Delayed Bleeding in a Hemophilic Patient After Sinus Floor Elevation and Multiple Implant Placements: A Case Report Open Access

Hemophilia A is an inherited bleeding disorder in which the blood does not clot properly because of the lack or low levels of proteins called clotting factors, more specifically factor VIII. This condition affects approximately 1 in 5000 male children worldwide.¹  This condition is divided into 3 levels of severity: mild (5–40% of clotting factor XIII), moderate (1–5%), and severe (<1%). The management and indication of elective dental procedures in patients with hemophilia A must consider the severity of the disorder, the type of the dental procedure, and the patients' medical history to choose the more adequate therapy.^2,3 

Considering the risk of prolonged or excessive bleeding, oral procedures can be divided into minor (eg, restorations, orthodontic treatment, single tooth extraction) or major oral procedures (eg, removal of impacted third molar).^3,4  It is well known that dental implants are the gold standard treatment when considering the rehabilitation of missing teeth.⁵  Likewise, in some cases with insufficient bone height and width, bone graft procedures, such as sinus floor elevation, could be indicated to allow the placement of implants.

A consensus article, published in 2017, suggested that implant placement would pose no more risk for the patients than the extraction of impacted third molars,⁶  whereas bone grafting and sinus floor elevation procedures were not indicated.^6–8  Considering that most of the recommendations in the literature are made by consensus statements or nonsystematic reviews, the evidence about implant's survival, success rates, and complication risks of these approaches in hemophilic patients are still scarce. Thus, to the best of our knowledge, this is the first clinical case describing a case of multiple dental implants with sinus floor elevation with osteotomes in a patient with mild hemophilia A (16% factor VIII level) performed at dental office under local infiltrative anesthesia (buccal and intrapapillary injections).

This clinical report was written in agreement with the CARE guidelines,⁹  and informed consent was obtained from the patient acknowledging the use of data and photographs to be used in this manuscript.

A 46-year-old White male sought specialized treatment for dental implants at the Dental School of the Federal University of Pelotas (UFPel), complaining about the absence of posterior teeth (Figure 1). During anamnesis, the patient reported having hemophilia A and being registered at the Regional Blood Center of Pelotas (HEMOPEL), where the Brazilian National Health Service (Sistema Único de Saúde [SUS]) provides multidisciplinary monitoring for all patients with inherited bleeding disorders. At the medical history taking, the patient also reported having 1 implant in the upper right canine and that all his past teeth extractions were performed in a hospital under general anesthesia. He did not smoke, drink alcohol, or consume other substances (opioids or sedatives). At clinical examination, the patient presented with the absence of the first and second right molar, a periodontally compromised right second premolar in the upper arch, and the absence of both lower first molars and the right second molar (Figures 1 and 2). After this first appointment, the blood center multidisciplinary team (BCMT) was contacted, and the medical record of the patient was obtained (Table 1). The viability and possible risks of the treatment with dental implants and adjunctive therapies were discussed with the BCMT.

Because the procedures were authorized by the BCMT, the patient was informed about the treatment possibilities, and a cone-beam computerized tomography (CBCT) scan was taken to assess bone availability to place the implants. With the CBCT images, we proposed a treatment plan that included the placement of 3 implants in the lower arch in previously healed sites and the extraction of the upper left second premolar and placement of 1 implant at the fresh extraction socket and sinus floor elevation with osteotomes with concave tips and implant-matched sizes, allowing osteotomy preparation in soft bone without drilling,¹⁰  and placement of another 2 implants in the posterior healed sites, because of the low bone height observed in the CBCT. The patient agreed with the proposed treatment, and the procedures were scheduled to be made at the dental office environment under local anesthesia during 2 different appointments.

The prophylaxis protocol prescribed by the BCMT consisted of the infusion of 2500 IU of plasmatic factor VIII (Fanhdi, Grifols, Barcelona, Spain) and oral administration of 500 mg tranexamic acid (EMS S/A, Hortolândia, Brazil) every 8 hours starting 24 hours before the procedures and maintained after 4 days. The same prophylaxis protocol was used in both appointments.

The first scheduled procedure was the placement of the lower implants (Figure 3), and after 1 week, the patient was assessed for postoperative pain and wound healing (Figure 4). At the same appointment, the procedures on the upper arch were done (Figure 5). No complications or excessive bleeding was observed during the procedures, even when the sinus floor elevation was performed. All implants were of the same model and brand (Alvim CM, Neodent Straumann, Curitiba, Brazil) and, in the region of upper left first and second molars, the sinus floor elevation was made using osteotomes with concave tips and implant-matched sizes, allowing osteotomy in soft bone without drilling. First, an implant site was created, and then the augmentation of the bone was carried out with the Summers osteotomes. A bone compression was performed using osteotomes to flex upward the sinus floor cortical, and therefore, the lateral bone of the site and graft bone (biphasic calcium-phosphate synthetic biomaterial; Nanosynt, Arcsys, Joinville, Brazil) were displaced to the sinus floor,¹⁰  allowing the surgeon to accurately and consistently control the height of the grafted space with less chance of perforation of the sinus membrane, which in the case of a hemophilic patient could result in major complications. Data of placed implants are presented in Table 2. Figure 6 presents the panoramic X ray demonstrating the position of the placed implants. Considering that the BCMT suggested that even for suture removal the patient should be submitted to prophylaxis, we used nylon sutures (5-0 nylon; Ethicon, Johnson and Johnson, New Jersey, USA) in the first surgery (lower implants), knowing that a second surgical procedure would be done for the upper implants, with no need for additional prophylaxis to remove it. Likewise, we opted to use 5-0 catgut sutures (Ethicon, Johnson and Johnson) in the second surgery to avoid the need for infusions because no additional procedure/prophylaxis was planned for the patient.

The team kept phone contact with the patient after all procedures, and the patient reported to have felt 0 in a 0 to 10 scale of postoperative pain and reported using analgesic drugs for only 2 days after each procedure.

Nine days after the last procedure, the patient observed low-volume, but constant, bleeding in the mouth that persisted for 12 hours starting at the beginning of the night. The patient later reported to wake up sometimes during the night suffocating on his blood. During the morning, the patient contacted the dental team and was immediately referred to the blood center. He received an infusion of 2500 IU plasmatic factor VIII, which was also prescribed for the day after, and oral administration of 500 mg tranexamic acid every 8 hours for 5 days.

After the infusion, the patient was assessed in the dental office, where the wound site was inspected. The bleeding had stopped after the infusion, and it was possible to observe the presence of a dense clot throughout the whole wound, where some of the catgut sutures were still present (Figure 7). The wound was cleansed and rinsed with 0.9% sodium chloride solution, and the reminiscent sutures were removed. Figure 8 shows that no infection was presented, and the wound healing process was compatible with 9-day postoperative healing of an ordinary patient. When asked about the reason for the postoperative bleeding, the patient did not recall any important situation other than eating regular food instead of soft food usually recommended after oral surgeries. The wound site after 21 days of the procedure is presented in Figure 9, where it is possible to observe proper healing with no other reported complications.

To the best of our knowledge, this is one of the few case reports where dental implants were placed in patients with an inherited bleeding disorder and is the first case report of sinus floor elevation procedure in a hemophilic patient.

Dental treatments in hemophilic patients are challenging, and the absence of adequate preparation for the procedures can be life-threatening.¹¹  Considering the current literature, there is no consensus on the need for hospital admittance and/or general anesthesia¹²  or the performance of the procedures in outpatient clinics (eg, dental offices) under local anesthesia.⁶  As the costs of patient's admittance, general anesthesia, and operating room use are high and can be unaffordable for some patients,¹²  this study is also one of the few reports on the treatment of a hemophilic patient at a dental office level under local anesthesia. Although some national health systems provide the plasmatic factors for free, as it is the case of Brazil, the costs of it should not be neglected, because the plasmatic factor used in the prophylaxis and management of the complications is very expensive (1000 IU = US$500).¹³ 

Considering the type of procedure, there is also no consensus on the indication of dental implants and sinus floor elevation procedures in patients with inherited bleeding disorders. Valera et al²  suggested that dentists should consider different prosthetic alternatives, and implant treatment should be prescribed only when an obvious indication is observed, whereas other authors suggested that placement of dental implants could be placed but bone grafting and sinus floor elevation procedures were not indicated.^6–8  The meaning of obvious indication is not clear, and recent studies suggest that, with appropriate consultation, patients with inherited bleeding disorders can undergo surgical procedures safely and predictably.¹²  Hence, the indication of such procedures depends on the patients' needs and willingness and, when facing a situation like that, a discussion with a hematologist or a BCMT to assess the risks and viability of the treatment plan is advised.¹⁴ 

In the presented clinical case, we described the placement of 6 implants in a hemophilic patient where sinus floor elevation was performed in the placement of 2 implants. Delayed bleeding was observed 9 days after this procedure; however, no sign of infection was observed, and the wound healing process was compatible with the postoperative healing of an ordinary patient. The patient reported eating regular food instead of the soft food usually recommended after oral surgeries, which is a possible cause of the delayed bleeding. Although eating hard or regular food does not pose a problem to ordinary patients, bruising in the surgical wounds could result in nonstoppable bleeding that could impact the patient's general health. Thus, it is recommended that when treating patients with inherited bleeding disorders, special attention should be given when explaining to the patient the dos and don'ts to avoid the occurrence of such complications.

According to the presented clinical case and pertinent literature discussion, the following suggestions can be drawn.

• A multidisciplinary team, including a hematologist, should study, discuss, and elaborate the treatment plan.

• Patients should be advised to report any complication observed after the procedures.

• Close contact between the professional and the patient should be maintained even after the first postoperative days.

• It should be highlighted to the patients that extreme care should be taken, including the avoidance of hard foods until the final healing of the surgical wound.

BCMT:

blood center multidisciplinary team

CBCT:

cone-beam computed tomography

IU:

international units

The authors thank the Regional Blood Center of Pelotas (HEMOPEL) and its staff for their contribution and support in managing the presented case. This study was financed in part by Coordination for the Improvement of Higher Education Personnel (CAPES) Finance Code 001.