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

Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders 5hours for those patients with a mild bleedingtendency whilst those with more severeconditions or a history of prolonged bleedingdespite hemostatic cover may requiresupervision overnight in hospital. [25]• Discuss treatment requiring theadministration of coagulation factor ordesmopressin (DDAVP) with thehemophilia unit. They will be responsiblefor arranging the administration andmonitoring of treatment products.• Discuss the use of local hemostatic agents.This could include the use of oxidizedcellulose (Surgicel ® ) or fibrin glue. Fibringlue should not normally be used in patientswho have never received human-derivedblood products or those who are receivingtreatment with recombinant factor VIII or IXbecause of the potential risks of human viraltransmission.• Consider whether to use antibioticsfollowing a dental extraction. This iscontroversial, but there are a number ofanecdotal reports suggesting that their usemay prevent a late bleed, which is thoughtto be due to infection. However, if a patienthas an infection before treatment, it shouldbe treated with antibiotics.• Always carry out treatment asatraumatically as possible.2. Pre-operative period• Ensure that the oral cavity is as healthy aspossible before any surgical procedure. Thiscan be achieved by arranging treatmentwith a hygienist to remove as much calculusand plaque as possible. The regular use ofan antibacterial mouthwash, for examplechlorhexidine, may also help.• Consider using an antifibrinolytic agent. Itmay be helpful to start the treatment the daybefore the surgery. Tranexamic acid (usualadult dose 1 g three times a day) and epsilonaminocaproic acid (EACA) (50 mg/kg fourtimes a day), are the most commonly useddrugs. They should be continued for a totalof 7 days.3. Peri-operative period• Have the patient rinse with chlorhexidinemouthwash for 2 minutes before theadministration of the local anesthetic.• Carry out the extraction out asatraumatically as possible.• Suture the socket if the gingival margins donot oppose well. Brewer [26] reports a smallseries where sutures were not usedroutinely and there was no significantincrease in post-extraction hemorrhage.Resorbable and non-resorbable sutures maybe used at the operator’s discretion. Theonly problem with non-resorbable sutures isthe need for a post-operative visit and thepossibility of bleeding when the suture isremoved.• Use local hemostatic measures if indicated.These include the use of oxidized celluloseor fibrin glue (see notes on the use of fibringlue).• Use a soft vacuum formed splint to protectthe socket if needed.4. Post-operative periodThe patient must be given detailed postoperativeinstructions:• No mouth rinsing for 24 hours;• No smoking for 24 hours;• Soft diet for 24 hours;• No strenuous activities for 24 hours;• Prescribed medication must be taken asinstructed;• Analgesia should be prescribed for use ifrequired;• Salt-water mouthwashes (1 teaspoon of saltin a glass of warm water) should be usedfour times a day starting the day after theextraction for 7 days [27];• Antibacterial mouthwash may be used;• Emergency contact details must be given tothe patient in case of problems.Post-extraction hemorrhageCareful pre-operative planning and the use ofantifibrinolytic agents will prevent many postoperativeproblems [28]. However, postextractionbleeding will occur on occasion. Ifpost-extraction hemorrhage occurs:Contact the hemophilia unit and consider usingadditional factor concentrate.Inspect the site of the bleed. If there is anyevidence of a tear in the gingiva or otherobvious bleeding point this should be treatedusing local measures as previously described.