This case report describes the dental treatment of a 4-year-old boy with severe hemophilia A under general anesthesia. The treatment included endodontic therapy, preventive laser diode pulpotomy, indirect pulp capping, fillings, and sealants. Close cooperation between the dental surgeon, hematologist, and anesthesiologist ensured the treatment was performed safely. The diode laser was effective for hemostasis during pulpotomy and should be widely used for managing bleeding in hemophilia patients. Three months post-treatment, the patient had no complaints or signs of complications.

1. Pulpotomy management using
laser diode in pediatric patient
with severe hemophilia A under
general anesthesia—A case
report
Vo Truong Nhu Ngoc, PhD;1 Trinh Do Van Nga, DDS;2 Dinh-Toi Chu, PhD;3,4* Le Quynh
Anh, DDS1
Spec Care Dentist XX(X): 1-5, 2018
PMID: 29537665.
IMPACT factor 1.13
DR.RACHAEL GUPTA
POSTGRADUATE

2. Introduction
 Hemophilia - a common bleeding disorder
- results from mutations of X-chromosome genes
- This inherited disease occurs in about 1 in every 10 000 people and 1
in every 5000 males.
Srivastava A, Brewer AK, MauserBunschoten EP, 2013
Peisker A, Raschke GF, Schultze-Mosgau S 2014
- It includes 3 types, namely,
hemophilia A (deficiency in coagulation factor VIII),
hemophilia B (lack of factor IX),
hemophilia C (shortage of factor XI).
The most common type, hemophilia A, accounts for 80% to 85% of all hemophilic cases.

3. Introduction
 In healthy people, factor quantification ranges from 50 to 100 IU/ dL
 Based on the amount of coagulation factor VIII in a patient’s plasma, hemophilia
A is classified into 3 levels of severity.
 Mild, moderate, and severe hemophilia cases have a plasma clotting factor
concentration of
 Mild- 6 to 50 IU/dL (6% to 50% of normal),
 Moderate- 2 to 5 IU/dL (2% to 5% of normal), and
 Severe- <1 IU/Dl (less than 1% of normal)
Nogami K, Shima M. Pathogenesis and treatment of hemophilia. In: Ishii E, ed.
Hematological Disorders in Children: Pathogenesis and Treatment. Singapore:
Springer Singapore; 2017:189-204

4. Introduction
 Hemophilia A -mostly occurs in male patients, while female ones are
often asymptomatic carriers
 Medical interventions may range from
- oral tranexamic acid prescription,
- to clotting factor infusion,
- to immune tolerance therapy (severe cases with inhibitors)

5.  Hemophilia patients, especially hemophilia A ones, may suffer from several oral
and dental health problems
- uncontrolled gum or
- socket bleeding after dental surgeries, and
- traumatic hematoma in buccal space.
 Hemophilia patients are at high risk of incurring the 2 most common oral
diseases—gingivitis/ periodontitis and dental caries.
 However, our knowledge of dental and oral health care for hemophilia A patients
is currently limited, for only a very few studies have been conducted.

6. Hemophilia patients, especially hemophilia A ones, may suffer from several oral and dental
health problems
N
o
Case Dental problems T/T references
1 Mild Hemophilia A Uncontrolled postsurgical
bleeding to expose 2
central incisors
Tranexamic acid,
vitamin K and saline
infusions
Martínez-Rider et al
2 Mild Hemophilia A Secondary bleeding post
extraction of tooth 14
Pressure on the
socket, locally
tranexamic injection,
and intravenous
vitamin K
Mamtha et al
3 Moderate Hemophilia A A Bleeding following steel
crown restoration
Intravenous factor
VIII administration
Lòpez-Villareal et al
4 Severe Hemophilia A with
inhibitor
Traumatic hematoma in
buccal space
Intravenous factor
VIII infusion
combined with
immune tolerance
therapy
Durham et al

7. Case report
 A 4-year-old boy presented at School of Odonto Stomatology, hanoi Medical University
 C/O - of provoked pain at meals
 He had H/O severe hemophilia A detected at 6 months old because of multiple bluish
patches on his lower limbs
 He was referred to and managed at National Institute of Hematology and Blood
Transfusion.
 Nervous and scared of getting hurt at his first dental visit, he could hardly point out his
decayed tooth

8. • The pretreatment
panoramic film showed
multiple translucent lesions
of varying sizes, in different
sites and stages in relation
to pulp chambers.
• Tooth 85 with a deep
carious lesion into the pulp
chamber, no periapical
lesion was found.

9.  To avoid unexpected injuries and bleeding caused by the lack of patient
coordination,
especially pediatric patients like this case, dental treatment under general anesthesia
was the best of choice.
 T/T was supposed to save the boy from mealtime toothache, as well as keep his
deciduous dentition in healthy conditions for chewing and preserving space
functions.
 The child’s conditions & T/T plan were explained to his parents
 Sent to hematologist whether child could undergo t/t or not and which medication
was needed

10.  His blood investigations
- a normal full blood count
- prolonged activated partial thromboplastin time (APTT) (>150 s)
- factor VIII concentration in plasma was 0.2% of normal (severe hemophilia)
with negative coagulant inhibitors;
-microbiological tests (HIV, HBsAg) were negative;
- physicochemical analyses (glutamic-oxaloacetic transaminase [GOT],
glutamic-pyruvic transaminase [GPT], urea, and creatinine) were in normal
ranges.
-Electrocardiogram (ECG),
ear – nose – throat (ENT), and chest x-ray examinations
were also normal.

11.  General anesthesia was processed using a 4.0-mm nasal-cuffed endotracheal
tube, reinforced to minimize nasal mucosa trauma.
 Ointment was applied on lips before a silicone bite was used to keep the patient’s
mouth open and prevent oral mucosa injuries due to hard instruments.
 Cotton rolls were used to isolate tooth instead of rubber dam placing for the
same reason.

12.  After supragingival scaling and lesion assessment,
confirmatory diagnoses, including
irreversible pulpitis in tooth 85
reversible pulpitis in teeth 55, 74, 75, and 84
2.3 cavity in tooth 65
1.1 cavity in teeth 54 and 64;
3.2 cavity in teeth 73 and 83 (Mount’s cavity classification)
 Treatments included
- A complete endodontic therapy for tooth 85;
- Preventive diode laser pulpotomy for teeth 55, 74, 75, and 84;
- indirect pulp capping with Biodentine for tooth 65,
- glass-ionomer cement (GIC) fillings for teeth 73 and 83;
- composite sealants for teeth 54 and 64;
- local fluoride varnish application

13.  Tooth 85:
- After accessing pulp chamber,
- working lengths were established by using Propex II apex locator to prevent periapical
damage due to over-instrumentation.
- The root canals were then shaped and irrigated with sterile saline before being obturated
with ZOE paste.
- The post-treatment crown was restored with GIC (Fuji IX, GC)
- preformed metal crown (stainless steel crown [SSC]) of 3M company

14.  Teeth 55, 74, 75, and 84
 - treated with laser diode pulpotomy as follows:
a pulp chamber was first removed by highspeed burs,
then by continuous diode laser beam 810 nm at 0.5 W energy level (AMD Lasers from Dentsply
Sirona (Dentsply International), USA) until the floor chamber was visible, going into orifices.
 Saline-damped cotton pellets were used to clean up and check for bleeding status.
 As hemostasis accomplished, the pulp chamber was filled up with layers of Biodentine
(Septodont) and GIC (Fuji IX, GC) .
 The crown was then covered with a preformed metal crown (SSC) of 3M company.
Diode laser pulpotomy for tooth 55. (A) Complete hemostasis by laser. (B) Biodentine layer.
(C) GIC restoration

15.  Tooth 65:
-This tooth showed the pink color of its pulp chamber right beyond.
-After carious tissue removal, indirect pulp capping with Biodentine (Septodont) was
performed, and the GIC (Fuji IX, GC) was built up.
-Then, all these endodontically treated teeth were each protected with a preformed
SSC (3M company), conformed to by a finishing line polished and in proper contact
with gingiva.
 Teeth 73 and 83 were filled with GIC (Fuji VII, GC)
 Teeth 54 and 64 had pit and fissure composite sealants.
 Finally, all exposed teeth were applied with fluoride varnish (MI Varnish, GC)

16.  As soon as the boy woke up from the procedure,
 he was able to eat without any complaint.
 Up till now, after 3 months of follow-up, all clinical signs and functions have proved to be
normal; no sign of toothache or swelling was diagnosed.
Posttreatment intraoral and panoramic images. (A)
Upper teeth. (B) Lower teeth. (C) Panoramic
image.

17. Discussion
 General anesthesia is considered to be used for pediatric patients with multiple dental
problems and inability to undergo dental treatment.
 Those patients are too young to overcome the fear of high-speed bur noises and many
types of dental hand pieces in their mouths, and they cannot continuously keep their
mouths open during the entire treatment
 This may lead to unexpected dangerous accidents, such as lacerating soft tissues,
swallowing endodontic files, or breaking instruments.
 Hemophilia A cases, especially severe ones, have a constant high risk of bleeding.

18.  In case of unconscious patients (due to general anesthesia), this is of critical
importance because they cannot express any feelings of hurt or injury during
the operation.
 Therefore, endotracheal anesthesia was designed to ensure those patients’
safety while being operated by keeping their respiratory and circulatory systems
under constant control.
This method helps prevent patients from choking or getting exposed to trace gas
contamination.

19.  Anesthesiologists also choose a smaller sized tracheal tube to avoid damaging
the mucosa of the upper respiratory tract.
 The inner diameter of the uncuffed endotracheal tube is commonly calculated
based on the Cole’s formula: age/4.0+4.0.
 Kline recommended that for children under 2 years old, the suitable formula
should be age/4.0+3.0,
 According to Motoyama, age/4.0+3.5 should be applied for those at least 2
years old.
 In the case of our 4-year-old patient, we used a 4.0-mm flexible cuffed tube,
smaller than calculated, to protect his mucosa.

20.  The inner metal spiral support prevents the tube from distortion
while keeping it flexible enough to fit his respiratory tract.
 In this case study, patient suffered from hemophilia A bleeding
disorder – any invasive procedures like tooth extraction should be
avoided.
 Due to his tooth status and general condition, we only used
conservative methods, namely, endodontics, tooth fillings and
sealants, as well as local fluoride application

21.  Lasers have been widely applied in dental procedures, including pulpotomy.
 In particular, diode lasers have become more frequently used in pulpotomy because of
their reliability and handiness.
 Favorable results of diode laser are at least as equal to those of other therapies such as
ferric sulfate, NaOCl, mineral trioxide aggregate (MTA), Biodentine,or even better.
Niranjani K, Prasad MG, Vasa AA, Divya G, Thakur MS, Saujanya K. Clinical evaluation of
success of primary teeth pulpotomy using mineral trioxide Aggregate®, laser and
BiodentineTM - an in vivo study. J Clin Diagn Res 2015;9(4):ZC35-ZC7

22.  In hemophilic cases, diode lasers are highly effective in hemostasis and should be widely applied as
a preventive method for pulp bleeding, especially in hemophilia patients.
 One important aspect of dental care in hemophilic patients is the cooperation between
hematologists and dental surgeons.
 Hematologists thoroughly examine both hematological statuses and oral conditions of the patients
in order to determine the hemophilic ,so the doctors can make a plan for hemostatic management
before, during, and after operation

23.  Good oral hygiene is always highly recommended to patients with hemophilia or
other bleeding disorders, since it is the simplest and easiest way to prevent
periodontitis and dental caries that could lead to gingival bleeding and more
invasive treatments.
 Parents should be well informed about oral health and its importance to
pediatric hemophilia patients.
 hemophilic children should be examined regularly, starting at the time of
eruption of milk teeth (or primary teeth).
 The patient has been treated for about 3 months, and we have so far no negative
signs or symptoms

24. Conclusion
 Haemophilia A patients can have their dental treatment safely performed under general
anaesthesia as long as the dental surgeon, haematologist, and anaesthesiologist
cooperate well with one another.
 To reduce trauma, any treatment, including preventive therapies, should be carefully
conducted with minimal invasion.
 For dental patients with haemophilia A, the diode laser technology is an excellent
nonchemical method of haemostasis during the pulpotomy procedure, and therefore, it
should be widely applied.

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