‫بسم هللا الرحمن الرحيم‬

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 Hemorrhage Disorders

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• Patients with a history of bleeding problems caused by disease or
drugs should be managed to minimize risks of hemorrhage
• Identification of these patients via the health history, clinical
examinations, clinical laboratory tests are paramount.
• Health questioning should cover history of bleeding after previous
surgery or trauma, past and present drug history, history of bleeding
problems among relatives, illnesses associated with potential
bleeding problems
• Clinical examinations should detect the existence of jaundice ,
ecchymosis, spider telangiectasia, hemarthrosis, petechiae,
hemorrhage vesicles, spontaneous gingival bleeding or gingival
hyperplasia.
• Laboratory test should include BT ,touriquet test, complete blood
cell count , PT , PTT and coagulation time
• Bleeding disorders may be classified as Coagulation disorders ,
Thrombocytopenic purpuras, Non thrombocytopenic purpuras

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 Coagulation disorders

• Inherited coagulation disorders include hemophillia A&B and Von

Willbrands disease
• Hemophillia A is due to deficiency of coagulation factor 8 , the
clinical severity of the disorder depends on the level of factor 8
remaining
• Severe Hemophilliacs with less than 1% of normal factor 8 levels
may have severe bleeding on the slightest provocation
• Moderate Hemophilliacs of 1 – 5% of factor 8 levels have less
frequent spontaneous hemorrhage but still bleed in minimal trauma
• Mild Hemophilliacs with 6-30% factor 8 levels rarely bleed
spontaneously but may still have hemorrhage after severe trauma or
during surgical procedures
• Therefore the clinician should consult the patients physician before
dental treatment to determine the risk for bleeding and ttt
4 modifications required
• Factor 8 levels should be atleast 30% to prevent surgical
hemorrhage
• Parenteral 1-deamino-8-d-arginine vasopressin (DDAVP) can be
used to raise factor 8 levels by 2-3 folds for patients with mild or
moderate Hemophillia
• DDAVP has the advantage of avoiding the risk of viral disease
transmission from factor 8 infusion and is considered the drug of
choice in responsive patients
• Most moderate and severe hemophilliacs require infusion of factor 8
concentrate before surgical procedures
• Hemophillia B (christmas disease) is due to defieciency of factor
9,and the clinical severity depends on the amount of existing factor
9
• Surgical therapy requires a factor 9 level of 30%- 50% , usually
achieved by adminstration of purified prothrombin complex
concentrates or factor 9 concentrates
• Von Willbrands disease is due to deficiency of Von Willbrands factor
which mediates the adhesion of platelets to the injured vessel wall
5 and is required for primary hemostasis
• Von Willbrands factor also carries the coagulant portion of factor 8
in the plasma
• Von Willbrands disorder has 3 major subtypes with a wide range of
clinical severity
• Severe forms require preoperative factor 8 concentrate or
cryoprecipitate infusion
• Milder forms respond favorably to adminstration of DDAVP before
periodontal surgery or tooth extraction
• Periodontal ttt maybe performed in patients with these coagulation
disorders but sufficient precautions are taken.
• Probing , scaling can usually be done without medical modification
• More invasive ttt such as block anesthesia , root planning or surgery
should be done after consulting the patients physician
• During ttt , local measures to ensure clot formation and stability are
of major importance
• Complete wound closure and application of pressure will reduce
hemorrhage
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• Antihemostatic agents such as oxidized cellulose or purified bovine
collagen maybe placed over surgical sites or into extraction sockets
• Antifibrinolytic agent epsilon-aminocaproic acid (EACA) given orally
or ivly is a potent inhibitor of initial clot dissolution
• Tranexamic acid is a more potent anti fibrinolytic agent than (EACA)
and has shown to prevent excessive oral hemorrhage after
periodontal surgery and tooth extraction, availiable in mouth rinse
form , can be used alone or in combination with the systemic form
for several days after surgery

• Non heriditery disorders

• Liver disease may affect all phases of blood clotting because most
coagulation factors are synthesized and removed by the liver
• Long term alcohol abusers or chronic hepatitis patients often
demonstrate inadequate coagulation
• Vit K Deficiency may impair coagulation, often caused by
malabsorbtion syndrome or by prolonged antibiotics adminstration
which alters the intestinal micro flora that produces vitamin K

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• Dental ttt planning in patients with liver disease should include:
• Physician consultation
• Laboratory evaluations : PT, BT, Platelet count , PTT
• Conservative, non surgical periodontal therapy whenever possible
• If surgery is required (may require hospitalization) : INR should be
less than 2.0 , for simple surgical procedure less than 2.5 is safe,
Platelet count should be more than 80000/mm3

• Abnormal coagulation is common during drug therapy ,pts with

prosthetic heart valves or histories of myocardial infarction, stroke,
or thromboembolism are frequently placed on anticoagulant therapy
such as warfarin and dicumarol, which are vit k antagonists
decreasing the production of vit k dependant coagulation factor
2,7,9,10
• The recommended level of anticoagulation for most pts is an INR of
2.0 – 3.0, with prosthetic heart valves pts 2.5 -3.5

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• Periodontal ttt should be altered by
• Consulting the pts physician to determine the nature of the
underlying medical problem and the degree of required
anticoagulation
• Infiltration anesthesia , scaling and root planning can be done with
an INR of less than 3.0, Block anesthesia, minor periodontal surgery
and simple extractions usually require an INR of less than 2.0,
complex surgery or multiple extractions may require an INR of less
than 1.5
• The pts physician should be consulted about discontinuing or
reducing anticoagulant dosage until desired INR is achieved.
Anticoagulants is discontinued for 2 – 3 days before periodontal ttt
as the clearance half life of warfarin is 36 – 42 hrs , and the INR is
checked on the day of the ttt , if the INR is within the acceptable
range, the procedure is done and the anticoagulant is resumed
immediately after ttt

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• Careful technique and complete wound closure are paramount, For
all procedures, application of pressure can minimize hemorrhage,
use of oxidized cellulose, topical thrombin and tranexamic acid
should be considered for persistant bleeding
• Aspirin interferes with normal platelet aggregation and can result in
prolonged bleeding, its binds irreversibly to platelets, the effect of
aspirin lasts for 4 – 7 days
• Pts taking aspirin doses more than 325 mg / day should discontinue
for at least 7 – 10 days before periodontal therapy in consultation
with the pts physician
• Ibuprofin also inhibits platelet function, they bind reversibly, lasting
for a short time after the last drug dose
• Heparin is generally used for short term anticoagulation and is given
ivly , it is a powerfull anti coagulant with a duration of action of 4 – 8
hrs, periodontal ttt is rarely required while a pt is taking heparin

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 Thrombocytopenic purpuras

• Platelet count less than 100000/mm3

• Bleeding is due to thrombocytopenia maybe seen with idiopathic
thrombocytopenic purpuras, radiation therapy,
chemotherapy,leukaemia or infections
• Purpuras are hemorrhagic diseases characterized be extravasation
of blood into the tissues under the skin or mucosa, producing
spontaneous petechiae (small red patches or ecchymoses)
• Periodontal therapy for pts with thrombocytopenia should reduce
inflammation be removing local irritants to avoid the need for more
aggressive therapy
• Oral hygiene instructions and frequent maintenance visits are
paramount
• Physician referral is indicated for a definitive diagnosis and to
determine any alterations in planned therapy

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• Scaling and root planning is generally safe unless platelet counts
are less than 60000 mm3
• No surgical procedures should be performed unless the platelet
count is above 80000 mm3
• Platelet transfusion may be required before surgery
• Surgical technique should be as atraumatic as possible , and local
hemostatic measures should be applied

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 Non thrombocytopenic purpuras

• Occurs as a result of either vascular wall fragility or thrombasthenia

(impaired platelet aggregation), which may result from
hypersentistivity reactions , scurvy ,infections chemicals (phenacetin
& Aspirin), dysproteineuremia and several others
• Thrombasthenia occurs in uremia, Glanzmanns disease , aspirin
ingestion and Von willbrands disease
• Both kinds of non thrombocytopenic purpuras may result in
immediate bleeding after gingival injury
• TTT : Direct pressure applied for atleast 15 mins to control the
bleeding unless coagulation times are abnormal or reinjury occurs
• Surgical therapy should be avoided unless the qualitative and
quantitive platelet problems are resolved

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 Blood dyscrasias

• Numerous disorders of red and wbc’s may affect the course of

periodontal therapy
• Alterations in wound healing , bleeding, tissue appearance and
susceptibility to infection may occur
• Clinicians should be aware of the clinical signs and symptoms of
blood discrasias, availability of screening laboratory tests and need
for physician referral
• Leukaemia :
• Altered periodontal ttt for pts with leukaemia is used on such pts
enhanced susceptability to infections, bleeding tendency and the
effect of chemotherapy
• TTT:
• Refer the pt for medical evaluation and ttt .Close cooperation with
the pts physician is required
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• Before chemotherapy, a complete periodontal ttt plan should be
developed with the pts physician
• Monitor hematologic lab values daily ( BT, CT, PT , PC )
• ِِِAdminster antibiotics coverage before any periodontal ttt because
infection is a major concern
• Extract all hopeless or potentially infectious teeth atleast 10 days
before the initiation of chemotherapy , if systemic condition allows
• Periodontal debridement (scaling &root planning) should be
performed and thorough oral hygiene instructions given if pts
condition allows , Twice daily rinsing with 0.12% chlorohexidine
gluconate is recommended after oral hygiene procedures.
Recognize the potential for bleeding due to thrombocytopenia, use
pressure and topical hemostatic agents as indicated
• During the acute phases of leukaemia, pts should receive only
emergency periodontal care , any source of potential infection must
be eliminated to prevent systemic dissemination , Antibiotic therapy
is frequently the ttt of choice combined with non surgical or surgical
debridement as indicated
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• Oral ulcerations or mucositis are treated with agents such as viscous
lidocaine, systemic antibiotics may be indicated to prevent secondary
infections
• Oral candidasis is common with leukaemic pts can be trated with
nystatin suspensions (100000 U/ml 4 times daily) or clotrimazol
vaginal suppositories 10 mg 4 -5 times daily
• For pts with chronic leukaemia, scaling and root planning can be
performed without complication but periodontal surgery is to be
avoided if possible
• Platelet count and BT should be measured on the day of procedure ,
if low , postpone the appointment and refer the pt to a physician

• Agranulocytosis
• Pts with agranulocytosis (cyclic neutropenia & granulocytopenia) have
increased susceptibility to infection
• The total WBC count is reduced and granular leucocytes
(neutrophils,eosinophils &/or basophils) are reduced or disappear

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• These disorders are often marked by early severe periodontal
destruction
• Periodontal ttt should be done during periods of disease remission
• TTT should be as conservative as possible while reducing potential
sources of infection
• After physician consultation severly affected teeth should be
extracted
• Oral hygiene instructions should include chlorohexidine mouth
rinses twice daily
• Scaling and root planning should be performed carefullr under
antibiotic protection

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 THE END

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