104 coagulation studies in 30% of the study participants (7 out of 23) and Langness and Behnke et al. in 11% of the study participants (9 out of 80) 24,25. A recent study of Rothschild et al. reported significant intraoperative blood loss in 17% of 205 surgeries among 83 OI patients without link to coagulation disorders 26. Also Morton et al. (n = 1), Wood et al (n = 2), Waters et al. (n = 1) and Mondal (n = 1) describe bleeding diathesis without explanatory coagulation disorders 27–30. Several studies try to discover a link between bleeding diathesis and laboratory abnormalities, but all were inconclusive 5,11,31–34. The use of a structured bleeding questionnaire as is used in this study seems to be far more useful than laboratory measurements because correlation between levels of a specific factor and the severity of bleeding symptoms is usually poor. This may be because standard tests poorly reflect in vivo haemostasis. The contribution of many factors (e.g. vessel fragility or fibrinolysis) cannot be measured. Also a genomic search for the molecular basis of inherited clotting and platelet defects will not be as useful as a good questionnaire because often variability in penetrance and expressivity 35, coinheritance of haemostatic defects or superimposed genetic modifiers make the relationship between genotype and phenotype less stringent than previously appreciated 12,14. For a mild bleeding disorder as OI a clinically driven “bleeding” diagnosis based on anamnestic risk factors can be of more benefit than preoperative laboratory investigation as is shown by Obaji et al. They applied desmopressin and/or tranexamic acid to a group of patients with a significant bleeding history with no reproducible abnormality with the standard tests of haemostasis, and found no bleeding in 90% of patients undergoing an intervention 36. Post extraction bleeding (PEB) 21% Of the patients in this study experienced unusual bleeding due to dental extraction. PEB (Post extraction bleeding) has divergent definitions but is a well-recognized, frequently encountered complication in dental practice with an varying incidence between 0-26% 37. Post extraction bleeding has been attributed to various factors that can be broadly classified as local and systemic. Locally soft tissue or bone bleeding can occur due to traumatic extraction leading to laceration of blood vessels. Also inflammation at the site of extraction, traumatic extraction, and failure of the patient to follow post‐extraction instructions have also been associated with PEB. Systemic factors include platelet problems, coagulation disorders or excessive fibrinolysis, and inherited or acquired problems (medication induced) 38. In the current study we did not differentiate the underlying factors that can cause bleeding and a literature review did not reveal any previous reports for bleeding risk after tooth extraction in relation to patients with OI. However, further differentiation in cause of post extraction bleeding would be very useful since patients with OI have also often dentinogenesis imperfecta 39 and are at risk of bisphosphonate related osteonecrosis of the jaw 40.
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