Bleeding Disorder

 Bleeding disorders: dental considerations

Acquired or congenital bleeding disorders of dental treatment concern include haemophilia, von Willebrand disease, other factor deficiencies and thrombocytopenia. Some systemic conditions also interfere with haemostasis, such as kidney, liver and bone marrow disorders.

Patients with bleeding disorders should be managed in a specialist setting, with appropriate consultation with the patient’s specialist or multidisciplinary team.

Bleeding Disorders

  1. haemophilia

  2. von Willebrand disease

  3. Other factor deficiencies 

  4. thrombocytopenia

Causes

Bleeding disorder may be due to defect in platelet activation, function and contact activation.  It may also be due to defect in clotting proteins or antithrombin function. 

The commonest caused of bleeding disorder are 

  1. warfarin
  2. von Willebrand disease

  3. aspirin

Warfarin is the commonest anticoagulant that interferes by preventing the production of clotting factors by blocking vitamin K.

von Willebrand disease is the most common inherited bleeding disorder.

Aspirin is the less commonly used drug for pain and more used in long term for its impairing ability for platelet function. One tablet of aspirin renders the platelet non-functional for almost one week. It is to be noted that it rarely causes significant post-operative bleeding.


How to confirm bleeding disorder of a patient

The single most important evaluation part is an adequate history since screening tests for bleeding disorders do not always detect mild defects. A history suggestive of a bleeding tendency must be taken seriously. History of previous dental extraction or tonsillectomy provide a useful guide. Physical examination is also necessary and for conformation of diagnosis, laboratory test are needed.

An accurate diagnosis is essential for replacement therapy, if needed and enable other management protocols to be followed.

The dentist must place special emphasis on the following that are suggestive of bleeding disorder:

  1. deep haemorrhage into  muscles, joints or skin (bruising)-suggests a clotting defect
  2. bleeding from or into skin or mucosae-suggests purpura
  3. most congenital bleeding disorders of significance become apparent in childhood
  4. however, mild haemophilia might escape the history part until the adult life if the child and the parents have managed well and avoided the injuries. A mild haemophiliac might give a history of mild oozing from an extraction socket for 2-3 weeks despite all local measures such as pressure pack and suturing etc
  5. history of blood transfusion or hospitalization might clearly give the idea of bleeding disorder in the same as a history of bleeding in a blood relative
  6. history of drugs such as anticoagulant, certain herbal products, systemic disease, for example, cirrhosis, HIV and kidney diseases can also impair platelet function 

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