Management of

bleeding in dentistry
Content
• Introduction
• Diagnosis
Introduction

• Bleeding disorders characterized by abnormal platelet function or blood vessel walls that
result in increased bleeding.

• Dentists must be aware of the impact of bleeding disorders on the management of their
patients.

• Proper dental and medical evaluation of patients is therefore necessary before treatment,
especially if an invasive dental procedure is planned
Diagnosis
• Patient evaluation and history should begin with standard medical questionnaires.

• Patients should be queried about any previous unusual bleeding episode after surgery or
injury, spontaneous bleeding and easy or frequent bruising.

• For the purpose of history-taking, a clinically significant bleeding episode is one that:
1. continues beyond 12 hours
2. causes the patient to call or return to the dental practitioner or
3. to seek medical treatment or emergency care
4. results in the development of hematoma or ecchymosis within the soft tissues
5. or requires blood product support
• The patient should be asked for any history of significant and prolonged bleeding after dental
extraction or bleeding from gingivae.

• A history of nasal or oral bleeding should be noted.

• Many bleeding disorders, such as hemophilia and von Willebrand’s disease, run in families;
therefore, a family history of bleeding disorders should be carefully elicited.
• A complete drug history is important.

• If a patient is taking anticoagulant drugs, it will be important to consult his or her physician
before any major surgical procedure

• Drugs of abuse, such as alcohol or heroin, may also cause excess bleeding by causing liver
damage resulting in altered production of coagulation factors

• A general examination of the patient might indicate a tendency to bleed. Multiple purpurae of
the skin, bleeding wounds, evident hematomas or swollen joints may be evident in patients
with severe bleeding defects.
PHYSICAL EXAMINATION :-

• The P/E should focus on whether bleeding symptoms are associated primarily with the mucous
membranes or skin (mucocutaneous bleeding) or with the muscles and joints(deep bleeding).

• The examination should determine the presence of petechiae, ecchymoses, hematomas, hemarthroses,
or mucous membrane bleeding.

• Patients with defects in platelet-blood vessel wall interaction (VWD or platelet function defects)
usually have mucocutaneous bleeding.

• Individuals with a clotting factor deficiency of factor VIII or IX (hemophilia A or B) have symptoms of
deep bleeding into muscles and joints.

• Individuals with disorders of the collagen matrix and vessel wall may have loose joints and lax skin
associated with easy bruising (Ehlers-Danlos syndrome).
 Lab investigations

 Blood count and film

• show the number and morphology of platelets and any blood disorder such as
leukaemia or lymphoma.
• The normal range for the platelet count is 150- 400 × 109 /L

 Bleeding time
• measures platelet plug formation in vivo
• normally between 3 and 10 minutes
• Prolonged bleeding times are found in patients with platelet function defects
Prolonged bleeding times are found in patients with platelet function defects:-

• Performed using blood collected into citrate, which neutralizes calcium ions and prevents
clotting.
• The prothrombin time (PT)
• The partial thromboplastin time (PTT)
• The thrombin time (TT)
• Correction tests
• Factor assays
• Special tests of coagulation
Coagulation tests:-

• The prothrombin time (PT)

• Time needed for the plasma to clot in the presence of tissue thromboplastin and
calcium
• Evaluates the ability of blood to clot properly
• Normal time for clotting is 10-14s
• Prolong PT results from def of:
• Factor V
• Factor VII
• Factor X
• Prothrombin
• Fibrinogen
Types of bleeding disorders:-

• Bleeding disorders can be classified as coagulation factor

deficiencies, platelet disorders,vascular disorders or
fibrinolytic defects.
Coagulation factor deficiencies:-

• Congenital
• Hemophilia A and B
• von Willebrand’s disease
• Other factor deficiencies (rare)
• Acquired
• Liver disease
• Vitamin K deficiency, warfarin use
• Disseminated intravascular coagulation
Platelet disorders
Quantitative disorder (thrombocytopenia)
• Immune-mediated
• Idiopathic
• Drug-induced
• Collagen vascular disease
• Sarcoidosis
• Non-immune-mediated
• Disseminated intravascular coagulation
• Microangiopathic hemolytic anemia
• Leukemia
• Myelofibrosis
Qualitative disorder
• Congenital
• Glanzmann thrombasthenia
• von Willebrand’s disease
• Acquired
• Drug-induced
• Liver disease
• Alcoholism
Vascular disorders

• Scurvy
• Purpura
• Hereditary hemorrhagic telangiectasia
• Cushing syndrome
• Ehlers-Danlos syndrome

Fibrinolytic defects

• Streptokinase therapy
• Disseminated intravascular coagulation
Coagulation factor deficiencies
Hemophilia
• Hemophilia A is due to a deficiency of clotting factor VIII or antihemophilic factor or
Hemophilia B is due to deficiency of clotting factor IX (hemophilia B).
• Inherited X-link disorder
• Prevelance 1 in 5000 in male population
Hemophilia A- X linked
• Clinical features:-

 Atypical profuse bleeding at circumcision

 Bruising at neonatal vaccines
 Joints and soft tissue bleeds and excessive bleeding when they start to be active
 Prolonged bleeding after teeth extraction
 Recurrent painful hemarthrosis
 Muscle haemoatomas
 Spontaneous haematouria
 GIT hemorrhage
 Spontaneous intracranial hemorrhage (rare)
• Clinical features

The clinical severity depend on the level of factor VIII:C = severity of

condition
• Severe = factor level < 1%
• Moderate = factor level 1 – 5%
• Mild = factor level > 5 %
Severe disease – factor level < 1%
 Frequent spontaneous bleeding from early life
 Haemarthroses are common and may lead to joint deformity
 Bleeding into muscles is also common

Moderate disease – factor level 1 – 5 %

 Post traumatic Bleeding
 Occasional apparently spontaneous episodes

Mild disease – factor level > 5 %

 Usually with bleeding only after injury or surgery
 Diagnosis in this group is often delayed until quite late in life
• Laboratory finding – investigations
 Coagulation testing
 Prolonged activated partial thromboplastin time (APTT)
 Normal prothrombin time (PT)
 Normal bleeding time (BT)
 Factor assay (reduced level of factor VIII
Hemophilia B

• Also known as Christmas disease

• Caused by a deficiency of factor IX
• The inheritance and clinical features are identical to hemophilia A
• Only can be distinguished by specific coagulation factor assays
• The incidence is only about 1 in 30 000 males
• Hemophilia B is treated with factor IX concentrates
General Management:-

• 1. Factor replacement
• Bleeding is treated by administration of factor VIII concentrate by intravenous
infusion.
• Minor bleeding: the factor VIII:C level should be raised to 20-30%
• Severe bleeding: the factor VIII:C should be raised to at least 50%
• Major surgery: the factor VIII:C should be raised to 100% preoperatively and
• maintained above 50% until healing has occurred.
2. Synthetic vasopressin (Desmopressin)
• An analogue of vasopressin
• Intravenous, subcutaneous or intranasal
• Produces a rise in factor VIII:C in mild hemophilia
• It avoids the complications associated with blood products
• It is ineffective in severe haemophilia
3. Tranexamic acid is a synthetic derivative of lysine, available for topical and
systemic usage. However, nausea is a common adverse effect.

4. The anti-fibrinolytic agent

• Epsilon amino caprioic acid (EACA) given orally of IV is a potent inhibitor of

initial clot dissolution. A regimen of 50 mg/kg body weight EACA given orally
as a 25% oral rinse every six hours for seven to ten days appears adequate as
an adjunct.
 Dental Management
Difficulties in the management of a hemophiliac dental patient include the
following:-

• Dental neglect necessitating frequent extractions

• Trauma and surgery
• Factor VIII inhibitors (recombinant FVIIa is an alternative Solution)
• Hazards of anesthesia and injections
• Risk of hepatitis B and liver disease and HIV infection
• Aggravation of bleeding by drugs
• Anxiety and drug dependence
• The bleeding tendency can be aggravated by NSAIDs. Safer alternatives for pain
control are acetaminophen, codeine and Cox-2 inhibitors.

• Local anesthetic regional blocks, lingual infiltrations or injections into the floor of
the mouth must not be used in the absence of Factor VIII replacement because of
the risk of hemorrhage hazarding the airway and being lifethreatening.

• If FVIII replacement therapy has been given, regional LA can be used

provided the FVIII level is maintained above 30%.

• Infiltrations, intraligamentary, intraosseous or intrapulpal injections are still

safer.
⦿ Restorative treatment can be undertaken routinely providing care is taken to
protect the mucosa. There is a risk of bleeding with the use of matrix bands
or wooden wedges. This can be controlled by local means or the application
of topical agents.
⦿ Cotton rolls should be wetted before removal.

⦿ High-speed vacuum aspirators and saliva ejectors can cause hematomas.

⦿ Trauma from the saliva ejector can be minimized by resting it on a gauze

swab in the floor of the mouth.
 Avoiding instrumentation through the periapex is of prime importance in
endodontic therapy.
 The presence of bleeding in the canal is indicative of pulp tissue
remaining in the canal.
 Sodium hypochlorite should be used for irrigation in all cases, followed
by the use of calcium hydroxide paste to control the bleeding.
 Formaldehyde-derived substances may also be used in cases where there
is persistent bleeding or even before the pulpectomy.
⦿ It also minimizes the potential for laceration of the buccal mucosa and lips.
⦿ Notches may be placed in buccal and lingual surfaces with a fissure bur
into which clamp prongs will fit tightly.
⦿ Isolation with rubber dam provides retraction of gingiva and
improves visibility.
⦿ Mild hemophiliacs requiring surgeries can be managed usually without factor
replacements.
⦿ Desmopressin and tranexamic acid are primary alternatives.
⦿ Desmopressin can be as a slow intravenous infusion over 20 min of 0.3-0.5
µg/kg, 30 to 60 min prior to the surgical procedure.
⦿ This results in a two- to threefold rise in Factor VIII activity with a mean half-
life of 9.4h.
⦿ If oral hygiene is poor treatment must start as soon as possible after the patient has
had a dental examination and treatment plan formulated to prevent additional
damage to the periodontal tissues.
⦿ In cases of severe periodontal disease, it may be necessary to carry out
supragingival scaling initially along with oral hygiene education.
⦿ Subgingival scaling can start as soon as the inflammation has decreased. The
treatment may need to be carried out over several visits to prevent excessive
blood loss.
⦿ In addition, chlorhexidine gluconate mouthwash can be used to control
periodontal problems.
⦿ Antibiotics may be required to help reduce the initial inflammation.
⦿ Dental pain can usually be controlled with a minor analgesic such as
paracetamol (acetaminophen). Aspirin should not be used due to its
inhibitory affect on platelet aggregation.
⦿ The use of any non-steroidal anti-inflammatory drug (NSAID) must be
discussed beforehand with the patient's hematologist because of their effect on
platelet aggregation
⦿ A buccal infiltration can be used without any factor replacement. It will
anesthetize all the upper teeth and lower anterior and premolar teeth.
• Contact the hemophilia unit and consider using additional factor concentrate.
• Inspect the site of the bleed.
• If there is any evidence of a tear in the gingiva or other obvious bleeding point
this should be treated using local measures. Instruct the patient to sit up and
bite on a damp gauze swab for at least 10 minutes.
• Use a 10% solution of tranexamic acid or EACA to dampen the swab or as a
mouthwash if the bleeding is difficult to stop.
• Monitor the patient’s blood pressure as it may increase due to worry and pain.
• In some hemophilia centres, fibrin glue is used as a local hemostatic
measure, along with an oral antifibrinolytic agent, to achieve hemostasis and
reduce the need for clotting factor replacement therapy

• All fibrin glue contains human or animal components, which has made a
number of physicians and patients being hesitant to use this treatment
particularly for patients who are receiving recombinant factor concentrates or
have never received blood products derived from humans.
◾ Hereditary coagulation abnormality
caused by either:
1. Reduced level of vWF
2. Abnormality in vWF

Due to Point mutation or Major deletion

⦿ Clinical
features
◾ Typically there is mucus membrane bleeding (epistaxis, menorrhage...)
◾ The severity of symptoms are variable with types
 Type 1, 2 usually mild symptoms

 Type 3 severe symptoms

⦿ Laboratory Investigations:

◾ The bleeding time is prolonged

◾ APTT is prolonged
◾ Factor VIII is low
◾ VWF is usually low (type 1,2)
◾ Platelets count is normal
Treatment

◾ Depends on the severity of the condition.

◾ May be similar to that of mild haemophilia, including the use
of Desmopressin where possible.
◾ Factor VIII or Von Willebrand factor concentrates should be used to treat
bleeding or to cover surgery in patients who require replacement
therapy.
⦿ Acquired coagulation disorders
◾ More common than inherited disorders
◾ Usually multiple clotting factors
◾ Includes
 Vitamin K deficiency

 Liver disease

 Coagulation disorders caused by antibodies

 Massive transfusion syndrome

Vitamin K is a fat soluble vitamin

◾ Obtained from green vegetables and bacterial synthesis in the gut

◾ Important on coagulation factors II, VII, IX and X and on proteins C and
S.
◾ Without it, these factors cannot bind calcium.
◾ Hemorrhagic disease of the newborn
◾ Biliary obstruction
◾ Malabsorption of vitamin K
◾ Vitamin K antagonist drugs
◾ Biliary obstruction results in malabsorption of vitamin K and
therefore
decreased synthesis of factors II, VII, IX and X.
◾ Also there are decreased in factor V and fibrinogen.
◾ Dysfibrinogenemia.
◾ Thrombocytopenia.
◾ Functional abnormalities of platelets.
◾ Hypersplenism associated with portal hypertension.
◾ DIC.
⦿ There is widespread deposition of fibrin within blood vessels with
consumption of coagulation factors and platelets occurs as a consequence
of many disorders which release procoagulant material into the
circulation or diffuse endothelial damage or generalized platelet
aggregation
• Infections • Obstetric complications
– Gram neg septicemia – Amniotic fluid embolism
– Septic abortion – Eclampsia, retained
• Malignancy placenta
– Widespread mucin secreting • Widespread tissue
adeno-carcinoma damage
– Acute promyelocytic – Following
leukemia surgery/trauma
• Hypersensitivity – After severe burns
reactions • Miscellaneous
– Anaphylaxis – Liver failure
– Incompatible blood – Severe burns
transfusion – Hypothermia
– Snake
Bleeding Disorders of Importance in Dental Care and Related Patient Management venoms
Anurag Gupta, BDS;
Joel B. Epstein, DMD, MSD, FRCD(C); Robert J. Cabay, MD, DDSJCDA–• • AcuteFebruary hypoxia
2007, Vol. 73, No. 1
•
⦿ Clinical features

◾ Bleeding, particularly from venipuncture

◾ Purpura
◾ Generalized bleeding in GIT, oropharynx,
lungs, urogenital tract, vaginal bleeding
◾ Less frequently, microthrombi may cause
skin lesions, renal failure, gangrene of
fingers
⦿ Laboratory finding
◾ The platelet count is low
◾ Fibrinogen low
◾ Thrombin time is prolonged
◾ High level of fibrin degradation products (FDP)
◾ PT and APTT are prolonged in acute
syndromes
⦿ Blood film
◾ Fragmentation of red cells
Treatment

◾ Treatunderlying cause
◾ Supportive therapy with fresh frozen plasma (FFP) and platelets
concentrates
◾ Cryoprecipitate may also required
 Instructions to be given to patients after
procedures

• Patient should be advised to rest for 2-3hrs post operatively

• Avoid rinsing of mouth for 24hrs
• Avoid disturbing that area with tongue or finger
• Avoid hot, hard, spicy food for rest of the day
• If bleeding restarts apply pressure using a clean folded hanky for 20mins
• Big chunk of cotton dipped in ice cold water for 30mins can be advised
• If bleeding doesn’t stop contact your dentist
• Ask the patient to wait for 30 mins to check the bleeding
• For post operative pain Tab Etody 120 mgs for two days
 General instructions

• Clinical problem is not amenable to a cook book approach

• Each patient must be considered individually and you must take into
consideration the risk – the benefit of stopping vs continuing anticoagulants
• Your decision depends upon:
medical condition/ stability
degree of anticoagulation
magnitude of planned surgery
scientific evidence
 Physical management (3-4 mins)
• Cotton , gauze, constant compression
• Do not be impatient and check again and again
• Have patience
• Suturing is advised specially advised in pt’s who are on blood thinners,
hypertensive, diabetic, smokers, alcoholics
• In case of distorted socket but if the socket is intact need not give (while
taking the bite for it will damage more)
 Physical management (3-4 mins)

• Cotton , gauze, constant compression

• Do not be impatient and check again and again
• Have patience
• Suturing is advised specially advised in pt’s who are on blood thinners,
hypertensive, diabetic, smokers, alcoholics
• In case of distorted socket but if the socket is intact need not give (while taking the
bite for it will damage more)
• Collagen sponges in the socket and suture so that it doesn’t get dislodged
• Soak the cotton with botroclot solution and apply topically to treat bleeding (ask
the patient to bite on cotton)
• It is not so effective though.
• Cauterization - Burn the skin or flesh of wound with a heated instrument and cut
the end in order to stop bleeding/prevent infection
• Tranexamic acid- PAUSE (antifibrinolytic)

• Medication to treat or prevent excessive blood loss

• Can be given as mouthwash 4times daily for 2days (drawback: risk of
systemic issues)
• Apply on a cotton swab and ask to bite
• Inj. PAUSE (we don’t give because of systemic issues)
 TEA BAGS

• Bite on moist tea bags

• Tannins within the tea leaves promotes clotting and caffeine increases
circulation
• Healing and recovery time increases
 MENSTRUAL CYCLE
• Always ask women if they are on their cycle
• If yes postpond the surgical procedures
• At this time, plasminogen levels are high
• Anticlotting factors are higher than clotting factors at this time
⦿ Ifthere is active bleeding, consultation with a hematologist may be
considered to assist with definitive diagnosis and, for patients who are
ultimately diagnosed with a bleeding disorder, individualized long-term
hemostatic management.
⦿ Treatment planning is essential for good outcome and should involve liaison
between the dentist and the haemophilia centre.
⦿ Consideration should be given to careful scheduling of invasive dental
procedures to minimise re-exposure to factor concentrate.
⦿ Written post-procedural instructions should be provided and must include
emergency contact numbers.