COAGULATION AND BLEEDING DISORDERS-DR AJMAL

1. HEMOSTATIC DISORDERS
DENTAL CONSIDERATIONS
DR AJMAL MOHAMED

2. HEMOSTASIS
Physiological Process of Stoppage or
Arrest Of Bleeding By Maintaining the
Normal Internal Blood Equilibrium

3. MECHANISM OF HEMOSTASIS

5. TOURNIQUET TEST
 Evaluates vascular integrity
 Place B.P. cuff and inflate to 90-100mm Hg over
forearm
 Wait for 5 minutes
 Check for number of Petechiae within a 2.5 cm circle
 Normal-less than 10 Petechiae
 Rumbell Leed phenomenon

10. BLEEDING TIME
 Time interval taken from oozing of blood to the
arrest of bleeding from a standard cut.
 Normal
 1-6 minutes
 Duke and Ivy methods
 Prick on the finger tip and check for the time taken
for stoppage of blood oozing out


11. PLATELET COUNT
 Determines increase or decrease of
platelets
 Normal
 1,50,000-4,00,000mm³
 Blood smear examination
 Hemocytometer analyzer

12. CLOTTING TIME
 Time taken for the blood to clot after collecting
from the body
 Intrinsic clotting factors
 Capillary tube method
 Normal
 5-10 minutes

13. PROTHROMBIN TIME/I.N.R.
 Indicates total prothrombin present in blood
 Thromboplastin and calcium added to pt serum and is
expressed in ratio(International Normalized Ratio=I.N.R.)
 Normal
 11-13 seconds
 I.N.R.
 1.0-2.0
 Evaluates extrinsic system and F I,II,V,VII,X

14. ACTIVATED PARTIAL THROMBOPLASTIN TIME
(a.P.T.T.)
 Tests intrinsic and common pathway system
 Activity of VIII,IX,XI,XII
 Kaolin added to patient plasma
 Normal value
 15-35 seconds

15. THROMBIN TIME
 Test the ability to form initial clot from
fibrinogen
 Thrombin is added to plasma and time taken
to clot is noted
 Normal
 9-13 seconds

16. CLASSIFICATION OF
HEMOSTATIC DISORDERS
Arises from disorders of
Vessel wall
Coagulation
system
Platelets

17. VESSEL WALL DISORDERS
HEREDITARY
Hereditary Hemorrhagic
Telangiectasia
Ehlers Danlos
Syndrome
ACQUIRED
scurvy
Henoch schoulein purpura
Senile Purpura
infections
Cushing's syndrome

18. PLATELET DISORDERS
CONGENITAL
Glanzmanns
Thrombasthenia
Wiskott-aldrich
Syndrome
May Hegglin
Anomaly
Bernaud Soulier
Syndrome
ACQUIRED
Idiopathic
Thrombocytopenic
Purpura
Drug Induced
Thrombocytopenic
Purpura
Thrombotic
Thrombocytopenic
Purpura

19. COAGULATION DISORDERS
CONGENITAL
HEMOPHILIA A
HEMOPHILIA B
VON WILLEBRAND
DISEASE
OTHER FACTOR
DEFICIENCIES

20. COAGULATION DISORDERS
ACQUIRED
ANTICOAGULANT
HEPARIN
COUMARIN
DISEASES
LIVER
DISEASE
VIT K
DEFICIENCY
KIDNEY DISEASE
AND UREMIA
D.I.C.

21. Hereditary Hemorrhagic Telangiectasia
 Rendu Osler Weber Syndrome
 Autosomal Dominant Disorder
 Telangiectasia
 Recurrent Epistaxis
 + ve Family History
 Multiorgan Arteriovenous Malformations
 Hemorrhage

22. Clinical features
 Spider like telangiectasia
 Skin lesions- face,neck,chest ,legs
 Gastrointestinal bleeding
Oral lesions
 Perioral and intraoral angiomatous nodules
 Telangiectasia- lips,tongue,palate
 Lesions blanch on applied pressure

27. TREATMENT
 Cryotherapy
 Laser Ablation
 Electrocoagulation
 Resection
 Blood Replacement
 Iron Therapy

28. Ehlers Danlos Syndrome
 Inherited connective tissue disorder
 Joint Hypermobility
 Cutaneous Fragility
 Hyperextensibility of skin
 11 subtypes –unique biochemical defects and
clinical features

29. Clinical features
 Type 1-classic form
 Varicose veins and prematurity
 Type VIII
 Early onset periodontal disease
 Type VII
 children
 Microdontia
 Dentinal structural defects in primary dentition
 Bleeding after brushing

32. Oral Manifestation
 Fragile gingiva and oral mucosa
 Gingival hyperplasia and fibrous nodules
 Hypermobilty of T.M.J.
 Lack of normal scalloping of D.E.J.
 Pulp stones
 Periodontal destruction
 Gorlin sign

35. SCURVY
 Dietary deficiency of Vit C
 Defect in collagen synthesis
 Petechial hemorrhages at the hair follicles
 Purpura on lower extremities
 Hemorrhage to muscles, joints ,nail beds,
gingival tissues

36. Oral manifestations
 Gingiva appears ulcerated and boggy
 Foul breath
 Loss of bone
 Loosening of teeth
 Implementation of Vit C
 1 g/d of Vit C-rapid resolution

38. Cushing's Syndrome
 Corticosteroid intake or production
 Protein wasting and atrophy of connective
tissue
 Skin bleeding and easy bruising

39. Henoch-Schönlein Purpura
 Immune complex mediated hypersensitivity
 Children with acute infections
 Vasculitis and purpuric lesions
 Joint pain and abdominal pain
 hematuria

41. Glanzmann Thrombasthenia
 Chronic hereditary hemorrhagic disease
 Autosomal recessive trait
 Deficiency of platelet glycoprotein II b & III a
 Spontaneous bleeding after minor trauma
 Purpuric hemorrhage of skin
 Prolonged bleeding time
 Microfibrillar collagen & C- Aminocaproic Acid

43. Wiskott-Aldrich Syndrome
 X-linked recessive genetic condition
 Immunoglobulin M Deficiency
 Defect in WAS p
 Thrombocytopenic purpura
 Eczema
 Petechiae and purpuric rashes
 Boils, Otitis Media, Bloody Diarrhea
 Respiratory infection

45.  High potential for Malignant Lymphoma
Laboratory findings
 Prolonged bleeding time
 Anisocytosis
 Reduced platelet
 Reduced Adenosine Diphosphate Nucleotide

46. Bernard Soulier Syndrome
 Autosomal dominant disease
 Deficiency of surface membrane
glycoprotein of platelets –binding of Vwf
 Prolonged bleeding time
 Large platelets
 Defective platelet aggregation

48. May-Hegglin Anomaly
 Thrombocytopenia
 Giant cells
 Inclusion bodies in leucocytes

49. Thrombocytopenic Purpura
 Bleeding disorder
 Below 1,50,000mm3
 Failure of platelet production
 Disordered platelet distribution
 Increased platelet destruction

50. I.T.P.
 Werlhofs disease
 Autoimmune Disorder
 High levels of IgG
 Types
 Acute
 chronic

51. ACUTE
 90% in children
 Below 10 years
 Viral or upper respiratory infections
 Fall and winter seasons
 Onset is sudden and severe
 Recovers within 3-6 months

52. CHRONIC
 Adults-women
 20-40 years
 Insidious -history of long standing bruises
 S.L.E.,A.I.D.S.,lymphoproliferative disorders
and hemolytic anemia

53. Clinical features
 Below 40,000 mm³
 Pinpoint Petechial hemorrhages
 Purpura and bruises
 Arms,legs,thighs,chest,neck
 Mucosal bleeding in G.I.T.
 Risk of intracranial hemorrhage-<20,000mm³

55. Oral manifestations
 Spontaneous bleeding from gingiva
 Blood filled bullae
 Profuse oozing of blood from gingival margin
 Purplish globs of clotted blood on teeth
 Bleeding along occlusal line
 Multifocal Petechial red spots that do not blanch
seen on soft palate

57. DRUG INDUCED T.P.
 Reversible within 7-10 days of discontinuation
 Aspirin induces functional platelet defect
 Single 100mg-rapid complete inhibition of platelet
cyclooxygenase activity and thrombaxone
production
 Prolonged bleeding time

58. MOSCHOWITZ DISEASE
 Also called as T.T.P.
 Life threatening multisystem disorder
 Presence of thrombotic microangiopathies
 Micro vascular lesions with platelet
aggregation

59. Clinical features
 Thrombocytopenia
 Hemolytic anemia
 Transitory neurological dysfunction
 Renal failure
 Young adults-women
 Precipitating factors-
 pregnancy
 Infections
 S.L.E.

60. DIAGNOSIS
 Widespread microthrombi in arterioles,venules and
capillaries
 Biopsy of gingival tissue confirm diagnosis
 Occlusive subintimal deposits of P.A.S. at arteriolocapillary
junctions
 L.D.H. levels are increased
 Proteinuria
 hematuria

61. TREATMENT
 Corticosteroids
 Prednisolone 1-2mg/kg
 Antacids for G.I. symptoms
 Plasma exchange therapy combined with corticosteroids-
T.T.P.
 Bone marrow transplantation
 Plasmapheresis-to remove circulating antibodies
 Splenectomy

62. HEMOPHILIA

63.  Hemophilia A-factor VIII
 Hemophilia B- factor IX
 Hemophilia C-factor XI
Hemophilia A:
 1 in 10,000
 X-linked recessive bleeding disorder
 Only Males are affected
 1/3rd of patients-no family history

64. CLINICAL FEATURES
 Hemorrhage to joints, subcutaneous tissues,
internal organs
 Massive hematoma
 30-50%-neonatal bleeding from umbilical cord
 Petechiae is rare
 Cyclic remissions and exacerbations

67. CLASSIFICATION
Clinical severity depends on extent of
clotting factor deficiency
 <1%-severe with life threatening bleeding
 1-5%-moderate with post traumatic bleeding
 5-20%-mild disease

68. Oral Manifestations
 Massive and prolonged gingival hemorrhage
 Tooth eruption and exfoliation with bleeding
 Mandibular pseudo tumor
 Subperiosteal bleeding with reactive new bone
formation causing tumor like expansion of bone
 Hematoma formation following nerve block
anesthesia

70. Investigations
 Prolonged a.P.P.T.(Activated Partial Thromboplastin Time)
 Whole blood coagulation time is prolonged
 Factor VIII is reduced
 Normal bleeding time
 Normal prothrombin time
 Functional assay

71. Rₓ
 Factor VIII & IX replacement
 30% for mild
 60% for major surgeries
 FRESH FROZEN PLASMA
 Desmopressin
 0.3 µg/kg body weight-I.V. or S.C. before dental procedures
 Increases F VIII,Vwf antigen,ristocetin co factor activity

74. Von willebrands disease
 Autosomal dominant disorder
 Abnormality of Vwf
 Males and females
 Acquired form
 Wilms tumor
 S.L.E.

75. TYPES
 Type I
 Partial quantitative decrease of Vwf and F VIII
 Type II
 Qualitative defect of Vwf
 Type III
 Severe form Less than 1%
 Type IV
 Platelet type mimicking platelet disorder

77. Laboratory Findings
 Prolonged bleeding time
 Normal clotting time
 Normal prothrombin time
 Normal serum fibrinogen
 Increased capillary fragility
 Positive tourniquet test

78. Treatment
 Type 1-desmopressin
 Factor VIII
 Cryoprecipitate
 Fresh Frozen Plasma
 Local Hemostatic agents

79. Anticoagulant Coagulopathies
Heparin
 Binds with antithrombin III
 Inhibit activation of F IX,X,XI
 Reduces thrombin generation & fibrin formation
 Duration of action-3-4 hours
 Antidote-Protamine Sulphate

80. COUMARIN
 Warfarin and dicumarol
 Slow thrombin production and clot formation
 Blocks the action of Vit K
 F II,VI,IX,X reduced
 Anticoagulant effect reversed by F.F.P.
 I.N.R. monitors the anticoagulation levels
 Returns to normal within 2-4 days after discontinuation

81.  Intramuscular injection cause bleeding and hematoma
 Additive effect when used with aspirin
 Drug potency increased with
 Metronidazole
 Penicillin
 Erythromycin
 Cephalosporin
 Tetracycline

82. LIVER DISEASES
 Depends on extent of liver damage
 Impaired protein synthesis
 Clotting and fibrinolytic systems reduced
 Acute or chronic disease
 Decreased Vit K dependent factors
 F II,VII,IX,X
 Rx is Vit K therapy for 3 days
 F.F.P.
 Desmopressin

83. VIT K DEFICIENCY
 Production of poorly functioning Vit K dependant
factors
 Severe hemorrhage in acutely ill patients of 7-10
days
 Rapid fall in F VII elevates I.N.R. resulting
prolongation of a.P.T.T
 Supplementation of Vit K restores the defect

84. DISSEMINATED INTRAVASCULAR
COAGULATION
 Due to widespread IV activation of clotting cascade
 Initially forms microthrombi and emboli throughout
vasculature
 bleeding tendency due to consumption of clotting factors
 bruising or purpura
 Oozing from venepuncture and surgical wound sites

85. Causes
 Severe infections
 Hypovolemic shock
 Burns
 Transfusion reaction
 Eclampsia
 Amniotic fluid embolus
 Promyelocytic leukemia
 Widespread mucin secreting metastatic adenocarcinoma

86. Investigations
 ↑P.P.T. &P.T.
 ↑Fibrin Degradation Products
 ↓serum fibrinogen levels(<1mg/ml)
 ↓ factor V and factor VIII activities
 Thrombocytopenia

87. Rₓ
 I.V. heparin to prevent thrombi initially
 Fluid resuscitation
 Treat underlying cause
Correct clotting abnormalities with
 Fresh frozen plasma
 Cryoprecipitate
 Platelet transfusion

88. ORAL FINDINGS & GUIDLINES
 Spontaneous gingival bleeding
 Hemosiderin deposits on tooth surface
 Poor oral hygiene
 Higher caries rate
 Severe periodontal diseases
 Risk of hematoma formation
 Hemarthrosis to T.M.J.

89. MEDICAL CONSULTATION
 Bleeding
 Alcohol abuse
 Anticoagulation therapy
 Corticosteroid therapy
 Need for additional medications
 Change in dosage or alternative medication

90. LABORATORY INVESTIGATIONS
 BLEEDING TIME
 PLATELET COUNT
 PROTHROMBIN TIME
 ACTIVATED PARTIAL THROMBOPLASTIN
 I.N.R.
 THROMBIN TIME
 CLOTTING TIME

91. ORAL SURGICAL PROCEDURES
 Replacement of coagulation factor 50-100%
 Post operative maintenance therapy
 Factor concentrates
 D.D.A.V.P.
 Cryoprecipitate
 F.F.P.
 Packing of extraction socket with Hemostatic
agents

92.  Gingival bleeding not responding to
antifibrinolytics requires 20-30% F VIII,F IX
 Local Hemostatic methods
 Pressure packs
 Vasoconstrictors
 Suturing
 Surgical stents
 Topical thrombin

94. ANTIFIBRINOLYTIC AGENTS
 E.A.C.A.
 Tranexamic acid
 Block conversion of plasminogen to plasmin
 Clot stabilization
 50 mg/kg-topically
 250mg/ml-systemically as oral rinse(6hrs,7-10 )
 Fibrin glue
 Forms an adhesive gel & attract platelets

95. PAIN CONTROL
 Hypnosis
 Intravenous sedation
 Nitrous oxide analgesia
 Intrapulpal anesthesia for pulp extirpation
 Periodontal ligament and gingival papillary
injections
 L.A. with epinephrine

96.  Aspirin & N.S.A.I.Ds contraindicated
 acetaminophen and codeine
 Intramuscular injections should be avoided
due to risk of hematoma
 Ice packs in area of hematoma during nerve
blocks

97. PERIODONTAL THERAPIES
 Inflamed and swollen gingiva treated with
chlorhexidine mouth wash
 Use of cavitron or hand instrument prior to deep
scaling
 Deep scaling & root planning performed in
quadrants
 Post treatment Antifibrinolytic oral rinses
 Periodontal surgical procedures-↑50%

98. RESTORATIVE THERAPY
 Rubber Dam Isolation
 Avoid Trauma with high speed evacuators
 Matrices,wedges,retraction cords use with caution
 Avoid denture related trauma with careful insertion

99. ENDODONTIC THERAPY
 Root canal treatment is the choice
 Avoid filling beyond apex
 Application of epinephrine to the apical
region provides Hemostasis

100. PEDIATRIC DENTAL THERAPY
 Extraction of mobile teeth with periodontal space
anesthesia with proper oral hygiene measures
 Bleeding control with gauze pressure
 Crown preparation with minimal removal of
enamel at gingival region
 Topical fluoride therapy
 Pit and fissure sealants

101. ORTHODONTIC THERAPY
 Avoid mucosal lacerations with brackets,
bands and wires
 Use of extra oral force
 Shorter treatment appointments

102. PATIENTS ON ANTICOAGULANTS
 I.N.R.- >3.5-4.0
 No treatment without coumarin modification
 I.N.R.- <3.5-4.0
 Minor procedures with local measures without drug modification
 During significant bleeding
 Drug modification
 INR-<2.0-3.0
 Local measures
 Extensive surgeries-I.N.R.-<1.5

103. EMERGENCIES
 Palliative Treatment
 Infections treated with high dose antibiotics
 Extractions should be avoided till bleeding
controlled
 Aspirin & N.S.A.I.Ds not indicated
 Consultation with physician

104. To summarize

107. CONDITIONS TESTS
History of bleeding problem P.T., aP. T.T.,T.T.,B.T.,P.C.
Aspirin therapy B.T., aP.T.T.
Coumarin therapy P.T.
Renal dialysis(heparin) aP.T.T
Liver diseases B.T.,P.T.
Chronic leukemia B.T.
Long term antibiotic therapy P.T.
Vascular wall integration B.T. TOURNIQUET TEST
Cancer(fibrinogenolysis) T.T.

108. CONCLUSION
 Proper History
 Physical Examination
 Oral Examination
 Laboratory Investigations
 Medical Consultation
 Infection Control

109. Enjoy The Rain