1
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Sundaresan PD, Kruger E, Lim M, McGeachie J, Tennant M. Dentistry for patients with haemophilia: Trialling a safe and economical change in management. Haemophilia 2024; 30:404-409. [PMID: 38379200 DOI: 10.1111/hae.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/16/2024] [Accepted: 01/20/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION While the dental management of patients with haemophilia has changed considerably in the last decade, haemophiliacs in Western Australia have continued to receive pre-operative factor support for dentistry regardless of the type of dental procedure. AIM To review the efficacy and safety of established dental protocols that reduce factor use in the dental management of patients with haemophilia and to estimate cost savings. METHODS Records of 11 patients with haemophilia that were seen in the pilot programme period were reviewed. These were cross-referenced with previous dental and haematology notes that stated the amount and type of pre-operative factor used. Cost savings were estimated using the Australian National Blood Authority's Product List. RESULTS All study participants were male, and included those with haemophilia A (n = 9), and B (n = 2). Mean age was 45 years (range 22-80). A variety of dental treatments were undertaken, and no pre-operative factor was used. Patients on prophylaxis (n = 6) received dental treatment the same day as their regular factor administration. It was estimated AUD$26,314 was saved by not using pre-operative factor. One patient had bleeding post-extraction and was seen the following day to achieve haemostasis using local measures. The remaining patients had no complaints of post-operative bleeding, and did not require any further haemostatic measures. CONCLUSION This pilot programme supports data that haemophiliacs can safely receive a variety of dental treatments without the need for pre-operative factor, and the significant cost savings of doing so. Further data is required to support this protocol for invasive dental procedures.
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Affiliation(s)
- Pritam Daniel Sundaresan
- School of Allied Health, The University of Western Australia, Perth, Australia
- Maxillofacial and Dental Surgery, Fiona Stanley Hospital, Perth, Australia
- Sedation and Special Care Dentistry, Guy's and St Thomas NHS Foundation Trust, London, United Kingdom
| | - Estie Kruger
- School of Allied Health, The University of Western Australia, Perth, Australia
| | - Mathew Lim
- Melbourne Dental School, The University of Melbourne, Melbourne, Australia
- Dental Unit, The Alfred, Melbourne, Australia
- Maxillofacial Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | - John McGeachie
- School of Allied Health, The University of Western Australia, Perth, Australia
| | - Marc Tennant
- School of Allied Health, The University of Western Australia, Perth, Australia
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2
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Bajkin B, Dougall A. Current state of play regarding dental extractions in patients with haemophilia: Consensus or evidence-based practice? A review of the literature. Haemophilia 2020; 26:183-199. [PMID: 31962377 DOI: 10.1111/hae.13928] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/17/2019] [Accepted: 01/03/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Branislav Bajkin
- Faculty of Medicine Novi Sad, University of Novi Sad, Dental Clinic of Vojvodina, Novi Sad, Serbia
| | - Alison Dougall
- Special Care Dentistry Division of Child and Public Dental Health, School of Dental Science, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
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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; 11:e395-e399. [PMID: 31110621 PMCID: PMC6522108 DOI: 10.4317/jced.55506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 03/06/2019] [Indexed: 11/06/2022] Open
Abstract
Hemophilia is an inherited coagulation disorder characterized by deficiency of the coagulation factor VIII or IX. When the management of hemostasis is inadequate, these patients are at high risk of experiencing intra and postoperative bleedings after tooth extractions. Coagulation factor replacement therapy allows performing most surgical procedures safely, although the factor levels and length of treatment have not been clearly determined. In this study, we present our experience in a retrospective series of 112 ambulatory tooth extractions under local anesthesia in 23 patients with hemophilia using a coagulation factor replacement therapy in combination with tranexamic acid. The results obtained with this protocol were satisfactory and only one episode of mild postoperative bleeding occurred after seven days in a patient who did not have good treatment compliance.
Key words:Hemophilia, factor replacement therapy, tooth extractions, postoperative complications.
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Affiliation(s)
- Emilio A Ramos
- DDS. Maxillofacial Surgery Department Staff, Dr. César Milstein Hospital, Argentina
| | - Maximiliano Diamante
- DDS. Head of the Maxillofacial Department, Dr. César Milstein Hospital, Argentina
| | - Diego Caruso
- MD, MSc. Head of the Clinical Research Department, Dr. César Milstein Hospital, Argentina
| | - Juan M Muiño
- DDS. Residents instructor, Maxillofacial Surgery Department, Dr. César Milstein Hospital, Argentina
| | - Alejandra Baques
- MD. Hemophilia and Complex Coagulopathies Department Staff, Dr. César Milstein Hospital, Argentina
| | - Ludmila B Antonelli
- DDS. Chief Resident, Maxillofacial Surgery Department, Dr. César Milstein Hospital, Argentina
| | - Josefina Gutierrez
- DDS. Resident, Maxillofacial Surgery Department, Dr. César Milstein Hospital, Argentina
| | - Marcelo O Minigutti
- MD. Hemophilia and Complex Coagulopathies Department Staff, Dr. César Milstein Hospital, Argentina
| | - Gabriela Guerrero
- MD. Hemophilia and Complex Coagulopathies Department Staff, Dr. César Milstein Hospital, Argentina
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4
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van Galen KPM, Engelen ET, Mauser‐Bunschoten EP, van Es RJJ, Schutgens REG. Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions. Cochrane Database Syst Rev 2019; 4:CD011385. [PMID: 31002742 PMCID: PMC6474399 DOI: 10.1002/14651858.cd011385.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease (VWD). The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date. This is an update of a previously published Cochrane Review. OBJECTIVES Primarily, we aim to assess the efficacy of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or VWD undergoing oral or dental procedures.Secondary objectives are to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or VWD and to establish the effects of these agents on bleeding in oral or dental procedures for each of these patient populations. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase, Cinahl and the Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 01 March 2019. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in people with haemophilia or VWD undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid (EACA)) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardised forms. MAIN RESULTS While there were no eligible trials in people with VWD identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of EACA published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference (RD) of -0.64 (95% confidence interval (CI) -0.93 to - 0.36) and the EACA trial a RD of -0.50 (95% CI 0.77 to -0.22). The combined RD of both trials was -0.57 (95% CI -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping EACA (combined RD of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the EACA trial, but overall the risk of bias appeared to be low for both trials. AUTHORS' CONCLUSIONS Despite the discovery of a beneficial effect of systemically administered tranexamic acid and EACA in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with VWD.
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Affiliation(s)
- Karin PM van Galen
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CT
| | - Eveline T Engelen
- University Medical Centre UtrechtPoortstraat 95UtrechtNetherlands3572HG
| | - Evelien P Mauser‐Bunschoten
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CT
| | - Robert JJ van Es
- University Medical Center UtrechtOral and Maxillofacial SurgeryHeidelberglaan 100UtrechtNetherlands3584CX
| | - Roger EG Schutgens
- University Medical Centre UtrechtVan Creveldkliniek / Department of HaematologyHeidelberglaan 100UtrechtNetherlands3584CT
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5
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Tomaszewski M, Bienz M, Kherad O, Restellini S, Laflèche T, Barkun A, Warner M, Bessissow T. Low endoscopy bleeding risk in patients with congenital bleeding disorders. Haemophilia 2019; 25:289-295. [PMID: 30748066 DOI: 10.1111/hae.13691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/06/2018] [Accepted: 01/17/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Haemophilia A and haemophilia B, von Willebrand disease (VWD), factor VII deficiency and factor XI deficiency are congenital bleeding disorders predisposing to bleeding during invasive procedures. The ageing population of people with congenital bleeding disorders will likely increasingly require gastrointestinal endoscopy. The bleeding risk postgastrointestinal endoscopy and optimal prophylactic treatment regimens are not well described. METHODS We performed a retrospective chart review at the McGill University Health Centre. Adult patients with haemophilia A or B, VWD, FVII deficiency and FXI deficiency who underwent gastrointestinal endoscopic procedures were included. Bleeding prophylaxis included combinations of plasma-derived factor (VWD) or recombinant factor (haemophilia A and haemophilia B), desmopressin and/or tranexamic acid. Our primary outcome was the 72-hour postendoscopy bleeding rate. RESULTS One hundred and four endoscopies were performed in 48 patients. Haemophilia A (45.3% of endoscopies) was the most common bleeding disorder, followed by VWD (38.5%), FXI deficiency (8.7%), haemophilia B (4.8%) and FVII deficiency (2.9%). All patients were reviewed by the Haemophilia Treatment Center with peri-procedure treatment protocols put in place as required. The overall 72-hour bleeding rate was 0.96%, confidence interval (CI) 95% (0.17%-5.25%). The colonoscopic postpolypectomy bleeding rate was 1/21 (4.8%, CI 95% (0.9%-22.7%)) in comparison with the general population rate of 0.3%-10% for high-risk endoscopy (including colonoscopic polypectomy). CONCLUSION To the best of our knowledge, this is the largest study describing patients with inherited bleeding disorders undergoing gastrointestinal endoscopy. The bleeding risk is not significantly higher to the general population when haemostatically managed by a team experienced in bleeding disorders.
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Affiliation(s)
- Marcel Tomaszewski
- Internal Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Marc Bienz
- Internal Medicine, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Omar Kherad
- Internal Medicine, Hôpital de la Tour and University of Geneva, Meyrin, Switzerland
| | - Sophie Restellini
- Service de gastroentérologie et d'hépatologie, Département des spécialités de Médecine, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Tania Laflèche
- Division of Hematology, McGill University Health Centre, Quebec, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Margaret Warner
- Division of Hematology, McGill University Health Centre, Quebec, Canada
| | - Talat Bessissow
- Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
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6
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Rasaratnam L, Chowdary P, Pollard D, Subel B, Harrington C, Darbar UR. Risk-based management of dental procedures in patients with inherited bleeding disorders: Development of a Dental Bleeding Risk Assessment and Treatment Tool (DeBRATT). Haemophilia 2017; 23:247-254. [DOI: 10.1111/hae.13122] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2016] [Indexed: 01/22/2023]
Affiliation(s)
- L. Rasaratnam
- Department of Restorative Dentistry; Eastman Dental Hospital; London UK
| | - P. Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - D. Pollard
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - B. Subel
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - C. Harrington
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
| | - U. R. Darbar
- Department of Restorative Dentistry; Eastman Dental Hospital; London UK
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7
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van Galen KPM, Engelen ET, Mauser-Bunschoten EP, van Es RJJ, Schutgens REG. Antifibrinolytic therapy for preventing oral bleeding in patients with haemophilia or Von Willebrand disease undergoing minor oral surgery or dental extractions. Cochrane Database Syst Rev 2015:CD011385. [PMID: 26704192 DOI: 10.1002/14651858.cd011385.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Minor oral surgery or dental extractions (oral or dental procedures) are widely performed and can be complicated by hazardous oral bleeding, especially in people with an inherited bleeding disorder such as haemophilia or Von Willebrand disease. The amount and severity of singular bleedings depend on disease-related factors, such as the severity of the haemophilia, both local and systemic patient factors (such as periodontal inflammation, vasculopathy or platelet dysfunction) and intervention-related factors (such as the type and number of teeth extracted or the dimension of the wound surface). Similar to local haemostatic measures and suturing, antifibrinolytic therapy is a cheap, safe and potentially effective treatment to prevent bleeding complications in individuals with bleeding disorders undergoing oral or dental procedures. However, a systematic review of trials reporting outcomes after oral surgery or a dental procedure in people with an inherited bleeding disorder, with or without, the use of antifibrinolytic agents has not been performed to date. OBJECTIVES The primary objective was to assess the efficacy of local or systemic use of antifibrinolytic agents to prevent bleeding complications in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures. Secondary objectives were to assess if antifibrinolytic agents can replace or reduce the need for clotting factor concentrate therapy in people with haemophilia or Von Willebrand disease and to further establish the effects of these agents on bleeding in oral or dental procedures for each of these populations. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches of the Cochrane Central Register of Controlled Trials (CENTRAL), of MEDLINE and from handsearching of journals and conference abstract books. We additionally searched the reference lists of relevant articles and reviews. We searched PubMed, Embase and The Cochrane Library. Additional searches were performed in ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP).Date of last search of the Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register: 14 December 2015. SELECTION CRITERIA Randomised and quasi-randomised controlled trials in people with haemophilia or Von Willebrand disease undergoing oral or dental procedures using antifibrinolytic agents (tranexamic acid or epsilon aminocaproic acid) to prevent perioperative bleeding compared to no intervention or usual care with or without placebo. DATA COLLECTION AND ANALYSIS Two authors independently screened the titles and abstracts of all identified articles. Full texts were obtained for potentially relevant abstracts and two authors independently assessed these for inclusion based on the selection criteria. A third author verified trial eligibility. Two authors independently performed data extraction and risk of bias assessments using standardized forms. MAIN RESULTS While there were no eligible trials in people with Von Willebrand disease identified, two randomised, double-blind, placebo-controlled trials (total of 59 participants) in people with haemophilia undergoing dental extraction were included. One trial of tranexamic acid published in 1972 included 28 participants with mild, moderate or severe haemophilia A and B and one of epsilon aminocaproic acid published in 1971 included 31 people with haemophilia with factor VIII or factor IX levels less than 15%. Overall, the two included trials showed a beneficial effect of tranexamic acid and EACA, administered systemically, in reducing the number of bleedings, the amount of blood loss and the need for therapeutic clotting factor concentrates. Regarding postoperative bleeding, the tranexamic acid trial showed a risk difference of -0.64 (95% confidence interval -0.93 to - 0.36) and the EACA trial a risk difference of -0.50 (95% confidence interval 0.77 to -0.22). The combined risk difference of both trials was -0.57 (95% confidence interval -0.76 to -0.37), with the quality of the evidence (GRADE) for this outcome is rated as moderate. Side effects occurred once and required stopping epsilon aminocaproic acid (combined risk difference of -0.03 (95% CI -0.08 to 0.13). There was heterogeneity between the two trials regarding the proportion of people with severe haemophilia included, the concomitant standard therapy and fibrinolytic agent treatment regimens used. We cannot exclude that a selection bias has occurred in the epsilon aminocaproic acid trial, but overall the risk of bias appeared to be low for both trials. AUTHORS' CONCLUSIONS Despite the discovery of a beneficial effect of systemically administered tranexamic acid and epsilon aminocaproic acid in preventing postoperative bleeding in people with haemophilia undergoing dental extraction, the limited number of randomised controlled trials identified, in combination with the small sample sizes and heterogeneity regarding standard therapy and treatment regimens between the two trials, do not allow us to conclude definite efficacy of antifibrinolytic therapy in oral or dental procedures in people with haemophilia. No trials were identified in people with Von Willebrand disease.
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Affiliation(s)
- Karin P M van Galen
- Van Creveldkliniek / Department of Haematology, University Medical Centre Utrecht, Heidelberglaan 100, Utrecht, Netherlands, 3584CT
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Coppola A, Windyga J, Tufano A, Yeung C, Di Minno MND. Treatment for preventing bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgery. Cochrane Database Syst Rev 2015:CD009961. [PMID: 25922858 DOI: 10.1002/14651858.cd009961.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In people with haemophilia or other congenital bleeding disorders undergoing surgical interventions, haemostatic treatment is needed in order to correct the underlying coagulation abnormalities and minimise the bleeding risk. This treatment varies according to the specific haemostatic defect, its severity and the type of surgical procedure. The aim of treatment is to ensure adequate haemostatic coverage for as long as the bleeding risk persists and until wound healing is complete. OBJECTIVES To assess the effectiveness and safety of different haemostatic regimens (type, dose and duration, modality of administration and target haemostatic levels) administered in people with haemophilia or other congenital bleeding disorders for preventing bleeding complications during and after surgical procedures. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the reference lists of relevant articles and reviews.Date of the last search: 20 November 2014. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing any hemostatic treatment regimen to no treatment or to another active regimen in children and adults with haemophilia or other congenital bleeding disorders undergoing any surgical intervention. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials (eligibility and risks of bias) and extracted data. Meta-analyses were performed on available and relevant data. MAIN RESULTS Of the 16 identified trials, four (112 participants) were eligible for inclusion.Two trials evaluated 59 people with haemophilia A and B undergoing 63 dental extractions. Trials compared the use of a different type (tranexamic acid or epsilon-aminocaproic acid) and regimen of antifibrinolytic agents as haemostatic support to the initial replacement treatment. Neither trial specifically addressed mortality (one of this review's primary outcomes); however, in the frame of safety assessments, no fatal adverse events were reported. The second primary outcome of blood loss was assessed after surgery and these trials showed the reduction of blood loss and requirement of post-operative replacement treatment in people receiving antifibrinolytic agents compared with placebo. The remaining primary outcome of need for re-intervention was not reported by either trial.Two trials reported on 53 people with haemophilia A and B with inhibitors treated with different regimens of recombinant activated factor VII (rFVIIa) for haemostatic coverage of 33 major and 20 minor surgical interventions. Neither of the included trials specifically addressed any of the review's primary outcomes (mortality, blood loss and need for re-intervention). In one trial a high-dose rFVIIa regimen (90 μg/kg) was compared with a low-dose regimen (35 μg/kg); the higher dose showed increased haemostatic efficacy, in particular in major surgery, with shorter duration of treatment, similar total dose of rFVIIa administered and similar safety levels. In the second trial, bolus infusion and continuous infusion of rFVIIa were compared, showing similar haemostatic efficacy, duration of treatment and safety. AUTHORS' CONCLUSIONS There is insufficient evidence from randomised controlled trials to assess the most effective and safe haemostatic treatment to prevent bleeding in people with haemophilia or other congenital bleeding disorders undergoing surgical procedures. Ideally large, adequately powered, and well-designed randomised controlled trials would be needed, in particular to address the cost-effectiveness of such demanding treatments in the light of the increasing present economic constraints, and to explore the new challenge of ageing patients with haemophilia or other congenital bleeding disorders. However, performing such trials is always a complex task in this setting and presently does not appear to be a clinical and research priority. Indeed, major and minor surgeries are effectively and safely performed in these individuals in clinical practice, with the numerous national and international recommendations and guidelines providing regimens for treatment in this setting mainly based on data from observational, uncontrolled studies.
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Anderson JAM, Brewer A, Creagh D, Hook S, Mainwaring J, McKernan A, Yee TT, Yeung CA. Guidance on the dental management of patients with haemophilia and congenital bleeding disorders. Br Dent J 2013; 215:497-504. [DOI: 10.1038/sj.bdj.2013.1097] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2013] [Indexed: 11/09/2022]
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Gringeri A, Muça-Perja M, Mangiafico L, von Mackensen S. Pharmacotherapy of haemophilia A. Expert Opin Biol Ther 2011; 11:1039-53. [PMID: 21682657 DOI: 10.1517/14712598.2011.570006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Haemophilia A is due to factor VIII (FVIII) deficiency. The main treatment is replacement therapy with FVIII concentrates. However, these concentrates carried a high risk of blood-borne viral infections and still have a high risk of inducing anti-FVIII inhibitors. AREAS COVERED An overview of products available and therapeutic options for haemophilia A management in order to help in decision making. A literature search using Medline with the keywords: 'haemophilia', 'factor VIII', 'therapy', 'inhibitor', 'concentrate', 'bleeding', 'prophylaxis', 'on demand', 'plasma-derived', 'recombinant', 'coagulation factors', 'immunotolerance' was performed. The years 1960 - 2010 are included. EXPERT OPINION Progress in management of patients with haemophilia A has allowed increased life expectancy and quality of life. There is evidence that prophylaxis prevents or, at least, slows down arthropathy development when started early in childhood. FVIII concentrates have achieved high levels of blood-borne pathogen safety. However, treatment is frequently complicated by development of FVIII-neutralizing inhibitors, which prevent control of bleeding and predispose to a high morbidity and mortality risk. Bypassing agents are effective in bleeding treatment in a high percentage of cases. Prophylaxis with bypassing agents and their use in combination are offering opportunities in management of inhibitor patients. More evidence is necessary to understand how to prevent and manage this complication.
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11
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MANCUSO ME, SANTAGOSTINO E. Dental surgery in inherited bleeding disorders with minimal factor support: commentary. Haemophilia 2010; 17:e183-4. [DOI: 10.1111/j.1365-2516.2010.02341.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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12
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HERMANS C, ALTISENT C, BATOROVA A, CHAMBOST H, DE MOERLOOSE P, KARAFOULIDOU A, KLAMROTH R, RICHARDS M, WHITE B, DOLAN G. Replacement therapy for invasive procedures in patients with haemophilia: literature review, European survey and recommendations. Haemophilia 2009; 15:639-58. [DOI: 10.1111/j.1365-2516.2008.01950.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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13
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Kaddour Brahim A, Stieltjes N, Roussel-Robert V, Yung F, Ginisty D. Extractions dentaires chez l’enfant présentant une maladie hémorragique constitutionnelle : protocole thérapeutique et résultats. ACTA ACUST UNITED AC 2006; 107:331-7. [PMID: 17128182 DOI: 10.1016/s0035-1768(06)77059-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION We report the results of our 10-year experience with a protocol of local hemostasis specifically elaborated for children with congenital bleeding disorders. MATERIAL AND METHOD Sixty-four dental extractions procedures were performed in 37 children. Local hemostasis was achieved with the CO2 laser at the site of extraction previously filled with regenerated oxidized cellulose. The site of extraction was then protected with thermomolded splint. The replacement therapy (hemostasis factor concentrates, platelet concentrates) was coordinated by the hematologist and restricted as much as possible. RESULTS 160 decidual teeth and 23 permanent teeth were extracted. None of the children with minor bleeding deficiency received replacement therapy. Ten post-operative bleedings were recorded but none was considered severe. DISCUSSION This protocol characterized by the use of CO2 laser for the hemostasis gave satisfaction in children. The rare and minor post-operative bleedings could be explained by multiple extractions, local infection and/or children's anxiety. This strategy requires a close cooperation between the stomatologist and the hematologist in order to determine the optimal therapeutic management.
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Affiliation(s)
- A Kaddour Brahim
- Service de Chirurgie Maxillo-faciale et Stomatologie Pédiatriques, Hôpital Saint-Vincent-de-Paul, 74-82, avenue Denfert-Rochereau, 75014 Paris
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14
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Franchini M, Rossetti G, Tagliaferri A, Pattacini C, Pozzoli D, Lorenz C, Del Dot L, Ugolotti G, Dell'aringa C, Gandini G. Dental procedures in adult patients with hereditary bleeding disorders: 10 years experience in three Italian Hemophilia Centers. Haemophilia 2005; 11:504-9. [PMID: 16128895 DOI: 10.1111/j.1365-2516.2005.01132.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Excessive bleeding after dental procedures are one of the most frequent complications occurring in patients with hereditary bleeding disorders. In this retrospective study we collected data from 10 years of experience in the oral care of patients with congenital haemorrhagic disorders in three Italian Hemophilia Centers. Between 1993 and 2003, 247 patients with inherited bleeding disorders underwent 534 dental procedures including 133 periodontal treatments, 41 conservative dentistry procedures, 72 endodontic treatments and 288 oral surgery procedures. We recorded 10 bleeding complications (1.9%), most of which occurred in patients with severe/moderate haemophilia A undergoing multiple dental extractions. Thus, our protocol of management of patients with hereditary bleeding tendency undergoing oral treatment or surgery has been shown to be effective in preventing haemorrhagic complications.
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Affiliation(s)
- M Franchini
- Servizio di Immunoematologia e Trasfusione--Centro Emofilia, Azienda Ospedaliera di Verona, Verona, Italy.
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15
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Zanon E, Martinelli F, Bacci C, Zerbinati P, Girolami A. Proposal of a standard approach to dental extraction in haemophilia patients. A case-control study with good results. Haemophilia 2000; 6:533-6. [PMID: 11012698 DOI: 10.1046/j.1365-2516.2000.00423.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We found no case-control studies on dental extraction in haemophilia patients in the literature even though the use of antifibrinolytic agents following a single infusion of factor VIII or IX has been accompanied by a lower number of bleeding complications in dental extractions. In this study we verified the incidence of bleeding complications after dental extraction in a group of 77 haemophilia patients. One hundred and eighty-four male patients requiring dental extraction represented the control group. All haemophilia patients received 20 mg kg-1 of tranexamic acid and a single infusion of factor VIII or IX to achieve a peak level about 30% of factor VIII or IX in vivo prior to dental extraction. Forty-five of 98 (45.9%) dental extractions in haemophilia patients and 110 of 239 (46%) dental extractions in the control group were surgical ones. We registered two bleeding complications in the group of haemophilia patients (one late bleeding and one haematoma in the site of the anaesthetic injection) and one (a late bleeding) in the control group. The difference of bleeding complications in the two groups of patients were not statistically significant (P=0.2; OR 0.2; CI 0.01-2.22). The protocol proposed in this study, characterized by the feasibility and the number of haemorrhagic complications not different from normal population, make dental extractions in haemophilia patients possible on an out-patient basis with a cost reduction for the community and minor discomfort for the patients.
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Affiliation(s)
- E Zanon
- Department of Medical and Surgical Sciences, University of Padua Medical School, Italy
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16
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Ramström G, Blombäck M, Egberg N, Johnsson H, Ljungberg B, Schulman S. Oral surgery in patients with hereditary bleeding disorders. A survey of treatment in the Stockholm area (1974-1985). Int J Oral Maxillofac Surg 1989; 18:320-2. [PMID: 2533604 DOI: 10.1016/s0901-5027(89)80026-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The results on the oral surgical management of patients with coagulation disorders at the Karolinska Hospital, Stockholm, during the period 1974-1985 have been compiled and compared with those obtained during the period 1965-1973. The present study included 380 tooth extractions performed in 250 treatment sessions in 107 patients. The incidence of postoperative bleeding and duration of hospitalization were reduced during the period of investigation.
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Affiliation(s)
- G Ramström
- Department of Oral and Jaw Diseases, Karolinska Hospital, Stockholm, Sweden
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17
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Orlian AI, Karmel R. Postoperative bleeding in an undiagnosed hemophilia A patient: report of case. J Am Dent Assoc 1989; 118:583-4. [PMID: 2497167 DOI: 10.14219/jada.archive.1989.0083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
An impacted mandibular third molar was extracted. Although the 20-year-old patient had no history of a bleeding disorder, he experienced severe bleeding which continued intermittently for 1 week. After hospital admission and testing, a diagnosis of hemophilia A was made. Additional review of the literature on this disorder is included.
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Affiliation(s)
- A I Orlian
- Department of Dentistry, Flushing Hospital and Medical Center, NY 11355
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18
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Stajcić Z, Baklaja R, Elezović I, Rolović Z. Primary wound closure in haemophiliacs undergoing dental extractions. Int J Oral Maxillofac Surg 1989; 18:14-6. [PMID: 2497202 DOI: 10.1016/s0901-5027(89)80007-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
215 teeth were extracted in 62 haemophiliacs following a single infusion of factor VIII supplemented with antifibrinolytics. Tooth sockets were packed with Sorbacel gauze soaked with an antifibrinolytic. 1 group was sutured and the other left open. Primary closure of the extraction wound did not show direct effect on haemostasis. However, the size of the clot showed a statistically significant difference between the primary closure and open wound groups. The authors conclude that primary closure of the extraction wound protects the blood clot, makes the postoperative period more comfortable for patients and may subsequently decrease the risk of postoperative bleeding.
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Affiliation(s)
- Z Stajcić
- Oral Surgery Clinic, Faculty of Stomatology, University of Belgrade, Yugoslavia
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Katz JO, Terezhalmy GT. Dental management of the patient with hemophilia. ORAL SURGERY, ORAL MEDICINE, AND ORAL PATHOLOGY 1988; 66:139-44. [PMID: 2970054 DOI: 10.1016/0030-4220(88)90081-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Classic hemophilia is the most common inherited bleeding diathesis. Recent advances in the management of hemophilia have enabled many hemophiliac patients to receive outpatient dental care on a routine basis. An overview of hemophilia, including etiology, clinical features, and recent advances in treatment, is presented. Guidelines for dental management of the hemophiliac patient are discussed.
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Affiliation(s)
- J O Katz
- Department of Oral Diagnosis, University of Missouri-Kansas City, School of Dentistry
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