Download Extraction Guidelines

Guidelines for Dental Extractions, Dental Restorations and
Orthodontic Procedures
•
Permanent molars and wisdom teeth
• VWD:
 ~ One hour prior to extraction in patients with type 1 VWD who
have a desmopressin (DDAVP) response to 50-60%, give
desmopressin (DDAVP), IN or IV

~ One hour prior to extraction in type 1 VWD non-responders,
type 2 or 3 VWD, give VWF/FVIII concentrate to raise VWF:RCo
and factor VIII to 50-60%
 ~ 24 hours post extraction in patients with type 2 or type 3 VWD,
repeat infusion of VWF/FVIII concentrate to raise VWF:RCo and
FVIII:C to 40-50%; no 24 hour treatment for patients with mild
VWD who respond to desmopressin
• Hemophilia A:

~ One hour prior to extraction in patients with mild hemophilia
who have a desmopressin response to 50-60%, give desmopressin
(DDAVP), IN or IV
 ~ One hour prior to extraction in patients with moderate or severe
hemophilia A and mild hemophilia A desmopressin nonresponders, give factor VIII concentrate to raise factor VIII to 80100%
 ~ 24 hours post extraction in patients with moderate or severe
hemophilia A, give factor VIII concentrate to raise factor VIII 6080 %; 24 hour treatment for patients with mild hemophilia A who
respond to desmopressin – repeat DDAVP
• Hemophilia B:

~ One hour prior to extraction, give factor IX concentrate to raise
factor IX level to 60-80%
 24 hours post extraction, give factor IX concentrate to raise factor
IX level to 40-60%; no additional treatment for mild hemophilia B
•
•
All patients: Antifibrinolytic for 3-7 days or until healed; may use
injectable Amicar as a mouthwash in older children and adults
Deciduous Teeth:
• Local measures to obtain hemostasis such as avatene, topical thrombin,
packing with Surgicel
• If bleeding around loose deciduous tooth, extract the tooth
• Antifibrinolytic for 2-4 days until healed; may use injectable Amicar or
tranexamic acid as a mouthwash in older children and adults
• If bleeding occurs in spite of local measures and antifibrinolytics, treat
with DDAVP or replacement therapy as recommended above
2
•
Nerve Block for Dental Restorations:
• VWD and mild hemophilia A patients who respond to desmopressin as
above, give desmopressin ~ one hour prior to the procedure
• VWD non-responders, type 2 and type 3 VWD, ~ one hour to the
procedure, give VWF/FVIII concentrate to raise the VWF and FVIII
levels to 40-50%
• Moderate and severe hemophilia A, ~ one hour prior to the infusion, give
factor VIII concentrate to raise the factor VIII level to 40-50%
• Hemophilia B, ~ one hour prior to the procedure, give factor IX
concentrate to raise the factor IX level to 30-40%
•
Orthodontic Procedures:
• Discuss procedure with oral surgeon/orthodontist to determine if gingival
damage/nerve blocks/extractions are anticipated and treat as recommended
above; in general, if no nerve block or extractions are planned, pretreatment is not necessary
• If gingival bleeding occurs, local measures are generally sufficient and
antifibrinolytic therapy can be given for several days until the area is
healed
•
Antifibrinolytic Therapy
• Systemic: Amicar (elixir of 1.25 m/5cc or tablets of 500 or 1000 mg), 50
mg/kg/dose (maximum 3 grams), PO, q 6 hours; when tranexamic acid
becomes available (500 mg tablets), give 25 mg/kg/dose TID or QID
• Mouthwash: Injectable Amicar (1.25 gm/5 cc) – swish 10 cc gently over
extraction site for 1-2 minutes and then expectorate; nothing to eat or
drink for 1 hour after dose
Revised 5/2008