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Oral consideration and laboratory investigations of bleeding and clotting disorder
- 1. BLEEDING AND CLOTTING DISORDERS RESOURCE FACULTY DR.JYOTSNARIMAL Additional professor & HOD DR.ICHHA KUMAR MAHARJAN Associate professor PRESENTER: KASHMIRA POKHREL 483 BDS-2011
- 2. CONTENTS • PATHOPHYSIOLOGY • BLEEDINGDISORDERS • COAGULATION DISORDERS • LABORATORY INVESTGATIONS • ORAL MANIFESTATIONS • DENTAL CONSIDERATION • DENTAL MANAGEMENT • CONCLUSION
- 3. PATHOPHYSIOLOGY • Hemostasis canbe divided into 4 phases: • Vascular phase • Platelet phase • Coagulation cascade phase • Fibrinolytic phase Principal mechanisms that prevent or diminish the loss of blood following vascular injury
- 4. VASCULAR PHASE Tissue injury Vasoconstrictionof the microvascular bed Serotonin, histamine,PG’s
- 5. PLATELET PHASE Circulating plateletsexposed to vascular injury Normal vWF, endothelial cells, collagen, basement membrane, elasti microfibrils and other cellular debris Physical and chemical changes Aggregation of platelet Primary platelet plug (adheres to basement membrane) Increase in size of plug Activates F-X Conversion of prothrombin to thrombin Platelet intermixed with other cellular components(RBC,WBC) which further contracts to reduce bleeding and seal vascular bed
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- 9. • VESSEL WALLDISORDERS • PLATELET DISORDERS • COAGULATION DISORDERS CLASSIFICATION
- 10. • Scurvy • Cushing’ssyndrome • Ehlers-Danlos syndrome • Rendu-Osler-weber syndrome VESSEL WALL DISORDERS
- 11. • Thrombocytopenic(quantative platelet deficiency) 1.May-hegglinanomaly 2.Wiskott-aldrich syndrome 3.Neonatal alloimmune thrombocytopenia • Nonthrombocytopenic(qualitative) 1.Glanzmann’s thromasthenia 2.Platelet type vWD 3.Bernard-soulier syndrome CONGENITAL PLATELET DISORDERS
- 12. ACQUIRED • Thrombocytopenic(quantitative) 1. Autoimmuneor idiopathic thrombocytopenia purpura 2. Thrombotic thrombocytopenia purpura 3. Cytotoxic chemotherapy 4. Drug-induced (eg, quinine, quinidine, gold salts, trimethoprim/ sulfamethoxazole, rifampin) 5. .Leukemia 6.Aplastic anemia 7.Myelodysplasia 8.Systemic lupus erythematosus 9.Associated with infection: HIV, mononucleosis, malaria 10.Disseminated intravascular coagulation
- 13. • Nonthrombocytopenic (qualitative) 1. Drug induced(aspirin,NSAIDS,penicillin,cephalosporin) 2.Uremia 3. Alcohol dependency 4. Liver disease 5. Myeloma 6. Acquired platelet type vWD
- 14. • CONGENITAL COAGULOPATHIES 1.Hemophilia A&B 2. Factors deficiency 3. von Willebrand’s disease • ANTICOAGULANT -RELATED COAGULOPATHIES 1. Heparin 2. Coumarin • DISEASE-RELATED COAGULOPATHIES 1. Liver disease 2. Vitamin K deficiency 3. Disseminated intravascular coagulation 4. Fibrinolytic disorders COAGULATION DISORDERS
- 15. • History taking •Physical examination • Laboratory Investigations • Observation IDENTIFICATION OF PATIENT WITH BLEEDING DISORDER
- 16. HISTORY TAKING H/O frequent •epistaxis, • spontaneous gingival and mucosal bleeding, • prolonged bleeding from superficial cuts • Excessive menstrual flow • Easy bruising • hematuria
- 17. CONTD…. • Family history •Past H/O bleeding after surgical procedures • Identification of medicine(heparin, aspirin, NSAIDS,coumarin, cytotoxic chemotherapy) • Active medical conditions (hepatitis,cirrhosis,renal disease, hematological malignancy, thrombocytopenia) • H/O heavy alcohol intake
- 18. Physical examination • Jaundice •Petechiae • Ecchymosis • Hemarthrosis
- 19. Laboratory investigations • Normal150,000-450,000/mm3 • Spontaneous clinical hemorrhage - <10,000 to 20,000 mm3 • Surgical/traumatic hemorrhage-<50,000mm3 • Normal- 1 to 6 minutes • Prolonged - >15 minutes • Test platelet and vascular phase 1. Platelet count 2. Bleeding time
- 20. Prothrombin time andINR • Normal PT-11 to 13 seconds • Evaluates extrinsic coagulation and F- I,II,V,VII and X • Now reported with it’s INR INR(international normalised ratio) •It’s the ratio of PT that adjusts for the sensitivity of the thromboplastin reagants, •such that normal coagulation profile is reported as an INR of 1.0
- 21. aPTT(activated partial thromboplastintime) • Activator – rare earth • Measures effectiveness of the intrinsic pathway • Considered normal if the control aPTT & test aPTT are within 10 secs of each other. • Control aPTT = 15-35secs. • It is altered in hemophilias A & B. and with the use of heparin.
- 22. • Tests abilityto form initial clot from fibrinogen • Normal - 9 to 13 seconds • Evaluates the presence of D-dimer of fibrinogens TT(Thrombin Time) Fibrin Degradation products
- 23. • Normal-60 to150% • Torniquet test to assess Rumpel-leede phenomenon Factor assays Tests of capillary Fragility
- 24. Bleeding Disorder Platelet Count PT/INR aPTT BT Thrombocytopenia Leukemia F VIII, IX, XI deficiency Heparin anticoagulation F II, V, X deficiency Vitamin K deficiency Intestinal malabsorption F VII deficiency Coumarin anticoagulation Liver disease von Willebrand’s disease DIC Severe liver disease F XIII deficiency Vascular wall defect ↓ N N N N, ↓ ↓ N N N N ↑ ↑ N ↑ N N N ↑ ↑ N N, ↑ ↑ N N ↑ N N N ↑ ↑ N ↑
- 25. Principal Agents forSystemic Management Agent Description Indications Platelets 1 unit = 50 mL; may raise count by 6,000 Platelet count • < 10,000 in non bleeding individuals • < 50,000 presurgical level • < 50,000 in actively bleeding individuals Fresh frozen plasma 1 unit = 150–250 mL Contains factors II, VII, IX, X, XI, XII, XIII and heat- labile V and VII • Undiagnosed bleeding disorder with active bleeding • Severe liver disease Cryo- precipitate 1 unit = 10–15 mL • Hemophilia A • von Willebrand’s disease, • when factor concentrates and DDAVP are unavailable • Fibrinogen deficiency Factor VIII concentrate 1 unit raises factor VIII level 2% • Hemophilia A with active bleeding • Presurgery
- 26. Factor IX concentrate 1 unitraises factor IX level 1–1.5% Hemophilia B, with active bleeding or presurgery Desmopressin Synthetic analogue of antidiuretic hormone 0.3μg/kg IV or SC Active bleeding or presurgery for some patients with von Willebrand’s disease, uremic bleeding of liver disease, bleeding esophageal varices Epsilon- aminocaproic acid Antifibrinolytic: 25% oral solution (250 mg/mL) Systemic: 75 mg/kg every 6 hours Adjunct to support clot formation for any bleeding disorder Tranexamic acid Antifibrinolytic: 4.8% mouth rinse Systemic: 25mg/kg every 8 hrs Adjunct to support clot formation for any bleeding disorder
- 27. Local hemostatic agents •ABSORBANT GELATIN SPONGE (GELFOAM) Dental size - 20x20x7mm3 • OXIDISED CELLULOSE (SURGICEL)
- 28. • TOPICAL THROMBIN •Obtained from bovine plasma • Applied as dry powder or freshly prepared solution • TRANXENAMIC ACID • 500mg tablets • 1000mg/10ml injection
- 29. • Epsilon Aminocaproic Acid • 50mg/kg • Oral rinse 250mg/ml • Fibrin sealants/Fibrin glue • Cryoprecipitate • 10,000units thrombin powder • 10ml saline • 10ml Calcium Chloride
- 30. • Application oflocal pressure • suture
- 31. Clinical features ofbleeding disorders Feature Vascular or platelet disorders Coagulation disorders Bleeding from superficial cuts and scratches Persistent,often profuse Minimal Delayed bleeding Rare Common Spontaneous gingival bleeding Characteristic Rare Petechiae Characteristic Rare Ecchymoses Small and multiple Large and solitary Epistaxis Common Common Deep disecting hematomas Rare Characteristic Hemarthroses Rare Characteristic
- 32. Oral manifestations • Petechiae •Ecchymoses • Spontaneous gingival bleeding
- 33. Contd…. • Brown coloredteeth due to depositsof hemosiderin as a result of continous long term bleeding. • Hemarthrosis (rarely)
- 34. DENTAL MANAGEMENT • Dentalmodifications required for the patient depends on 1. type and invasiveness of the dental procedure and 2. Type and severity of bleeding disorder
- 35. • For reversiblecoagulopathies: Remove the causative agent (eg:coumarin anticoagulants) Treat the primary illness or defect to allow pt. to return to manageable bleeding risk for the dental treatment period For irreversible coagulopathies: Defective element may need to be replaced from exogenous source
- 36. Consultation with hematologist Thismay involve treatment either in specialized hospital facilities or local general dentist’s office
- 37. PLATELET DISORDERS • Plateletlevel >50,000mm3 required prior to surgical procedures. • Avoidance of aspirin therapy recommended 1 week prior to extensive oral surgical procedures • Aspirin is rarely witheld in case of minor oral surgical procedures such as extraction where local hemostatic agents can be use
- 38. • When extensivesurgery in emergency is indicated DDAVP can be used • DDAVP decreases the aspirin induced prolongation of BT and prevents post operative oozing
- 39. Considerations in HEMOPHILIA Aand B and vWD
- 40. ORAL SURGICAL PROCEDURES •Surgical treatment, including a simple dental extraction, must be planned to minimize the risk of bleeding, excessive bruising, or hematoma formation. • Emergency surgical intervention in dentistry is rarely required as pain can often be controlled without resorting to an unplanned treatment. • All treatment plans must be discussed with the hemophilia unit if they involve the use of prophylactic cover.
- 41. PREVENTIVE AND PERIODONTAL THERAPY •Periodontal probing and supragingival scaling can be done routinely • Severly inflamed and swollen tissues are best treated initially with chlorhexidine oral rinses and gross debridement with hand instruments to allow gingival shrinkage
- 42. • Deep subgingivalscaling and root planing should be performed quadrant wise • Locally applied pressure and post-treatment anti-fibrinolytics oral rinses are successful in controlling protracted oozing. • Periodontal surgical procedures requires prior elevation of circulating factor levels by 50% and use of post treatment antifibrinolytics.
- 43. RESTORATIVE AND PROSTHODONTIC THERAPY •Rubber dam isolation advised to minimize the risk of lacerating soft tissue and avoid creating ecchymoses and hematomas with high speed evacuators or saliva ejectors • Removable prosthodontic appliances can be fabricated without complications Denture trauma should be minimized
- 44. ENDODONTIC THERAPY • Instrumentationshould not extend beyond apex • Filling beyond the apical seal also should be avoided • Application of epinephrine intrapulpally to apical area provides hemostasis
- 45. PEDIATRIC DENTAL THERAPY •Administration of factor concentrate before extraction • Pulpotomies to be performed without excessive pulpal bleeding • Topical fluoride application • Pit and fissure sealant
- 46. ORTHODONTIC THERAPY • Caremust be taken to avoid mucosal laceration by orthodontic bands, brackets and wires. • Fixed orthodontic appliance prefered over removable functional appliance • Use of extraoral force and • shorter treatment duration
- 47. PAIN CONTROL • Selectionof pain control method based on patient’s pain threshold and invasiveness of the procedure • Hypnosis, IV diazepam, nitrous oxide/oxygen analgesia can be used • Anesthetic with vasoconstrictor should be used when possible
- 48. • Hemostatic cover(20-30%)required for: inferior alveolar ,posterior superior alveolar,infraorbital, lingual and long buccal nerve block As these injections place anesthetic solutions in highly vascularised loose connective tissue with no distinct boundaries where formation of dissecting hematoma is possible
- 49. • Hemostatic covernot required for: Intrapulpal, periodontal ligament, gingival papillary anesthesia In mild disease-buccal, labial and palatal infiltration for maxillary teeth can be attempted slow injection and local pressure for 3-4 minutes
- 50. PATIENTS ON ANTICOAGULANTS • HigherINR result in high bleeding risk • Non surgical dental treatment can be successfully accomplished without alteration of anti coagulant regimen
- 51. • For surgicalprocedures, physician consult is advised • Thromboembolic complication is small and hemorrhagic risk is high coumarin therapy can be discontinued 2 days prior to surgery with prompt reinstitution post operatively. • Moderate thromboembolic and hemorrhagic risks-coumarin therapy can be maintained within therapeutic range and local measures used to control postoperative oozing
- 52. • High thromboembolicand hemorrhagic risk- requires hospitalization Managed with combination unfractioned heparin-coumarin method Coumarin is withheld 24 hrs prior to surgery Heparin therapy instituted on admission is stopped 6-8 hours preoperatively Coumarin reinstituted on the night of the procedure heparin reinstituted 6-8 hrs after surgery when adequate clot has formed
- 53. • Use ofaditional hemostatic agents recommended
- 54. CONCLUSION • Pre-operative assessment: –Proper history • Medical history • Family history • Drug intake history • General physical examination • Oral examination
- 55. • Lab investigations –Full blood count,platelet count – PT and INR – APTT – TT – Serum for blood grouping and cross-matching • Assess if hemostatic cover is required • Consult with patient’s physician for drugs like aspirin, warfarin to be discontinued before procedure
- 56. • Warn thepatient about intra and post operative bleeding • Consider using antifibrinolytic agents a day before the surgery
- 57. • Peri-operative procedure: –The factor that is deficient must be arranged – Local hemostatic agents should be used – Bleeding must be controlled
- 58. • post-operative care: –Prevention of infection – Management of post-operative bleeding • Tranxenamic acid can be used – Reinstitution of the oral anticoagulants
- 60. Which of thefollowing phase does not prevent bleeding? a) Vascular phase b) Platelet phase c) Coagulation phase d) Fibrinolytic phase
- 61. Hemostatic cover isrequired in patients with bleeding disorder in following anesthetic techniques: a)Inferior alveolar nerve block b)Buccal infiltration c)Lingual nerve block d)a and c both e)All of the above
- 62. When extensive surgeryis indicated aspirin should be avoided prior to a) 2 days b) 24 hours c) 7 days d) Not required
- 63. Patients on anti-coagulanttherapy with high thromboembolic and hemorrhagic risk is managed by a) coumarin therapy can be discontinued 2 days prior to surgery b) combination unfractioned heparin- coumarin method c) Aspirin therapy d) None
- 64. References • Burket’s OralMedicine - 1Oth&11th Edition • Textbook of oral medicine -2nd Edition ByAnil Ghom • Davidson’s principles and practice of medicine- 20th Edition • Medical problems in dentistry-6th Edition- crispian scully