Alaraji BDSFIBMS These are conditions that alter ability of blood vessels platelet and coagulation factors to maintain homeostasis Inherited bleeding disorder are genetically transmitted while acquired bleeding disorders occur as the result of diseases that affect vascular wall integrity ID: 998802
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1. Bleeding Disorder Dr. Mohammed AlarajiB.D.S.F.I.B.M.S
2. These are conditions that alter ability of blood vessels, platelet, and coagulation factors to maintain homeostasis. Inherited bleeding disorder are genetically transmitted while acquired bleeding disorders occur as the result of diseases that affect vascular wall integrity, platelets, coagulation factors, and drugs which cause bleeding, radiation, or chemotherapy for treatment of cancer also result in bleeding problems .
3. PathophysiologyThree phases of homeostasis for controlling the bleeding; Primary phase:A-Vascular phase.B-Platelet phase. Secondary phase: Coagulation phase.Tertiary phase :- Fibrinolytic phase
4. I-Vascular phase:Vascular SpasmWhen a vessel is severed or punctured, or when the wall of a vessel is damaged, vascular spasm occurs. In vascular spasm, the smooth muscle in the walls of the vessel contracts dramatically. This smooth muscle has both circular layers; larger vessels also have longitudinal layers.The vascular spasm response is believed to be triggered by several chemicals called endothelins that are released by vessel-lining cells and by pain receptors in response to vessel injury.
5. II- platelet phasePlatelet is cellular fragments they don't have nucleus stay 8-12 days in the circulation. Nonviable platelets are removed and destroyed by the spleen. Function of platelets includes; maintenance of vascular integrity, formation of platelet plug to aid in initial control of bleeding & stabilization of platelet plug through involvement in the coagulation process.
6. III- coagulation phaseThe process of coagulation is mean fibrin-forming system take 9-18 minutes from injury to a fibrin-stabilized clot.Two systems involved in the coagulation the extrinsic system is initiated through tissue factor after tissue injury. This process activate factor VII (Vlla) which called in the past tissue thromboplastin.The intrinsic system is initiated by surface contact to activate factor XII. Both systems (pathways) use common pathway to form the end product fibrin.
7. IV-Fibrinolytic phaseFibrin-lysing (fibrinolytic) system is needed to prevent coagulation of intra vascular blood away from the site of injury & to dissolve the clot once it has served its function in homeostasis. The effect of plasmin on fibrin & fibrinogen is to split off large piece that are broken up into smaller segments called fibrin degradation products (FPDs), those increase vascular permeability & interfere with thrombin induced fibrin formation.
8. Summery of Normal Control of Bleeding1. Vascular phasea. Vasoconstriction in the area of injuryb. Begins immediately after injury2. Platelet phasea. Platelets and vessel wall become “sticky”b. Mechanical plug of platelets seals off openings of cut vesselsc. Begins seconds after injury3. Coagulation phasea. Blood lost into surrounding area coagulates through extrinsic and common pathwaysb. Blood in vessels in area of injury coagulates through intrinsic and common pathwaysc. Takes place more slowly than other phases4. Fibrinolytic phasea. Release of antithrombotic agentsb. Spleen and liver destroy antithrombotic agents.
9. What are the main signs of a bleeding disorder?unexplained and easy bruisingheavy menstrual bleedingfrequent nosebleedsexcessive bleeding from small cuts or an injurybleeding into jointpetechiae, and ecchymosis of skin.
10. Spider angioma on the skin
11. Ecchymoses on the mucosa of the hard and soft palate
12. The arm of a patient with thrombocytopeniashows numerous petechiae.
13. Laboratory Tests Partial Thromboplastin Time PTT: (25-35 seconds) this check the intrinsic system Prothrombin Time PT: (11-15 seconds) used to check the extrinsic pathway. Bleeding time (BT); Used to screening for disorder platelet dysfunction & thrombocytopenia. Thrombin time (TT) :Normal (9-13 sec). 16-18 sec. consider prolonged.
14. Vascular defectsHereditary hemorrhagic telangictasia (osler –weber –rendu disease) autosomal dominant, a feature of telangictasia lesions involving the skin & mucous membrane. Bleeding as epistaxis due to inert mechanical fragility of the vessels. Ehler –Danlod syndromeabnormal vessels wall weakness arterial aneurysms & bleeding from spontaneous rupture. Long use of steroid therapy also lead to thinning of connective tissue may result in bleeding
15. Platelet disordersvon WilleBrands disease; most common disorder, autosomal dominant traits cause mild to moderate bleeding due to defect in platelet adhesion . Clinical findingsevere bleeding after trauma or surgery it manifested as cutaneous & mucosal bleeding because of platelet adhesion lacking ,hemarthrosis and or epistaxis. Investigation PT& TT are normal .PFA-100 and aPTT prolonged , platelet count normal . TREATMENT; by given cryoprecipitate.
16. THROMBOCYTOPENIAThe concentration of platelets in the blood is too low. Usually blood contains about 150,000 to350,000 platelets per mm3. Signs may include gingival bleeding, frequent epistaxis (bloody nose), ecchymosis, blood in the stool or urine, or menstrual periods that are unusually heavy.Oral surgery or trauma may also lead to bleeding that is difficult to control.
17. Coagulation disordersHemophilia AIs an x-linked recessive trait. The abnormal homeostasis due to deficiency in factor VIII, this factor is bounded to vWF in circulation. Clinical findings; sever HE cause severe bleeding. hemarthrosis , ecchymosis ,soft tissue hematomas, after trauma or surgery there will be severe bleeding which may threaten life. Spontaneous bleeding from mouth ,gingivae , tongue ,lips. Replacement of factor VIII needed.
18. Hemophilia B;(Christmas Disease,Factor IX Deficiency) X –linked recessive trait. Clinical manifestation the same as hemophilia A .screening laboratory tests results are similar to both A&B ,specific factor assays for factor IX establish the diagnosis .purified factor IX product are recommended for treatment of minor & major bleeding recombinant factor IX is now available for clinical use .
19. Disseminated Intra Vascular Coagulation DICDIC is a condition that results when the clotting system is activated in all or a major part of vascular system, despite widespread fibrin production.the major clinical problems are bleeding not thrombosis , the syndrome is associated with infection , burn , snake bite ,shock ,antigen/antibody complex , acidosis ,obstetric complication Clinical finding of DIC; Sever bleeding from small wound ,purpura ,spontaneous bleeding from the nose ,gum ,GIT.UT. Treatment ; control of bleeding or thrombosis ,replacement of coagulation factors ,platelet & fibrinogen .patient given cryoprecipitate ,fresh frozen plasma .
20. Anti Coagulant Drugs; Heparin; heparin is used in high doses to treat thrombo embolism (IV bolus of 5000IU& iv infusion over 5-10 days period) & in low dose as prophylaxis for thromboembolism. Heparin should be given to the hospitalized patient; it has plasma half life of 1-2 hours .it's required monitoring with a PTT.
21. warfarinis most widely used as oral anticoagulant that inhibits the biosynthesis of VIT K-dependent coagulation proteins (factor VII,IX ,X & prothrpmbin ).PT is used to monitor warfarin therapy .the international normalized ratio is used to allows better comparison of PT values among different laboratories INR for warfarin is 2.5 with rang 2.0-3.0 .
22. Anti Platelet Drugs Aspirin has been widely used, exert it's anti platelet action through anti thrombotic function & impairing aggregation. non steroidal anti inflammatory drugs such as ibuprofen also inhibits the function of platelets
23. Detection of the Patient Who Is a “Bleeder”1. Historya. Bleeding problems in relativesb. Bleeding problems after operations and tooth extractionsc. Bleeding problems after trauma (cuts, etc.)d. Medications that may cause bleeding problems(1) Aspirin(2) Anticoagulants(3) Long-term antibiotic therapye. Presence of illnesses that may have associated bleeding problems(1) Leukemia(2) Liver disease(3) Hemophilia(4) Congenital heart disease(5) Renal disease—uremiaf. Spontaneous bleeding from nose, mouth, ears, etc.
24. 2. Examination findingsa. Jaundice, pallorb. Spider angiomasc. Ecchymosesd. Petechiaee. Oral ulcersf. Hyperplastic gingival tissuesg. Hemarthrosis3. Screening laboratory testsa. PTb. aPTTc. TTd. PFA-100e. Platelet count4. Surgical procedure—excessive bleeding after surgery may be first clue to underlying bleeding problem
25. Dental Management Of The Patient With Bleeding DisorderHemophilia injection ; block anesthesia ,lingual infiltration , or injection in the floor of the mouth ,& intra muscular injection should be avoided unless replacement of factors have been used in the patient with mild to sever factor VIII deficiency . infiltration anesthesia & intraligamentary injection usually given with out factor replacement . orthodontic treatment ,root canal with out over instrumentation , polishing can be done . periodontal surgery ,root planning ,extraction ,dento alveolar surgery & complex oral surgery need factor replacement .
26. preoperative ;consult the hematologist to confirm the diagnosis ,severity of the disease ,mild to moderate form usually treated in dental clinic , sever cases treated in the hospital . replacement of factor VIII ,one hour before procedure . dental treatment ;good surgical technique , treat acute infection , pressure packs , use gelfoam with thrombin to control bleeding , splint for patient with multiple extraction .
27. postoperative ; in dental clinic patient need second dose of factor VIII . hospitalized patient will need additional doses of factor replacement . also should check for signs of allergy . avoid uses of aspirin or NSAI Ds.
28. Von Wellbrand's Disease; Mild form, surgical procedure can be done in the dental clinic with out use of desmopressin & EACA(e-aminocaptoic acid) or tranexamic acid (cyklocapron) . more sever require factor VIII construction . Dental management; establish for good oral hygiene, palatal splint, treatment of acute infection. post operative patient should examined 24-48 hours for bleeding if bleeding present give the patient tranexamic acid & EACA.
29. Thrombocytopenia; Dental management 30,000 cubic mm inflitation & block anesthesia can given also most routine dental procedure can performed . 50,000 /cubic mm exo or dentoalveolar surgery can be done. More advanced surgery need 80,000-100,000/cubic mm or higher .replacement of platelet by transfusion (platelet concentration) after blood centrifugation. The use of tranexamic acid & EACA minimize the need for platelet replacement .
30. Thank you