MALABAR DENTAL COLLEGE

1. A N J A L I . S
P O S T G R A D U A T E S T U D E N T
D E P A R T M E N T O F P U B L I C H E A L T H
D E N T I S T R Y
V I V E K A N A N D H A D E N T A L C O L L E G E F O R
W O M E N , T I R U C H E N G O D E .
Haemorrhage

2. A N J A L I . S
L E C T U R E R
D E P A R T M E N T O F P U B L I C H E A L T H
D E N T I S T R Y
M A L A B A R D E N T A L C O L L E G E
Haemorrhage

3. Contents
 Haemorrhage
 Haemostasis
 The mechanism of coagulation
 Common bleeding disorders and management
 Methods of preventing bleeding –DENTAL PROCEDURES
 Laboratory evaluation
Public Health Dentist point of view..
References

4. Haemorrhage
 Haemorrhage means escape of blood from blood vessel.
Any damage to the vasculature leads to outflow of
blood (bleeding)

5. Types
 Depending on the type of blood vessel involved
 Arterial
 Venous
 Capillaries

6. Types
 According to the time of appearance
Primary Haemorrhage – It occurs at the time of injury .
Reactionary Haemorrhage –Within 24hours of injury or
operation, due to dislodgement of blood clot .
Secondary Haemorrhage – After 7-14days of injury or
operation, due to infection and sloughing of part of
arterial wall.

7. Haemostasis
Haemostasis means “Arrest of bleeding “.
Natural attempt to haemostasis or stoppage of bleeding
starts immediately at the site of bleeding .

9. Haemostasis
Primary haemostasis – It is the process of platelet plug
formation at the site of injury .
It occurs within seconds after injury.
Secondary haemostasis – It is the activation of clotting
process in plasma that ultimately results in formation of
fibrin clot .

11. Procoagulant factors
FACTORS ALTERNATIVE NAMES
1 FIBRINOGEN
2 PROTHROMBIN
3 TISSUE THROMBOPLASTIN
4 CALCIUM
5 PRO ACCELERIN
6 NOT PRESENT
7 STABLE FACTOR
8 ANTI HAEMOPHILIC FACTOR
9 CHRISTMAS FACTOR
10 STUART PROWER FACTOR
11 PLASMA THROMBOPLASTIN ANTICEDENT
12 HEGMAN FACTOR
13 FIBRIN STABLIZING FACTOR

13. Common bleeding disorders
Coagulation factor deficiencies
 Congenital: Haemophilia A & B
Von willebrands disease
 Acquired : Liver disease
Vitamin k deficiencies
Warfarin use
Disseminated intravascular coagulant
Fibrinolytic defects : Streptokinase therapy

14. Common bleeding disorders
Coagulation factor deficiencies
 Congenital: Haemophilia A & B
Von willebrands disease
 Acquired : Liver disease
Vitamin k deficiencies
Warfarin use
Disseminated intravascular coagulant
Fibrinolytic defects : Streptokinase therapy

15. Hemophilia
 (Bleeders disease,disease of the Hapsburg,disease of
kings)
 Sex linked inherited disease featured by prolonged
clotting time
 Males are affected & females-carriers
 Mild trauma excess bleeding death

16. Types of Hemophilia
Hemophilia A
• Also called
classical
hemophilia
• Deficiency of
factor VIII
• 85% of people
are affected
Hemophilia B
• Also called
christmas disease
• Deficiency of
factor IX
• 15% are affected
Hemophilia C
• Plasma
thromboplastin
antecedent(PTA,
Factor XI)

17. Oral manifestations
 Site-Frenum of lip and tongue
 Symptoms –Prolonged bleeding after tooth extraction
 Tooth eruption-Physiological process of tooth eruption
and exfoliation associated with severe and prolonged
hemmorrhage

18. DENTAL TREATMENT-
Haemophila - A
 Factor VIII level - 50% and 75% - extractions.
 Postoperatively, antibiotic oral penicillin (250 mg four
times a day for 7 days) to reduce the chance of wound
infection and secondary haemorrhage.
 The risks of bleeding - greatest on the day of operation &
from 4 to 10 days postoperatively.

19. DENTAL TREATMENT
Haemophila - A
 Administration of tranexamic acid is usually continued
for 10 days.
Extractions in mild haemophilia
 Antifibrinolytic drugs- tranexamic acid or
desmopressin

20. DENTAL TREATMENT
Haemophila - B
 Clinically identical to haemophilia A.
 Factor IX is more stable than factor VIII. Dried factor IX
fraction is given for replacement.
 Factor IX remains active in the blood for more than 2
days, so that replacement therapy can be given at longer
intervals than for haemophilia A

21. Common Dental Treatment
 Tooth extraction
Rubberbands,being placed around the cervix of the
tooth and allowed to migrate apically causing
exfoliation of the tooth through pressure necrosis of the
Periodontal ligament.

22. Von willebrands disease
 (Pseudohemophilia,vascular hemophilia)
 Excessive bleeding in patients with normal platelet
count, clotting time, serum fibrinogen,prothrombin time

23. Oral manifestations
 Spontaneous bleeding
 Bleeding occurred only after brushing
 Disease may be discovered after dental extractions
because of the prolonged and excessive bleeding.

24. Treatment
 Transfusions of plasma and/or antihemophilic factor
and by local control of hemostasis.
 Patients become refractory to this treatment after
repeated transfusions, and occasionally patients develop
antibodies against antihemophilic factor
 Inherent dangers of tooth extraction should be
recognized by the dentist .
 Surgical procedures of an unessential nature should be
avoided.

25. Parahemophilia
 Parahemophilia is a rare hemorrhagic disorder
 Similar to hemophilia,
 Deficiency of an unrelated blood factor, proaccelerin
(factor V), responsible for the conversion of
prothrombin to thrombin.

26. Oral manifestation
 Spontaneous gingival bleeding
 Petechiae of the oral mucosa are rare.
 Prolonged bleeding following dental extractions

27. Treatment
 There is no effective treatment for parahemophilia.
 Transfusions, as well as freshly frozen plasma, are
given to replace blood lost through hemorrhage or
prior to a necessary surgical procedure

28. Vitamin k deficiency
Causes
 Obstructive jaundice
 Malabsorption.
 Hepatitis,
 Gall stones
 Carcinoma of the pancreas.

29. Vitamin k deficiency
• Extractions or other surgery should preferably be
delayed until haemostasis recovers.
• Emergency- vitamin K can be given, preferably by
mouth- effectiveness checked by the prothrombin
time.

30. Liver disease
 In mild liver disease, vitamin K may be effective
 Tranexamic acid and fresh plasma infusions may
control bleeding.

31. Management of prolonged dental bleeding
 The patient should then be given a local anaesthetic and
the mouth cleaned up to identify the source of bleeding.
 Any rough edges of the socket should be tidied up, the
margins squeezed together and the soft tissue margins
neatly sutured over it
 A small piece of Surgicel or fibrin gauze can be put in the
socket mouth beforehand, but suturing is the essential
measure.
 Ask family history of bleeding tendencies, or any other
cause of haemorrhagic disease .

32. Management of prolonged dental bleeding
 Continued oozing of blood from beneath the sutured
tissues suggests some haemorrhagic disease .
 Referring the patient to hospital, as prolonged dental
bleeding is a recognised.

33. Methods of achieving Haemostasis
Mechanical methods
Chemical methods
Local agents
Systemic agents
 Thermal agents

34. Mechanical methods
Suturing – the area should be anesthetized and a mat
suture inserted firmly over the bleeding area
Direct pressure – direct pressure may be applied over
the bleeding area, followed by asking the patient to bite
firmly on a gauze.

35. Chemical agents and local agents
Astringent agent and styptics
Bone wax
Thrombin
Gel foam
Oxycel
Adrenaline

37. Thermal agents
 Cautery
 Electro surgery
 Cryosurgery
 Lasers

39. Principal agents for systemic management of
patients with bleeding disorder

40. Agent Description Common indications
Platelets 1 unit = 50 mL; may
raise count by 6,000
• Platelet count
< 10,000 in
nonbleeding
individuals
• < 50,000
presurgical level
• < 50,000 in
actively bleeding
individuals
• Thrombocytopenia
Fresh frozen
plasma
1 unit = 150–250 mL
Contains factors II,
VII, IX, X, XI, XII,
XIII
and heat-labile V and
VII
• Undiagnosed
bleeding disorder
with active
bleeding
• Severe liver disease

41. Cryoprecipitate 1 unit = 10–15 mL • Hemophilia A, von
Willebrand’s disease
Factor VIII
concentrate
1 unit raises
factor VIII level
by 2%.
Hemophilia A with
active bleeding or
presurgery

42. Factor IX concentrate 1 unit raises
factor IX level
1–1.5%
Contains factors
II, VII, IX and X
• Hemophilia
B, with active
bleeding or
presurgery
Desmopressin Synthetic
analogue of
antidiuretic
hormone
0.3μg/kg IV or
SC
Intranasal
application
Active bleeding
or presurgery
for some
patients with
Von
Willebrand’s
disease,
Liver disease

43. Epsilon-
aminocaproic acid
Antifibrinolytic:
25% oral solution
(250 mg/mL)
Systemic: 75
mg/kg every 6
hours
Clot formation for
any
bleeding disorder
Tranexamic acid Antifibrinolytic:
4.8% mouth rinse
Systemic:
25mg/kg every 8
hours
Adjunct to support
clot formation for
any bleeding
disorder

44. Laboratory evaluation
Platelet count
Bleeding time
Clotting time
Prothrombin time
Partial thromboplastin time
Thrombin time

45. Platelet count
 Normal - 100,000 - 400,000 cells/mm3
< 100,000 -thrombocytopenia
50,000 - 100,000-mild thrombocytopenia
< 50,000 -severe thrombocytopenia

46. Bleeding time
Provides assessment of platelet count and function.
Normal value
2-6 minutes

47. Prothrombin time
 Measures effectiveness of the extrinsic pathway.
 Normal value
 10-15 secs

48. Partial thromboplastin time
 Measures effectiveness of the intrinsic pathway
NORMAL VALUE
25-40 SECS

49. Thrombin time
 Time for Thrombin to Convert
 Fibrinogen Fibrin
 A Measure of Fibrinolytic Pathway
NORMAL VALUE
9-13 SECS

50. Public health dentist point of view…
 Hemorrhage is a major problem mostly seen in
developing countries producing traumatic morbidity and
mortality.
 Major road accidents are mostly seen in middle income
countries
 As a public health dentist we should outline the
underlying cause and implimenting modern trauma care
practice centres and explore it to the developing
countries.

51. Public health dentist point of view..
 Dental hygienists should be on the front lines of helping
patients manage their general health in addition to
promoting good oral health.
 Frequent dental visits provide an opportunity for dental
hygienists to systematically follow patients' medical and
dental histories, which may help them recognize
developing conditions, like hemorrhagic disorders.

52. Public health dentist point of view..
 Dental hygienists can make a difference by noting these
symptoms and referring patients for accurate diagnosis
and treatment before serious health consequences
ensue.
 Health care providers should be able to identify a case
of and be ready to employ precautions or practical
barrier nursing techniques.

53. Public health dentist point of view..
 They should further be capable of requesting diagnostic
tests or prepare samples and testing elsewhere.
 Dental education programmes should be carried out to
disseminate the knowledge effectively regarding
HEMORRHAGIC DISEASES and highly infectious
diseases.

54. References
 Cawsons .Essentials of oral pathology and oral
medicine,7th edition.Newdelhi:2011.
 Vanders .Mechanism of body function,12th
edition.Newdelhi:2010.
 Best and Taylors .Physiological basis of medical
practice ,13th edition.2012.
Guyton G. Text Book of Medical Physiology, 9th
Edition, Prism Saunders Publication. 1996.
Neelima Anil Malik. Text Book of Oral and
Maxillofacial surgery, 2ND edition , Jaypee Brothers ;
2002.

55. References
 Cawsons .Essentials of oral pathology and oral
medicine,7th edition.Newdelhi:2011.
 Vanders .Mechanism of body function,12th
edition.Newdelhi:2010.
 Best and Taylors .Physiological basis of medical
practice ,13th edition.2012.
Guyton G. Text Book of Medical Physiology, 9th
Edition, Prism Saunders Publication. 1996.
Neelima Anil Malik. Text Book of Oral and
Maxillofacial surgery, 2ND edition , Jaypee Brothers ;
2002.