHODS
A cross-sectional study was carried-out using a questionnaire and based on an internet survey. A total of 502 dental students and dentists were included. Around 331 clinical year dental students and 171 dentists participated in the study. The questionnaire contained 15 questions. To examine the reliability of the questionnaire, a sample of 20 dental students and general dentists completed the questionnaire twice with a 1 week interval. There answers were excluded later from the sample size.
Descriptive statistics for the variables was presented in the form of frequencies and percentages. The knowledge of participants about bleeding disorders was assessed based on the number of correct answers to 6 questions. Comparison of the knowledge level between different categories was done using Chi square test. IBM SPSS version 26 for windows software was used for the analysis. A p-value of < 0.05 was considered significant.

RESULTS AND DISCUSSION
A total of 502 dental students and dentists participated in this study. The highest percentage of participants were from the Eastern Province (31.1%), followed by the Riyadh region (26.5%). Almost half of the participants were males (51.2%). The dentists represented 34.1%, while the clinical year dental students were 65.9% (Table 1).
Around 47.8% participants replied that they had encountered bleeding disorder patients before. Almost 50.8% participants who encountered those patients said that they referred them to a physician for a consent, while 21.3% performed the procedure without physician consent, 19.6% sent the patient for laboratory investigations and 8.3% refused to treat the case.
Almost half of the participants (52.6%) said that they knew the normal value for bleeding time test. The opinions of the participants regarding the best measure to stop bleeding varied. Around 36.9% chose "apply pressure", 35.9% chose "local agent", and 27.3% chose "Systemic homeostatic agent".
When participants were asked about how they grade themselves regarding knowledge of bleeding disorders, 46.4% considered their knowledge poor, 44.4% considered it average, and 9.2% considered it good. Most of the participants (93.8%) said that they need to learn more about bleeding disorders (Table 2).
Six questions were used to assess the knowledge of the participants about the bleeding disorders based on the number of the correct answers. Only 1% were able to answer all the questions correctly, 5.2% answered 5 questions correctly and 11.4% answered four questions correctly. Almost 65% participants answered 2 questions or less correctly. The percentage of correct answers for each question ranged from 21.1% to 49.4% (Table 3).  The results of this study showed that 50.8% refer the bleeding disorder patient to a physician for consent before treating them. The finding of this study is in agreement with another study which was conducted in Buraidah and Riyadh city where 82.5% would refer the patient to a physician for a consent [5]. It is also in agreement with another study which was conducted in Kerala where 80% refer the bleeding disorders patients to a physician [10]. Bleeding time is a clinical laboratory test performed to evaluate platelet function [11]. In this study only 52.6% were aware about the normal value of bleeding time. In a research conducted in Shiraz only 34.2% general dentists were aware of normal values of INR test [12].
Whereas, in the current research only 21.1% knew the normal values of INR test. Standard therapeutic range (STTR) of international normalized ratio (INR) of 2.0 to 3.0 is important for the safety and effectiveness of warfarin anticoagulation [13]. Unfortunately, in this study only 24.9% knew the STTR for patients taking warfarin and aspirin. It is recommended that aspirin should be stopped for a minimum of 3 days prior to any invasive dental procedure to avoid excessive postoperative bleeding [14]. Around 35.3% participants only knew the minimal duration to stop aspirin, warfarin prior to invasive dental procedures.

CONCLUSION
Majority of the dental students and general practitioners had poor knowledge of the management of bleeding disorders patients. Therefore, additional courses and training is required to improve their skills and knowledge about the management of bleeding disorders patients.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors CONSENT All authors declare that 'written informed consent was obtained from the participants.