[Downloaded free from http://www.jisponline.com on Friday, August 20, 2021, IP: 112.215.170.

200]

Case Report

Dental management of a patient with

incidentally detected hemophilia:
Report of a clinical case
Sreenivas Nagarakanti, Hasya Sappati, Sumanth Gunupati,
Bhumanapalli Venkata Ramesh Reddy, Vijay Kumar Chava

Department of Abstract:
Periodontology, Individuals with hemophilia are at risk for bleeding episodes, which range from mild mucosal/soft‑tissue bleeding
Narayana Dental to life‑threatening hemorrhages. This report describes the dental/medical management provided to a 23‑year‑old
College and patient suffering from uncontrolled bleeding after an electrosurgical procedure (operculectomy) in relation to the
Hospital, Nellore, mandibular right third molar, in which hemophilia was a true accidental finding. Various safety measures that
Andhra Pradesh, India need to be considered during the dental surgical management of hemophilic patients are discussed.
Key words:
Bleeding, cautery, hemophilia, pericoronitis

INTRODUCTION Pericoronitis is defined as inflammation in the

soft‑tissues encircling the crown of a partially erupted

Access this article online B leeding disorders are classified as deficiencies in

coagulation factors, platelet function disorders,
fibrinolytic defects, and vascular disorders.[1]
Website:
www.jisponline.com Hemophilia is an X‑linked recessive disorder caused
by insufficiency in coagulation factors, clinically
DOI:
10.4103/jisp.jisp_461_18 characterized by prolonged clotting time.[2]
Quick Response Code:
Hemophilia A, which is known as classical
hemophilia, is a hereditary hemorrhagic disorder
that results due to scarcity or congenital deficit
of factor VIII (FVIII), which manifests as unusual
and excessive bleeding either spontaneously
or secondary to trauma. About 50% of male
offsprings inherit the disorder due to female
hemophilia A gene carriers. Female hemophilia
gene carriers have lower quantities of FVIII
compared to healthy females, but they do
not manifest symptoms of hemophilia A. The
gene with the information for building factor
is found only on the sex chromosome labeled
X (dominant). This is the reason why only female
offsprings will be carriers to the male hemophilia
A patients.[3]
Address for
correspondence:
Dr. Sreenivas Nagarakanti, Hemophilia A, which occurs in one out of
Department of 5000 males which accounts for 80% of hemophilia
Periodontology, Narayana cases, is considered the most common hereditary
Dental College and disorder of hemostasis. More than 400,000 males
Hospital, Nellore ‑ 524 003, are affected by hemophilia A, many of whom
Andhra Pradesh, India. remain undiagnosed in developing countries.
E‑mail:
Severe hemophilia often manifests in the first
sreenivasnagarakanti@
gmail.com months of life, whereas mild or moderate
hemophilia will present later in childhood or
Submission: 17‑07‑2018 adolescence often incidentally or following
Accepted: 19‑09‑2018 trauma.[4]
© 2018 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow 281
tooth or sometimes fully erupted tooth. Mostly, it is
seen in teeth that erupt very slowly or partially
erupted tooth and more frequently affects the
lower 3rd molar. Patients with chronic pericoronitis
complain of a dull pain or mild discomfort lasting a
day or two, with remission lasting many months.[5]
The highest incidence of pericoronitis was found in
the 20–29 years age group. The condition was rarely
seen before 20 or after 40 years of age.[6]
The purpose of the current report is to outline
and discuss the diagnostic and therapeutic
actions provided to an adult patient suffering
from pericoronitis in relation to the mandibular
right 3rd molar, in which hemophilia was a true
incidental finding.
CASE REPORT
A 23‑year‑old male  patient, warden of a private
boys hostel, presented to the Department of
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are
licensed under the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Nagarakanti S, Sappati H,
Gunupati S, Ramesh Reddy BV, Chava VK. Dental
management of a patient with incidentally detected
hemophilia: Report of a clinical case. J Indian Soc
Periodontol 2019;23:281-3.
[Downloaded free from http://www.jisponline.com on Friday, August 20, 2021, IP: 112.215.170.200]
Nagarakanti, et al.: Incidentally detected hemophilia
Periodontology, (Narayana Dental College and Hospital)  with
a complaint of food lodgment and intermittent pain in relation
to the mandibular right wisdom tooth for few weeks. The
patient’s general health status was good with no past significant
bleeding events or exposure to surgical interventions. On
clinical examination, there was an inflamed soft‑tissue covering
the distobuccal and distoocclusal surface of the mandibular
right 3rd molar (tooth number‑48). Clinically, the tooth was
fully erupted and in the line of occlusion with 18 (maxillary
right 3rd molar) [Figure 1a]. An intraoral periapical radiograph
was taken to examine the surrounding hard tissue. Based
on clinical and radiographic findings, it was diagnosed as
chronic pericoronitis in relation to fully erupted 48. Basic blood
investigations were done, and the results are in the normal
range (bleeding time: 3 min 30 s and clotting time: 6 min 43 s).
Full‑mouth scaling was performed, and acute pericoronitis
was treated by gently flushing the area with sterile saline to
remove debris and exudate and swabbing with antiseptic
after elevating the flap gently from the tooth with a curette.
After taking written informed consent, operculectomy was
planned on the same day, as there were no systemic signs,
swelling, or lymphadenopathy, and there was available space
for the 3rd molar with proper alignment in the arch. Under local
anesthesia, the pericoronal flap was surgically excised using
electrocautery (ART – Electorsurge – Unicorn). Electrocautery
instrument was prepared and a bracelet was put on the patient’s
arm, connecting it with the main electrosurgical equipment.
The surgical site and the surrounding tissue were prepared by
swabbing with povidone‑iodine. After topical application of
anesthesia, the area was infiltrated with lidocaine HCL 2% and
epinephrine 1:100,000. The pericoronal flap was then surgically
excised using a loop and straight electrode, while hemostasis
was achieved using a ball electrode [Figure 1b]. The operated
area was irrigated with sterile saline and povidone‑iodine. The
patient was instructed to avoid chewing and brushing on that
side for first 2  days and prescribed analgesics  (Zerodol P: a
combination of aceclofenac 100 mg and paracetamol 500 mg)
for 2 days.
The patient reported back to the department the next day
morning with a complaint of bleeding from the operated area
for 4 h. Bleeding could not be controlled with the pressure
pack. Under local anesthesia (infiltration), hemostasis was
achieved using a ball electrode. Postoperative instructions were
reinforced. On the 4th day, the patient returned with a complaint
of uncontrolled bleeding for few hours. On examination,
mild continuous bleeding was observed and hemostasis was
achieved with pressure pack. Patient was advised for a complete
haemogram and all the parameters were in the normal range,
except for activated partial thromboplastin time which is 48.7 s.
a b
Figure 1: (a) Pericoronitis in relation to 48; (b) immediate postoperative; (c) postoperative healing after 10 days
282 Journal of Indian Society of Periodontology - Volume 23, Issue 3, May-June 2019
The same parameter was repeated again in a different laboratory,
which showed 54 s. Then, the patient was referred to a general
physician and administered a subcutaneous injection of Vitamin
K1 (Phytonadione Injectable Emulsion, USP) once daily for
3 days. The patient was closely monitored in an ambulatory
approach. Close control visits were programmed for 7 days, and
at the 10th day, there were no bleeding or other complications at
the operated site [Figure 1c]. Then, the patient was referred to
a higher center (Department of Hematology, Christian Medical
College, Vellore, Tamil Nadu, India) for further investigations
and management. In the coagulation workup report, they found
all the parameters were in normal range except for FVIII, which
is 7.1% (reference range: 50%–150%). With clinical and laboratory
findings, the patient was diagnosed as having mild hemophilia
A. All India Haemophilic society has various branches at district
level, where this patient got registered under hemophilia
federation (India), Kadapa Chapter.
DISCUSSION
Hemophilia
 A is characterized by a deficiency of FVIII,
whereas hemophilia B is caused by a deficiency of FIX.  Women
tend to be asymptomatic and men typically express diseases
such as hemophilia which is X‑linked. It is common in dental
practice to encounter patients
 with bleeding disorders in daily
practice; therefore, it is essential to be able to identify such
patients and safely manage their dental treatment.[7]
Based on the total amount of clotting factors in a human
blood, hemophilia is classified into mild, moderate, and
severe. The normal range of FVIII and FIX is between 50%
and 150%. Patients suffering from severe form of hemophilia
(<1% factor activity) account for 60% of total hemophilia
patients who may experience spontaneous bleeding into joints
and muscles. Moderate hemophilia (1%–5% factor activity)
patients account for about 15% of hemophilia population
and exhibit bleeding after minor injuries and occasional
episodes of spontaneous bleeding. Bleeding generally
occurs only after trauma or surgery in mild hemophilic
individuals (6%–49% factor activity).[8] Individuals with mild
hemophilia accounts for about 25% who may have very few
symptoms otherwise.
The incidence of hemophilia A is approximately 1 in every
10,000 persons. However, 30% of cases are caused by new
mutations and hence may not be associated with a family
history.[9,10] According to a study conducted by the World
Federation of Hemophilia, almost 50% of the world’s
hemophilia population lives in India, and over 70% of people
with hemophilia do not have adequate knowledge or access
to treatment.[11]
c
[Downloaded free from http://www.jisponline.com on Friday, August 20, 2021, IP: 112.215.170.200]
Nagarakanti, et al.: Incidentally detected hemophilia
CONCLUSION
General dentists should always be aware of the potential
risks of bleeding disorders and should give special attention;
hemophilia is one of the most common clotting disorders
worldwide, and in many cases, it was undiagnosed in
developing countries such as India. These disorders represent
a serious challenge during the clinical practice since routine
dental treatment can produce life‑threatening conditions. In
the case reported by the authors, using electrocautery helped
the patient to some extent in minimizing the unnecessary
postsurgical complication.
The involvement of specialist and the experienced
multidisciplinary team at hemophilia treatment center is very
important for effective planning and undertaking elective surgery.
For a successful elective surgery in hemophilia patients, careful
preoperative planning that includes dental examination, physical
assessment and prehabilitation, laboratory testing, development
of hemostasis, and pain management plans is very important.
Care should be taken by hemophilic patients to maintain good
oral hygiene to prevent periodontal and other dental diseases.
It is the responsibility of a dentist to assess the oral hygiene and
oral source of infection as it takes several weeks to resolve.[12]
Newer tools, dental bleeding risk assessment and treatment tool,
which facilitate a comprehensive evaluation of bleeding risk
with the potential to minimize unnecessary treatment and aid
interdisciplinary communication among different clinical teams
should be used for successful outcomes in dental management
of patients with inherited bleeding disorders.[13]
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not be
published and due efforts will be made to conceal their identity,
but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Journal of Indian Society of Periodontology - Volume 23, Issue 3, May-June 2019 283
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Martínez‑Rider R, Garrocho‑Rangel A, Márquez‑Preciado R,
Bolaños‑Carmona MV, Islas‑Ruiz S, Pozos‑Guillén A, et al. Dental
management of a child with incidentally detected hemophilia:
Report of a clinical case. Case Rep Dent 2017;2017:7429738.
2. Fijnvandraat K, Cnossen MH, Leebeek FW, Peters M. Diagnosis
and management of haemophilia. BMJ 2012;344:e2707.
3. Salen P, Babiker HM, Hemophilia A. StatPearls. Treasure
Island (FL): StatPearls Publishing; 2018.
4. Arruda VR, Doshi BS, Samelson‑Jones BJ. Novel approaches
to hemophilia therapy: Successes and challenges. Blood
2017;130:2251‑6.
5. Moloney J, Stassen LF. Pericoronitis: Treatment and a clinical
dilemma. J Ir Dent Assoc 2009;55:190‑2.
6. Nitzan DW, Tal O, Sela MN, Shteyer A. Pericoronitis: A reappraisal
of its clinical and microbiologic aspects. J Oral Maxillofac Surg
1985;43:510‑6.
7. Shastry SP, Kaul R, Baroudi K, Umar D. Hemophilia A: Dental
considerations and management. J Int Soc Prev Community Dent
2014;4:S147‑52.
8. National Hemophilia Foundation. Hemophilia A (Factor VIII
Deficiency); 2006. Available from: http://www.hemophilia.org/
NHFWeb/MainPgs/MainNHF.aspx?menuid=180&contentid=45
&rptname=bleeding. [Last accessed on 2018 May 25].
9. Rogaev EI, Grigorenko AP, Faskhutdinova G, Kittler EL,
Moliaka YK. Genotype analysis identifies the cause of the “royal
disease”. Science 2009;326:817.
10. Lawn RM, Vehar GA. The molecular genetics of hemophilia. Sci
Am 1986;254:48‑54.
11. World Federation of Hemophilia. Report on the Annual Global
Survey 2016. Published by World Federation of Hemophilia; 2017.
12. Escobar MA, Brewer A, Caviglia H, Forsyth A, Jimenez‑Yuste V,
Laudenbach L, et  al. Recommendations on multidisciplinary
management of elective surgery in people with haemophilia.
Haemophilia 2018;24:1-10.
13. Rasaratnam L, Chowdary P, Pollard D, Subel B, Harrington C,
Darbar UR, et al. Risk‑based management of dental procedures
in patients with inherited bleeding disorders: Development of a
dental bleeding risk assessment and treatment tool (DeBRATT).
Haemophilia 2017;23:247‑54.