ten years follow up of hereditary ten years follow up of hereditary hemorrhagic patients in the dental hemorrhagic patients in the dental

practicepractice

Makris SP, Makris MP, Makris PEMakris SP, Makris MP, Makris PE

Haemostasis and Thrombosis Unit, Aristotle University of Haemostasis and Thrombosis Unit, Aristotle University of

Thessaloniki, GreeceThessaloniki, Greece

introductionintroduction

the provision of dental care in the provision of dental care in hereditary hemorrhagic hereditary hemorrhagic patients was always a patients was always a

challengechallenge

pain + bleeding kept away pain + bleeding kept away patients from the dentistpatients from the dentist

introduction Iintroduction I the last 10 years we are trying to the last 10 years we are trying to

make dental procedures more make dental procedures more comfortable and less complicated to comfortable and less complicated to this group of patientthis group of patient

in order to accomplice that, we in order to accomplice that, we thought that thought that preventionprevention must be must be the key wordthe key word

introduction IIintroduction II

regular periodic preventive regular periodic preventive checkoutcheckout

examination – teeth cleaning – instructionsexamination – teeth cleaning – instructions

early care of dental problemsearly care of dental problems fillings, endodontic treatments, teeth scalingsfillings, endodontic treatments, teeth scalings

to avoid teeth lossto avoid teeth loss

introduction IIIintroduction III

bloodless confrontation of the mainly bloodless confrontation of the mainly hemorrhagic interventions hemorrhagic interventions tooth extraction, cyst excision, tooth extraction, cyst excision,

apicoectomyapicoectomy

proper measures during the proper measures during the apoptosis of deciduous teethapoptosis of deciduous teeth

materialmaterial Ι Ι

160 adults hemophiliacs A+B 160 adults hemophiliacs A+B (155+5)(155+5)

255 adults with vWD255 adults with vWD

25 children25 children mostly hemophiliacsmostly hemophiliacs

materialmaterial Ι ΙII

2

3

10

57

85

213

353

2500

4300

0 500 1000 1500 2000 2500 3000 3500 4000 4500

cyst excisions

apicoectomies

surgical extractions

endodontic treatments

primary teeth extractions

simple extractions

fillings

teeth scalings

teeth cleanings

work protocol Iwork protocol I

with the criterion of DDAVP response with the criterion of DDAVP response we divided our group of patients in II we divided our group of patients in II categoriescategories responders responders

coverage with ddavp during dental procedure coverage with ddavp during dental procedure when neededwhen needed

non-responders non-responders coverage with 40 units/kg-BW of recombinate factorscoverage with 40 units/kg-BW of recombinate factors during dental during dental

procedure procedure when neededwhen needed

work protocol IIwork protocol II

to both groups to both groups local haemostasis local haemostasis

measures were the measures were the samesame

√√ fibrin sealantfibrin sealant

√√ splintsplint

√√ suturesuture

√√ collagen fleececollagen fleece

√√ surgicelsurgicel

√√ pressing tamponpressing tampon

√√ tranexamic acidtranexamic acid

our experience Iour experience I

while we started with the use of splint in all while we started with the use of splint in all patients, we observed:patients, we observed:

the splint in young patients the splint in young patients had to be had to be replaced replaced every now and thenevery now and then and hence discomfort and and hence discomfort and extra cost. (because of their growing)extra cost. (because of their growing)

the placement of splint in adults was not always the placement of splint in adults was not always possible (because of the morphology of teeth).possible (because of the morphology of teeth).

they exists more procedures where the splint they exists more procedures where the splint cannot offer local cannot offer local haemostasis (extraction of haemostasis (extraction of impacted toothimpacted tooth, apico, apicoectomy ectomy , , cyst excision)cyst excision)

our experience IIour experience II

we replaced the splint with fibrin we replaced the splint with fibrin sealants with very good results, but sealants with very good results, but also with considerably increased cost also with considerably increased cost of workof work

our experience IIIour experience III

we observed that the gauze we observed that the gauze surgicelsurgicel although it was extremely effective, although it was extremely effective, it easily induced superficial it easily induced superficial infections, what however they could infections, what however they could jeopardise the fragile balance of jeopardise the fragile balance of wound at the first post-operative wound at the first post-operative hours.hours.

our experience IVour experience IV

because of that we replaced it with because of that we replaced it with collagen fleece in combination with collagen fleece in combination with pressing tampon with very good pressing tampon with very good results so far.results so far.

our experience Vour experience V

suturing in combination with surgicel suturing in combination with surgicel or or collagen fleece collagen fleece and and pressing pressing tampon in all cases of tampon in all cases of minor oral minor oral surgerysurgery

our experience VIour experience VI

10% aqua solution of tranexamic 10% aqua solution of tranexamic acid (for 10 days) as a mouth rinse acid (for 10 days) as a mouth rinse had been used all those years with had been used all those years with no exception in any dental procedure no exception in any dental procedure where blood could be involved (from where blood could be involved (from a teeth cleaning to a teeth a teeth cleaning to a teeth extraction).extraction).

teeth cleaningteeth cleaning 43043000 11

teeth scalingteeth scaling 25025000 22

fillingsfillings 353353 11

endodontic endodontic treatmenttreatment 5757 11

simple extractionsimple extraction 213213 22

deciduous teeth deciduous teeth extractionextraction 8585 11

surgical extractionsurgical extraction 1010 11

apicoectomyapicoectomy 33 11

cyst excisioncyst excision 22 11

1=NO bleeding2=RARE bleeding3= FREQUENT bleeding4=REPEATED bleeding

resultsresults

today’s standard protocol

ddavp splintfibrin

sealantsuture surgicel

collagen fleece

pressing tampon

tranexamicacid

teeth cleaning √             √

teeth scaling √             √

tooth fillings                

endodontic treatment√              

simple extraction √         √ √ √

deciduous teeth extraction

√       √ √ √

surgical extraction √     √   √ √ √

apicoectomy√     √   √ √

cyst excision √     √ √   √ √

regional anesthesia √              

responders

today’s standard protocol

40 units/kg-BW of Recombinate

factorssplint

fibrin sealant

suture surgicelcollagen fleece

pressing tampon

tranexamic acid

teeth cleaning               √

teeth scaling √             √

tooth fillings                

endodontic treatment √              

simple extraction √         √ √ √

deciduous teeth extraction √         √ √ √

surgical extraction √     √   √ √ √

apicoectomy √     √   √ √

cyst excision √     √ √   √ √

regional anesthesia √              

non-responders

conclusionconclusion

with our occupation with the oral cavity of with our occupation with the oral cavity of patients with hereditary haemorrhagic patients with hereditary haemorrhagic

diathesis, we conclude the following:diathesis, we conclude the following: dental action was rendered blood-free dental action was rendered blood-free this installed the foundation of confidence this installed the foundation of confidence

in the dentist’s facein the dentist’s face it removed the hesitations and the phobias it removed the hesitations and the phobias

of the past of the past ensured the acceptance of preventive ensured the acceptance of preventive

dental measures.dental measures.

THANK YOU ALL FOR YOUR THANK YOU ALL FOR YOUR ATTENTIONATTENTION