A THROMBOLIZED PATIENT Department Of Oral And Maxillofacial

A THROMBOLIZED PATIENT Department Of Oral And Maxillofacial Surgery Dentistry Explorer

CONTENTS: • • • Disorders Clinical features Laboratory test Considerations Management Dentistry Explorer

Classification • Vessel Wall Disorders • Platelet Disorders • Coagulation Disorders Dentistry Explorer

• • Clinical features Bleeding from Superficial cuts and scratches Delayed Bleeding Spontaneous gingival bleeding Petechiae Ecchymoses Epistaxis Deep dissecting hematomas Hemarthroses Dentistry Explorer

Laboratory test: Platelet Count • Normal 150, 000 -450, 000/mm 3 • Surgical/traumatic hemorrhage<50, 000 mm 3 Bleeding Time § Normal- 1 to 6 minutes • Prolonged - >15 minutes • Test platelet and vascular phase Dentistry Explorer

Prothrombin time and INR. • Normal PT-11 to 13 seconds • Evaluates extrinsic coagulation and F-I, II, V, VII and X • Now reported with it’s INR(international normalised ratio) • It’s the ratio of PT that adjusts for the sensitivity of the thromboplastin reagants, • such that normal coagulation profile is reported as an INR of 1. 0 Dentistry Explorer

a. PTT(activated partial thromboplastin time) • Measures effectiveness of the intrinsic pathway(factor I, II, V, VIII, IX, X, XII) • It is altered in hemophilias A & B. and with the use of heparin. • Normal-30 to 40 seconds . Dentistry Explorer

. TT(Thrombin Time) -measures the time it takes for a clot to form in the plasma of a blood sample containing anticoagulant, after an excess of thrombin has been added. -Normal 9 to 13 seconds -in blood samples containing heparin, batroxobin is used instead of thrombin. Dentistry Explorer

q Platelet problem may be Quantitative or Qualitative If platelet count <50, 000 abnormal postoperative bleeding occurs q For platelet count between 20, 000 and 50, 000, withhold platelet transfusion until postoperative bleeding becomes a problem. q Platelet count<20000 requires presurgical platelet transfusion. q Platelet transfusion may be needed in patient with platelet count greater than 50, 000 if qualitative problems exists. Dentistry Explorer

Dental management considerations • Local hemostatic measures – Pressure, surgical packs, vasoconstrictors, sutures, surgical stents, topical thrombin • Susceptibility to infection • Pain control • Ability to withstand care • Preventive & periodontal therapies • Restorative endodontic & prosthodontic therapy • Pediatric dental therapy • Orthodontic therapy Dentistry Explorer

§ Local anesthesia should be given by local infiltration rather than by field blocks to lessen the likelihood of damaging large blood vessels. § Topical coagulation promoting substances in oral wounds should be used. Dentistry Explorer

Management of patient whose blood is therapeutically anticoagulated PATIENTS RECEIVING ASPIRIN OR OTHER PLATELET INHIBITING DRUGS § Consult the physician to determine the safety of stopping the anticoagulant drug for several days. § Defer surgery until the platelet inhibiting drugs have been stopped for 5 days. § Take extra measures during and after surgery to help promote clot formation and retention. § Restart drug therapy on the day after surgery if no bleeding is present. Dentistry Explorer

PATIENTS RECEIVING WARFARIN 1. Consult the patient’s physician to determine the safety of allowing the prothrombin time to fall 2. 0 to 3. 0 INR for a few days. 2. Obtain the baseline PT. 3. (a)If the PT is less than 3. 1 INR, proceed with surgery and skip to step 6. (b) if the PT is more than 3. 0 INR, go to step 4 4. Stop the warfarin approx. 2 days before surgery 5. Check the PT daily and proceed with surgery ant the day when the PT falls to 3. 0 INR Dentistry Explorer

PATIENTS RECEIVING HEPARIN • Consult the patient’s physician to determine the safety of stopping heparin for the post operative period • Defer surgery until at least 6 hours after the heparin is stopped or reverse heparin with protamine. • Restart heparin once a good clot has formed. Dentistry Explorer

Management of patient with coagulopathy • Defer surgery until a hematologist is consulted about the patient’s management. • Obtain baseline coagulation test as indicated. • Schedule the patient in a manner that allows surgery soon after any coagulation correcting measures have been taken. • Augment clotting during surgery with the use of topical coagulation-promoting substances, sutures and well placed pressure packs. Dentistry Explorer

• Monitor the wound for 2 hours to ensure that a good initial clot forms • Instruct patient to prevent dislodgement of clot and in what to do if bleeding restarts. • Avoid prescribing NSAIDS. • Take hepatitis precaution during surgery. Dentistry Explorer

REFERENCES: • CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY -5 TH EDITION • BURKET’S ORAL MEDICINE 12 TH EDITION Dentistry Explorer

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