1. ten years follow up of hereditary hemorrhagic patients in the dental practice Makris SP, Makris MP, Makris PE Haemostasis and Thrombosis Unit, Aristotle University of Thessaloniki, Greece

2. introduction the provision of dental care in hereditary hemorrhagic patients was always a challenge pain + bleeding kept away patients from the dentist

3. introduction I the last 10 years we are trying to make dental procedures more comfortable and less complicated to this group of patient the last 10 years we are trying to make dental procedures more comfortable and less complicated to this group of patient in order to accomplice that, we thought that prevention must be the key word in order to accomplice that, we thought that prevention must be the key word

4. introduction II regular periodic preventive checkout regular periodic preventive checkout examination – teeth cleaning – instructions examination – teeth cleaning – instructions early care of dental problems early care of dental problems fillings, endodontic treatments, teeth scalings fillings, endodontic treatments, teeth scalings to avoid teeth loss to avoid teeth loss

5. introduction III bloodless confrontation of the mainly hemorrhagic interventions bloodless confrontation of the mainly hemorrhagic interventions tooth extraction, cyst excision, apicoectomy tooth extraction, cyst excision, apicoectomy proper measures during the apoptosis of deciduous teeth proper measures during the apoptosis of deciduous teeth

6. material Ι 160 adults hemophiliacs A+B (155+5) 160 adults hemophiliacs A+B (155+5) 255 adults with vWD 255 adults with vWD 25 children mostly hemophiliacs 25 children mostly hemophiliacs

7. material ΙI

8. work protocol I with the criterion of DDAVP response we divided our group of patients in II categories with the criterion of DDAVP response we divided our group of patients in II categories responders responders coverage with ddavp during dental procedure when needed coverage with ddavp during dental procedure when needed non-responders non-responders coverage with 40 units/kg-BW of recombinate factors during dental procedure when needed coverage with 40 units/kg-BW of recombinate factors during dental procedure when needed

9. work protocol II to both groups local haemostasis measures were the same to both groups local haemostasis measures were the same √fibrin sealant √ splint √ suture √ collagen fleece √ surgicel √ pressing tampon √ tranexamic acid

10. our experience I while we started with the use of splint in all patients, we observed: the splint in young patients had to be replaced every now and then and hence discomfort and extra cost. (because of their growing) the splint in young patients had to be replaced every now and then and hence discomfort and extra cost. (because of their growing) the placement of splint in adults was not always possible (because of the morphology of teeth). the placement of splint in adults was not always possible (because of the morphology of teeth). they exists more procedures where the splint cannot offer local haemostasis (extraction of impacted tooth, apicoectomy, cyst excision) they exists more procedures where the splint cannot offer local haemostasis (extraction of impacted tooth, apicoectomy, cyst excision)

11. our experience II we replaced the splint with fibrin sealants with very good results, but also with considerably increased cost of work we replaced the splint with fibrin sealants with very good results, but also with considerably increased cost of work

12. our experience III we observed that the gauze surgicel although it was extremely effective, it easily induced superficial infections, what however they could jeopardise the fragile balance of wound at the first post- operative hours.

13. our experience IV because of that we replaced it with collagen fleece in combination with pressing tampon with very good results so far. because of that we replaced it with collagen fleece in combination with pressing tampon with very good results so far.

14. our experience V suturing in combination with surgicel or collagen fleece and pressing tampon in all cases of minor oral surgery

15. our experience VI 10% aqua solution of tranexamic acid (for 10 days) as a mouth rinse had been used all those years with no exception in any dental procedure where blood could be involved (from a teeth cleaning to a teeth extraction).

16. teeth cleaning 4300 1 teeth scaling 2500 2 fillings3531 endodontic treatment 571 simple extraction 2132 deciduous teeth extraction 851 surgical extraction 101 apicoectomy31 cyst excision 21 1=NO bleeding 2=RARE bleeding 3= FREQUENT bleeding 4=REPEATED bleeding results

17. today’s standard protocol ddavpsplint fibrin sealant suturesurgicel collagen fleece pressing tampon tranexamic acid teeth cleaning √ √ teeth scaling √ √ tooth fillings endodontic treatment √ simple extraction √ √√√ deciduous teeth extraction √ √√√ surgical extraction √ √ √√√ apicoectomy √ √ √√ cyst excision √ √√ √√ regional anesthesia√ responders

18. today’s standard protocol 40 units/kg-BW of Recombinate factors splint fibrin sealant suturesurgicel collagen fleece pressing tampon tranexamic acid teeth cleaning √ teeth scaling√ √ tooth fillings endodontic treatment√ simple extraction√ √√√ deciduous teeth extraction√ √√√ surgical extraction√ √ √√√ apicoectomy√ √ √√ cyst excision√ √√ √√ regional anesthesia√ non-responders

19. conclusion with our occupation with the oral cavity of patients with hereditary haemorrhagic diathesis, we conclude the following: dental action was rendered blood-free dental action was rendered blood-free this installed the foundation of confidence in the dentist’s face this installed the foundation of confidence in the dentist’s face it removed the hesitations and the phobias of the past it removed the hesitations and the phobias of the past ensured the acceptance of preventive dental measures. ensured the acceptance of preventive dental measures.

20. THANK YOU ALL FOR YOUR ATTENTION THANK YOU ALL FOR YOUR ATTENTION