Bleeding disorders AND HEAMOSTATSIS AGENT.pptx

Bleeding disorders and how to achieve haemostatis

1. Bleeding Disorders AND Hemostatic Agents Presented By Dr.Ashwini Bhandare Guided By Dr. Neema Shetty Dr. Aditi Mathur Dr .Ashish Bali Dr . Trishi

2. contents INTRODUCTION CLOTTING FACTOR STAGES OF BLOOD COAGULATION LABROTARY INVESTIGATION CLASSIFICATION OF BLEEDING DISORDER CONGENITAL BLEEDING DISORDERS VASCULAR DEFICIENCY DISORDER PLATELATE DIFICIENCY DISORDER PERIODONTAL TREATMENT OF PATIENT WITH BLEEDING DISORDER haemostatic agent PHASES OF HAEMOSTASIS IDEAL REQUIREMENT OF H AEMOSTATIC AGENT METHODS OF HAEMOSTATIC AGENT LOCAL HAEMOSTATIC AGENT CONCLUSION REFERENCES

3. INTRODUCTION Bleeding disorders- conditions characterized by prolonged bleeding time or clotting time. Causes of excessive bleeding- coagulation factor deficiencies, fibrinolytic defects, vascular disorders and platelet disorders. Patients with congenital bleeding disorders have an increased risk of significant bleeding from invasive dental and oral surgery procedures. The blood clotting mechanism involves various factors which participate in the formation of blood clot.

4. FACTORS INVOLVED IN BLOOD CLOTTING Substances necessary for clotting are called clotting factors-

5. The patient should be asked for any history of significant and prolonged bleeding after dental extraction or bleeding from gingiva. A history of nasal or oral bleeding should be noted. Many bleeding disorders run in families- family history of bleeding disorders should be carefully elicited. A complete drug history is important. patient is taking anticoagulant drugs, consult his or her physician before any major surgical procedure.

6. SPECIFIC BLOOD TESTS TO CONFIRM BLEEDING DISORDERS

7. CONGENITAL BLEEDING DISORDERS It include Hemophilia A Hemophilia B Von Willebrand disease HEMOPHILIA Both the Hemophilia A and B are inherited as an X –linked recessive conditions and share identical clinical manifestations. Hemophilia A is more common, accounting for approximately 85% of all the cases of Hemophilia Hemophilia A is characterized by the deficiency of factor VIII. Hemophilia B is DUE deficiency of factor IX

8. Spontaneous bleeding Hemorrhage in GIT Bleeding in Joints Blood in Urine Post-extraction Hemorrhage Symptoms

9. Oral Ulcerations & Ecchymosis in toddlers Sharp teeth can be prone to oral bleeding Recession of the attached gingiva & bone loss Pseudohaemophilia Tumour 11

10. MANAGEMENT dependent upon the severity of disease, type and site of hemorrhage. Factor Replacement Therapy - the primary mode of management. Cryoprecipitate and Fresh Frozen Plasma are rarely used .

11. VON WILLBRAND DISESASE commonest of the congenital bleeding disorders due to deficiency von Willebrand factor. Binding with plasma proteins (especially factor VIII) is the main function of von Willebrand’s factor. Its autosomal dominant condition ,affects both male and females.

12. It subdivided into 3 categories.

13. MANAGEMENT Depends on the type of disease. Type I and type 2A and 2M patients respond to desmopressin acetate Type 2B and type 3 require Vwf replacement. The currently available replacement is vWF containing factor VIII concentrates derived from pooled human plasma.

14. VITAMIN K DEFICENCY Requires in small, regular amounts. Essential for formation of coagulation factors ,work together to clot the blood Insufficient vitamin K -lead to excessive bleeding and easy bruising. Vitamin k is a fat soluble vitamin necessary for the synthesis(activation) of clotting factors : Clotting factor II Clotting factor VII Clotting factor IX Clotting factor X

15. characterized by the widespread activation of the clotting cascade that results in the formation of blood clots in the small blood vessels throughout the body. MANAGEMENT • Platelet and plasma transfusion Coagulation factor concentrates such as prothrombin complex Symptoms and signs Bleeding GI petechiae and ecchymosis Bleeding surgical sites Renal Failure pulmonary involvement Disseminated Intravascular Coagulation

16.   caused by the deficiency of vitamin C, results in hemorrhagic features because of defects in collagen synthesis. Hemorrhages in skin, bleeding gums leading to loosened teeth, bone pain, hemarthroses, perifollicular hemorrhage, and a painful tongue eventually develop. Cushing's Syndrome: resulting from excessive Corticosteroid intake or production, leads to general protein wasting and atrophy of supporting connective tissue around blood vessels. Vascular Disorder SCURVY

17. Ehlers- Danlo Syndrome: It is an autosomal dominant inherited disorder of connective tissue matrix, generally resulting in fragile skin blood vessels and easy bruising. MANAGEMENT a detailed case history and a thorough clinical examination. The underlying cause managed, if reversible. Blood replacement and iron therapy may be necessary following dental procedures

18. It`s most important components of clotting mechanism. Normal platelet count is 250,000 ± 150,000/mm3. less than 100,000 cells/mm3 =thrombocytopenia. Less than 50,000 cells/mm3 =excessive bleeding during the surgery.. PLATELET DISORDERS

19. ITP is also known as primary immune thrombocytopenic purpura. It is a characterized by abnormally increased destruction of circulating platelets. ITP occurs in two distinct clinical forms: an acute self-limiting form seen in children and chronic form observed in adults. The oral findings -bleeding In mucous membranes and petechiae which can be seen in areas most prone to friction. Idiopathic/immune thrombocytopenic purpura (ITP)

20. Clinical features 23 Petechial rash Purplish Blotches Ecchymosis Bleeding Gums Palatal Petechiae

21. In this case, there is no immunogenic destruction of platelets but platelet count is reduced due to either less production or more destruction of the platelet. Platelets may have adhesion (Bernard- Soulier syndrome), aggregation (Glanzmann thrombasthenia) or granule defects (Gray platelet syndrome). Many drugs are also known to have significant adverse effects on platelet number and function. Non-immunogenic thrombocytopenias

22. The hematological malignancies can be grouped into three categories: leukemia, lymphoma and plasma cell tumors. These malignancies may alter bleeding and clotting time, wound healing. Blood dyscrasias

23. The multiplication of leukemic cell at the expense of normal hematopoietic cell lines causes marrow failure, depressed blood cell count (cytopenia), and death as a result of infection, bleeding, or both . The four principal diagnostic categories are the following Acute myelogenous leukemia (AML), Acute lymphocytic leukemia (ALL), Chronic myelogenous leukemia (CML) and Chronic lymphocytic leukemia (CLL).

24. show gingival bleeding, gingival enlargement petechiae ecchymosis due to thrombocytopenia. Infiltration of the gingival tissue with leukemic cells. progressive enlargement of interdental papillae , marginal and attached gingiva. Gingiva appears swollen, devoid of stippling and pale red to deep purple in color. Oral findings Patients with leukemia

25. The bleeding disorders are clinically confirmed by the case history of the patient. Usually, most of the patients are under medical supervision for their condition. Most of the procedures in non-surgical periodontal therapy do not require augmentation of coagulation factor levels. Procedures that require increment in the clotting factor levels (depending on the type of hemophilia and vWD ), Periodontal treatment of patients with bleeding disorders

26. A detailed history of the patient should be recorded with a description. If the platelet count is > 75,000/mm3, no need of additional support If the platelet count is 40,000 to 75,000/mm³-platelet transfusions. Localized procedures include sutures, hemostatic agents, pressure packs, and/or gelatin foams. Periodontal treatment of patients with platelet disorders

27. The main problems in the dental treatment of patients with hematologic malignancies of white cells are: 1. Tendency to bleed. 2. Increased risk of infection, • Odontogenic. • Opportunistic. 3. Anemia. 4. Secondary adrenal insufficiency due to corticosteroids

28. HEMOSTATIC haemostatic agent

29. A PROCESS WHICH CAUSES BLEEDING TO STOP PHASES OF HEMOSTASIS PRIMARY HEMOSTASIS ARTERIOLES CONSTRICTION FORMATION OF PLATELET PLUG SECONDARY HEMOSTASIS ACTIVATION OF COAGULATION CASCADE FORMATION OF PERMANENT PLUG

30. Astringents: Precipitate proteins locally in the bleeding site and control capillary oozing. E.G.- Tannic acid, ferric chloride, ferric sulfate , aluminum chloride, aluminum sulfate , Adrenaline: Topical application of adrenaline brings about vasoconstriction of bleeding capillaries. Cotton pad soaked in 0.1% adrenaline solution is applied on the bleeding site to control capillary oozing.

31. Haemocoagulase : Haemocoagulase enzyme complex is isolated from the venom of Bothrops atrox (viper). Mechanism of action: It has a powerful haemostatic effect. It promotes coagulation by two enzymes: One has thrombin like action (converts fibrinogen to fibrin) Another has thromboplastin- like action. Also shortens the bleeding and clotting time; thereby it controls capillary bleeding.

32. Sep Gard This works by stopping oozing of blood. It activates thrombin which promotes clot formation. It also combines with blood proteins to form a gel like substance that covers and protects the wound surface which further helps in stoppage OF Bleeding. sepgard Solution helps in controlling bleeding by speeding up blood clotting. It helps to prevent excessive loss of blood, stops bleeding and enhances the healing process. This helps prevent complications of excessive bleeding such as hemorrhage.

33. Mechanical methods Direct pressure Simplest & fastest Surgeon's first choice pads/gauzes/sponges Application of direct pressure Packaging of body cavity Sutures/staples/ligating clips Sutures and ties used as ligatures to tie off blood vessels Ligating clips - quick & easy to apply Applicator required Site of application should be clearly visible

34. Thermal/energy based methods Electro Cautery Heat achieves hemostasis by denaturation of protein, which results in coagulation of large areas of tissues. In cauterization heat is transmitted from the instrument by conduction directly to the tissues. Electro cautery has replaced direct heat application.

35. Cooling is applied to control bleeding. Mostly involves use of liquid Nitrogen. Direct cooling is effective and acts by increasing the local intravascular hematocrit and decreasing blood flow by vasoconstriction. Temperature ranging between -20°C to -180°C are used and freezing occurs around the tip of the cannula within 5 seconds. Cryosurgery

36. LASER- Light Amplification by Stimulated Emission of Radiation Solid state semiconductor 655- 980nm Tissue penetration- 0.5-5mm Photons at 630-640nm are absorbed by oxygen, improve microcirculation, can change the viscosity of the blood and affect vascular endothelium Chromophores absorb light –physical chemical mechanical temperature changes may occur

37. Chemical methods - • Causes direct vasoconstriction & increases heart rate • Can be applied topically or injected with local anesthesia Vitamin K • Administered pre-operatively to reverse effects of warfarin & to avoid need of transfusion of plasma • Only agent with ability to reverse heparin anticoagulation • Can cause anaphylaxis, acute pulmonary vasoconstriction, right ventricular failure

38. Collagen based products Activated on contact with bleeding. Provide stable matrix for clot formation CollaPlug , CollaCote , CollaTape , Helistate absorbable hemostatic collagen. Microfibrillar collagen hemostat Derived from purified bovine dermal collagen Effective agents when there is capillary, venous or small arterial bleeding Potential adverse events: allergic reaction, adhesion formation, inflammation and abscess formation Absorbable collagen hemostat sponge Derived from purified and lyophilized bovine flexor tendon Collagen sponge gets absorbed into 8 to 10 weeks

39. Oxidized regenerated cellulose • ORC reacts with blood, increases in size and forms a gelatinous mass and promotes clot formation Gelatins • Derived from purified bovine gelatin solutions • Can be used in dry or wet form • Conforms easily to wounds and therefore can be used for irregular wounds Polysacchride hemospheres • Derived from vegetable starch • Contains no human or animal component

40. Thrombin products Bovine thrombin • Applied using a pump or spray kit, or in a saturated, absorbable gelatin sponge Pooled human plasma thrombin • Delivered via saturated, absorbable gelatin sponge • Has potential risk of viral or prion disease transmission Recombinant thrombin • Reduced risk of antibody formation and eliminates risk of viral or prion disease transmission

41. Many patient suffering from various hematological conditions seek dental treatment. As many periodontal treatments involve bleeding, it is essential for periodontists to understand various hematological disorders and the periodontal management of patients with these disorders. In certain situations, it is recommended to consult the physician before rendering the periodontal treatment. Conclusion

42. Periobasics : A text book of periodontics and implantology – 1st edition –Dr. Nitin Saroch Gupta A, Epstein JB, Cabay RJ. Bleeding disorders of importance in dental care and related patient management. Journal of the Canadian Dental Association. 2007 Feb 1;73(1). Guidelines on oral anticoagulation: Third edition. EssentialPathology for Dental Students- Harsh Mohan  REFERENCES