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 POKHREL 483 BDS-2011 Department of oral medicine and radiol
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Oral consideration and laboratory investigations of bleeding and clotting disorder
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• Brown colored teeth due to depositsof hemosiderin as a result of continous long term bleeding.
• Hemarthrosis (rarely)
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
• 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
Consultation with hematologist
This may involve treatment either in specialized hospital facilities or local general dentist’s office
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
• When extensive surgery in emergency is indicated DDAVP can be used
• DDAVP decreases the aspirin induced prolongation of BT and prevents post operative oozing
Considerations in
HEMOPHILIA A and B and vWD
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.
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
• 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.
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
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
PEDIATRIC DENTAL THERAPY• Administration of factor concentrate before
extraction
• Pulpotomies to be performed without excessive pulpal bleeding
• Topical fluoride application
• Pit and fissure sealant
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
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
• 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
• 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
PATIENTS ON ANTICOAGULANTS
• Higher INR result in high bleeding risk
• Non surgical dental treatment can be successfully accomplished without alteration of anti coagulant regimen
• 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
• 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
• Use of aditional hemostatic agents recommended
CONCLUSION• Pre-operative assessment:
– Proper history• Medical history• Family history• Drug intake history
• General physical examination
• Oral examination
• 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
• Warn the patient about intra and post operative bleeding
• Consider using antifibrinolytic agents a day before the surgery
• Peri-operative procedure:– The factor that is deficient must be
arranged
– Local hemostatic agents should be used
– Bleeding must be controlled
• post-operative care:
– Prevention of infection
– Management of post-operative bleeding• Tranxenamic acid can be used
– Reinstitution of the oral anticoagulants
MCQ
Which of the following phase does not prevent bleeding?
a) Vascular phase
b) Platelet phase
c) Coagulation phase
d) Fibrinolytic phase
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
When extensive surgery is indicated aspirin should be
avoided prior toa) 2 days
b) 24 hours
c) 7 days
d) Not required
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
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