Guidelines for Dental Treatment of Patients with Inherited Bleeding ...

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2 Guidelines for Dental Treatment of Patients with Inherited Bleeding Disordersprovide guidelines that allow dental treatmentto be carried out safely whilst minimizing theuse of factor concentrates.Historically, international guidelines for oralsurgery recommended the administration ofclotting factor concentrates both before and aftersurgery. Doses are calculated to increase thelevel of factor VIII or IX to 50-100 IU/dL for aperiod of at least seven days [9,10]. Ublansky etal. [11] advised an increase of factor VIII or IX to50% for either regional or infiltration localanesthesia.The literature describes many successful dentaltreatment protocols that provide a remarkablereduction in the number of bleeding episodesfollowing oral procedures using oralantifibrinolytic agents, systemic hemostaticreplacement therapy, and local hemostaticagents [12-17].In a WFH monograph by Harrington [18], lowerdoses (30% of normal) of clotting factorconcentrates are recommended for infiltrationanesthesia of the lower jaw and periodontalcurettage. For more invasive surgicalinterventions, the recommendation is to increasethe factor level from 50-100 IU/dL of normalpre-operatively, and use an oral antifibrinolyticagent pre- and post-operatively.Sindet-Pedersen [15,17] suggests that the dose offactor replacement therapy can be significantlyreduced if used with an oral rinse of anantifibrinolytic agent (tranexamic acid) is usedfollowing a dental extraction. He recommends asingle dose of factor, in cases of severehemophilia A elevating the factor VIII level to10IU/dL. Desmopressin, a synthetic derivativeof the hormone vasopressin, has been shown toincrease factor VIII level in some patients withmild or moderate forms of hemophilia A or type1 von Willebrand disease. Unfortunately, not allpatients respond so this should be checkedbefore performing any surgical procedure. Itsuse is well documented in cases of mild andmoderate hemophilia A [19-21]. DDAVPreleases bound factor VIII and is therefore notused to treat patients with hemophilia B. Areport by Ehl et al. [22] showing a clinicalresponse to desmopressin in four patients withhemophilia B with baseline factor IX levels of 1.4to 5% for oral surgery. They report a reductionin the use for plasma products followingtreatment.Fibrin glue is used as a local hemostatic measurein some centres for achieving hemostasis andreducing the needs for clotting factorreplacement therapy (see section on page 6).PreventionThe prevention of dental problems is anessential component of oral care. A successfulregimen will reduce the need for treatment andshould reduce the number of emergency visits.Dental prevention depends on a number ofdifferent factors. Some of these may not beavailable in developing countries but areincluded to demonstrate the ideal situation.• Brushing twice daily with a fluoridetoothpaste.- 1,000-ppm fluoride toothpaste forchildren under 7 years of age.- 1,400-ppm fluoride toothpaste forpeople over 7 years of age.The use of fluoride toothpaste depends onthe fluoride concentration in the watersupply as well as the use of additionalfluoride supplements. It should not be usedif fluoride supplements are taken or if thewater supply has a fluoride content of 1ppm or more.• The toothbrush should have mediumtexture bristles because hard bristles cancause abrasion of the teeth and soft bristlesare inadequate to remove plaque.• Interdental cleaning aids, such as floss, tape,and interdental brushes, should be used toprevent the formation of dental caries andperiodontal disease.• Fluoride supplements may be used, but arenot recommended if the water supply has afluoride content of 1 ppm or more.Supplements include:- Fluoride drops- Fluoride tablets- Topical application of fluoride usingtrays- Fluoride mouthrinses which can be usedon either a daily or a weekly basis.
Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders 3• The consumption of foods and drinks with ahigh sugar or acid content should be limitedto mealtimes. Three exposures per day is therecommended maximum. The aim is toensure that the intake of food and drinkdoes not cause the pH of the oral cavity tofall below the critical level of pH 5.5.• Artificial sweeteners can be used as analternative to sugars in food and drinks.Examples are aspartame, sorbitol,acesulfamate, etc.• Regular dental visits, usually every 6months, will help identify problems early,reinforce prevention, and emphasize theimportance of reducing the intake of foodand drink containing high levels of sugar oracid.The Scottish Intercollegiate Guideline Networkhas published Preventing Dental Caries inChildren at High Risk, which includes a quickreference guide, may also be a useful resource[23]. It is available from their website athttp://www.sign.ac.uk/pdf/sign47.pdf.Dental treatmentIt is essential to prevent accidental damage to theoral mucosa when carrying out any procedure inthe mouth. Injury can be avoided by:Careful use of saliva ejectors;Careful removal of impressions;Care in the placement of X-ray films,particularly in the sublingual region;Protection of soft tissues during restorativetreatment by using a rubber dam or applyingyellow soft paraffin (vaseline ® ).blood loss. In addition, chlorhexidine gluconatemouthwash can be used to control periodontalproblems. Antibiotics may be required to helpreduce the initial inflammation.Blood loss of all kinds can be controlled locallywith direct pressure or periodontal dressingswith or without topical antifibrinolytic agents.Periodontal surgery in patients with bleedingdisorders must always be regarded as a highriskprocedure with a significant risk of bloodloss. It should only be considered wereconservative treatment has failed and oralhygiene is good. Periodontal surgery can be agreater challenge to hemostasis than a simpleextraction. The procedure must be carefullyplanned and the risks fully explained to thepatient.Removable prosthodonticsPatients with bleeding disorders can be givendentures as long as they are comfortable. If apartial denture is provided it is important thatthe periodontal health of the remaining teeth ismaintained.Orthodontic treatmentFixed and removable orthodontic appliancesmay be used along with regular preventiveadvice and hygiene therapy. Special care shouldbe taken when treating patients with a severebleeding disorder to ensure that the gingiva isnot damaged when fitting the appliance.Periodontal treatmentHealthy periodontal tissue is essential to preventbleeding and tooth loss. If oral hygiene is poortreatment must start as soon as possible after thepatient has had a dental examination andtreatment plan formulated to prevent additionaldamage to the periodontal tissues. In cases ofsevere periodontal disease, it may be necessaryto carry out supragingival scaling initially alongwith oral hygiene education. Subgingival scalingcan start as soon as the inflammation hasdecreased. The treatment may need to be carriedout over several visits to prevent excessiveRestorative proceduresRestorative treatment can be undertakenroutinely providing care is taken to protect themucosa. There is a risk of bleeding with the useof matrix bands or wooden wedges. This can becontrolled by local means or the application oftopical agents. The risks of using localanesthetics and the requirement for prophylaxisare discussed in a later section.
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