|Year : 2016 | Volume
| Issue : 4 | Page : 271-274
Oral bleedings in hereditary blood coagulation disorders: A retrospective study
Rekhalakshmi Kamatham, Kumar Raja Gaddam, Sivakumar Nuvvula
Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
|Date of Web Publication||23-Dec-2016|
Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Aim: To analyze the oral bleeding episodes in individuals with hereditary blood coagulation disorders (HBCDs).
Materials and Methods: Information regarding oral bleeding episodes (gingival, tongue, lip, cheek, and palate) as well as treatment rendered for those individuals was extracted retrospectively from the records of the local hemophilia society. The obtained data was analyzed from the pediatric dentist's point of view.
Results: Gingival bleedings were relatively high (85.5%) compared to other tissues (14.5%). Most of the gingival bleedings were found in individuals aged between 6 and 12 years (58.2%), corresponding to the period of mixed dentition, whereas soft tissue bleedings were high in the younger age group (<6 years) (57.7%). On observing the primary treatment rendered, 55.5% and 47.3% of individuals who needed extractions and scaling, respectively, required factor infusion.
Conclusion: The present study highlights the importance of anticipatory guidance in this group of individuals and reminds the hematologists/physicians to work in collaboration with pediatric dentist/dentist, to improve the oral health-related quality of life in HBCDs.
Keywords: Bleeding, coagulation, disorders, oral
|How to cite this article:|
Kamatham R, Gaddam KR, Nuvvula S. Oral bleedings in hereditary blood coagulation disorders: A retrospective study. J NTR Univ Health Sci 2016;5:271-4
|How to cite this URL:|
Kamatham R, Gaddam KR, Nuvvula S. Oral bleedings in hereditary blood coagulation disorders: A retrospective study. J NTR Univ Health Sci [serial online] 2016 [cited 2020 Apr 5];5:271-4. Available from: http://www.jdrntruhs.org/text.asp?2016/5/4/271/196561
| Introduction|| |
World federation of hemophilia surveyed 89% of world population in 2007, and reported 2, 13, 904 identified individuals with hereditary blood coagulation disorders (HBCDs) that included hemophilia A and B, Von Willebrand disease (vWD), and other bleeding disorders such as hereditary thrombotic tendencies, anomalies in fibrinogen to fibrin conversion, contact factor, extrinsic, and common pathway factor deficiencies.  Most often, the diagnosis of these disorders were made around 6-24 months of age with 13.6% diagnosed due to persistent oral bleeding that made the highly vascular oral cavity gain more attention. , Despite the fact that the dentist might be the first person to encounter, these disorders are not well-understood in the dental setting. As an extension, dental professionals even avoid individuals diagnosed with these disorders time to time, contributing to the complication of the patient's simple needs.  As reported earlier, 29.1% of bleeding events in hemophiliacs per year on an average required factor infusion, of which 9% episodes were related to oral structures.  These individuals experience many oral bleeding episodes during their lifetime, primarily due to traumatic injuries, poor oral hygiene practices, and/or reasons of iatrogenic nature. ,,,, Though meager studies regarding frequency of oral bleeding in HBCDs are reported, ,, the literature did not focus on age and type of treatment rendered. The crucial aspects that can determine the frequency of bleeding were not discussed in previous studies as well. Hence, this retrospective study was undertaken from the records of the local hemophilia society to extract information regarding the frequency of oral bleeding episodes as well as treatment rendered for these individuals and analyze the data with a pediatric dentistry perceptive as the primary focus.
| Materials and Methods|| |
After obtaining necessary permission from the concerned authorities, a 3-year data from April 2010 to March 2013 was extracted from the computers and records separately, for determining the frequency of gingival bleeding and other soft tissue bleeding (tongue, lip, cheek, and palate) among the individuals who visited the society. The data regarding episodes and treatment provided was segregated based on the gender, age, type, and severity of the disease and descriptively analyzed.
| Results|| |
A total number of 324 individuals visited 2,651 times to the hemophilia society with bleeding during the selected period, with age ranging from 5 months to 58 years. When the oral bleedings alone were considered, a total number of 91 individuals reported to the society with 153 episodes of gingival bleeding and 24 individuals with 26 episodes of other soft tissue bleeding in the oral cavity; the details of which are represented in [Table 1] and [Table 2]. The primary treatment rendered for oral bleeding episodes are presented in [Table 3]. Approximately 75,000 international units (IU) were consumed to stop oral bleeding episodes, with a mean of 500 IU, 950 IU, and 1500 IU for mild, moderate, and severe hemophiliacs, respectively.
|Table 1: Episodes of gingival and other soft tissue bleedings with respect to gender, type, and severity of deficient factor|
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|Table 2: Episodes of gingival and other soft tissue bleedings with respect to age and factor deficiency |
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| Discussion|| |
This retrospective analysis demonstrated that gingival bleeding episodes are relatively high, compared to other soft tissue bleedings, which is in accordance with another study that reported 64% of oral bleeding from the gingiva and 30% from other soft tissues.  However, these findings are contradictory to a previous study that reported gingival hemorrhage to be extremely rare, and additionally projected the frenulum of tongue as the most common site for oral bleeding.  The frequency of gingival and soft tissue bleeding decreased with age in the present retrospective study. Most of the gingival bleeding episodes were found in individuals aged between 6 years and 12 years, which corresponds to the period of mixed dentition. This increased frequency of bleeding can be attributed to the exfoliation of primary teeth and eruption of permanent teeth, as these factors pose some discomfort during oral hygiene practices, which in turn, predispose for the accumulation of plaque, leading to gingival inflammation and bleeding. Moreover, the fibrinolytic activity in gingival fluid is increased during inflammation, compared to healthy gingiva.  The presence of fibrinolytic activators associated with oral epithelial cells and saliva as well as the absence of fibrinolytic inhibitors, thus, increase the tendency for gingival bleeding irrespective of the severity of the disorder,  which is evident in the present study as well. The frequency of soft tissue bleeding was high in the younger age group (<6 years) that could be attributed to high physical activity at this age and possible predisposing factors such as the lack of motor coordination and placing sharp objects in the mouth. Though the frequency of bleeding episodes are low in older age, poor oral hygiene practices are always a risk factor for both spontaneous as well as provoked bleeding, and the awareness of the medical condition in these individuals could be the reason for less frequent bleeding.
The options available in the existing literature to control bleeding during primary dental care or during bleeding episodes are factor replacement therapy (FRT), release of endogenous factor stores and/or clot stabilization by antifibrinolytic agents, fibrin glue, Ankaferd blood stopper (new hemostatic agent from a herbal origin), FRT being the main mode of treatment. ,,,,,,,,,, According to the records of the society considered in the study, dental extractions were performed with minimal soft tissue trauma under topical anesthesia for mobile teeth or intraligamentary anesthesia for nonmobile teeth, with pressure application over the socket. Majority with mild hemophilia underwent extractions either under topical or systemic tranexamic acid, whereas moderate and severe hemophiliacs underwent either with a combination of desmopressin or factor concentrate along with tranexamic acid. Dental scaling was performed either under desmopressin or factor concentrate, depending on the severity. Most other soft tissue injuries required factor concentrates along with systemic tranexamic acid and they were monitored over a period of 2-5 days. The consumption of factor concentrates to stop the other soft tissue bleeding was much higher than gingival bleeding. These bleeds were life-threatening, gained better attention by both the dentist and the medical professionals, and hence, required high factor concentrates. Few bleeding episodes with severe hemophilia were refractory to the treatment and hence, referred to higher hemophilic center for treatment and their data was not available.
The present retrospective analysis illuminates the essentiality of dentists to focus on primary level of prevention in these individuals with special health care needs. In addition, it highlights the importance of implementing local measures to control bleeding, such as pressure application, surgical packs, local antifibrinolytic agents, and/or desmopressin rather than direct systemic replacement therapy and a need for further research on the role of these measures during dental treatments.
In summary, mixed dentition age group was associated with higher gingival bleeding, whereas higher number of children under 6 years of age had other soft tissue injuries of oral cavity. Factor consumption was in line with severity of deficiency as well as bleeding into tissues. The present study highlights the essentiality of anticipatory guidance to decrease the dental morbidity as soon as the diagnosis of the disease. Proper collaboration of the pediatric dentist with the hematologist/physician can improve the oral health-related quality of life in HBCDs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]