Dental Management of Patients on Emicizumab - A systematic review and modified Delphi study
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Ahmad Fisal, Aisyah Binti, Dental Management of Patients on Emicizumab - A systematic review and modified Delphi study,Trinity College Dublin.School of Dental Sciences, 2021Download Item:
Abstract:
Background: Dentistry is associated with a number of procedures that pose a risk of bleeding. This is important for patients who have an increased tendency to bleed, such as patients with severe haemophilia A (PSHA). The emergence of Emicizumab as a novel prophylactic agent opens up an entirely new area comprising of possibilities for routine dental care under minimal haemostatic cover. However, there is a gap of information required on providing safe dental treatment in this cohort.
Aims: To investigate the optimal way to manage patients on Emicizumab undergoing dental procedures.
Method: The Trustworthy Consensus-Based Statement (TCBS) methodology was used to fulfil the aim of the study which involved a systematic review (SR) and a complementary Delphi study. The SR aimed to investigate the current literature on the provision of dental treatment on patients on Emicizumab whereas the modified Delphi study tested the assignment of bleeding risk against a comprehensive list of contemporary dental procedures among expert dentists with a background of treating patients with bleeding disorders.
Results: Eleven studies were identified for the SR (search spanned studies published between September 2010 to December 2020). Out of the 91 dental procedures carried out, there were 10 reported bleeding events, with 2 occurring with the sole usage of Emicizumab. None of the studies documented the presence of a standard dental protocol for patients on Emicizumab. All studies were observed to be at a high risk of bias particularly for the cohort studies whereas the reporting of all observational studies was observed to have missing items.
The modified Delphi study recruited around 31 expert dentists with a total of 26 responses in Round 1 (response rate of 83.9%), 25 responses in Round 2 (response rate of 96.2%), and 25 responses in Round 3 (response rate of 100%). As 25.8% of the panel did not have experience treating patients on Emicizumab, a patient with factor VIII levels between 10-15% in the mild haemophilia bleeding phenotype range was used as a proxy. Very high levels of consensus were noted for items in the three levels of risk; Level 0-1 requiring no haemostatic measures and just careful technique, Level 4 requiring low or single dose factor therapy and Level 5 requiring higher or multiple dose factor therapy. However, there remain a number of procedures for whom this is insufficient to provide safe care. In particular the extraction of two teeth, that may involve adjacent or separate teeth.
Conclusions: Bleeding events associated with dental surgery are traumatic for children and adults alike. Therefore, we need to identify and manage those procedures appropriately according to the consensus level of risk this study identified. Conversely, it is important not to over-medicalise them or over-estimate the risk of most routine dental procedures. Further discussion is required between the members of the dental team on agreeing the procedures under each level of risk. Future research should incorporate the usage of standardised bleeding outcome measures for ease of developing dental protocols with larger sample sizes carried out in a multicentre setting to ensure the translation of these findings into the provision of safe dental care for patients on Emicizumab.
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https://tcdlocalportal.tcd.ie/pls/EnterApex/f?p=800:71:0::::P71_USERNAME:AHMADFIADescription:
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Author: Ahmad Fisal, Aisyah Binti
Advisor:
Dougall, AlisonPublisher:
Trinity College Dublin. School of Dental Sciences. Discipline of Dental ScienceType of material:
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