Current state of play regarding dental extractions in patients with haemophilia: Consensus or evidence‐based practice? A review of the literature

Abstract

Due to the global prevalence of oral disease, tooth extraction is the most common surgical procedure required in general population thus likely to be similarly common in patients with haemophilia, especially those in older age and those living in countries with restricted resources. There are little or no consensus about optimal level and duration of factor replacement (FRP) therapy required to prevent bleeding complication following surgery and low levels of evidence to inform protocols and guidelines. The goal of this article was to review the literature regarding haematological treatment protocols and to assess their effectiveness in prevention of bleeding complications during and after tooth extractions in people with haemophilia. A total number of 29 articles were identified. Only two of the studies were randomized controlled trials, and meta‐analysis was not possible. Significant heterogeneity regarding haematological regimes, dental surgical procedures, disease severity and sample size of published studies which are unable to reliably inform the provision of safe dental surgery was noted. Based on the haematological regimens, all studies were classified into one of three groups: pre‐ and postoperative FRP or DDAVP, single preoperative FRP or DDAVP, and no FRP treatment. The overall reported bleeding rate in case of both pre‐ and postoperative FRP and single dose FRP preoperative is similar, 11.9% and 11.4%, respectively, indicating that minimizing the use of clotting factor concentrate is possible if proper local haemostatic measures are provided. Strictly designed prospective studies with higher number of patients are necessary to get firm conclusions about optimal FRP treatment required to prevent bleeding complications during and after oral surgery in patients with haemophilia.

Single centre, real‐world experience of perioperative rFIXFc use in adult patients with haemophilia B undergoing major and minor surgery

“…A recent review of the literature assessing rates of bleeding complications during and after oral surgery, particularly tooth extractions in PWH, reported similar bleeding rates with both pre-and postoperative factor replacement versus a single infusion of preoperative factor. 34 In our centre, PWHB routinely receive a single rFIXFc infusion prior to invasive dental surgery, tranexamic acid for 5 days postoperatively, and this approach, alongside local haemostatic measures, allows CFC consumption to be minimised. Factor replacement is only routinely used for dental extractions and not required for non-invasive dental procedures.…”

Case-Control Study to Evaluate the Oral Hygiene Habits in 31 Children with Hemophilia in Bulgaria Using the Oral Health Impact Profile-14 (OHIP-14) Questionnaire

“…Even though different national and international protocols and programs have considered dental treatment of children with hemophilia, there are still no strict recommendations or absolute statements in dental guidelines for Bulgaria. It may be because most studies showed diverse attitudes of medical and dental professionals to the treatment approach regarding this topic [ 23 ].…”

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

“…Thus, the readily available expertise in dental care has likely allowed a predating low bleeding rate and favourable outcomes before protocol implementation, as we did not find any major bleed either before or after protocol implementation and our post-procedural bleeding was comparable to or lower than reported bleeding rates in other cohorts of patients with haemophilia, von Willebrand disease and other bleeding disorders. 6,7,18 Alternatively, non-compliance to the protocol may have limited its effect and affected the outcomes in those patients. Lastly, as the baseline bleeding rate was low and given the rarity of inherited bleeding disorders, our study might lack the statistical power to detect a small difference in post-procedural bleeding rate between both groups.…”