approach to the

dental patient
with bleeding
problems
FATIMA A. ELMAHGOUB

In Brief:

Physiology
Evaluation
Disorders
Dental Management

PHYSIOLOGY

Haemostasis
Prevention

of blood loss by arrest of bleeding

and maintenance of blood in the fluid state.
Anticoagulant

Procoagulant

Endothelium
Collagen
Vascular tone
Platelets
Clotting and
fibrinolytic systems

Primary Hemostasis
(Vascular and Platelet activity)

Abnormalities in Primary Haemostasis:

Abnormal platelet number/ function

Abnormal vWF

Defects in blood vessel wall

Haemorrhage from mucosal surfaces (epistaxis, melaena,

haematuria)
Petechiae
Ecchymosis

Secondary Haemostasis
(Blood Clotting)

Abnormalities in the Coagulation cascade

Bleeding into cavities (Chest, joints, cranium)

Subcutaneous haematoma

Tertiary haemostasis
(Fibrinolysis)

Enzymatic degradation of fibrin by the enzyme plasmin

Plasmin is produced by the liver in inactive form (Plasminogen)
Plasminogen is activated by factors called Plasminogen
activators, from:
Blood: thrombin, aXII
Tissues: tPA
Urine: Urokinase
Bacteria: Streptokinase

Haemostasis
Prevention

of blood loss by arrest of bleeding

and maintenance of blood in the fluid state.
Anticoagulant

Anti-clotting

Normal endothelium
Blood flow
Antithrombin III (Liver)
Protein C and Protein S (Liver)
Heparin

Evaluation

Types of haemorrhage

Primary haemorrhage

During surgery

Injury of tissue

Can easily be controlled

Intermediate/reactionary haemorrhage

Within a few hours after surgery

Failure of coagulation to occur

Patients with bleeding problems

Patients who have unknowingly dislodged the clot

Secondary haemorrhage

Occurs 7-10 days after surgery

Due to infection

NB: The management depends on the type of haemorrhage

encountered

Local causes of haemorrhage

Injury to blood vessels

Arterial

Venous

Capillary

Injury to bone
Periosteum

Systemic Causes

History

PMH:

Unusual bleeding after trauma or surgery

Spontaneous bleeding

Frequent bruising

Prolonged bleeding after dental extraction

Bleeding from gingiva

History of oral or nasal bleeding

FHx

Drug Hx:

Anticoagulant

Medications that interfere with haemostasis

Drugs of abuse

Examination

Purpura
Bleeding wound
Haematomas
Swollen joints

Underlying systemic disease

Liver disease: jaundice, spider naevi, ascites

Cardiac patient: tachycardia, HTN

Lab Investigations
Normal ranges for haematological measurements

Bleeding time: Determines platelet function: 2-7 minutes

APTT: Evaluates Intrinsic coagulation pathway: 25 10 seconds

Platelet count: to quantify platelet function: 150,000- 450,000/L

PT and INR: Measure extrinsic pathway: 1.0

Complete blood count.

POST-OPERATIVE BLEEDING

Prolonged bleeding after dental extraction is one of the most

common signs of haemorrhagic disease and may lead to a
haemorrhagic emergency.

It is sometimes the way by which the bleeding tendency is first

recognized.

Faced with a bleeding patient, it is important to establish whether

the situation is urgent and whether there could be a bleeding
tendency, or if the patient is losing large quantities of blood,
hypotensive (hypovolaemic) or bleeding internally.

MANAGEMENT OF POSTOPERATIVE BLEEDING

Find the precise site or origin of the bleeding by cleaning out the
mouth with swabs.

Pressing firmly with a gauze pad over the socket for 1015 min
will usually stop the bleeding even in some bleeding tendencies
but often only temporarily.

Quicker and more effective is to suture the socket under local

anaesthesia (LA). If the bleeding persists, consider a systemic
cause.

In emergencies an intravenous line must be established and

Plasma expanders or blood given

Aprotinin and tranexamic acid may be used.

Disorders

PLATELET DISORDERS

May be due to decreased production OR excessive destruction

Congenital
Megakaryocyte depression
Bone marrow failure

Autoimmune
Drugs
Disease

May be due to abnormal platelet function (Glanzmann disease,

disproteinemias) or abnormal distribution (Splenomegaly)

Platelet count

Normal: 150,000- 450,000/microL

100,000-150,000 Mild

50,000-100,000 Moderate

Platelets may be needed

Local haemostatic measures]

TMW

30,000-50,000 Severe

Platelets infusion

Local haemostatic measures

TMW

<30,000 Life threatning

Avoid surgery

Platelets infusion

Local haemostatic measures

TMW- 3 days

Dental aspects of platelet

disorders
The main danger is haemorrhage but it is rarely as
severe as in the clotting disorders.

Regional LA block injections can be given if the

platelet levels are above 30 109/L.

Haemostasis after dentoalveolar surgery is usually

adequate if platelet levels are above 50 109/L.

Major surgery requires platelet levels above 75

109/L.

Conscious sedation can be given but, if by the

intravenous route, care must be taken not to damage
the vein.

GA can be given in hospital but expert intubation is

needed to avoid the risk of submucous bleeding into
the airway.

Platelets can be replaced or supplemented by platelet

transfusions, but sequestration of platelets is very
rapid.

COAGULATION DEFECTS

Coagulation defects are due mainly to:

Genetic defects of clotting factors (von Willebrand disease and

haemophilia)

Anticoagulant therapy

A range of diseases, especially liver or kidney diseases, vitamin K

deficiency

Haemophilias

Excessive bleeding, particularly after trauma and sometimes

spontaneously.

Haemorrhage appears to stop immediately after the injury (due

to normal vascular and platelet haemostatic responses) but
intractable oozing with rapid blood loss soon follows.

Haemorrhage is dangerous either because of acute blood loss or

due to bleeding into tissues, particularly the brain, larynx,
pharynx, joints and muscle.

Bleeding into the cranium, or compression of the larynx and

pharynx following haematoma formation in the neck, can be
fatal.

Abdominal haemorrhage

Haemarthroses

The severity of bleeding in haemophilia correlates with the level

of factor VIII and IX coagulant activity and degree of trauma.

Von Willebrand disease

Von

Willebrand disease (vWD;

pseudohaemophilia) is the most common
inherited bleeding disorder and is due to a
deficiency of von Willebrand factor (vWF)

Von Willebrand disease causes bleeding that has features similar

to those caused by platelet dysfunction, but if severe it can
resemble haemophilia

The common pattern is bleeding from, and purpura of, mucous

membranes and the skin. Gingival haemorrhage is more common
than in haemophilia.

Post-operative haemorrhage can be troublesome: excessive

haemorrhage may occur after dental treatment and surgery.

Excessive menstrual bleeding is common in females.

Haemarthroses are possible but are rare.

ANTICOAGULANT TREATMENT

Anticoagulants are given to prevent and treat thromboembolic

disease but have many uses.

They are used to treat:

Atrial fibrillation,

Cardiac valvular disease,

Ischaemic heart disease

Postmyocardial infarction (sometimes)

deep venous thrombosis (DVT)

pulmonary embolism

cerebrovascular accident

heart valve replacements or renal dialysis.

Commonly used anticoagulants are warfarin for long-term

treatment and heparin for short-term treatment

Because it takes several days for the maximum effect of warfarin

to be realized, heparin is normally given first.

Warfarin, a 4-hydroxycoumarin derivative, is the most commonly

used oral anticoagulant. It is a vitamin K antagonist, which acts
by inhibiting the post-translational glutamate carboxylation of
blood coagulation factors II, VII, IX and X.

Warfarin

Warfarin effects begin after 812 h, are maximal at 36 h, and

persist for 72 h, prolonging the international normalized ratio
the ratio of the patients prothrombin time to a standardized
control.

An INR above 1 indicates that clotting will take longer than

normal.

The INR is used as a guideline to care and should be checked on

the day of operation or, if that is not possible, within 24 h prior to
surgery

Omar Alamin Ahmed Mustafa, a 52 year old male patient came to

your clinic complaining of severe pain on his lower back tooth
that kept him up last night.

After completing history taking and clinical examination, you

diagnosed the tooth as having irreversible pulpitis

In the PMH, he says that is healthy and doesnt mention any

abnormality. In the drug history, he tells you that he has been
taking blue pills everyday for the past 6 months.

You find out that he is on Warfarin therapy.

How do you manage this patient?

Why is he on Warfarin
therapy?

Omar mentioned that he had previous heart problems and you

find out that he was diagnosed with IHD

Management

Things that must be kept in mind:

The type of procedure

INR

Underlying condition

Manage the patients chief complaint.

Alternative to dental surgery

Explain to the patient the dangers of intra and postoperative

bleeding

Warfarin doesnt need to be stopped before primary care dental

surgical procedures

Check INR value

Should be checked at day of extraction
The normal INR=1
Warfarin shouldnt be discontinued for patient with INR of 4 or
less

Local anaesthesia:

Warn patient of intra and postoperative bleeding

Avoid intramuscular injection

Avoid Regional block anaesthesia

Better to give intraligamentary/intrapapillary LA

Minimizing risk and extent of postoperative bleeding:

Number of teeth to be extracted should be limited

LA injection containing epinephrine should be given

Resorbable gelatin/ oxidized cellulose material placed in socket

Compress bony wound

Tight multiple interrupted sutures placed

Patient should bite on saline soaked gauze for 30 mins.

No exercise

No rinsing 24 hr

Cold liquids 48 hr

Tranexamic acid rinse (4 times a day for 2 minutes)

If INR >4 or if surgery is not minor or if there are other risk factors,
patient should be treated in the hospital.

Consideration should be given to whether the anticoagulation

should be modified.

Discontinue Warfarin for 2-3 days pre-operatively. Heparin can be

used instead in the preoperative period.

To prevent post-operative bleeding, an antifibrinolytic agent can be

used topically to control haemorrhage. Warfarin therapy should be
restarted simultaneously with heparin.

Heparin should be stopped once the INR reaches the required

therapeutic level. Generally, heparin and warfarin overlap for
approximately 4 days. Follow-up INR with the patients physician
should be arranged for 3 days after discharge.

As Omar is leaving the clinic, he asks you what he should take if

he feels any pain. (You forgot to mention it in the postoperative
instructions)

Medications and dietary interactions with Warfarin:

Aspirin and NSAIDs- interfere with platelet function and cause gastric
bleeding

Warfarin + Aspirin = Increased risk of IC haemorrhage

Postoperative

pain management:

Paracetamol 500mg 4 tabs/ day

**Excessive and prolonged paracetamol can enhance Warfarin

activity and increase risk of haemorrhage

Codeine may be given with paracetamol to enhance analgaesic

effect

Heparin
Blocks

conversion of fibrinogen to fibrin.

The

anticoagulant effect of standard or unfractionated heparin has

an immediate action on blood clotting, which is usually lost within 6
hours of stopping it.

Dental aspects
For uncomplicated forceps extraction of 13 teeth, there is usually
no need to interfere with heparin.
No specific treatment is needed to reverse its effect.
The effect of heparin is best assessed by the APTT.
In an emergency, this can be reversed by intravenous protamine
sulfate given in a dose of 1 mg per 100 IU heparin, but a medical
opinion should be sought first.
Where heparin has been stopped, any surgery can safely be carried
out after 68 h

Aspirin

Aspirin irreversibly impairs platelet aggregation and is used long-term

in the prevention of cardiovascular events and stroke in patients at risk.

Even small doses of aspirin prolong the bleeding time and impair
platelet adhesiveness

In patients with no other cause for a bleeding tendency and receiving

up to 100 mg aspirin daily, in general, for uncomplicated forceps
extraction of 13 teeth, there is no need to interfere with aspirin
treatment.

In patients with no other cause for a bleeding tendency and receiving

doses of aspirin higher than 100 mg daily, if there is concern, the
current value of the bleeding time should be established. If it is over 20
min, surgery should be postponed

Thank you