Extraction in a Six-Year-Old With Severe Haemophilia A
A 6-year-old boy with severe haemophilia A (factor VIII activity below 1%, no inhibitors, on prophylactic factor replacement) is referred for dental care. Teeth 74 and 84 are grossly carious with pulpal involvement and are considered unrestorable; 75 and 85 have deep occlusal lesions that are restorable. The referring dentist planned inferior alveolar nerve blocks for quadrant care in the community clinic. The mother reports two episodes of prolonged bleeding - after a fall that split his lip, which oozed for most of a day, and after a bite to the tongue that needed hospital review. His haematologist has provided a written plan stating that dental extractions require factor cover, with a target level to be confirmed on the day, and that tranexamic acid should be used. He weighs 20 kg and has no other medical conditions and no known drug allergies.
1. Set out the preoperative planning and coordination needed before 74 and 84 are extracted, and explain why the setting matters.
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Coordination is the treatment. Nothing should be planned without a written, current haematology plan, because factor target levels differ between protocols and depend on inhibitor status and prior bleeding history.
Preoperative steps:
- Confirm the written plan: which factor VIII product, the dose, the target level at the time of extraction (commonly around 50 IU/dL for a dental extraction, with a further dose to maintain a trough above about 30 IU/dL for several days), and who administers it. Confirm with the haematologist rather than inferring from memory.
- Schedule the extraction for shortly after factor administration, on a day when the haematology team is on site, not at the end of a Friday clinic.
- Hospital or haemophilia centre setting with blood bank access and factor concentrate available. A community clinic without factor on the shelf cannot manage a primary haemorrhage in a child with below 1% activity - this is the reason the setting matters, not the prestige of the building.
- Preoperative: full blood count if recent bleeding, check for inhibitors, confirm no aspirin or NSAID exposure, and check the restorations on 75 and 85 can be done at the same visit to reduce the number of bleeding episodes.
- Consent: explain bleeding risk, the possibility of admission, and the need for the child to avoid trauma to the socket.
- Plan analgesia in advance: paracetamol only; avoid ibuprofen, aspirin and other NSAIDs because they inhibit platelet function and worsen bleeding.
2. The referring dentist planned inferior alveolar nerve blocks. Discuss the local anaesthetic approach you would use and the reasoning behind it.
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I would not give an inferior alveolar nerve block in this child. The pterygomandibular space is a non-compressible fascial space; a haematoma there can track to the parapharyngeal and submandibular spaces, distort the airway and is difficult to control by pressure. In a child with factor VIII below 1%, that risk is not justified when an alternative exists. The same applies to a lingual block, a greater palatine block, and intraligamentary injection, which delivers high pressure into the periodontal ligament.
Alternative:
- Buccal infiltration with 2% lidocaine and 1:100,000 adrenaline, slowly, with aspiration, using a fine gauge needle, after topical anaesthetic. Infiltration into the buccal mucosa is accessible to direct pressure if a haematoma forms.
- For the mandibular primary molars, a buccal infiltration plus, if needed, a small supplemental infiltration is usually enough for extraction of 74 and 84 when combined with the factor cover and good technique; if it is not, the answer is not to reach for a block but to consider the procedure under general anaesthesia in theatre.
- Avoid excessive volume of local anaesthetic: calculate the maximum dose against 20 kg, and avoid adrenaline-containing solution if there is any cardiovascular concern (not the case here, but state the check).
- No NSAID-containing analgesics, and do not prescribe aspirin for any reason postoperatively.
- If the extraction cannot be done comfortably with infiltration, stop and re-plan in theatre rather than convert to a block under pressure.
3. Describe your local haemostatic measures and postoperative instructions, and how you would manage a call at 10 p.m. reporting that the socket is still oozing.
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At the time of extraction:
- Atraumatic technique, minimal periosteal stripping, and avoid a large flap.
- Resorbable sutures placed to approximate the margins - a figure-of-eight or interrupted technique that holds a pack in place.
- A haemostatic pack in the socket: oxidised cellulose or a gelatin sponge, held with pressure for at least 5 minutes with a moist gauze.
- Tranexamic acid mouthwash (typically 4.8–5%, 10 mL, four times daily for 5–7 days, rinsed for 2 minutes and not swallowed) as specified by the haematologist, started postoperatively, in addition to systemic cover.
- Confirm factor cover continues after discharge as per the written plan; do not discharge until bleeding has been observed to stop.
Instructions to the mother, in writing: no rinsing, spitting, sucking or hot drinks for 24 hours; soft cold diet; no fingers or toys in the mouth; avoid vigorous exercise for a week; paracetamol only; the ward and haematology contact numbers; a follow-up call the next day and review at 48–72 hours.
The 10 p.m. call: assess by phone - is it oozing or actively bleeding, is there a clot, is there airway compromise, faintness or a swollen floor of mouth? If it is minor oozing, advise firm gauze pressure for 20 minutes and a tranexamic acid rinse if prescribed. If it is active bleeding, a large clot, swelling or any airway concern, direct the family to the hospital emergency department with the haematology plan in hand - not to the community clinic - and arrange factor replacement and review there. Document the call and the advice given.