Orthodontics and dentistry for the hemophilic patient

Abstract

In this presentation we have contrasted the normal blood-clotting mechanisms with the failure to form blood clots in hemophiliacs due to the absence of protein factors necessary for conversion of prothrombin to thrombin. The statistics, hereditary basis, and long-term disabling consequences of hemophilia to the severely affected patient are described. The systemic means of minimizing severe joint disabilities and serious internal bleeding hazards by employing concentrates of antihemophilic factors to reverse the bleeding defects are discussed. Availability and advantages of the types of concentrates are explained. The fatalistic attitude of hemophiliacs toward hepatitis is discussed, along with admonitions to avoid the use of aspirin, alcohol, and buttock injections. Alternative medications for pain are recommended, and injection sites for pediatric patients are suggested. The details of simplified oral surgical management of hemophilic patients without hospitalization are described, including local anesthetic injection technique, method of performing extractions, general anesthesia technique when indicated, materials for packing of extraction sockets, regimen and precautions in use of Amicar administration for clot maintenance, postoperative diet, and postsurgical activity guidelines. Also noted is the self-administration of intravenous concentrate infusions at home in the event of hemorrhaging, so that bleeding is on the way to being controlled even before the patient reaches the hospital. We avoided orthodontic treatment of hemophilic patients in the past; however, recently developed bracket-fixation techniques and auxiliary aids, along with an enlightened understanding that gingival bleeding is not to be feared, have changed our attitude, and we now treat hemophilic patients in much the same manner as otherwise normal orthodontic patients. Oral hygiene is usually a problem in hemophiliacs. Therefore, much attention is paid to techniques for maintaining gingival health as the best mechanism to avert gingival bleeding. Mention is made of my use of hypnosis and nitrous oxide and oxygen analgesia and their salutary effect on reducing gingival bleeding from 5 minutes to 10 seconds. The beneficial effects of these modalities have been replaced by routinely establishing a unique doctor-patient relationship which inspires the patient's confidence and relaxes and reassures him. Also previously unreported is a method for shrinking an oozing or weeping tag, strand, or miniflap of gingival tissue and cauterizing an oozing site between teeth undergoing orthodontic manipulation. Appropriate timing for orthodontic evaluation is discussed, along with arguments in favor of topical and dietary fluoride ion. It is stressed that prevention of tooth decay and malocclusion decreases the frequency of need for dental restorations and extractions and, therefore, decreases the number of local anesthetic injections which have been a major problem for hemophilics. Finally, a discussion of anesthesia for operative dentistry is presented, along with a recommendation that use of a rubber dam tends to minimize soft-tissue injury and permits the operator to do better dentistry. With use of the current techniques as described in this article, hemophilia should no longer be considered as a contraindication to orthodontic procedures; nor should it be regarded, at least in a dental and orthodontic sense, as a handicapping disease.