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Bleeding disorders and blood coagulation disorders can be genetic or acquired. The most frequent bleeding disorders include congenital hemophilia A,B and Von Willebrand disease whereas coagulation disorders are acquired due to use of oral anticoagulant drugs. The patient suffering from such diseases require special consideration during any dental or other surgery. They are subjected to adequate hemostatic prophylaxis. The patients of hemophilia and Von Willebrand disease may present serious hemorrhagic risks during dental surgeries if they are not subjected to proper hemostatic prophylaxis.
The patients with coagulation disorders use anticoagulant drugs like Warfarin. To reduce the risk of hemostatic alterations during dental surgeries, an anticoagulant protocol was developed . This protocol suggests stopping the use of Warfarin in addition to administration of vitamin K or heparin before surgeries. However this may increase the chance of thromboembolism in patient. To overcome these challenges offered during surgeries and extraction in patients with bleeding disorders, a treatment protocol was proposed. This article is a review of such patient having severe hemophilia.
Hemophilia is a bleeding disorder that is mostly due to deficiency of clotting factors for example hemophilia A is due to deficiency of factor VIII and hemophilia B due to deficiency of factor IX. Von Willebrand disease is also a type of hemophilia which is most commonly inherited bleeding disorder. In 30% patients suffering from hemophilia, inhibitors or antibodies developed in the body. These inhibitors bind to the factor VIII and neutralize its function. In severe types of hemophilia A, the amount of this inhibitor is greater than 5 Bethesda unit (BU). This is referred as high inhibitor titer. Once hemophiliac patients develop inhibitors or antibodies, the dental surgical procedures become more challenging. In such situations, even factor VIII replacement therapy is ineffective in stopping the bleeding during extractions. So other therapies are approached which consist of inhibitor bypassing agents.
Currently used by passing agents include factor eight inhibitor bypassing activity (FEIBA) and recombinant activated factor VIII (rF VIIIa ). FEIBA is activated prothrombin complex concentrate (a PCC ) which bypass the factor VIII dependant step in coagulation cascade and hence maintain hemostasis by synthesis of thrombin. These bypassing agents are effective in controlling bleeding during dental extractions and other surgeries in hemophiliac patients with high inhibitor level. Similarly in patients with Von Willebrand disease, Von Willebrand factor concentrate (Haemate -P) is administrated in the surgical setting as preoperative prophylaxis against excessive bleeding. This article highlights case of 45years old patient of hemophilia A and a 25 years old Asian male suffering from severe hemophilia.
Materials and method:
A 45 years old patient suffering from severe hemophilia A having factor VIII less than 1% was reported. He was diagnosed with hemarthrosis of the right knee at the age of tree than he was treated with plasma and cryoprecipitate at the age of 5 which resulted in high level of inhibitor. Another patient 27 years old was also reported who was diagnosed as having severe hemophilia at the time of birth. He received factor VIII infusion as prophylactic regimen. The patient then developed factor inhibitor at age of 12.
The patients were then seen by the dentist and reported periodontal disease and several carious lesions. Extractions of those carious lesions were suggested as their treatment. Several coagulation tests were performed preoperatively to check the severity of hemophilia. The levels of antibodies or inhibitors were high so as a prophylactic therapy a bypassing agent was used. FEIBA was preferred and administrated to the patients to prevent bleeding. One hour before extraction, 85 IU/Kg dose of FEIBA was given. Then a local anesthetic without a vasoconstrictor was administrated. The affected teeth with destructive caries were extracted. As local haemostatic measures, the sockets were stitched with non absorbable sutures. Over these sutures, oxidized cellulose sponges were applied. After the surgical procedures FIEBA was given to the patients at a dose of 50 IU/ Kg on the first day. Over following 5 days, the dose was increased to 65 IU/ Kg after every 12 hours. After few days, FEIBA at a dose of 30 IU/ Kg thrice a week was started.
Several replacement therapies are used in hemophiliacs depended on the type of anesthesia and coagulation factors concentrates. Those hemophiliac patients that are more sensitive to bleeding and have high level of antibodies have limited treatment options. To maintain the hemostasis of hemophiliac patients, various treatment therapies have been introduced the risk of excessive bleeding. Use of heparin and vitamin A instead of anticoagulant drug like warfarin can be helpful in minimizing the hemostatic alterations but they may result in formation of thromboembolism. Therefore other regiments are preferred which include administration of bypassing agents that bypass the coagulation steps in a coagulation cascade and keep the clotting factor functional.
Bypassing agents have proved to be effective and save to perform surgical operations in hemophiliacs with high level of inhibitors. Those hemophiliac patients that have controlled inhibitor levels are managed by avoiding the use of anticoagulants like warfarin. The patients who have removed two teeth were given FEIBA as factor VIII prophylaxes before dental extractions to treat serious bleeding. The patient underwent extraction of teeth successfully, even the extraction of multi rooted teeth went effectively. The dose of bypassing agents suggested by the protocol associated with sutures using oxidized cellulose sponges proved highly effective in preventing bleeding in complex dental extractions.
Use a bypassing agent as a prophylaxis in patients of hemophilia who are at a risk of developing inhibitors is a choice of treatment to control bleeding. The patients were given a suggested dose of these agents preoperatively and postoperatively. No bleeding episodes were reported by the patient after surgery and during sugery. No thrombic episodes or other side effects following infusion on concentrate were observed.