Clinical Impact of Oral Health Indexes in Dental Extraction of Hemophilic Patients

Current state of play regarding dental extractions in patients with haemophilia: Consensus or evidence-based practice? A review of the literature

Due to the global prevalence of oral disease, tooth extraction is the most common surgical procedure required in general population thus likely to be similarly common in patients with haemophilia, especially those in older age and those living in countries with restricted resources. There are little or no consensus about optimal level and duration of factor replacement (FRP) therapy required to prevent bleeding complication following surgery and low levels of evidence to inform protocols and guidelines. The goal of this article was to review the literature regarding haematological treatment protocols and to assess their effectiveness in prevention of bleeding complications during and after tooth extractions in people with haemophilia. A total number of 29 articles were identified. Only two of the studies were randomized controlled trials, and meta-analysis was not possible. Significant heterogeneity regarding haematological regimes, dental surgical procedures, disease severity and sample size of published studies which are unable to reliably inform the provision of safe dental surgery was noted. Based on the haematological regimens, all studies were classified into one of three groups: pre- and postoperative FRP or DDAVP, single preoperative FRP or DDAVP, and no FRP treatment. The overall reported bleeding rate in case of both pre- and postoperative FRP and single dose FRP preoperative is similar, 11.9% and 11.4%, respectively, indicating that minimizing the use of clotting factor concentrate is possible if proper local haemostatic measures are provided. Strictly designed prospective studies with higher number of patients are necessary to get firm conclusions about optimal FRP treatment required to prevent bleeding complications during and after oral surgery in patients with haemophilia.

Local fibrin glue and chitosan-based dressings in haemophilia surgery

Fibrin glue and chitosan-based dressings (CBDs) could be useful local haemostatic agents for severe haemorrhage in persons with haemophilia undergoing surgical procedures. The aim of the present study was to clarify the role of fibrin glue and CBDs in persons with haemophilia. A review of the most recent literature on the topic was performed. Local fibrin glue and CBDs are not always necessary to achieve haemostasis in all surgical procedures performed in persons with haemophilia. However, they could be good adjunct therapies, mainly when a surgical field or a surgical wound potentially will bleed more than expected (i.e. patients with inhibitors), and also circumcisions, dental extractions, and some orthopaedic procedures (mainly the surgical removal of pseudotumours). Although a correct surgical haemostasis can be usually achieved by the infusion of factor concentrate at the right dose, my recommendation for surgeons is always to have fibrin glue and CBDs by their side. CBDs could be better haemostatic dressings for control of haemorrhage than current standards of care. To clarify the real value of fibrin glue and CBDs in surgery of haemophilia in specific situations new well designed prospective comparative studies should be carried out.