When Terri-Lynn Hoskins was 5 years old, she lost her first tooth and bled for three hours. Because her father had factor V deficiency, her parents suspected she, too, had a bleeding disorder. Initially, tests were negative, but her parents persisted and she was eventually diagnosed with mild factor V deficiency, an extremely rare bleeding disorder.
Now 17, Terri-Lynn, of Ottawa, Ontario, Canada, encountered another tooth problem in August 2011: Her wisdom teeth were causing pain and needed to be removed. To prep for her wisdom tooth extraction, she took Cyclokapron™, an oral form of tranexamic acid available in Canada that helps slow down or stop bleeding. The procedure was done under anesthesia by an oral surgeon in an Ontario hospital. She had no serious complications though the Cyclokapron made her nauseous, a known side effect of the drug. She also lost enough blood during the procedure to feel weak afterward. But soon after surgery her tooth pain was gone.
“When I found out I had to have wisdom tooth surgery, I had nightmares,” Terri-Lynn says. “But the doctors were very patient with me and helped me a lot. I’m glad to have gotten them all out when I did, because now I never have to worry about wisdom tooth pain again.”
Wisdom tooth extraction is common among teenagers and young adults, including those with bleeding disorders. Wisdom teeth are four molars in the back of the mouth that don’t usually erupt above the gums until a person’s late teens or early 20s. Often the molars fail to emerge properly and can remain trapped under the gums, where they may damage other teeth, trigger infections and cause pain and other problems. When this happens, a dentist or oral surgeon may recommend extraction.
Another common dental procedure among teenagers is getting braces, which are used for straightening crooked teeth or correcting an out-of-line bite. An orthodontist or other dental professional typically cements brackets or bands to the teeth, then connects them with a wire. The braces slowly and steadily push teeth into a more pleasing arrangement over time. Most people need to wear braces for one to three years.
With the right preparation, youths with bleeding disorders can have their wisdom teeth removed and get braces. Here’s what you need to know:
Helping Your Child Through Dental Procedures
Darcy*, a Wisconsin mom of two grown sons with factor VII deficiency, found that one of the hardest challenges in getting her sons’ wisdom teeth removed was finding an oral surgeon who would treat them.
During an 18-month period, eight surgeons turned Darcy down before she found one who would extract her older son’s wisdom teeth in 2009 when he was 18. Darcy took her younger son to the same doctor when he needed his wisdom teeth removed in 2011, also at age 18. “For wisdom teeth, the top thing I’d suggest is to start searching well in advance for an oral surgeon. If your child’s teeth are hurting, that’s no time to start looking,” Darcy says.
Most dental professionals don’t learn much about bleeding disorders in their training, says Alan Kennell, DDS, an orthodontist in Gilford, New Hampshire. He has a son with severe hemophilia A. “Because hemophilia is so rare, not a lot of time is dedicated to teaching it.” He recalls hearing only one lecture on it in dental school, and it covered von Willebrand disease, hemophilia and the other bleeding disorders.
Because of this lack of training and experience, when a parent mentions “bleeding disorder,” many dentists and oral surgeons may immediately envision a case that’s complicated with challenges they don’t fully understand, says Edward Bekx, DDS, a dentist in Kimberly, Wisconsin. He also has a son with severe hemophilia A.
As a result, parents will need to play a key role in finding a dentist or oral surgeon who is comfortable performing procedures on someone with a bleeding disorder. (See “Finding a Dentist Who Treats People With Bleeding Disorders.”)
Encourage communication and collaboration with your hemophilia treatment center (HTC). Before the procedure, put your dentist in touch with your HTC so the two can collaborate on the care plan. “In a patient with hemophilia, extractions should never be taken lightly. You’re causing a large wound in the mouth, and that’s something that needs to be closely monitored with the HTC,” Kennell says.
Factor in the factor. Talk with your HTC about the amount and timing of factor before an extraction procedure. Be ready to use more in the following days as needed, Bekx says. Before routine orthodontic visits your child probably won’t need factor infusions. However, infusing may be necessary before the first appointment when the braces are put on, and the final appointment when they’re removed, he says.
Choose the right setting. No one wants the trip to the dental office to end with an ambulance ride to the ER, Kennell says. For complicated procedures, the wisest choice may be to perform them in a hospital. The hospital will probably be better staffed and equipped for a bleeding emergency than a dentist’s or oral surgeon’s office.
Make a blueprint. The provider should do plenty of X-rays of your child’s mouth to plot an approach to remove the teeth in the least traumatic way, Bekx says. Wisdom teeth can be stubborn. Sometimes they need to be broken up within the bone and removed piece by piece, which requires careful planning, he says.
For braces, go slowly. Orthodontists can often bring unruly teeth into line using lighter forces over a longer time period, Bekx says. This can reduce trauma to surrounding tissues.
When putting in braces, the orthodontist may choose other options because of bleeding concerns, such as gluing anchoring brackets to molars, rather than using bands around the teeth that can cause bleeding, Kennell says.
You may also want to consider Invisalign®, which uses a series of clear trays, rather than brackets on each tooth, to nudge the teeth a quarter of a millimeter at a time. However, Invisalign may not be a good choice for people with complicated cases, including those who have an overbite, Kennell says. And they’re only for straightening teeth that are fully erupted, so most young kids aren’t good candidates. Invisalign also typically costs more than traditional braces.
Ensuring that dental treatments go smoothly for kids with bleeding disorders may take a little extra time and effort. Proper preparation can alleviate fears and complications from bleeding disorders.
* Her last name is not being used to protect her sons’ privacy.
American Association of Oral and Maxillofacial Surgeons, http://www.aaoms.org/wisdom_teeth.php
American Association of Orthodontists