OralSurgerywithminimalfactorsupport inHaemophiliaandvWDpatientsastudy of50consecutivepatientsatthe AlfredHospital p

DrIanHewson DirectorDentalServices AlfredHospital MelbourneAustralia

HISTORICPROTOCOLS
InferiorDentalNerveBlockInjections: Pretreatment HaemophiliaA: M d t &Severe: Moderate S Factor F t VIII10U/kg U/k p B: Haemophilia Moderate&Severe:ProthrombinHT20U/kg vonWillebrands disease: Severe:FactorVIII10U/kg
M.Stubbs,JLloydADJ2001;Vol46(1)3740

AlfredHaemophiliapatients
PreviousprotocolatAlfred:

Factorsto70% % 100% %beforeoralsurgery, g y,post p operative p dosesdependingoncomplexityofprocedure. Protocol P t lwould ldvarywith ithdegree d of foral lsurgeryand dpatients ti t oralhealth Factorsforfivedayspostopwithremovaloffourwisdom teeth

AlfredHaemophiliapatients
Previousfactoradministration:

Forfourwisdomteeth:Daily4550U/kgPreoperativeandfor fivedayspostoperative. Lessextensiveoralsurgery:Initial30U/kgwithafollowupof 20U/kgfortwodays Wisdomteeth=$ 17,000 $19,000 Simpleextractions=$ 5,000 $5,500

AlfredHaemophiliapatients
Protocolnow: Noadditionalfactorsprescribedpreoralsurgery,regardless ofdegreeofdifficultyoforalsurgeryandpatientsfactor% LAviaInferiorDentalNerveblockifrequired NopostopABcover(perioperativeifrequired) 5%t tranexamic i acid idmouthwash th h10 10ml lth threeti timesad day providedfor7days Generalanaestheticpatientsarekeptinhospitalovernight.

AlfredHaemophiliapatients
Protocolnow: Patientsonregularprophylacticprogram,maintainthis regime(factorlevelsatoperationnowbeingmeasured). UseLaryngealmaskforGApatients Marcain*.5%1:200,000adrenalineto16ml Noadditional N dditi lfactors f t prescribed ib dunless l post topbleeding bl di a problem. Localhaemostaticmeasuresonly
*BupivacineHCLAstraZeneca

AlfredHaemophiliapatients
Localhaemostaticmeasures:

Floodsocket with5%tranexamic acid

orsurgicel Place l gelfoam lf i l#

Closewith30or40Monocryl

#OxidizedcelluloseEthiconJohnson&Johnson Sterilegelatin Pharacia Poliglecaprone 25absorbablesutureEthicon

POST DENTAL EXTRACTION CHART FOR HAEMOPHILIA PATIENTS

Please fill out the following chart for any bleeding associated with the extraction(s) that you have had today, tick the relevant box. Thank You.
BLEEDING FROM SOCKET(S) DAY NIL MILD MODERATE SEVERE 1 2 3 4 5 6 7 8 INJECTION SITE

MILD = some blood in saliva MODERATE = need to apply pressure to socket to stop ooze or bleeding SEVERE = need to attend Hospital for management Injection Site: Did you have any: Swelling Significant bruising at the site of the injection for a lower jaw tooth extraction. Please tick which problem(s) and tick days in box on right Thank You

Please return to the Alfred Dental Clinic;

Post: Dental Unit, The Alfred PO Box 315 Prahran 3181 Fax: 9276 6938 Or bring in when attending for your next appointment

AlfredHaemophiliapatients
50ConsecutivePatients(Noinhibitors)

Allp patienthaveg givenwritten&oralconsent

Patientpopulation
All Patients Disorder and % Factors
14 13 12 11 10 9 Number of p patients 8
Haem A

7 6 5 4 3 2 1 0 Severe < 1% Moderate 1% - 5% F t % Factor Mild < 5%

H Haem B VWD

Type of patient
30

25

HAEMA
20

No of patient ts

Haem A

15

Haem B VWB

10

HAEMB
5

vWD

Number and Type of Extraction

100

90 82 80

70

60 Total l

SIMPLE
Surgical Simple

50

40 31 30

20

10

SURGICAL
1

IDN Block Numbers

60

50

Infiltration, 48

IDN 41 IDN, 40

INFILTRATIONS IDNBLOCKS
IDN Infiltration

30

20

10

0 T Type of f LA Injection I j ti

T t l Number Total N b of f patients ti t and d degree d of f Post-Op P t O bleeding bl di

45

40

35

30 Number of Pa atients

25

Nil Mild Moderate

20

Severe

15 5

10

0 1 2 3 4 Days 5 6 7 8

AtDayeight:Nil=41(82%),Mild=6(12%),Moderate=3(6%)

All Patients Severe & Moderate degree of post op bleeding

18

16

14

12

Numb ber

10

Nil Mild Moderate

Severe

0 1 2 3 4 Days 5 6 7 8

AtDayeight:Nil=16(80%),Mild=2(10%),Moderate=2(10%)

All patients degree of post op bleeding: Mild >5%

30

25

20

Nil

Patients

15

Mild Moderate Severe

10

0 1 2 3 4 D Days 5 6 7 8

AtDayeight:Nil=25(83%),Mild=4(13%),Moderate=1(4%)

All Haemophilia A Patients degree of post op bleeding

25

20

Number of p patients

15
Nil Mild Moderate Severe

10

0 1 2 3 4 Days 5 6 7 8

AtDayeight:Nil=20(77%),Mild=4(15%),Moderate=2(8%)

All Haemophilia B patients degree of post op bleeding

12

10

8 Number of f patients

Nil

Mild Moderate Severe

0 1 2 3 4 D Days 5 6 7 8

AtDayeight:Nil=6(82%),Mild=1(9%),Moderate=1(9%)

All VWD patients degree of post op bleeding

14

12

10

Number of f patients

Nil Mild Moderate

Severe

0 1 2 3 4 D Days 5 6 7 8

AtDayeight:Nil=12(92%),Mild=1(8%),Moderate=0(0%)

Simple v Surgical All patients degree of post op bleeding %

100

90

80

70
Nil Mild Moderate

60

50

Severe Nil Mild

40

Moderate Severe

30

20

10

0 1 2 3 4 Days 5 6 7 8

RESULTS
Extraction Type & No Simple x 1 Simple x 2 Simple x 5 Simple x 7 Simple x 9 Surgical x 1 Surgical x 2 Surgical x 3 Surg 1 Simp 1 Surg 1 Simp 2 Surg 2 Simp 1 Surg 2 Simp 2 Surg 3 Simp 1 Total cases Nil days (%) 109 (80%) 66 (75%) 15 (94%) 1 (12%) 5 (63%) 16 (67%) 16 (100%) 3 (37.5%) 16 (67%) 5 (63%) 17 (71%) 17 (53%) 8 (100%) Mild days (%) 20 (15%) 20 (23%) 1 (6%) 7 (88%) 2 (25%) 6 (25%) 0 2 (25%) 5 (21%) 0 2 (8%) 9 (28%) 0 Moderate days (%) 7 (5%) 2 (2%) 0 0 0 2 (8%) 0 3 (37.5%) 3 (12%) 1 (12%) 3 (13%) 3 (9%) 0 Severe days (%) 0 0 0 0 1 (12%) 0 0 0 0 2 (25%) 2 (8%) 3 (9%) 0 17 11 2 1 1 3 2 1 3 1 3 4 1

RESULTS
Severe<1%,12patients(24%)Moderate>1% 5%,8patients (16%)andMild6% 35%30patients(60%) Atotalof113extractionperformed: 31Surgical,82Simple. Bydayeight94%ofallpatientshadNilormildbleedingbut 6%stillhadmoderatebleeding(Requiredtoapplypressureto sockettostopooze/bleed) Fourpatientsrequiredpostoperativetreatmentathospital

RESULTS
41INDblocksadministeredwith27gaugelongneedlesNo haematomaorswellingatsiteofinjection 31Surgicalextractions(flap (flap,boneremoval+/ division):at dayeight71%hadnilbleedingand18%hadmildbleeding (89%) 82Simpleextractions:atdayeight88%hadnilbleedingand 9%hadmildbleeding(97%) Nopatienthashaddrysocket

RESULTS
FourPatientsrequiredpostoptreatment 1. HaemophiliaA0%2Surgical2SimpleDay3 1750U FactorVIIIDay5 redresssocket 2 HaemophiliaB2%2surgical1simpleDay2 4000U 2. FactorVIIIDay7 gauzepressure&tranexamic acid 3. HaemophiliaA3% 9xsimpleDayI&32000UDay2 1500UFactorVIII 4. HaemophiliaA<1% 2surgical2simpleDay5 2000U FactorVIII

RESULTS

Considerablesavinginfactorusecomparedwithprevious protocol

Carefulsurgicaltechniqueisnecessaryforgoodhaemostasis

ThankYou