Dental management of the hemophilic patient

Presented by:

Dr. Vibhuti Kaul

DENTAL MANAGEMENT OF THE HEMOPHILIC

PATIENT

INTRODUCTION

• 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.

LABORATORY TESTS

- 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

NO

RM

AL

LOW

NORMAL NORMAL NORMAL

NORMAL

NORMAL

PR

OL

ON

GE

D

PR

OL

ON

GE

D

PR

OL

ON

GE

D

PLATELETCOUNT

FACTOR XIII DEF.,DRUGS & OTHERS

FACTOR VIIDEFICIENCY

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%.


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.


DENTAL ASPECTS

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.


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.


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.

SURGICAL ENDODONTICS• 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.


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.


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.


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.


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.


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.

THANK YOU

Health & Medicine

Dental management of the hemophilic patient