cally suspected in an individual with or with- out an elevated PTT, a specific factor activity level would best identify those afflicted.


Of great concern to the general dental practitioner is TMJ hemarthrosis and airway obstruction by a developing hematoma in the oropharynx that can develop severe symptomatology, requiring endotracheal intubation after anesthetic block. The best practice is preventative dentistry, therefore, especially in these patients, excellent dental habits should be initiated early and main- tained through adulthood, thus minimizing dental caries and periodontal disease. Caries reduction techniques such as use of fluorides, fissure sealants and reduction of refined carbohydrate consumption are pertinent to reduce need for dental surgical intervention.


The World Federation on Hemophilia has published guidelines on the treatment of hemophiliac dental patients7


via nasal spray. Its action appears multifacto- rial, including an increase in plasma levels of factor VIII and von Willebrand’s factor, stimulation of platelet adhesion and an increased expression of tissue factor.


Local anesthesia via blocks should attempt to be avoided if possible6,7


. Buccal infiltration,


intra-papillary injections and intraligamen- tary injections usually can be given without replacement therapy. Dental blocks and lin- gual infiltration require hemostatic coverage. Intraligamental, interosseous techniques or infiltration with articaine should be consid- ered in place of mandibular blocks.


CONCLUSION . It is important


to be advised that much of this is not based on clinical trials but extrapolation from other specialties and anecdotal evidence. Few dental-based studies have been completed. It is always a best practice to work closely with the patient’s hematologist in regard to recommendations prior to treatment, based on the invasive nature of the procedure and the patient’s response levels to therapy.


The goal of replacement therapy is to achieve plasma factor VIII activity levels of 25 to 30 percent for minor procedures/bleeds and at least 50 percent clotting factor activity for the treatment or prevention of severe bleeds (e.g., periodontal surgery), and 80 to 100 percent activity for any life-threatening event (e.g., major oral and maxillofacial surgery). Guidelines do differ per country or institution where replacement factors may be limited.


Replacement options include delivery of fresh-frozen plasma, cryoprecipitate and re- combinant factor; however, this should be in coordination with the hematologist. As the half-life of factor VIII is 10 to 12 hours, care- ful attention must be made for appropriate re-dosing or establishment of a continuous IV infusion1. For mild cases of hemophilia A, with appropriate testing for responsiveness, Desmopressin administration may prove to be useful. It may be conveniently delivered


This case is interesting in the late diagnosis of this patient’s coagulopathy, especially with a history of invasive surgery. Additionally, it highlights a general concern with the discon- nect between our medical colleagues when posed with a dental-related issue. Although the diagnosis is relatively uncommon, it is pressed in dental training, that with all new patients, to inquire about possible coagu- lopathies. What is greater concern is that this has not been the first case diagnosed by the authors in an emergency room setting without appropriate work up in light of con- tinued bleed without known coagulopathy. This highlights a need for dental expertise in the emergency room department, and as a profession, to provide better understanding about dental disease to our colleagues. Ad- ditionally, the understanding of the manage- ment of this population is of great impor- tance. It is unfortunate, but many of these patient’s do not present for general routine dental care until advance disease is present due to a fear of bleeding. Understanding a safe approach to this patient population is crucial to avoid major risks of bleed. Oral surgery, when performed on patients with inherited bleeding disorders, has a significant risk of postoperative bleed unless there is careful management. f


REFERENCES


1) Cervero A, Roda R, Bagan J and Soriano Y. “Dental Treatment of Patients with coagulation fctor al- terations: An Update.” (2007) Med Oral Patol Oral Cir Buccal;12:E380-7.


2) Goldman L, Schafer A. 24e “Goldman’s Cecil Medicine, Twenty Fourth Edition” (2011) e177-1-e177-10. Elsevier. Philadelphia.


3) Madan N , Rathnam A and Bajaj N. “Treatment of an Intraoral Bleeding in Hemophilic Patient with a Thermo- plastic Palatal Stent–A Novel Approach.” (2011) Int J Crit Illln Inj Sci. Jan-Jun;1(1) 79-83.


4) Naveen KJ, Anil Kumar R, Varadarajan R, Sharma N. “Specialty dentistry for the hemophiliac: Is there a proto- col in place?” (2007) Indian J Dent Res;18:48-54


5) Stevens R. “The history of hemophilia in the royal fami- lies of Europe.” (1999) Br J Haematol. 1999 Apr;105(1):25-32.


6) Hewson I, Makhmalbaf P, Street A, McCarthy P, Walsh M. “Dental Surgery with Minimal Factor Support in the Inherited Bleeding Disorder Population at the Alfred Hospital.” (2011) Haemophilia, 17, e185-e188.


7) Brewer A, Correa M. “Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders.” (2006) World Federation of Hemophilia Dental Committee. No 40. www.wf.org/2/docs/Publications/Dental_Care/TOH- 40_Dental_treatment.pdf.


DR. ROBERT RETI graduated from the University of Detroit Mercy School of Dental Medicine in 2009. He went on to complete his General Surgery and Oral and Maxillofacial Surgery training at Tufts Medical Center in Boston, Massachusetts. He is currently the 2013-2014 Surgical Fellow at the Oral and Facial Surgery institute and Implant Center in St. Louis Missouri


with Dr. Michael Noble. He can be contacted at robert. reti@tufts.edu or 314-251-6725. Allison Winkler will gradu- ate from Tufts School of Dental Medicine in May 2013. Dr. Michael Noble is an attending oral surgeon at Mercy Hospital in St. Louis.


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GO ONLINE to www.modental.org/focusce to access quiz questions that can be taken for CE credit. Follow the instructions provided, submit responses to the MDA after which you will be notified of credit. For questions contact Melissa Albertson.


Take article quizzes Earn CE Credit


MDA/ADA MEMBER DENTISTS can earn CE credit through the MDA Focus Continuing Education program.


Members read one or both of these articles, and from this, may answer the related ques- tions using the online test (or PDF form, also available online). If a dentist correctly answers three of the four questions per article, they may earn one half hour of CE credit; it is the intention to provide two articles per issue that may be taken for a total of 1 CE credit.


Learn more at www.modental.org/ focusce. Members also are encouraged to consider submitting articles for publishing. See complete submission guidelines at www.modental.org/focusarticles.


For questions, please contact Melissa Albertson.


ISSUE 2 | MAR/APR 2013 | focus 23


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