Epsilon-Aminocaproic acid therapy for dental extractions in haemophilia and Christmas disease: a double blind controlled trial

The combined local/systemic use of antifibrinolytics in hemophiliacs undergoing dental extractions

A total of 185 permanent teeth were extracted in 43 hemophiliacs. The patient material is divided into 3 groups with respect to antifibrinolytic therapy. Patients in group 1 were given antifibrinolytics systemically. In group 2, antifibrinolytics were applied locally, and in group 3 they were used both locally and systemically. The results of the treatment were evaluated using the number of units per kilogram of F VIII administered per patient and the Coagulum Index (CoI). It is shown that local use of antifibrinolytics can reduce the amount of F VIII required for the control of bleeding, but regarding the high values of the CoI, the therapeutic effects are unsatisfactory. Approximately 20 U/kg of F VIII per patient, given in single infusion prior to intervention, were required in group 1 as well as in group 3. However, with respect to the CoI, a statistically significant difference is found between groups 3 and 1. On this basis, it is concluded that antifibrinolytics, used both locally and systemically, appear to show distinct advantages in the treatment of hemophiliacs undergoing dental extractions and also receiving F VIII therapy.

Blood loss following dental extractions in anticoagulated rabbits: effects of tranexamic acid and socket packing

The present study demonstrates the feasibility of chronic anticoagulation in rabbits and of estimating the resulting increase in blood loss following extraction of four front teeth from labeled red cell disappearance curves. This setup proved useful for the evaluation of hemostatic techniques. Socket packing with oxidized cellulose soaked in thrombin solution or local application of cyanobutylacrylate reduced early blood loss; oral administration of tranexamic acid reduced both early and late bleeding; the combination of socket packing and oral tranexamic acid completely abolished the excessive blood loss that resulted from anticoagulation alone.

Dental extractions in hemophilia: reflections on 10 years' experience

During the past ten years we have witnessed a remarkable reduction in complications following dental extractions in patients with hemophilia. Thirty-six of 100 patients experienced delayed bleeding during the first half of this period; fourteen of 112 patients had a hemorrhagic problem after extraction during the second half. From a major undertaking involving hospitalization and general anesthesia, it has become a simple procedure in the outpatient office. During the entire period, no changes were made in the transfusion policy or in the oral administration of antifibrinolytic agents. Factors contributing to the favorable evolution have been the increasing experience of the oral surgeon, the improving dental status of our hemophilia patients, prophylactic measures to reduce gingival inflammation, and changes in the composition and amount of material used to pack the dental sockets.

Treatment modalities for inherited factor IX deficiency and the implications of inherited bleeding disorders

Two cases of factor IX deficiency are presented. Therapeutic methods for anticipated abnormal bleeding during dental surgical procedures on these patients are discussed, and two are illustrated. One treatment regimen, plasmapheresis, has not been discussed previously in the dental literature. Epidemiologic data relative to the frequency and type of inherited bleeding diatheses seen by the dental surgeon were obtained from a 2-year retrospective study involving all admissions to the dental service of a regional hospital. These data, in conjunction with the presented cases, illustrate the need for dentists, especially those in the surgical specialties, to be familiar with the inherited bleeding diatheses and their treatment.

The fibrinolytic system in man

The existence of a system in the human body capable of inducing the dissolution of endogenous pathologically formed thrombi was appreciated in ancient times. Considered in detail in this article are the data that have elucidated the physiologic regulation of which plasmin formation is dependent on, the plasma concentration of plasminogen, availability of activators of plasminogen in the plasma and surrounding tissue environment, the concentration of naturally present inhibitors, and the existence of fibrin in the circulation. Important in this rapidly progressive scientific discipline is consideration of the factors which control the synthesis of the components of this proteolytic enzyme system. Recently abundant information has indicated that this plasminogen-plasmin proteolytic enzyme system can be utilized therapeutically. Knowledge of the mechanisms of this system has permitted identification of agents that can be exogenously administered to releave thrombotic obstruction to blood flow in the venous (pulmonary emboli, deep vein thrombosis) and arterial (peripheral and central vessels) circulatory systems. Particularly important is the demonstration that thrombolytic agents can directly attack and alleviate the immediate cause of acute myocardial infarction. As a result of the innovations in the present decade, it is evident that the plasminogen system can be advantageously employed to reverse the pathologic effects of all thrombotic diseases.

Evidence that less replacement therapy is required for dental extractions in hemophiliacs

The requirements for factor VIII (AHF) or factor IX (PTC) of hemophilic patients undergoing dental extractions were evaluated to determine the minimum effective regimen. Sixteen patients underwent 19 operative procedures. The mean total dose of factor VIII or IX was 45.8 U/kg for 11 procedures with preoperative replacement therapy and 34.5 U/kg for the 8 without. Four patients received no replacement therapy at all. Our results compared favorably to published studies employing factor replacement alone or in combination with antifibrinolytic agents such as epsilon-amino-caproic acid (EACA), with respect to blood products utilized and duration of hospitalization. However, our patients received less factor replacement than usually suggested. General anesthesia with intubation, a common recommendation, was not required in any patients. Dental extractions can be carried out in hemophiliacs using less replacement therapy than currently recommended. In some circumstances, no replacement therapy may be necessary. The reported efficacy of antifibrinolytic agents in reducing the requirement for replacement therapy is difficult to assess because of the relatively large amount of prophylactic factor replacement used in conjunction with these agents.

Maintenance of hemostasis during exodontia in two hemophiliacs with factor VIII inhibitors

This paper reviews hemophilia A with emphasis on the 10% of afflicted patients who have inhibitors to factor VIII. Two patients with the latter problem are presented, and a management program is described and illustrated.

Epsilon aminocaproic acid in hemophiliacs undergoing dental extractions: a concise review

On the basis of our review of the literature, it can be concluded that the advantages of E-A.C.A. include (1) safe execution of oral surgical procedures in persons with hemophilia of varying degrees of severity, (2) decrease or total elimination of the need for specific factor replacement therapy, (3) extremely positive cost effectiveness, and (4) reproducibility of results at different hemophilia centers.

Emergency care of the hemophiliac patient

Hemophilia is a congenital disorder characterized by prolonged bleeding, many times in association with little or no trauma, in which proper treatment may save lives or prevent permanent sequelae. We report an illustrative case and review the management of common problems with which a hemophiliac might present to the emergency department.

Hemophilia: a guide for the primary care physician

The hemophiliac knows when he is bleeding. When such a patient is aware of bleeding and consults a primary care physician, the episode usually has been of sufficient duration and is severe enough to demand prompt treatment with high-potency materials. Needless delay results in further complications and additional costly treatment. The type of deficiency can usually be ascertained from the patient or family member. If there is no history of an inhibitor, replacement therapy should be initiated promptly.

The female carrier of haemophilia--a problem for the anaesthetist

Three case histories reflect the difficulties of pre-operative assessment and management of female obligatory carriers for Factor VIII or Factor IX deficiency (haemophilia). The dangers of operation in these individuals is emphasized in view of the often confusing laboratory and clinical findings in this group of patients. A protocol is presented which, if used by the anaesthetist, will provide for logical and safe diagnostic and therapeutic approaches for these patients.

Maxillo-facial injury in severe haemophilia

A case of maxillo-facial injuries in a patient with severe haemophilia is described. Problems of treatment and management are discussed from both surgical and haematological points of view.

Hemophilia and dental treatment

Hemophilic patients must be thought of as special patients. Since routine dental procedures, however, do not usually involve bleeding, there is no contraindication to general dental treatment for hemophiliacs. Aspirin-containing compounds should never be prescribed. Caution must be used with local anesthetic block techniques. Preventive dentistry is vital to the younger hemophiliac; older hemophiliacs may require extensive treatment to restore mouths that have been neglected for years. Surgical dental procedures are now considered possible for hemophiliacs and may be performed on an outpatient basis, but they must be judiciously coordinated by the dental and medical team.

1-Deamino-8-d-arginine vasopressin: a new pharmacological approach to the management of haemophilia and von Willebrands' diseases

1-Deamino-8-d-arginine vasopressin (D.D.A.V.P.) infusion causes a marked increase in factor-VIII (antihaemophilic-factor)-related properties in patients with moderate and mild haemophilia and von Willebrand's disease (vWd). The possibility was therefore evaluated that such an autologous factor-VII response might be haemostatically effective, allowing patients to undergo surgery without plasma concentrates. 0.3 microng/kg of D.D.A.V.P. given before dental surgery and repeated in the early postoperative period was followed by a two to three fold rise in factor-VIII coagulant activity (VII C.A.) in four patients with moderate and mild haemophilia. In two, there was no abnormal bleeding after dental extraction, whereas plasma concentrates were necessary to control oozing from the sockets in the remaining two patients. A higher D.D.A.V.P. dosage (0.4-0.5 microng/kg) in patients with higherstarting VII C.A. (9% or more) was followed by a more marked response (four to six fold). VII C.A. levels up to 100% of average normal were achieved and dental extraction and major surgery (such as cholecystectomy, thoracotomy, and two tonsillectomies) were carried out successfullly in six patients with mild haemophilis and in two with vWd. The mean half-life of autologous VII C.A. was 9.4 h (range 7.5-11.6). Plasma and urine osmolality showed no consistent variation after drug administration. Thus D.D.A.V.P. appears a promision pharmacological alternative to plasma concentrates in the management of some patients with haemophilis and vWd.

Ocular enucleation in a patient with severe classic hemophilia A

A 27-year-old man with severe classic hemophilia A (antihemophilic globulin level: 1.5% of normal) had blunt trauma to his left eye that produced a corneoscleral laceration with prolapse of the intraocular contents. His left eye was enucleated under management with factor VIII replacement. This consisted of sufficient cryoprecipitate to increase the calculated circulating factor VIII level to 125%, sufficient factor VIII every 12 hours to increase peak postinfusion levels from 100 to 120%, and to maintain minimum levels of 30% immediately before infusion. Because he had developed a gingival hematoma when he was placed on epsilon amino caproic acid after only one day of factor VIII replacement following extraction of mandibular molars, we continued the high level of factor VIII replacement for five days and then began antifibrinolytic epsilon amino caproic acid therapy. His surgical and postoperative course were uneventful on this regimen.

The use of epsilon-aminocaproic acid for the management of hemophilia in dental and oral surgery patients

The use of epsilon-aminocaproic acid has proved to be an efficient and practical method for treating hemophiliacs who require dental work. In the past, patients requiring extractions were admitted to a hospital for approximately ten days and received replacement infusions every 12 hours during their stay. This resulted in a large expense because of the cost of the material and the hospitalization itself, not to mention the trauma sustained by the patient both physically and psychologically. Also, by decreasing the number of factor infusions, the risk of complications such as the transmission of hepatitis, allergic reaction, or inhibitor formation decreased. The same protocol using a single infusion of the appropriate factor replacement with supplementary epsilon-aminocaproic acid can be used for the management of patients with other coagulation disorders such as factor IX deficiency (Christman disease), factor XI deficiency, and von Willebrand's disease. Since this paper was submitted, seven more patients have been treated using this protocol. An additional seven odontectomies, 33 extractions, operative dentistry in 18 quadrants, and alveoloplasties in two full arches have been performed. This brings the total to 23 treatment sesions with 18 patients undergoing 124 procedures. One additional minor bleeding episode occurred, resulting in a total rate of four bleeding episodes in 23 treatment sessions and 124 procedures. Our incidence of complications secondary to epsilon-aminocaproic acid specifically remains zero.

Survival of transfused factor VIII in hemophilic patients treated with epsilon aminocaproic acid

The effect of EACA (epsilon aminocaproic acid) on the survival of factor VIII (F. VIII, antihemophilic factor, AHF) concentrates after infusion in hemophilic subjects was studied using two F. VIII preparations: an intermediate purity "cryoglobulin" and a high purity glycine-precipitated concentrate. In vivo recoveries of F. VIII with both concentrates were found to be close to the values predicted on the basis of concentrate potencies assayed prior to infusion, but not if the labeled potency was used in the calculation. Control studies showed similar first and second phase half-life times and half-disappearance times when the two F. VIII preparations were infused, and both preparations were found to follow a biphasic disappearance curve. The biological half-life (second phase rate of disappearance) was 12 to 13 hours. The administration of EACA in conjunction with the F. VIII concentrates did not prolong the half-life times (first or second phase) or the half-disappearance times.

The therapeutic role of epsilon-aminocaproic acid (EACA) for dental extractions in hemophiliacs

The results of a double-blind controlled trial, previously reported, showed that EACA is a useful adjunct to preoperative therapeutic concentrates of factor VIII or IX for dental extractions in hemophilia and Christmas disease. To estimate the amount of factor VIII and IX conserved in hemophiliacs receiving EACA for dental surgery compared with those not receiving EACA we have surveyed the usage of therapeutic materials in ten hemophilia centers in the U.S. and at Oxford. The amount of postoperative factor-VIII containing materials given to 20 U.S. hemophiliacs not receiving EACA averaged 11 062 units of factor-VIII activity per patient; 4,146 units for each of 22 U.S. patients receiving EACA; and 717 units for each of 56 patients at Oxford receiving EACA. Conservation of factor-IX-containing material was not as great. At Oxford 62.5% of patients receiving preoperative factor-VIII or -IX concentrates sufficient to raise the deficient factor to 50% of normal together with EACA, 24 g per day for ten days, required no postoperative therapeutic materials to control bleeding. The remainder required an average of two postoperative doses to control bleeding.

Tranexamic acid in control of haemorrhage after dental extraction in haemophilia and Christmas disease

In a double-blind trial tranexamic acid (AMCA, Cyclokapron), 1 g three times a day for five days, significantly reduced blood loss and transfusion requirements after dental extraction in patients with haemophilia and Christmas disease. No side effects were seen in either group of patients. Screening tests showed no toxic action of tranexamic acid on the liver, kidney, or heart.