Dealing with Evidence in Dental Professional Liability Lawsuits-General Recommendations for Dental Expert Witness Work Using the Example of Germany: A Narrative Review

Dental treatment can lead to disputes between patients and dentists, which are then brought before the civil courts as medical malpractice cases. The court regularly commissions a dental expert to answer questions of evidence in court. In the majority of cases, the expert is able to answer these questions based on his professional expertise and practical experience. In order to make the assessment comprehensible and credible for the judge and the parties, it can be helpful and reasonable to cite relevant literature references from dental textbooks and specialist journals. In individual cases, it may be necessary to carry out a systematic literature search on specific topics. Based on the situation in Germany, this narrative review makes recommendations of how to perform a literature search and make citations specifically for expert opinions that are generally applicable independent of national jurisdiction.

Dentistry for patients with haemophilia: Trialling a safe and economical change in management

INTRODUCTION

While the dental management of patients with haemophilia has changed considerably in the last decade, haemophiliacs in Western Australia have continued to receive pre-operative factor support for dentistry regardless of the type of dental procedure.

AIM

To review the efficacy and safety of established dental protocols that reduce factor use in the dental management of patients with haemophilia and to estimate cost savings.

METHODS

Records of 11 patients with haemophilia that were seen in the pilot programme period were reviewed. These were cross-referenced with previous dental and haematology notes that stated the amount and type of pre-operative factor used. Cost savings were estimated using the Australian National Blood Authority's Product List.

RESULTS

All study participants were male, and included those with haemophilia A (n = 9), and B (n = 2). Mean age was 45 years (range 22-80). A variety of dental treatments were undertaken, and no pre-operative factor was used. Patients on prophylaxis (n = 6) received dental treatment the same day as their regular factor administration. It was estimated AUD$26,314 was saved by not using pre-operative factor. One patient had bleeding post-extraction and was seen the following day to achieve haemostasis using local measures. The remaining patients had no complaints of post-operative bleeding, and did not require any further haemostatic measures.

CONCLUSION

This pilot programme supports data that haemophiliacs can safely receive a variety of dental treatments without the need for pre-operative factor, and the significant cost savings of doing so. Further data is required to support this protocol for invasive dental procedures.

A Retrospective Analysis of the American Thrombosis and Hemostasis Network Dataset Describing Outcomes of Dental Extractions in Persons with Hemophilia

INTRODUCTION

dental extractions (DEs) in persons with hemophilia A or B (PWH-A or PWH-B) are often associated with bleeding and needing hemostatic therapies (HTs).

AIM

to analyze the American Thrombosis and Hemostasis Network (ATHN) dataset (ATHNdataset) to assess trends, uses and impacts of HT on bleeding outcomes following DEs.

METHODS

PWH seen at ATHN affiliates who underwent DEs and opted to share their data with the ATHNdataset between 2013-2019 were identified. The type of DEs, use of HT and bleeding outcomes were assessed.

RESULTS

Among 19,048 PWH ≥2 years of age, 1157 underwent 1301 episodes of DE. Those on prophylaxis experienced a nonsignificant reduction in dental bleeding episodes. Standard half-life factor concentrates were used more often than extended half-life products. PWHA were more likely to undergo DE in the first 30 years of life. Those with severe hemophilia were less likely to undergo DE than those with a mild disease (OR: 0.83; 95% CI: 0.72-0.95). PWH with inhibitors had statistically significantly increased odds of dental bleeding (OR: 2.09, 95% CI; 1.21-3.63).

CONCLUSION

our study showed that persons with mild hemophilia and younger age were more likely to undergo DE; the presence of inhibitors increased the likelihood of bleeding, while those with prophylaxis and receiving HT experienced a non-statistically significant reduction in bleeding.

Current state of play regarding dental extractions in patients with haemophilia: Consensus or evidence-based practice? A review of the literature

Due to the global prevalence of oral disease, tooth extraction is the most common surgical procedure required in general population thus likely to be similarly common in patients with haemophilia, especially those in older age and those living in countries with restricted resources. There are little or no consensus about optimal level and duration of factor replacement (FRP) therapy required to prevent bleeding complication following surgery and low levels of evidence to inform protocols and guidelines. The goal of this article was to review the literature regarding haematological treatment protocols and to assess their effectiveness in prevention of bleeding complications during and after tooth extractions in people with haemophilia. A total number of 29 articles were identified. Only two of the studies were randomized controlled trials, and meta-analysis was not possible. Significant heterogeneity regarding haematological regimes, dental surgical procedures, disease severity and sample size of published studies which are unable to reliably inform the provision of safe dental surgery was noted. Based on the haematological regimens, all studies were classified into one of three groups: pre- and postoperative FRP or DDAVP, single preoperative FRP or DDAVP, and no FRP treatment. The overall reported bleeding rate in case of both pre- and postoperative FRP and single dose FRP preoperative is similar, 11.9% and 11.4%, respectively, indicating that minimizing the use of clotting factor concentrate is possible if proper local haemostatic measures are provided. Strictly designed prospective studies with higher number of patients are necessary to get firm conclusions about optimal FRP treatment required to prevent bleeding complications during and after oral surgery in patients with haemophilia.

Infected tooth extraction, bone grafting, immediate implant placement and immediate temporary crown insertion in a patient with severe type-B hemophilia

Haemorrhagic disorders combined with soft tissue inflammation and infection may lead to severe bleeding complications before, during or after dental treatment. In selected cases, a combined therapeutic approach involving clinical therapies and systemic and local medication could improve the treatment outcomes and the patient's quality of life. This clinical case report, presents for the first time a successful combined approach, completed in a 38-year-old male patient with severe type-B haemophilia in which an infected tooth was extracted, an immediate implant was inserted, bone grafting was performed and early implant loading was successfully applied. In addition to the clinical therapy, medication was provided orally, systemically and locally, thus preventing the haemorrhagic complications and improving the patient's quality of life.

Bleeding during and after dental extractions in patients with liver cirrhosis

Little is known about the prevention and management of acquired coagulopathies, such as those affecting cirrhotic patients. The objective of this analytic retrospective observational study was to evaluate patients on the liver transplant waiting list according to the following outcomes: (1) presence of unusual intraoperative bleeding (>10min after routine haemostatic procedures); and (2) presence of postoperative haemorrhagic complications. The outcomes were analysed according to clinical and laboratory variables. A total of 190 visits were performed for extraction of 333 teeth (ranging from 1 to 9 teeth per visit), with platelet count ranging from 16,000 to 216,000 and international normalized ratio (INR) below 3. Twelve cases (6.31%) had unusual intraoperative bleeding and 12 had postoperative haemorrhagic complications. All the events were controlled by local measures. Intraoperative bleeding was associated with low count of platelets (P=0.026). However, this counting could explain only 16% (adjusted R²=0.16) of the cases of bleeding (P=0.44), meaning that platelet function changes might be involved. Our results show that cirrhotic patients presenting platelet count above 16,000 and INR below 3 need no previous blood transfusion, with local measures being enough to manage haemorrhagic events.

Fibrin glue for local haemostasis in haemophilia surgery

INTRODUCTION

Local fibrin glue (FG) appears to be a useful local haemostatic agent for severe haemorrhage in people with haemophilia (PWH) undergoing surgical procedures.

AIM

To evaluate the role of local FG in PWH.

METHODS

A review of the literature on the topic has been performed.

RESULTS

Local FG is not always necessary to achieve haemostasis in all surgical procedures performed in PWH. However, it could be a good adjunct therapy, primarily when a surgical field will bleed more than expected (e.g. patients with inhibitors), and also for circumcisions, dental extractions, and surgical treatment of pseudotumours.

CONCLUSIONS

Although correct surgical haemostasis can typically be achieved by the infusion of factor concentrate at the adequate dose, my recommendation for surgeons is always to have local FG by their side. Local FG appears to be an effective adjunctive therapy for cases in which bleeding is likely (e.g. patients with inhibitors), and for circumcisions, oral surgery, and treatment of pseudotumours. Through the use of local FG, the doses of factor concentrate necessary to prevent bleeding could be reduced, providing considerable cost savings.

Outcomes in Patients With Hemophilia and von Willebrand Disease Undergoing Invasive or Surgical Procedures

Adults with hemophilia A (HA), hemophilia B (HB), and von Willebrand disease (VWD) frequently require surgery and invasive procedures. However, there is variability in perioperative management guidelines. We describe our periprocedural outcomes in this setting. A retrospective chart review from January 2006 to December 2012 of patients with HA, HB, and VWD undergoing surgery or invasive procedures was conducted. Type of procedures, management including the use of continuous factor infusion, and administration of antifibrinolytics were reviewed. Adverse outcomes were defined as acute bleeding (<48 hours), delayed bleeding (≥48 hours), transfusion, inhibitor development, and thrombosis. We identified 59 patients with HA and HB. In all, 24 patients had severe hemophilia and 12 had mild/moderate hemophilia. Twelve patients had inhibitors. There were also 5 female carriers of HA and 6 patients with VWD. There were 34 major surgeries (26 orthopedic, 8 nonorthopedic) and 129 minor surgeries. Continuous infusion was used in 55.9% of major surgeries versus 8.5% of minor surgeries. Antifibrinolytics were administered in 14.7% of major surgeries versus 23.2% of minor surgeries. In all, 4 patients developed acute bleeding and 10 patients developed delayed bleeding. Delayed bleeding occurred in 28.6% of genitourinary procedures and in 16.1% of dental procedures. Five patients acquired an inhibitor and 2 had thrombosis. In conclusion, patients with HA, HB, or VWD had similar rates of adverse outcomes when undergoing minor surgeries or major surgeries. This finding underscores the importance of an interdisciplinary management and procedure-specific guidelines for patients with hemophilia and VWD prior to even minor invasive procedures.