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Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
Bleeding disorders
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Bleeding disorders

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  • 1. BLEEDING DISORDERS www.freelivedoctor.com
  • 2. HEMOSTASIS 1. VASCULAR PHASE 2. PLATELET PHASE 3. COAGULATION PHASE 4. FIBRINOLYTIC PHASE www.freelivedoctor.com
  • 3. VASCULAR PHASE WHEN A BLOOD VESSEL IS DAMAGED, VASOCONSTRICTION RESULTS. www.freelivedoctor.com
  • 4. PLATELET PHASE PLATELETS ADHERE TO THE DAMAGED SURFACE AND FORM A TEMPORARY PLUG. www.freelivedoctor.com
  • 5. COAGULATION PHASE THROUGH TWO SEPARATE PATHWAYS THE CONVERSION OF FIBRINOGEN TO FIBRIN IS COMPLETE. www.freelivedoctor.com
  • 6. FIBRINOLYTIC PHASE ANTICLOTTING MECHANISMS ARE ACTIVATED TO ALLOW CLOT DISINTEGRATION AND REPAIR OF THE DAMAGED VESSEL. www.freelivedoctor.com
  • 7. HEMOSTASIS <ul><li>DEPENDENT UPON : </li></ul><ul><li>Vessel Wall Integrity </li></ul><ul><li>Adequate Numbers of Platelets </li></ul><ul><li>Proper Functioning Platelets </li></ul><ul><li>Adequate Levels of Clotting Factors </li></ul><ul><li>Proper Function of Fibrinolytic Pathway </li></ul>www.freelivedoctor.com
  • 8. THE CLOTTING MECHANISM INTRINSIC EXTRINSIC PROTHROMBIN THROMBIN FIBRINOGEN FIBRIN (II) (III) (I) V X Tissue Thromboplastin Collagen VII XII XI IX VIII www.freelivedoctor.com
  • 9. LABORATORY EVALUATION <ul><li>PLATELET COUNT </li></ul><ul><li>BLEEDING TIME (BT) </li></ul><ul><li>PROTHROMBIN TIME (PT) </li></ul><ul><li>PARTIAL THROMBOPLASTIN TIME (PTT) </li></ul><ul><li>THROMBIN TIME (TT) </li></ul>www.freelivedoctor.com
  • 10. PLATELET COUNT <ul><li>NORMAL 100,000 - 400,000 CELLS/MM 3 </li></ul><ul><li>< 100,000 Thrombocytopenia </li></ul><ul><li>50,000 - 100,000 Mild Thrombocytopenia </li></ul><ul><li>< 50,000 Sev Thrombocytopenia </li></ul>www.freelivedoctor.com
  • 11. BLEEDING TIME <ul><li>PROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTION </li></ul><ul><li>NORMAL VALUE </li></ul><ul><li>2-8 MINUTES </li></ul>www.freelivedoctor.com
  • 12. PROTHROMBIN TIME <ul><li>Measures Effectiveness of the Extrinsic Pathway </li></ul><ul><li>Mnemonic - PET </li></ul><ul><li>NORMAL VALUE </li></ul><ul><li>10-15 SECS </li></ul>www.freelivedoctor.com
  • 13. PARTIAL THROMBOPLASTIN TIME <ul><li>Measures Effectiveness of the Intrinsic </li></ul><ul><li>Pathway </li></ul><ul><li>Mnemonic - PITT </li></ul>NORMAL VALUE 25-40 SECS www.freelivedoctor.com
  • 14. THROMBIN TIME <ul><li>Time for Thrombin To Convert </li></ul><ul><li>Fibrinogen Fibrin </li></ul><ul><li>A Measure of Fibrinolytic Pathway </li></ul>NORMAL VALUE 9-13 SECS www.freelivedoctor.com
  • 15. So What Causes Bleeding Disorders? <ul><li>VESSEL DEFECTS </li></ul><ul><li>PLATELET DISORDERS </li></ul><ul><li>FACTOR DEFICIENCIES </li></ul><ul><li>OTHER DISORDERS </li></ul>www.freelivedoctor.com
  • 16. VESSEL DEFECTS <ul><li>VITAMIN C DEFICIENCY </li></ul><ul><li>BACTERIAL & VIRAL INFECTIONS </li></ul><ul><li>ACQUIRED </li></ul>www.freelivedoctor.com
  • 17. So What Causes Bleeding Disorders? <ul><li>VESSEL DEFECTS </li></ul><ul><li>PLATELET DISORDERS </li></ul><ul><li>FACTOR DEFICIENCIES </li></ul><ul><li>OTHER DISORDERS </li></ul>www.freelivedoctor.com
  • 18. PLATELET DISORDERS <ul><li>THROMBOCYTOPENIA </li></ul><ul><li>THROMBOCYTOPATHY </li></ul>www.freelivedoctor.com
  • 19. THROMBOCYTOPENIA INADEQUATE NUMBER OF PLATELETS www.freelivedoctor.com
  • 20. THROMBOCYTOPATHY ADEQUATE NUMBER BUT ABNORMAL FUNCTION www.freelivedoctor.com
  • 21. THROMBOCYTOPENIA <ul><li>DRUG INDUCED </li></ul><ul><li>BONE MARROW FAILURE </li></ul><ul><li>HYPERSPLENISM </li></ul><ul><li>OTHER CAUSES </li></ul>www.freelivedoctor.com
  • 22. THROMBOCYTOPENIA <ul><li>DRUG INDUCED </li></ul>.Alcohol .Thiazide Diuretics www.freelivedoctor.com
  • 23. THROMBOCYTOPENIA <ul><li>BONE MARROW FAILURE </li></ul><ul><li>Viral Infections </li></ul><ul><li>Nutritional Deficiencies </li></ul><ul><li>Chemotherapy & Radiation Therapy </li></ul><ul><li>Infiltration of Abnormal Cells </li></ul><ul><ul><li>Aplastic Anemia </li></ul></ul><ul><ul><li>Leukemia </li></ul></ul><ul><ul><li>Metastatic Cancer </li></ul></ul>www.freelivedoctor.com
  • 24. THROMBOCYTOPENIA <ul><li>HYPERSPLENISM </li></ul><ul><ul><ul><li>Increase in Size Leads to Destruction of Platelets </li></ul></ul></ul><ul><ul><ul><li>Associated with Portal Hypertension Seen in Patients with Cirrhosis </li></ul></ul></ul>www.freelivedoctor.com
  • 25. THROMBOCYTOPENIA <ul><li>OTHER CAUSES </li></ul><ul><ul><ul><li>Lymphoma </li></ul></ul></ul><ul><ul><ul><li>HIV Virus </li></ul></ul></ul><ul><ul><ul><li>Idiopathic Thrombocytopenia Purpura (ITP) </li></ul></ul></ul>www.freelivedoctor.com
  • 26. THROMBOCYTOPATHY <ul><li>UREMIA </li></ul><ul><li>INHERITED DISORDERS </li></ul><ul><li>MYELOPROLIFERATIVE DISORDERS </li></ul><ul><li>DRUG INDUCED </li></ul>www.freelivedoctor.com
  • 27. THROMBOCYTOPATHY <ul><li>DRUG INDUCED </li></ul>ASPIRIN IRREVERSIBLY BINDS TO THE PLATELET FOR ITS ENTIRE LIFESPAN (7-10 DAYS) www.freelivedoctor.com
  • 28. <ul><li>DRUG INDUCED </li></ul>THROMBOCYTOPATHY NSAIDS REVERSIBLY BINDS TO THE PLATELET FOR A LIMITED TIME PERIOD (APPROX 6 HOURS) www.freelivedoctor.com
  • 29. FACTOR DEFICIENCIES (CONGENITAL) <ul><ul><li>HEMOPHILIA A </li></ul></ul><ul><ul><li>HEMOPHILIA B </li></ul></ul><ul><ul><li>VON WILLEBRAND’S DISEASE </li></ul></ul>www.freelivedoctor.com
  • 30. FACTOR DEFICIENCIES <ul><li>HEMOPHILIA A (Classic Hemophilia) </li></ul><ul><ul><ul><li>80-85% of all Hemophiliacs </li></ul></ul></ul><ul><ul><ul><li>Deficiency of Factor VIII </li></ul></ul></ul><ul><ul><ul><li>Lab Results - Prolonged PTT </li></ul></ul></ul><ul><li>HEMOPHILIA B (Christmas Disease) </li></ul><ul><ul><ul><li>10-15% of all Hemophiliacs </li></ul></ul></ul><ul><ul><ul><li>Deficiency of Factor IX </li></ul></ul></ul><ul><ul><ul><li>Lab Test - Prolonged PTT </li></ul></ul></ul>www.freelivedoctor.com
  • 31. FACTOR DEFICIENCIES <ul><li>VON WILLEBRAND’S DISEASE </li></ul><ul><ul><ul><li>Deficiency of VWF & amount of Factor VIII </li></ul></ul></ul><ul><ul><ul><li>Lab Results - Prolonged BT, PTT </li></ul></ul></ul>www.freelivedoctor.com
  • 32. OTHER DISORDERS (ACQUIRED) <ul><li>ORAL ANTICOAGULANTS </li></ul><ul><ul><li>COUMARIN </li></ul></ul><ul><ul><li>HEPARIN </li></ul></ul><ul><li>LIVER DISEASE </li></ul><ul><li>MALABSORPTION </li></ul><ul><li>BROAD-SPECTRUM ANTIBIOTICS </li></ul>www.freelivedoctor.com
  • 33. OTHER DISORDERS <ul><li>ORAL ANTICOAGULANTS </li></ul><ul><ul><ul><li>Coumarin Prevents Thromboembolic Events & </li></ul></ul></ul><ul><ul><ul><li>is a Vit K Antagonist. Monitored by PT times. </li></ul></ul></ul><ul><ul><ul><li>Heparin Therapy is Monitored by PTT times. </li></ul></ul></ul>www.freelivedoctor.com
  • 34. OTHER DISORDERS <ul><li>MALABSORPTION </li></ul><ul><ul><ul><li>Various Intestinal Diseases Will Interfere w/ Bile Acid Metabolism. </li></ul></ul></ul><ul><ul><ul><li>Bile Acids are Required for Vit K Absorption so You Will See a Deficiency in Vit K Dependent Coagulation Factors (II,VII,IX,X). </li></ul></ul></ul>www.freelivedoctor.com
  • 35. OTHER DISORDERS <ul><li>LIVER DISEASE </li></ul><ul><li>Jaundice Results in Malabsorption of Vit K. </li></ul><ul><li>Liver Disease can Result in Reduced Production of Coagulation Factors (I,II,V,VII,IX,X). </li></ul>www.freelivedoctor.com
  • 36. OTHER DISORDERS <ul><li>BROAD-SPECTRUM ANTIBIOTICS </li></ul><ul><ul><ul><li>Change in Intestinal Flora which Might Decrease Vitamin K Production. </li></ul></ul></ul><ul><ul><ul><li>Vitamin K is Necessary for the Liver to Produce Coagulation Factors II,VII,IX,X. </li></ul></ul></ul>www.freelivedoctor.com
  • 37. DENTAL EVALUATION <ul><li>GOOD THOROUGH MEDICAL HISTORY </li></ul><ul><li>A PHYSICAL EXAMINATION </li></ul><ul><li>SCREENING CLINICAL LAB TESTS </li></ul><ul><li>EXCESSIVE BLEEDING FOLLOWING SURGICAL PROCEDURE </li></ul>www.freelivedoctor.com
  • 38. GOOD THOROUGH HISTORY <ul><li>Family HX </li></ul><ul><li>Personal HX </li></ul><ul><li>Medications </li></ul><ul><li>Past & Present Illness </li></ul><ul><li>Spontaneous Bleeding </li></ul>www.freelivedoctor.com
  • 39. REVIEW PATIENT’S MEDS <ul><li>FIVE DRUGS THAT INTERFERE WITH HEMOSTASIS </li></ul><ul><li>ASPIRIN </li></ul><ul><li>ANTICOAGULANTS </li></ul><ul><li>ANTIBIOTICS </li></ul><ul><li>ALCOHOL </li></ul><ul><li>ANTICANCER </li></ul>www.freelivedoctor.com
  • 40. ORAL MANIFESTATIONS <ul><li>Petechiae & Ecchymosis </li></ul><ul><li>Gingival Hyperplasia </li></ul><ul><li>Spontaneous Gingival Bleeding </li></ul><ul><li>Ulceration of Oral Mucosa </li></ul><ul><li>Lymphadenopathy </li></ul><ul><li> </li></ul>www.freelivedoctor.com
  • 41. DENTAL PATIENTS <ul><li>LOW RISK </li></ul><ul><ul><ul><li>Patients with No Hx of Bleeding Disorders </li></ul></ul></ul><ul><ul><ul><li>Normal Laboratory Results </li></ul></ul></ul><ul><li>MODERATE RISK </li></ul><ul><ul><ul><li>Patients on Chronic Oral Anticoagulant Therapy. PT is 1.5 - 2 Times Control Range </li></ul></ul></ul><ul><ul><ul><li>Patients on Chronic Aspirin Therapy </li></ul></ul></ul>www.freelivedoctor.com
  • 42. DENTAL PATIENTS <ul><li>HIGH RISK </li></ul><ul><ul><ul><li>Patients with Known Bleeding Disorders </li></ul></ul></ul><ul><ul><ul><li>Patients without Known Bleeding Disorders Who Have Abnormal Laboratory Results </li></ul></ul></ul>www.freelivedoctor.com
  • 43. DENTAL MANAGEMENT <ul><li>LOW RISK PATIENTS </li></ul><ul><ul><ul><li>Normal Protocol </li></ul></ul></ul><ul><li>MODERATE RISK PATIENTS </li></ul><ul><ul><ul><li>Anticoagulants - Consult Physician </li></ul></ul></ul><ul><ul><ul><li>Aspirin Therapy - BT, Consult Physician </li></ul></ul></ul>www.freelivedoctor.com

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