The dental treatment of patients with inherited bleeding disorders has been widely discussed in the literature with the goal of developing guidelines for common procedures. Most of them recommend the use of coagulation factor replacement therapy before invasive oral surgery.
Hemophiliacs are at risk of experiencing intra- and postoperative bleeding after oral surgery procedures. These should therefore be performed at specialized centers in collaboration with hematologists experienced in the management of this disease. The World Federation of Hemophilia (WFH) recommends that factor deficiency be treated with the specific concentrate when possible and that factor levels be restored to normal before any invasive procedure.
Preventing dental issues is an essential component of oral hygiene. Some of the important factors for prevention are: brushing teeth twice a day with a fluoride toothpaste; using a medium bristle toothbrush, because hard bristles can cause abrasion of the teeth and soft bristles are inadequate for removing plaque; and using interdental cleaning products, such as dental floss, dental tape, and interdental brushes, to prevent dental decay and periodontal disease.
Consumption of foods and beverages high in sugar or acid should be limited to meals.1 Regular dental visits, usually every 6 months, can help identify problems early and improve prevention.
In hemophiliacs, surgical treatment, including simple tooth extraction, should be planned to minimize the risk of bleeding, excessive bruising, or hematoma formation. All treatment plans should be discussed with the hemophilia unit if they involve the use of prophylactic coverage.
In order to help prevent and manage postoperative bleeding in hemophilic patients, a dentist should contact the hematologist before the procedure to explain the planned dental procedure, report on the patient’s medical condition, and describe what types of local postoperative hemostatic measures he intends to apply. The hematologist will then prescribe the most appropriate antihemophilic treatment in due advance to ensure that plasma levels of the deficient coagulation factor are optimal during the procedure.
In particular, it is recommended that factor VIII be kept between 50% and 75% of normal levels before oral and periodontal surgery and between 75% and 100% before maxillofacial surgery. The dentist should immediately inform the hematologist of any events of prolonged bleeding, difficult speaking or breathing following a dental procedure.
Periodontal surgery in patients with bleeding disorders should always be considered a high-risk procedure with a significant possibility of bleeding. Periodontal surgery may pose a greater challenge to hemostasis than a simple extraction. The procedure must be carefully planned and the risks fully explained to the patient.
References
- Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders. Brewer A, Correa ME. Treatment of Hemophilia monograph no. 40, World Federation of Hemophilia, 2006.
- Ramos EA, Diamante M, Caruso D, Muiño JM, Baques A, Antonelli LB, Gutierrez J, Minigutti MO, Guerrero G. Outpatient minor oral surgery in patients with hemophilia: A case series of 23 patients. J Clin Exp Dent. 2019 Apr 1;11(4):e395-e399. doi: 10.4317/jced.55506.
- Liras A, Romeu L. Dental management of patients with haemophilia in the era of recombinant treatments: increased efficacy and decreased clinical risk. BMJ Case Rep. 2019 Apr 8;12(4):e227974. doi: 10.1136/bcr-2018-227974.
