JURNAL

BLEEDING DISORDER IN ORAL AND

DENTAL CARE

LILA ESI MUSTIKA, AMKG

NIK : PK2013050

RUMAH SAKIT AWALBROS

PEKANBARU
 BLEEDING DISORDER IN ORAL AND
DENTAL CARE

ABTRAC
Bleeding disorders are states of bleeding caused by the ability of blood vessels, platelets,
and coagulation factors in the hemostatic system. Bleeding disorders can be genetic or acquired. In
disorders can occur due to diseases that interfere with the integrity of blood vessel walls, platelets,
coagulation factors, drugs, radiation, or chemotherapy during cancer treatment. Some procedures in
the treatment of teeth and mouth can cause bleeding. Under normal circumstances this action does
not cause interference, but in patients with blood clotting disorders dental and oral care measures
can cause the patient's condition to become more severe. Initial examinations which include general
health examinations, physical examinations, laboratory screening, and observations after surgery
are the things to consider when doing dental care. Dentists should know the factors and processes
that occur in blood clots so that the actions to be taken do not cause fatal conditions.
Keywords: bleeding disorders, treatment, teeth and mouth.

PRELIMINARY
Bleeding disorders are states of bleeding caused by the ability of blood vessels, platelets,
and coagulation factors in the hemostatic system. Bleeding disorders can be genetic or acquired. In
disorders can occur due to diseases that interfere with the integrity of blood vessel walls, platelets,
coagulation factors, drugs, radiation, or chemotherapy during cancer treatment. Iatrogenic factors
can also be a cause of blood clotting disorders.1-2 Patients who use coumarin for the prevention of
recurrent thrombosis have the potential to experience blood clotting disorders. Patients with heart
disorders who use aspirin also have the potential for bleeding disorders.
In the practice of dentistry in the United States shows that among 2000 adult patients about 100-150
patients have the possibility of experiencing bleeding disorders. Patients on low intensity warfarin
therapy for venous thromboembolism prophylaxis have a risk factor of major bleeding of less than
1% and 8% of minor bleeding.
A very frequent bleeding disorder is von Willebrand's disease (vWD). The American
population suffering from this disease is approximately 1%, passed down through autosomal
dominant. Hemophilia A patients suffering from factor VIII deficiency are sufferers with
coagulation disorders, occurring in more than 20,000 people in America. Hemophilia B (Christmas
disease) has a factor IX deficiency found in 1 person every 30,000 births of boys. The data show
that about 80% of all hereditary coagulation disorders are Hemophilia A, 13% are Hemophilia B,
and 6% represent factor XI deficiency. Patients with chronic leukemia have a tendency to
experience bleeding due to thrombocytopenia caused by cancer cells in the bone marrow so that
there is no place for red blood cells and platelet precursors. As a result, leukemia patients will
experience thrombocytopenia as a result of the toxic effects of several types of chemotherapy
treatments that are used. Bleeding disorders are a risk factor for dental and oral care measures.
Patients experiencing a long bleeding time can even experience continuous bleeding. Some factors
that trigger systemic diseases and drug use can also be a cause.

ETIOLOGY
Classification of bleeding disorders can be grouped based on the number of normal platelets
(nontrombocytopenia purpura), decreased platelet count (thrombocytopenia purpura), and
coagulation disorders. Non-thrombocytopenia purpura can be caused by changes in blood vessel
walls due to blockages, infections, chemicals, and allergies. Other causes are platelet dysfunction
due to genetic defects (Bernard-Soulier disease), drugs (aspirin, NSAIDs, alcohol, beta lactam
antibiotics, penicillin, and cephalosporin), allergies, autoimmune diseases, von Willebrand's disease,
and uremia.
Thrombocytopenia purpura is divided into primary / idiopathic and secondary. Secondary
causes due to chemical, physical (radiation) factors, systemic diseases, bone cancer metastases,
splenomegail, drugs (alcohol, diuretic drugs, estrogens, and gold salts), vasculitis, pacemakers, viral
and bacterial infections. Coagulation disorders can be inherited such as hemophilia A, hemophilia B
and can (sufferers of liver disease, vitamin deficiency, anticoagulation drugs, disseminated
intravascular coagulation, and primary fibrinogenolysis).

PATHOPHYSIOLOGY
The bleeding process occurs through three phases, namely vascular, platelet, and
coagulation. Vascular and platelet are primary phases while coagulation is secondary. The
coagulation phase will be followed by the fibrinolytic phase. The vascular phase occurs shortly after
the trauma, which involves arterial and venous vasoconstriction, arterial restriction, and
extravascular pressure. The platelet phase begins with the occurrence of platelet stiffness and blood
vessels, then the blood vessels will become blocked.
This process occurs a few seconds after the vascular phase occurs. In the coagulation phase
blood will go out to the surrounding area and will limit the area where bleeding occurs with the help
of extrinsic and intrinsic factors. The time required in this phase is slower than the previous phase.
The advanced phase is the fibrinolytic phase which is characterized by the release of antithrombotic
agents and destruction of lymph and liver by anthrombotic agents.
 Figure 1. Primary and Secondary Coagulation Systems

CLINICAL DESCRIPTION
Patients with blood clotting disorders will be clearly seen on the skin and mucous
membranes shortly after a trauma or other invasive action. Looks for jaundice, spider angiomas,
ecchymosis, and a little tremor when handling something will be found in patients with liver.
Approximately 50% of liver sufferers will experience a decrease in the number of platelets due to
hypersplenism due to the effects of portal hypertension so that ptechiae is found on the skin and
mucosa.
Ecchymosis, hemarthrosis, and dissecting hematomas are clinical features that are often seen
in patients with genetic coagulation disorders, and patients with abnormal platelet counts /
thrombocytopenia often experience ptechiae and ecchymosis. Patients with acute and chronic
leukemia often show symptoms of oral mucosal ulceration, gum hyperplasia, ptechiae and
ecchymosis of the skin and mucous membranes, as well as lymphadenopathy.
 Gambar 2. Ecchymosis and Ptechiae in the Hand

Gambar 3. Gums Hyperplasia, and Petechiae Palatum

LABORATORY EXAMINATION
Some laboratory tests conducted for patients with bleeding disorders are partial
thromboplastin time (PTT), prothrombin time (PT), platelet count, ivy bleeding time, platelet
function analyzer 100 (PFA-100), and thrombin time.
 Partial thromboplastin time (PTT) is used to examine the intrinsic system (factors VIII, IX,
XI, and XII) and the main pathway (factors V and X, prothrombin, and fibrinogen). This test is also
the best test for screening for coagulation disorders. Prothrombine time is used to examine the
extrinsic pathway (factor VII) and the main pathway (factors V and X, prothrombin, and
fibrinogen). Platelet count is used to examine the causes of bleeding disorders due to
thrombocytopenia. The normal platelet count is 140,000-400,000 / mm3 of the total blood count.
Ivy bleeding time is used to see impaired platelet function and thrombocytopenia. Platelet function
analyzer 100 (FA-100) is an invitro examination to detect platelet dysfunction. Thrombine time
shows the amount of fibrinogen present in the blood.

MEDICAL MANAGEMENT
Diseases included in vascular defects are hereditary hemorrhagic telangiectasia (Osler-
Weber-Rendu syndrome), Ehler-Danlos, osteogenesis imperfecta, pseudoxanthoma elasticum, and
Marfan syndrome. Patients with this disease should avoid surgery, but if surgery is still performed,
it should be done special handling of damage to blood vessels.
Platelet disorders occur in patients with von Willebrand's disease, Bernard-Soulier disease,
Glanzmann's thrombosthenia, and disorders of platelet release. Treatment can be done is platelet
transfusion and replacement of factor VIII. 2 Hemophilia A and B are manifestations of coagulation
disorders. Handling is done by giving prednisone; IV gamma globulin, and platelet transfusion,
administration of factor VIII, and factor VIIa and steroids.

Types of Diseases Medical Defects

1) Von Willebrand's disease Deficiency or vWF DDAVP, EACA, defects that cause damage to
factor VIII that is damaged by platelet adhesion, vWF factor VIII deficiency.
2) Hemophilia A Factor I deficiency or defect in DDAVP, EACA, factor VIII; porcine factor
VIII, PCC, aPCC, factor VIIa, and / or steroids.
3) Hemophilia B Deficiency or defect in the provision of factor IX.
4) Platelet primary thrombocytopenia is damaged The administration of prednisone, IV due to
the autoimmune process of gamma globulin and platelet transfusion.
5) Secondary thrombocytopenia Platelet deficiency in which platelet transfusion causes it to
occur
accelerated platelet destruction, reduced platelet production, and abnormal platelets.
6) Bernard-Soulier Genetic defects in platelet transfusion membrane platelets, there is no
glycoprotein Ib (GP-Ib) which causes interference with platelet adhesion.
7) Liver Disease
 8) DIC
9) A defect in multiple coagulation factors
Multiple coagulation factor defects that cause fibrin and fibrinogen degradation resulting in
fibrinolysis and thrombocytopenia.
10) Giving vitamin K, giving replacement therapy only if there is serious bleeding after surgery.

MANAGEMENT IN THE FIELD OF DENTAL MEDICINE

The method of examination that should be performed by a dentist when identifying patients
with bleeding disorders is to make a complete history of the disease, physical examination,
laboratory screening, and observation of the occurrence of extensive bleeding after surgery.
The patient's medical history must be as complete as possible. The questions should be arranged
sequentially starting from previous patient experiences. Some bleeding disorders can be brought
down, so questions also need to be directed to other family members. Grouping questions is done
according to the types of bleeding disorders that may occur.
The questions include: is there a family member who has a bleeding disorder, has
experienced bleeding for a long time after surgery, such as surgery and tooth extraction, has there
been bleeding for a long time after experiencing rtauma, is taking medication for prevention
coagulation disorders or chronic pain, a history of previous illnesses, and whether they have
experienced spontaneous bleeding.

Detection of Patients with a History of Bleeding

1. Complete Disease History
• Family history of bleeding disorders
• Bleeding disorders after surgery and tooth extraction
• Bleeding disorders after trauma
• Take medications that cause bleeding problems such as aspirin,
anticoagulants, long-term antibiotic use, and herbal medicines
• Diseases associated with bleeding disorders such as leukemia,
liver disease, hemophilia, congenital heart disease, kidney disease
• Spontaneous bleeding from the nose, mouth, ears, etc.
2. Physical Examination
• Jaundice dan pallor
• Spider angiomas
• Ecchymosis
• Ptechiae
 • Oral ulcers
• Hyperplastic gingival tissues
• Hemarthrosis
3. Skrining laboratoris
• PT
• aPTT
• TT
• PFA-100
• Platelet count
4. Surgery has ever been experienced, causing bleeding disorders

Laboratory screening needs to be carried out, especially PT, aPTT, TT, PFA-100 and platelet count
examinations. The type of examination performed is adjusted to the grouping of bleeding disorders.

PREVENTION MEASURES IN THE FIELD OF DENTAL MEDICINE

Precautions that can be taken for patients with bleeding disorders are in principle the same
as normal patients, namely brushing teeth twice a day using toothpaste with fluorine content of 1
ppm for children under the age of seven years and 1.4 ppm for children over the age of seven ,
toothbrushes used should have a medium texture, use interdental tools such as dental floss, tape, and
inter-tooth brush, supplementation of fluorine through liquids, tablets, topical applications,
mouthwash containing fluorine, eat foods that are healthy for teeth, consume artificial sweeteners,
and visit the dentist every three to six months.
1) PERIODONTAL CARE
Periodontal treatment can be one of the triggers of bleeding. Periodontal dressing
with or without topical antifibriolytic agents can be a way to stop bleeding. The use of
mouthwash containing chlorhexidine gluconate can maintain oral hygiene. Providing
complete information to the patient before the action is a good first step, so that the patient
will understand the possibility of complications that will occur.
2) USING ARTIFICIAL DEMANDS OF REMOVAL
Patients with bleeding disorders can be recommended to use removable dentures as
long as they are comfortable to wear. Periodontal treatment still needs to be done to maintain
the remaining teeth.
3) ORTODONTI TREATMENT
Use of removable and fixed orthodontic appliances can be done, but still note the
compressive strength that will hit the gums so that bleeding does not occur. Maintaining
 clean teeth and mouth are the main requirements so that spontaneous bleeding does not
occur.
4) FILLING
The use of matrices and wedges when patching needs to be considered properly.
Injuries caused by incorrect use can be a problem when patching.
5) ENDODONTIC CARE
Conventional endodontic treatment is highly recommended for patients with
bleeding disorders, because the use of an endodontic needle that overflows the apex will
cause continuous bleeding so that it will settle in the root canal.

PAIN AND ANALYSIS

Pain in the teeth can be overcome by giving paracetamol or acetaminophen. The use of
aspirin must be avoided because it can lead to inhibition of platelet aggregation. If you are going to
give an NSAID, you should first consult with a hematologist because this class of drugs can cause
inhibition of platelet aggregation.
Local anesthesia by means of infiltration in the buccal, intra-papillary and intraligament areas does
not require anti-hemostatic drugs but anesthesia by blocking the mandible and lingual infiltration
must be given anti-hemostatic.

CONCLUSION
Patients with bleeding disorders are one group of patients with medically compromise.
Bleeding disorders can be reduced and acquired. Management of patients with bleeding disorders
needs to pay attention to the effects that will arise, especially when carrying out invasive measures
so that dentists should know the factors and processes that occur in blood clots so that the action to
be taken does not cause a fatal condition.

DAFTAR PUSTAKA
1. Patton, L. L. Bleeding and clotting disorders. In: Greenberg, M. S., and Glick, M. Burket’s
oral medicine diagnosis and treatment. 10th ed. Spanyol: BC Decker Inc; 2003 p. 454-477.
2. Little, J. W., Falace, D. A., Miller, C. S., Rhodus, N. L. Dental management of the medically
compromised patient. 7th ed. Canada: Mosby Elsevier; 2008 p. 396-432.
3. Lockhart, P. B., Gibson, J., Pond, S. H., and Leitch, J. Detnal management considerations for
the patient with an acquired coagulopathy. Part I coagulopathies from systemic disease.
British Dent Jour (serial on internet). 2003 October 25; [ cited 2008 December 12 ]; 195:43-
9445:[about 7 screen].
4. Dental management considerations for the patient wtih an acquired coagulopathy. Part 2
coagulopathies from drugs. British Dent Jour (serial on internet). 2003 November 8; [ cited
2008 December 12 ]; 195:439-445:[about 6 screen].
5. Israels. S., Schwetz, N., Boyar, R., McNicol, A. Bleeding disorders characterization, dental
considerations and management. J Can Dent Assoc (serial on internet). 2006 November;
[cited 2008 November 24]; Vol 72 No. 9:[about 13 screen].
6. Moreno, G. G., Soriano, A. C., Arana, C., Scully, C. Hereditary blood coagulation disorders:
mangement and dental treatment. J Dent Res (serial on internet). 2005 June 20;[cited 2008
October 12]; 84(11):1978-985:[about 8 screen].
7. Gupta, A., Epstein, J. B., Cabay, R. J. Bleeding disorders of importance in dental care and
related patient management. JCDA (serial on internet). 2007 February;[cited 2008
November 1]; Vol 73 No. 1:[about 8 screen].
8. Cervero, A. J., Roda, R. P., Bagan, J. V., Soriano, Y. J. Dental treatment of patients with
coagulation factor alterations: An update. Med Oral Patol Oral Cir Bucal (serial on internet).
2007 March 25:[cited 2008 October 11]; 12:E380-7:[about 7 screen].
9. Brewer, A., Correa, M. E. Guidelines for dental treatment of patients with inherited bleeding
disorders. World Federation of Hemophilia’s [homepage on internet].
 LAPORAN REVIEW JURNAL KEPERAWATAN
RS AWALBROS PEKANBARU

Nama : Lila Esi Mustika,AMKG Judul Jurnal : Bleeding Disorder In Oral And
Dental Care
NIK : PK2013050 Penulis : Lila Esi Mustika,AMKG
Jenjang Karir : PK II Bulan : Desember 2019
Ruangan : Poliklinik Gigi
RESUME ISI JURNAL :

Berdasarkan jurnal ilmiah kesehatan oleh Eriska Riyanti Bagian Kedokteran Gigi Anak RSGM - Unpad tentang
judul diatas dapat disimpulkan :

Gangguan perdarahan merupakan keadaan perdarahan yang disebabkan oleh kemampuan pembuluh darah, platelet, dan
faktor koagulasi pada sistem hemostatis. Gangguan perdarahan dapat bersifat genetik maupun dapatan. Pada kelainan
dapatan terjadi oleh karena adanya penyakit-penyakit yang mengganggu integritas dinding pembuluh darah, platelet, faktor
koagulasi, obat-obatan, radiasi, atau kemoterapi saat perawatan kanker.

Beberapa prosedur di dalam perawatan gigi dan mulut dapat menyebabkan perdarahan. Dalam keadaan normal tindakan ini
tidak menyebabkan gangguan, namun pada pasien dengan gangguan pembekuan darah tindakan perawatan gigi dan mulut
dapat menyebabkan keadaan pasien menjadi lebih parah.

Pasien dengan gangguan perdarahan merupakan salah satu kelompok pasien dengan medically compromise. Gangguan
perdarahan dapat diturunkan dan dapatan. Penanggulangan pasien dengan gangguan perdarahan perlu memperhatikan efek
yang akan timbul terutama saat melakukan tindakan invasif sehingga para dokter gigi sebaiknya mengetahui faktor- faktor
dan proses yang terjadi pada pembekuan darah sehingga tindakan yang akan dilakukan tidak menjadi penyebab terjadinya
keadaan yang fatal.

MANFAAT
1. Manfaat untuk pasien dan keluarga, dapat mengatasi dan mencegah terjadinya pendarahan pada saat akan
dilakukan tindakan invansif oleh tenaga kesehatan jika pasien mengetahui riwayat penyakitnya.
2. Bagi tenaga kesehatan, akan gampang mencari solusi dan alternatif pengobatan lain untuk menghindari terjadinya
kedaan pasien yang lebih parah.

Nilai Review Jurnal

Pekanbaru, 09 Desember 2019
Comment:
Dilaporan Oleh :

Ns. Hj. Herlyna, [Link]

(Lila Esi Mustika, AMKG) Koordinator Poliklinik