Community Oral Health Project

Exploring the Oral Health of

People with Haemophilia and
Investigation into the role of the
Dental Hygienist.

Diploma in Dental Hygiene

School of Dental Science

Faculty of Health Sciences
Trinity College, Dublin

Class of 2013

Diploma in Dental Hygiene

Trinity College Dublin

May 2013

i
 Acknowledgements

Firstly, and most importantly, I would like to thank my supervisor Dr. Alison

Dougall, for taking the time out of her busy schedule to meet with me on several

occasions to discuss my project and to help steer me in the right direction. Thank

you Dr. Dougall for your patience and support throughout this project, it was

greatly appreciated.

Finally, I would like to thank my family and friends who have taken an interest in

this topic while listening to me discuss it over the past several weeks. Thank you

for your encouragement and support.

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 Abstract

Individuals living with haemophilia can experience the same oral diseases as

those without. Dental treatment can be more complicated due to potential for

prolonged dental bleeding and also the reluctance of general dentists willing to

treat this group of patients. With such barriers in place people with haemophilia

are at increased risk of having worse oral health than the general population.

There is very little research on the oral health of individuals with haemophilia.

There are limited conclusions that can be made about the oral health of this group

of patients as the evidence that is available is of poor quality. In order to improve

the oral health of people with haemophilia a ‘shared-care approach’ must be

implemented. This will provide the necessary specialist care where required but

will also decrease unnecessary travel times to Haemophilia Centres, decrease

waiting lists and as a result will help improve the oral health of these individuals.

Education of both students and qualified health care workers is imperative in order

to reduce the feeling of fear when treating this group of patients. Caries and

periodontal disease are preventable oral diseases; therefore the patient must be

educated on the best preventable measures at home as well as preventable

treatment that can be given by the dentist and the dental hygienist, such

treatments will reduce the likelihood of invasive treatment and the requirement of

factor replacement therapy which also comes with its risks.

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 Table of Contents

Declaration of Academic Integrity ii

Acknowledgements iii

Abstract iv

Introduction 1

General characteristics of people with haemophilia 2

Oral health of people with haemophilia 3

Barriers to primary dental care for people with haemophilia 5

Solutions to Barriers 6

Model of Dental Service – Shared Care 7

Special High Risk Group 8

Dental Treatment Considerations for the Dental Hygienist 8

Local measures for the Dental Hygienist to control bleeding 11

Discussion and Conclusions 12

References 13

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v
 Introduction

The types of inherited bleeding disorders that are going to be discussed

throughout this project include Haemophilia A, Haemophilia B and Von Wilebrand

disease, all of which come under the umbrella of Haemophilia. Haemophilia is an

X-linked disorder in which a clotting factor is greatly reduced or even absent

(Freedman et al., 2009). This condition is usually hereditary; however thirty

percent of cases are caused by spontaneous mutations with no family history

(Arruda and High, 2008).

Haemophilia A is a deficiency of factor VIII, which affects ninety percent of suffers.

Haemophilia B is a deficiency in factor IX. Both A and B will result in long-term

bleeding for the patient. The most common type of bleeding disorder is von

Willebrand disease, affecting up to one percent of the world’s population (Lillicrap

& James 2009). Von Willebrand disease is characterised by mucosal bleeding, this

disease affects both males and females equally. Individuals experience reduced

amounts of von Willebrand factor, or abnormal forms in circulation (Lillicrap &

James 2009). People with haemophilia (PWH) will experience the same oral

diseases as those without. However, dental treatment for PWH may be more

complicated due to the risk of prolonged bleeding due to an inherent platelet

dysfunction. Throughout this project I will include a literature review on the general

characteristics of PWH, oral health of these individuals and the hygienist’s role in

treating these patients. I will also discuss barriers to primary dental care for people

with haemophilia (PWH) and possible solutions to these barriers.

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 Literature Review

General Characteristics of People with Haemophilia:

The most severe form of haemophilia affects males only, the majority of the time.

While it is extremely rare, females can be seriously affected but only if their father

suffers from Haemophilia and their mother is a carrier. Women who are carriers

may suffer from symptoms of mild haemophilia (National Haemophilia Council).

“Haemophilia describes a group of inherited blood disorders in which there is a life

long defect in the clotting mechanism of the blood. PWH are at a risk of

haemorrhaging for longer periods of time, compared to individuals whose blood

factor levels are normal” (Irish Haemophilia Society).

Haemophilia can be classified into three different categories such as severe,

moderate and mild. Severe is when an individual has one percent or less factor,

moderate, between two and five percent factor, and mild between six and forty

percent factor.

Living with Haemophilia:

Haemophilia can be characterised by prolonged bleeding and at times,

spontaneous bleeding (especially into the joints in severe cases). Bleeding into the

joints and muscles is the most common problem for those individuals living with

haemophilia which, in time may lead to joint damage and loss of mobility if

bleeding occurs in the same joint repeatedly (Arruda and High 2008). Individuals

with mild haemophilia may experience spontaneous bleeding and the disorder

may not be diagnosed unless they suffer major trauma or till a time where they

require surgical intervention (Roberts et al., 2010).

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 Oral Health of People with Haemophilia:

Several studies have shown oral health and oral health related quality of life is

poor in this group of patients when compared to the general population.

Dental Caries:

In 1982, the World Dental Federation and the World Health organisation jointly

advocated that certain goals in relation to dental health be achieved by the year

2000 (Carcao et al., 2010). These goals stated “that at least fifty percent of

children aged five to six years should be free of dental caries and on average,

children aged twelve years should have a dmft/DMFT (decayed, missing and filled

teeth because of caries, DMFT representing adult teeth) scores no more than

three. As well as these goals it was also stated that eighty five percent of the

population should still have all their teeth at the age of eighteen. In most high

income countries, these goals are being achieved in healthy children (Carcao et

al., 2010).

Petersten et al. (2005) noted “in Demark there was sixty to seventy percent of five

to twelve year olds free of dental caries”. It has also been shown that these targets

are also being achieved by healthy children and also boys with haemophilia in

other high income countries. Unfortunately, patients with von Willebrand disease

(VWD) are not meeting these targets as only thirty eight percent of the patients

were caries free and had a mean dmft score of 6.8 and DMFT score of 4.0. Sonbol

et al (2001) demonstrated, “that boys with haemophilia have better dental health

than normal healthy children”. It was also concluded that this was a result of

regular dental check-ups, including comprehensive, preventative dental

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programmes given to children and parents with haemophilia from their

haemophilia centres. Individuals with VWD have experienced dental disease

significantly higher than what is seen in patients with haemophilia or in the normal

paediatric population. According to Carcao et al (2010) it appears that patients with

type three VWD are at a greater predisposition to the development of gingivitis and

dental caries, leading to the requirement of dental extractions, restorations and

other procedures that places the patient at increased risk of bleeding.

Periodontal Disease:

Patients with VWD have experienced significant mucosal bleeding in comparison

to PWH. Consequently when they brush their teeth they are at increased risk of

gingival bleeding which results in negative reinforcement brushing behaviour. This

leads to a vicious circle of persistently poor oral hygiene, and consequently

gingivitis and also risk of further gingival bleeding (Carcao et al., 2010). Ziebolz et

al (2011) carried out a case control study to investigate the effect of congenital

coagulation disorders (CCD) on oral health and periodontal bone loss on

individuals with CCD when compared to healthy individuals. It was concluded that

there was “no clinical relevant difference of oral health between patients with CCD

and controls despite better oral hygiene of patients with CCD”. It was also

observed that there was a significant difference in periodontal bone loss; however,

the observed difference was not clinically meaningful. There was no evidence that

oral health or the periodontal status in patients with CCD is worse when compared

to healthy subjects. However, Ziebolz et al (2011) suggested that they needed

larger studies and longitudinal studies to confirm their results.

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 Barriers to primary dental care for people with haemophilia:

According to Kalsi et al. (2012) “PWH may face difficulty in accessing primary

dental care either due to disease specific or patient related barriers”. Access to

dental care for this group of patients may not only be about location or distance

away from the dental surgery. Kalsi et al. (2011) showed that twenty percent of

individuals with bleeding disorders in the UK have experienced being refused

treatment by a dentist. A study carried out between December 2010 and July 2011

included 105 anonymous patient surveys and 50 GDP surveys. The patient survey

demonstrated more patients were affected by patient-related barriers, than

disease specific barriers to access dental care. The GDP survey showed that just

under half of GDP’s were not confident in the dental management of PWH (Kalsi

et al., 2012).

Fear from both the patient and the dentist also contributes to the barriers for PWH

in accessing primary dental care. Avoidance of dental care from this group of

patients is common as well as neglect of oral care. Early intervention and ongoing

prevention is therefore imperative in order to avoid high risk and invasive

procedures (ID Hewson et al., 2011). A study carried by Hitchings (2012) assessed

whether PWH felt they attended a dental professional often enough and if not why.

The study consisted of 12 adults who had not done so in the previous year and

reasons were given throughout the study as to why they had not attended. Twenty

percent of the patients felt that a dentist would not treat them in case they bled.

Other reasons included extrinsic factors such as time and cost, intrinsic values

such fear, additional medical interventions, patients did not feel the need, and risk

of joint bleeds and finally unwilling dentist (Hitchings 2012).

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 Solutions to Barriers:

Many of the barriers to care can be removed by facilitating care in general practice

settings for those patients with a mild haemophilia (Freedman et al., 2009).

“The cost of providing factor replacement therapy (FRP) is substantial. By

reducing the number of patients requiring FRP, more time and resources can be

allocated to patients with severe bleeding disorders while access to care for all is

improved” (Freedman et a.,l 2009). A protocol was designed at the National Centre

for Hereditary Coagulation Disorders, St. James’ Hospital Dublin, to reduce the

number of patients requiring factor replacement therapy. Since the introduction of

the protocol, the waiting time for dental treatment has been reduced dramatically

(Freedman et a.,l 2009).

Education of dental students regarding treatment of patients with special

healthcare needs (SHCN) is a subject of great importance, due impact on future

interactions they will have with these patients (Pani et al., 2012). A study was

carried out on Saudi Arabian dental students to assess their perception on the

adequacy of their education in special care dentistry. It also assessed the

willingness and confidence to carry out effective dental care to patients that

require SHCN. The survey demonstrated that most students were satisfied with

the theoretical training they received; however, the vast majority of the students

felt they lacked clinical experience to treat a patient with SHCN confidently.

Overall, when the willingness of the student was compared to their confidence, the

group of students showed to be more willing to treat individuals with SHCN than

they were confident of their ability to do so (Pani et al., 2012). This study suggests

6
that the more exposure and education students have when training, the more

confident and less fear the students will feel in the future when treating patients

with SHCN. This in turn, helps to reduce barriers for PWH to attend primary dental

care.

Model of Dental Service – Shared Care

‘Shared care’ is essential in order to treat PWH. Brewer et al (2003) states “there

is a need to simplify the process and identify what can be safely carried out on a

shared care basis in General Dental Practice or Community Dental Service”. A

document formulated by Brewer et al (2003) proposes guidance for both doctors

and dentists to help establish what patients require comprehensive dental

treatment in a hospital and those patients that can have some of their treatment

carried out safely in a primary care setting by a general dental practitioner. It has

been suggested that people with severe haemophilia have all of their dental

treatment except for prosthetics such as dentures, carried out in a hospital

environment or in a General Dental Practice or Community Dental Service, but

only if special arrangements had been made with the Haemophilia Centre.

Moderate suffers of haemophilia should be treated in the same manner as severe

patients. Individuals with mild haemophilia may have their dental treatment carried

out in a General Dental Practice or Community Dental Service. However, Brewer

et al (2003) suggests that it is very important that the patient with mild haemophilia

is seen at two year intervals by a specialist team of the Haemophilia Centre to

ensure that they are maintaining their dental health.

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 Special High Risk Group:

Patients with severe haemophilia and von Willebrands Disease (VWD) – type

three, are considered to be at increased risk and also increased exposure to

systemic treatment. Therefore these patients are considered to be high priority

patients (Hewson et al., 2011).

One major issue is the development of inhibitors. Both, patients with severe

haemophilia and type three VWD who require multiple transfusions are at risk of

developing inhibitory antibodies to factor replacement therapy (Carcao et al.,

2010). It is important that prevention is optimised, dental treatment is minimised

and management regimes are in place for all patients with haemophilia in order to

reduce the impact of their oral health on their medical condition, but even more so

in patients with inhibitors to clotting factors.

Dental Treatment Considerations for the Dental Hygienist:

It is the responsibility of the Dental Hygienist as well as other members of the

dental team to develop an understanding of the nature of the condition, how

severe the condition is and also the patient’s previous response to treatment in

order to carry out an effective and safe treatment plan for the patient (Hewson et

al., 2011).

Prevention:

Both dental caries and periodontal disease are two oral diseases in which the

Dental Hygienist can play a significant role in the prevention and in turn prevent

the need of a clotting factor (Brewer et al., 2003). Oral health promotion is the

responsibility of the dental hygienist; this helps to educate PWH the best oral care

8
to prevent the occurrence of oral diseases. Instruction such as brushing the teeth

and supporting tissues twice daily using a fluoride tooth paste, dietary advice

including limiting sugar intake to meal times should be given to this entire group of

patients (Brewer et al., 2003). Appropriate dental care is important for all types of

patients; however, dental care is of significant importance for those individuals

living with haemophilia as it affects the general health of these patients

(Mohammad et al., 2009).

Periodontal Treatment:

The dental hygienist also plays a significant role in the maintenance of periodontal

health, it is imperative that adequate home care is instructed to the patient as well

as regular prophylaxis visits of up to six months in order to prevent bleeding and

tooth loss (Brewer et al., 2003). Periodontal treatment may need to be carried out

over a number of visits in order to prevent excessive bleeding. Chlorhexidine

gluconate mouthrinse may also be used as an adjunct therapy to help with initial

inflammation and is required antibiotics may also be prescribed by the dentist

(Brewer et a.,l 2003). The protocol designed for the management of patients with

hereditary coagulation disorders recommended that an antimicrobial mouthwash

to be used for all treatments to reduced the likelihood of post operative infection

(Freedman et al. 2009). “Post procedure dental pain can normally be controlled

with a minor analgesic such paracetamol, possibly in conjunction with codine”

(Hewson et al., 2011).

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Treatment of the elderly patient:

In the past, the average life expectancy for PWH was forty years of age (Jones

2000). The life expectancy for PWH is much greater now; this is the first

generation of individuals to live into old age. For this reason the dental hygienist

will also be involved in the management of treating oral conditions associated with

the elderly such as Xerostomia, angular chelitis, denture stomatitis and root caries.

These oral conditions may also lead to inadequate vitamin intake, which in turn

may cause atrophy of the oral mucosa and other problems throughout the body.

Medical issues associated with elderly such as cardiovascular conditions, diabetes

mellitus, arthritis, cancer, osteoporosis, dementia and depression may also have

further implications on the treatment a dental hygienist will carryout for this group

of patients. The dental hygienist is a useful and valuable member of the health

promotion team. Educating these patients on the common oral risks linked to

smoking, cardiovascular conditions and diabetes mellitus is imperative

(Holm-Pedersen and Loe, 1996).

Local anaesthesia and pain control:

Hewson et al., (2011) advises that the use of local anaesthetic for this group of

patients must always be discussed with the Haemophilia Centre. Oral injections

with local anaesthetic show varying degrees of risks for PWH. Typically,

infiltrations can be given without systemic haemostatic cover. A local anaesthesia

that contains a vasoconstrictor is advised as it will provide additional local

haemostasis. In individuals with severe haemophilia, the use of regional nerve

blocks, lingual infiltrations and floor of the mouth injections should be discussed

with the haematologist. “In the past, bleeding following deep nerve injections has

10
been implicated in airway obstruction due to haematoma formation in the

retromolar or pterygoid space; therefore inferior alveolar nerve blocks have been

associated with a greater risk”. However, due to modern fine-gauge single use

needles the risk of a haematoma is now considered to be lower (Hewson et a.,l

2011). Where possible, a long-acting local anaesthesia such as bupivacaine

hydrochloride should be used as long lasting local anaesthetics can provide the

patient with up to eight to ten hours of effective pain relief. Patients must be

warned against lip, cheek or tongue biting while numb to reduce the risk of self-

trauma (Hewson et al., 2011).

Local measures for the Dental Hygienist to control bleeding:

Routine dental procedures such as scaling may often cause soft tissue trauma,

resulting in localised haemorrhage (Franchini et al., 2005). “In PWH this may result

in uncontrollable bleeding and therefore may require prophylactic measures pre-

operatively, special caution peri-operatively and special management post-

operatively (Brewer et al., 2006). Local pressure to the area of interest with gauze

may help to control bleeding; if this method is not successful, the use of

tranexamic acid may be introduced. Tranexaminc acid (TA) which is a synthetic

amino acid used in a mouthwash formation has also been used to control oral

bleeding (Lee et al., 2005). Lee et al (2005) carried out a study including thirteen

patients undergoing gingival scaling to assess the effectiveness of tranexamic acid

against factor replacement therapy. The study concluded that “the use of

tranexamic acid after dental scaling is well tolerated by patients and is as effective

as using factor replacement therapy before dental scaling in controlling gingival

bleeding”. By taking this approach, it will also avoid the need for factor

replacement therapy.

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 Discussion and Conclusions

It is evident that most routine dental procedures for this special needs group can

be carried out, and safely managed in a general dental setting following

consultation with the patient’s haematologist and adherence to simple protocols.

‘Shared care’ is a concept that when used, will help in the management of the oral

health of this group of patients. Recognising misconceptions and barriers in

accessing primary dental care will enable further development of the shared-care

approach between general dental services, hospital or community dental services

and the haemophilia centre, optimising regular preventative advice and follow ups

to prevent dental disease and invasive dental treatment requiring haemostatic

treatment.

It is evident that education of the healthcare care workers as well as the patient is

highly important, including early intervention and prevention to make the most

positive changes in the oral health of a PWH. With a team approach amongst

health care workers, the patient and where children are involved, parents and

guardians can help in improving oral health of those PWH. Pani et al (2012) shows

that the more exposure students get in treating patients with special healthcare

needs the more comfortable these students become in treating these patients, and

this is important as these students are the future of dentistry and the more

confident these students become, results in less barriers for patients that require

special healthcare needs to access dental care. There is little research on the oral

health of individuals with haemophilia. There are limited conclusions that can be

made about the oral health of this group of patients as the evidence that is

available is of poor quality, which suggests there is plenty of scope for further

research.

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