Bleeding disorders medicine /endodontic courses

AN APPROACH TO BLEEDINGAN APPROACH TO BLEEDING
DISORDERSDISORDERS
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

CONTENTSCONTENTS
DEFINITIONDEFINITION
CLASSIFICATIONCLASSIFICATION
AN APPROACH TO BLEEDING DISORDERAN APPROACH TO BLEEDING DISORDER
INHERITED COAGULATION DISORDERS:INHERITED COAGULATION DISORDERS:
HEMOPHILIA AHEMOPHILIA A
HEMOPHILIA BHEMOPHILIA B
VON WILLEBRANDS DISEASEVON WILLEBRANDS DISEASE
ACQUIRED COAGULATION DISORDERS:ACQUIRED COAGULATION DISORDERS:
VITAMIN KVITAMIN K
LIVER DISEASELIVER DISEASE
DISSEMINATEDDISSEMINATED
INTRAVASCULARINTRAVASCULAR
COAGULATIONCOAGULATION

DEFINITION:DEFINITION:
Bleeding disorders are a group of
conditions of the blood clotting (coagulation)
system in which bleeding is prolonged and
excessive.
A bleeding disorder is an acquired or
inherited tendency to bleed excessively.
The body stops the blood loss through a
complex clotting process called Hemostasis.

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COAGULATION CASCADE:COAGULATION CASCADE:
Each of these pathways utilizes different
coagulation factors, proteins that are carried in an
inactive form in the blood.
.
If a component is missing, deficient, or
dysfunctional, excessive bleeding may occur.
Bleeding disorders may cause symptoms like
nosebleeds, bleeding gums, bruising, heavy
menstrual periods, blood in the stool and urine to
arthritis type symptoms loss of vision and chronic
anemia.

CLASSIFICATION OF BLEEDING DISORDERS:CLASSIFICATION OF BLEEDING DISORDERS:Coagulation Factor deficiency or dysfunction
Inherited:
Hemophilia A
Hemophilia B
Von Willebrand’s disease
Other factor deficiencies:
II, V, VII, IX, X
Acquired:
Liver dysfunction or disease
Vitamin K deficiency
DIC (disseminated
intravascular
coagulation)
Fat malabsorption
Snake venom
Therapy for bone marrow and
myeloproliferativewww.indiandentalacademy.comwww.indiandentalacademy.com

Platelet deficiency (thrombocytopenia) orPlatelet deficiency (thrombocytopenia) or
dysfunctiondysfunction
InheritedInherited
A variety of rare inherited conditionsA variety of rare inherited conditions
may cause platelet disordersmay cause platelet disorders
AcquiredAcquired
Bone marrow not making enough (Bone marrow not making enough (
bone marrow disorderbone marrow disorder))
Idiopathic thrombocytopenic purpuraIdiopathic thrombocytopenic purpura
(ITP),(ITP),
Drugs such as heparin, quinine, sulfaDrugs such as heparin, quinine, sulfa
antibiotics, and gold salts,antibiotics, and gold salts,
Drugs such as aspirin and nonsteroidalDrugs such as aspirin and nonsteroidal
anti-inflammatory drugs,anti-inflammatory drugs,
Disease related: HIV, liver disease,Disease related: HIV, liver disease,
kidney failure, leukemia, multiplekidney failure, leukemia, multiple
myeloma, cirrhosis of the liver, andmyeloma, cirrhosis of the liver, and
systemic lupus erythematosussystemic lupus erythematosus
Massive blood replacementMassive blood replacement
Cardiopulmonary bypass surgery.Cardiopulmonary bypass surgery.

AN APPROACH TO BLEEDINGAN APPROACH TO BLEEDING
DISORDER PATIENTSDISORDER PATIENTS
Spontaneous, or excessive post-traumaticSpontaneous, or excessive post-traumatic
(immediate or delayed) bleeding may be an(immediate or delayed) bleeding may be an
indication of a localized pathological process orindication of a localized pathological process or
a disorder of the haemostatic process.a disorder of the haemostatic process.
Accurate diagnosis and treatment -Accurate diagnosis and treatment -
pathophysiology of hemostasis.pathophysiology of hemostasis.
The process is divided into primary andThe process is divided into primary and
secondary components.secondary components.
Primary hemostasisPrimary hemostasis is formation ofis formation of
platelet plug at sites of injury and occurs withinplatelet plug at sites of injury and occurs within
seconds of injury.seconds of injury.
Secondary hemostasisSecondary hemostasis describes thedescribes the
coagulation system, which result in fibrincoagulation system, which result in fibrin
formation. It requires several minutes toformation. It requires several minutes to
complete.complete.www.indiandentalacademy.comwww.indiandentalacademy.com

Bleeding disorders can thus be categorizedBleeding disorders can thus be categorized
into three groups:into three groups:
Disorders of platelet function or numberDisorders of platelet function or number
Disorders of clotting factorsDisorders of clotting factors
A combination of the above.A combination of the above.
HISTORY AND PHYSICAL EXAMINATIONHISTORY AND PHYSICAL EXAMINATION
The evaluation of the bleeding patient shouldThe evaluation of the bleeding patient should
primarily be focused on the following:primarily be focused on the following:
Is the patient bleeding?Is the patient bleeding?
If bleeding is suspected; identify theIf bleeding is suspected; identify the
site and severity,site and severity,
duration of bleeding andduration of bleeding and
clinical setting.clinical setting.

Mucocutaneous bleeding-Mucocutaneous bleeding- plateletplatelet
disorder.disorder.
It includesIt includes
petechiae,petechiae,
ecchymoses,ecchymoses,
epistaxis, andepistaxis, and
genitourinary and gastrointestinalgenitourinary and gastrointestinal
bleedingbleeding
Bleeding into potential spacesBleeding into potential spaces (joints,(joints,
fascial planes, retroperitoneum) -fascial planes, retroperitoneum) -
coagulation factor deficiency.coagulation factor deficiency.
Bleeding from multiple sitesBleeding from multiple sites inin
hospitalized patients can be seenhospitalized patients can be seen
Disseminated intravascularDisseminated intravascular
coagulation (DIC) orcoagulation (DIC) or
Thrombotic ThrombocytopenicThrombotic Thrombocytopenic
Purpura (TTP).Purpura (TTP).
..

Clinical Features of BleedingClinical Features of Bleeding
DisordersDisorders
Platelet Coagulation
disorders factor disorders
Site of bleeding Skin Deep in soft tissues
Mucous membranes (joints, muscles)
(epistaxis, gum,
vaginal, GI tract)
Petechiae Yes No
Ecchymoses Small, superficial Large, deep
Hemarthrosis / Extremely rare Common
muscle bleeding
Bleeding after cuts Yes No
& scratches
Bleeding after surgery Immediate, Delayed (1-2 days)
or trauma usually mild often severewww.indiandentalacademy.comwww.indiandentalacademy.com

A family history for bleeding disorders mayA family history for bleeding disorders may
be helpful for the assessment of pathologicbe helpful for the assessment of pathologic
bleeding.bleeding.
The clinical setting of the bleeding patient:The clinical setting of the bleeding patient:
Acute massive mucocutaneousAcute massive mucocutaneous
bleeding without symptoms-bleeding without symptoms- immuneimmune
thrombocytopenic purpura (ITP).thrombocytopenic purpura (ITP).
Massive bruising and oozing fromMassive bruising and oozing from
multiple sites in asymptomaticmultiple sites in asymptomatic
individuals-individuals-
accidental warfarin ingestionaccidental warfarin ingestion, or, or
acquired factor VIII inhibitorsacquired factor VIII inhibitors
(particularly in older individuals).(particularly in older individuals).
Postoperative bleeding at a surgical sitePostoperative bleeding at a surgical site
is usually related to ais usually related to a local surgicallocal surgical
problem.problem.www.indiandentalacademy.comwww.indiandentalacademy.com

Physical examination should focus onPhysical examination should focus on
identifyingidentifying
signs of bleedingsigns of bleeding
petechiae,petechiae,
mucosal bleeding,mucosal bleeding,
soft tissue bleeding andsoft tissue bleeding and
ecchymosesecchymoses
signs of systemic diseasesigns of systemic disease

LABORATORY INVESTIGATIONSLABORATORY INVESTIGATIONS
Initial laboratory investigations should include aInitial laboratory investigations should include a
complete blood cell (CBC) count,complete blood cell (CBC) count,
prothrombin time (PT),prothrombin time (PT),
partial thromboplastin time (PTT) andpartial thromboplastin time (PTT) and
peripheral smear.peripheral smear.
A preoperative screen for a patient with aA preoperative screen for a patient with a
negative history and examination should includenegative history and examination should include
aa
CBC,CBC,
PT, andPT, and
activated partial thromboplastin timeactivated partial thromboplastin time
(aPTT) only(aPTT) only

The following is a brief description of commonlyThe following is a brief description of commonly
obtained tests in the evaluation of hemorrhagicobtained tests in the evaluation of hemorrhagic
disorders.disorders.
Platelet countPlatelet count::
always verify thrombocytopenia byalways verify thrombocytopenia by
reviewing a peripheral smear.reviewing a peripheral smear.
accurate platelet count can beaccurate platelet count can be
obtained by using citrated tubes.obtained by using citrated tubes.
Partial thromboplastin timePartial thromboplastin time (PTT):(PTT):
ItIt represents the time for clot formationrepresents the time for clot formation
after adding calcium, phospholipids, and kaolinafter adding calcium, phospholipids, and kaolin
to citrated blood.to citrated blood.
It is prolonged byIt is prolonged by
heparin,heparin,
direct thrombin inhibitorsdirect thrombin inhibitors

vitamin K deficiency, or severe livervitamin K deficiency, or severe liver
diseasedisease
Prothrombin timeProthrombin time (PT):(PT):
It represents the time for clot formationIt represents the time for clot formation
after the addition of thromboplastin (tissueafter the addition of thromboplastin (tissue
factor) and calcium to citrated blood.factor) and calcium to citrated blood.
It is prolonged with deficiencies ofIt is prolonged with deficiencies of
factors II, V, VII, X or fibrinogen;factors II, V, VII, X or fibrinogen;
liver disease;liver disease;
vitamin K deficiency andvitamin K deficiency and
Warfarin use.Warfarin use.
Thrombin timeThrombin time (TT):(TT):
Time to clot formation after the additionTime to clot formation after the addition
of thrombin to citrated blood.of thrombin to citrated blood.www.indiandentalacademy.comwww.indiandentalacademy.com

TT is prolonged byTT is prolonged by
heparin,heparin,
direct thrombin inhibitors,direct thrombin inhibitors,
fibrin degradation products (FDPs),fibrin degradation products (FDPs),
Para proteins, andPara proteins, and
fibrinogen deficiency.fibrinogen deficiency.
It is used to establish the presence ofIt is used to establish the presence of
adequate fibrinogen and is falling out of favoradequate fibrinogen and is falling out of favor
for a fibrinogen assay.for a fibrinogen assay.
Reptilase time:Reptilase time:
Measures the time to clot formation afterMeasures the time to clot formation after
the addition of reptilase (a thrombin-like snakethe addition of reptilase (a thrombin-like snake
enzyme) to citrated blood.enzyme) to citrated blood.

It is not affected by heparin.It is not affected by heparin.
It can useful to determine if heparin is theIt can useful to determine if heparin is the
cause of the prolonged TT.cause of the prolonged TT.
Urea clot solubilityUrea clot solubility::
Reflects the ability of 5 M urea to solubilizeReflects the ability of 5 M urea to solubilize
clots.clots.
Normal clots are not solubilized by urea orNormal clots are not solubilized by urea or
monochloracetic acid, but patients withmonochloracetic acid, but patients with
factor XIII deficiency have clots thatfactor XIII deficiency have clots that dissolvedissolve
in 5 M urea.in 5 M urea.
D-dimers:D-dimers:
Are FDPs that can be measuredAre FDPs that can be measured
specifically by enzyme-linkedspecifically by enzyme-linked
Immunosorbent assay.Immunosorbent assay.
They are commonly elevated in DIC and inThey are commonly elevated in DIC and in
thrombotic conditions.thrombotic conditions.

Platelet function screen:Platelet function screen:
The PFA-100 is a platelet functionThe PFA-100 is a platelet function
analyzer that is slowly supplanting theanalyzer that is slowly supplanting the
bleeding time in the clinical arena.bleeding time in the clinical arena.
It tests the ability of platelets to aggregateIt tests the ability of platelets to aggregate
in two cartridges.in two cartridges.
98% positive predictive value to detect98% positive predictive value to detect
aspirin induced platelet defects.aspirin induced platelet defects.
Platelet aggregation study:Platelet aggregation study:
They remain the gold standard in detectingThey remain the gold standard in detecting
platelet function defects.platelet function defects.
In this test, platelet aggregation inIn this test, platelet aggregation in
response to a variety of agents is testedresponse to a variety of agents is tested
including:including:
ADP, epinephrine, collagen,ADP, epinephrine, collagen,
Arachidonic acid, and RistocetinArachidonic acid, and Ristocetinwww.indiandentalacademy.comwww.indiandentalacademy.com

Von Willebrand screen:Von Willebrand screen:
Includes tests of platelet function.Includes tests of platelet function.
It has a low negative predictive value andIt has a low negative predictive value and
may require repeat testing.may require repeat testing.
It includes the following tests:It includes the following tests:
Von Willebrand factor antigen (vWF:Ag):Von Willebrand factor antigen (vWF:Ag):
Von Willebrand factor activity (vWF:RCo):Von Willebrand factor activity (vWF:RCo):
Factor VIII:C activity:Factor VIII:C activity:
vWF:Ag and vWF:RCovWF:Ag and vWF:RCo may be elevatedmay be elevated
during pregnancy, oral contraceptive use, andduring pregnancy, oral contraceptive use, and
liver disease. They are decreased byliver disease. They are decreased by
hypothyroidism and type O blood.hypothyroidism and type O blood.

INHERITED COAGULATIONINHERITED COAGULATION
DISORDERSDISORDERS
HEMOPHILIA A:HEMOPHILIA A:
Hemophilia A- hereditary bloodHemophilia A- hereditary blood
coagulation (clotting) disorder.coagulation (clotting) disorder.
Caused by- deficient activity of plasmaCaused by- deficient activity of plasma
protein factor VIII, which affects the clottingprotein factor VIII, which affects the clotting
property of blood.property of blood.
CAUSES:CAUSES:
InheritedInherited X-linked recessiveX-linked recessive trait, with thetrait, with the
defective gene located on the X chromosome.defective gene located on the X chromosome.

Incidence about 1 in 10000 live male birthsIncidence about 1 in 10000 live male births
Hemophilia AHemophilia A - 7 times more common than- 7 times more common than
hemophilia B.hemophilia B.
Inheritance 1
All men
carrying the
mutated gene
will have
haemophilia
Male offspring
will be normal
Female
offspring will
be carrierswww.indiandentalacademy.comwww.indiandentalacademy.com

SYMPTOMS:SYMPTOMS:
BruisingBruising
SpontaneousSpontaneous bleedingbleeding
Bleeding into joints and associatedBleeding into joints and associated
pain andpain and swellingswelling
Blood in the urineBlood in the urine or stoolor stool
Prolonged bleeding from cuts, toothProlonged bleeding from cuts, tooth
extraction, and surgery.extraction, and surgery.
TESTS INCLUDE:TESTS INCLUDE:
ProlongedProlonged PTTPTT
Low serum factor VIII activityLow serum factor VIII activity

TREATMENT:TREATMENT:
IV infusion of factor VIII concentrates toIV infusion of factor VIII concentrates to
replace the defective clotting factor.replace the defective clotting factor.
Mild hemophilia - infusion ofMild hemophilia - infusion of
cryoprecipitate orcryoprecipitate or
desmopressin (DDAVP)desmopressin (DDAVP)
release of factor VIII that is stored withinrelease of factor VIII that is stored within
the body on the lining of blood vessels.the body on the lining of blood vessels.
Immunization with Hepatitis B vaccine.Immunization with Hepatitis B vaccine.
Factor VIIa – needed if inhibition to FVIII.Factor VIIa – needed if inhibition to FVIII.

HEMOPHILIA B:HEMOPHILIA B:
Hemophilia B - hereditary blood
coagulation disorder.
Caused by- deficiency of a blood plasma
protein called factor IX that affects the
clotting property of blood.
CAUSES:
An inherited X-linked recessive trait, with
the defective gene located on the X
chromosome.

Inheritance 2
Women carrying
the mutated
gene are
obligate carriers
50% of male
offspring will be
affected
50% of female
offspring will be
carriers

PTTPTT is prolonged.is prolonged.
Serum factor IXSerum factor IX is reduced.is reduced.
Infusion of factor IX concentrates toInfusion of factor IX concentrates to
replace the defective clotting factor.replace the defective clotting factor.
Hepatitis B vaccine is recommended forHepatitis B vaccine is recommended for
individuals with Hemophilia B becauseindividuals with Hemophilia B because
they are at increased risk of developingthey are at increased risk of developing
hepatitishepatitis due to exposure to blooddue to exposure to blood
products.products.

VON WILLEBRANDS DISEASE:VON WILLEBRANDS DISEASE:
Von Willebrand's disease is a hereditaryVon Willebrand's disease is a hereditary
bleeding disorderbleeding disorder caused by acaused by a
deficiency of von Willebrand factor.deficiency of von Willebrand factor.
Von Willebrand factor helpsVon Willebrand factor helps plateletsplatelets toto
stick to the blood vessel wall and to eachstick to the blood vessel wall and to each
other, which is necessary for normalother, which is necessary for normal
blood clottingblood clotting

CAUSES:CAUSES:
Is the most common hereditary bleedingIs the most common hereditary bleeding
disorderdisorder ((autosomal dominant)autosomal dominant)
Mild, and bleeding mayMild, and bleeding may occur after aoccur after a
surgical procedure or tooth extraction.surgical procedure or tooth extraction.
Worsened by the use of aspirin andWorsened by the use of aspirin and
other nonsteroidal anti- inflammatoryother nonsteroidal anti- inflammatory
drugs (NSAIDs).drugs (NSAIDs).
TESTS INCLUDE:
Prolonged bleeding time
Reduced von Willebrand factor level
Reduced platelet aggregation
(platelet aggregation test)
Ristocetin co-factor is reduced.www.indiandentalacademy.comwww.indiandentalacademy.com

For most patients, bleeding is mild.For most patients, bleeding is mild.
If trauma occurs or surgery is scheduled,If trauma occurs or surgery is scheduled,
cryoprecipitate or DDAVP can be givencryoprecipitate or DDAVP can be given
to raise the levels of von Willebrandto raise the levels of von Willebrand
factor, which will decrease the tendencyfactor, which will decrease the tendency
toward bleeding.toward bleeding.
Fresh plasma or certain factor VIIIFresh plasma or certain factor VIII
preparations- decrease bleeding.preparations- decrease bleeding.
A trial of DDAVP can be done prior toA trial of DDAVP can be done prior to
surgery to test whether vonsurgery to test whether von
Willebrand factor levels increase.Willebrand factor levels increase.
Should not take nonsteroidal anti-Should not take nonsteroidal anti-
inflammatory drugs (NSAIDs) such asinflammatory drugs (NSAIDs) such as
aspirin or ibuprofen.aspirin or ibuprofen.

IDIOPATHIC THROMBOCYTOPENICIDIOPATHIC THROMBOCYTOPENIC
PURPURA:PURPURA:
Idiopathic thrombocytopenic purpura is aIdiopathic thrombocytopenic purpura is a
bleeding disorderbleeding disorder characterized by too fewcharacterized by too few
platelets in the blood.platelets in the blood.
Because platelets are being destroyed byBecause platelets are being destroyed by
the immune system.the immune system.
CAUSE:CAUSE:
The disease occurs when immune systemThe disease occurs when immune system
cells, called lymphocytes, producecells, called lymphocytes, produce
antibodies against platelets.antibodies against platelets.
The presence of antibodies on plateletsThe presence of antibodies on platelets
leads to their destruction in the spleen.leads to their destruction in the spleen.www.indiandentalacademy.comwww.indiandentalacademy.com

A characteristicA characteristic
skin rash,skin rash,
easy bruising,easy bruising,
abnormal menstrual bleeding, orabnormal menstrual bleeding, or
sudden and severe loss of blood fromsudden and severe loss of blood from
the gastrointestinal tract may occur.the gastrointestinal tract may occur.
In children, the disease is sometimesIn children, the disease is sometimes
preceded by a viral infection and usually runspreceded by a viral infection and usually runs
its course without treatment.its course without treatment.
In adults, it is more often a chronic (long-term)In adults, it is more often a chronic (long-term)
disease and can follow a viral infection, certaindisease and can follow a viral infection, certain
drugs, pregnancy, or other immune disorders.drugs, pregnancy, or other immune disorders.
ITP affects women more frequently than men,ITP affects women more frequently than men,
and is more common in children than adults.and is more common in children than adults.www.indiandentalacademy.comwww.indiandentalacademy.com

SYMPTOMS:SYMPTOMS:
BruisingBruising
Nosebleed or oral bleedingNosebleed or oral bleeding
Bleeding into the skin - also calledBleeding into the skin - also called
pinpoint red spots and petechial rashpinpoint red spots and petechial rash
Abnormally heavy menstruation.Abnormally heavy menstruation.
Complete blood count (CBC) shows lowComplete blood count (CBC) shows low
platelet count.platelet count.
Bone marrow aspiration or biopsyBone marrow aspiration or biopsy
appears normal.appears normal.
PTT (coagulation studies) is normal.PTT (coagulation studies) is normal.
PT (coagulation studies) is normal.PT (coagulation studies) is normal.
Platelet associated antibodies may bePlatelet associated antibodies may be
detected.detected.

In children, the disease often runs itsIn children, the disease often runs its
course without treatment.course without treatment.
In adults, the initial treatment is usuallyIn adults, the initial treatment is usually
with a drug called prednisone.with a drug called prednisone.
A splenectomy (removal of the spleen) isA splenectomy (removal of the spleen) is
sometimes advised.sometimes advised.
The spleen is the major site of plateletThe spleen is the major site of platelet
destruction, but removal of the spleen willdestruction, but removal of the spleen will
only bring up the platelet count in 50% ofonly bring up the platelet count in 50% of
people.people.
OTHER TREATMENT:OTHER TREATMENT:
Oral danazolOral danazol
High-dose gamma globulin injectionsHigh-dose gamma globulin injections
Drugs that suppress the immune systemDrugs that suppress the immune system
Anti-RhD therapy can also be useful inAnti-RhD therapy can also be useful in
people with specific blood typespeople with specific blood types

People with ITP should avoid takingPeople with ITP should avoid taking
aspirin,aspirin,
ibuprofen, andibuprofen, and
warfarinwarfarin
These drugs interfere with platelet functionThese drugs interfere with platelet function
and blood clotting, and bleeding mayand blood clotting, and bleeding may
occur.occur.
COMPLICATIONS:COMPLICATIONS:
Severe bleedingSevere bleeding
Bleeding into the brain or loss of bloodBleeding into the brain or loss of blood
into the digestive tractinto the digestive tract

FEATURES OF ACUTE AND CHRONICFEATURES OF ACUTE AND CHRONIC
ITPITP
FEATURES ACUTE ITP CHRONIC ITP
Peak age Children (2-6yrs) Adults (20-40yrs)
Female: male 1:1 3:1
Antecedent Common Rare
infection
Onset of Abrupt Abrupt-
symptoms indolent
Platelet count <20,000 <50,000
at presentation
Duration 2-6 weeks Long-term
Spontaneous Common Uncommon
remission

Initial Treatment of ITPInitial Treatment of ITP
Platelet count Symptoms Treatment
(per µl)
>50,000 None
20-50,000 Not bleeding None
Bleeding Glucocorticoids
IVIG
<20,000 Not bleeding Glucocorticoids
Bleeding Glucocorticoids
IVIG
Hospitalizationwww.indiandentalacademy.comwww.indiandentalacademy.com

Initial Evaluation of a BleedingInitial Evaluation of a Bleeding
Patient - 1Patient - 1
Normal PT
Normal PTT
Urea
solubility Factor XIII deficiency
Consider evaluating for:
Mild factor deficiency Monoclonal
Gammopathy Platelet disorder
Abnormal fibrinolysis Vascular disorder
(α2 anti-plasmin def)
Abnormal
Normal

Normal PT
Abnormal PTT
Repeat
with
50:50
mix
Test for inhibitor activity:
Specific factors: VIII,IX, XI
Non-specific (anti-
phospholipid
Ab)
Test for factor deficiency:
Isolated deficiency in intrinsic pathway (factors VIII, IX,
XI)
Multiple factor deficiencies (rare)
50:50 mix
abnormal
50:50 mix is normal

Abnormal PT
Normal PTT
Repeat
with
50:50
mix
Specific: Factor VII (rare)
Non-specific: Anti-
phospholipid
(rare)
Consider evaluating for:
Mild factor deficiency Monoclonal gammopathy
Abnormal fibrinolysis Platelet disorder
(a2 anti-plasmin def) Vascular disorder
Elevated FDPs
50:50 mix
abnormal
50:50 mix is normal

Abnormal PT
Abnormal PTT
Repeat
with
50:50
mix
Specific : Factors V, X,
Prothrombin,
fibrinogen (rare)
Non-specific: anti-
phospholipid
(common)
Test for factor deficiency:
Isolated deficiency in common pathway: Factors V, X,
Prothrombin, Fibrinogen
Multiple factor deficiencies (common)
(Liver disease, vitamin K deficiency, warfarin, DIC)
50:50 mix
abnormal
50:50 mix is normal

BLEEDING DISORDERS ANDBLEEDING DISORDERS AND
DENTAL PRACTISEDENTAL PRACTISE
Management of the patient with a bleedingManagement of the patient with a bleeding
disorder must be based on a completedisorder must be based on a complete
understanding of the disease.understanding of the disease.
The dentist should consult with the patient'sThe dentist should consult with the patient's
primary physician or hematologist to discussprimary physician or hematologist to discuss
The severity of the disease;The severity of the disease;
The dental and oral/maxillofacialThe dental and oral/maxillofacial
procedures planned and nature of theprocedures planned and nature of the
bleeding risk;bleeding risk;
The patient's response to previous dentalThe patient's response to previous dental
treatment, surgery, and trauma; andtreatment, surgery, and trauma; and
The patient's response to various modesThe patient's response to various modes
of systemic therapy.of systemic therapy.www.indiandentalacademy.comwww.indiandentalacademy.com

When a general anesthesia or trunk nerveWhen a general anesthesia or trunk nerve
infiltration is indicated, clotting factorinfiltration is indicated, clotting factor
concentrates are to be used in patients withconcentrates are to be used in patients with
severe bleeding disorders.severe bleeding disorders.
DesmopressinDesmopressin is to be used in patients withis to be used in patients with
mild bleeding disorders.mild bleeding disorders.
AnAn antifibrinolyticantifibrinolytic treatment and atreatment and a fibrinfibrin
glueglue are also used.are also used.
The management of oral surgery proceduresThe management of oral surgery procedures
on patients treated with anticoagulants shouldon patients treated with anticoagulants should
be influenced by several factors:be influenced by several factors:
Extent and urgency of surgery,Extent and urgency of surgery,
Laboratory values,Laboratory values,
Treating physician's recommendation,Treating physician's recommendation,
Available facilities,Available facilities,
Dentist expertise, andDentist expertise, and
Patient's oral, medical, and generalPatient's oral, medical, and general
condition.condition.

Bleeding disorders medicine /endodontic courses

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