Bleeding disorders

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Bleeding disorders

  1. 1. BLEEDING DISORDERS www.freelivedoctor.com
  2. 2. HEMOSTASIS 1. VASCULAR PHASE 2. PLATELET PHASE 3. COAGULATION PHASE 4. FIBRINOLYTIC PHASE www.freelivedoctor.com
  3. 3. VASCULAR PHASE WHEN A BLOOD VESSEL IS DAMAGED, VASOCONSTRICTION RESULTS. www.freelivedoctor.com
  4. 4. PLATELET PHASE PLATELETS ADHERE TO THE DAMAGED SURFACE AND FORM A TEMPORARY PLUG. www.freelivedoctor.com
  5. 5. COAGULATION PHASE THROUGH TWO SEPARATE PATHWAYS THE CONVERSION OF FIBRINOGEN TO FIBRIN IS COMPLETE. www.freelivedoctor.com
  6. 6. FIBRINOLYTIC PHASE ANTICLOTTING MECHANISMS ARE ACTIVATED TO ALLOW CLOT DISINTEGRATION AND REPAIR OF THE DAMAGED VESSEL. www.freelivedoctor.com
  7. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 18. PLATELET DISORDERS <ul><li>THROMBOCYTOPENIA </li></ul><ul><li>THROMBOCYTOPATHY </li></ul>www.freelivedoctor.com
  19. 19. THROMBOCYTOPENIA INADEQUATE NUMBER OF PLATELETS www.freelivedoctor.com
  20. 20. THROMBOCYTOPATHY ADEQUATE NUMBER BUT ABNORMAL FUNCTION www.freelivedoctor.com
  21. 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. 22. THROMBOCYTOPENIA <ul><li>DRUG INDUCED </li></ul>.Alcohol .Thiazide Diuretics www.freelivedoctor.com
  23. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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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