This document provides an overview of blood coagulation. It discusses the components of blood, the plasma proteins, platelets, and the coagulation factors involved in the coagulation cascade. It describes the intrinsic and extrinsic pathways, mechanisms of coagulation, fibrinolysis, and factors that prevent coagulation in the body under normal physiological conditions such as heparin and thrombomodulin. Common anticoagulants like heparin and coumarin derivatives are also mentioned.

1. BLOOD COAGULATION
CH. SUMA PRIYANKA
1ST YEAR PG
DEPT. OF PERIODONTICS
GUIDED BY
DR. P. SURESH, MDS
PROFESSOR & HOD
DEPT.OF PERIODONTICS

2. CONTENTS:
• Introduction & properties of blood
• Functions of blood
• Plasma proteins
• Platelets….a few words!!
• Coagulation of blood
• Clotting factors
• Mechanism of blood coagulation
• Fibrinolysis

3. • Anticoagulants
• Screening tests
• Bleeding disorders
• Recent advances in diagnosing bleeding disorders
• Hemostatic agents
• PRF…….??Role in periodontal regeneration!!
• Conclusion
• Bibliography

4. INTRODUCTION:
Connective tissue in Fluid form
Fluid of Life
Fluid of Growth
Fluid of Health
“William Harvey” – “Father of Modern Physiology”

5. PROPERTIES:
Color: Arterial blood– Scarlet red
Venous blood– Purple red.
Volume: 5L in a normal adult
450ml in newborn.
• It is about 8% of the body weight in a normal young adult.
Reaction & PH: slightly alkaline; 7.4
Specific gravity: 1.052-1.061
Viscosity: 5 times more viscous than water due to RBC and plasma
proteins.

6. COMPOSITION:
Blood cells-Formed elements
Liquid portion-Plasma.
HEMATOCRIT VALUE/ PACKED CELL VOL:
Volume of RBC expressed in %.(45%)
PLASMA: Straw colored clear fluid part of
blood containing 91%-92% of water & 8%-9%
of solids.
SERUM: Clear fluid left after blood has clotted.
Serum=Plasma-fibrinogen

7. FUNCTIONS OF BLOOD:
Nutrient function
Respiratory function
Excretory function
Transport of hormones & enzymes
Regulation of water balance
Regulation of acid-base balance
Regulation of body temperature
Storage function
Defensive function.

8. PLASMA PROTEINS: (6.4-8.3g/dl)
Albumin-4.7g/dl
Globulin-2.3g/dl
Fibrinogen-0.3g/dl

9. SEPARATION OF PLASMA PROTEINS:
Precipitation method
Salting out method
Electrophoretic method
Cohn’s fractional precipitation method
Ultracentrifugation method
Gel filtration chromatography
Immunoelectrophoretic method

10. PLASMAPHERESIS:
• An experimental procedure done in dogs to demonstrate the importance
of plasma proteins.
• Earlier called as “Whipple’s experiment” “George Hoyt Whipple”.
• “Extracorporeal therapy”.
• Used to demonstrate:
a. Importance of plasma proteins for survival
b. Synthesis of plasma proteins by liver.

11. Clinical significance:
• Also called as “ Therapeutic plasma exchange”.
• Plasmapheresis is used as a blood purification procedure for an effective
temporary treatment of many autoimmune diseases like-
i. Myasthenia gravis
ii. Thrombocytopenic purpura
iii. Lambert-Eaton myasthenic syndrome

13. PLATELETS….a few words!!
 Platelets or thrombocytes are small,
colorless, non nucleated and
moderately refractive bodies.
2-4 microns in diameter and volume
is 7.5 cubic microns.
Cell membrane consists of
glycoproteins and phospholipids.
 Glycoproteins prevents adherence
of platelets to normal endothelium
but accelerate the adherence to
collagen and damaged endothelium
in ruptured blood vessels.

14. Glycoproteins also form receptors for ADP & THROMBIN.
Phospholipids accelerates clotting reactions.
Cytoplasm of platelet contains certain proteins like-
i) Contractile proteins Actin and Myosin
Thrombosthenin

15. ii) Von Wille brand factor
iii) Fibrin stabilizing factor.
iv) Platelet derived growth factors.
v) Platelet activating factors.
vi) Vitronectin (serum spreading factor)
Vii) Thrombospondin

16. Properties:
i) Adhesiveness
ii) Aggregation
iii) Agglutination
FUNCTIONS:
• Role in blood clotting.
• Role in clot retraction.
• Role in repair of ruptured blood vessel
• Role in defense mechanisms.

18. EVENTS IN HEMOSTASIS:

19. Injury to blood vessel & damage of epithelium
Exposure of collagen
VWB factor
Adherence of platelets to collagen
Activation of platelets
Secretes Serotonin Secretion of ADP & TXA2 Prothrombin activator
PAF
Aggregation of platelets
Vasoconstriction Formation of platelet plug Blood coagulation

20. FIBROUS ORGANISATION:
Once a blood clot is formed,
a) It can become invaded by fibroblasts , which forms CT all
through the clot.
b) It can dissolve.
• The usual course for a clot is invasion by fibroblasts within a few hours
after clot is formed. This continues to complete organization of the clot
into fibrous tissue with in about 1-2 weeks.
• Conversely , when excess blood has leaked into tissues and tissue clots
have occurred where they are not needed, special substances in the clot
become activated which dissolve the clot. (clot retraction)

22. FACTORS OF COAGULATION:
Coagulation of blood occurs through a series of reactions due
to activation of a group of substances called “Clotting factors”.
I- Fibrinogen
II- Prothrombin
III- Tissue thromboplastin
IV- Calcium
V- Labile factor
VII- Stable factor
VIII- Anti hemophilic factor A
IX- Christmas factor
X- Stuart-prower factor

23. XI- Plasma thromboplastin antecedent
XII- Hageman factor (Contact factor)
XIII- Fibrin stabilizing factor
XIV- Pre kalikerin
XV- HMW Kinogen
XVI- VWF
XVII- AntithrombinIII
XVIII- Heparin cofactorII
XIX- Protein C
XX- Protein S

24. MECHANISM OF BLOOD COAGULATION:
ENZYME CASCADE THEORY:
Most of the clotting factors are proteins in the form of
inactive pro-enzymes. These pro-enzymes must be activated into enzymes
for clot formation. It is carried out by series of proenzyme-enzyme
conversion reactions.
• This theory explains how various reactions are involved in the conversion
of proenzymes to active enzymes in the form of cascade.

25. STAGES OF COAGULATION:

26. Formation of prothrombin activator:
Coagulation of blood initiates with the formation of a substance
called “Prothrombin activator” which converts prothrombin into thrombin.
• Formation of prothrombin activator occurs in 2 pathways:
i. Extrinsic pathway
ii. Intrinsic pathway

29. Role of Ca in intrinsic & extrinsic pathways:
Except for the first 2 steps , Ca ions are required for
promotion or acceleration of all the blood clotting reactions.
• So, in the absence of Ca, blood coagulation doesn’t occur by either of the
pathways.
• However, Ca ion concentration seldom falls low enough to significantly
affect the kinetics of clotting.

30. MODERN CONCEPT OF COAGULATION: “Hoffmann” & “Munroe”
Tissue injury
Tissue factor + VIIa INITIATION
Xa IXa
+Va+XIa + VIIIa
AMPLIFICATION
Thrombin
Fibrinogen Fibrin PROPAGATION

31. BLOOD CLOT:
Mass of
coagulated blood which
contains RBC, WBC ,
Platelets entrapped in
fibrin meshwork.
Trapped RBC are
responsible for the red
color of the clot.
• External blood clot is
called as ‘Scab’.

32. CLOT RETRACTION:
• Within a few minutes (20-60) after
a clot is formed, it begins to
contract & a straw colored fluid
called “Serum” oozes out of the clot.
• The process involving the
contraction of blood clot and
oozing of serum is called “Clot
retraction”.
• The contractile proteins namely
Actin, Myosin and Thrombasthenin
in the platelets are responsible for
clot retraction.
• So, failure of clot retraction is an
indication that the number of
platelets might be less.

33. • As the clot retracts, the edges of the broken vessel are pulled together,
thus contributing still further to the ultimate state of hemostasis.
• Clot formation has a positive feedback due to the proteolytic action of
thrombin which allows it to act on many other clotting factors along with
fibrinogen.
• Once a critical amount of thrombin is formed , a vicious circle develops
that causes still more blood clotting and more and more thrombin to be
formed.
• Thus, the blood clot continues to grow until blood leakage ceases.

34. FIBRINOLYSIS:
Lysis of blood clot inside the blood vessel is called “Fibrinolysis”.
• This helps to remove the clot from the lumen of the blood vessel and
requires a substance called “Plasmin”/ “Fibrinolysin”.
Formation of plasmin:
• Plasmin is formed from inactivated glycoprotein called “Plasminogen”
which is synthesized in liver .
• Plasminogen is converted into Plasmin by Tissue plasminogen activator
(t-PA), lysosomal enzymes and thrombin.
• Plasmin causes lysis of clot by dissolving and digesting the fibrin threads.

35. Damaged tissues & Endothelium
Lysosomal enzymes
Thrombomodulin + Thrombin
Thrombin – Thrombomodulin complex
Protein C Activated protein C
Inactivation of V & VIII Inactivation of t-PA inhibitor
u-PA Activation of t-PA Lysis of clot
Plasminogen Plasmin

37. Significance of lysis of clot:
 In vital organs, particularly heart, the blood clot
obstructs the minute blood vessels leading to MI.
 Lysis of clot allows re-opening of the affected blood-
vessels and prevents the development of infarction.
 Fibrinolytic enzymes like “Streptokinase” are used for the lysis of clot
during treatment in early stages of MI.

38. ANTICOAGULANTS
• Substances which prevent/ postpone coagulation of blood.
in vitro
in vivo
Both
Eg; Heparin
Coumarin derivatives
EDTA
Oxalate compounds
Citrates

39. WHY BLOOD DOESN’T CLOT IN THE BODY…..!!??????
Under physiological conditions , intravascular clotting doesn’t occur
because of some physicochemical factors in the body.
PHYSICAL FACTORS:
i. Continuous circulation of blood
ii. Smooth endothelial lining of blood vessels.
CHEMICAL FACTORS:
i. Presence of heparin produced in liver.
ii. Production of thrombomodulin by endothelium of blood
vessels.
iii. All the clotting factors are in inactive state.

40. HEPARIN:
• Conjugated polysaccharide.
• Produced by mast cells and basophils in the body.
• Commercially prepared from liver and other organs of
animals.
• Available in liquid form or dry form as Na, Ca, NH4, Li salts.

42. Uses: both in vivo & in vitro.
• i.v heparin (0.5-1mg/kg) postpones clotting for 3-4 hrs. Used widely in
clinical practice.
i. To prevent intravascular clotting during surgeries.
ii. In dialysis when blood is pumped through artificial
kidney.
iii. During cardiac surgeries.
iv. Before blood transfusion as an anticoagulant.
• also used in vitro about 0.1-0.2mg is sufficient for 1ml of blood.
• Effective for 8-12 hrs.
• Most expensive anticoagulant.

43. COUMARIN DERIVATIVES:
Dicoumarol
Warfarin
Acts by inhibiting action of Vit. k epoxide reductase enzyme complex.
EDTA: available as
Disodium salt
Tri potassium salt
• Given i.v in lead poisoning.
• As an anticoagulant in labs (0.5-2mg) prevents blood for at least 6 hrs.

44. OXALATE COMPOUNDS:
Prevents coagulation by forming Calcium oxalate, and
reduces blood Ca level.
• Mixture of Ammonium oxalate & Potassium oxalate in 3:2 ratio is used.
Potassium oxalate- Shrinkage of RBC
Ammonium oxalate- Swelling of RBC.
• Used in vitro, 2mg of mixture for 1ml of blood.
• Cant be used in vivo, as it is poisonous.

45. CITRATES:
• Sodium, Potassium, Ammonium citrates are used as anti-coagulants.
• Citrates combine with Ca in blood to form insoluble calcium citrate
lack of Ca no coagulation.
• Used to store blood in blood banks. Available as:
a. Acid citrate dextrose (ACD)-1 part ACD with 4 parts of blood.
b. Citrate phosphate dextrose (CPD)- 1 part CPD with 4 parts of
blood.
c. Citrate phosphate dextrose adenine (CPDA-1)
• Formal-citrate solution (Dacie’s solution) is used for RBC & Platelet
counts in labs.

46. CLASSIFICATION OF COAGULATION DISORDERS:
INHERITED ACQUIRED
Hemophilia A Vit . K deficiency
Hemophilia B DIC
Hemophilia C Liver diseases
Von Willebrand disease

47. PLATELET DISORDERS:
Thrombocytopenia
Thrombocytosis
Defective platelet functions

48. Dental procedures carrying significant risk of bleeding:
 LA with IANB or other regional nerve blocks.
 Subgingival scaling and Root surface instrumentation (RSI)
 Crown & bridge preparations
 Extractions
 Periodontal surgeries
 Biopsies
 Incision & drainage of swellings
 Surgical endodontics.

49. QUESTIONNAIRE FOR HEMOSTASIS :
1. Have any of the following members of your family ever have a
problem with prolonged or unusual bleeding?
2. Have you ever had marked bleeding for up to 24 hours after a surgical
procedures ( tooth extraction )?
3. Have you ever required a blood transfusion after surgery ?
4. Women : do you feel that you have abnormal bleeding during
menstruation?
5. Do you get bruises larger than the size of a quarter for which you
cannot remember the injury ?

50. 6.Do you experience numerous nose bleeds for up to several hours?
7. Do your gums often bleed not related to trauma or brushing ?
8. Are you taking any blood thinner (anticoagulant)?
9. Have you taken any medication (aspirin) in the last week ?
10.Have you had or do you have any liver diseases ?

51. Clinical findings :
• Jaundice ,pallor
• Ecchymoses, petechiae
• Oral ulcers
• Hyperplastic gingival tissue
• Hemarthrosis

52. Screening tests :
• Platelet count
• Ivy bleeding time / platelet functional analysis (PFA)
• Hess capillary resistance test (Tourniquet test)
• Prothrombin time & INR
• Activated partial thromboplastin time (aPTT)
• Thrombin time

53. Quantitative (platelet count) :
• Normal count -1,50,000 to 4,40,000/mm3
• Thrombocytopenia - < 1,50,000
• Severe intra operative bleeding -< 40,000 to 70,000
• Spontaneous bleeding-< 20,000

54. Qualitative:
1. Ivy bleeding time
2. Platelet functional analysis

55. • Consists of a microprocessor-
controlled instrument and a
disposable test cartridge containing
a biologically active membrane.
• 2 types of test cartridges are
available:
Standard cartridge containing
collagen-ADP
Cartridge containing collagen-
epinephrine.
• Time required to obtain full
occlusion of the aperture 
“Closure time” (CT)
PLATELET FUNCTIONAL ANALYZER: (60-120secs)

56. Prolonged bleeding—
Thrombocytopenia
Von Willebrand’s disease
Severe deficiency of factor V & XI.

57. HESS CAPILLARY RESISTANCE TEST ( TOURNIQUET TEST):
Sphygmomanometer cuff is tied to the upper arm and pressure is
raised in between diastolic and systolic for 5 mins.
• After deflation, number of petechiae appearing in 5 mins in 3cm2 area over the
cubital fossa are counted.
• Presence of >20 petechiae is a positive test.
• Positive in- a) Increased capillary fragility
b) Thrombocytopenia.

58. Prothrombin time : 11-15 sec
Time taken by blood to clot after adding tissue thromboplastin to it
Tests extrinsic and common pathways
Prothrombin time is increased in-
Liver diseases
Vit.k deficiency
Warfarin therapy
Def. of fac. II , V ,VII , X
INR: 1-1.2
A mathematical correction of PT ratio for differences in the sensitivity
of thromboplastin reagents
INR= patient PT ÷mean normal PT

59. activated partial thromboplastin time( aPTT):25-35 sec
• Initiated by phospholipid platelet substitute and activated by addition
of contact activator(Kaolin )
• Test both intrinsic and common path ways.
• Increased in-
Use of heparin
Hemophilia A,B
Thrombin time : (TT) 9-13 sec
• Test the common pathway, thus the ability to form initial clot from
fibrinogen
• Increased in heparin therapy.

60. HEMOPHILIA:
• Sex linked inherited disease with prolonged CT.
• Usually affects males, females being carriers.
• Because of prolonged CT, even a mild trauma causes excess bleeding which may
lead to death.
• Easy bruising and hemorrhage in muscles and joints are common.

62. Hemophilia A- factor VIII
85% ; 1:5,000
Hemophilia B- factor IX
15% ; 1:15,000
Hemophilia C – factor XI
10% ; 1:1,00,000
• Severe hemophilia ( <1%)  Severe bleeding on slight provocation
• Moderate (1-5%)  less frequent spontaneous hemorrhage but still it
bleeds.
• Mild (6-30%)  bleeds rarely but still have hemorrhage after severe
trauma or surgical procedures.

63. Clinical features:
• Often not noticed during 1st year of life.
• Prolonged bleeding even after minor injury.
• Hemarthrosis of the joints
• Deep muscle bruising
• Joint deformities with contractures
• Intracranial hemorrhage and abdominal bleeding.

64. TREATMENT:
• Dental management of any patient with a bleeding disorder should involve a joint
interaction between patient dentist and hematologist.
• An established protocol has been maintained for the management of oral surgical
procedures.
• To prevent surgical hemorrhage, at least 30% of factor VIII levels are needed.
• 1 unit of fac.VIII per kg of body weight raises fac.VIII levels by 2%. Hence, an
average 70kgs adult require infusion of 3500 units to raise the levels from 1% to
100%.
• Parenteral 1-deamino-8-D-arginine vasopressin (DDAVP, desmopressin) can be
used to raise fac.VIII levels 2-3 folds in mild & moderate hemophilia.
• DDAVP has the significant advantage of avoiding the risk of viral disease
transmission from fac.VIII infusion, and is considered the DOC.

65. Protocol for Hemophilia A:
PROCEDURE MILD
>5u/dl
MODERATE
2-5u/dl
SEVERE
<2u/dl
LA Infiltration No pre-treatment No pre-treatment No pre-treatment
IANB No pre-treatment Fac.VIII 10u/kg pre-
treatment
Fac.VIII 10u/kg pre-
treatment
Supragingival scaling No pre-treatment No pre-treatment Pre-treatment dose
of 1g oral
TRANAXAMIC ACID
capsules.
Subgingival scaling Pre-treatment dose
of 1g TRANEXEMIC
ACID capsules
followed by 1g qid for
24 hrs post-
treatment
Fac.VIII 7u/kg
+
Tranexamic acid 1g
followed by post-
treatment 3 days.
Fac.VIII 7u/kg
+
Tranexamic acid 1g
followed by post-
treatment 3 days.
Minor soft tissue
abscess/ Swelling
Fac.VIII 10u/kg pre-
treatment.
Fac.VIII 10u/kg pre-
treatment.
Fac.VIII 10u/kg pre-
treatment.

66. Protocol for Hemophilia B:
PROCEDURE MILD
>5u/dl
MODERATE
2-5u/dl
SEVERE
<2u/dl
LA Infiltration No pre-treatment No pre-treatment No pre-treatment
IANB No pre-treatment No pre-treatment No pre-treatment
Supragingival scaling No pre-treatment Prothrombin x-HT 20u/kg
pre-treatment
Prothrombin x-HT
20u/kg pre-treatment
Subgingival scaling Pre-treatment dose of 1g
TRANEXEMIC ACID
capsules followed by 1g
qid for 24 hrs post-
treatment
Prothrombin x-HT 14u/kg
pre-treatment
+
Tranexamic acid 1g
followed by post-
treatment 3 days.
Prothrombin x-HT
14u/kg pre-treatment
+
Tranexamic acid 1g
followed by post-
treatment 3 days.
Minor soft tissue abscess/
Swelling
Prothrombin x-HT
20u/kg pre-treatment
Prothrombin x-HT 20u/kg
pre-treatment
Prothrombin x-HT
20u/kg pre-treatment

67. VONWILLE BRAND DISEASE:
• Most common hereditary coagulation disorder
occurring due to qualitative or quantitative defect in
Von Willebrand’s factor.
• This factor also carries the coagulation portion
of fac.VIII in the plasma.
• Many cases of VWD are undiagnosed , and bleeding during dental treatment
may be the first sign of the underlying disease.
• Most severe forms require pre-operative fac.VIII concentrate or cryoprecipitate
infusion.

68. Clinical features:
• Characterized by spontaneous bleeding from mucous membranes and
excessive bleeding from wounds.
TYPES:
Type I –most common; mild-moderate decrease in plasma vWF
Type II –less common; normal or near normal levels of Vwf
 Type III –extremely rare but most severe.

69. Thrombocytopenia:
Reduction of platelets in peripheral blood count
below 1,50,000/ul.
• Characterized by spontaneous bleeding from large
number of capillaries causing large number of hemorrhagic
spots under the skin-”Purpuric spots”.
TYPES:
• Thrombocytopenic purpura: deficiency of platelets
• Thrombosthenic purpura: abnormal platelets in circulation
• Idiopathic thrombocytopenic purpura: Unknown cause.

71. Idiopathic thrombocytopenic purpura:
characterized by immunologic destruction of platelets and
normal or increased megakaryocytes in the bone marrow.
ACUTE:
• Self-limited disorder , seen most frequently in children following recovery
from a viral illness ( HCV, IMN ,CMV ,HIV).
• Sudden onset and severe thrombocytopenia but recovery occurs within
few weeks to 6 months.
• Mechanism is by formation of immune complexes containing viral antigens
, and by formation of antibodies against viral antigens which cross react
with platelets and lead to their immunologic destruction.

72. CHRONIC:
• Common in adults ( women).
• By formation of anti - platelet auto antibodies, usually by
platelet associated igG humoral antibodies synthesized
mainly in spleen.
• These antibodies are directed against target antigens on the platelet
glycoproteins.
• Sensitized platelets are destroyed mainly in the spleen.

73. Clinical features:
• Petechial hemorrhages , easy bruising ,nasal bleeding
• Bleeding from gums, melaena and hematuria
• Intracranial hemorrhage ( rare)
• Splenomegaly and hepatomegaly in chronic cases.

74. Management:
• Platelets ( Only for severe bleeding and extremely low platelet counts)
• Corticosteroids
• ivIG or antiD-immunoglobulin
• Splenectomy.

75. Changes in inherited disorders:
Clotting
factor
deficiency
PT ( INR) aPTT TT BT
Factor VIII N N N
Factor IX N N N
VWF N N
Factor XI N N N
Fibrinogen N N

76. DISSEMINATED INTRAVASCULAR COAGULATION ( DIC):

77. MANAGEMENT:
Treat the underlying cause
Replacement therapy – platelet transfusion
Heparin

78. General recommendations for preventing bleeding post-operatively:
 Prohibition of rinsing
 Liquid , high protein diet
 Antifibrinolytic mouthwash
 Antibiotics
 Pain medication

79. RECENT ADVANCES IN DIAGNOSING BLEEDING DISORDERS:
Thromboelastography
Thrombo portable systems for rapid measurement of PT & INR.

80. • Acc.to “European school of thought”, a literature review and guideline
development process found that interruption of aspirin before dental
procedures is un-necessary.
• Most procedures carry a low risk of bleeding and any bleeding that
occurs can usually be controlled by local hemostasis; so
discontinuation of (aspirin) anti-platelet therapy is not recommended.

81. HEMOSTATIC AGENTS:
Absorbable gelatin
Absorbable collagen
Oxidized cellulose
Thrombin
Tranexamic acid
Fibrin glue
Bone wax

82. PRF……..ROLE IN PERIODONTAL REGENERATION!!!
• Described by CHOUKROUN et.al
• PRF is a 2nd generation platelet concentrate which contains platelets
and growth factors in the form of fibrin membranes prepared from
patients own blood free of any anti-coagulants.
• Platelets play a key role in wound healing and hence wound healing
after periodontal treatment can be accelerated by the use of platelet
concentrates.

83. PRF……?????
• Choukroun’s PRF(France) is a leucocyte & platelet rich fibrin biomaterial
prepared as a natural concentrate without addition of any anti-coagulants.
• PRF has a dense fibrin network with leucocytes , cytokines , structural
glycoproteins and also growth factors like-
Transforming growth factorβ
Platelet-derived growth factor
Vascular endothelial growth factor
Glycoproteins like thrombospondin

84. It is advantageous over platelet-rich plasma(PRP):
i. Ease of preparation
ii. Ease of application
iii. Minimal expense
iv. Lack of biochemical modifications
• PRF contains physiologically available thrombin that results in slow
polymerization of fibrinogen into fibrin which results in wound healing.

85. Types of PRF: based on their Fibrin architecture & cell content-
Pure Platelet-rich plasma (P-PRP)  PRGF -Endoret technique , Vivo stat
PRF
Leucocyte-and platelet-rich plasma (LPRP)  Biomet GPS III system
Pure platelet-rich fibrin (P-PRF)  Fibrinet PRFM
Leucocyte-and platelet-rich fibrin (L-PRF)  Intra-spin L-PRF.

86. PREPARATION:
• A standard protocol for PRF preparation should be followed to obtain
proper quality and quantity of fibrin matrix, leucocytes, platelets &
growth factors.
• Equipment PC-02 table centrifuge
Blood collecting kit with a 24 gauge butterfly needle & 10ml
blood collection tubes.

88. • A sample of blood is collected from patient without anti-coagulant in
10ml tubes which are immediately centrifuged at 3000rpm for 10 mins.
• During centrifugation process, when the blood gets in contact with the
test-tube wall, platelets gets activated leading to the initiation of
coagulation cascade.
• After centrifugation, the resultant product consists of 3 layers:
Top most layer-acellular PPP(platelet poor plasma)
Middle layer-PRF clot
Bottom layer-RBC

90. • The duration of time between blood collection & centrifugation process is
an important parameter affecting the success and clinical outcome of the
procedure.
• Slow handling of blood to centrifugation process will result in diffuse
polymerization of fibrin leading to the formation of a small clot with
irregular consistency.

91. CLINICAL APPLICATIONS:
Treatment of periodontal intra bony defects
Treatment of furcation
Sinus lift procedures
As a scaffold for human periosteal cells in vitro

92. DISADVANTAGES:
• Main shortcomings of PRF is its preparation and storage.
• Clinical benefits of PRF depends on time interval between blood collection
and centrifugation as PRF is prepared without any anticoagulants.
• Also PRF membrane should be immediately used after preparation as it shrink
resulting in dehydration altering the structural integrity.
• Dehydration decreases growth factor content in PRF and leukocytes viability
will be adversely affected altering the biological properties.
• PRF when stored in refrigerator can result in risk of bacterial contamination of
the membranes.

93. CONCLUSION:
A careful equilibrium between coagulation factors and anti-
coagulation factors maintains blood fluidity.
• Any upset in this equilibrium results in either-
Thrombosis: formation of a clot or
Hemorrhage: Bleeding
• It’s better to be safe and know your patient well by taking a detailed case
history with special emphasis on medical history , than to be sorry and
complicate things.

94. BIBLIOGRAPHY:
 Textbook of medical physiology - Guyton & Hall 11th ed
 Essentials of medical physiology - K Sembulingam 5th ed
 Carranza’s clinical periodontology-11th ed
Essential pathology for dental students – Harsh Mohan & Sugandh Mohan 4th ed
 Bleeding disorders in dental practice: A diagnostic overview- journal of the international
clinical dental research organization July-December 2014 vol 6 issue 2
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