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Dental surgery in inherited bleeding disorders with minimal factor support: commentary

Excessive bleeding after dental procedures is a common symptom in patients with inherited bleeding disorders in the absence of adequate replacement and/or local haemostatic treatment [1–3]. For this reason, replacement therapy with clotting factor concentrates (associated or not with antifibrinolytic drugs) is usually recommended to cover any dental surgical procedure [4–6] and general guidelines for treatment in case of dental procedures have been drawn up by the World Federation of Haemophilia Dental Committee [7]. Indeed, no controlled trials have been conducted so far to define the optimal haemostatic therapy in case of surgical dental procedures in patients with inherited bleeding disorders and the published literature is based on retrospective series describing the routine practice at single institutions [6,8–11]. Usually, treatment with clotting factor concentrates targeting quite high levels of factor VIII (FVIII) or factor IX in plasma is recommended before and after surgery for 5–7 days and antifibrinolytics are used as adjuvant therapy in most of the patients [12]. Nonetheless, in the past it was suggested that less replacement therapy, and even no treatment at all, may be needed for dental extractions in patients with inherited bleeding disorders [11,13]. The article by Hewson et al. in this issue of Haemophilia, titled ‘Dental surgery with minimal factor support in the inherited bleeding disorder population at the Alfred Hospital’, adds a piece of evidence on this line [14]. In the study by Hewson et al. [14], 113 dental extractions were performed without previous administration of clotting factor concentrates in 50 patients: no severe bleeding complication occurred during the follow-up period of 8 days and only four patients required repeated concentrate infusions to control excessive bleeding after the procedure. However, looking at the study population, the reader may argue that patients with a wide spectrum of bleeding phenotype were included [from severe haemophilia to von Willebrand’s disease (VWD) type 1] and that some severe patients were on regular prophylaxis with a likely influence on the clinical outcome. However, the authors state that baseline levels of clotting factors ranged between <5% and 15% at the time of the procedure and this underlines how even a low residual clotting activity may prevent bleeding or oozing and how in most cases the use of antifibrinolytics and local haemostatic techniques may be sufficient per se to ensure haemostasis. Nevertheless, the occurrence of bleeding complications in this study seems comparable in patients with severe, moderate or mild bleeding disorders [14]. Similarly, an Italian retrospective study including 63 patients with VWD found no difference in the frequency of bleeding complications after dental extraction between patients who received only local therapy with tranexamic acid and fibrin glue and those who received either desmopressin or FVIII/VWF concentrates [11]. The study by Hewson and co-workers [14] particularly emphasizes the role of local haemostatic techniques as careful incision procedures, the use of tranexamic acid to fill the sockets and as mouth washes, and the use of absorbable haemostats and reabsorbable sutures. Indeed, all these aids help to minimize the risk of complications and, therefore, in case of bleeding it should be carefully considered whether local measures have been sufficiently accomplished instead of attributing the entire fault to a suboptimal replacement therapy. In addition, other factors, often considered of marginal importance, may influence the clinical outcome and these include the type of anaesthetic infiltration (usually plexic or intraligamentous infiltration should be the preferred options rather than the trunkular infiltration that may cause local haematomas), the type of antibiotic therapy (because some drugs may interfere with the coagulation cascade), analgesics (that should not be anti-inflammatory drugs that impair platelet function) and finally, the surgical expertise in the management of patients with bleeding disorders (that is non-negligiHaemophilia (2011), 17, e183–e184 DOI: 10.1111/j.1365-2516.2010.02341.x