National Centre for Hereditary Coagulation Disorders (NCHCD)
Comprehensive national centre for the treatment of adults with coagulation disorders in Ireland.
Extensive multi-disciplinary team
Consultant-led dental team - 3 sessions per week
SCD Post-Grad, student nurses & hygienists from Dublin Dental Hospital
2 on-site dental surgeries
Full range of restorative, surgical, preventive care
IV sedation for phobic and anxious patients
Max Fax input once per month
The Dental Liason Nurse
Co-ordination and administration of clotting factors for patients attending the dental clinic
Support and advice for patients
Medical Education of Dental Personnel
Dental Education of Nursing/Medical staff
Development of new guidelines, policies and procedures in relation to service
New treatment protocol
2006: new WFH guidelines on dental treatment of patients with inherited bleeding disorders.
2005: Lee et al - effectiveness of Tranexamic Acid mouthwash for dental scaling in pts with haemophilia
Proposal to the Coagulation Team to implement new dental protocol at the Dublin Haemophilia Centre
Only pts with severe or moderate haemophilia needed to receive continuing dental care at the centre
Pts with mild disease discharged to General Practice for continuing or shared care
All patients being discharged from the centre given final dental appointment and advice.
Newly diagnosed or adolescents transfered from childerens hospital assessed by medical/dental team categorised according to whether need shared care or continuing dental care at centre.
A follow up letter including diagnosis, guidelines and contact details for the centre posted to the patient to give to the GDP
Telephone contact assured for support and queries from patients and dentists
Development of leaflet
Fiske et al. Exressed needs of Patients with Haemophilia JDOH 2000
Audited - House Officer
Dental attendance query at yearly coagulation review appt.
Development of supporting information leaflet by dental nurses
Haemophilia and Dental Care Prepared by K. Dineen, C Edmonds, E. Lawless with the Irish Society of Haemophilia
It is important for people with bleeding disorders to take good care of their teeth and gums. Making regular visits to the dentist will reduce the chances of future problems like extractions or infections which can lead to further complications Sometimes dental care falls to the bottom of a very busy list of things to do. However, when you have been diagnosed with a bleeding disorder such as Haemophilia or Von Willebrands Disease, taking care of your teeth needs to be given high priority. Attending the Dentist If you have mild or haemophilia (30% or greater) it is fine to attend your own dentist for routine care such as check ups, filllings, scale and polish and other things like root canal, crowns and cosmetic work. You should inform your dentist about your bleeding disorder and advise him/her that further information is available from your haemophilia treatment centre. However, should you need a tooth extraction, some deeper injections, gum surgery or a dental implant or then your dentist should contact your haemophilia consultant or nurse for advice as this type of treatment will usually need to be provided in a specialist centre. The contact details are on the back of this leaflet Your dentist will chat with you about how often you need to attend for check ups and give you information how to prevent dental problems. Everyone with haemophilia should attend their dentist at least once a year Taking Your Oral Health Seriously
Can I use my local dentist? Being able to visit a local dentist is very important as it allows you a get full range of care in a convenient location. In most cases, once your dentist has more details and guidance about your bleeding disorder from your haemophilia centre they are more than happy to safely carry out routine dental care. Information on the back of this leaflet will advise your dentist how to make contact with your haemophilia team who are all very experienced and knowledgeable about dental treatment for persons with a bleeding disorder and they will give your dentist the necessary assurances. F.A.Q
Should I brush my teeth if my gums bleed? Gums that bleed regularly after tooth brushing are a sign of early gum disease which is very common, but it is important that this does not progress to more severe gum problems. The recognised treatment is to visit your dentist or hygienist for advice and to get the teeth professionally cleaned and monitored. Your dentist might advise for you to use a medicated mouthwash and will recommend methods for brushing and cleaning your teeth more effectively. Your bleeding disorder may mean that your gums bleed a little more easily and for a little longer until the gums heal but it is important during this time to continue toothbrushing with a soft brush to remove the plaque and food debris which causes the gum disease. F.A.Q
What Happens if I need a tooth extraction? This should always be co-ordinated by your haemophilia centre so that it can be carried out safely with some special precautions to prevent bleeding afterwards. Depending on the severity of your bleeding disorder your haemophilia team may choose to give you factor replacement therapy and/or tablets before the tooth is extracted and a special mouthwash afterwards. In addition the dentist may stitch the wound and use a special surgical packing to stop any bleeding. This method has been used very successfully for many years to overcome the problems previously associated with extracting teeth and has been recommended by the World Federation of Haemophilia (WFH) F.A.Q
It is recommended that you liase with the patients haemophilia team for advice regarding the severity of your patients bleeding disorder before undertaking any treatment for the first time. Patients with moderate or severe haemophilia (less rthan 5% clotting factor) should usually be seen in a specialist setting. However, patients with mild Haemophilia and Von Willebrands Disease can safely receive most of their dental care in general dental practice. It is essential that a rigorous preventive regime is followed to minimise the need for future surgery or development of periodontal problems. General Tips Comprehensive up to date guidelines for treating patients with mild haemophilia can be found at www.wfh.org Fillings, scaling, root canal and all cosmetic and preventive care can be carried out routinely on patients with mild disease, however care should be taken with the soft tissues, especially the use of impression trays, aspirators and x-ray films in the floor of the mouth and retromolar region. Areas of Concern Extractions and surgery, gingival surgery/deep root planing and implant placement all pose a bleeding risk even in patients with mild haemophilia so it is essential that these procedures are carried out with the necessary pre-operative special measures such as factor replacement, DDAVP or Cyclokapron Tablets, suturing and packing. Please refer your patient with a dental treatment plan and suitable radiograph to your nearest haemophilia centre, if such procedures are required, when the on-site dental team will arrange and carry out the treatment if required. Local Anaesthetic and Analgesia Infiltration injections pose no risk to patients with haemophilia. Inferior Dental Blocks (ID Blocks) however, potentially could cause a muscle bleed which might compromise the airway, so should be avoided where possible in patients with less than 30% factor levels. Alternative techniques should first be considered in order to anaesthetise posterior molar teeth; such as buccal infiltration with articaine or intraligamentory anaethesia. If an ID Block is unavoidable, patients with less than 30% factor levels will require factor replacement prior to administration. Take care when recommending pain relief, NSAID;s and Aspirin are likely to aggrevate a bleeding condition so paracetamol or codeine based products are more appropriate. Information for Dentists
www.wfh.org GUIDELINES FOR DENTAL TREATMENT OF PATIENTS WITH INHERITED BLEEDING DISORDERS Andrew Brewer Oral & Maxillofacial Surgery Department The Royal Infirmary, Glasgow, Scotland Maria Elvira Correa Centro de Hematologia e Hemoterapia da Unicamp Sao Paulo, Brazil On behalf of World Federation of Hemophilia Dental Committee
Haemophilia and Dental Care
Thank - you
Brewer A, Correa M.E. (2006) Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders. World Federation of Haemophilia Monograph no. 40.
Fiske J. Ford H, Savidge G, Smith M. (2000) The expressed dental needs of patients attending a Haemophilia Reference Centre. Journal of Disability and Oral Heath 20 (5).
Lee A, Boyle C, Savidge G, Fiske J. (2005) Effectiveness in controlling haemorrhage after dental scaling in people with haemophilia by using tranexamic acid mouthwash. British Dental Journal 198:33-38.
Dougall A ,Fiske J. (2008) Special Care Dentistry-Safety. British Dental Journal 204 (15)