Safety of buccal infiltration local anaesthesia for dental procedures

Dental management of people with complex or rare inherited bleeding disorders

Advances in haematological therapies for people with complex or rare inherited bleeding disorders (IBD) have resulted in them living longer, retaining their natural teeth with greater expectations of function and aesthetics. Dental management strategies need to evolve to meet these challenges. Utilising low level laser diode therapy to reduce pre-operative inflammation to reduce the intraoperative and postoperative burden on haemostasis is described in a case series of 12 patients. For these individuals who previously required further medical management to support haemostasis or experienced such prolonged haemorrhage sufficient to warrant hospital admission, haemostasis was achieved in the dental surgery such that they were able to return home with no further medical intervention or overnight stays. Global inequities in accessing novel treatments for complex or rare IBD necessitates a comprehensive understanding of the local haemostatic agents available to dentists and the most commonly used agents and techniques are described including the use of single tooth anaesthesia (STA). STA is a computerised delivery mechanism that allows routine dental procedures that would previously have required block injections needing factor replacement therapy to be undertaken safely and effectively with no additional haemostatic intervention. The challenges of inhibitors in oral surgery are explained and discussed although more research and evidence is required to establish new treatment protocols. The importance of establishing good dental health in the quality of life of people with complex or rare IBD is highlighted with respect to the dental specific impact that more novel therapies may have on people with IBD.

Neurological Complications of Local Anesthesia in Dentistry: A Review

Local anesthesia is a technique that temporarily desensitizes a specific body area, typically for a surgical procedure, dental work, or pain management. It is described as a sensation loss in a specific area of the body due to depression of excitation in the nerve endings or due to the inhibition of the conduction process within the peripheral nerves. It allows for safer and more comfortable medical procedures, reducing the need for general anesthesia and facilitating faster recovery. Local anesthesia is generally safe, but like any medical intervention, it carries potential risks and side effects. The complications related to local anesthetics can be assessed in terms of neurological, vascular, local, systemic, and neurological. In this review article, we discussed the neurological complications of local anesthesia related to the ophthalmic nerve, maxillary nerve, mandibular nerve, branches of the trigeminal nerve, and facial nerve. These include diplopia, ptosis, paralysis of the eye, blindness, paresthesia, trismus, soft tissue lesions, edema, hematoma, facial blanching, infection, allergy, overdose, neuralgia, facial palsy, etc.

Complications and treatment errors in periodontal therapy in medically compromised patients

Patients who are medically compromised may be at an increased risk of complications and treatment errors following periodontal therapy. A review of the evidence on the topic is presented, in relation to the type of complication reported, of periodontal treatment, and of patients' medical status. Further, a framework for risk assessment and appropriate treatment modifications is introduced, with the aim of facilitating the management of patients with existing comorbidities and reducing the incidence of treatment complications.

Knowledge and Awareness regarding Dental Management of Hemophilic Patients among Students of a Malaysian University: A Cross-Sectional Study

Background:

Improper management of bleeding disorders in the dental setting can lead to complications that can endanger the lives of such patients.

Objective:

This study aimed to assess the knowledge and awareness of dental management of hemophilia among undergraduate students of a Malaysian university.

Methodology:

A cross-sectional survey was conducted in the year 2018-2019 to collect the data. A 23-item questionnaire developed and validated by the authors was used to collect data on the knowledge and awareness regarding dental management of hemophilia patients. A total of 216 dental students participated in this research. Unpaired t-test and one-way ANOVA were used to compare the knowledge score between gender and academic year.

Results:

Only 21% of the participants were confident in treating a hemophilia patient. About 97% of the participants believed that the dental curriculum must be modified to emphasize the dental management of bleeding disorders. The overall mean of the knowledge score was 47.38% and awareness was 73.7% regarding the management of patients with hemophilia.

Conclusion:

The study revealed significant scope for improvement in the dental students' knowledge, which can be achieved by modifying the dental curriculum suitably to provide more emphasis on the management of bleeding disorders.

Bleeding disorders in implant dentistry: a narrative review and a treatment guide

Purpose

Considering a high prevalence of congenital and especially acquired bleeding disorders, their heterogeneity and the multitude of possible treatments strategies, a review of the scientific data on this topic is needed to implement a treatment guide for healthcare professionals.

Methods

A selective literature review was performed via PubMed for articles describing oral surgery / dental implant procedures in patients with congenital and acquired bleeding disorders. Out of the existing literature, potential treatment algorithms were extrapolated.

Results

In order to assess the susceptibility to bleeding, risk stratification can be used for both congenital and acquired coagulation disorders. This risk stratification, together with an appropriate therapeutic pathway, allows for an adequate and individualized therapy for each patient. A central point is the close interdisciplinary cooperation with specialists. In addition to the discontinuation or replacement of existing treatment modalities, local hemostyptic measures are of primary importance. If local measures are not sufficient, systemically administered substances such as desmopressin and blood products have to be used.

Conclusions

Despite the limited evidence, a treatment guide could be developed by means of this narrative review to improve safety for patients and practitioners. Prospective randomized controlled trials are needed to allow the implementation of official evidence-based guidelines.

People with congenital bleeding disorders perspectives on why dentists refused to treat them: An exploratory qualitative study using a card sorting technique

AIMS

This qualitative study aimed to assess people with congenital bleeding disorders (CBDs) perspectives on why their dentists refused to treat them.

METHODS

Using validated and reliable questions, people with CBDs were asked about their attitude toward dental visit and teeth brushing, perceived thought about dentists' knowledge and skill in treating them, perceived dental anxiety, and perceived barriers toward receiving dental services. Free text responses were added to report reasons of why people with CBDs could not brush their teeth sometimes and why the dentists refused to treat them. An open card sorting method was used to analyze participants free text reports.

RESULTS

A total of 30 participants were recruited for the purpose of this qualitative study (70% adults and 30% children). Hemophilia A affected the majority of both groups. The majority of participants (n = 20, 67%) reported that they have been refused to be treated by their dentists (71% of adults versus 56% of children, as reported by their parents, p-value = 0.398). Adult participants reported that they have been refused to be treated by dentists due to fear of dentists from uncontrolled gingival bleeding, their dentists' beliefs that no dental treatment required for them, their thoughts that their dentists will refuse to treat them and difficulty of accommodating the dental visit with other medical appointments. Parents of children reported other reasons such as parents did not ask for dental treatments, difficulty of dental treatment to dentists, young age of patient, and poor accessibility to dental services due to long waiting list. Fear of adult participants from uncontrolled gingival bleeding (n = 4, 57%) and poor compliance of children toward teeth brushing (n = 2, 29%) were the reasons behind why they could not brush their teeth sometimes.

CONCLUSIONS

Among several reported reasons, fear of dentists from uncontrolled gingival bleeding was the most reported reason of why dentists refused to treat adults with CBDs. While other reasons were reported by parents of children with CBDs such as parents did not ask for dental treatment to their children, difficulty of dental treatment to dentists, young age of patients, and poor accessibility due to long waiting list.

An Update on the Dental Management of Children with Haemophilia

Children with haemophilia present a bleeding risk and a challenge for dentists. Guidelines on the dental management of haemophilia patients are largely based on expert consensus. Many existing guidelines also provide generic guidance mainly for adult patients, which have been adapted for children. However, children have unique needs that require additional considerations. With limited evidence available, it is important that dentists have an understanding of the principles of both medical and dental management and have a close collaboration with the haematologist at all times. Therefore, this paper provides some key principles related to various aspects of dental management of children with haemophilia. Furthermore, there has been a recent update to the World Federation of Haemophilia (WFH) Guidelines for the Management of Haemophilia,¹ with references to novel medical therapies for haemophilia. Hence, this paper also aims to inform dentists with the standard and newer medical therapies for haemophilia, including a specific focus on the novel agent Emicizumab and the associated dental considerations.

Adverse effects following dental local anesthesia: a literature review

Local anesthesia is indispensable in dentistry. Worldwide, millions of local anesthetic injections are administered annually, and are generally considered safe invasive procedures. However, adverse effects are possible, of which dentists should be aware of. This scoping review aimed to provide an extensive overview of the reported literature on the adverse effects of dental local anesthesia. The types of papers, what is reported, and how they are reported were reviewed. Additionally, the incidence and duration of adverse effects and factors influencing their occurrence were also reviewed. An electronic search for relevant articles was performed in PubMed and Embase databases from inception to January 2, 2020. The titles and abstracts were independently screened by two reviewers. The analysis was narrative, and no meta-analysis was performed. This study included 78 articles. Ocular and neurological adverse effects, allergies, hematomas, needle breakage, tissue necrosis, blanching, jaw ankylosis, osteomyelitis, and isolated atrial fibrillation have been described. Multiple adverse effects of dental local anesthesia have been reported in the literature. The results were heterogeneous, and detailed descriptions of the related procedures were lacking. Vital information concerning adverse effects, such as the dosage or type of anesthetic solution, or the type of needle used, was frequently missing. Therefore, high-quality research on this topic is needed. Finally, the adverse effects that are rarely encountered in real-world general practice are overrepresented in the literature.

Practical Recommendations for Treatment of Dental Patients with Congenital Bleeding Disorders during the Covid-19 Pandemic: A Narrative Review

At the end of 2019, a new disease -COVID-19-was identified, and a few months later, the World Health Organization announced a pandemic. It is now known that SARS-CoV-2 is highly contagious and most confirmed infections are mild to moderate. The situation is particularly difficult for dentists due to the high risk of virus transmission in the dental surgery. Complications including, but not limited to, problems with the respiratory and cardiovascular systems have been reported in patients with SARS-CoV-2. Several changes in the coagulation system, such as lower platelet numbers or increased prothrombin time, as well as increased D-dimer and fibrinogen, were observed. This review is intended to systematize the knowledge on the treatment of patients with congenital bleeding disorders (CBD) during the SARS-CoV-2 pandemic. Extensive literature research was conducted into COVID-19 and the general medical and dental treatment of patients with CBD. Case studies, research results and recommendations of international societies were used in the study. The results of this research are presented in the form of recommendations for the treatment of patients with coagulopathies. It should be remembered that the impact of COVID-19 on the health condition of patients with CBD is unknown to date.

"I have been refused to be treated by three dentists": Barriers to patient care

BACKGROUND

Factor X deficiency (known as; Stuart-Prower factor deficiency or F10 deficiency) is a rare inherited bleeding disorder. It affects one per 1 million individuals worldwide. Patients with inherited bleeding disorder reported difficulty in accessing primary dental care either due to their medical diseases or their related barriers.

AIM

This article aims to identify barriers to oral health as perceived by the patient with factor X deficiency who had been refused treatment by three dentists. A further aim is to provide dentists with the knowledge required to manage patients diagnosed with factor X deficiency.

METHODS AND CASE REPORT

A 30-year-old male with the inherited, severe factor X deficiency (<1%) was asked to complete a survey which includes 22 semistructured, validated questions to assess his perceived barriers to dental services. Dental examination revealed that the patient required having nonsurgical periodontal therapy under local anesthesia. The treatment plan was discussed with the patient and his hematologist. The patient's hematologist advised performing dental treatment shortly (ie, 1-2 h) after hematological cover with a prothrombin complex concentrate (1000 U; Octoplex^® ) via intravenous infusion. The hematologist also prescribed tranexamic acid mouthwash (250 mg in 5 mL) and the patient was instructed to rinse his mouth for 3-5 min with 500 μg (10 mL) in case of bleeding following treatment.

FINDINGS

The patient reported several barriers to dental services such as high anxiety levels regarding oral bleeding, difficulty in finding a suitable dental clinic, high cost of dental treatment, and the need for hematological cover prior to dental treatment.

CONCLUSIONS

The proper communication between dentist and hematologist was a vital step to render safe and effective dental care and to reduce the patient's anxiety toward the dentist.

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.