Tooth extraction in a patient with

bleeding disorders
Zahirabbas Abdulrasul
2021-04-16077
DDS4-2024
Bleeding Disorders
• These are conditions that alter ability of blood vessels, platelet, and
coagulation factors to maintain hemostasis.

 Inherited bleeding disorder

 Acquired bleeding disorder
Normal Control of Bleeding
The 3 phases of normal bleeding control are:

1. Vascular Phase

2. Platelet phase

3. Coagulation Phase

The Coagulation phase is followed by the proteolytic phase that

dissolves the clot
III-Coagulation phase
• The process of coagulation is mean fibrin-forming system from injury
to a fibrin-stabilized clot.

Two systems involved in the coagulation

The extrinsic system

The intrinsic system

common pathway
Coagulation Cascade
• If a component Is missing, deficient or dysfunctional, excessive
bleeding may occur.
• Bleeding disorders may cause symptoms like nosebleeds, bleeding
gums. Bruising etc
CLASSIFICATION OF BLEEDING
AND CLOTTING DISORDERS:
VASCULAR DISORDERS:
 Scurvy
 Purpura

PLATELET DISORDERS:
• Thrombocytopenic Purpura
• Drug Induced Aspirin

- Heparin

- Warfarin
Cont….
• COAGULATION FACTOR DEFICIENCIES:
• Hemophilia A
• Hemophilia B
• Von Willebrand's Disease
• Liver Disease
• Vitamin K Deficiency
IDENTIFICATION OF PATENT WITH
BLEEDING DISORDER
• History taking
• Physical examination
• Laboratory Investigations
Clinical Evaluation of the
Bleeding Patient
• Careful evaluation of the
patient with coordinated history Questions:
and physical examination 1. Is there any personal or family
provides valuable clues as to history of a bleeding tendency?
whether the bleeding 2. Has the patient undergone surgery
abnormality resides in (a) the or dental extractions previously?
vessels walls, (b) platelets or (c) 3. Is there any history of haematuria,
in the process of coagulation. gastrointestinal haemorrhage, easy
• Laboratory tests should bruising, haemarthrosis,
metromenorrhagia, or epistaxis?
supplement and not supersede
a careful review of history and 4. Is there any history of cancer or
physical examination. The collagen vascular disease?
history should include the 5. What medications is the patient
following taking or has taken recently?
6. Is the patient on any special diet?
Lab Investigations
• Initial laboratory investigations should include a complete blood cell
(CBC) count, prothrombin time (PT), partial thromboplastin time (PTT)
• Preoperative screen for a patient with a negative history and
examination should include a
 CBC

 Bleeding Time
 Clotting Time
 Prothrombin Time
 INR and
 Activated partial thromboplastin time (aPTT)
Bleeding Time
• Measures the time taken for a normal wound to stop bleeding Normal
Bleeding time: 2-7mins (Ivy method) Any clotting factor deficiency or
platelet abnormality will lead to increased BT Usually Prolonged in:
Thrombocytopenia Liver diseases Von-Willebrand's disease
Clotting Time
• Measures the time required for formation of first clot. Normal Clotting
time-5-8 mins (capillary tube method) Screening test for coagulation
disorders
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
• Increased PT:
• Patients on Warfarin Therapy
• Vitamin K deficiency
• End stage Liver failure
• 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
Activated Partial Thromboplastin
Time (aPTT):
- Time in seconds that's required for a clot to form in citrated or
oxalated plasma Performance indicator of both the intrinsic & common
pathways

- Typical reference range - 30-40 secs

- Increased aPTT seen in:

• Patients on Heparin Therapy
• Von Willebrand's disease
• Early Stage Liver failure
• Hemophilia
Local Haemostatic Measures

• In a patient with normal coagulation mechanism, the control of

haemorrhage is dependent on vessel contraction, retraction, and clot
formation. During any surgical procedure, complete haemostasis
must be achieved before closure of the wound. Direct control of
bleeding at the site of injury is the best method to achieve
haemostasis. Surgical bleeding most of the times is caused by
ineffective local haemostasis. The techniques for local haemostasis
may be classified as

(i) mechanical,

(ii) thermal or

(iii) chemical
Mechanical Methods

• Pressure Application of pressure basically counteracts the

hydrostatic pressure within the bleeding vessel until such time, that
a clot can form and occlude the bleeding orifice.
• Use of haemostats Haemostat (Mosquito, artery) forceps are
specially designed to catch bleeding points in the surgical area.
These can be straight or curved. Curved haemostats are used more
frequently, because of their versatility and ease in tying the ligature
around the tip of forceps. Usually electrosurgical thermocoagulation
is done after catching the bleeding point with artery forceps, if the
vessel is small. The large vessels are ligated with suture
• Sutures and ligation Transected blood vessel may need to be tied
with the help of ligature.
• Embolization of the vessels With the help of angiography, the
exact bleeding point can be localized. Agents which can be used for
embolization include steel coils, polyvinyl alcohol foam, gel foam,
silicon spheres and methyl methacrylate. These particles are placed
via a catheter superselectively into the bleeding vessel usually via
femoral artery.
Thermal Agents
• Cautery Heat achieves haemostasis by denaturation of proteins
which results in coagulation of large areas of tissue. In cauterization,
heat is transmitted from the instrument by conduction directly to the
tissues. Electrocautery has replaced direct heat application. When an
electrosurgery unit is not available, dental burnisher like instrument
can be directly heated over a flame and applied directly to the
bleeding point in the oral cavity.
Electrosurgery (Electrocautery)
•Uses heat from alternating current to stop bleeding.
•Can be applied directly to a bleeding point or via a haemostat (tool holding the
vessel).
•Seals blood vessels with heat, but produces a burning smell and smoke.
•Cannot control bleeding from large vessels, which need surgical ligation (tying
off).

Cryosurgery
•Uses extremely low temperatures (-20°C to -180°C) for haemostasis.
•Destroys tissue by freezing, causing dehydration and damage to cell membranes.
•Mainly used for treating surface-level haemangiomas (benign blood vessel
growths).
Local Hemostatis Agents
Hemophilia
• Hemophilia comprises a group of hereditary disorders caused due to
the deficiency of one or more clotting factors leading to prolonged
clotting time and excessive bleeding tendencies.
• Haemophilia A is the commonest than B, accounting for approximately
85% of all cases of haemophilia.
• It is characterised by a deficiency of factor VIII while Haemophila B
has a deficiency of factor IX.
• Inherited X-linked recessive trait, with the defective gene located on
the X chromosome.
Hemophilia Cont..
• Incidence about 1 in 10000 live male births

- All men carrying the mutated gene will have hemophilia

- Female offsprings will be carriers

Classification:
Hemophilia Cont..
SYMPTOMS:
• Bruising
• Spontaneous bleeding
• Bleeding into joints(TMJ) and associated pain and swelling
• Generalized spontaneous gingival bleeding Hematomas of tongue,
mucosa and hard palate
• Prolonged bleeding from cuts, tooth extraction, and surgery.

TESTS INCLUDE

Prolonged PTT

Low serum factor VIII activity and Serum factor IX is reduced.

Management..
1. Preoperative Preparation

Hematologist Consultation: The patient should be evaluated by a hematologist to assess

the severity of Hemophilia A and develop a bleeding management plan.

Factor VIII Replacement Therapy: Administer Factor VIII concentrates to raise the levels
to at least 50–100% of normal levels before surgery. This ensures adequate clotting during
and after the procedure.
o Dosage is calculated based on the patient’s weight and target levels.
o Factor VIII may be given on the day of the procedure and for a few days after,
depending on the severity.

Antifibrinolytic Agents: Medications like tranexamic acid or epsilon-aminocaproic

acid may be prescribed to prevent breakdown of blood clots.
Management..cont..
2. During the Procedure

Local Hemostasis:
o Use local anesthesia with vasoconstrictors (e.g., lidocaine with
epinephrine) to minimize bleeding.
o Apply pressure and use hemostatic agents like surgical gauze, gelatin
sponges, or oxidized cellulose.
o Place sutures if necessary to ensure proper wound closure.

Atraumatic Technique: Minimize tissue trauma during extraction.

Management..cont..
3. Postoperative Care

Hemostatic Measures:
o Use topical agents like fibrin glue or thrombin-soaked gauze to
control bleeding.
o Instruct the patient to bite on gauze for 30-60 minutes after
extraction.

Pain Management:
o Avoid NSAIDs (e.g., ibuprofen, aspirin) as they increase bleeding
risk. Use acetaminophen (paracetamol) instead.

Antifibrinolytic Therapy: Continue antifibrinolytic agents for a few days

to stabilize the clot.
Management..cont..
• 4. Monitoring

 Monitor for signs of delayed bleeding and ensure proper

follow-up with the dentist and haematologist.

 Provide emergency contact information for immediate care if

bleeding persists.
Von Willebrand’s disease (VWD)
an autosomal dominant inherited disorder of coagulation, that results
from a quantitative or qualitative abnormality of the plasma protein, i.e.
Von Willebrand’s factor (VWF). It is a glycosylated protein which is
synthesized in endothelial cells of blood vessel and megakaryocytes

Three main roles of VWF in haemostasis

1. It enables the binding of platelets to the subendothelial collagen

matrix at the sites of vascular injury.

2. It mediates subsequent platelet aggregation allowing the formation

of platelet plug ;

3. It acts as carrier protein for factor VIII protecting it from proteolytic

degradation.
Preoperative and Intraoperative Care for Tooth Extraction in VWD

Preoperative Considerations:
 Consult a hematologist to assess vWF and factor VIII levels.
 Use desmopressin (DDAVP) for mild/moderate VWD or vWF/factor VIII
replacement for severe cases.
 Administer antifibrinolytics (e.g., tranexamic acid).
 Perform coagulation tests to evaluate bleeding risk.
 Schedule procedure at a center with hematology support if needed.
Intraoperative Management:
 Use local anesthetics with epinephrine and atraumatic techniques to
minimize bleeding.
 Apply local hemostatic agents (e.g., oxidized cellulose, gelatin sponges,
fibrin sealants).
 Avoid NSAIDs and aspirin.
Postoperative Care for Tooth Extraction in VWD
Bleeding Control:

 Prescribe antifibrinolytics to prevent clot breakdown.

 Use pressure packs to control site bleeding.

Monitoring and Pain Management:

 Monitor for delayed bleeding post-surgery.

 Use acetaminophen for pain instead of NSAIDs or aspirin.

Follow-Up:

 Schedule follow-up visits to ensure proper healing and manage any

complications.
THANK YOU
References
• Burket's Oral Medicine-11th Edition
• Little and Falace's Dental Management of the Medically Compromised
Patient
• Medical problems in dentistry-6 th Edition crispian scully
• Textbook of Oral and Maxillofacial Surgery 5th Edition
by Neelima Anil Malik (Editor), Suresh Bhosale