Peri-operative hemostatic management of tooth extraction in patients with hemophilia A, with and without inhibitors, receiving emicizumab prophylaxis.

INTRODUCTION: Emicizumab treatment may allow patients with hemophilia A without (PwHA) and with inhibitors (PwHA-I) to undergo some minor surgeries, such as tooth extraction, without peri-operative factor infusions. However, criteria for determining the necessity of factor infusions before minor surgeries are unknown. AIM: We report the peri-operative hemostatic management and outcomes of emicizumab-treated PwHA and PwHA-I cases who underwent tooth extractions using our institutional protocol. METHODS: We retrospectively evaluated PwHA and PwHA-I who underwent tooth extraction with emicizumab prophylaxis at our institution. Local bleeding risk was assessed based on the method, number, and site of tooth extraction. Hemostasis was monitored peri-operatively by rotational thromboelastometry (ROTEM). Hemostatic agents and a mouth splint were used. RESULTS: Twenty-nine extractions (17 interventions) were performed in eight PwHA and two PwHA-I. Based on ROTEM, pre-operative factor infusions were used in ten PwHA and four PwHA-I interventions. Among nine low local bleeding risk interventions, three (33.3%) each received no infusions, one dose of factor infusion pre-operatively, and pre- and post-operative factor infusions. All eight high local bleeding risk interventions involved planned factor infusions. Absorbable hemostats were used in all extractions. A mouth splint was used in 21/25 (84.0%) PwHA and in 4/4 (100%) PwHA-I extractions. No post-extraction bleeding or thrombotic events occurred. CONCLUSIONS: Use of a systemic hemostatic treatment plan according to the local bleeding risk, peri-operative coagulation status assessment using ROTEM, filling the extraction socket with hemostats, and use of a mouth splint can achieve effective and safe hemostatic management in emicizumab-treated PwHA and PwHA-I.

Risk factors for post-extraction bleeding in patients with haemophilia: a retrospective cohort study.

Many guidelines and studies describe haemostatic management protocols for patients with haemophilia, but few have evaluated the risk factors for post-extraction bleeding. This retrospective cohort study was performed to investigate these risks among this group of patients. We used medical records to identify patients with haemophilia who underwent tooth extraction(s) between April 2006 and April 2019 in the Department of Oral and Maxillofacial Surgery at Nara Medical University Hospital, Nara, Japan, and conducted logistic regression analyses to identify risk or protective factors for post-extraction bleeding in procedures involving factor replacement therapy. Post-extraction bleeding was defined as bleeding that could not be stopped by biting down on gauze, and that required medical treatment between 30min and 14 days after the extraction. A total of 151 extractions (84 interventions) in 55 patients fulfilled the inclusion criteria (130 extractions (72 interventions) in 48 patients with haemophilia A, and 21 extractions (12 interventions) in seven patients with haemophilia B). Post-extraction bleeding was observed in nine patients (16.3%), 10 interventions (11.9%), and 12 extractions (7.9%). On average, it occurred six days after the intervention, and on the fifth postoperative day after extractions. Use of mouth splints significantly reduced the risk (odds ratio: 0.13; p=0.01) in patients on factor replacement therapy. We will conduct a prospective study to investigate the optimal type of splint and optimal splint-wearing period.

Bite injuries caused by transcranial electrical stimulation motor-evoked potentials' monitoring: incidence, associated factors, and clinical course.

PURPOSE: The incidence of bite injuries associated with transcranial electrical stimulation motor-evoked potentials monitoring reportedly ranges from 0.13 to 0.19%. However, in clinical practice, bite injuries appear to occur more frequently than previously reported. Our aim was to identify the incidence of and perioperative risk factors associated with bite injuries caused by transcranial electrical stimulation motor-evoked potential monitoring. METHODS: Patients who underwent elective surgery with transcranial electrical stimulation motor-evoked potential monitoring at a single tertiary hospital in Japan between June 2017 and December 2017 were included in this study. All patients were assessed by oral surgeons preoperatively and postoperatively. The associated factors with bite injuries were explored by the univariate analysis. RESULTS: 12 of 186 patients experienced 13 bite injuries, including three lip, six oral mucosa, and four tongue injuries. No patient required suture repair. 11 of 12 patients had uneventful postoperative courses and were cured within 12 postoperative days. One patient with a tongue ulcer and a hematoma had difficulty in oral intake and persistent dysgeusia. Patient severe movement during transcranial electrical stimulation motor-evoked potential monitoring was associated with bite injuries (p = 0.03). CONCLUSIONS: The incidence of bite injuries assessed by oral surgeons was 6.5% in patients with transcranial electrical stimulation motor-evoked potential monitoring, and the patients with severe movement during the monitoring tended to incur bite injuries. In rare cases, transcranial electrical stimulation motor-evoked potential monitoring may cause difficulty in oral intake and dysgeusia.