Blood Disorders: Hemophilia and Anemia

Within the vascular system of the human body, blood flows in its liquid state, and the clotting components flow in their inactive forms. When activated, the clotting elements go through a series of responses to produce a clot at the site of injury resulting in repair of the injured area. If the normal reaction is defective, either by means of a bleeding disorder, abnormal clotting or blood deficiency, then the result is an unstable hemostasis system. Mainly, multiple inherited conditions such as hemophilia or acquired abnormalities like anemia can seriously compromise hemostasis. Furthermore, some drugs, especially from the counter medicine, can adversely aggravate the situation. As such, administrators of health care, especially oral care providers, must be aware of the impact of bleeding disorders during management of dental patients. Concurrently, recognizing the condition at its initial stages may assist in the systematic pathological process of dental practice. This can also help in the management of invasive procedures as they prolong bleeding, impede proper wound healing, and increase risks of infection. However, practitioners who have knowledge about the preoperative systematic measures and the intraoperative management of hemostasis best accomplish restorative and surgical dental care without putting the health of a patient at risk. 

Hemophilia and Anemia

The prevalence and incidence of blood disorders manifest itself in several ways. Primarily, a blood disorder affects any of the three main components of blood, which include red blood cells, white blood cells, and platelets.  Virtually, this condition influences the liquid portion of the blood also called the plasma. Some of these issues may be genetic, acquired after birth or as one grows old. Although there are other blood disorders, anemia and hemophilia are some of the most common. While anemia is a common condition, hemophilia is a rare bleeding disorder where the blood does not clot normally (Anderson et al., 2013). The condition is inherited, which means it is passed from parents to children. People suffering from hemophilia lack the clotting factor, a protein needed to control bleeding. On the other hand, anemia is the condition triggered by lack of enough healthy red blood cells protein, or hemoglobin. The cells play an important role because they are oxygen carriers to the organs. Without enough red blood cells, the body is likely to experience a shortage of oxygen and carbon dioxide. In most cases, anemia is mild, but in sometimes it can get severe, and people may experience faintness, sweating, weak and increased heart rate, or fast breathing. Severe anemia may result in lower leg cramps, and in extreme cases, brain damage. Lack of enough red blood cells may also trigger heart-related conditions because the heart is required to work harder to supply oxygen to the body. Unfortunately, people who suffer from hemophilia are at a higher risk of developing anemia, especially if they lose a lot of blood.

Why It Is Important for Dental Hygienist to Understand Hemophilia and Anemia

For prior diagnosing of oral bleeding disorders, dental hygienists must understand their elements for proper management of their oral patients. People with hemophilia may experience increased bleeding in the lifetime, with the frequency being determined by the severity of the condition. The incident of dental caries is higher in patients with bleeding disorders, which may be due to lack of proper oral hygiene or dental care.  According to Israels, Schwetz, Boyar, and McNicol (2006), understanding how hemophilia and anemia manifest themselves is relevant to the dental hygienists attending to patients with bleeding gums or dental caries. This is because management of patients with bleeding disorders is dependent on the severity of the condition and the complexity of the required dental procedure. In patients with mild bleeding, it is easy to manage since only a slight modification is needed. However, for patients who have severe bleeding, the first goal of the dentist would be to restore and manage the hemostasis system to an acceptable level. Therefore, most surgical procedures contain the high risk so safety procedures are necessary.  For patients with hemophilia, additional postoperative measures may be required after extensive surgeries. 

Potential Oral Findings 

During dental procedures, there are several findings likely to be found in patients with hemophilia or anemia. According to Gupta, Epstein, and Cabay (2007), platelets deficiency can cause ecchymosis in oral mucosa leading to gingival bleeding. The disorders may be present alone or together with gingival hyperplasia especially in cases of leukemia. Blood degradation or hemosiderin can cause teeth browning due to extreme bleeding. People with hemophilia may experience multiple bleeding, with the frequency depending on the severity of the condition. There might be a possibility of dental caries and periodontal diseases due to lack of proper oral hygiene or neglecting professional dental care for prolonged periods.

Dental Management 

During any dental care procedure, dentists should start with evaluating the history of a patient with standard medical procedures. According to Gupta et al. (2007), the patient should be asked about previous history of any prolonged bleeding after a dental extraction or from gingivae. Nasal or oral bleeding history should also be considered. Similarly, dentists should take into account the family history to check for conditions such as hemophilia. The other aspect that oral care providers need to focus on is the complete drug history of the patient. For example, if the patient has been on anticoagulant drugs, Gupta et al. (2007) recommend that it is important to consult with his or her physician before starting on any treatment procedures. A general examination of the patient might indicate a tendency to bleeding disorders. Patients who exhibit potential bleeding disorders should undergo laboratory investigations to check CD4 blood counts and clotting abilities (Gupta et al., 2007). The tests are used to determine whether the patient is anemic or suffering from hemophilia.

Specific Instructions to Include in Treatment Plans for Patients with Hemophilia and Anemia 

Before starting on the treatment procedure of patients with hemophilia and anemia conditions, dentists should take into consideration certain technical measures. Firstly, as Gupta et al. (2007) explain, examination of an oral care patient with a history of medical problems should be extensive to evaluate the overall health of the patient. Physical assessment should include examination of the patient’s general appearance, such as the color of the nails, skin, blood pressure, pulse rate, temperature rate, among other comprehensive tests as required by medical examination standards. Secondly, if the patient has problems identified at an examination and have not been reported to any health practitioner, the dentist should collaborate with the appropriate specialist. This can help to identify potential pathology and make the relevant referrals needed for further medical evaluation. Thirdly, for patients with pre-existing conditions such as hemophilia and anemia, preparation for dental treatment should include the determination of the disease status. Virtually, patients with blood disorders will be required to undergo some treatment before the dental hygienist can initiate the oral care procedure. 

Special Problems That May Need a Referral

During dental care of patients with extreme cases of hemophilia, complications are imminent. According to Israels et al. (2006), the dental hygienist should consult the patient’s hematologist before initiating treatment. For patients taking warfarin, their international normalized ration should be tested before a surgical procedure. If their INR values are above 3.0, then Gupta et al. (2007) assert that a physician referral is required. Although there are other severe cases, this one is, however, one of the rarest cases that are likely to trigger a referral. 

In the last decade, dentists were facing increased cases of inherited, acquired, and drug-related conditions associated with abnormal blood disorders. These raise the possibility of excessive bleeding, poor wound repair, and possible severe infections on the exposed tissue. For proper management of such cases, dentists must adhere to a clear and open communication process with the patient and their hematologist. This approach will make sure that the dental hygienist has obtained complete and important information on the severity or mildness of the patient’s condition. Too often, patients suffering from hemophilia assume that any amount of bleeding is normal because of their condition. Thus, this procedure helps inform the patient of the risks involved. It also enhances alertness on the part of the practitioner and patient as well, thus minimizing the risk. Lastly, patients with bleeding disorders are may turn up in emergency departments believing they have an abnormal bleeding. As such, dentists must be well equipped to deal with intraoperative hemorrhage in a calm and efficient manner. 

References

Anderson, J. A., Brewer, A., Creagh, D., Hook, S., Mainwaring, J., McKernan, A., Yee, T. T., & Yeung, C. A. (2013). Guidance on the dental management of patients with hemophilia and congenital bleeding disorders. British Dental Journal, 215(10), 497-504.

Gupta, A., Epstein, J. B., & Cabay, R. J. (2007). Bleeding disorders of importance in dental care and related patient management. Journal of the Canadian Dental Association, 73(1), 77-83.Israels, S., Schwetz, N., Boyar, R., & McNicol, A. (2006). Bleeding disorders: Characterization, dental considerations and management. Journal of theCanadian Dental Association, 72(9), 827.