Oral consideration and laboratory investigations of bleeding and clotting disorder
-
Upload
kashmira483 -
Category
Health & Medicine
-
view
117 -
download
10
Transcript of Oral consideration and laboratory investigations of bleeding and clotting disorder
![Page 1: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/1.jpg)
BLEEDING AND
CLOTTING DISORDERS
RESOURCE FACULTY
DR.JYOTSNA RIMAL
Additional professor & HOD
DR.ICHHA KUMAR MAHARJAN
Associate professor
ORAL CONSIDERATION &LABORATORY INVESTIGATIONS OF
PRESENTER:KASHMIRA POKHREL483BDS-2011
Department of oral medicine and radiology
![Page 2: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/2.jpg)
CONTENTS
• PATHOPHYSIOLOGY• BLEEDING DISORDERS• COAGULATION DISORDERS• LABORATORY INVESTGATIONS• ORAL MANIFESTATIONS• DENTAL CONSIDERATION• DENTAL MANAGEMENT• CONCLUSION
![Page 3: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/3.jpg)
PATHOPHYSIOLOGY
• Hemostasis can be 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
![Page 4: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/4.jpg)
VASCULAR PHASE
Tissue injury
Vasoconstriction of the microvascular bed
Serotonin, histamine,PG’s
![Page 5: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/5.jpg)
PLATELET PHASECirculating platelets exposed to
vascular injury
Normal vWF, endothelial cells, collagen, basement membrane, elastin, microfibrils and other cellular debris
Physical and chemical changes
Aggregation of platelet
Primary platelet plug (adheres to basement membrane)
ADP
Increase in size of plug
PF-3
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
![Page 6: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/6.jpg)
COAGULATION CASCADE
![Page 7: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/7.jpg)
![Page 8: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/8.jpg)
FIBRINOLYTIC PHASE
![Page 9: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/9.jpg)
• VESSEL WALL DISORDERS
• PLATELET DISORDERS
• COAGULATION DISORDERS
CLASSIFICATION
![Page 10: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/10.jpg)
• Scurvy
• Cushing’s syndrome
• Ehlers-Danlos syndrome
• Rendu-Osler-weber syndrome
VESSEL WALL DISORDERS
![Page 11: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/11.jpg)
• Thrombocytopenic(quantative platelet deficiency)
1.May-hegglin anomaly
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
![Page 12: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/12.jpg)
ACQUIRED • Thrombocytopenic(quantitative)
1. Autoimmune or 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
![Page 13: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/13.jpg)
• Nonthrombocytopenic
(qualitative)
1. Drug induced(aspirin,NSAIDS,penicillin,cephalosporin)
2. Uremia
3. Alcohol dependency
4. Liver disease
5. Myeloma
6. Acquired platelet type vWD
![Page 14: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/14.jpg)
• CONGENITAL COAGULOPATHIES1. Hemophilia A&B
2. Factors deficiency
3. von Willebrand’s disease
• ANTICOAGULANT -RELATED COAGULOPATHIES1. Heparin
2. Coumarin
• DISEASE-RELATED COAGULOPATHIES1. Liver disease
2. Vitamin K deficiency
3. Disseminated intravascular coagulation
4. Fibrinolytic disorders
COAGULATION DISORDERS
![Page 15: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/15.jpg)
• History taking
• Physical examination
• Laboratory Investigations
• Observation
IDENTIFICATION OF PATIENT WITH BLEEDING DISORDER
![Page 16: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/16.jpg)
HISTORY TAKINGH/O frequent• epistaxis,
• spontaneous gingival and mucosal bleeding,
• prolonged bleeding from superficial cuts
• Excessive menstrual flow
• Easy bruising
• hematuria
![Page 17: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/17.jpg)
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
![Page 18: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/18.jpg)
Physical examination
• Jaundice
• Petechiae
• Ecchymosis
• Hemarthrosis
![Page 19: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/19.jpg)
Laboratory investigations
• Normal 150,000-450,000/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
![Page 20: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/20.jpg)
Prothrombin time and INR
• 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
![Page 21: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/21.jpg)
aPTT(activated partial thromboplastin time)
• 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.
![Page 22: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/22.jpg)
• Tests ability to form initial clot from fibrinogen
• Normal - 9 to 13 seconds
• Evaluates the presence of D-dimer of fibrinogens
TT(Thrombin Time)
Fibrin Degradation products
![Page 23: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/23.jpg)
• Normal-60 to 150%
• Torniquet test to assess Rumpel-leede phenomenon
Factor assays
Tests of capillary Fragility
![Page 24: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/24.jpg)
Bleeding Disorder Platelet Count
PT/ INR aPTT BT
Thrombocytopenia Leukemia
F VIII, IX, XI deficiencyHeparin anticoagulation
F II, V, X deficiencyVitamin K deficiencyIntestinal malabsorption
F VII deficiencyCoumarin anticoagulationLiver disease
von Willebrand’s disease
DICSevere 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
↑
![Page 25: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/25.jpg)
Principal Agents for Systemic ManagementAgent 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 mLContains 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
![Page 26: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/26.jpg)
Factor IX concentrate
1 unit raises factor IX level 1–1.5%
Hemophilia B, with active bleeding or presurgery
Desmopressin Synthetic analogue of antidiuretic hormone0.3μg/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 anybleeding disorder
Tranexamic acid
Antifibrinolytic: 4.8% mouth rinse Systemic: 25mg/kg every 8 hrs
Adjunct to support clot formation for anybleeding disorder
![Page 27: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/27.jpg)
Local hemostatic agents• ABSORBANT GELATIN SPONGE
(GELFOAM)
Dental size - 20x20x7mm3
• OXIDISED CELLULOSE
(SURGICEL)
![Page 28: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/28.jpg)
• TOPICAL THROMBIN• Obtained from bovine plasma• Applied as dry powder or freshly prepared
solution
• TRANXENAMIC ACID• 500mg tablets• 1000mg/10ml injection
![Page 29: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/29.jpg)
• Epsilon Amino caproic Acid• 50mg/kg• Oral rinse 250mg/ml
• Fibrin sealants/Fibrin glue• Cryoprecipitate• 10,000units thrombin powder• 10ml saline• 10ml Calcium Chloride
![Page 30: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/30.jpg)
• Application of local pressure
• suture
![Page 31: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/31.jpg)
Clinical features of bleeding 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
![Page 32: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/32.jpg)
Oral manifestations • Petechiae
• Ecchymoses
• Spontaneous gingival bleeding
![Page 33: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/33.jpg)
Contd….
• Brown colored teeth due to depositsof hemosiderin as a result of continous long term bleeding.
• Hemarthrosis (rarely)
![Page 34: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/34.jpg)
DENTAL MANAGEMENT
• Dental modifications required for the patient depends on
1. type and invasiveness of the dental procedure and
2. Type and severity of bleeding disorder
![Page 35: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/35.jpg)
• For reversible coagulopathies:
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
![Page 36: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/36.jpg)
Consultation with hematologist
This may involve treatment either in specialized hospital facilities or local general dentist’s office
![Page 37: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/37.jpg)
PLATELET DISORDERS• Platelet level >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
![Page 38: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/38.jpg)
• When extensive surgery in emergency is indicated DDAVP can be used
• DDAVP decreases the aspirin induced prolongation of BT and prevents post operative oozing
![Page 39: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/39.jpg)
Considerations in
HEMOPHILIA A and B and vWD
![Page 40: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/40.jpg)
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.
![Page 41: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/41.jpg)
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
![Page 42: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/42.jpg)
• Deep subgingival scaling 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.
![Page 43: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/43.jpg)
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
![Page 44: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/44.jpg)
ENDODONTIC THERAPY• Instrumentation should not extend beyond
apex
• Filling beyond the apical seal also should be avoided
• Application of epinephrine intrapulpally to apical area provides hemostasis
![Page 45: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/45.jpg)
PEDIATRIC DENTAL THERAPY• Administration of factor concentrate before
extraction
• Pulpotomies to be performed without excessive pulpal bleeding
• Topical fluoride application
• Pit and fissure sealant
![Page 46: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/46.jpg)
ORTHODONTIC THERAPY• Care must 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
![Page 47: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/47.jpg)
PAIN CONTROL• Selection of 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
![Page 48: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/48.jpg)
• 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
![Page 49: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/49.jpg)
• Hemostatic cover not 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
![Page 50: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/50.jpg)
PATIENTS ON ANTICOAGULANTS
• Higher INR result in high bleeding risk
• Non surgical dental treatment can be successfully accomplished without alteration of anti coagulant regimen
![Page 51: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/51.jpg)
• For surgical procedures, 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
![Page 52: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/52.jpg)
• High thromboembolic and hemorrhagic risk-requires hospitalization
Managed with combination unfractioned heparin-coumarin method
Coumarin is withheld 24 hrs prior to surgeryHeparin therapy instituted on admission is
stopped 6-8 hours preoperativelyCoumarin reinstituted on the night of the
procedure heparin reinstituted 6-8 hrs after surgery
when adequate clot has formed
![Page 53: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/53.jpg)
• Use of aditional hemostatic agents recommended
![Page 54: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/54.jpg)
CONCLUSION• Pre-operative assessment:
– Proper history• Medical history• Family history• Drug intake history
• General physical examination
• Oral examination
![Page 55: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/55.jpg)
• 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
![Page 56: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/56.jpg)
• Warn the patient about intra and post operative bleeding
• Consider using antifibrinolytic agents a day before the surgery
![Page 57: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/57.jpg)
• Peri-operative procedure:– The factor that is deficient must be
arranged
– Local hemostatic agents should be used
– Bleeding must be controlled
![Page 58: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/58.jpg)
• post-operative care:
– Prevention of infection
– Management of post-operative bleeding• Tranxenamic acid can be used
– Reinstitution of the oral anticoagulants
![Page 59: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/59.jpg)
MCQ
![Page 60: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/60.jpg)
Which of the following phase does not prevent bleeding?
a) Vascular phase
b) Platelet phase
c) Coagulation phase
d) Fibrinolytic phase
![Page 61: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/61.jpg)
Hemostatic cover is required 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
![Page 62: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/62.jpg)
When extensive surgery is indicated aspirin should be
avoided prior toa) 2 days
b) 24 hours
c) 7 days
d) Not required
![Page 63: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/63.jpg)
Patients on anti-coagulant therapy with high thromboembolic and
hemorrhagic risk is managed bya) coumarin therapy can be discontinued 2
days prior to surgery
b) combination unfractioned heparin-coumarin method
c) Aspirin therapy
d) None
![Page 64: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/64.jpg)
References
• Burket’s Oral Medicine - 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
![Page 65: Oral consideration and laboratory investigations of bleeding and clotting disorder](https://reader031.fdocuments.net/reader031/viewer/2022012322/55c46cf0bb61eb22438b4829/html5/thumbnails/65.jpg)