During the COVID-19 pandemic, some of the comprehensive care services for people affected by rare bleeding disorders may be limited.

Here is a set of resources to aid the self management of a dental appointment during COVID-19 Pandemic. We recognise that most dental care is limited to emergency procedures only at this time to address toothache or trauma. We understand that you may be seeing a dentist who you don’t know well. It is important that you inform the dentist that you have a bleeding disorder and so the resources have been designed to facilitate this process. This pack includes a general letter that you can email the dentist so that they know that you have a bleeding disorder and gives them some outline information including the contact details of your team. It also includes a algorithm that they can use to ensure that they provide safe care in partnership with you and your coagulation team. Both can be emailed to your dentist when you initially make contact with them via your telephone or video consultation.

The EHC wishes to thank Dr Alison Dougall and Dr Kirsten Fitzgerald for developing the resources below on how to maintain oral health, navigate virtual consultations and home remedies for basic dental problems.

Dental treatment during COVID-19

During the COVID-19 pandemic, providing most aspects of dental care is very difficult, and many dental clinics have closed. Dental care has been impacted by the well-documented evidence that asymptomatic patients may transmit the virus. Furthermore, dental teams may be inadvertent vectors with physical distancing between dentist and patients being impossible during dental treatment.

COVID-19 virus is present in the saliva, throat, and the nasal passages, and therefore, dental interventions can provoke involuntary coughing or gagging, which propels infective droplets and aerosols into the air. Furthermore, routine dental procedures such as fillings and cleanings create spray and aerosols, which propel smaller particles into the air and the surrounding areas. For those aerosol-generating procedures (AGPs), dental teams need to wear specially fitted respirator masks, goggles and face shields and carry out lengthy deep cleaning protocols of the surgery areas between patient appointments. Moreover, during the pandemic, many hospital-based dentists have been repurposed to other roles. Many dental clinics in the community have chosen to close for operational safety reasons as personal protective equipment (PPE) is scarce and only variably available outside of hospitals. PPE is understandably being prioritised for staff at the frontline carrying out emergency intubation and or those teams nursing sick COVID positive patients.

The result is that most people with dental problems are being offered video or phone consultations in the first instance. These virtual consultations offer dentitsts the opportunity to safely triage problems and offer advice for interim self-management of dental pain and infection without patients leaving the comfort and safety of their own homes. If you have a broken filling or tooth, which is causing sensitivity or problems eating, the dentist may ask you to visit a local pharmacy and buy an off-the-shelf temporary filling kit for ‘self-dentistry.’ This is usually in the form of a soft, sticky paste, which you can press into the cavity or hole with a clean finger and let it set hard after a few minutes with instructions not to eat or drink for a couple of hours. This is an effective self-management strategy and temporary fillings such as these will usually will stay in place for a few weeks and can be topped up from time to time if they wear down or are lost over time.

See Appendixes for guidance on optimal interim pain management of toothache in (1a) adults and in (1b) children.

See Appendix (2) for guidance on how to communicate your dental problem and bleeding disorder during a telephone triage.

For those patients identified at triage with urgent/emergency dental problems that would need face-to-face care, this will be arranged in a timely fashion according to local measures in place.

Urgent or Emergency Care would include:

(1) Dental Trauma,

(2) Prolonged or severe bleeding following a dental intervention,

(3) Severe swelling, which impacts on breathing or the eye socket, or

(4) Persistent pain which is not relieved by the maximum strength analgesia.

It is important to note that during this pandemic, the range of emergency dental treatment on offer may be limited to dental extractions only rather than fillings or other restorative care, which has higher significance for people with bleeding disorders due to managing the risks of bleeding. It is important before attending an emergency appointment that you have communicated your bleeding disorder to the emergency dentist who you may not have met before.

It is also very important that you inform your haemophilia treatment centre so that an appropriate multi-disciplinary management plan can be put in place before any emergency treatment is carried out, and you don’t have to make unnecessary additional visits where treatment cannot be carried out.  Please note that it is NEVER safe to have a dental extraction without first contacting your haemophilia team, however mild your bleeding phenotype, and however severe your toothache. This is even when the dentist suggests that they are happy to go ahead and extract a tooth  because it is loose or it is a simple extraction. If you are unable to access care because of your medical condition or unavailability of medial teams you should contact your National Member  Organisation for assistance.

See appendix (3) for instructions for dentists to help them take the correct local measures when providing emergency dental extractions for people with bleeding disorders. You can provide them with the algorithm and the template letter provided to help their decision making and risk assessment.

Finally, during this pandemic and indeed after it is over, access to routine dentistry may be impacted for many months. During this time it is imperative to care for your mouth and keep it healthy by brushing twice a day with fluoride toothpaste, limiting sugar intake to mealtimes where possible and avoiding habits, which may cause fillings to fracture, such as opening things with your teeth, chewing hard sticky foods, and carrying our risk activities such as physical sports without mouthguards or play fighting.

At this time it is especially important to carry out good toothbrush hygiene etiquette including washing your hands before and after brushing, rinsing your brush in hot water after use, never sharing your toothbrush, and throwing away your toothbrush if you have experienced symptoms of COVID-19. Don’t forget to go and get a dental check-up once the pandemic is over and your dental team is back at work in their clinics so that they can check your teeth and gums to ensure that your mouth is healthy and carry out any remedial work.

Dr Alison Dougall
Consultant for Medically Compromised Dentistry and Special Care Dentistry
National Coagulation Centre, Dublin, Ireland
Dental Member of MASAG EHC
Chair of the International Association for Disability and Oral Health 

Dr Kirsten Fitzgerald
Consultant in Paediatric Dentistry
Our Lady’s Hospital, Crumlin, Dublin
Clinical Lead For Paediatric Dentistry in Ireland 

Severe Pain is usually caused by Dental Nerve Pain OR Dental Abcess.

Dental Nerve Pain is usually caused by 1) dental caries, which has reached the nerve of a tooth, or 2) due to a broken filling, or 3) cracked tooth. All of these cause the nerve to become inflamed and hyper-responsive to hot and cold stimuli. Initial symptoms include intermittent sharp or shooting pain following eating or drinking. Over time this becomes persistent and throbbing, severely impacting eating, sleeping and concentrating. The treatment of choice to relieve this pain is via root canal therapy to treat the inflamed nerve or via a dental extraction. Antibiotics are not effective or appropriate for dental nerve pain.

The most appropriate effective self-management to address severe nerve pain, whist awaiting treatment, is by adjusting to a diet, which is soft with no hot or cold drinks and using a staged approach with a combination of two analgesics together. It is sensible to use pain-killers in divided doses throughout the day just before known dental pain triggers, such as eating a meal or lying down at night.

Maximum daily dose (4g) of Paracetamol/Acetominophen (usually 1g four times per day)

PLUS

Maximum dose (120mg) of Etoricoxib (Cox 2 Inhibitor), once a day before bed.

Opioids have limited use in dental pain. However, appropriate regimes for severe breakthrough pain include the addition of  Tramadol to the above regime. Please note that if you have a bleeding disorder, you should NOT take ibuprofen for dental pain due to risk of gastrointestinal (GI) bleeding. That is unless your haemophilia team have agreed that you may take it for a short period of time.

Please check with your doctor if you have any co-morbidities, which impact on your choice of analgesics.

Dental Abscess is caused by infection underneath or around a tooth and is typically associated with pain on biting or chewing with a palpable tender area in the gum or bone above or below the tooth. Abcess causes a deep throbbing pain and can be associated with fever/elevated temperature. There may be evidence of a gum boil or localised swelling in the gum near the tooth. Initial treatment for dental abcess is via incision and draining of the abscess through the soft tissues or the tooth, or via a dental extraction. For people with bleeding disorders, both of these procedures require adjustment of clotting levels prior to treatment, as they carry a higher bleeding risk due to local inflammation, which impacts clotting.

In the absence of available treatment, self-management of dental abcess includes pain killers as above with the addition of high dose broad spectrum antibiotics. Antibiotics will only control infection for a short period of time. Continued infection may cause swelling to spread and involve the eye or the neck, which is a dental emergency requiring immediate treatment

Managing Dental Pain for CHILDREN with a Bleeding Disorder

Dental pain in children is often caused by dental decay/caries or infection. Children may not always be able to describe pain in terms of its intensity, location, duration and type. You will have to judge by their behaviour. Pain can be worst at night time, and can be worse when eating or after eating due to food sticking in the cavity. Keeping the cavity clean by thorough brushing can be a big help. For pain relief in children, paracetamol/acetaminophen is the first line of treatment and is usually adequate when given at the correct dose. Your pharmacist can help you calculate the appropriate dose for your child based on weight, which will be more accurate than age-based dosing. Some children will have breakthrough pain and will need additional pain relief. For this, you should contact your haemophilia treatment team to discuss. Once pain is controlled, a plan can be made for the ongoing care of the problem. Due to COVID-19 restrictions, waiting times for definitive dental care are likely to be longer than usual. Establish a good line of communication with your dental team so you can keep each other up-to-date on your child’s situation.

Facial Swelling in CHILDREN with a Bleeding Disorder

If your child has swelling of his/her face caused by a dental infection, he/she will usually need antibiotic therapy. You can consult your dentist or your general medical practitioner to discuss this. Usually, your child will require a dental extraction, later on, to eliminate the infection, and this is even more likely in light of COVID-19 because dentists are now asked to avoid performing fillings and root canal therapy due to infection risks. This can be discussed and planned with your dentist and your haemophilia team. Helping your child to cope with a procedure such as extraction will be a team effort. You will help to reassure them, and your dentist may be able to provide additional behavioural supports. Your haemophilia team will help to prepare them medically and may be able to offer other types of support. Make sure you involve the haemophilia team early on so that all necessary supports can be put in place.

Teething in Children with a Bleeding Disorder

Teething rarely causes bleeds, but if minor bleeding or oozing from the gums does occur, contact your haemophilia treatment centre. Due to the moistness of the mouth, blood clots cannot form as easily and might fall out before a cut or tooth socket is healed. If a baby has persistent mouth bleeds, a product may be prescribed to help clots stay in the mouth.

Teething may cause irritability, disturbed sleep, cheek flushing, drooling, and sometimes a small rise in temperature and/or a rash. It does not cause diarrhoea or bronchitis, though these may occur coincidentally, and indeed during the COVID-19 pandemic, parents should be careful not to blame fevers, coughing and diarrhoea on “teething” as these are important signs of infection with the COVID virus.

Losing “Baby Teeth” for Children with a Bleeding Disorder

The loss of baby (primary) teeth begins at around age six and continues up to around 13 years. Children should be encouraged to keep loose teeth very clean and to gently “wiggle” them to encourage them to fall out. If more than a little bit of bleeding occurs when a tooth falls out, biting on damp gauze/facecloth/teabag for 10 minutes should help. If there is still bleeding, contact your haemophilia team. The tooth fairy and friends such as the tooth mouse can find it extra-difficult to travel in your country due to COVID-19 restrictions, but your child can be reassured that they will get there eventually!

Dental Trauma for Children with Bleeding Disorders

Good supervision in the home and when playing outside should help to reduce the risk of dental trauma. If an accident causes damage to the mouth (teeth, gums, lips, cheeks), don’t panic. This is a stressful time for everyone! Apply gentle but constant pressure with a clean facecloth or gauze, helping the bleeding to stop while reassuring your child, allowing you to think and your child to settle. If the soft tissue injury is concerning, or if teeth are broken or loosened, contact your primary care dentist/doctor or local urgent care centre. If bleeding continues, you will need to contact your haemophilia team. Taking a photo using a smartphone is a great way to record the injury and allows you to share it with your dentist/doctor. This will be helpful at this time when attendances at the dentist are restricted. Detailed information about dental trauma is available at www.dentaltraumaguide.org

Brushing, Bad Breath and Braces in Children with Bleeding Disorders

One of the most important ways to keep a healthy mouth is by brushing twice daily with a fluoridated toothpaste. Toothpaste should be spat out at the end of brushing, and rinsing after brushing is best avoided. Brushing helps to keep the gums healthy and leaving a little bit of toothpaste in the mouth after brushing reduces tooth decay/caries. Children up to around age seven will need help with brushing. Healthy gums don’t bleed, so if you notice some “pink in the sink” when your child spits out, try to see where the bleeding is coming from and pay particular attention to that area when brushing. If this doesn’t settle in a few days, contact your haemophilia team for advice. Bad breath can be due to poor brushing but can also be due to tummy problems or respiratory infections. If the tongue is coated (common in febrile conditions), brushing it will help. After children have been unwell, it is a good idea to change the toothbrush. Lastly, for young people with braces/orthodontic appliances, breakages are always a pest, but even more so now with COVID restrictions on dental practice. Making sure the young person avoids hard and sticky foods will help to prevent breakages. If a breakage does occur, or a wire is hurting or causing bleeding, be sure to contact your treating dentist/orthodontist for advice by telephone in the first instance.

Preventing Dental Caries in Children with Bleeding Disorders

Children love to snack, and boredom can often lead to increased requests for snack foods between meals. At this time, when we are confined to our homes more than ever before, it is tempting to allow children to help themselves to food, to offer sweets as a reward for “good” behaviour, or to increase access to sugary drinks as a way to offset some of the challenges of parenting in a pandemic. Having a good routine that involves exercise, academic work, artistic and cultural pursuits, time for rest or “downtime,” family time and scheduled times for eating meals and snacks will be better for everyone’s physical and mental health. Try to keep sweet treats to mealtimes, and only allow two snacks (a snack is any food taken outside of the usual three mealtimes) per day. This way, your child should have no more than five episodes of eating on a typical day, and this will help them to avoid tooth decay/caries. Good choices for snacks are fruits, vegetables, complex carbohydrates with fibre (e.g. wholegrain bread, crackers), cheese and other unsweetened dairy products. Water is the healthiest drink for thirsty children

 

Preparing for a Video or Phone Consultation ‘Tele-dentistry’

A telephone or video consultation can never replace a face-to-face clinical dental examination; however, it can be very effective to help a dental professional provide an accurate diagnosis where patients provide a clear history. Because this consultation may not be with your usual dentist and may be with an emergency hub, it’s good to get organised beforehand and move to a location where you are in the same room as your router if possible to get the best signal.

  • The dentist will ask you a number of questions to about the nature of your dental pain.

The more accurate information that you can provide the more likely you get the right treatment to addresses your dental problem appropriately. It is a good idea to write this down beforehand so that you get the right management and treatment.

  • The dentist will ask you details about your tooth pain and ask you to rate it from 0 to 10, with 10 being unbearable pain leaving you unable to function. People with bleeding disorders can tend towards stoicism when dealing with pain, so please score your dental pain realistically rather than bravely.
  • Where possible, ask someone to take a photograph of your dental problem beforehand. This can be done with good lighting using a smart phone with the flash switched off. Take several photographs from different angles. Don’t forget to wash your hands and sanitise your phone before and after photos are taken.
  • Make sure that have the name and contact details of your haemophilia team ready so that you can connect the dentist and the treater before you attend for an appointment.
  • If you cannot access care because of your bleeding disorder, then contact you haemophilia team and National Member Organisation for assistance and advocacy.

Dear Dentist,

Thank you for agreeing to see me for Emergency Dental Care.

I have an inherited bleeding disorder, which means we may need to make some adjustments to ensure my dental care is managed effectively. To aid this process, please read the algorithm overleaf to aid with decision making with details on how to provide safe care.

The algorithm details how to proceed if I need a dental extraction or pulp treatment/root canal. It also includes what do if I need If I have a dental abscess treated or if I have sustained dental trauma.

I hope that we can work together with my coagulation team to achieve the best outcome.

The name and contact details of my Haematology team is as follows.

Names

Address

Telephone Number

I have been in touch with my coagulation team for a haemostatic management plan and have already taken their advice and started my recommended haemostatic regime

I have not yet been in touch with my coagulation team for a haemostatic management plan as I am waiting to find out what dental treatment is required first.

Please note that I am usually not advised to take ibuprofen or most NSAIDs because of my condition however my bleeding disorder does not contra-indicate the use of a short course of Cox 2 inhibitors such as etoricoxib (arcoxia) to supplement Paracetamol (acetaminophen) if required.

Nether my bleeding disorder or the factor replacement therapy, which I take is a contra-indication to antibiotics such as Amoxycillin or Metronidazole. I attach a list of any other medication I am taking or any allergies.

Thank you for your help