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Title Systemic Plus Local Therapy Provides No Significant Difference In The Successful Management Of Bleeding In A Patient With Type 1 von Willebrand Disease Compared to Local Therapy Alone
Clinical Question In order to limit bleeding complications during surgical extractions in a patient with Type 1 von Willebrand Disease, does systemic use of desmopressin plus local use of tranexamic acid produce a better result than tranexamic acid alone?
Clinical Bottom Line For patients with type 1 von Willebrand disease (vWD), a quantitative defect in vWD factor, there is no current evidence showing a significant difference in the number of bleeding episodes after dental extraction when treated with desmopressin and tranexamic acid compared to tranexamic alone. The management of post surgical bleeding is most successfully treated when a hematologist is consulted when determining surgical precautions. This is due to the fact that therapeutic benefits of desmopressin are not consistent among patients with type 1 vWD. Overall, the number one predictor for management success is obtaining proper diagnosis and characterization of the von Willebrand Disease.
Best Evidence (you may view more info by clicking on the PubMed ID link)
PubMed ID Author / Year Patient Group Study type
(level of evidence)
#1) 10781191Federici/200027 Patients with type 1 vWD.Case Series
Key resultsThere was not a statistically significant difference in the number of bleeding episodes after dental extraction when type 1 vWD patients were treated with desmopressin and tranexamic acid compared to tranexamic acid alone (p=.95). In this retrospective study of 27 patients, both the systemic plus local therapy and the local therapy alone prevented any postoperative bleeding episodes. However, choice of treatment was decided prior to surgery by the hospital hematologist based on the patients’ therapeutic response to desmopressin and characterization of disease.
Evidence Search ("von willebrand disease"[MeSH Terms] AND ("deamino arginine vasopressin"[MeSH Terms] OR ("deamino"[All Fields] OR "arginine"[All Fields] AND "vasopressin"[All Fields]) AND ("tranexamic acid"[MeSH Terms] OR ("tranexamic"[All Fields AND ("tooth extraction"[MeSH Terms] OR (“Dental Extraction”)
Comments on
The Evidence
Validity: This was a retrospective study of a limited amount of patients and therefore the evidence does not carry as much weight as would a randomized control study. In addition, the surgical precautions provided for each patient was decided on a case-by-case basis prior to the surgical extraction. Perspective: Although von Willebrand disease is the most common hereditary bleeding disorder it exists in less than 1% of the population. Consequently, it is hard to conduct a large randomized control study.
Applicability This study provides insight on how to manage bleeding in a patient with type 1 von Willebrand disease. The use of desmopressin and tranexamic acid provides low cost options whereas the alternative use of von Willebrand Factor concentrates (vWFc) is very expensive per infusion. While desmopressin is an inexpensive option, therapeutic benefits are not consistent and some type 1 patients do not respond to the mediation, as indicated by their lab results. Tranexamic acid is a local hemostatic agent and systemic contraindications are rare. An additional intervention is the local use of fibrin glue.
Specialty/Discipline (General Dentistry) (Oral Surgery) (Periodontics)
Keywords von Willebrand Disease, Dental Extraction, Bleeding Management, Tranexamic Acid, Desmopressin
ID# 2654
Date of submission: 02/28/2014spacer
E-mail Felicetta@livemail.uthscsa.edu
Author Chris Felicetta
Co-author(s) e-mail
Faculty mentor/Co-author Barbara MacNeill, DMD
Faculty mentor/Co-author e-mail macneill@uthscsa.edu
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