Delivering Integrated Care and Cost Management
The IHTC works collaboratively with payors to optimize care. We ensure that the patients and families we serve have access to care and therapies, thereby helping to contain costs and reduce both bleeding events and utilization of resources.
The IHTC Pharmacy’s ability to purchase clotting factor through the Public Health Service 340B discount program and our overall pricing structure benefit payors and patients by dispensing clotting factor at significantly reduced prices.
Bleeding Disorder Dental Care
Important Dental Care Information for Parents of Children with Bleeding Disorders
Good dental hygiene is important for all children, including those with bleeding disorders. However, there are some special precautions to take in preparing your child for dental procedures as well as in providing essential information to the dental care provider to ensure the best outcome both procedurally and in your child’s long-term dental health.
Planning for Dental Procedures
It is very important for your child’s dentist to collaborate with the nearest comprehensive hemophilia treatment center (HTC) in developing treatment plans for dental procedures to ensure that they are performed safely. Special considerations may be called for in some dental procedures, depending upon the severity of your child’s bleeding disorder.
In preparing for selected dental procedures, factor replacement, Stimate® (desmopressin acetate) nasal spray or Amicar® may be necessary. Such procedures include block anesthesia, deep scaling, extractions, large fillings and any oral surgery. It is imperative that you contact your HTC prior to any dental procedure to determine what pre-treatment may be required.
Amicar® or aminocaproic acid is an important medication for anyone with a bleeding disorder, and is only available by prescription. Amicar works by preventing enzymes in the saliva from breaking down a newly formed clot, thus allowing the tissue beneath the clot to heal and preventing the reoccurrence of bleeding.
The safety and effectiveness of Amicar in pediatric patients has not been established; however, Amicar is generally well tolerated. Amicar, like most medications, may cause side effects or an allergic reaction in some children. Before giving Amicar, be sure to call your hemophilia treatment center to confirm the dose and course of therapy. Amicar comes in tablet or syrup form. The weight of the child determines the dosage. If your child has any reaction upon taking Amicar, you should immediately contact your doctor. Please note that Amicar should not be used if you child has any of the following medical issues: a urinary tract infection, blood in the urine, or a kidney problem.
Amicar should be stored at room temperature and protected from heat, light and moisture. Amicar may also be stored in the refrigerator, which helps improve its taste. Over time, Amicar loses its potency. As with all medications, be sure to check the expiration date.
Young children with bleeding disorders tend to have more bleeding when teeth are exfoliating or newly erupting. Oozing can often be controlled by applying firm yet gentle pressure to the affected area using a small amount of Avitene®. Avitene (microfibrillar collagen hemostat) is a shredded gauze-like substance designed to control soft tissue bleeding, especially when other conventional bleeding controls are ineffective. Amicar (aminocaproic acid) may be needed as well. Condense a small amount of Avitene and apply it to the bleeding site. Avitene can be used along with Amicar.
Informing Your Dentist
To provide the best dental care for your child, your dentist needs to have answers to the following questions:
- What is the type and severity of your child’s bleeding disorder?
- Does he/she have an inhibitor or venous access device?
- What medications does your child take?
- Is pre-dental treatment with factor concentrate, Stimate, or Amicar required?
- Who should we contact at your hemophilia treatment center?
- Obtain bleeding disorders treatment instructions from your comprehensive hemophilia treatment center. The HTC will have the necessary patient data on hand to assist your dentist in providing the best dental care for your child.
- Preventing and Treating Mouth Bleeding Although tooth decay is unfortunately widespread among the pediatric dental patient population, the main dental issue for children is injury. Dental-involved trauma – injuries to the mouth, tongue, teeth, gums, cheeks, and lips – are common childhood experiences.
- For those with bleeding disorders, taking part in high contact sports such as football, soccer, boxing and wrestling are discouraged. For those children who may take part in high contact sports, a proven dental protection measure is mouthguards.
- When bleeding in the mouth does occur, it is frequently difficult to ascertain its severity. A small amount of blood mixed with saliva seen on a pillow or bed sheet can be alarming. Because some bleeding from the mouth is dangerous, it is appropriate to contact your HTC when your child experiences a mouth bleed. Before calling the center, try to determine the source of the mouth bleed so the HTC dental hygienist, nurse or physician can provide the best treatment advice.
- The mouth’s naturally moist environment makes it difficult for clot formation. Therefore, to stop the bleeding it may be necessary to treat with factor concentrate or Stimate nasal spray. Amicar is frequently given to maintain the clot and promote healing.
- Bleeding in the mouth should be treated by applying firm but gentle pressure to the bleeding site using either clean gauze, a washcloth or a moist tea bag. Tea leaves’ tannic acid cause blood vessel constriction. Gently holding an ice pack against the child’s face or having him/her eat a Popsicle can put a stop to blood oozing.
- If a “liver clot” has developed (a traumatized area in the mouth with a liver-like texture and appearance), it should be removed so that proper healing can occur. This can usually be done using a moist gauze square. Then apply gentle pressure and Avitene. If the bleeding continues, give the child Amicar and call your HTC. As well, if the liver clot cannot be completely removed, your child should be seen by his/her dentist or your hemophilia treatment center to have it removed. Once the liver clot is removed, the patient should begin taking Amicar.
A mouth injury can take as long as two weeks to heal completely. To promote healing, serve your child soft foods, either served cold or at room temperature. To keep the teeth clean during the healing process, either brush gently or use a cotton swab. During healing, don’t let your child use straws to drink from nor rinse the mouth too vigorously, for either may dislodge the clot.
A word of caution: Some mouth bleeding can block a child’s airway. The following symptoms should be considered medical emergencies:
- Nonstop bleeding of the tongue, cheek, or floor of the mouth;
- Bruising or swelling of the tongue, throat, or neck; and/or
- Difficulty breathing or swallowing.
Should any of these symptoms occur, contact your local HTC and take your child to the emergency room.
Saving a Knocked-Out Tooth
If your child has a knocked-out tooth, be careful to pick it up by the crown or top part of the tooth. Try not to touch the roots. Then, ideally, place the dislodged tooth in milk. If milk is not available, use water to keep the tooth moist. Get to your dentist or an emergency room as soon as possible. There is a chance that your dentist may be able to successfully reinsert the tooth. Until you reach your dentist, be sure to apply firm pressure with a clean gauze square or washcloth to the bleeding site. Also, contact your HTC for recommendations to control the bleeding.
Fixing a Chipped Tooth
If your child chips a tooth, try to retrieve the chipped fragment and take it to your dentist. The dentist may be able to bond the chipped piece back onto the damaged tooth. The dentist also has the option of repairing the chipped area with a filling material and can file any sharp edges that could cut your child’s cheek or tongue.
Children with bleeding disorders are able to wear braces. If your child needs braces, your dentist will refer you to an orthodontist. This dental specialist will fit your child with removable or fixed braces. However, before beginning orthodontic treatment, it is highly recommended that you review the treatment plan with your comprehensive hemophilia treatment center.
The orthodontist should be informed about your child’s bleeding disorder, so the he can be especially careful to avoid irritating or cutting the gums when the orthodontic appliance – bands and wires – is placed on the teeth. Please note that in most cases, the placement of braces does not cause bleeding. As an additional preventive measure, the orthodontist can show you how to apply dental wax to the appliance wires to protect gum tissue.
Following Post-Treatment Instructions
Once any dental work is completed, your dentist and the HTC will provide you detailed instructions to follow throughout the mouth healing process. Ice may be suggested to reduce any mouth swelling. When there is a tooth extraction, have your child avoid the use of straws, eating hot foods and mouth rinsing for several days. It is important to complete the Amicar regimen prescribed by your hematologist. Stopping the use of Amicar too early can cause bleeding to reoccur. Your dentist can recommend a non-aspirin pain reliever if necessary. (Please note that when Amicar is prescribed, the recommended dosage course of 5-7 days should be completed.)
Special precautions must be taken in some cases, such as:
If your child has a venous access device or heart murmur, be sure to discuss the need for prophylactic antibiotic therapy before selected dental procedures. The IHTC follows the American Heart Association recommendations regarding the use of amoxicillin:
- Adults: 2 grams 1 hour before dental treatment
- Children: 50 mg/1 kg 1 hour before dental treatment
- For penicillin allergy, take clindamycin:
- Adult: 600 mg 1 hour before dental treatment
- Children: 20 mg/kg 1 hour before dental treatment
- If your child has an inhibitor, every dental procedure must be discussed in advance with your HTC.
Contact the IHTC
Always consider your HTC as a partner in your child’s complete healthcare needs, including dental healthcare. Call the IHTC at 877-256-8837 or 317- 871-0000 and ask to speak to a dental hygienist.