General Internal Medicine

MED373

Bleeding tendency and Anemia

Done by:

Naeem Idrees & Abeer Khasawneh

*Special Pearls Idea for my colleagues (Pearls Batch 2011) Our Prophet Mohammad -Peace be upon him- said:" convey from me, even a verse of the Quran"And from this hadeeth comes this idea, memorizing two verses of the Quran with every page of the script...Sometimes we might complain about not having enough time for reading and memorizing the Quran because lots of studiesBut if we look to this idea from a different angle, we actually find that it would be an interesting thing if we found ourselves finishing an entire surah of the Quran, or maybe a number of verses, by the end of each script...For example: by the end of this script that I made, you will have been memorized surah almonafiqoon, awesome right?! How happy we should be when we graduate with both: an educational and a religious certificate, and we've been able to memorize the holy Quran in a way that didn't consume a lot of our timesI truly hope that this idea is acceptable and can be seen in other scripts, and if it didn't spread unfortunately, you can do it by yourself, by memorizing one or two verses with every page of the Quran

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Bleeding tendency & Anemia

Notes :* Dr. Mahmoud Ayesh said that he will put the exam questions from what he has said in the lecture. So, we don't need to get into details.* This lecture contains general rules that would be much beneficial for you if applied in your clinical practice.* This lecture is divided into 2 parts. The 1st part is talking about bleeding tendencies seen in patients attending Dental clinics. And the 2nd part is talking about Anemia and its oral manifestations.

-Now, we will start talking about bleeding. We have some terms that you should be familiar with: Hematology: is the study of blood, the blood-forming organs, and blood diseases. Blood cells are of 3 types: red blood cells, white blood cells and platelets.

Complete Blood Count (CBC):1-White cells counts: Abnormalities seen in the number of WBCs will lead to: LeukemiaInfectionCandida*Mouth ulcers**Most important for us as Dentists.2-Platelets count: Function of this count is to detect number of platelets and patient's bleeding tendency. Normally, should be (140,000 to 400,000 cells/mm3).

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You Still Have 6 Pages to finish the Script! If a patient is having oral surgery or dental treatment, the platelets count should be normally more than 50,000 cells/mm3 for safe procedure. Patients with zero platelets count have continuous bleeding tendency. Platelets dysfunction is either congenital or acquired. Congenital you should ask the patient if he/she has any positive history of bleeding. Acquired could be due to use of certain drugs, and the most important drug that makes platelets dysfunction is Aspirin. Chronic renal failure leads to platelets dysfunction.

You Still Have 8 Pages to finish the Script !Hemophilia. It's a disorder of coagulation factors. There are 2 types of hemophilia: Hemophilia A represents factor VIII deficiency. It's treated by replacement of factor VIII, and it should be (40% - 50%) level for Dental extraction. Hemophilia B represents factor IX deficiency. The patient presents with hemarthrosis which is swelling of the joints because of bleeding into joint spaces. It occurs in both genders, but seen most in males because it's an x-linked recessive disorder. So, males will be affected and females will be carriers. Gives an abnormal aPTT (activated partial thromboplastin time) with normal bleeding tendency and PT. Treatment drugs: 1.recombinant factor seven (Not used here commonly because it's expensive). 2. Ant-fibronlytic agents like Tranexamic acid and E-aminocaproic acid because they can stop bleeding.

Warfarin. It's an oral anti-coagulant, used to prevent clotting in patients having thrombosis. So, usually it's associated with high bleeding tendency. It's the most commonly used anti-coagulant in Jordan. Its half-life is 36 hrs. So, patients should stop taking warfarin at least 2 days before any surgery.

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It's monitored by a test called PT (prothrombin time) or INR (international normalized ratio)test. Normally, INR is (1-1.5), so it should be less than 2 for safe surgical purposes. 5mg of warfarin may raise the INR level to 3 or 4. Conditions that cause prolongation of PT (INR) are: (Very important) Warfarin intake. (Ex. Is seen in chronic liver disease). Disseminated intravascular coagulation (DIC).

Gingival hypertrophy: It's associated with acute myeloid leukemia. People with poor oral hygiene could have a high bleeding tendency because they might have problems in their gingiva.

Heparin. It's monitored by aPTT test. Normally, it should be (50-65sec). Its half-life is (2-6hrs) depending on the type of heparin: Conventional heparin has a half life of 2 hours. Low molecular weight heparin has a half life of 6 hours. So, it should be discontinued 6hrs before any surgical procedure. It's given by intravenous or subcutaneous injection.

Von Willebrandis disease. Patients will have platelets dysfunctions. So, they should be given platelets transfusion or DDAVP." " (5)" " (6)You Still Have 3 Pages to finish the Script !

Hemorrhage. Clotting results from interactions between clotting factors, blood vessels, platelets and formation of fibrin. Interactions Fibrinogen formation Fibrin formation stop Bleeding. Abnormalities here are either in the extrinsic or intrinsic pathways: Abnormalities in aPTT most likely present in the intrinsic pathway. While in PT they present in the extrinsic pathway.

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Bleeding disorders. Most likely, patients will have abnormal blood vessels. Can also be seen in Anemia and Thrombocytopenia. And if patients are having platelets abnormalities, this will lead to high bleeding tendency.

Low platelets count. It has many causes:

1. Bone Marrow failure. It's called aplastic anemia. It causes: i. Replacement of hematological elements by fats.ii. Patients could have hypersplenism which is the enlargement of spleen like in the case of chronic liver disease.** Chronic liver disease is characterized by jaundice and yellowish eyes.iii. Bone marrow doesn't produce any hematologic cells.

2. Bone marrow infiltration like acute leukemia. Produces low platelets count. Produces infections (mouth bleeding). Produces gingival hypertrophy.

3. Other diseases.A- Disseminated intravascular coagulation (DIC). There will be: Low platelets count. Prolonged INR. Sever bleeding that is difficult to stop. Low fibrinogen test.B- Thrombotic thrombocytopenic purpura (TTP). It's the destruction of platelets. More common in females. The platelets count will be low; less than 20,000cells /mm3. Treatment is done by 1.taking steroid and 2.platelets transfusion to raise platelets count above 50,000 cells /mm3.

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You Still Have 3 Pages to finish the Script! ** Steroid: It's an important drug in Dental procedures. But might cause: 1- Oral candidiasis.2- Prolonged use can lead to bleeding tendency and neutropenia (Low white cells count).**Now, we will talk about the most important part of this lecture, which is how to apply all the previous information in your clinical life as a dentist.

Clinical procedures

1. Take the history of the patient. History of bleeding ask the patient if he/she has any history of bleeding tendency. If yes, then you as a Dentist should not perform any dental procedure for this patient like tooth extraction. Rather, you should transform the patient to the Department of Internal Medicine, so that a proper management can be achieved. Family history.

2. Ask the patient if he/she is taking one of the drugs that cause bleeding tendency like (Warfarin, Heparin, Aspirin & Non-Steroidal anti-inflammatory drugs)? If the patient is taking warfarin, then you should do the following Check the PT or INR level. It should be less than 2 for safe surgical procedures. Warfarin half-life is 36hrs. So, patients should stop taking warfarin at least 2 days before any surgery.

If the patient is taking heparin, then you should do the following Check the aPTT test. Normally, it should be (50-65sec). Heparin half-life is (2-6hrs) depending on the type of heparin. So, it should be discontinued 6hrs before any surgical procedure.

If the patient is taking aspirin, then you should do the following it should be stopped at least 1 week before any surgical procedure because its half-life is 5 days.

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You Still Have 2 Pages to finish the Script! **Aspirin used to be given in ischemic heart diseases and back pain, but nowadays it's used commonly as an oral anti-coagulant.** The best time for a safe surgery to a patient having bleeding tendency is not preferred to be in morning, because you need time to check platelets count and INR. So, the best time is 10 or 11AM.3. If the patient is shown to have one of the diseases that cause low platelets count, or any disorder of coagulation factor, then: Check the level of factors VIII and IX and do aPTT test to reveal the presence of hemophilia there should be deficiencies in one of those factors with abnormal aPTT and normal PT and BT. It's treated by 1.recombinant factor seven and 2. Ant-fibronlytic agents like Tranexamic acid and E-aminocaproic acid.

Check the level of INR and PTT and do CBC and platelets count to reveal the presence of Chronic liver disease characterized by jaundice and yellowish eyes. It's treated by 1- stopping warfarin intake, 2-Vit.K administration, 3-fresh frozen plasma (FFP) is given to the patient and 4- if the patient is also taking Aspirin, then he/she should take platelets as well.

Check CBC and platelets count, INR and aPTT to reveal the presence of Thrombocytopenia for safe surgical procedures, platelets count should be above 50,000/mm3. If it's less than 20,000/mm3 the patient will have spontaneous bleeding. So, the patient should be given platelets about (1-2hrs) before any procedure or during procedure, but not before 1 day, because platelets need to be fresh.

** Question: Imagine that you were doing a dental procedure like extracting a third molar for your patient, and then the patient started suddenly to have a severe bleeding, what will be your management in such case? You Still Have 1 Pages to finish the Script! Before answering the question, you have to know that you as a Dentist are the only one responsible for this condition. It was your fault that you didn't take your patient's history as you were requested to! So, you should be always conscious about your patient's health because it's a serious life-threatening condition. **Answer: 1. Apply pressure at the area of bleeding, 2. Reverse the action of warfarin by giving Vitamin K. 3. Give the patient fresh frozen plasma.

4. Mouth ulcers seen in patients attending Dental clinics can be due to one of the following diseases:i. Neutropenia.ii. Behcet () disease recurrent painful ulcers.iii. Inflammatory bowel disease.

Anemia (Low Hemoglobin)

Iron deficiency anemia. Causes Megaloplastic causes like Vit. B12 deficiency. The tongue will be red, beefy, smooth and painful. Check CBC and hemoglobin. WBCs abnormalities present as infectious ulcers. RBCs abnormalities: Mean Cell Volume (MCV): measures the size of RBCs. Low MCV Microcytic anemia. hemoglobin abnormalities: Mean corpuscular hemoglobin(MCH): measures hemoglobin concentration. Low MCH Hyperchromic Microcytic Anemia. So, it can be due to: 1-Iron deficiency anemia (common in females because of menses).2-Thalassemias.3-Anemia of chronic illness seen in patients with Rheumatoid Arthritis. One complication of iron deficiency anemia is Angular Stomatitis. We should also perform Ferritin test to confirm diagnosis. So, it would be low.

You are Done! :D -The End-