Dental Care In Pwh
All patients with hemophilia should be assessed for treatment needs, not only in the procedure that should be undertaken, but also in the time it would take to carry out such a procedure, so that if an opportunity develops at some time in the future, they could be called up at short notice and have their dental needs attended to. This identification of persons with hemophilia would not only allow their dental treatment needs to be identified, but also allows this group of patients and their families to be specially targeted with the preventive dental care message to reduce the progression of existing disease and diminish future dental treatment needs.
Guidelines in developing a Dental treatment strategy
Patients with hemophilia are different from ordinary patients in that the latter group can have multiple visits to achieve a definitive treatment even on one tooth. This is a luxury that is not usually available to persons with hemophilia: therefore, a much more restrictive view should be taken Assessment of the necessity of treatment must be taken, as there may be only one opportunity for dental intervention to take place. So by definition, the options available to the dentists responsible for making the decisions for treatment of persons with hemophilia are much more restricted. There are multiple causes for this including costs, availability of service, and availability of factor replacement post- operative care.
In relation to infiltration anaesthesia used mainly in the upper jaw, a 30% factor rise is a normal requirement.
However where extractions, deep scalings, and /or inferior dental nerve (lower jaw) injections deep into the tissue are anticipated, then a 50% factor rise would be the level of choice.
Where the procedures intended are much more extensive, or become more extensive as the procedure develops, such as a surgical extraction, 100% rise may be necessary.
This might necessitate an increase in the rise from 50% to 100% immediately post-operatively, if the treatment being undertaken becomes more extensive than was originally planned.
Extractions
Surgical extractions should not be undertaken lightly. They should only be undertaken when the circumstances absolutely demand it.
In all cases of patients undergoing dental treatment involving blood clotting, the patient should be prescribed tranexamic acid. The adult dose is 500 mg. one tablet four times a day, to be taken for 10 days post-operatively to prevent the breakdown of any clot that forms. For children, the above dose must be modified for their size and age. If no extractions or periodontal treatment is undertaken, only restorations, then the tranexamic acid should be taken for 3 to 7 days.
While the use of sutures following extractions can be warranted there is normally no necessity for these to be in place longer than about 24 hours.
Four extractions in different areas of the mouth are less traumatic than four extractions next to each other. In the latter instance, there would be an extensive wound; because of the scalloped edge of the gum around the teeth it can be at least 50% larger than the distance corresponding to the extracted teeth width. If the sutures are removed within 24 hours, there is usually no need for a follow-up factor replacement treatment rise. Sometimes, it may be necessary to retain sutures for longer, but a dentist would decide when it is appropriate; usually it would only occur in an exceptional case if the dental surgery is very expensive.
In relation to any oral surgical intervention, it is of paramount importance that there is the least possible interference with the attached gingival (gum) around the teeth and periosteum. Simply lifting the attached gum tissues from the underlying tissue or periosteum, even in healthy patients will cause post-operative bleeding. The goal is "key hole" surgery, where there is as little interference as possible with the attached gum to minimize post-operative bleeding.
Management of Extraction/Scaling
Start Transmenic Acid the night before the procedure: 250 mg for a child and 500mg for an adult four times daily. Continue for 5-7 days after the procedure.
If there is an infection start an antibiotic the day before the procedure
Bacampicillin 400 mg [Trade name - Penglobe] twice daily for adults and 200mg twice daily for children
Or Metrondazole 400mg [Trade name - flagyl] thrice daily for adults and 200 mg thrice daily for children
One dose of factor concentrate 10 units/kg to be administered before a major procedure and repeated if necessary
Dentures or Orthodontic Treatment
There is normally no problem in providing a routine prosthesis or denture for a patient with hemophilia or undertaking simple orthodontic procedures with either fixed or removable appliances. However, these prostheses in themselves, as with all prostheses, generate an accumulation of plaque around them, which increases the necessity for homecare preventive programmes, some of which have to be specially tailored for the individual needs of the patient.
@ Source: "Primary Dental Care of Patients with Haemophilia" by Dr. Barry Harrington (published by World Federation of Haemophilia) Revised edition 2000)
