Hematology disorder in dental treatment

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Hematology disorder in dental treatment

  1. 1. Hematology disorder in dental treatment 指導老師 : 高壽延主任 雷文天醫師 報告者 : 李育融 2004/07/16
  2. 2. Content <ul><li>Hemostasis </li></ul><ul><li>Etiology of bleeding disorder </li></ul><ul><li>Evaluation of bleeding disorders </li></ul><ul><li>Dental management of bleeding disorders </li></ul><ul><li>Summary </li></ul>
  3. 3. Hemostasis <ul><li>1. Vascular phase : vasoconstriction, immediately </li></ul><ul><li>2. Platelet phase : adhesion & aggregation, several seconds after </li></ul><ul><li>3. Coagulation phase : later, contains extrinsic & intrinsic pathways </li></ul><ul><li>4. Metabolic (fibrinolytic) phase: release antithrombotic agent </li></ul>primary secondary
  4. 4. Hemostasis <ul><li>The intrinsic pathway : </li></ul><ul><li>Initiated through surface contact activation of factor XII by exposed subendothelial tissues--collagen </li></ul><ul><li>The extrinsic pathway : </li></ul><ul><li>Initiated through tissue thromboplastin released by injured tissue, which activates factor VII </li></ul>Antihemophilic factor; von Willebrand factor, VWF Plasma thromboplastin component , PTC; Christmas factor
  5. 6. Antihemophilic factor; von Willebrand factor, VWF
  6. 7. Gla domain: activated by vit. K and NADH
  7. 8. Antithrombotic agent <ul><li>Postaglandin: secretion by endothelial cell </li></ul><ul><li>Antithrombin III (AT III): main Antithrombotic agent </li></ul><ul><li>Protein C: inactivate factor V and VIII with protein S </li></ul><ul><li>Plasmin: activated by urokinase and streptokinase from plasminogen </li></ul>primary secondary
  8. 9. Etiology of bleeding disorder <ul><li>1. Nonthrombocytopenia </li></ul><ul><li>2. Thrombocytopenia purpuras </li></ul><ul><li>3. Disorders of coagulation </li></ul>
  9. 10. Etiology of bleeding disorder <ul><li>Nonthrombocytopenia </li></ul><ul><li>1. vascular wall alteration : infection, chemical, allergy </li></ul><ul><li>2. Disorder of platelet function : </li></ul><ul><li>Genetic defects (bernard-soulier disease: glycoprotein, GP-Ib dysfunction with VWF ) </li></ul><ul><li>Aspirin, NSAIDs, broad-spectrum antibiotics(Ampicillin, Penicillin, Gentamycin, Vancomycin) </li></ul><ul><li>Autoimmue disease </li></ul>
  10. 11. Etiology of bleeding disorders <ul><li>Thrombotic Thrombocytopenia purpuras (TTP) : 血栓性血小板低下紫斑 </li></ul><ul><li>1. primary </li></ul><ul><li>2. secondary : Chemicals, ex: mitomycin C </li></ul><ul><li>Physical agent (radiation) </li></ul><ul><li>Systemic disease (leukemia ) </li></ul><ul><li>Character: </li></ul><ul><li>1.Thrombocytopenia 2. Micro-angiopathic hemolytic anemia(MAHA) 3. Fever 4. Hyporenal function 5. Neural systemic desturbance due to ischemic </li></ul><ul><li>Considered to be an emergency </li></ul><ul><li>Tx: plasma exchange ( 血漿置換術 ) and glucocortisone application </li></ul>
  11. 12. Etiology of bleeding disorders <ul><li>Disorders of coagulation </li></ul><ul><li>1. Inherited : Hemophilia A </li></ul><ul><li>Christmas disease </li></ul><ul><li>von Willebrandis Disease </li></ul><ul><li>2. Acquired : Liver disease </li></ul><ul><li>Vitamin K deficiency </li></ul><ul><li>Anticoagulation drugs (heparin, coumarin) </li></ul><ul><li>Anemia </li></ul>
  12. 13. Evaluation of bleeding disorders <ul><li>1. Take history </li></ul><ul><li>2. Physical examination </li></ul><ul><li>3. Screening clinical laboratory tests </li></ul><ul><li>4. Observation of excessive bleeding following a surgical </li></ul><ul><li>procedure </li></ul>
  13. 14. History <ul><li>Bleeding problems in relatives </li></ul><ul><li>Bleeding problems following operations and tooth extractions, trauma </li></ul><ul><li>Use of drugs for prevention of coagulation or pain </li></ul><ul><li>Spontaneous bleeding from nose mouth etc.. </li></ul>
  14. 15. Physical examination <ul><li>Jaundice ( 黃疸 ) </li></ul><ul><li>Petechiae ( 淤點 ) : < 0.2 cm </li></ul><ul><li>Purpura ( 紫斑 ) : 0.2 cm-1 cm </li></ul><ul><li>Eccymoses ( 淤斑 ) : > 1 cm </li></ul><ul><li>Spider angioma ( 蜘蛛斑 ) </li></ul><ul><li>Oral ulcer </li></ul><ul><li>Hyperplasia of gingiva </li></ul><ul><li>Hemarthrosis ( 關節血腫 ) </li></ul>
  15. 16. Screening laboratory tests <ul><li>1. Platelet count </li></ul><ul><li>2. BT (Bleeding Time) </li></ul><ul><li>3. PT (Prothrombin Time) </li></ul><ul><li>4. aPTT (active Partial Thrombopastin Time) </li></ul><ul><li>5. TT (Thrombin Time) </li></ul>primary secondary
  16. 17. Platelet count <ul><li>Test platelet phase: evaluation of platelet function </li></ul><ul><li>Normal (140,000 to 400,000/mm3) </li></ul><ul><li>Thrombocytopenia : < 140,000/mm3 </li></ul><ul><li>Clinical bleeding problem : <50,000/mm3 </li></ul><ul><li>Spontaneous bleeding with life theartening : <20,000/mm3 </li></ul>
  17. 18. BT (Ivy method) <ul><li>Test platelet & vascular phase </li></ul><ul><li>Normal if adequate number of platelets of good quality present intact vascular walls </li></ul><ul><li>Normal ( 1 to 6 minutes ) </li></ul>
  18. 19. PT (Prothrombin Time) <ul><li>Activated by tissue thromboplastin </li></ul><ul><li>Tests extrinsic ( factor VII ) and common ( I,II,V,X ) pathways </li></ul><ul><li>Normal ( 11-15sec ) </li></ul><ul><li>Coumarin therapy- PT at 1.5 to 2.5 time </li></ul><ul><li>International normalized ratio= INR, (1) surgery can be done under INR< 3.0 (2) when INR=3.0-3.5, consultation is needed (3) delay surgery when INR>3.5 </li></ul>
  19. 20. Activated PTT (aPTT) <ul><li>Activated by contact activator (kaolin) </li></ul><ul><li>Tests intrinsic and common pathway </li></ul><ul><li>Normal ( 25-35 sec ) </li></ul><ul><li>Heparin therapy- PTT in 50-65 sec range by promote AT III </li></ul>
  20. 21. TT (Thrombin Time) <ul><li>Activated by thrombin </li></ul><ul><li>Tests ability to form initial clot from fibrinogen </li></ul><ul><li>Normal ( 9 to 13 seconds ) </li></ul>
  21. 22. 1. No historical bleeding problem 3. Aspirin therapy 4. Coumarin therapy 6. Possible liver disease 7. Chronic leukemia 8. Long term antibiotic therapy 5. Renal dialysis (heparin) 2. History bleeding problem 9. Vascular wall alteration 10. Cancer (fibrinogenolysis) Following surgical procedure PT, aPTT, TT, BT BT, aPTT PT aPTT BT, PT BT PT BT TT Dental management of the medically compromised patient
  22. 23. condition 8. thrombocytopenia 2. Coumarin therapy 4. Liver disease 7. Vascular wall defect 9. hemophilia 1. Aspirin therapy Platelet count 5. leukemia 6. Long term antibiotic 3. Heparin therapy 10. fibrinogenolysis + - + + + - - ++ - - BT + - + + + - + ++ - - PTT + ++ ++ ++ - ++ - - ++ + PT + ++ - ++ - ++ - - - + TT - - - ++ - ++ - - - ++ -: normal, +: may be abnormal, ++: abnormal
  23. 24. Patient at low risk <ul><li>1. patient with no history of bleeding disorders, normal </li></ul><ul><li>examinations, no medications associated with bleeding </li></ul><ul><li>disorders and normal bleeding parameters </li></ul><ul><li>2. patients with nonspecific history of excessive bleeding </li></ul><ul><li>with normal bleeding parameters (PT, PTT, BT, </li></ul><ul><li>platelet count, are within normal time) </li></ul>
  24. 25. Patient at moderate risk <ul><li>1. patients in chronic oral anticoagulant therapy </li></ul><ul><li>(coumadin) </li></ul><ul><li>2. patients on chronic aspirin therapy </li></ul>
  25. 26. Patient at high risk <ul><li>1. patients with known bleeding disorders </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Thrombocytopathy </li></ul><ul><li>Clotting factor defects </li></ul><ul><li>2. Patient without known bleeding disorders found to </li></ul><ul><li>have abnormal , platelet count, BT, PT, PTT </li></ul>
  26. 27. Dental management of bleeding disorders <ul><li>Replacement therapy : </li></ul><ul><li>1. platelet concentrate : thrombocytopenia ( 1 unit= 30,000/ uL enough for 1 day ) </li></ul><ul><li>2. Fresh frozen plasma : liver disease, Hemophilia B, vWD type III </li></ul><ul><li>3. Factor VIII,IX concentrate : Hemophilia A ( 1 unit /kg can add 2%, so 50 unit /kg add 100% ) </li></ul><ul><li>4. Factor IX concentrate : Hemophilia B </li></ul><ul><li>5. 1-desamino-8-darginine vesopressin (DDAVP) : Hemophilia A, vWD type I, II </li></ul><ul><li>Antifibrinolytic therapy: </li></ul><ul><li>1. E-aminocaproic acid (EACA, Plaslloid) </li></ul><ul><li>2. Tranexamic acid (AMCA, Transamin) </li></ul>
  27. 28. Local hemostatic methods <ul><li>splints, pressure packs, sutures; gelfoam with thrombin, surgicel, oxycel, microfibrillar collagen(avitene), topical AHF </li></ul>
  28. 29. Heparin (anticoagulant) <ul><li>Complex inhibited ( IXa, Xa, XIa, XIIa ) </li></ul><ul><li>Used in deep vein thrombosis , renal dialysis </li></ul><ul><li>Rapid onset, Duration 4-6hrs ( given IV ) </li></ul><ul><li>Monitoring by aPTT: 50-65 sec </li></ul><ul><li>Discontinue 6 hrs before surgery then reinstituting therapy 6-12hrs post –op </li></ul><ul><li>Protamine sulfate can reverse the effect </li></ul>
  29. 30. Coumarin (Vit k anatagonist) <ul><li>Inhibit Vit K action (Factor II,VII,IX,X) </li></ul><ul><li>Used venous thrombosis, cerebrovascular disease </li></ul><ul><li>Duration haft-life 40hrs </li></ul><ul><li>Monitored by PT : INR 1.5-2.5 </li></ul><ul><li>PT>2.5, reduction coumarin dosage ( 2-3 days ) </li></ul><ul><li>Vit. K can reverse the effect </li></ul>
  30. 31. Aspirin (antiplatelet) <ul><li>Inhibit cycloxygenase, TxA2 formation </li></ul><ul><li>Analgesic drug impairs platelet function </li></ul><ul><li>Aterial thrombosis, MI </li></ul><ul><li>Tests-BT, aPTT </li></ul><ul><li>If tests are abnormal , MD should be consulted before dental surgery is done </li></ul><ul><li>Stop aspirin for 5 days , substitute alternative drug in consultation with MD </li></ul>
  31. 32. Thrombocytopenia <ul><li>Disease in number of circulation platelets </li></ul><ul><li>Idiopathic thrombocytopenia, secondary thrombocytopenia </li></ul><ul><li>TX : is none indicated unless </li></ul><ul><li>platelets<20000/mm3, or excessive bleeding </li></ul><ul><li>TX : Steroid, platelet transfusion </li></ul>
  32. 33. Von Willebrandis Disease <ul><li>Gene mutation on Von Willebrandis factor; most common Inherited disease in America ( 1% ) </li></ul><ul><li>Type I : 70%-80%, partial loss on quantity </li></ul><ul><li>Type II : poor on quality </li></ul><ul><li>Type III : severe loss on quantity, inactive to DDAVP </li></ul>
  33. 34. Hemophilia <ul><li>Sex-linked recessive trait, X chromosome, male > female </li></ul><ul><li>Prolong aPTT, normal BT,PT </li></ul><ul><li>Hemophilia A (factor VIII deficiency) </li></ul><ul><li>Hemophilia B or Christmas disease (factor IX deficiency) </li></ul><ul><li>Severity of disorder : severe<1%, moderate 1-5%, </li></ul><ul><li>mild 6-30% </li></ul><ul><li>TX : Replacement factors, antifibrinilytic agents, steroids </li></ul>
  34. 35. Hemophilia-dental management <ul><li>Preventive dentistry </li></ul><ul><li>1. tooth brushing, flossing, rubber cup prophylaxis & </li></ul><ul><li>topical fluoride, supragingival scaling </li></ul><ul><li>2. without prior replacement therapy </li></ul><ul><li>Pain control </li></ul><ul><li>1. block anesthesia: factor level>50% </li></ul><ul><li>2. Avoid aspirin, NSAIDs </li></ul>
  35. 36. Hemophilia-dental management <ul><li>Orthodontic treatment : </li></ul><ul><li>1. no contraindication in well-motivated patients </li></ul><ul><li>2. care with placement of bands and wires </li></ul><ul><li>Operative dentistry </li></ul><ul><li>1. rubber dam to protect tissue against accidental </li></ul><ul><li>laceration </li></ul><ul><li>2. wedges should be place to protect and retract </li></ul><ul><li>papilla </li></ul>
  36. 37. Hemophilia-dental management <ul><li>Pulp therapy </li></ul><ul><li>1. Preferable to extraction </li></ul><ul><li>2. Avoid overinstrumentation and overfilling </li></ul><ul><li>Periodontal therapy </li></ul><ul><li>1. no contraindication of probing and supragingival </li></ul><ul><li>scaling </li></ul><ul><li>2. deep scaling, curettage, surgery need replacement </li></ul><ul><li>therapy </li></ul>
  37. 38. Hemophilia-dental management <ul><li>Oral surgery : </li></ul><ul><li>1. Dental extraction: 40%-50% level </li></ul><ul><li>2. Maxillofacial surgery (including surgery </li></ul><ul><li>extraction of impaction teeth): 80-100% </li></ul><ul><li>3. Antifribrinilytic therapy & local hemastatic </li></ul><ul><li>measure </li></ul><ul><li>4. do not open lingual tissue in lower molar regions to </li></ul><ul><li>avoid hemorrhage track down a endanger airway </li></ul>
  38. 39. Summary <ul><li>History, PE, Lab data </li></ul><ul><li>Consultation with physician </li></ul><ul><li>Antibiotics to prevent post-op infection </li></ul><ul><li>Avoid aspirin and NSAIDs </li></ul><ul><li>Local hemostatic measure is very important </li></ul>
  39. 40. The End <ul><li>Thank you! </li></ul>

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