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Hematologic disorders

Hemostasis
not
Homeostasis

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The end product of the coagulation system, which shows a fibrin clot or
thrombus. White threads are fibrin, the structure with yellow on the surface
is a white blood cell, platelets are green, and the red structures are red
blood cells.

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hemostasis
Vascular phase
Platelets phase
Coagulation cascade
extrinsic
common
intrinsic

Fibrinolytic phase

Let me thank my dear friend,

Dr. Abd El Rahman El Mekkawi

Assistant Lecturer of Endodontics
for these amazing videos,

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Coagulation cascade
This process involves multiple proteins, many of which are
synthesized by the liver
fibrinogen, prothrombin, V, VII, IX, X, XI, XII, and XIII
Some are vitamin K dependent
II, VII, IX, and X
The process of coagulation essentially involves three
separate pathways.

Laboratory Assessment of Hemostasis

Platelets

Coagulation
factors

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Platelets
Platelet Count: quantitative assessment of circulating platelets.
A normal count is within the range of 150,000 to 450,000/mm3
of blood. Below 100,000/ mm3 is
Thrombocytopenia
If it is 50,000-100,000/mm3 excessive bleeding occurs only with
severe trauma. Below 50,000/mm3 shows skin and mucosal
purpura and bleed excessively with minor trauma.
Below 20,000/mm3 may experience spontaneous bleeding

Bleeding Time: screening test for assessing adequacy of

platelet function. The normal range is usually between 2
and 10 minutes.
It is unreliable

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Coagulation factors
Prothrombin Time (PT): informs about the extrinsic
coagulation pathway (Factor VII) and the common
pathway (Factors V, X, prothrombin and fibrinogen).
Factors VII, X and prothrombin are Vitamin K-dependent
Normal PT is 11 to 15 seconds, depending on laboratory

International normalized ratio (INR)

International sensitivity index (ISI=0.93) value calibrated
from World Health Organization.

INR = (PT patient/PT normal) x ISI

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Activated Partial Thromboplastin Time (aPTT): measures

the effectiveness of the

intrinsic

factors (VIII, IX, XI, XIII) and

common pathways of the coagulation cascade.

The test is termed "partial" due to the absence of

tissue factor

from the reaction mixture. it is prolonged in cases of mild to

severe deficiency of factor VIII or IX.
Normal aPTT is 25 to 35 seconds, depending on laboratory

Thrombin Time: measures the efficiency of fibrinogen turning

into to insoluble fibrin,
Generally, the normal range for the TT test is 9 to 13 seconds,
and results in excess of 16 to 18 seconds are considered
abnormal or prolonged.

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PL: Phospholipid

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Common Bleeding Disorders

Extremely fragile blood vessels
Decreased number of platelets or impaired function
Abnormalities in coagulation factors (coagulopathies) )
Defects in the fibrinolytic pathway
Combination of these

Reversible coagulopathies
anticoagulation Therapy
Warfarin Sodium : It interferes with the livers synthesis
of vitamin K-dependent clotting factors
II, VII, IX, and X.
Its therapeutic target is to prevent new thrombi
INR is now used to monitor patients on warfarin therapy.

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Heparin: is not an anticoagulant by itself.

Plasma antithrombin III which is a protien formed in liver is the
actual anticoagulant, heparin serves as a catalyst. It inhibits
factor Xa and thrombin
Standard heparin has a half-life of 1 to 2 hours

Low-molecular-weight heparin
LMWH
can be used instead of regular heparin and is rapidly
becoming the treatment of choice. It has greater activity
against factor Xa than thrombin and longer half-lives.
Half-life of these preparations is about 2 to 4 hours.

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Antidotes are available for overdosing of

Heparin.......... Potamine
and
Warfarin.......... Vitamin K

Warfarin
Wisconsin Alumni Research
Foundation

-arin Coumarin

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irreversible coagulopathies
Inherited Coagulation Disorders

Hemophilia A
(Classic hemophilia) is caused by deficiency in factor VIII.
minimally 30% of factor VIII is required for normal activity.
Mild

F VIII is 5-30% of normal value

Moderate

F VIII is 1-5% of normal value

Severe

Below 1% of normal value

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Hemophilia B

Christmas disease: It is a bleeding disorder caused

by a deficiency factor IX

Greek haima "blood philia "to love"

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Management of patients with bleeding disorders will

undergo dental treatment !!!!
For me this phrase means nothing , it is no more than SOS
message, just I need help!!!
You should know the type of the dental procedure and
the type and severity of the bleeding disorder.

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In case of Platelet-Related
disorders

1-Thrombocytopenia (<50,000/mm3) not responding to

treatment.

platelet transfusions
Infusion of one unit of platelets increases its number by
10,000 to 12,000/mm3.
Six units of platelets are commonly infused at a time.

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Routine dental procedures can be performed if platelets is

above 50,000/mm.
If it is below this level, routine dental treatment should be
delayed. In case of urgent dental needs, platelet replacement is
indicated.
For more advanced surgery, the platelet count should be above
100,000/mm

2-Antiplatelet therapy
Aspirin acts as an inhibitor of cyclooxygenase, and this causes
irreversible damage to the platelets. This prevents production
of Thromboxan that is needed in platelets aggregation
The old concept of stopping the antiplatelet therapy for three
days

before

surgery

in

no

more

used,

it

obsolete

recommendation..

DO NOT STOP
the use of daily aspirin before routine dental extractions even
in multiple extractions

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Patient under Anticoagulation therapy

Warfarin

Recommended therapeutic range for warfarin therapy

Low intensity warfarin
therapy INR 2-3
(Target 2.5)

Prophylaxis of venous thrombosis

Treatment of pulmonary embolism

High intensity warfarin

therapy INR 2.5-3.5
(Target 3)

Prevention of recurrent MI
Prosthetic heart valves

Acute myocardial infarction (MI)

Atrial fibrillation
valvular heart disease

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Low intensity warfarin therapy

simple surgical procedures
Maintain INR between the range of 2.0-3.0
Control bleeding with local hemostatic measures
Complex surgical procedures
Stay at safe INR range between 2-2.5
Control bleeding with local hemostatic measures

High intensity warfarin therapy

simple surgical procedures
Maintain INR in the 2.5-3.5 range then proceed
Control bleeding with local hemostatic measures
Complex surgical procedures
Stay at safe INR range between 2.5-3
Control bleeding with local hemostatic measures

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Do not to operate when the

INR value is out of range
( 4)

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Inherited Coagulation
Disorders

Patient with mild to moderate hemophilia

are treated in the dental clinic
Patient with severe hemophilia are treated
in the hospital

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Hemophilia A
F VIII replacement
one unit of F VIII concentrate per kilogram of body weight
raises the F VIII level by 2%
a 70 kg patient would require infusion of 3,500 units to
raise his factor level from < 1% to 100%.
Aminocaprioc acid or Tranexamic acid as mouth wash for
clot stabilization

Factor VIII replacement

For minor spontaneous bleeding or minor traumatic bleeding,
25% to 30% replacement of factor VIII is required.
Treatment or prevention of severe bleeding during procedures
such as major dental surgery, 50% replacement or greater is
needed.
Treatment of life-threatening bleeding during major surgery
requires 80% to 100% replacement

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Hemophilia B
F IX replacement
By using F IX complex concentrates (prothrombin
complex concentrate [PCC]) F II, VII, IX, and X.
One unit of PCC given by bolus per kilogram of body
weight raises the F IX level by 1 to 1.5%.

During the procedure:

Pain control
Anesthetic solutions with vasoconstrictors should be
used when possible.
If a hematoma develops, ice packs should be applied to
the area to stimulate vasoconstriction
Nerve block injections require minimal coagulation factor
greater risk occurred with severe disease.

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Hepatic disease and bleeding disorder:

Deficiency of vitamin Kdependent clotting factors
II, VII, IX, and X
Can be reversed with vitamin K injections for 3 days either
intravenously or subcutaneously.
If used in management of emergency hemorrhage, bout 24hr is
needed to reach significant INR.
However, infusion of Fresh frozen plasma (FFP) may be
employed when more immediate hemorrhage control is
necessary.

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