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Haemostasis Disorders (Vascular defects (Hereditary Haemorrhagic…

- - - - Measure INR within 24 hours of surgery
      - INR >4 refer to hospital for dental care
      - Dental care close cooperation with specialist/physician
      - Drug Interactions
        
        Warfarin and Macrolides
        
        Warfarin and Metronidazole
        
        Warfarin and azole antifungals (miconazole - Daktarin gel)
        
        Effects
        
        Increased risk of significant bleeding
      - Preventative dentistry
  - - - inhibits factor IIa
    - - inhibit factor Xa
    - - inhibit factor Xa
    - - More effective and safer
      - Wider therapeutic range and easier to manage
      - Do not require routine monitoring
      - More predictable levels of anticoagulation
    - - Stroke prevention in AF patients
      - Thromboembolic diseases (DVT, PE)
- - - - Bernard-Soulier Syndrome
    - - Chemotherapeutic agents
      - Viruses- parvovirus infection, mumps, HIV
    - - Aplastic anaemia
      - Leukaemia
      - Lymphoma
      - Metastases
    - - increased destruction of platelets
    - - Idiopathic thrombocytopenic purpura
        
        Cytotoxic drugs
        
        Diseases
        
        SLE
        
        Malaria
        
        Disseminated intravascular coagulation
    - - Patients with suspected thrombocytopenia
        
        Investigate platelet count by requesting full blood count prior to dental treatment
        
        Refer to GP/haematologist for further management
        
        Risk of spontaneous bleeding, PC <20,000/mm3
  - - - NSAIDs
        
        Reversible effect and last until drugs clear from system (24-48 hours)
      - Clopidogrel
      - Aspirin
        
        Acts irreversibly and permanently on platelet lifespan (7-10 days)
      - Dipyridamole
    - - Post extraction bleeding
        
        Compressive packing
        
        Sutures and absorbable haemostatic agents e.g. Oxidised regenerated cellulose
        
        Moist tea bag (Tannic acid)
      - NSAIDs stopped 24 hours before surgery and resumed the next day
      - All antiplatelet drugs except NSAIDs - stopped 7 days before surgery and resumed 1-2 days postoperatively
      - Never stop medication without consulting GP
      - Minor dental procedures - continue medication
  - - - pinpoint hemorrhagic flat lesions in clusters
    - - large clusters of petechiae
- - - - Haemophilia B
        
        Factor 9 deficiency
        
        X-linked
      - Haemophilia A
        
        X-linked disorders - affects males only
        
        Categorised based on factor 8 levels
        
        Moderate 1-5% normal
        
        Bleed after minor injury and requires urgent attention
        
        Severe <1%
        
        Bleed very often with or without provocation
        
        Mild 5-30% normal
        
        Bleed minimally, usually associated with surgery
        
        For all categories, haemorrhage appears to stop immediately after injury but intractable oozing soon follows resulting in bleeding into deep tissues i.e joints, fascial spaces, muscles
        
        Factor 8 deficiency
      - Management
        
        Diagnosis
        
        Positive family history
        
        Clinical Presentation
        
        Investigations - clotting factor assays
        
        Treatment
        
        Increase production of Factors VII - Vasopressin
        
        Replacement therapy for specific clotting factor from
        
        Clotting factor concentrate from plasma
        
        Commercially produced recombinant factor
        
        Inhibit fibrinolysis - Antifibrinolytic Agents
        
        Tranexamic acid
        
        Epsilon-amino caproic acid (EACA)
      - Dental Aspects
        
        Preventative Dentistry
        
        Dental care - close cooperation with haematologist/physician/specialist dentist
        
        Significant risk of haemorrhage after surgery or LA
        
        Ensure adequate level of clotting factors (VIII/IX)
        
        Post operatively: monitor signs of haematoma formation (swelling, hoarseness or dysphagia)
        
        Trauma to head and neck - prophylactic factor VIII replacement is essential