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Open Journal of Blood Diseases, 2013, 3, 13-14
doi:10.4236/ojbd.2013.31003 Published Online March 2013 (http://www.scirp.org/journal/ojbd) Dental Treatment with 30% Trichloroacetic Acid in a
Patient with Moderate Hemophilia A

Evelyn Gonzalez Delgado1,2, Gianluca Sottilotta2
1Dental Clinic, Fundación Hemo Hermanos Venezuela, Barinas, Venezuela; 2Foundation Hope and Life USA, Miami, USA. Email: dra.evelyn@foundationhopeandlifeusa.org Received December 28th, 2012; revised January 30th, 2013; accepted February 10th, 2013 ABSTRACT
We present the case of a 51-year-old moderate hemophiliac with gingival bleeding due to papillary inflammation and
adherence in the molar area 47. After dental diagnosis a calculus was removed and 30% trichloroacetic acid was placed
by a pressurized applicator for five seconds; the procedure was repeated until the bleeding stopped, then tranexamic
acid was placed by a gauze. The patient chewed the gauze for 30 minutes and was discharged after repeating the same
procedure for 30 minutes more. We observed how local treatment with trichloroacetic acid combined to tranexamic acid
placed on the hemorrhagic site was able to stop the bleeding.
Keywords: Hemophilia; Dental Treatment; 30% Trichloroacetic Acid; Clotting Factor
1. Introduction
acne scars and aging skin treatment [3,4]; at higher con- centrations it is used in condylomata acuminata, warts Hemophilia A is a congenital bleeding disorder caused and peeling. The TCA procoagulant effect can be locally by the mutation of gene on the X chromosome coding for used in dentistry for patients with bleeding disorders [5]. coagulation Factor VIII (FVIII). The normal FVIII range is 50% - 150%. The severity of hemophilia is related to the amount of the clotting factor in the blood. The classi- fication is made in severe (<1%), moderate (1% - 5%), A 51-year-old male patient with mild hemophilia A was and mild (5% - 40%). Patients with severe hemophilia admitted to the “Fundación Hemo Hermanos Venezuela” experience repeated and frequent spontaneous hemor- Dental Clinic. He presented gingival bleeding due to rhagic episodes, most commonly hemarthroses [1]. Pa- papillary inflammation and adherence in the molar area tients with moderate hemophilia mostly suffer from 47 because of presence of local irritants in the same traumatic bleeds only and generally do not experience lower right area. His hemorrhagic history was more se- spontaneous bleeding. The treatment involves the re- vere than his grade of hemophilia severity due to about placement of the deficient clotting factors by intravenous 10 - 12 hemarthroses per year treated “on-demand” with infusion to either control or prevent bleeding. Desmo- FVIII concentrates. Before dental treatment he was re- pressin, a synthetic derivative of the vasopressin, can ferred to the local hospital for the hematologic evaluation: increase factor VIII level in some patients with mild or the clinical examination confirmed the gingival hemor- moderate forms of hemophilia A. In the dental manage- rhage excluding other sites. Laboratory coagulation tests ment of hemophilic patients, it is important to manage evidenced absence of inhibitor to Factor VIII, prolonged the bleeding areas and also prevent any trauma during activated partial thromboplastin time (74 sec.) and was dental procedure [2]. Bleedings may be caused by mu- confirmed the moderate hemophilia (FVIII level 2%); the cosal irritation due to the continuous contact of dental outpatient dental treatment was authorized. At the dental calculus, or because of presence of plaque and its miner- clinic the calculus was removed immediately and 30% alization produced by gingival inflammation related to TCA was placed by a pressurized applicator for five food and bacterial deposition in the periodontal pockets. seconds. This procedure was repeated several times until In hemophiliac patients the excess of irritant agents can the bleeding stopped; then was placed tranexamic acid cause continuous bleedings. The 30% trichloroacetic acid 500 mg in vial directly to the site by a gauze. The patient (TCA) is an organic product with caustic action fre- chewed the gauze for 30 minutes and was discharged quently used in dermatology for various treatments as after repeating the same procedure for 30 minutes more. Copyright 2013 SciRes. OJBD
Dental Treatment with 30% Trichloroacetic Acid in a Patient with Moderate Hemophilia A 3. Discussion/Conclusion
The literature described many dental treatment protocols for hemophiliacs using oral antifibrinolytic agents, sys- REFERENCES
temic hemostatic replacement therapy, and local hemo- [1] A. Coppola, M. Di Capua, M. N. Di Minno, et al., “Treat- static agents [6]. Minimizing the use of clotting factor ment of Hemophilia: A Review of Current Advances and concentrates may be very important in those countries Ongoing Issues,” Journal of Blood Medicine, Vol. 1, 2010, where their availability is difficult. This patient, despite of moderate hemophilia, reported a significant history of [2] C. Scully, P. D. Dios and P. Giangrande, “Oral Care for intra-articular bleedings episodes: this could imply the People with Hemophilia or a Hereditary Bleeding Ten- possibility of a significant bleeding during dental proce- dency,” 2nd Edition, Treatment of Hemophilia Mono- dures, but the factor replacement as well as desmopressin graph Series, The World Federation of Hemophilia, Mon- treal, 2008, pp. 10-11. therapy was successfully avoided. Our case report con- http://www1.wfh.org/publication/files/pdf-1164.pdf firms how local dental hemostatic measures can achieve [3] K. R. Beutner, D. J. Wiley, J. M. Douglas, et al., “Genital hemostasis reducing the needs for clotting factor re- Warts and Their Treatment,” Clinical Infectious Diseases, We observed how local treatment with 30% TCA http://cid.oxfordjournals.org/content/28/Supplement_1/S3 combined with tranexamic acid 500 mg in vial, placed on the hemorrhagic site by a gauze, was able to stop the [4] V. K. Malviya, G. Deppe, R. Pluszczynski, et al., “Tri- bleeding. In our experience we did not report significant chloroacetic Acid in the Treatment of Human Papillo- side or adverse effects related to the use of TCA also in mavirus Infection of the Cervix without Associated Dys- patients without congenital hemorrhagic diseases. The plasia,” Obstetrics and Gynecology, Vol. 70, No. 1, 1987, TCA at 30% concentration has only hemostatic effect. pp. 72-74. http://pdfs.journals.lww.com/greenjournal/1987/07000/Tr When used in patients with conditions affecting the ichloroacetic_Acid_in_the_Treatment_of_Human.18.pdf mucosa precautions should be short TCA application [5] M. Vasallo and E. Rey, “Tratamiento Periodontal en time and drying of the applicator to limit the mucosal Pacientes Bajo Regimen de Anticoagulación Crónica,” contact. In any case, an accidental damage to the mucosa, Actualizaciones Odontológicas, Buenos Aires, Gador, 2011. related to the contact with TCA, will be mild and http://www.gador.com.ar/iyd/fao/fao55.pdf transient and will resolve within few days without [6] A. Brewer and M. E. Correa, “Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders,” Further studies on patients with bleeding disorders are Treatment of Hemophilia Monograph Series, The World needed to confirm the role of 30% TCA as procoagulant Federation of Hemophilia, Montreal, 2006, pp. 1-2. in dental hemorrhagic episodes or as antihemorrhagic in http://www1.wfh.org/publication/files/pdf-1190.pdf Copyright 2013 SciRes. OJBD

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