Primary Dental Care of Patients with Haemophilia1
Primary Dental Care of Patients with Haemophilia[1]
Dr. Barry Harrington[2]
Introduction
Haemophilia patients are special patients from a dental point of view as routine dental treatment, including extractions, can be and often are is life- threatening.
Primary dental care is where the haemophilia patients themselves, together with their immediate and extended family and friends, all help to prevent dental disease in the first instance.
The two main dental diseases affecting all persons, including those with haemophilia are:
- Dental caries; and
- Dental gingivitis/periodontitis (gum disease).
Both these diseases are practically almost totally preventable within the knowledge that is currently available to those who
seek it.
Dental Caries
Dental caries (holes in teeth) is whereoccur when the hard tissues of the tooth, namely enamel and dentine, are softened by demineralisation caused by the action of bacteria on foods, especially sugars, which produceing an acid that, whichdemineralizesdemineralises the hard tooth surface. This results in a collapse of the hard outer enamel covering of the tooth and eventually leadsing to softening of the dentine, which will eventually increase in size and expose the underlying pulp and nerve tissue, which causinges dental pain, abscesses and death of the living part of the tooth.
Dental pain as a result of caries is only found occurs when the condition has developed for months, if not years of previous excesses, once where the hole has travelled through the hard tooth structures and is adjacent to or near the pulp or nerve tissue.
The main cause of tooth decay (caries) is access to unrestricted eating of sugars which is foundare found in various forms including sweets, cake, biscuits and soft drinks.
Excessive drinking of natural fruit juices instead of water can also cause a demineralisation of the enamel of thze thooth. The very high acidity levels in natural fruit juices can result in caries-like lesions or demineralisation of the tooth structure. This can also cause some of the teeth to be shortened by being ground down, even by the normal eating patterns of the teeth or by the tongue moving over the back of the demineralised tooth structure. This is not to say that natural fruit juices are no good and wholesome; it is excessive consumption is the problem. This is explained more fully in the section on diet.
Prevention of Dental Caries
Fluoride
The best way to prevent dental caries is toby increaseing the resistance of the tooth to decay by making sure that there is enough ingesting ion ofenough fluoride in the diet.
Fluoride is a naturally occurring element. It is found in rocks, clay and water. When present in water, the fluoride is available to helps strengthen the teeooth and make them teeth more resistant to decay.
In areas of the world where the Nnatural water fluoridation is less than 0.8 ppm, this is not enough to be effective. In areas of the world wWhere fluoride in the waterthis is absent,fluoridationit could be beguninstalled as a public health measure, where approximately one part per million of fluoride is added to the public water supply.
The amount of parts per millionfluoride needed in public water depends on climate, etc. Advice from the local Department of Health or from a dentist should be sought, so that the maximum amount can be supplied. All patients, including those with haemophilia, would benefit by receiving fluoride in thethis water supply. The resultant caries disease reduction effect is in the order of 60% worldwide.
In areas where this facility is not available or beyond the resources of the community or the engineering capacity to provide it, then fluoride can be provided in two additional other ways:
In tablet form,which is distributedtaken once per day. T and the dosage depends on the age of the child and the amount of fluoride available in the natural water supply.
Another alternative way of getting your supply of fluoride is Iin a mouthrinse programme, administered once a week by local healthcare personnel. Very little specialised training is required for people to implement a healthcare mouthrinse programme. Rinsing programmes are not advised for children underless than six years of age, as they are unable to spit the mouthwash out fully.
Either of the above two ways are more selective, in that the fluoride is delivered directly to those affected by haemophilia. The availability of fluoride in toothpaste is also essential. Some countries are putting fluoride in salt as another method of community distribution.
The overall costs of any of the above services are insignificant compared to the benefit per head of population, particularly of people withthis haemophilia group. In the case of this susceptible group, then all means or a combination of the above should be seriously considered in co-operation with the local dental authorities in each jurisdiction to implement a cost-effective, efficient programme. The local Department of Health will advise on details of local application of dosages, etc., in all cases.
Fissure Sealants
A second way of reducing the incidence of dental decay is to applying aapply a fissure sealant to the biting surface of back (molar) teeth. This is carried out by drying the biting surfaces of the teeth, applying a special acid for only 15 seconds, followed by washing the tooth surface with water to wash the acid away for 15-/30 seconds to wash the acid away, drying the tooth again and subsequently applying to the microscopically roughened surface of the tooth, a (biz-gma resin) plastic coat to the microscopically roughened surface of the tooth which will in effect seal the cracks on the biting surface of the tooth. This could further reduce the incidence of decay or caries.
Diet
The third method is to cut down between meals, the eating of foods between mealsthat are high in any of the sugars, (fructose, sucrose, maltose, etc.). In effect, eating between meals of any food containing sugars between meals causes an increased acidity of the saliva.where tThe pH can drop below 5.5 (normal 7.0), and allowing demineralisation of enamel and dentine can take place at this level. This also applies to natural fruit juices taken instead of plain drinking water.
It would appear that sugars eaten at main meals, or where the incidence is less than three attacks a day which lasts no more than 45 minutes in all, have an insignificant role, particularly if combated by fluoride applications as mentioned above.
If, however, there is continuous exposure to acidic attacks by continuous eating or drinking with any sugar-containing foods, then the acid attacks could in theory proceed all day. This would result in rampant decay which will progressively cause the teeth to decay within a very short period and then to become unrestorable. This would have a catastrophic effect on any haemophilia patient particularly where replacement factor was unavailable or even restricted. Sugars are found in all processed foods, including sweet cakes, biscuits and soft drinks.
Implementing this dietary restrictive attitude requires co-operation, particularly of the parents, guardians and the haemophilia community. It requires their full co-operation to make sure that the sucrose exposure time is reduced to a minimum and soto further prevent decay.
This dietary restriction of sugars is not easy on the patients themselves, their families and the community. However, it is a proven fact that if it is rigorously adhered to, then the misery of tooth decay could be eliminated almost completely.
These methods, if used in combination, could effectively reduce the incidence of dental caries in haemophilia patients by a significant amount (70-80%) and save a great deal of pain and worry. This problem can affect people of any age, but it affects mainly children and young adults.
Gum Disease
Gum disease is very common in the whole of the universeworld and affects all nationalities, creeds and races, irrespective of social/economic group. While it can aeffect children, it is mainly a disease of adults and the aged.
To develop gum disease, effectively it must be remembered, you one must have teeth. Gum disease is a disease of the gum and bone which holds the teeth in the mouth.
Development of Gum Disease
Saliva, present in peoples' mouths, is a solution which, when released from the glands in the mouth, allows calcium ions to be released.
In addition, the salivary fluid itself consists of long-chained sticky molecules. These long-chained molecules are deposited on the teeth and are worn off most parts of the teeth under normal eating function, except at the point where the tooth enters the gum. This sticky matrix provides then an ideal area for the accumulation of bacterial bugs to attach themselves to the teeth. The calcium ions are also deposited in this matrix film which hardens to form tartar, or calculus.
The sticky matrix or "film" which forms on the teeth is called "plaque". It is a bacterial active matrix and every time the a person feeds him- or herselfthemselves, he or shethey also feeds the bacteria.
The by-products of such feeding of the bacteria causes the development of endotoxins or poisons to develop which creates causes an inflammation of the gingival (gum) tissues such as swelling, bleeding and bad breath.
If this "film" is left undisturbed, then each day allows a new deposit to form on the previous day's deposit. After about four days, if still undisturbed, the bacteria present starts to change to a more aggressive form type of bacteria forms which is much more virulent in causing a inflammation of the gums inflammatory process.
To put this into perspective, if it were possible to have start with a totally sterile mouth, at point A, and then allow the normal bacterial flora development to take place in the mouth, there would be a bacteria count of approximately 400 million bacteria attached to the teeth at the end of 24 hours. It is these bacteria which are the active ingredients in the plaque which causes gum disease.
Dental plaque is also called the invisible enemy, in that, under normal circumstances, it cannot be seen by the naked eye. However, it can be made visible using any strong-coloured vegetable dye, which stains this plaque would be stained from a dark purplypurple/red to a light pink colour, depending on the type of dye used, which is then more easily seen by the patients. Theis dye is sometimes manufactured in tablet form which is chewed and swished around in the mouth. The mouth is then rinsed with water, which washes out the dye, but leaves the plaque remains stained. The objective is to make plaque more easily seen by patients, becauseis that if they patient sees the plaque, they can more easily understand where it is and get have it removed.
The objective of any oral hygiene cleaning procedure is to lower if not eliminate theis bacterial count to a level where the natural disease resistance of the patient to the bacteria can be dealt with by the patient's natural disease resistance.
This cCleaning can be achieved by oral hygiene aids, such as toothbrushes, inter-dental sticks or chewing sticks. The objective, again, is to remove the plaque which is stained. When the amount of plaque is lower than 20% on the tooth surfaces is lower than 20%, there is usually little gum disease.
There are other chemical ways used to lower the bacteria count, such as 0.2% of chlorhexidine, which is the most economical and efficient chemical that can be used to reduce the bacteria count. The level of tThis chemical in a mouth wash has been used for years in a mouthwash and is very effective. However, the teeth must be cleaned initially, otherwise, a brown stain may become visible. This is a surface stain and can be removed; it is not disease.
All toothpastes are simply lubricants with a nice taste and some abrasive properties and a nice taste which may help to make it more pleasant and, therefore, increase the frequency of use.,but normally in itselfUsually it contains no medicinal properties. If hHowever, if it is used frequently, mainly in the morning and before going to bed at night, it is very effective as an aid to brushing/cleaning.
Some toothpastes do however contain fluoride and that element, if present and available, which is absorbed by the outer layers of the enamel. This which produces a much stronger enamel surface, which is more resistant to decay. See the section on fluoride for detailsfaction in paragraph 3.
Some toothpastes can may also contain another agent, namely an active enzyme, which acts on the plaque itself and so reduces it's formation.
Susceptibility to Gum Disease
It would appear that in any given population, even with the most stringent oral hygiene procedures, about 10% of theat population would be susceptible to the by-products of bacteria (, namely endotoxins or poisons), i.e., the inflammatory response is in excess of what might be seen in the normal population. As yet, dDespite extensive research, there is,as yet, no way that these susceptive individuals can be pre-determined. The progression of gum disease in these individuals is faster than normal, resulting in loss of gum from around the teeth and, more importantly, loss of the underlying bony support holding the teeth in position. Stringent oral hygiene will reduce the rate at which this gingival support is lost, but may not eliminate it entirely, even in susceptible patients.
Who Can Support Its Message?
The first and most important group to bring this message to haemophilia patients is the patients themselves, closely supported by their family, enlarged family and friends.
This message must also be supported by the professionals involved with the patient, whether a doctor, dentist, nurse, nurse's aide or and all other healthcare professionals associated with the patient and their his familyies.
In various countries and regions throughout the world, some dental professionals/dentists are trained so to enable direct assistance to the patients and their families.
These healthcare workers (H.C.W.) can be trained to teach the preventive oral hygiene practices to individuals to care for their own teeth. They can and should train the parents and/or guardians of such patients also. One of the important issues is to assist these patients in maintaining their own oral hygiene,. and so prevent caries and gum disease.
Where Do We Start?
It should be the perogativeprerogative of the nNational haemophiliaMemberOorganisation in each country to identify, with the assistance of the National national mMedical and dDental teams' support, all persons with haemophilia. These persons should then be specially targeted with a special dental preventive programme to reduce, if not eliminate, the incidence of preventable dental disease that causes these patients such a problem. In this way, the major problem in providing dental treatment for patients suffering from haemophilia could be diminished to a level which could be managed in each given region in a more economical and efficient way and create less problems for patients.
All patients with haemophilia 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 haemophilia patients would not only allow to identify their dental treatment needs to be identified, but also allow this group of patients and their families to be especially targeted with the preventive dental care message to reduce the progression of existing disease, but also diminishand diminish future dental treatment needs.
This may necessitate, depending on circumstances, yearly reviews, so that the list of patients with haemophilia is constantly updated and modified with the progression of time. In doing so, a realistic, holistic treatment plan is constantly available in to manageable groups of patients who can be treated in at a pre-determined time that is available when any replacement factors become available.
This requires co-operation and co-ordination between the medical and dental team, which is best achieved when they work in an integrated fashion and have a good understanding of the problems that each of the responsible individual teams hasve.
It must be remembered that,prevention in the case of dental disease for patients with haemophilia,prevention is better, cheaper and safer than the treatment of the result of the dental disease itself.
Development of a Dental Team with Regard to Treatment of Patients with Haemophilia
For the best results, tThe dental team which provides services to patients with haemophilia should be part of an overall integrated medical team for the best results to be achieved. As such, the dental team should be housed in, or extremely close by anyto the haemophilia centre. In this way, they should be able to achieve a holistic approach to any individual haemophilia patient.