Preventive Berinert Treatment Protects Against Angioedema Attacks After Dental Procedures

Short-term preventive treatment with Berinert, a plasma-derived form of the C1 inhibitor protein, protects people with hereditary and acquired C1-inhibitor (C1-INH) deficiency from angioedema attacks after dental procedures, according to a recent study.

The study, “Short-term prophylaxis in patients with angioedema due to C1-inhibitor deficiency undergoing dental procedures: An observational study,” was published in the journal PLOS One.

Dental procedures are potential triggers for angioedema attacks among patients with C1-INH deficiency. When these attacks occur in or near the airways, they can be life-threatening. This can make patients reluctant to seek dental care and dentists hesitant to deliver it — especially if the dentist is unfamiliar with the condition.

Berinert, a treatment manufactured by CSL Behring and obtained from the plasma of healthy donors, contains the C1-INH molecule that angioedema patients lack. It temporarily restores that molecule to healthy levels.

Thus, researchers at the Fatebenefratelli Sacco Hospital in Milan, Italy, investigated whether its use as a preventive measure — called a prophylaxis — protected patients from angioedema attacks following dental procedures.

The team reviewed all relevant patient records from their hospital from 2009 to 2017. A total of 29 people with angioedema — 27 with a hereditary form of the disorder and two with an acquired form — had dentist appointments in that period. Their median age was 45 (range 8-85 years), and 14 were male.

A majority of these individuals (63%) experienced obstacles in accessing dental care, largely due to dentists being unfamiliar with angioedema and its treatments. Of note, delays in dental care can result in poor oral health, and infections are another known trigger for angioedema attacks.

More than half of the patients in this study (59%) had oral disease ranging from moderate to severe. Conditions included cavities, the need for tooth extractions, and the complete loss of teeth, a condition known as endentulism.

Nine of the 29 patients did not undergo dental procedures following their initial consultations and were, therefore, not considered for further analysis.

Of the remaining 20 individuals, 10 were taking long-term prophylaxis. Among them, one was receiving Berinert and the other nine were taking attenuated androgens, or male hormones, which increase the level of C1-INH.

These 20 patients had records of 75 dental procedures.

The majority of these procedures (80%, or 60 procedures) occurred after short-term preventive treatment. The 13 that did not involve short-term prophylaxis did involve long-term preventive treatment.

One patient with hereditary angioedema declined prophylaxis after being informed of the risk. After the procedure, which required emergency treatment, this patient experienced an attack in the oropharynx, a part of the upper airway.

Another individual, who had acquired angioedema, also experienced a swelling episode after a tooth extraction, despite short-term Berinert.

Among the 20 patients in the study, 19 had data concerning the frequency of attacks per month, before and after dental care. Four patients (21%) reported a reduction in the number of attacks. The other patients reported no change in the number of attacks.

To the investigators, a reduced frequency of attacks in this proportion of patients was significant.

“This highlights the importance of treating oral pathologies in patients affected by angioedema due to C1-INH deficiency,” they wrote.

“Taking into account our results and other data in the literature, we recommend considering tooth extractions as posing a high risk of attack in these patients and therefore advise the use of [short-term prophylaxis] before these procedures,” they concluded.