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Dental health care workers are increasingly called upon to provide quality dental care to individuals whose bleeding and clotting mechanisms have been altered by inherited or acquired diseases. A number of dental procedures result in the risk of bleeding that can have serious consequences, such as severe hemorrhage or possibly death.
Dental health care workers are increasingly called upon to provide quality dental care to individuals whose bleeding and clotting mechanisms have been altered by inherited or acquired diseases. A number of dental procedures result in the risk of bleeding that can have serious consequences, such as severe hemorrhage or possibly death.
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Dental health care workers are increasingly called upon to provide quality dental care to individuals whose bleeding and clotting mechanisms have been altered by inherited or acquired diseases. A number of dental procedures result in the risk of bleeding that can have serious consequences, such as severe hemorrhage or possibly death.
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Attribution Non-Commercial (BY-NC)
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Unduh sebagai PPT, PDF, TXT atau baca online dari Scribd
GUIDED BY: DR. RAJESH K. THAKUR M.D.S. CONTENTS INTRODUCTION PATHOPHYSIOLOGY Basic Mechanisms of Hemostasis and Their Interactions Vascular Phase Platelet Phase Coagulation Phase Fibrinolytic Phase CLINICAL AND LABORATORY FINDINGS Clinical Manifestations Clinical Laboratory Tests CLASSIFICATION OF BLEEDING DISORDERS Vessel Wall Disorders Platelet Disorders Coagulation Disorders Fibrinolytic Disorders
IDENTIFICATION OF THE DENTAL PATIENT WITH A BLEEDING DISORDER
MANAGEMENT Platelet Disorders Hemophilias A and B Von Willebrands Disease Disease-Related Coagulopathies PROGNOSIS ORAL HEALTH CONSIDERATIONS Oral Findings Dental Management CONCLUSION REFERENCES INTRODUCTION Dental health care workers are increasingly called upon to provide quality dental care to individuals whose bleeding and clotting mechanisms have been altered by inherited or acquired diseases. This provides an opportunity for the dentist who is trained in the recognition of oral and systemic signs of altered hemostasis to assist in the diagnosis of the underlying condition. A number of dental procedures result in the risk of bleeding that can have serious consequences, such as severe hemorrhage or possibly death, for the patient with a bleeding disorder. Safe dental care may require consultation with the patients physician, systemic management, and dental treatment modifications.
BLOOD It is a fluid, which circulates in the vascular channels of human body due to the pumping action of heart. It consists of a liquid portion PLASMA in which various types of cells are present .The cells are of 3 types.
1. Erythrocytes of Red Blood Cells. normal count: males:- 4.5-6.5 million / cu mm females:- 4.0-5.6million / cu mm
2. Leucocytes or white blood cells. TLC:- 4000- 11,000 / cu mm
3. Thrombocytes or platelets Round or oval disc (2-4) Normal 150,000- 350,000/cu mm Half life- 8-12 days
PLASMA Fluid part of blood. Relative quantity of plasma and cells is in ratio of 55:45.
COMPOSITION : Plasma proteins (6.5 to 8 gm%). Glucose (80-120 mg%). Cholesterol & lipid (150-250 mg%). Non protein nitrogenous substance like urea, uric acid, creatinine etc. Hormones, enzymes etc.
Plasma proteins are of 3 types.
1. Albumin 2. Globulin 3. Fibrinogen
PATHOPHYSIOLOGY OHemostasis means preventions of blood loss. OWhenever a vessel is ruptured, hemostasis is achieved by different mechanisms, including Vascular phase Platelet phase Coagulation phase Fibrinolytic phase
Vascular Phase
If the blood vessel is cut or ruptured, the stimulus of the traumatized vessel causes the wall of the vessel to contract. This reduces the flow of the blood from the vessel rupture. The contraction results from nervous reflexes, local myogenic spasm, and local humoral factors from the traumatized tissues and blood platelets.
Platelet Phase OPlatelet have many functional properties as follows; Actin and myosin molecules, similar to those found in muscle cells, as well as another contractile protein, thrombosthenin Residuals of both the endoplasmic reticulum and the Golgi apparatus Mitochondria and enzymes systems that are capable of forming adenosine triphosphate and adenosine diphosphate
Enzymes systems that synthesize prostaglandins Fibrin stabilizing factor Growth factor
OMechanism of the platelet plug When platelet come in contact with a damaged vascular surface, such as the collagen fibers in the vascular wall or damaged endothelial cells They begin to swell; they assume irregular forms with numerous irradiating processes protruding from their surfaces
Their contractile proteins contract forcefully and cause the release of granules containing multiple active factors They become sticky so that they stick to the collagen fibers They secrete large quantities of ADP and their enzymes form thromboxane A2 The ADP and thromboxane act on platelets to activate them and the stickiness of these additional platelets cause them to adhere to the originally activated platelets. Therefore at the site of damaged vascular wall or extravascular tissues elicit a vicious cycle of activation of increasing numbers of platelets that attract more and more additional platelets, thus forming a platelet plug. Coagulation Phase OThe generation of thrombin and fibrin the end product of the third phase of hemostasis, the coagulation phase. OThis process involves multiple proteins, many of which are synthesized by the liver (fibrinogen, prothrombin, V, VII, IX, X, XI, XII, and XIII) and are vitamin K dependent ( II, VII, IX, X).
THE CLOTTING MECHANISM INTRINSIC MECHANISM
The intrinsic pathway is initiated when F XII is activated by surface contact (e.g. with collagen or subendothelium), and it involves the interaction of F XI. The next step of intrinsic coagulation, the activation of F IX to F XIa. Once activated, F IXa forms a complex with F VIII, in a reaction that requires the presence of both calcium ions and phospholipids, which, in turn, converts FX to an activated form F Xa.
EXTRINSIC MECHANISM
The extrinsic pathway is initiated by the release of tissue thromboplastin, also called tissue factor, and does not require contact activation. Tissue thromboplastin binds to F VII in the presence of calcium, and this complex is capable of activating F IX and X, linking the intrinsic and extrinsic pathways.
Fibrinolytic Phase It is the major means of disposing of fibrin after its hemostatic function has been fulfilled.
Hemostasis Dependent upon: *Vessel Wall Integrity - Adequate Numbers of Platelets 4 Proper Functioning Platelets ^ Proper Function of Fibrinolytic Pathway ^Adequate Levels of Clotting Factors
CLINICAL AND LABORATORY FINDINGS Clinical Manifestations Clinical Laboratory Tests
Clinical Manifestations Clinical manifestations of bleeding disorders can involve various systems, depending on the extent and type of disease. Individuals with mild disease may present with no clinical signs, whereas individuals with severe coagulopathies may have definite stigmata.
When skin and mucosa are involved, individuals may present with petechiae, ecchymoses, spider angiomas, hematomas, or jaundice.
Clinical Laboratory Tests Common laboratory test that help to identify deficiency of required elements or dysfunction of the phases of coagulation.
PLATELET COUNT BLEEDING TIME (BT) PROTHROMBIN TIME (PT) PARTIAL THROMBOPLASTIN TIME (PTT) THROMBIN TIME (TT)
PLATELET COUNT The two clinical tests used to evaluate primary hemostasis are the platelet count and bleeding time.
ONORMAL 100,000 - 400,000 CELLS/MM 3
< 100,000
Thrombocytopenia
50,000 - 100,000 Mild Thrombocytopenia
< 50,000 Severe Thrombocytopenia
BLEEDING TIME It is the time taken from puncture of the blood vessel to the stoppage of bleeding PROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTION
NORMAL VALUE 2-6 MINUTES
PROTHROMBIN TIME It is a test that measures how much time blood takes to clot Measures Effectiveness of the Extrinsic Pathway
NORMAL VALUE 10-15 SECS PARTIAL THROMBOPLASTIN TIME
Measures Effectiveness of the Intrinsic Pathway Measures coagulation disorders. NORMAL VALUE 25-40 SECS THROMBIN TIME Is a measure of the rate of conversion of fibrinogen to fibrin
Time taken for Thrombin to Convert Fibrinogen to Fibrin A Measure of Fibrinolytic Pathway
NORMAL VALUE 9-13 SECS CLASSIFICATION BLEEDING DISEASES Vessel Wall Disorders
HEMORRHAGIC DISORDER DUE TO PLATELET ABNORMALITIES
ACQUIRED Vitamin K deficiency Liver disease Anti-coagulant drugs Disseminated intravascular coagulation Massive transfusion of stored blood
CONGENITAL Haemophilias Von willebrands disease Other congenital deficiency disorders Fibrinogen deficiency Prothrombin deficiency Factor V deficiency Factor VII deficiency Factor X deficiency Factor XI deficiency Factor XII deficiency Factor XIII deficiency
HEMORRHAGIC DISORDER DUE TO COAGULATION ABNORMALITIES THE SYMPTOMATIC VASCULAR PURPURAS (Non thrombocytopenic)
Aquired vascular disorder. - The term symptomatic vascular purpura is used to describe the purpura occurring in association with number of disorders. - Alterations in capillaries resulting in capillary fragility. - Some causes are Infections
Cushings disease and corticosteroids administration
Scurvy
Dysproteinaemias
Henoch-Schoenlein syndrome Scurvy: Results from vit C deficiency
Clinical manifestations:. Impairement in the synthesis of collagen & 0r antioxidant property of vit C Blood vessel fragility resulting in vascular purpura Decreased immunocompetence Delayed wound healing Hemorrhage Osteopororosis Swollen joints
Oral manifestations: +Interdental & marginal gingiva is bright red with swollen smooth surface. +In advance cases gingiva becomes boggy, ulcerates and bleeds. In severe chronic cases, hemorrhage and swelling of the periodontal membrane occurs, followed by loss of bone, loosening of teeth & exfoliation.
Treatment: + Administration of vitamin C + Vitamin C intake normal: infants- 35mg adults- 60mg
(a) Upper and lower generalized gingivitis characterized by haemorrhagic and necrotic interdental papillae;
Congenital haemorrhagic vascular disorder Autosomal dominant disorder identified typically by the triad of: + Telangiectasis + Recurrent epitaxis + Positive family history Development of abnormal vasculature, defects in endothelial cell junctions, endothelial cell degeneration and weakness of perivascular connective tissue dilatation of capillaries, and arteriovenous malformation. CLINICAL FEATURES
Most common sites are the skin and mucous membranes of nose and mouth. May also occur in conjunctiva, bronchi, gastrointestinal and renal tracts and in vagina.
The telangiectatic spots range in size from a pin point to lesions upto several mm in diameter, vary in colour from purple to bright red and they blanch on pressure.
The lesion tend to become more numerous and larger with advancing age.
Bleeding may occur either spontaneously or following mild trauma. Epistaxis is the most common symptom.
lesions of oral cavity- gingiva, buccal mucosa, palate, floor of the mouth and tongue.
Blanching round and reticulated reddish- purple plaques Treatment : Spontaneous hemorrhage may be controlled by pressure packs.
The angiomatous and telangiectatic areas are sometimes cauterized, treated with X-ray radiation or surgically excised.
Epistaxis is usually the most common problem requiring treatment. Short terms measures includes nasal packing.
The main long term treatment is the administration of larger dosages of oestrogen. (dose 0.25 mg per day ethinyl oestradies. Thrombocytopenic purpura: Quantitative Platelet Defect It can be Primary- unknown cause (idiopathic thrombocytopenic purpura) Secondary- which may be due to wide variety of situations thrombotic thrombocytopenic purpura
SECONDARY THROMBOCYTOPENIA : is defined as a decreasing in the peripheral blood platelet count below the lower normal limit (<1,50,000 per cubic mm).
Causes of thrombocytopenia
1. Impaired platelet production. a. Generalised marrow failure Aplastic anaemia Leukaemia Myelofibrosis Megaloblastic anaemia Marrow infiltrations b. Selective suppression of platelet production Drugs (quinine, sulpha drugs, rifampicin, anti metabolites)
2; Increased consumption or destruction of platelets. Disseminated intravascular coagulation Idiopathic thrombocytopenic purpura Gram negative septicaemia Viral infections
3; Splenic sequestration Hypersplenism Lymphoma Liver disease Peripheral smear of a patient reported to have platelet counts of 10,000- 150,000/mL on various occasions. The smear shows clumping of the platelets and satellitism involving neutrophils and platelets. Investigations: > 1,00,000 per cubic mm asymptomatic and bleeding time remains normal.
between 50,000 to 1,00,000 per cubic mm prolong BT and bleeding occurs only with severe trauma < 50,000 counts easy bruising which is manifested by purpura or bleeding with minor trauma.
< 20,000 / cubic mm spontaneous bleeding such as petechiae or may have internal bleeding.
Leukemia: Increased overproduction of WBCs Appear in circulating blood in an immature form Any of WBCs may be involved lymphoid myeloid Etiology unknown but may be due to viral infections (EB virus), chromosomal abnormality etc. Acute- survival< 6months chronic- over 1yr subacute- b/w the two CLASSIFICATION OF LEUKEMIA Acute lymphocytic leukemia Acute Lymphoblastic Leukemia, or ALL) is the most common type of leukemia in young children. This disease also affects adults, especially those age 65yrs and older.
Anemia, thrombocytopenia. Leukocyte count rises to 100,000 or more cell per cubic mm. Increase in lymphoid cells in the differential count. Acute myelogenous leukemia (also known as Acute Myeloid Leukemia, or AML) occurs more commonly in adults than in children Predominant cell often resembles the myeloblast. Chronic lymphocytic leukemia (CLL) most often affects adults over the age of 55. It sometimes occurs in younger adults, but it almost never affects children.
Anemia and thrombocytopenia. WBC count> 500,000 cells percubic mm Differential count of lymphoid cells elevated. Chronic myelogenous leukemia (CML) A very small number of children also develop this disease.
_
Acute myelogenous leukemia Leukemia Cell GINGIVAL ENLARGEMENT Clinical menifestations: Damage to the bone marrow, by way of displacing the normal bone marrow cells with higher numbers immature white blood cells, results in a lack of blood platelets, which are important in the blood clotting process. Patients with with leukemia may become bruised, bleed excessively, or develop pinprick bleeds (petechiae). White blood cells, may be suppressed or dysfunctional, putting the patient at the risk of developing infections. Finally, the red blood cell deficiency leads to anemia, All symptoms may also be attributable to other diseases; for diagnosis, blood tests and a bone marrow biopsy are required. Oral menifestations: + Gingivitis + Gingival hyperplasia(Such lesions may occur due to direct leukaemic infiltration of tissues, or be secondary to immunodeficiency, anemia and thrombocytopenia.) + Hemorrhage + Petechiae + Ulceration of the mucosa , rapid loosening of the teeth due to necrosis of periodontal ligament.
Treatment: Bone marrow transplant Chemotherapeutic drugs Radiation therapy Corticosteroids etc Aplastic anemia: The term 'aplastic' means the marrow suffers from an aplasia that renders it unable to function properly Typically, anemia refers to low red blood cell counts, but aplastic anemia patients have lower counts of all three blood cell types: red blood cells, white blood cells, and platelets Causes: One known cause is an autoimmune disorder, where the white blood cells attack the bone marrow. Exposure to radiation (radiation sickness) Chemotherapy Environmental toxins (insecticides, benzene, nitrogen mustards) Many different medications, including chloramphenicol (Chloromycetin), phenylbutazone (Butazolidin), sulfonamides (Gantanol and others), anticonvulsants, cimetidine (Tagamet) and others Certain viral infections, including viral hepatitis, parvovirus B19, human immunodeficiency virus (HIV) and infectious mononucleosis (Epstein-Barr viral infection)
Clinical features Pale skin Fatigue Weakness Dizziness Light-headedness Rapid pulse Heart murmur Bruising and tiny areas of bleeding in the skin Abnormal bleeding from the gums, nose, vagina or gastrointestinal tract, or blood in the urine Infections
Treatment: bone marrow transplant is the most effective therapy Some patients will be treated with immunosuppressive medications instead of bone marrow transplantation. Like anti-thymocyte globulin (Thymoglobulin), known as ATG; antilymphocyte globulin (ALG); prednisone (Deltasone, Orasone, Meticorten); and cyclosporine (Neoral, Sandimmune, SangCya). Blood-cell production also can be stimulated with erythropoietin, granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony- stimulating factor (GM-CSF) or other hematopoietic growth factor medications. Megaloblastic anemia Megaloblastic anemia is an anemia (of macrocytic classification) which results from a deficiency of vitamin B12 and folic acid. It is characterized by many large immature and dysfunctional red blood cells (megaloblasts) in the bone marrow Causes: nutritional defects (vitamin B12 is mainly from animal sources, and vegans may require supplementation) chronic liver diseases alcoholism pregnancy decreased production of intrinsic factor (this disease entity is called pernicious anemia) intestinal malabsorption (due to an enteritis, celiac disease or other causes). Folate and Vitamin B12 Interaction
Tetrahydrofolate is necessary for DNA synthesis Cobalamin and folate are cofactors for tetrahydrofolate production Deficiency of either impairs cell division in the bone marrow while RNA and protein synthesis continues enlarged erythrocytes Cobalamin deficiency impairs synthesis of S- adenosylmethionine necessary for proper nervous system functioning Investigations:
The RBC are almost as large as the lymphocyte. Note the hypersegmented neurotrophil. There are fewer RBCs. Decreased red blood cell (RBC) count and hemoglobin levels The platelet count may be reduced. Neutrophil granulocytes may show multisegmented nuclei ("senile neutrophil"). This is thought to be due to decreased production and a compensatory prolonged lifespan for circulating neutrophils IDIOPATHIC THROMBOCYTOPENIC PURPURA Quantitative platelet defect
Autoimmunity is thought to be one of the cause + Auto antibodies are formed against the membrane glycoprotein, leading accelerated destruction and removal of platelets. + Some patient have absence of platelet stimulating or megakaryocyte ripeneing factor.
Clinical manifestation On the basis of duration of illness, ITP is classified into acute and chronic forms. + Acute form is self limiting disorder observed frequently in children recovering from a viral illness (eg- hepatitis) or an upper respiratory tract infection. + Spontaneous appearance of purpuric or hemorrhagic lesions of the skin + Epitaxis is common. Bleeding in urinary tract (hematuria), GIT producing melena, intracranial hemmorhage + Many cases occur before 30yrs of age
One Plasmacytoid Lymphocyte. Idiopathic thrombocytopenic purpura (ITP) blood - 100X , giant platelets Purpura rash on the forearm Multiple lesions on the face, lips and tongue. +Investigations:
BT is prolonged Platelet count in blood film examination is decreased. platelet count <60,000/cu mm. coagulation time normal (failure of retraction) torniquet test strongly positive (capillary fragility ) Bone marrow shows increase megakaryocytes indicating peripheral destruction of platelet Giant platelets in peripheral blood smear.
TREATMENT :
No specific treatment +Trauma & agents likely to interfere with platelet function ex- aspirin, alcohol must be forbidden.
+The main therapeutic measures are the administration of corticosteroids and splenectomy .
+Persistent bleeding or internal. bleeding-platelet transfusions IV Immunoglobulin are indicated in selected cases.
DEFECTS IN PLATELET ENZYMES
Qualitative platelet defect Familial deficiency of the enzymes, cyclo-oxygenase and thromboxane synthetase involved in the metabolism of arachidonic acid and production of thromboxane A2.
The bleeding defect is mild and it is of clinical significance only in the case of serious trauma or surgery.
BT is prolonged.
Platelet aggregation to ADP, collagen and arachidonic acid is abnormal.
Platelet transfusion to cover trauma or surgery is usually the only therapy required.
HEMOPHILIA ( bleeders disease, disease of Hapsburgs, the disease of kings) Congenital coagulation abnormality. +Defect carried by X chromosome, and is transmitted as a gender linked mendelian recessive trait ; thus hemophilia occurs only in males. +Heterozygous daughters carry the defect to half of their sons and as a recessive trait to half of their daughters.
Persistent bleeding ( spontaneous or mild trauma) Usually present at birth (30-50%), but may not become clinically apparent for years. Hemophilia classified according to clinical severity as:
Haemophilia is characterized by bleeding into subcutaneous tissue, muscle, weight bearing joints, internal organs etc. (hematomas)
Classification Factor activity % Cause of hemorrhage Mild >5 Major trauma or surgery Moderate 1-5 Mild to moderate trauma Severe <1 Spontaneous, soft tissue bleeding In Hemophilia C, absence of bleeding into joints and muscles Haematuria is common. The most feared site of bleeding is central nervous system which is frequently fatal.
Oral manifestations: +Gingival hemorrhage ( even in tooth eruption and exfoliation) +Mandibular pseudotumor (subperiosteal bleeding with reactive bone formation) +Bleeding during surgery
investigations The normal factor VIII level is 50-100% and is usually measured by CLOTTING ASSAY. Normal haemostasis require 25% factor activity, symptomatic patients have factor VIII levels below 5%. BT normal Coagulation time PT normal aPTT Functional assay of factor is useful in diagnosing the disease. Hematoma Gingival bleeding following Minor trauma Bleeding into weight bearing joints No known cure . Pts should be protected from traumatic injuries. Hemophilia A For Minor Dental Procedures a single infusion of factor VIII concentrate coupled with 4-6 gm of D-aminocaproic acid (anti-fibrinolytic agent) four times daily for 72-96 hrs after the dental procedure and antibiotic for same duration. For major dental procedure patient is hospitalized. Factor VIII concentrate infusion started just prior to surgery and to be continued for a minimum of 48-72 hrs. with an antibiotic administration.
Hemophilia B Treatment is by infusion of factor IX concentrate.
Hemophilia B is the result of factor IX deficiency. It is managed by replacement therapy with highly purified, virally inactivated factor IX concentrates. Prothrombin complex concentrates can also be used for factor IX replacement.
Most common congenital coagulation disorder occurring due to qualitative or quantitative defect in the von-Willebrands factor. The disease is mainly transmitted in an autosomal dominant manner.
The von-Willebrands factor is a protein, synthesized by endothelial cells and megakaryocytes. Due to deficiency of factor vWF, two important abnormalities result. 1- PLATELET DYSFUNCTION normally the vWF forms a bridge between platelets and endothelial wall component that is collagen which allows the platelets to adhere to damaged vessel walls. Low vWF leads to bleeding related to platelets dysfunction. 2- LOW LEVEL OF FACTOR VIII. The vWF acts as a carrier protein for factor VIII and therefore its deficiency leads to secondary reduction of factor VIII level. von-WILLEBRANDS DISEASE (vWD): Clinical manifestations: + Many children are asymptomatic + Excessive bleeding (spontaneous or minor trauma) + Common sites nose, skin, GIT, & severe menorrhagia + Bleeding tendency cyclic or sporadic.
Clinically these patients have a dual mechanism of bleeding due to platelet dysfunction superficial bruising, epistaxis, gastrointestinal haemorrhage. defective coagulation mechanism similar to haemophilia leading to spontaneous bleeding or following trauma or surgery
Oral manifestations: Gingival bleeding Bleeding during surgery
Management: + Transfusion of plasma or anti hemophilic factor and by local control of hemostatsis. + Mild episodes of bleeding can be treated with desmopression. + Serious or persistent bleeds, haemostasis can be achieved with factor VIII concentrate.
Rare Coagulation Factor Deficiencies + Congenital deficiencies in coagulation factors, other than Factor VIII and Factor IX, are very rare. Factor XI deficiency in the Ashkenazi Jewish population has a prevalence of 1 in 1,000; however, the prevalences of fibrinogen, prothrombin and Factors V, VII, X and XIII deficiencies are in the order of only 1 in 0.51 million.
+ These disorders are inherited as autosomal recessive traits and manifest clinically in homozygotes or compound heterozygotes. Although, with some exceptions, the bleeding manifestations in these disorders are less severe than hemophilia, patients may require coagulation factor replacement before dental surgery. Specific factor concentrates are available for some deficiencies (e.g., Factor VII); fresh frozen plasma is used as the source for others (e.g., Factor V)
Liver disease Aquired coagulation defect Hepatitis (viral, toxic), cirrhosis -underlying causes. The proteins that initiate and maintain clotting of blood are synthesized by the liver. A diseased liver is unable to synthesize these proteins, leading to a potential bleeding problem. Synthesized in the liver factors II, VII, IX, X, fibrinogen, protein c & s(Anticoagulants)& protein Z ( activates thrombin)
The liver synthesizes bile acids and secretes them into the small intestine where they play a critical role in absorption of lipids. Vitamin K, as a fat-soluble vitamin, requires proper lipid absorption for its own absorption. Liver disease that results in decreased bile salt synthesis leads to impaired vitamin K absorption and deficiency.
Inadequate gamma-carboxylation of vitamin K- dependent coagulation proteins ( Factors II (prothrombin), VII, IX, and X, protein Z, protein C&S )interferes with the coagulation cascade, and inhibits blood clot formation Lab-PT, PTT, BT
DISSEMINATED INTRAVASCULAR COAGULATION
Acquired coagulation defect. + Also known as defibrination syndrome or consumption coagulopathy. + It is a pathological process in the body where the blood starts to coagulate throughout the whole body. This depletes the body of its platelets and coagulation factors, and there is a paradoxically increased risk of hemorrhage. + It may be acute, subacute or chronic characterized by thrombo haemorrhagic manifestations. + It is usually a secondary complication of some systemic diseases 1. infections gram ve septicaemia, meningococcal septicaemia, certain viral infections and malaria. 2. liberation of tissue factors retain dead foetus, massive trauma and malignancies. 3. wide spread endothelial damage severe burns, acute glomerulonephritis.
CLINICAL FEATURES
Skin and mucus membrane bleeding and hemorrhage from multiple sites that is surgical incisions, vein puncture, catheter sites.
DIC may appear that develops suddenly and usually causes bleeding, which may be very severe.. Bleeding may occur at the site of an intravenous injection or in the brain, digestive tract, skin, muscles, or cavities of the body. LABORATORY FINDINGS
DIC results in lower fibrinogen (as it has all been converted to fibrin), A more specific test is for "fibrin split products" (FSPs) or "fibrin degradation products" (FDPs) which are produced when fibrin undergoes degradation when blood clots are dissolved by fibrinolysis. Platelet count is low. Prothrombin time is prolonged. Thrombin time is prolonged.
DIC kidney DIC - Gangrene in patient with meningococcal sepsis MANAGEMENT
Treatment is aimed at treating the underlying cause DIC and taking measures to control the major symptoms. Aggressive antibiotic therapy is recommended for infections.
Factors such as acidosis, dehydrations, hypoxia and renal failure should be corrected accordingly. Patients with bleeding should receive (i) fresh frozen plasma and cryoprecipitate to replace depleted clotting factor. (ii) Platelet concentrate to correct thrombocytopenia. The use of heparin is controversial. It is used in those patients who have thrombosis or those rare patients who continue to bleed despite vigorous treatment with plasma and platelets.
Anticoagulant drugs:
Aspirin therapy Irreversible inhibitor cyclooxygenase 1. decreasing platelet release and aggregation owing to blockage of thromboxane A2 generation by platelets. 2. Short effect on endothelial synthesis of prostacyclin (inhibits plt. aggregation). Net result inhibition of plt aggregation. The effect lasts 9 days.
Ticlopidine, Clopidogrel
Inhibits ADP activation pathway of platelets aggregation inhibited. No effect on prostaglandins. ADP released by injured tissue, red blood cells and platelets. Indicated for reduction of cardiovascular events following MI, CVA, unstable angina pectoris, stent implantation.
Coumarin therapy -warfarin -vitamin K antagonist (oral anticoagulants). V k is coupled in gamma-carboxilation reaction of factors II (prothrombin), VII, IX, X, and protein C. Coumarin competes Vk. -1-3 days from peak plasma concentration and maximum anticoagulant effect.
For adjustments: takes 2-3 days for reduction (when needed) to be reflected. Or small dose of subcutaneous Vk. Patient should be evaluated before possible bleeding causing procedure. Local agents should be used in case of excessive post operative bleeding.
Heparin therapy Short acting anticoagulant (t1\2- 4 hr).
Extrarenal metabolism. Binds to endothelial surface and to various plasma proteins. Activity depends upon antithrombin III (ATIII) Which inhibit clotting factor proteases IXa, Xa, XI, XII, IIa(thrombin). Heparin enhances ATIII reaction 1000-fold.
CONCLUSION O Management of the patient with a bleeding disorder must be based on a complete understanding of the disease. The dentist should consult with the patient's primary physician or hematologist to discuss O The severity of the disease; O The dental and oral/maxillofacial procedures planned and nature of the bleeding risk; O The patient's response to previous dental treatment, surgery, and trauma; O The patient's response to various modes of systemic therapy, O There should be inclusion of blood component replacement therapies. O With appropriate management strategies, nearly all bleeding disorder patients can benefit from the full range of dental procedures available to establish and maintain good oral health.
References Textbook of medical physiology by Arthur C. Guyton Burkits oral medicine by Malcolm A. Lynch Textbook of oral pathology by William G. Shafers Text book of physiology by Ganong
ORAL SURGERY If the procedure has limited invasiveness and the patient has a mild bleeding disorder, only slight or no modification will be required. The patients physician should be consulted before invasive treatment is undertaken. In patients with drug-induced coagulopathies, drugs may be stopped or the doses modified. For irreversible coagulopathies, replacement of missing factors may be necessary.
Pain Control
Nerve-block anesthetic injections are contraindicated unless there is no better alternative and prophylaxis is provided, (risk of hematoma formation. Extravasation of blood in the oropharyngeal area by an inferior alveolar block or in the pterygoid plexus can produce gross swelling, pain, dysphasia, respiratory obstruction and risk of death from asphyxia.)
The commonly used blocks require minimum clotting factor levels of 20% to 30%.
Anesthetic infiltration and intraligamentary anesthesia are potential alternatives
An anesthetic with a vasoconstrictor should be used when possible.
Alternative techniques,:- including sedation with diazepam or nitrous oxideoxygen analgesia, Patients undergoing extensive treatment requiring factor replacement may be treated under general anesthesia in a hospital operating room. Surgical procedures carry the highest risk of bleeding, and safety precautions are needed.
For coagulopathies- The patients hematologist should be consulted before planning, and patients with severe disease should be treated in speciality centres.
Transfusion of appropriate factors to 50% to 100% of normal levels is recommended when a single bolus infusion is used in an outpatient setting.
In patients with hemophilia, additional postoperative factor maintenance may be required after extensive surgeries. This can be done with factor infusion, DDAVP, cryoprecipitate or fresh frozen plasma depending on the patients condition.
Local hemostatic agents and techniques such as pressure, surgical packs, sutures and surgical stents may be used individually or in combination and may assist in the local delivery of hemostatic agents, such as topical thrombin and vasoconstrictors.
use of vasoconstrictors because of the risk of rebound vasodilatation, which may increase late bleeding risk.
The use of absorbable hemostatic materials may favour clot formation and stability. However, these materials also carry a risk of infection and may delay healing; (avoided in immunosuppressed patients.)
Management of patients with platelet disorders, who require dental procedures
Drugs: The patients physician should be consulted before any decision is made to modify the patients drug regimen.
If ASA has to be withdrawn, this should be done at least 10 days before surgery. In most cases, ASA therapy does not need to be stopped, and local hemostatic measures are sufficient to control bleeding.
Similarly, other antiplatelet drugs, such as clopidogrel and dipyridamole, usually do not need to be stopped.
For patients taking warfarin, their international normalized ratio (INR) should be measured before a surgical procedure. The normal therapeutic range is 2.03.0. According to current recommendations, most oral surgical procedures can be performed without altering the warfarin dose if the INR is less than 3.0. If INR values are greater than 3.0, physician referral is suggested.
It is important to consider the risk of reducing the level of anticoagulation in patients on warfarin due to the risk of a thromboembolic event.
Patients taking heparin are often those who are on hemodialysis due to end-stage renal disease. Heparin has a short half-life (about 5 hours) and patients can often be treated safely on the days between dialysis.
Periodontal therapy: Periodontal health is of critical importance in patients with bleeding disorders as inflamed and hyperemic gingival tissues are at increased risk of bleeding. (Periodontitis may cause tooth mobility and warrant extraction,)
Patients with coagulopathies may neglect their oral health due to fear of bleeding during tooth brushing and flossing, which leads to increased gingivitis, periodontitis and caries.
Periodontal probing, supragingival scaling and polishing can be done normally without the risk of significant bleeding.
Factor replacement is seldom needed for subgingival scaling and root planing if these procedures are done carefully. Ultrasonic instrumentation may result in less tissue trauma. For severely inflamed tissues, initial treatment with chlorhexidine mouthwashes and gross debridement is recommended to reduce tissue inflammation before deep scaling.
Factor replacement may be required before extensive periodontal surgery and use of nerve blocks.
Periodontal packing materials and custom vinyl mouthguards (stents) are used to aid in hemostasis and protect the surgical site, but these can be dislodged by severe hemorrhage or subperiosteal hematoma formation. Antifibrinolytic agents may be incorporated into periodontal dressings for enhanced effect.
Post-treatment antifibrinolytic mouthwashes are usually effective in controlling protracted bleeding.
Restorative and Endodontic Procedures
General restorative procedures do not pose a significant risk of bleeding. Care should be taken to avoid injuring the gingiva while placing rubber dam clamps, matrices and wedges. A rubber dam should be used to prevent laceration of soft tissues by the cutting instruments. Saliva ejectors and high-speed suction can injure the mucosa in the floor of the mouth and cause hematoma or ecchymosis; thus, they should be used carefully. Endodontic therapy is preferred over extraction whenever possible in these patients. Endodontic therapy does not usually pose any significant risk of bleeding and can be performed routinely. Endodontic surgical procedures may require factor replacement therapy.
Prosthodontic Procedures These procedures do not usually involve a considerable risk of bleeding. Trauma should be minimized by careful post-insertion adjustments. Oral tissue should be handled delicately during the various clinical stages of prosthesis fabrication to reduce the risk of ecchymosis. Careful adjustment of prostheses is needed to reduce trauma to soft tissue.
Orthodontic Procedures Orthodontic therapy can be carried out without bleeding complications, although care should be taken that appliances do not impinge on soft tissues and emphasis should be put on excellent, atraumatic oral hygiene.