Guidelines for Dental Extractions, Dental Restorations and Orthodontic Procedures



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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 non-responders, give factor VIII concentrate to raise factor VIII to 80-100%

      • ~ 24 hours post extraction in patients with moderate or severe hemophilia A, give factor VIII concentrate to raise factor VIII 60-80 %; 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




  • 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, pre-treatment 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




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