Dental management of the hemophilic patient

Presented by:
Dr. Vibhuti Kaul
DENTAL
MANAGEMENT OF
THE HEMOPHILIC
PATIENT

• Hemostasia is a defense mechanism that
protects vascular integrity, avoids blood
loss, and maintains blood fluidity
throughout the circulatory system. When a
blood vessel is damaged, rupture of the
endothelial lining exposes the blood to
proteins within the subendothelial tissue;
this in turn triggers three different but
overlapping mechanisms:
1. Vascular phase
2. Platelet phase
3. Plasmatic phase
Jover-Cerveró A, Poveda-Roda R, Bagán JV, Jiménez-Soriano Y.
Dental treatment of patients with coagulation factor alterations:
An update.Med Oral Patol Oral Cir Bucal 2007;12:E380-7.

• Dentists must be aware of the impact of
bleeding disorders on the management of
their patients. Proper dental and medical
evaluation of patients is therefore
necessary before treatment, especially if
an invasive dental procedure is planned.
• Patient evaluation and history should
begin with standard medical
questionnaires.
Gupta A, Epstein JB, Cabay RJ. Bleeding Disorders of importance
in dental care and related patient management. JCDA. 2007;
73(1): 77-83a.

A clinically significant bleeding episode is
one that:
• continues beyond 12 hours
• causes the patient to call or return to the
dental practitioner or to seek medical
treatment or emergency care
• results in the development of hematoma or
ecchymosis within the soft tissues or
• requires blood product support.
Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management
considerations for the patient with an acquired coagulopathy.
Part 1 Coagulopathies from systemic disease. Br Dent J 2003;
195(8):439–45.

- Bleeding time: This test assesses the vascular and
platelet phases of blood clotting. Although it is a
functional test of limited sensitivity, it remains a
good screening option.
- Activated partial thromboplastin time (aPTT): This
test evaluates the intrinsic and common pathways
of blood coagulation
- Prothrombin time (PT): This parameter evaluates
the extrinsic and common pathways
- International Normalized Ratio (INR): is the ratio
between the PT of the patient in seconds and a
control PT standardized by means of the so-called
International Sensitivity Index(ISI)
- Specific factor tests
Jover-Cerveró A, Poveda-Roda R, Bagán JV, Jiménez-Soriano Y.
Dental treatment of patients with coagulation factor alterations:
An update. Med Oral Patol Oral Cir Bucal 2007;12:E380-7.

BLEEDING
TIME APTT PT
APTT
PT
NORMALLOW
NORMAL NORMAL NORMAL
NORMAL
NORMAL
PROLONGED
PROLONGED
PROLONGED
PLATELET
COUNT
FACTOR XIII DEF.,
DRUGS &
OTHERS
FACTOR VII
DEFICIENCY
HEMOPHILIAS,
FACTOR XI & XII
DEFICIENCY
LIVER DISEASE,
ANTICOAGULANTS,
DIC, OTHERS
DISORDERS OF
PLATELET
FUNCTION
von WILLEBRAND’S DISEASE
THROMBOCYTOPENIAS
Naveen Kumar J, Anil Kumar R, Varadarajan
R, Sharma N. Specialty dentistry for the
hemophiliac: Is there a protocol in place? Indian
J Dent Res 2007;18:48-54.

GENERAL CONSIDERATIONS
Hemophilia is the most common hemorrhagic
diathesis across the globe with an
occurrence of 1 per every 10,000 people.
The severity of hemophilia is variable, but
correlates well with the Factor VIII level of
the plasma.
Normal plasma contains 1 unit of Factor VIII
per ml, a level defined as 100%.
Naveen Kumar J, Anil Kumar R, Varadarajan R, Sharma N.
Specialty dentistry for the hemophiliac: Is there a protocol in
place? Indian J Dent Res 2007;18:48-54.

FACTOR ACTIVITY SEVERITY OF HEMOPHILIA
<1% Severe hemophilia
1-5% Moderate hemophilia
>5% Mild hemophilia

PREVENTION OF DENTAL
PROBLEMS
• Brushing twice daily with a fluoride
toothpaste.
- 1,000-ppm fluoride toothpaste for children
under 7 years of age.
- 1,400-ppm fluoride toothpaste for people
over 7 years of age.
• The use of fluoride toothpaste depends on
the fluoride concentration in the water
supply as well as the use of additional
fluoride supplements. It should not be
used if fluoride supplements are taken or if
the water supply has a fluoride content of
1ppm or more.

• The toothbrush should have medium
texture bristles because hard bristles can
cause abrasion of the teeth and soft
bristles are inadequate to remove plaque.
• Interdental cleaning aids, such as floss,
tape, and interdental brushes, should be
used to prevent the formation of dental
caries and periodontal disease.
• Fluoride supplements may be used, but
are not recommended if the water supply
has a fluoride content of 1 ppm or more.
• The consumption of foods and drinks with
a high sugar or acid content should be
limited to mealtimes. Three exposures per
day is the recommended maximum.

• Artificial sweeteners can be used as an
alternative to sugars in food and drinks.
Examples are aspartame, sorbitol,
acesulfamate, etc.
• Regular dental visits, usually every 6
months, will help identify problems early,
reinforce prevention, and emphasize the
importance of reducing the intake of food
and drink containing high levels of sugar
or acid.
Brewer A, Correa ME. Guidelines for dental treatment of patients
with inherited bleeding disorders. Treatment of hemophilia.
2006; 40.

GENERAL MANAGEMENT
Factor VIII must be replaced to a level
adequate to ensure hemostasis if bleeding
starts or is expected. Replacement of
missing factor is achieved with porcine
Factor VIII or recombinant Factor VIII.

One unit of Factor VIII concentrate per
kilogram of body weight raises the Factor
VIII level by 2% and hence an average 70
kg individual would require infusion of
3500 units to raise the factor level from
less than 1% to 100%. Thus a simple
formula may be derived as:
Dose to be infused (Units) =
{Weight (Kg) x Increment needed (U/dl)}/2
Hoffbrand VA, Catovsky D, Edward GD, Tuddenham. Post graduate
haematology, 5th ed. Blackwell Publishing: London; 2005.

• Cover for surgery, other than very minor
procedures or for mild hemophiliacs,
requires maintenance of normal Factor VIII
levels for approximately one week,
followed by a period of reduced dosage
during convalescence. This can be
achieved either by repeated bolus
injections every 12 hours (paying
particular attention to trough levels) or by
continuous infusion. It must be noted that
the doses required during the immediate
postoperative period may be considered
more than expected.

• In mild hemophlia, desmopressin and
antifibrinolytics such as tranexamic acid
may be adequate.
• Desmopressin, a synthetic analogue of
vasopressin is available for intranasal
spray and intravenous infusions. It
provides adequate transient increases in
coagulation factors in some patients with
mild to moderate hemophilia avoiding the
need for plasma concentrates.
• Tranexamic acid is a synthetic derivative
of lysine, available for topical and systemic
usage. However, nausea is a common
adverse effect.
• The anti-fibrinolytic agent Epsilon amino
caprioic acid (EACA) given orally of IV is a
potent inhibitor of initial clot dissolution.

• A regimen of 50 mg/kg body weight EACA
given orally as a 25% oral rinse every six
hours for seven to ten days appears
adequate as an adjunct.
• Still tranexamic acid is 10 times more
potent than EACA with fewer side-effects.

Difficulties in the management of a
hemophiliac dental patient include the
following:
1. Dental neglect necessitating frequent
extractions
2. Trauma and surgery
3. Factor VIII inhibitors (recombinant FVIIa is
an alternative Solution)
4. Hazards of anesthesia and injections
5. Risk of hepatitis B and liver disease and
HIV infection
6. Aggravation of bleeding by drugs
7. Anxiety and drug dependence
Scully C, Cawson RA. Medical problems in dentistry. 5th ed.
Elsevier: London; 2005.

• The bleeding tendency can be aggravated
by NSAIDs. Safer alternatives for pain
control are acetaminophen, codeine and
Cox-2 inhibitors.
• Local anesthetic regional blocks, lingual
infiltrations or injections into the floor of the
mouth must not be used in the absence of
Factor VIII replacement because of the
risk of hemorrhage hazarding the airway
and being life-threatening. If FVIII
replacement therapy has been
given, regional LA can be used provided
the FVIII level is maintained above 30%.
• Infiltrations, intraligamentary, intraosseous
or intrapulpal injections are still safer.

RESTORATIVE PROCEDURES
• Restorative treatment can be undertaken
routinely providing care is taken to protect
the mucosa. There is a risk of bleeding
with the use of matrix bands or wooden
wedges. This can be controlled by local
means or the application of topical agents.
• Cotton rolls should be wetted before
removal.
• High-speed vacuum aspirators and saliva
ejectors can cause hematomas.
• Trauma from the saliva ejector can be
minimized by resting it on a gauze swab in
the floor of the mouth.
2006; 40.

Batawi HYE. Minimizing the risk of perioperative bleeding in a child with
hemophilia A during dental rehabilitation under general anesthesiia: a case
report. Int J Clin Ped Dent 2013; 6(3): 217-222.

ENDODONTICS
• Avoiding instrumentation through the
periapex is of prime importance in
endodontic therapy.
• The presence of bleeding in the canal is
indicative of pulp tissue remaining in the
canal.
• Sodium hypochlorite should be used for
irrigation in all cases, followed by the use
of calcium hydroxide paste to control the
bleeding.
• Formaldehyde-derived substances may
also be used in cases where there is
persistent bleeding or even before the
pulpectomy.
2006; 40.

RUBBER DAM ISOLATION
• Isolation with rubber dam provides
retraction of gingiva and improves visibility.
• It also minimizes the potential for
laceration of the buccal mucosa and lips.
• Notches may be placed in buccal and
lingual surfaces with a fissure bur into
which clamp prongs will fit tightly.

SURGICAL ENDODONTICS
• Mild hemophiliacs requiring surgeries can
be managed usually without factor
replacements.
• Desmopressin and tranexamic acid are
primary alternatives.

• Desmopressin can be as a slow
intravenous infusion over 20 min of 0.3-0.5
µg/kg, 30 to 60 min prior to the surgical
procedure. This results in a two- to
threefold rise in Factor VIII activity with a
mean half-life of 9.4h. Intranasal
administration as a spray of 1.5 mg per ml
with each 0.1 ml pump spray is an
alternative, but it requires a tenfold higher
dose of desmopressin to achieve a
maximal twofold increase in Factor VIII
activity after 90 min, limiting treatment to
those hemophiliac patients whose basal
factor levels are sufficiently high.

• Tranexamic acid significantly reduces
blood loss and can be given topically or
systemically.
Borea G, Montebugnoli L, Capuzzi P, Magelli C. Tranexamic acid as
a mouthwash in anticoagulant-treated patients undergoing oral
surgery. An alternative method to discontuing anticoagulant
therapy. Oral Surg Oral Med Oral Pathol 1993; 75: 29-31.

• Systemically, its given in a dose of 1g (30
mg/kg) orally qid starting atleast 1h
preoperatively for surgical procedures.
• Tranexamic acid infusions can be given as
10 mg/kg in 20 ml normal saline over 20
min, then 1g tds orally for five days
(children: 20 mg/kg)
• Stubbs M, Llyod J. A protocol for the dental management of von
Willebrand’s disease, haemophlia A and haemophilia B. Aus
Dent J 2001; 46(1): 37-40.

PERIODONTAL TREATMENT
• Healthy periodontal tissue is essential to prevent bleeding
and tooth loss.
• If oral hygiene is poor treatment must start as soon as
possible after the patient has had a dental examination and
treatment plan formulated to prevent additional damage to
the periodontal tissues.
• In cases of severe periodontal disease, it may be necessary
to carry out supragingival scaling initially along with oral
hygiene education.
• Subgingival scaling can start as soon as the inflammation
has decreased. The treatment may need to be carried out
over several visits to prevent excessive blood loss.
• In addition, chlorhexidine gluconate mouthwash can be
used to control periodontal problems.
• Antibiotics may be required to help reduce the initial
inflammation.
Naveen Kumar J, Anil Kumar R, Varadarajan R, Sharma N. Specialty dentistry for the
hemophiliac: Is there a protocol in place? Indian J Dent Res 2007;18:48-54

• A case was reported wherein local
treatment with 30% trichloroacetic acid
combined with tranexamic acid was used
to stop the bleeding in 51 year old patient
with moderate hemophilia.
• Delgado EG, Sottilotta G. Dental treatment with 30%
tricholoracetic acid in a patient with moderate hemophilia A.
Open J Blood Dis. 2013; 3: 13-14.

REMOVABLE
PROSTHODONTICS
• Patients with bleeding disorders can be
given dentures as long as they are
comfortable.
• If a partial denture is provided it is
important that the periodontal health of the
remaining teeth is maintained.
2006; 40.

ORTHODONTIC TREATMENT
• Fixed and removable orthodontic
appliances may be used along with regular
preventive advice and hygiene therapy.
Special care should be taken when
treating patients with a severe bleeding
disorder to ensure that the gingiva is not
damaged when fitting the appliance.
• Brewer A, Correa ME. Guidelines for dental treatment of
patients with inherited bleeding disorders. Treatment of
hemophilia. 2006; 40.

ANESTHESIA AND PAIN
MANAGEMENT
• Dental pain can usually be controlled with
a minor analgesic such as paracetamol
(acetaminophen). Aspirin should not be
used due to its inhibitory affect on platelet
aggregation. The use of any non-steroidal
anti-inflammatory drug (NSAID) must be
discussed beforehand with the patient's
hematologist because of their effect on
platelet aggregation.

ANESTHESIA AND PAIN
MANAGEMENT
• A buccal infiltration can be used without
any factor replacement. It will anesthetize
all the upper teeth and lower anterior and
premolar teeth.

POST-EXTRACTION
HEMORRHAGE
• Contact the hemophilia unit and consider using
additional factor concentrate.
• Inspect the site of the bleed. If there is any evidence of a
tear in the gingiva or other obvious bleeding point this
should be treated using local measures.
• Instruct the patient to sit up and bite on a damp gauze
swab for at least 10 minutes.
• Use a 10% solution of tranexamic acid or EACA to
dampen the swab or as a mouthwash if the bleeding is
difficult to stop.
• Monitor the patient’s blood pressure as it may increase
due to worry and pain.
Brewer A, Correa ME. Guidelines for dental treatment of patients with
inherited bleeding disorders. Treatment of hemophilia. 2006; 40.

FIBRIN GLUE
• In some hemophilia centres, fibrin glue is
used as a local hemostatic measure, along
with an oral antifibrinolytic agent, to
achieve hemostasis and reduce the need
for clotting factor replacement therapy. All
fibrin glue contains human or animal
components, which has made a number of
physicians and patients being hesitant to
use this treatment particularly for patients
who are receiving recombinant factor
concentrates or have never received blood
products derived from humans.
• Brewer A, Correa ME. Guidelines for dental treatment of patients with

SPLINTS
• Soft vacuum-formed splints can be used to
provide local protection following a dental
extraction or prolonged post-extraction
bleed.
• If the splint is to be used to stop a post-
extraction hemorrhage, the impression
must be thoroughly cleaned and
disinfected before it is transported to the
laboratory.
• Brewer A, Correa ME. Guidelines for dental treatment of patients with

MANAGEMENT OF ORAL
INFECTIONS
• The initial treatment usually starts based on the normal
oral pathogens, Streptococcus viridans, anaerobic gram-
positive cocci and anaerobic gram-negative rods.
• Antibiotic regimes should cover all of these groups of
organisms.
• Penicillin is a first-line antibiotic used to treat dental
infections.
• Metronidazole is extremely effective in treating
anaerobes and is often used in combination with
penicillin to give good coverage of both the aerobic and
anaerobic bacteria present in the oral cavity.
• Erythromycin and clindamycin have been prescribed to
patients who are allergic to penicillin.
• Brewer A, Correa ME. Guidelines for dental treatment of patients with inherited
bleeding disorders. Treatment of hemophilia. 2006; 40.

CONCLUSION
• Early dental care is of prime importance in
such patients to avoid invasive procedures
at a future date.
• A thorough understanding of the condition,
helps the dental professional to perform a
systematic evaluation and anticipate
potential hazards rather than being caught
unawares with meager and desperate
local haemostatic measures.
• A protocol should be followed while
treating these cases to continue with
specialty dental procedures without major
risks.

Dental management of the hemophilic patient

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