BLEEDING AND

CLOTTING DISORDERS

RESOURCE FACULTY

DR.JYOTSNA RIMAL

Additional professor & HOD

DR.ICHHA KUMAR MAHARJAN

Associate professor

ORAL CONSIDERATION &LABORATORY INVESTIGATIONS OF

PRESENTER:KASHMIRA POKHREL483BDS-2011

Department of oral medicine and radiology

CONTENTS

• PATHOPHYSIOLOGY• BLEEDING DISORDERS• COAGULATION DISORDERS• LABORATORY INVESTGATIONS• ORAL MANIFESTATIONS• DENTAL CONSIDERATION• DENTAL MANAGEMENT• CONCLUSION

PATHOPHYSIOLOGY

• Hemostasis can be divided into 4 phases:

• Vascular phase

• Platelet phase

• Coagulation cascade phase

• Fibrinolytic phase

Principal mechanisms that prevent or diminish the loss of blood following vascular injury

VASCULAR PHASE

Tissue injury

Vasoconstriction of the microvascular bed

Serotonin, histamine,PG’s

PLATELET PHASECirculating platelets exposed to

vascular injury

Normal vWF, endothelial cells, collagen, basement membrane, elastin, microfibrils and other cellular debris

Physical and chemical changes

Aggregation of platelet

Primary platelet plug (adheres to basement membrane)

ADP

Increase in size of plug

PF-3

Activates F-X Conversion of prothrombin to thrombin

Platelet intermixed with other cellular components(RBC,WBC) which further contracts to reduce bleeding and seal vascular bed

COAGULATION CASCADE

FIBRINOLYTIC PHASE

• VESSEL WALL DISORDERS

• PLATELET DISORDERS

• COAGULATION DISORDERS

CLASSIFICATION

• Scurvy

• Cushing’s syndrome

• Ehlers-Danlos syndrome

• Rendu-Osler-weber syndrome

VESSEL WALL DISORDERS

• Thrombocytopenic(quantative platelet deficiency)

1.May-hegglin anomaly

2.Wiskott-aldrich syndrome

3.Neonatal alloimmune thrombocytopenia

• Nonthrombocytopenic(qualitative)

1.Glanzmann’s thromasthenia

2.Platelet type vWD

3.Bernard-soulier syndrome

CONGENITAL

PLATELET DISORDERS

ACQUIRED • Thrombocytopenic(quantitative)

1. Autoimmune or idiopathic thrombocytopenia purpura

2. Thrombotic thrombocytopenia purpura

3. Cytotoxic chemotherapy

4. Drug-induced (eg, quinine, quinidine, gold salts, trimethoprim/ sulfamethoxazole, rifampin)

5. .Leukemia

6.Aplastic anemia

7.Myelodysplasia

8.Systemic lupus erythematosus

9.Associated with infection: HIV, mononucleosis, malaria

10.Disseminated intravascular coagulation

• Nonthrombocytopenic

(qualitative)

1. Drug induced(aspirin,NSAIDS,penicillin,cephalosporin)

2. Uremia

3. Alcohol dependency

4. Liver disease

5. Myeloma

6. Acquired platelet type vWD

• CONGENITAL COAGULOPATHIES1. Hemophilia A&B

2. Factors deficiency

3. von Willebrand’s disease

• ANTICOAGULANT -RELATED COAGULOPATHIES1. Heparin

2. Coumarin

• DISEASE-RELATED COAGULOPATHIES1. Liver disease

2. Vitamin K deficiency

3. Disseminated intravascular coagulation

4. Fibrinolytic disorders

COAGULATION DISORDERS

• History taking

• Physical examination

• Laboratory Investigations

• Observation

IDENTIFICATION OF PATIENT WITH BLEEDING DISORDER

HISTORY TAKINGH/O frequent• epistaxis,

• spontaneous gingival and mucosal bleeding,

• prolonged bleeding from superficial cuts

• Excessive menstrual flow

• Easy bruising

• hematuria

CONTD….• Family history

• Past H/O bleeding after surgical procedures

• Identification of medicine(heparin, aspirin, NSAIDS,coumarin, cytotoxic chemotherapy)

• Active medical conditions (hepatitis,cirrhosis,renal disease, hematological malignancy, thrombocytopenia)

• H/O heavy alcohol intake

Physical examination

• Jaundice

• Petechiae

• Ecchymosis

• Hemarthrosis

Laboratory investigations

• Normal 150,000-450,000/mm3• Spontaneous clinical hemorrhage - <10,000

to 20,000 mm3• Surgical/traumatic hemorrhage-<50,000mm3

• Normal- 1 to 6 minutes• Prolonged - >15 minutes• Test platelet and vascular phase

1. Platelet count

2. Bleeding time

Prothrombin time and INR

• Normal PT-11 to 13 seconds• Evaluates extrinsic coagulation and F-

I,II,V,VII and X• Now reported with it’s INR

INR(international normalised ratio)

• It’s the ratio of PT that adjusts for the sensitivity of the thromboplastin reagants,

• such that normal coagulation profile is reported as an INR of 1.0

aPTT(activated partial thromboplastin time)

• Activator – rare earth • Measures effectiveness of the intrinsic

pathway• Considered normal if the control aPTT

& test aPTT are within 10 secs of each other.

• Control aPTT = 15-35secs.• It is altered in hemophilias A & B. and

with the use of heparin.

• Tests ability to form initial clot from fibrinogen

• Normal - 9 to 13 seconds

• Evaluates the presence of D-dimer of fibrinogens

TT(Thrombin Time)

Fibrin Degradation products

• Normal-60 to 150%

• Torniquet test to assess Rumpel-leede phenomenon

Factor assays

Tests of capillary Fragility

Bleeding Disorder Platelet Count

PT/ INR aPTT BT

Thrombocytopenia Leukemia

F VIII, IX, XI deficiencyHeparin anticoagulation

F II, V, X deficiencyVitamin K deficiencyIntestinal malabsorption

F VII deficiencyCoumarin anticoagulationLiver disease

von Willebrand’s disease

DICSevere liver disease

F XIII deficiency

Vascular wall defect

↓

N

N

N

N, ↓

↓

N

N

N

N

↑

↑

N

↑

N

N

N

↑

↑

N

N, ↑

↑

N

N

↑

N

N

N

↑

↑

N

↑

Principal Agents for Systemic ManagementAgent Description Indications

Platelets 1 unit = 50 mL; may raise count by 6,000 Platelet count

• < 10,000 in non bleeding individuals• < 50,000 presurgical level• < 50,000 in actively bleeding individuals

Fresh frozen plasma

1 unit = 150–250 mLContains factors II, VII, IX, X, XI, XII, XIII and heat-labile V and VII

• Undiagnosed bleeding disorder with active bleeding• Severe liver disease

Cryo-precipitate

1 unit = 10–15 mL • Hemophilia A• von Willebrand’s disease,• when factor concentrates and DDAVP are unavailable• Fibrinogen deficiency

Factor VIII concentrate

1 unit raises factor VIII level 2%

• Hemophilia A with active bleeding• Presurgery

Factor IX concentrate

1 unit raises factor IX level 1–1.5%

Hemophilia B, with active bleeding or presurgery

Desmopressin Synthetic analogue of antidiuretic hormone0.3μg/kg IV or SC

Active bleeding or presurgery for some patients with von Willebrand’s disease,uremic bleeding of liver disease,bleeding esophageal varices

Epsilon-aminocaproic acid

Antifibrinolytic: 25% oral solution (250 mg/mL)Systemic: 75 mg/kg every 6 hours

Adjunct to support clot formation for anybleeding disorder

Tranexamic acid

Antifibrinolytic: 4.8% mouth rinse Systemic: 25mg/kg every 8 hrs

Adjunct to support clot formation for anybleeding disorder

Local hemostatic agents• ABSORBANT GELATIN SPONGE

(GELFOAM)

Dental size - 20x20x7mm3

• OXIDISED CELLULOSE

(SURGICEL)

• TOPICAL THROMBIN• Obtained from bovine plasma• Applied as dry powder or freshly prepared

solution

• TRANXENAMIC ACID• 500mg tablets• 1000mg/10ml injection

• Epsilon Amino caproic Acid• 50mg/kg• Oral rinse 250mg/ml

• Fibrin sealants/Fibrin glue• Cryoprecipitate• 10,000units thrombin powder• 10ml saline• 10ml Calcium Chloride

• Application of local pressure

• suture

Clinical features of bleeding disorders

Feature Vascular or platelet disorders

Coagulation disorders

Bleeding from superficial cuts and scratches

Persistent,often profuse Minimal

Delayed bleeding Rare Common

Spontaneous gingival bleeding

Characteristic Rare

Petechiae Characteristic Rare

Ecchymoses Small and multiple Large and solitary

Epistaxis Common Common

Deep disecting hematomas

Rare Characteristic

Hemarthroses Rare Characteristic

Oral manifestations • Petechiae

• Ecchymoses

• Spontaneous gingival bleeding

Contd….

• Brown colored teeth due to depositsof hemosiderin as a result of continous long term bleeding.

• Hemarthrosis (rarely)

DENTAL MANAGEMENT

• Dental modifications required for the patient depends on

1. type and invasiveness of the dental procedure and

2. Type and severity of bleeding disorder

• For reversible coagulopathies:

Remove the causative agent (eg:coumarin anticoagulants)

Treat the primary illness or defect to allow pt. to return to manageable bleeding risk for the dental treatment period

For irreversible coagulopathies:

Defective element may need to be replaced from exogenous source

Consultation with hematologist

This may involve treatment either in specialized hospital facilities or local general dentist’s office

PLATELET DISORDERS• Platelet level >50,000mm3 required prior to

surgical procedures.

• Avoidance of aspirin therapy recommended 1 week prior to extensive oral surgical procedures

• Aspirin is rarely witheld in case of minor oral surgical procedures such as extraction where local hemostatic agents can be use

• When extensive surgery in emergency is indicated DDAVP can be used

• DDAVP decreases the aspirin induced prolongation of BT and prevents post operative oozing

Considerations in

HEMOPHILIA A and B and vWD

ORAL SURGICAL PROCEDURES

• Surgical treatment, including a simple dental extraction, must be planned to minimize the risk of bleeding, excessive bruising, or hematoma formation.

• Emergency surgical intervention in dentistry is rarely required as pain can often be controlled without resorting to an unplanned treatment.

• All treatment plans must be discussed with the hemophilia unit if they involve the use of prophylactic cover.

PREVENTIVE AND PERIODONTAL THERAPY

• Periodontal probing and supragingival scaling can be done routinely

• Severly inflamed and swollen tissues are best treated initially with chlorhexidine oral rinses and gross debridement with hand instruments to allow gingival shrinkage

• Deep subgingival scaling and root planing should be performed quadrant wise

• Locally applied pressure and post-treatment anti-fibrinolytics oral rinses are successful in controlling protracted oozing.

• Periodontal surgical procedures requires prior elevation of circulating factor levels by 50% and use of post treatment antifibrinolytics.

RESTORATIVE AND PROSTHODONTIC THERAPY

• Rubber dam isolation advised to minimize the risk of lacerating soft

tissue and avoid creating ecchymoses and hematomas

with high speed evacuators or saliva ejectors

• Removable prosthodontic appliances can be fabricated without complications

Denture trauma should be minimized

ENDODONTIC THERAPY• Instrumentation should not extend beyond

apex

• Filling beyond the apical seal also should be avoided

• Application of epinephrine intrapulpally to apical area provides hemostasis

PEDIATRIC DENTAL THERAPY• Administration of factor concentrate before

extraction

• Pulpotomies to be performed without excessive pulpal bleeding

• Topical fluoride application

• Pit and fissure sealant

ORTHODONTIC THERAPY• Care must be taken to avoid mucosal

laceration by orthodontic bands, brackets and wires.

• Fixed orthodontic appliance prefered over removable functional appliance

• Use of extraoral force and

• shorter treatment duration

PAIN CONTROL• Selection of pain control method based on

patient’s pain threshold and invasiveness of the procedure

• Hypnosis, IV diazepam, nitrous oxide/oxygen analgesia can be used

• Anesthetic with vasoconstrictor should be used when possible

• Hemostatic cover(20-30%) required for: inferior alveolar ,posterior superior

alveolar,infraorbital, lingual and long buccal nerve block

As these injections place anesthetic solutions in highly vascularised loose connective tissue with no distinct boundaries where formation of dissecting hematoma is possible

• Hemostatic cover not required for:Intrapulpal, periodontal ligament, gingival

papillary anesthesia

In mild disease-buccal, labial and palatal infiltration for maxillary teeth can be attempted slow injection and local pressure for 3-4 minutes

PATIENTS ON ANTICOAGULANTS

• Higher INR result in high bleeding risk

• Non surgical dental treatment can be successfully accomplished without alteration of anti coagulant regimen

• For surgical procedures, physician consult is advised

• Thromboembolic complication is small and hemorrhagic risk is high coumarin therapy can be discontinued 2 days prior to surgery with prompt reinstitution post operatively.

• Moderate thromboembolic and hemorrhagic risks-coumarin therapy can be maintained within therapeutic range and local measures used to control postoperative oozing

• High thromboembolic and hemorrhagic risk-requires hospitalization

Managed with combination unfractioned heparin-coumarin method

Coumarin is withheld 24 hrs prior to surgeryHeparin therapy instituted on admission is

stopped 6-8 hours preoperativelyCoumarin reinstituted on the night of the

procedure heparin reinstituted 6-8 hrs after surgery

when adequate clot has formed

• Use of aditional hemostatic agents recommended

CONCLUSION• Pre-operative assessment:

– Proper history• Medical history• Family history• Drug intake history

• General physical examination

• Oral examination

• Lab investigations– Full blood count,platelet count– PT and INR– APTT– TT– Serum for blood grouping and cross-matching

• Assess if hemostatic cover is required

• Consult with patient’s physician for drugs like aspirin, warfarin to be discontinued before procedure

• Warn the patient about intra and post operative bleeding

• Consider using antifibrinolytic agents a day before the surgery

• Peri-operative procedure:– The factor that is deficient must be

arranged

– Local hemostatic agents should be used

– Bleeding must be controlled

• post-operative care:

– Prevention of infection

– Management of post-operative bleeding• Tranxenamic acid can be used

– Reinstitution of the oral anticoagulants

MCQ

Which of the following phase does not prevent bleeding?

a) Vascular phase

b) Platelet phase

c) Coagulation phase

d) Fibrinolytic phase

Hemostatic cover is required in patients with bleeding disorder in following

anesthetic techniques:

a)Inferior alveolar nerve block

b)Buccal infiltration

c)Lingual nerve block

d)a and c both

e)All of the above

When extensive surgery is indicated aspirin should be

avoided prior toa) 2 days

b) 24 hours

c) 7 days

d) Not required

Patients on anti-coagulant therapy with high thromboembolic and

hemorrhagic risk is managed bya) coumarin therapy can be discontinued 2

days prior to surgery

b) combination unfractioned heparin-coumarin method

c) Aspirin therapy

d) None

References

• Burket’s Oral Medicine - 1Oth&11th Edition

• Textbook of oral medicine -2nd Edition ByAnil Ghom

• Davidson’s principles and practice of medicine- 20th Edition

• Medical problems in dentistry-6th Edition-crispian scully