Dental management: On a day to day practice dentist may encounter patients with various types of bleeding disorders. A detailed medical history when the patient enters the clinic is of prime importance. Medical history should report past episode of bleeding, h/o bleeding which continues beyond 12 hrs, H/o blood transfusion of concentrates, h/o hematomas, h/o easy bruising, spontaneous haemorrhage from middle ear, epistaxis, bleeding into soft tissues. Also positive family history or a clinical history of exaggerated bleeding response to minor trauma gives a clue regarding presence of some underlying bleeding disorders.
Bleeding disorders are grouped into coagulation factor deficiencies, vascular disorders, platelet disorders and fibrinolytic defects. Out of these Haemophilia A, Haemophilia B and Von Willebrand’s disease are commonly seen congenital coagulation disorders.
Haemophilia A are a group of disorders characterized by prolonged clotting time and excessive bleeding. It is due to deficiency of factor VIII. Haemophilia A is more common than Haemophilia B.
Haemophilia B (Christmas disease) is caused due to deficiency of factor IX. In haemophilia B usually females are the carriers and males are affected.
Haemophilia are classified according to severity:
<1% – severe haemophilia 1-5% – moderate >5%- mild
This classification helps in treatment planning. A dentist should consult general physician, haematologist before undertaking dental treatment. Laboratory reports should be used as reference for diagnosis of the disease.
Dental and Health Management:
Patients with severe form of disease have frequent , spontaneous bleeds into muscles and joints, those with moderate have few spontaneous bleeds but bleed after minor trauma and those with mild haemophilia bleed only after surgery, dental extraction or trauma.
Patients with moderate and severe haemophilia may be on prophylactic factor regimens eg (factor VIII,IX infusions).It is important that the dental treatment should be scheduled at times of factor administration or as close to the time to minimize risks if possible.
Patients with mild haemophilia and Von Willebrand’s disease desmopressin and antifibrinolytic agents such as tranexamic acid is administered. Patients with haemophilia B do not respond to desmopressin.
Dental management of Haemophilia
Haemophilic patients experiencing dental pain are not given NSAID as bleeding tendency is aggravated. Safer drugs are: Acetaminophen,COX 2 inhibitors. Aspirin should be avoided as it has an inhibitory effect on platelet aggregation.
Infiltration in the floor of the mouth, lingual infiltration should be avoided in the absence of factor VIII replacement because of risk of haemorrhage.
Can be routinely undertaken but care should be taken to avoid damage to the mucosa. Matrix bands, wedges should be used carefully to avoid risk of bleeding. Bleeding can be controlled by use of topical agents eg ferrous sulphate impregnated on retraction cords.High speed vacuum aspirators and saliva ejectors can cause haematomas. Trauma by saliva ejectors can be reduced by resting it on a gauze.
Endodontics: Periapical bleeding by files during treatment should be avoided. Isolation by rubber dam minimises the laceration of buccal mucosa and lips.
Surgical endodontics: Mild haemophilia requiring surgeries can be managed usually without factor replacement. Desmopressin and tranexamic acid are alternatives. Dosage of desmopressin: I.V 0.3-0.5µg/kg over 20 mins 1 hr prior to surgical procedure. Dosage of tranexamic acid: can be used topically or systemically.1g (30 mg/kg)orally qid 1 hr prior OR 10mg/kg in 20ml NS over 20 mins ,then 1g tds orally for 5 days.
Periodontal treatment: Healthy periodontium is essential to prevent bleeding and tooth loss. In case of severe periodontal disease supragingival scaling must be started first along with oral hygiene education. Subgingival scaling can be done as soon as the inflammation has decreased. Antibiotics to be given as an adjunct. Treatment should be carried out multiple visits to avoid excessive bleeding.
Periodontal surgeries: If bleeding is encountered during surgery Ab-Gel/ Inj. pause 500mg /electrocautery can be used .
Orthodontic treatment: Special care should be taken in treating patients with severe bleeding disorders to ensure that gingiva is not damaged when fitting the appliance.
Post extraction haemorrhage: It continues beyond 12 hrs after extraction. Inspect the site of bleed. First use local measures. Ask the patient to bite tightly on the gauze for atleast 15 mins. Use 10% tranexamic acid to dampen the gauze if bleeding is difficult to stop, placement of local anaesthetic with vasoconstrictor on gauze. Bleeding from soft tissues is usually arrested by placing a horizontal mattress suture across the socket. Common local haemostatic agents are: AB-GEL, thrombin, ethamsylate, fibrin glue, oxidized cellulose. If local measures fail blood transfusion, hospitalisation or both are needed. Antibiotics commonly used in such patients are: Penicillin, metronidazole, clindamycin.Leave a reply