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Bleeding Disorders

What type of bleeding disorder do you have?#

Most hemostatic impairments are associated with quantitative and qualitative platelet disorders or with coagulation disorders.

The most common inherited coagulopathy is von Willebrand disease (vWD) (see below). Other inherited disorders include hemophilia A (see below) and hemophilia B (see below).

Platelet disorder may be associated with immune dysfunction, such as immune thrombocytopenic purpura (ITP), hematologic diseases, or different medications, such as aspirin and NSAIDs Camera icon..

What type of bleeding tendencies do you experience?#

Platelet disorders may manifest as persistent bleeding from superficial wounds, spontaneous gingival bleeding, petechiae Camera icon., small and multiple ecchymoses, and epistaxis.

Coagulation disorders typically manifest as delayed onset of bleeding, deep dissecting bleeding, bleeding within large joints, and large and solitary ecchymoses.

What are the laboratory values associated with your bleeding disorder?#

Normal laboratory values:

  • Platelet count (Plt) - 150-400 x cells/mm³
  • Prothrombin time (PT) - 11-13 s
  • International normalized ratio (INR) - 1.0-1.3
  • Activated partial thromboplastin time (aPTT) - 30 s-40 s
  • Coagulation factor assay - 60%-100%
  • Bleeding time (BT) - 3 min-8 min

Laboratory values for hemostasis may suggest a potential to develop adverse events during dental procedures.

Combination of different laboratory values may suggest specific bleeding disorders.

Do you have any other medical conditions associated with your bleeding disorder?#

Hemostatic defects are associated with several underlying medical conditions, such as liver disease, vitamin K deficiency, kidney disease, cytotoxic chemotherapy, leukemia, aplastic anemia, myelodysplasia, myeloproliferative disorders, systemic lupus erythematosus (SLE), and alcohol abuse.

Do you drink any alcoholic beverages?#

Alcohol is toxic to platelets and may dramatically reduce the number of these cells, resulting in impaired hemostasis.

In patients with underlying disorders, such as severe liver disease, ingestion of alcohol may become life threatening.

What types of medications are you taking?#

Aspirin and aspirin-containing drugs may irreversibly impair platelet function. NSAIDs also affect platelet function, but the effect diminishes within 4-6 hours.

COX-2 inhibitors do not have a significant clinical effect on platelets.

von Willebrand Disease#

  • vWD is an autosomal dominant transmitted disorder, which quantitatively and qualitatively affects the von Willebrand factor.
  • The von Willebrand factor is used to anchor platelets to tissue in a high shear stress area of bleeding to help create an initial platelet plug.
  • Clinical signs of the most common type of vWD (Type 1) may include mucosal bleeding, epistaxis, soft tissue hemorrhage, and increased bleeding after dental extractions.
  • More severe clinical signs are found in uncommon types (Type 2, 3, 4) of vWD.
  • The severity of vWD can be assessed by measuring the bleeding time.

Hemophilia A and B#

  • Hemophilia A and B are X-linked transmitted disorders characterized by a lack of coagulation factor VIII (FVIII) or coagulation factor IX (FVIII), respectively, or by antibodies against FVIII or FIX.
  • Although females may carry a trait, with very mild clinical signs, hemophilia A is mainly found in males.
  • Severe hemophilia (factor activity <1%) is associated with severe spontaneous bleeding into major joints (elbows, knees and ankles) leading to hemarthroses, intramuscular bleeding, and retroperitoneal bleeding.
  • Moderate hemophilia (factor activity 1% – 5%) is associated with less significant bleeding.
  • Mild hemophilia (factor activity >5% – <40%) usually only manifests as impaired hemostasis after severe trauma or surgical procedures.
  • Total joint replacements are not uncommon in patients with severe hemophilia.

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