Dental practitioner should be aware of the impact of bleeding disorder on the management of patients. Initial recognition of bleeding disorder helps to identify the disorder and guide towards proper management in dental care settings.

1. Bleeding Disorders in Primary
Dental Care
Chow Peng Yue DDS

2. Disclaimer
• The material on this presentation is intended to provide an overview of the issues and terminology
surrounding a particular medical and dental topic and is not intended as medical and dental advice.
Because medicine and dentistry is not static, and one situation may differ from the next, the author
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3. Introduction
• Bleeding disorder – impact on management
• Recognition bleeding disorder – indicate
systemic pathology

4. Patient Evaluation
• Medical
• Dental

5. History Taking
• Previous unusual bleeding episode after
surgery or injury
• Spontaneous bleeding
• Easy or frequent bruising

6. Clinically Significant Bleeding Episode
• Continues beyond 12 hours
• Causes the patient to call or return to the
dental clinic or seek medical treatment or
emergency care
• Development of hematoma or ecchymosis
within the soft tissues
• Requires blood product support

7. History Taking
• Significant & prolonged bleeding after dental
extraction or bleeding from gingiva
• Nasal or oral bleeding
• Family history of bleeding disorder:
– Hemophilia
– Von Willebrand’s disease

8. Drug History
• Some medications interfere hemostasis
• If anticoagulant drugs – consult medical
before major procedure

9. Drug Abuse
• Drug abuse (alcohol, heroin):
– Liver damage
– Altered production of coagulation factors
– Excessive bleeding
• Illegal drug injection:
– Risk of viral pathogen
– Viral hepatitis
– Altered liver function

10. General Examination of Patient
• Tendency to bleed:
– Multiple purpura of skin
– Petechiae
– Ecchymosis
– Bleeding wounds
– Hematoma
– Swollen joints
– Spontaneous gingival bleeding

11. Patients with Liver Disease
• Jaundice
• Spider nevi
• Ascites

12. Cardiac Patients
• Tachycardia
• Hypertension
• Difficult to achieve hemostasis

13. If Bleeding Disorder Suspected
• Refer medical for laboratory test:
– Bleeding time (platelet function): 2-7 min
– APTT (activated partial thromboplastin time)
(intrinsic coagulation pathway): 25 ± 10 s
– INR (international normalized ratio) (extrinsic
coagulation pathway): 1.0
– Platelet count (quantify platelet function):
150,000 – 450,000/µL

14. Types of Bleeding Disorder
• Coagulation factor deficiency
• Platelets disorders
• Vascular disorders
• Fibrinolytic defects

15. Coagulation Factor Deficiencies
• Congenital:
– Hemophilia A and B
– Von Willebrand’s disease
• Acquired:
– Liver disease
– Vitamin K deficiency
– Warfarin use
– Disseminated intravascular coagulation

16. Platelet Disorders
• Quantitative disorder (thrombocytopenia):
– Immune mediated
– Non-immune mediated
• Qualitative disorder:
– Congenital
– Acquired

17. Platelet Quantitative Disorder
(Thrombocytopenia)
• Immune mediated:
– Idiopathic
– Drug-induced
– Collagen vascular disease
– Sarcoidosis
• Non-immune mediated:
– Disseminated intravascular coagulation
– Microangiopathic hemolytic anemia
– Leukemia
– Myelofibrosis

18. Platelet Qualitative Disorder
• Congenital:
– Glanzmann thrombasthenia
– Von Willebrand’s disease
• Acquired:
– Drug-induced
– Liver disease
– Alcoholism

19. Vascular Disorders
• Scurvy
• Purpura
• Hereditary hemorrhagic telangiectasia
• Cushing syndrome
• Ehler-Danlos syndrome

20. Fibrinolytic Defects
• Streptokinase therapy
• Disseminated intravascular coagulation

21. Hemophilia A
• Deficiency of clotting factor VIII
• Inherited X-linked recessive trait
• Found in males
• Symptoms:
– Delayed bleeding
– Ecchymosis
– Deep hematomas
– Epistaxis
– Spontaneous gingival bleeding
– Hemarthrosis

22. Management of Hemophilia A
• Refer medical
• Replacing factor VIII:
– Factor VIII concentrates
– Fresh frozen plasma
– Cryoprecipitate
• Desmopressin (DDAVP) - transient increase in
factor VIII
• Antifibrinolytics:
– Tranexamic acid (oral rinse)
– Epsilon-aminocaproic acid

23. Hemophilia B
• Deficiency of factor IX
• Refer medical
• Management:
– Factor IX concentrates
– Prothrombin complex concentrates

24. Von Willebrand’s Disease
• Common hereditary coagulation disorder
• Not sex linked
• Type I – IV: vary in severity
• Refer medical
• Management:
– Mild: use DDAVP
– Severe: factor VIII replacement

25. Liver Disease
• Liver parenchyma disease or obstruction
• Reduced synthesis of clotting factors
• Refer medical
• Management:
– Vitamin K
– Fresh frozen plasma
– Cryoprecipitate

26. Drug Induced Coagulopathies
• Warfarin
• Low molecular weight heparin
• Dicumarol (coumadin)
• Refer medical to modify medications

27. Platelet Disorders
• Hereditary or acquired
• Decreased platelet production, excess
consumption, or altered function
• Signs:
– Superficial lesions
– Spontaneous gingival bleeding
– Petechiae
– Ecchymosis
– Epistaxis

28. Drugs – Platelet Function
• ASA (acetylsalicylic acid) (aspirin)
• Dipyridamole
• For platelet function inhibition
• No need stop these drugs for routine
procedures

29. Vascular Defects
• Rare
• Mild bleeding confined to skin or mucosa
• Example: scurvy, hereditary hemorrhagic
telangiectasia

30. Oral Findings
• Platelet deficiency - petechiae or ecchymosis
in oral mucosa
• Leukemia – gingival hyperplasia
• Chronic bleeding – brown deposit on surface
of teeth (hemosiderin – blood degradation
product)

31. Oral Findings
• Hemophilia – hemarthrosis of TMJ (rare)
• Dental caries & periodontal disease:
– Lack of oral hygiene & professional dental care
– Fear of oral bleeding

32. Dental Management
• Factors:
– Severity of condition
– Invasiveness of dental procedure
• If mild bleeding disorder and limited
invasiveness:
– Slight or no modification
• Refer medical before invasive treatment

33. Pain Control
• Avoid nerve block anesthesia:
– Highly vascularized area
– Risk of hematoma
• Extravasation of blood in oropharyngeal area:
– Gross swelling
– Pain
– Dysphasia
– Respiratory obstruction
– Asphyxia

34. Pain Control
• Alternative: infiltration or intraligamentary
• Use anesthetic with vasoconstrictor
(adrenaline)
• Major procedure:
– Refer specialist
– May need: diazepam, nitrous oxide-oxygen, GA

35. Oral Surgery
• Refer medical
• Severe bleeding disorder:
– Refer specialist
• Need transfusion of coagulation factors until
50-100% normal level
• Hemophilia:
– Post-op factor maintenance (factor infusion,
DDAVP, cryoprecipitate, fresh frozen plasma)

36. Oral Surgery
• Achieve hemostasis:
– Pressure
– Surgicel
– Suture
– Anesthesia with vasoconstrictor
– Tranexamic acid

37. Patients Taking Medications
• Usually no need stop:
– Aspirin
– Clopidogrel
– Dipyridamole
• Patient taking warfarin:
– INR < 3.0
• Patient on dialysis taking heparin:
– Heparin has short half-life (5 hours)
– Treatment on day between dialysis

38. Periodontal Procedures
• Can be done normally:
– Periodontal probing
– Supragingival scaling
– Polishing
– Subgingival scaling & root planing – need to be
careful

39. Periodontal Procedures
• Additional steps:
– Chlorhexidine rinse before start
– Gross debridement before deep scaling (reduce
gingival inflammation)
– Tranexamic acid rinse after procedure

40. Restorative and Endodontic Procedure
• Can be done routinely, with care
• Careful with:
– Rubber dam clamp
– Matrix band
– Wedge
– Suction (can cause hematoma at floor of mouth)

41. Prosthodontic Procedure
• Can be done normally
• Careful with:
– Impression tray
– Prosthesis adjustment
– Soft tissue manipulation

42. Drugs That Interact With Warfarin
• Drugs that potentiate effects of warfarin:
– Prolonged use of:
• Aspirin
• NSAIDS
– Penicillin
– Erythromycin
– Metronidazole
– Tetracycline
– Miconazole

43. Conclusion
• Do not stop patient’s medication
• Any doubt:
– Consult physician
• Major bleeding disorder and/or major dental
procedure:
– Refer specialist

44. References
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JCDA 2007; 73(1):77-83a