Dental Management of Patients With Acquired and Congenital Bleeding Disorders

Oral surgery: Considerations for the medically complex patient

As life expectancy and the number of people living with chronic illness increases, the medical complexity of patients requiring oral surgery will also increase. This and the continuously evolving range of medical treatments used to manage their conditions will increasingly challenge dentists in both primary and secondary care to avoid complications and treat this patient group safely.This paper will describe the importance of careful treatment planning including consideration of the timing and location in which oral surgery is undertaken for medically complex patients. The risk of acute medical events, bleeding, infection, and impaired healing which may complicate oral surgical procedures in this group of patients is discussed and the role in their care played by general dental practitioners explored.

Post-procedural bleeding rate and haemostatic treatment use for dental procedures before and after the implementation of a standardized protocol for people with inherited bleeding disorders

INTRODUCTION

Persons with inherited bleeding disorders are at a substantial risk of bleeding following dental procedures.

AIM

To compare the outcomes and use of haemostatic treatment pre- and post-implementation of a standardized protocol for dental procedures at a Hemophilia Treatment Centre.

METHODS

We conducted a retrospective cohort study of outpatient and inpatient dental procedures and maxillofacial surgeries sustained by people with bleeding disorders treated at a comprehensive Hemophilia Treatment Centre (2013-2020), comparing patients' outcomes before and after the introduction of the protocol in 2018. The protocol, built using a multidisciplinary approach, suggested haemostatic treatment based on the invasiveness of the dental procedure and the proposed anaesthesia. Our primary outcome was the rate of procedural bleeding leading to medical or dental reintervention within 10 days. Secondary outcomes included the use of systemic haemostatic treatment and treatment-related adverse effects.

RESULTS

Overall, 137 dental procedures in 95 patients (median age: 29 years; 78% males; 74% haemophilia, 14% von Willebrand disease, 12% other disorders) were included. Seventeen procedural bleedings were reported (12.4%). Procedural bleeding occurred in 14.8% and 8.9% of patients in the control and intervention groups (p = .304). No major bleeding occurred. Tranexamic acid was used more consistently after protocol implementation (72.8% vs. 89.3%, p = .019), while factor concentrates use decreased (65.4% vs. 44.6%, p = .016), and desmopressin use remained constant (46.4% vs. 32.1%, p = .100). No treatment-related adverse effects were reported.

CONCLUSION

The use of a standardized protocol increased the use of tranexamic acid, with a nonstatistically significant reduction in procedural bleeding rate.

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.