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ARTICLE Table of Contents   
Year : 2007  |  Volume : 10  |  Issue : 2  |  Page : 59-63
Endodontics for the haemophiliac, a multidisciplinary perspective


1 Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Chennai 600 095, India
2 Department of Endodontology, Ragas Dental College, Chennai, India
3 Haemophilia Society, Chennai, India

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   Abstract 

Bleeding disorders have always been a stigma to dentists. The apparent complexities in diagnosis and handling of a bleeding problem contribute to this and force us to avoid such patients in clinical practice. Preventive dentistry obviates the need for invasive dental procedures. Quite often, help from conservative dentists may be sought after, making it mandatory to be aware of the basics of handling a "hemorrhagic patient". Haemophilia, being the commonest bleeding disorder in the world requires special mention. This article presents a systematic approach to successful endodontics in haemophiliac patients and highlights the importance of a multi­disciplinary approach.

How to cite this article:
Kumar NJ, Kumar A, Varadarajan, Sharma N. Endodontics for the haemophiliac, a multidisciplinary perspective. J Conserv Dent 2007;10:59-63

How to cite this URL:
Kumar NJ, Kumar A, Varadarajan, Sharma N. Endodontics for the haemophiliac, a multidisciplinary perspective. J Conserv Dent [serial online] 2007 [cited 2021 Jul 23];10:59-63. Available from: https://www.jcd.org.in/text.asp?2007/10/2/59/42294

   Introduction Top


Health care for hemophiliacs is one of the important challenges to concerned professionals today although the relevance is underrated. The high incidence of dental problems in hemophiliac patients is most likely caused by neglect. Fear of bleeding during dental treatment by both patients and dentists has been the primary reason for lack of good dental care for hemophiliacs [1],[2],[6],[7],[8] . There are no basic differences in the oral health problems of the hemophiliac than those of the average individual; however, optimum dental health is more of a necessity for the hemophiliac in view of the problems posed by surgical dentistry. Therefore, it is reasonable to expect that today's dental health professionals can and should provide the care so desperately needed by the hemophiliacs.

Hemophilia like many other coagulation defects presents a hazard to surgery and to local anaesthetic injections, but in general teeth erupt and exfoliate without problems, and non-invasive dental treatment is safe. Close coordination is needed between dental specialists and haematologists to plan a safe, comprehensive dental care. Education of parents and preventive dentistry should be initiated as early as possible.


   Case study Top


A 40-year-old affluent male reported with malposed and discolored left upper lateral incisor. There were no associated symptoms like pain or pus discharge. He gave a history of mild trauma to the tooth during childhood. History also revealed an eventful extraction of his left lower molar 2 years ago. Considerable bleeding from the extracted area had started a day after the procedure, necessitating transfusion of 6 units of fresh whole blood. The patient was unaware of any other details pertaining to his previous diagnosis or his current medical status.

On examination, tooth number 22 was discolored, rotated and slightly tender to percussion. Teeth numbers 21, 22 and 23 did not respond to heat, cold or electronic pulp tester. Standard periapical film demonstrated a pear shaped radiolucency involving 21, 22 and 23 [Figure 1]. The left upper lateral incisor also had an open apex with evidence of root resorption. Considering the size of the periapical radiolucency, a root canal therapy and subsequent periapical surgery was planned.

An hematologist's opinion was sought regarding the apparent bleeding disorder. On investigation he was found to be a mild hemophiliac with factor VIII concentration of 20%. Treatment alternatives were discussed with the patient and informed written consent was obtained prior to the procedure. Modified protocol for management of a haemophiliac' was followed. Oral tranexamic acid (500mg) was prescribed 6% hourly starting 1 day prior to the surgery. IV infusions of Factor VIII were given to build up the concentration to 50% 1 hour prior to surgery. Labial and palatal infiltration of 2% Xylocaine with 1:200,000 adrenaline was administered in relation to the operative area with caution. Root canal therapy was performed in all three teeth using standard techniques. Incision was placed and a trapezoidal mucoperiosteal flap was elevated, exposing the labial alveolus on the left side. The cyst was enucleated in-toto. Hemostasis was achieved and the wound closed primarily with 3-0 vicryl on atraumatic needle. Intraoperatively, no topical hemostatic agents were necessary. The patient was put on a postoperative regimen of tranexamic mouth rinse and tablets for 3 days. An extended antibiotic cover was provided with oral amoxicillin 500mg Q8H for 7 days apart from oral acetaminophen for pain control. The entire course of the therapy was uneventful and comfortable for the patient.


   Discussion Top


There is generally no contraindication for performing endodontic treatment for hemophiliac patients. Pulpotomy and pulpectomy are preferable to extraction [2],[7],[11],[15],[20] , but instrumentation and filling should never be done beyond the apical region of a vital tooth. Non-vital teeth should be treated at least 2 to 3 mm short of the radiographic apex [Figure 2].

In all but severe haemophiliac patients endodontic treatment (taking into consideration the question of LA) can be usually carried out under antifibrinolytic cover (usually tranexamic acid). Avoiding instrumentation through the periapex is of prime importance in endodontic therapy. The use of electronic endometric instruments will reduce the number of intraoperative radiographs. Rubber dam usage is extremely helpful. Notches may be placed in buccal and lingual surfaces with a fissure bur in to which clamp prongs will fit tightly [9] [Figure 3],[Figure 4]. Intracanal injection of LA solution containing adrenaline or topical application (using paper points) of adrenaline 1: 1000 may be useful to minimize bleeding.

Apicoectomy involves the surgical management of a tooth with a periapical lesion which cannot be resolved by conventional endodontic treatment. The objective of periapical surgery is to obtain tissue regeneration. This is usually achieved by the removal of periapical pathologic tissue and by exclusion of any irritants within the physical confines of the affected root.

Endodontic surgeries must be carefully planned in haemophiliac patients. Ideally all necessary surgery (and other dental treatments) should be performed in a single operation. A factor VIII level of 50 to 75% is required [4],[5],[13] . The need for post operative maintenance of such factor levels should correlate with the extensiveness of the surgery and the type of haemophilia. The importance of local measures to prevent postoperative bleeding cannot be overemphasized. Mild haemophiliacs requiring such surgeries can be managed usually without factor replacements [1],[21],[22] . Desmopressin and tranexamic acid are primary alternatives. Desmopressin can be given as a slow intravenous infusion over 20 min of 0.3-0.5µg/kg, 30 to 60 minutes prior to the surgical procedure. This results in a two- to three fold rise in Factor VIII activity with a mean half-life of 9.4 hours. Intranasal administration as a spray of 1.5mg per ml with each 0.1 ml pump spray is an alternative, but it requires a 10 fold higher dose of desmopressin to achieve a maximal two fold increase in Factor VIII activity after 90 minutes, limiting treatment to those haemophiliac patients whose basal factor levels are sufficiently high. Tranexamic acid significantly reduces blood loss and can be given topically or systemically. Systemically, it is given in dose of 1 g (30mg/kg) orally, 4 times a day starting at least 1 day preoperatively for surgical procedures. Tranexamic acid infusions can be given as 10mg/kg in 20 ml normal saline over 20 min, then I g Q8H orally for 5 days (child dose is 20mg/kg) [3] .

Local measures are important to minimize the risk of postoperative bleeding [6],[8] . Surgery should be carried out with minimal trauma to soft tissues and bone, and careful postoperative mouth toilet is essential. Suturing is desirable to stabilize gum flaps and to prevent postoperative disturbance of wounds by eating. A non-traumatic needle must be used, and the number of sutures minimized [14] . Vicryl sutures are preferred and catgut is best avoided. Non-resorbable sutures such as black silk should be removed at 4 to 7 days. One must not forget that suturing carries with it the inherent risk of tracking blood downwards towards deeper tissue planes [10],[16],[17],[18] . Reflecting lingual tissues are best avoided or at least kept to a minimum to avoid opening up dangerous planes. Acrylic protective splints can be more troublesome than helpful by containing within them, debris and promoting sepsis. Packing of surgical site is usually unnecessary if replacements have been sufficient. When deemed necessary a little oxidised cellulose (Surgicel R ) soaked in tranexamic acid may be placed. Collagen or cyanoacrylate or fibrin glues can also be helpful. Local use of fibrin glue and/or swish and swallow rinses of tranexamic acid before and after the procedure is a cost-effective solution. Postoperatively a diet of cold liquid or semisolid food should be taken for 5 to 10 days [19] . Care should be taken to watch for haematoma formation manifesting as dysphagia, swelling or hoarseness. Infection induces fibrinolysis and so antimicrobials such as amoxicillin 500 mg three times daily should be given postoperatively for a full course of 7 days to reduce risk of secondary haemorrhage.


   Conclusion Top


It is evident that, with sufficient precautions and effective protocols, based on the merits of a case, surgical endodontics can be performed without major concerns. It is also a humble opinion of the authors that mild haemophiliacs can effectively undergo surgical endodontics often without the need for factor replacements alleviating the inherent concern of transfusion associated problems.[28]

 
   References Top

1.Naveen et al: Specialty dentistry for the haemophiliac: Is there a protocol in place? Indian J Dent Res, 18:48-54,2007.  Back to cited text no. 1    
2.Aida Chohayeb: Endodontic therapy in the hemophiliac patient, N Y State Dent J, 47:326­327,1981.  Back to cited text no. 2    
3.Arne M. Bjorndal: Endodontic treatment of an upper first molar in a hemophiliac, Oral Surg Oral Med Oral Path, 14:472-473, 1961.  Back to cited text no. 3    
4.Borea G, Montebugnoli L, Capuzzi P, Magelli C: Tranexamic acid as a mouthwash in anti­coagulant-treated patients undergoing oral surgery, Oral Surg, Oral Med, Oral Path, Oral Rad and Endo, 29:3 1-32,1993.  Back to cited text no. 4    
5.Crispian Scully,Roderick A. Cawson: Medical Problems In Dentistry, (5 th Ed.), Elsevier, London, 2005.  Back to cited text no. 5    
6.Edwards C R W, Bouchier I.A.D, Haslett C: Davidson's Principles and practice of medicine, (17 th Ed.), Churchill Livingston, Edinburgh, 1995.  Back to cited text no. 6    
7.Evans BA: The role of the dentist in the comprehensive management of hemophilia, Southeast Asian J Trop Med Public Health, 10:285-294,1979.  Back to cited text no. 7    
8.Evans BA: Consideration in the dental treatment of the hemophiliac patient, J Dent Guid Counc Handicap, 15:3-7,1976.  Back to cited text no. 8    
9.Evans BE, Aledort LM: Hemophilia and dental treatment, JAm DentAssoc, 96:827-834,1978.  Back to cited text no. 9    
10.Franklin S. Wein: Endodontic Therapy, (5 th ed.), Mosby Missouri, 1996.  Back to cited text no. 10    
11.Harry Archer, Harold J. Zubrow: Fatal hemorrhage following regional anesthesia for operative dentistry in a hemophiliac, Oral Surg Oral Med Oral Path, 7:464-470,1954.  Back to cited text no. 11    
12.Jerald O. Katz, Geza T. Terezhalmy: Dental management of the patient with hemophilia, Oral Surg Oral Med Oral Path, 66:139-144,1988.  Back to cited text no. 12    
13.Lombard J: Root canal hemorrhages in endodontics: a preventive solution, Chir Dent Fr, 46:45-51,1976  Back to cited text no. 13    
14.Martin Greenberg, Michael Glick: Burket's Oral Medicine diagnosis and treatment, (10 th ed.), J B Lippincott company, Philadelphia, 2002.  Back to cited text no. 14    
15.Powell D, Bartle J: The hemophiliac: prevention is the key, Dent Hyg(Chic), 48:214-219, 1974.  Back to cited text no. 15    
16.Richter S, Stratigos GT: Management of a hemophiliac with a dental abcess and subsequent root canal therapy and apicoectomy, N Y State Dent J,39:11-14,1973.  Back to cited text no. 16    
17.Russell R G, Norman S Williams, Christopher J K Bulstrode (Eds): Bailey and Love's Short practice of surgery, (23 rd Ed.), Arnold Publishers, London, 2000.  Back to cited text no. 17    
18.Sciullo PA, Nacht ES, Tesone AR: Postsurgical complications in an undiagnosed hemophiliac: a case report, ASDC J Dent Child, 39:194-196, 1972.  Back to cited text no. 18    
19.Scully c, Watt-Smith P, Dios RD, Giangrande PL: Complications in HIV-infected and non-HIV infected haemophiliacs and other patients after oral surgery, Int J Oral Maxillofac Surg, 31:634­640,2002.  Back to cited text no. 19    
20.Shoa DN: Apicoectomy on a hemophiliac performed in the dental office with home care to prevent bleeding, J Mich Dent Assoc, 62:7-8, 1980.  Back to cited text no. 20    
21.Small JC: Endodontics for the hemophiliac, Tex Dent J,96:6-10,1978.  Back to cited text no. 21    
22.Snyder DT, Penner JA: Preventive and restorative dental care for the hemophiliac, J Mich State Dent Assoc, 52: 6-8, 1970.  Back to cited text no. 22    
23.Vinay Kumar, Nelso Fausto, Adul Abbas: Robbins & Cotran pathologic basis of disease, 7'h Ed.), WB Saunders Company Ltd, London, 2004.  Back to cited text no. 23    
24.See http://www.hemophilia.ca/en/2.I.2.php for more information.  Back to cited text no. 24    
25.See ?content_ id =87&parent=278 for more information.  Back to cited text no. 25    
26.See GFFchapl.pdf for more information.  Back to cited text no. 26    
27.27.See treatment.html for more information.  Back to cited text no. 27    
28.See down load-centre/reports/english.pdf for more information.  Back to cited text no. 28    

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Correspondence Address:
Naveen J Kumar
Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College, Chennai 600 095
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-0707.42294

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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