Paper cuts, falls, trauma, toothbrushing – there are many ways in which the average person may find themselves bleeding. In the UK, around one in 2,000 men, women and children are diagnosed with a bleeding disorder (BD), caused by hereditary factors or a spontaneous gene mutation. This demographic is small but important due to the impact BDs have on morbidity and mortality. The three most prevalent BDs are Haemophilia A and B, and Von Willebrand disease. They all affect people indiscriminately, with diagnosis often coming without warning where there is no family history of BDs.
Bleeding disorders pose a challenge for dentists when it comes to delivering a restorative treatment. A simple procedure can potentially result in life-threatening bleeding if there is insufficient awareness and preventative measures are not taken. This may be one of the factors for why BD patients are less likely to visit the dentist, with the impact of this being a higher risk of developing an oral disease. Encouraging a consistent oral hygiene routine and regular dental appointments for affected patients can lower the risk of adverse oral health outcomes and make solutions such as root canal treatments safer.
Blocking and clotting
Platelets in the blood are required to start the formation of a blood clot, producing the enzymes and clotting factors needed to stop the bleeding and then contract after completion. Those with haemophilia have fewer clotting factors, meaning wounds bleed for longer. For patients with Von Willebrand’s disease – between 0.8 to two per cent of the population – deficiency in Von Willebrand’s factor, a glycoprotein that binds the platelets together, leads to difficulties in forming the platelet plug and the final fibrin clot. This also extends bleeding time.
Bleeding disorders can lead to major oral health neglect once issues have already developed. Bleeding of the gingivae during toothbrushing is often a consequence of gingival diseases. Bleeding disorder patients may fear the risk of bleeding and avoid either brushing effectively or consistently, or brushing at all. A neglected oral cavity can lead to periodontitis, alveolar bone loss, gingival recession and caries, presenting the need for restorative dental treatments when function and aesthetic is lost.
Risk reduction
To combat oral health neglect, practitioners must promote the importance of regular dental appointments, toothbrushing and interdental brushing: the more the teeth and gingivae are cleaned, the less likely they are to bleed and the healthier the oral cavity will be. However, patients should be warned that brushing and interdental cleaning may cause bleeding in the first few days, but once the gingivae are healthy than they are less likely to bleed.
Treatment preparation
As saving an infected or damaged tooth is safer than extracting one for BD patients, endodontic treatments are preferred where at all possible. Dentists should be fully prepared to deliver safe treatments, identifying those with a bleeding disorder, and receiving the contact details for the patient’s haemophilia centre in case the dentist needs to correspond about previous healthcare treatments.
For root canal work and the subsequent restoration, BD patients can be prepared by being prescribed tranexamic acid and epsilon aminocaproic acid beforehand to control the bleeding – this should be continued with for a total of seven days afterwards. Using an electronic apex locator is a safe and precise way of determining the working length, ensuring that the treatment does not risk bleeding by going past the apex. In the event of a bleed, there must always be haemostatic agents available in the dental practice and patients should be recommended not to rinse and spit up to 24 hours after the procedure to avoid dislodging the clot.
To finish a root canal treatment, a crown or effective composite restoration provides protection and prevents the tooth from fracturing. Choosing materials which maximise treatment success and promote long-term stability is key. This means clinicians can reduce the need for a BD patient to return for follow-up appointments. Besides saving both parties time, this also minimises the need for further retreatments which may increase the risk of bleeding – especially in the case of restoration failure which prompts an extraction.
The Filtek One Bulk Fill Restorative from Solventum, formerly 3M Health Care, offers a solution to simplify restorative treatments. Its excellent adaptation enables dentists to access deep cavities, removing the need for layering. Using the Filtek One Bulk Fill Restorative supports the first-class restoration work that can be carried out on BD patients with ease and safety.
A BD should not inhibit a patient’s oral health. Promoting consistent oral hygiene for BD patients is crucial for their long-term health, and dental practitioners should be prepared for the challenge of treating them for long-term success.
For more information visit www.solventum.com/en-gb/home/oral-care/