Moffitt Restorative Dentistry

Von Willebrand Disease

Mar 23 2019

Treating Patients with von Willebrand Disease

Von Willebrand disease (VWD) is a disorder that delays blood clotting. It was first described in 1926 by Finnish physician Erik Adolf von Willebrand. VWD is relevant to oral health professionals because some of its clinical signs may be readily observed in the oral mucosa, and delayed clotting can adversely affect the provision of timely and appropriate oral care. Patients with VWD are best served when dental professionals collaborate with medical providers to aid in managing potential bleeding problems. Proper assessment, diagnosis, treatment planning, implementation, evaluation, and documentation—including systemic considerations and patient communication—are critical to the successful oral management of this disease.

Dental care for individuals with VWD includes a comprehensive medical and dental health history review, including the documentation of vital signs; oral health screening; notation of current prescription therapies and allergies to any drugs used in dental care; assessment of the potential for substance abuse; and identification of other potential intrinsic diseases. The invasiveness of the planned procedure and the potential for prolonged bleeding post-operatively are important considerations when treatment planning. The assessment incorporates the type of VWD, symptoms manifested, proposed treatment, and collaboration with the patient’s hematologist to determine if a factor replacement blood transfusion is recommended pre- or post-treatment.

A full radiographic survey with routine follow-up bitewing and periapical X-rays can be performed on a case-by-case basis.  Caries, oral cancer, and periodontal risk assessment should be conducted at the initial dental hygiene visit and a personalized treatment plan should be developed based on the findings.

A treatment plan should be implemented immediately in patients with VWD (as well as other bleeding disorders) who elicit poor oral hygiene to prevent further damage to periodontal tissues. The use of topically applied antibacterial agents, such as chlorhexidine gluconate and/or antibiotics, prior to invasive dental procedures may reduce infection and inflammation. In addition to traditional caries and periodontal interventions, the treatment plan may include a referral to a registered dietitian for nutrition analysis and possible treatment—as anemia and vitamin deficiency also may be contributing factors for gingivitis and periodontitis.

The best strategy to prevent a prolonged bleeding episode is consistent, routine oral examination and prophylaxis so that biofilm and inflammatory levels are kept to a mini­mum.  Most patients with VWD are at moderate to severe caries risk due to their medication use and tendency to bleed.  As such, oral health professionals may recommend: consumption of fluoridated drinking water; application of topical fluoride varnish every 3 months to 6 months; use of xylitol chewing gum to increase salivary flow; and daily use of a fluoride dentifrice with a power toothbrush.  Caries prevention is critical so as to avoid the need for invasive dental procedures that can put patients with VWD at elevated risk for a prolonged bleeding episode.

During dental treatment, measures should be taken to reduce mucosal trauma with careful use of the saliva ejector. Special care is recommended while taking radiographs and impressions and during the use of rubber dams to protect surrounding tissues. The use of cautery for invasive operative procedures is recommended. The utilization of a diode laser in both nonsurgical periodontal procedures and oral surgical procedures reduces patient discomfort, operative and post-operative bleeding, and scarring.

Post-operative drugs that may interfere with platelet function, such as aspirin, must be avoided, and nonsteroidal anti-inflammatory agents should be used with caution. The World Federation of Hemophilia recommends the use of acetaminophen with or without codeine for pain control and cites the potential for drug interactions when ­multiple medications are prescribed.  A custom mouthpiece may offer local compression in the area where post-operative bleeding is expected.  Applying pressure with gauze, resting, administering ice to the treatment area, and compression and elevation can minimize post-operative bleeding.

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