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CDHO Advisory: Hemophilia, VWD or Other Bleeding Disorder

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with hemophilia, von Willebrand disease or other bleeding disorder.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Hemophilia, von Willebrand Disease or Other Bleeding Disorder, 2019-11-04

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Hemophilia, von Willebrand disease or other bleeding disorder

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have hemophilia, von Willebrand disease or other bleeding disorder, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with hemophilia, von Willebrand disease or other bleeding disorder.

MAJOR OUTCOMES CONSIDERED

For persons who have hemophilia, von Willebrand disease or other bleeding disorder: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Bleeding disorder, a general term for a wide range of conditions that

  1. lead to impairment of blood clotting, which results in
    1. prolonged bleeding 
    2. continuous bleeding
  2. are classified as
    1. coagulation factor deficiencies
      1. congenital
        1. hemophilia
          1. hemophilia A
          2. hemophilia B
        2. von Willebrand disease
        3. other factor deficiencies (rare)
      2. acquired
        1. liver disease associated with
          1. drugs of abuse, such as alcohol or heroin (CDHO Advisory) 
          2. viral hepatitis associated with illicit injection drug use  (CDHO Advisory) 
          3. vitamin K deficiency (CDHO Advisory) 
        2. medications, including those that aggravate bleeding
    2. systemic conditions that interfere with coagulation, such as
      1. renal failure and uremia (CDHO Advisory) 
      2. liver failure (CDHO Advisory) 
      3. bone marrow failure 
    3. thrombocytopenia 
    4. defects in clotting processes that involve fibrin.

Other terminology is as follows.

  1. Angiodysplasia, a condition of the colon in which enlarged and fragile blood vessels cause bleeding into and therefore from the gastrointestinal tract.
  2. Clotting factors, proteins in the blood that 
    1. act in sequence to stop bleeding by forming a clot
    2. result in bleeding disorders when deficient in
      1. factors VIII and factor IX, the most commonly deficient 
      2. factors I, II, V, VII, X, XI, or XIII, which are only rarely deficient. 
  3. Disseminated intravascular coagulation, in which certain proteins in the blood become abnormally active causing small blood clots in the liver, brain or kidney. 
  4. Ecchymosis
    1. the purple or black-and-blue area resulting from a bruise 
    2. the escape of blood from blood vessels into the surrounding tissue to form a purple or black-and-blue spot on the skin. 
  5. Fibrin, a protein in the blood plasma that 
    1. is essential for the coagulation of blood clotting 
    2. is formed by many as 20 different clotting factors which act together with other chemicals.
  6. Hemarthrosis, bleeding into a joint.
  7. Hematoma, localized swelling filled with blood.
  8. Hemophilia, a group of bleeding disorders in which clotting is abnormally slow.
  9. Menorrhagia, excessive uterine bleeding occurring at the expected intervals of the menstrual periods.
  10. Mutation, permanent changes in genes.
  11. Palliative care, services of care for persons towards the end of life with terminal illnesses, when the focus of the care 
    1. is relieving symptoms
    2. attending to physical and spiritual needs.
  12. Petechiae, round  pinpoint spots on the skin 
    1. caused by bleeding under the skin
    2. appear red, brown or purple
    3. may look like a rash
    4. are flat and do not lose their colour when pressed
    5. may indicate serious conditions. 
  13. pH, hydrogen ion concentration, expressed as a set of values ranging from 1 to 14 where 1 is very acidic; 7, neutral; and 14, very alkaline.
  14. Platelets, cells in the blood that help the blood clot.
  15. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from serious illness or its treatment.
  16. Thrombocytopenia, any disorder in which platelets are abnormally low, and which may be associated with abnormal bleeding.
  17. von Willebrand disease (VWD), comprises a family of hereditary bleeding disorders caused by abnormality of the von Willebrand factor (VWF).
  18. von Willebrand factor (VWF), a protein which 
    1. is required for normal platelet function
    2. is normally the carrier for factor VIII
  19.  Wilms’ tumour, cancer of the kidney, one of the most common types of childhood cancer, affecting 1 in every 10,000 children.

Overview of hemophilia, von Willebrand disease or other bleeding disorder

Resources consulted

Occurrence, types and causes of bleeding disorders generally

Bleeding disorders

  1. occur when certain clotting factors are low or missing, causing bleeding problems which range from mild to severe
  2. may be present at birth, arising from rare inherited disorders 
  3. occur as various types, including 
    1. hemophilia A
    2. hemophilia B
    3. von Willebrand disease 
  4. have various causes, including
    1. immune system-related effects, such as 
      1. allergies to medications
      2. reactions to infection 
      3. antibodies’ destruction of blood clotting factors 
    2. cancer, especially of the blood and blood forming organs, such as leukemia
    3. thrombocytopenia
    4. bone marrow disease
    5. liver disease 
    6. disseminated intravascular coagulation  
    7. medications that
      1. aggravate bleeding
      2. involve long-term use of antibiotics 
    8. vitamin K deficiency.

Occurrence of hemophilia 

Hemophilia

  1. occurs in persons of all races and ethnic origins
  2. is a life-long condition
  3. is hereditary, passed from mother to child, and
    1. therefore occurs in children
    2. occurs in its most severe forms
      1. in males, almost always  
      2. in which the blood clots abnormally because it is lacking a blood-clotting factor essential for stopping or preventing bleeding
    3. seriously affects females only if the father is a hemophiliac and the mother is a carrier, a rare occurrence
  4. reduces quality of life for women who are carriers and who also have symptoms of mild hemophilia
  5. occurs  as
    1. hemophilia A, which 
      1. affects fewer than 1 in 10,000 people, about 2500 Canadians
      2. is also called
        1. factor VIII deficiency hemophilia
        2. classical hemophilia, the most common of the factor deficiencies
    2. hemophilia B, which
      1. affects about 1 in 50,000 people, about 600 Canadians
      2. is also called
        1. factor IX deficiency hemophilia
        2. Christmas disease2
  6. is classified according to its severity
    1. mild
      1. clotting factor VIII or clotting factor IX level is 5 percent of normal or greater
      2. may only be recognized with excessive bleeding after major injury or surgery 
    2. moderate
      1. clotting factor VIII or clotting factor IX level is 1 percent to 5 percent of normal
      2. bleeding usually follows a fall, sprain, or strain 
    3. severe
      1. clotting factor VIII or clotting factor IX level is less than 1 percent of normal
      2. bleeding occurs spontaneously one or more times per week for no apparent reason.

Occurrence of von Willebrand disease

von Willebrand disease

  1. is the most common of all bleeding disorders
  2. is the most common hereditary bleeding disorder, affecting  at least 0.1% of the Canadian population; i.e., about 37,000 Canadians, although many others remain undiagnosed. (With up to 9 out of 10 persons with VWD being undiagnosed, prevalence estimates are up to 1% of the world’s population.)
  3. in occurrence is
    1. unrelated to ethnicity
    2. is distributed equally between males and females
    3. is generally less severe than other bleeding disorders
  4. occurs as three types 
    1. type 1, mild to moderate, the most common form, which
      1. affects about 75 percent of persons with von Willebrand disease 
      2. is characterized by normal von Willebrand factor that is insufficient in quantity
      3. creates no problems for many persons until they encounter serious injury or surgery causing heavy bleeding
      4. for other persons creates mild symptoms, such as  
        1. bleeding from the gums
        2. menorrhagia
        3. minor bruises  
        4. prolonged bleeding from cuts
    2. type 2, usually mild, which
      1. occurs in 15–20 percent of all cases of von Willebrand disease
      2. is characterized by flawed von Willebrand factor, often in the normal range in the blood, but which functions inadequately  
      3. exists as several sub-types of type 2 von Willebrand disease 
    3. type 3, most severe, a complete lack of von Willebrand factor, which
      1. is rare
      2. prevents the platelets from properly forming clots.

Risk factors and causes of bleeding disorders, hemophilia and von Willebrand disease

Risk factors of

  1. bleeding disorders include all the causes identified in occurrence and causes of bleeding disorders
  2. hemophilia are associated with 
    1. the genes responsible for producing clotting factors
    2. mutation, which reduces clotting factors in the blood, and which
      1. causes bleeding to be prolonged beyond the normal time
      2. creates risk that is 
        1. greatest from internal bleeding in a vital organ, especially the brain, which may be life-threatening
        2. moderate from bleeding into
          1. joints, especially knees, ankles and elbows
          2. tissues and muscles 
        3. least from bleeding from external wounds such as minor cuts
  3. von Willebrand disease risk factors relate to family history of a bleeding disorder.

Signs and symptoms of bleeding disorders, hemophilia and von Willebrand disease

  1. Bleeding disorders symptoms and signs generally include
    1. bleeding into joints
    2. excessive bruising
    3. heavy bleeding
    4. menorrhagia
    5. nosebleeds.
  2. Hemophilia symptoms and signs are chiefly 
    1. mild bleeding, which may occur unremarked unless it arises during surgery or following trauma
    2. serious bleeding, which may arise 
      1. without any apparent cause
      2. internally anywhere in the body
      3. into joints, which is common and troublesome.
  3. von Willebrand disease symptoms and signs
    1. are characterized by a lifelong tendency for 
      1. easy bruising
      2. frequent nose bleeds
      3. menorrhagia, which 
        1. occurs in more than 50 percent of women with von Willebrand disease
        2. may be the only clinical manifestation of the disease
    2. vary from individual to individual
    3. may be unnoticed for some children who though they seem asymptomatic
      1. bruise easily
      2. are prone to bleeding of the mucous membranes
    4. in the rare type 3 von Willebrand disease can resemble the severe bleeding of hemophilia, such as 
      1. hemarthrosis
      2. intramuscular bleeding.
  4. Common to hemophilia and von Willebrand disease is the symptom of pain, which
    1. is neither well understood nor effectively managed
    2. is often the major element affecting the quality of life of adults and children with hemophilia, von Willebrand disease or other bleeding disorder, especially those with chronic joint damage 
    3. provides the primary clinical signal of a new bleeding episode
    4. varies in intensity and pattern from person to person 
    5. from hemarthrosis 
      1. is most common
      2. may be severe
      3. is caused by the inflammatory reaction of blood in the joint
      4. may be exacerbated by swelling of the joint
      5. arises from chronic joint damage of which pain is the major element affecting quality of life 
    6. is managed according to its phase  
      1. acute pain phase, which
        1. arises from 
          1. bleeding
          2. surgery
          3. trauma
        2. is caused by toxic effects on nerve endings
        3. is managed during the first few hours of an episode with the purpose of relieving suffering
      2. chronic pain phase, which  
        1. arises from
          1. tissue damage
          2. joint degeneration
          3. altered brain and spinal cord functions
        2. is managed over the longer term with the goal of
          1. providing continuing relief 
          2. maintaining daily functioning
          3. making best use of modalities according to their benefits for the individual person, including
            1. medications
            2. physical treatments
            3. psychological methods.

Medical investigation of bleeding disorders, hemophilia and von Willebrand disease

  1. Bleeding disorders investigation may involve tests such as
    1. complete blood count
    2. bleeding time
    3. partial thromboplastin time (PTT)
    4. platelet aggregation test
    5. prothrombin time (PT).
  2. Hemophilia is most commonly diagnosed following the combination of
    1. an abnormal bleeding episode 
    2. a known family history of the condition.
  3. von Willebrand disease investigation may require tests such as
    1. bleeding time
    2. blood typing
    3. factor VIII level
    4. platelet aggregation test
    5. platelet count
    6. von Willebrand factor, specific tests.

Treatment of bleeding disorders, hemophilia and von Willebrand disease

  1. Bleeding disorders treatment generally may include
    1. factor replacement
    2. fresh frozen plasma transfusion
    3. platelet transfusion
    4. other therapies.
  2. Hemophilia treatment lacks a cure though clotting factor replacement therapy enables hemophilia to be managed effectively with injections of clotting factors
    1. on a regular regimen to prevent bleeding episodes
    2. as needed to prevent or control a bleeding episode that has occurred or is likely to occur.
  3. von Willebrand disease treatment involves medications.

Prevention

Of the severe consequences of 

  1. bleeding disorders depends on effective treatment of the underlying disease
  2. hemophilia depends on early and accurate diagnosis to enable prompt and appropriate care when required
  3. von Willebrand disease depends on genetic counseling.

Prognosis of hemophilia and von Willebrand disease

  1. Hemophilia prognosis
    1. varies with the hemophilia’s severity, which is related to the abnormal bleeding that occurs in the
      1. most severe form spontaneously several times a month 
      2. moderate form as a result of minor trauma
      3. mild form in association with  
        1. dental extraction
        2. surgery
        3. serious injury
        4. menstruation
    2. depends on the site the hemophilia’s bleeding, whether
      1. in the brain or other vital organ, where the bleeding puts life in danger
      2. in joints, especially knees, ankles and elbows, and in tissues and muscles,  where the bleeding is serious 
      3. in minor cuts, where the bleeding does not usually affect prognosis
  2. von Willebrand disease prognosis depends on
    1. the bleeding, which 
      1. may decrease during pregnancy
      2. is not usually excessive during childbirth
      3. may rarely be dangerous
    2. genetic counseling, which may help prospective parents understand the outlook for their children.

Social considerations

Are reflected in the work of support groups, such as

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with hemophilia, von Willebrand disease or other bleeding disorder but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

With hemophilia, von Willebrand disease and bleeding disorder generally, comorbidity and complications coexist and relate chiefly to excessive or frequent blood loss, such as the following.

  1. Bleeding that is severe, usually from the gastrointestinal tract or injuries.
  2. Bleeding in the digestive system, noticed in vomit or stool, may cause anemia (CDHO Advisory).
  3. Blood loss in significant amounts, leading to severe anemia (CDHO Advisory)
  4. Compartment syndrome, a rare complication that develops when bleeding in a muscle pressures arteries and nerves inside the muscle, leading to serious damage to the limb. 
  5. Degenerative changes due to bleeding in joints which, despite modern treatments, still
    1. exist as a risk
    2. cause disabling pain and stiffness in the affected joints. 
  6. Hematuria, though common and not usually dangerous when treated appropriately, may lead to clots in the urethra that block urine flow from the bladder, a painful condition. 
  7. Hepatitis (CDHO Advisory), which
    1. in the form of hepatitis A remains a remote risk for persons using blood-derived products, because it can resist some purification processes
    2. creates the recommendation for hepatitis B vaccine for persons with hemophilia
    3. in the form of hepatitis C transmission to persons with bleeding disorder has not been reported since 1997. 
  8. HIV/AIDS (CDHO Advisory), which
    1. was contracted from blood products by 60 percent of severe hemophiliacs from the late 1970s to 1985
    2. since 1986, following the development of genetically engineered factor and improved purification processes, has produced no documented instance of HIV/AIDS transmission from clotting factors. 
  9. Intracranial hemorrhage and bleeding in the brain often resulting from head injury, may cause brain damage and death.
  10. von Willebrand disease 
    1. is believed to develop occasionally from or in association with other conditions though, because it is relatively common, its comorbidity with other diseases may be coincidence
    2. has acquired forms, which include
      1. angiodysplasia 
      2. congenital heart disease 
      3. hypothyroidism (CDHO Advisory).
      4. seizure disorders treated with valproic acid 
      5. systemic lupus erythematosus (CDHO Advisory)
      6. Wilms’ tumour. 

Oral health considerations

  1. Periodontal health is of critical importance for persons with bleeding disorders and, given the role of gingivitis in the development of periodontitis, so too is effective dental hygiene care because 
    1. inflamed and hyperemic gingival tissues are at increased risk of bleeding 
    2. infection in periodontal pockets causes gingival inflammation, which can be severe in persons who are immune-compromised (CDHO Advisory), and who may require antibiotic medications as well as dental hygiene treatment
    3. periodontitis may lead to tooth mobility sufficient to require extraction, which may be a complex and possibly risky procedure in the presence of bleeding disorder 
    4. dental caries may be increased by failure to seek oral healthcare because of fear of dental bleeding
    5. dental hygiene care should start as soon as possible after finalization of the patient/client’s treatment plan with the goal of preventing additional damage to the periodontal tissues
    6. in instances of severe periodontal disease, it may be necessary to 
      1. begin with supragingival scaling
      2. delay subgingival scaling until the inflammation has decreased
      3. stage the Procedures over several visits to prevent excessive blood loss.
  2. Because persons with bleeding disorder may neglect their oral health owing to fear of bleeding during tooth-brushing and flossing, thus favouring gingivitis, periodontitis and caries, dental hygienists have a particular responsibility for
    1. providing oral hygiene education
    2. promoting oral health care and oral self-care
    3. providing informed and reliable reassurance to persons hesitant about oral healthcare and oral self-care.
  3. Preventive oral healthcare includes
    1. dental hygiene, which should be aimed at reducing 
      1. need for oral healthcare treatment
      2. oral healthcare emergency visits 
    2. nutritional advice related to the consumption of foods and drinks with a high sugar or acid content with the objective of
      1. preventing the
        1. oral cavity from becoming too acidic
        2. pH of the oral cavity from falling below the critical level of pH 5.5
      2. limiting consumption to
        1. meal times 
        2. the recommended maximum of three exposures per day. 
  4. Before implementing the Procedures, the dental hygienist should
    1. take a careful history of incidents of bleeding abnormalities
    2. receive clearance from a physician, who may be helped by an outline of what the intended Procedures involve and, in particular, the information that, for most persons with a bleeding disorder
      1. periodontal probing, supragingival scaling and polishing can normally be performed without the risk of significant bleeding 
      2. prophylactic therapies such as factor replacement are seldom needed for subgingival scaling and root planing if these procedures are done carefully.
  5. Bleeding episodes associated with
    1. the Procedures in the presence of mild bleeding disorder are mostly reported
      1. as minor
      2. as not affecting oral healthcare significantly 
    2. invasive or surgical dentistry, which is not within the scope of the Procedures, in the presence of moderate or severe bleeding disorder could require premedication by
      1. restoration of hemostasis 
      2. adjustment of medications
      3. avoidance of medications that aggravate bleeding
      4. factor replacement therapy
      5. use of vasoconstrictors
      6. avoidance of nerve block
      7. sedation.
  6. Careful performance of the Procedures and dental hygiene generally, to prevent accidental damage to the oral mucosa, may require the dental hygienist to consider
    1. ultrasonic instrumentation to reduce tissue trauma
    2. for severely inflamed tissues
      1. initial treatment with chlorhexidine mouthwash
      2. gross debridement to reduce tissue inflammation before deep scaling
    3. the possibility of injury to the mucosa in the floor of the mouth, leading to hematoma or ecchymosis, caused by
      1. saliva ejectors
      2. removal of impressions
      3. placement of X-ray films
      4. generally insufficient protection of the soft tissues of the oral cavity.
  7. Oral examination should include inspection specifically for  
    1. petechiae
    2. ecchymosis in oral mucosa
    3. hematomas
    4. excessive or spontaneous gingival bleeding 
    5. brown deposits  on teeth arising from blood degradation.
  8. Management of pain following the Procedures 
    1. can usually be controlled with acetaminophen
    2. should avoid medications that aggravate bleeding.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect databases
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Medications

  1. Hemophilia medication treatment consists primarily of replacing clotting factors that are missing or abnormal.
  2. von Willebrand disease medication for
    1. primary treatment
    2. secondary treatment  
      1. for persons with von Willebrand disease 
        1. who do not respond to desmopressin
        2. of the rare types
      2. includes 
  3. Pain medications
    1. acute pain
      1. mild-to-moderate: taken by mouth in normal doses
        1. non-opioids
        2. non-steroidal anti-inflammatory drugs (NSAIDs)
      2. moderate-to-severe: opioids taken by mouth 
      3. severe: opioids
        1. administered subcutaneously
        2. administered intravenously, by
          1. single dose
          2. patient-controlled analgesia, computer-assisted self-administration of opioid pain medication, used for
            1. acute bleeds
            2. post-operative pain control
    2. adjuvants for analgesics which
      1. enhance pain control and are used in combination with analgesics
      2. include
        1. anti-depressants
        2. anti-convulsants

Side effects of medications

See links above for specific medications.

  1. Medications, supplements and beverages that may aggravate bleeding and that should be avoided include
    1. non-steroidal anti-inflammatory drugs, such as
      1. ASA and compounds with ASA, such as
      2. non-steroidal anti-inflammatory drugs, such as
    2. corticosteroids
    3. blood-thinning medications, which prevent blood from clotting such as 
    4. antihistamines such as 
    5. antibiotics, such as
    6. food and drink, such as
      1. alcohol
      2. caffeine
    7. certain herbal supplements which also contain ingredients that may cause bleeding with hemophilia, including
      • garlic, which has been associated with multiple cases of bleeding; caution is warranted in patients at risk of bleeding or prior to surgical or dental procedures 
      • ginger, which may inhibit platelet aggregation or platelet production, and thus theoretically increase bleeding risk
      • ginkgo, which should be used cautiously in bleeding disorder prior to some surgical or dental procedures
      • ginseng, which should be used with caution for persons with bleeding disorders
      • glucosamine, which may in theory increase the risk of bleeding; caution is advised in patients with bleeding disorders 
      • kava, which may increase the risk of bleeding through effects on blood platelets
      • St. John’s wort, which may greatly increase or decrease the potency of many medications and cause serious side effects; caution is advised when taking it with other herbs and supplements that may have blood-thinning effects
      • Wilbrintin and Willetab, which are advertised for sale through the Internet with the claim of effectiveness in the treatment of von Willebrand disease; the Medical Advisory Board of the World Federation of Hemophilia does not support the use or marketing of these products for the treatment of a potentially serious condition such as von Willebrand disease in the absence of any supporting evidence of clinical efficacy or approval by the usual pharmaceutical regulatory agencies.
  2. Some persons develop antibodies to the injected clotting factor, which 
    1. create difficulties in treating bleeding episodes
    2. develop in as many as 20 percent of children with hemophilia receiving some types of clotting factor. 
  3. Adverse effects of drug or alcohol dependence (CDHO Advisory)
    1. addiction
    2. abuse
    3. tolerance
    4. diversion for
      1. for use by others
      2. for sale.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. explore any history of bleeding abnormalities especially relating to 
    1. bleeding episodes after surgery or injury
    2. spontaneous bleeding and easy or frequent bruising
    3. comorbidities and complications of bleeding disorder 
    4. medications, especially those which aggravate bleeding
  2. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. current medications relating to 
      1. aggravation of bleeding
      2. pain management
      3. acute pain
      4. continuing pain
    3. contraindications
    4. complications
    5. comorbidities
  3. explore the need for advice from the appropriate primary or specialized care provider(s)
  4. inquire about
    1. pointers in the history pertaining to bleeding, including
      1. easy, frequent or spontaneous bleeding
      2. episode(s) of bleeding that required medical attention
      3. excessive bleeding from wounds 
      4. family history of bleeding disorder
      5. increased or easy bruising 
      6. menorrhagia
      7. postpartum bleeding
      8. prolonged bleeding after dental extraction 
      9. prolonged bleeding from gingiva, especially when associated with dental or surgical procedures
      10. recurrent nose bleeds
    2. pain control and use of analgesics
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements
    5. problems with previous dental/dental hygiene care
    6. problems with infections generally and specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
    9. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

With hemophilia, von Willebrand disease or other bleeding disorder, the Procedures require prior consultation with the appropriate primary or specialist care provider(s).

The Procedures may also be postponed pending medical advice if the patient/client 

  1. has indications of increased tendency to bleed since the most recent medical consultation
  2. has a history of 
    1. comorbidity, complication or an associated condition of the bleeding disorder
    2. problems with 
      1. pain management
      2. pain medication that raises the dental hygienist’s concern about pain management following the Procedures
  3. has not recently or ever sought and received medical advice relative to dental procedures
  4. has recently changed significant medications, under medical advice or otherwise
  5. has recently experienced changes in his/her medical condition
  6. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

  1. First-aid provisions and responses as required for current certification in first aid.
  2. Relative to bleeding that is persistent following the Procedures or other aspects of oral healthcare
    1. the Canadian Hemophilia Society recommends patients/clients to prepare a Personal Emergency Plan with the staff at their hemophilia treatment centre, and if bleeding persists following the Procedures, among other interventions
      1. the patient/client should be guided by his or her Personal Emergency Plan. 
      2. in the absence of a Personal Emergency Plan, the dental hygienist and patient/client may be guided by the concept of clinically significant bleeding episode, which
        1. is defined as one that continues beyond 12 hours
        2. signals need for medical treatment or emergency care
        3. may create the risk of significant airway obstruction
    2. the dental hygienist should
      1. inspect the site of the bleed for evidence of a tear in the gingiva or other obvious bleeding point, which should be treated using local measures, including instructing the patient/client to 
        1. sit up
        2. bite on a damp gauze swab for at least 10 minutes
      2. monitor the blood pressure
      3. treat pain with an appropriate analgesic. 

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of hemophilia, von Willebrand disease or other bleeding disorder, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test to the
    1. history of hemophilia, von Willebrand disease or other bleeding disorder
    2. medications he or she is taking
  2. should discuss, as appropriate 
    1. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth
    4. the importance of an appropriate diet in the maintenance of oral health
    5. for persons at an advanced stage of a disease or debilitation
      1. regimens for oral hygiene as a component of supportive care and palliative care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth relating to hemophilia, von Willebrand disease or other bleeding disorder, comorbidities, complications or associated conditions, medications or diet
    9. pain management following oral healthcare, with particular regard to the patient/client’s pain management for the bleeding disorder
    10. over-the-counter medications that increase coagulation time or cause bleeding
    11. what to do if bleeding is prolonged following a Procedure.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have hemophilia, von Willebrand disease or other bleeding disorder.
  2. Reducing adverse effects, such as excessive bleeding and fear of excessive bleeding, by
    1. providing appropriate advice and counselling before, during and after the Procedures
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing excessive bleeding and failing to advise the patient/client appropriately. 
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client is inadequately prepared 
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with hemophilia, von Willebrand disease or other bleeding disorder.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2010-07-15; 2012-03-01; 2019-11-04

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2010, 2012, 2019 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 Named for the Canadian, Steven Christmas who, in 1952, was the first person to be diagnosed with this form of hemophilia.