1. Management Of Hemorrhage In Dental Surgery

2. Hemorrhage(bleeding):
Extravasation of blood due to rupture of blood vessels, which could be capillary, artery or vein.
The effect of bleeding depends on:
1.Amound of blood loss.
2.Site of bleeding.

3. Phases of hemostasis Vascular phase: Platelet phase:
When a blood vessel is damaged, vasoconstriction results.
Platelet phase:
Platelet adhere to the damaged surface and form a temporary plug.
Coagulation phase:
Through two separate pathways the conversion of fibrinogen to fibrin is complete.
Fibrinolytic (metabolic) phase:
Anti clotting mechanisms are activated to allow clot disintegration and repair of the damaged vessels.

4. Timing of clinical bleeding
A disorder in the vascular or platelet phase results in immediate clinical bleeding following injury or surgery.
If the coagulation phase is abnormal the bleeding problem will be delayed for several hours after injury or surgery.

5. The hemostasis depend upon:
Vessel wall integrity.
Adequate number of platelets.
Proper functioning platelets.
Adequate levels of clotting factors.
Proper function of fibrinolytic pathway.
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6. Bleeding disorders can be defined as those disorders that alter the ability of blood vessels, platelets and coagulation factors to maintain haemostasis. These can either be congenital or acquired (2ndry to disease, drugs, radiation or chemotherapy

8. Purpura NTCP Vascular wall alteration - Scurvy
- Infections
- Chemicals
- Allergy
Disorders of platelet function
- Genetic (Bernard-Soulier disease)
- Drugs (Aspirin ,Cephalosporin ,Penicillin's ,NSAIDS, Beta-Lactam antibiotics and Alcohol).
- Autoimmune
- vW disease (2ndry factor 8 deficiency)
- Uremia

9. Purpura TCP 1- Primary (idiopathic –Autoimmune) 2- Secondary
- Chemicals
- Physical agents (radiation)
- Leukemia
- Metastatic cancer to bone
- Splenomegaly
- Drugs (Alcohol,Thiazide diuretics,Estrogens,Gold salts)
- Prosthetic heart valve
- Viral or bacterial infections

10. Clotting or Coagulation defects
Congenital
1- Hemophilia A (Factor 8 Def.)
2- Hemophilia B (Factor 9 Def.)
3-VW disease

11. Clotting or Coagulation defects
Acquired
1-Liver disease
2-Vit K deficiency
Biliary tract obstruction
Malabsorption
Excessive use of broad spectrum antibiotics
4- Anticoagulants
Heparin
Coumarin
Warfarrin and NSAIDS
5- Primary fibrinolysis

12. Notes 1- Congenital deformities involves def. of one factor.
2- Acquired coagulation defects involve multiple factors
3- Hemophilia A is the most commonly inherited coagulation disorder (80%).
4 –Anticoagulants are used to prevent thrombosis in:
- MI
- CVA
- Thrombophlebitis
- Atrial fibrillation
- Open heart surgery
- Hip or Knee replacement
- Asprin is also used in Rheumatoid arithritis

13. Notes
6-The liver produces all the protein coagulation factors.
7-Patients with liver disease who develop portal hypertension and hypersplenism may be thrombocytopenic as a result of splenic over activity.
8-Vitamin K is needed by the liver to produce factors 2,7,9 and 10.

14. Hemorrhage in Oral Surgery
Hemorrhage following Oral Surgical procedures can occur due to local or systemic causes. In healthy patients the postoperative bleeding is mainly due to local causes.
Local causes of haemorrhage in oral surgery Local causes of hemorrhage originate in either soft tissue or bone.

15. Types of bleeding. Go .Reactionary bleeding .Secondary bleeding
.Immediate bleeding
.Reactionary bleeding
.Secondary bleeding Go

16. Immediate bleeding: which occur at the time of surgery as a result of injury like cutting or laceration of the artery or bleeding from bone. This also occurs when surgery is done in an infected area with a lot of granulation tissue
Reactionary bleeding: During the first 48 hours because a clot in a vessel has been displaced, or a ligature has slipped due to increase in blood pressure
Secondary bleeding: 8 to 14 days later when the wound has become infected and eroded a vessel, usually quite a small one.

17. Management of Primary Hemorrhage in Normal patients
The management of bleeding during surgery (Primary bleeding) can be achieved by the following means,
Securing / ligation of blood vessels with silk sutures.
Use of pressure swab to achieve hemostasis.
Use of electrocautery to achieve hemostasis.
Use of hemostatic agents like bone wax, surgicel,e.t.c.,
use of vasoconstrictors in L.A.

18. Local Measures ( Synthetic Materials)There are several materials that are commerciallyavailable that are used locally for achievingadequate hemostasis.
Surgicel (Oxidised Regenerated Cellulose)
Gelfoam with activated thrombin
Tranexamic acid 5%)
Etik Collagen (Packed collagen)Regenerated Cellulose)

19. Management of reactionary Hemorrhage
in Normal patients The management of (Reactionary bleeding involves proper examination of the surgical wound to identify the site of bleeding (i.e ) from bone or soft tissue.
If bleeding is from bone then the hemostatic agents like bone wax or gelfoam is usually used.
If bleeding is from soft tissues then, ligation / cauterization of blood vessels along with the use of hemostatic agents like surgicel and suturing of the wound is carried out.

20. Management of Secondary Hemorrhage
in Normal patients The management of this type of bleeding that occurs a few days after surgery involves the removal of any debris from the wound surface that promotes the infection of the wound. Identify the source of bleeding and treat as would be done in a patient with reactionary bleeding. Surgical stents can be placed over extraction sockets for stabilization of clot and prevention of wound contamination.

21. Management of Hemorrhage in patients with bleeding disorders / and those on anticoagulant therapy
The usual protocol involved in the treatment of this group of patients consists of pre-operative blood investigations and preoperative correction of the underlying deficiency (Replacement of Clotting factors /platelets) if any in these patients. Subsequently, after this appropriate local measures are used to decrease the chances of post-operative bleeding.

22. Dental evaluation:
Good thorough medical , family and personal history.
Physical examination.
Medication
Past and present illness.
Spontaneous bleeding.
Consult physision
Screening clinical lab tests.

23. Laboratory evaluation
Platelet count.
Bleeding time (BT(.
Prothrombin time(PT(.
Partial thromboplastin time (PTT(.
Thrombin time (TT(.
International normalized ratio(INR).
Platelet function analyzer 100 (PFA100(.

24. Platelet Count: Normal 100,000 – 400,000 cell / mm3
less than 100, Thrombocytopenia.
50,000 – Mild thrombocytopenia.
Less than 50,000 Sever thrombocytopenia.
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25. Bleeding time: Partial thromboplastin time:
Provides assessment of platelet count and function.
Normal value: 1-6 minutes.
Partial thromboplastin time:
Measures the effectiveness of the intrinsic pathway.
Important in hemophilic status.
Normal value: sec.
PROTHROMBIN TIME
Measures Effectiveness of the Extrinsic Pathway NORMAL VALUE SECS

26. International normalized ratio (INR( INR formula:
THROMBIN TIMETime
for Thrombin To ConvertFibrinogen FibrinA Measure of Fibrinolytic PathwayNORMAL VALUE 9-13 SECS
International normalized ratio (INR(
INR formula:
INR value of considered as in patient on anticoagulant therapy.
INR value of is acceptable in patient prosthetic heart valve disease.
INR value of 4.0 used as upper limit for simple surgical procedure.
INR value of 3.0 used as maximal level for surgery with extensive blood loss such as extraction with alveolplasty.

27. Platelet function analyzer 100:
An in vitro system used for detection of platelet dysfunction, it produces quantitative measure of platelet function in anticoagulation whole blood.

28. Systemic measures: I. platelet disorders:
Platelet transfusion (alloimmunization(:
One unit of platelet concentrate(equal to platelet derived from one unit of whole blood) elevates the platelet count in adult from 4000 to 10,000 cell/mm3.
Drug induced thrombocytopenia treated primarily by with drawl the affecting drugs.
Idiopathic thrombocytopenia may benefit from corticosteroid administration, spleenectomy,
Patient receiving aspirin therapy should reduce or discontinuing there aspirin intake for 4-7days before surgery

29. II.Hemophilia:
Antihemophilic factor (bioclate, refractor) *correct or prevent bleeding episodes or allow necessary surgery.
Coagulation factor VIIa (novoseven)
* Treat bleeding episodes with hemophilia A or B.
Factor IX complex (benefix, profilnine SD(
* Prevent or treat hemophilia B, control bleeding episodes in hemophilia A

30. Review patient's medications:
Five drugs that interfere with hemostasis
Aspirin
Anticoagulants
Antibiotics
Alcohol
Anticancer

31. Oral manifestation: Petechiae , ecchymosis Gingival hyperplasia
Spontaneous gingival bleeding
Ulceration of oral mucosa
Lymphadenopathy

32. Thanks