JOURNAL OF COAGULATION DISORDERS

ORIGINAL ARTICLE

Dental and Periodontal Health in Children with Hemophilia

E Alpklc Baskirt1, H Albayrak2, G Ak1, A Pnar Erdem2, E Sepet2 and B Zulfikar3
Affiliations: Departments of Oral Medicine and Oral Surgery1 and Pedodontics2, Faculty of Dentistry, Istanbul University and
3
Department of Paediatric Haematology-Oncology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
Submission Date: 9th June 2009, Revision Date: 14th July 2009, Acceptance Date: 30th July 2009

A B S T R A C T
Aim
The aim of this study was to determine the dental and periodontal health of children with hemophilia A in different
aspects.

Methods
The gingival index, plaque index, and dmf(t)-dmf(s), DMF(T)-DMF(S) scores of 36 children (aged between 6 and 12 years)
with hemophilia A and 39 healthy children were analyzed. Type of hemophilia, dietary habits, and frequency of tooth
brushing, educational and economic level of the parents, and parents dental habits were determined by a
questionnaire.

Results
All the analyses were carried out by means of commercial statistical software. Statistical analyses were performed by
chi-square, KruskalWallis and independent t tests. The difference in plaque index scores between the study and control
groups (P50.077) was not statistically significant. Gingival index scores of the children with hemophilia were statistically
higher than the control group (t53.10; P50.003). No difference was found in dmf(t)-dmf(s) scores, but DMF(T)-DMF(S)
scores of the study group were statistically higher than the control group (P50.001; P50.012). The frequency of tooth
brushing was defined statistically different between the two groups (P50.044). The frequency of sugar consumption by the
children with hemophilia was found to be statistically higher than that of the control group (P50.006). Although the
maternal educational levels of the two groups were similar (P50.130), paternal education levels and the economic levels
of the study group were statistically lower than those of the control group (P50.002).

Conclusion
We conclude that children with hemophilia A have significantly higher GI and DMF(T)-DMF(S) scores compared with
matched, healthy control subjects. Expanded preventive measures, educational, and recall programs should be
organized for these special needs patients.
Keywords: hemophilia, dental, periodontal, children, DMF
Correspondence: Esra Alpkilic Baskirt, Halclar Avenue, Oksuzler Street, No: 18/6 Fatih, Istanbul, Turkey. Tel: +9-0542321-21-42; fax: +9-0212-531-22-31; e-mail: esra_alpkilic@yahoo.com

Alpkilic et al [2] reported that prevalence of tooth

brushing was significantly higher in the healthy
control group. Healthy control subjects have a more
regular brushing habit than people with hemophilia.
As a result, poor oral hygiene causes an increase in
dental caries. Severe gingivitis and periodontitis can
also be seen in these patients.

INTRODUCTION
Hemophilia is a life-threatening inherited bleeding
disorder characterized by a lifelong defect in the
clotting mechanism [1]. Like every part of the body,
hemophilia also has effects on the oral region.
Spontaneous bleeding can occur in hemophilia
patients with periodontal disease. In thinner regions
of the gingival, there are a number of enlarged
capillaries near the surface. Therefore, minor trauma
such as tooth brushing or food abrasion and infection
can cause bleeding in gingival tissues [1]. Patients
with hemophilia neglect their oral hygiene because of
the bleeding during tooth brushing. In a recent study,
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Mild hemophilia may not be diagnosed until adolescence or even later, particularly if major surgery,
severe trauma, or dental extractions have been
avoided. In a study that investigated the nature of
bleeding episodes leading to the diagnosis of 132
patients with hemophilia A, 14% of hemophilia
1

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Journal of Coagulation Disorders

patients and 30% of cases with mild type were reported

to have been initially diagnosed following an episode
of severe oral bleeding. The most common site of oral
bleeding was the labial frenulum and the tongue [3, 4].
Thus, the dentist may be the first to diagnose a patient
with hemophilia.

RESULTS
The qualitative and quantitative data gained from
the study and control groups are presented in
Tables 1 and 2. The data gained from comparison of
the hemophilia group (severe, moderate, mild) are
presented in Table 3.

However, there have been several reports related to

the surgical procedures of hemophilia; there are few
data for the dental health of children with hemophilia
and their parents or adults. The purpose of the study
reported here was to investigate the dental and
periodontal health of children with hemophilia A and
to evaluate the relation of childrens dental health
with parents educational and economic status.

The difference in mean age scores between the study

and control groups was not statistically significant. GI
scores of the children with hemophilia were determined statistically higher than control group. DMF(T)
scores of the study group were found higher than those
of the control group. DMF(S) scores of the study group
were statistically higher than those of the control
group. No difference was found in dmf(t)-dmf (s) scores
between the study and control groups.

PATIENTS AND METHODS

A statistically significant difference was found in the

prevalence of tooth brushing between the study and
control groups. In the study group, the number of
participants who never brushed his/her teeth is significantly higher than in the control group (P,0.05). It
was found that children with no systemic disease
consume candy more frequently than those with
hemophilia (P,0.05). Consumption of foods such as
cakes, biscuits, and cookies was found to be higher in
healthy children compared with the study group
(P,0.05). Intergroup comparison for maternal education level revealed no significant difference, whereas
paternal education level and families financial circumstances were statistically lower in the study group
than in the control group.

The study group included 36 children suffering from

hemophilia A in the age range 612 years who were
registered with the Haemophilia Society of Turkey.
Fourteen patients had mild hemophilia A, whereas 12
had moderate and 10 had severe type. The control
group included 39 healthy children who were referred
to Istanbul University Faculty of Dentistry, Department of Pedodontics. They were matched with children
with hemophilia with regard to age and gender.
A questionnaire including questions about the presence of other hemophilic members of the family, type
of hemophilia, dietary habits, frequency of tooth
brushing, educational and economic level of the
parents, and parents dental hygiene habits was
administered to the participants.

The GI, PI, DMF(T), and DMF(S) scores revealed no

significant difference between the groups with severe,
moderate, and mild types of hemophilia. However,
values of dmf(t) and dmf(s) in patients with mild
hemophilia were found to be significantly higher than
those with moderate and severe hemophilia.

All participants including the study and control

group were examined in a dental chair under a
standard dental light. The gingival index (GI) (Loe &
Silness) [5], plaque index (PI) (Silness & Loe) [6], and
dmf(t)-dmf(s), DMF(T)-DMF(S) [7, 8] scores of children
with hemophilia A and healthy children were compared. The DMF(T/S) index, which was developed by
the World Health Organization, was created to express
the caries experience of people and to obtain data
regarding the dental health of populations. The D
component is used for untreated caries, M for missing
teeth due to caries, and F for filling (dental restorations for caries treatment). The T means index per
tooth (as opposed to S per surface). Also, dmf(t/s) is the
form of the index used for deciduous teeth [7, 8]. In the
study group, each patient had an initial consultation
prior to dental examination and treatment to determine the required type of replacement therapy procedure that was organized with the collaboration of the
hematologist and dentist.

DISCUSSION
Tooth brushing is the main component of preventive
dentistry and the removal of dental plaque [5, 6, 9].
In this study, GI values were significantly higher in
Table 1. Gingival, Plaque, dmf, and DMF Indices Scores of the
Study and Control Groups
Study group
(n536)

The data was subjected to statistical analysis by

using Graphpad Prisma V.3. Statistical analyses were
performed by Chi-Square, Kruskal Wallis and independent t tests. The level of significance was p , 0.05.

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Control group Independent

(n539)
t test

Age

9.54 2.39

9.49 1.70

0.11

0.913

GI

0.39 0.48

0.15 0.14

3.10

0.003*

PI

0.88 0.42

0.72 0.37

1.79

0.077

DMF(T)
DMF(S)

3.44 3.30
5.78 6.64

1.37 1.62
2.45 4.04

3.41
2.58

0.001*
0.012*

dmf(t)

3.44 3.43

3.24 2.62

0.27

0.788

dmf(s)

5.89 6.57

6.32 6.84

0.25

0.803

*The statistically significant values which provide the rule P#0.05.

GI, gingival index; PI, plaque index.

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Dental and Periodontal Health in Children with Hemophilia

Table 2. The Data gained by the Survey applied to the Parents of the Study and Control Groups

Did your child breast-feed?

Yes

Study group
(n536) (%)

Control group
(n539) (%)

Chi-square
test

92.3

79.5

x2 2.64

No

7.7

20.5

P50.104

Did you add sugar or sweet food to your childs night

milk?

No

53.8

56.4

x2 0.05

Sugar, honey

46.2

43.6

Did you do any dental cleaning when your child was

young?

Yes

7.7

17.9

x2 1.83

No

92.3

82.1

P50.176

How often does your child brush his/her teeth?

Twice/more than twice a day

Once a day

30.8
33.3

7.7
53.8

Once/twice a week

20.5

25.6

Once/twice a month

2.6

7.7

Never

12.8

5.1

In your opinion, does your child consume candies

frequently?

No

61.5

30.8

Yes

38.5

69.2

How often does your child eat cariogenic foods (i.e.,

cakes, biscuits)

Never

12.8

0.0

Once/twice a week
Once/twice a day

64.1
23.1

53.8
46.2

Maternal educational level

University

How often do you brush your teeth? (mother)

Paternal educational level

How often do you brush your teeth? (father)

P50.0820

x2 9.79
P50.044*
x2 7.42
P50.006*
x2 8.34
P50.015*

3.1

20.5

High school

15.6

23.1

Secondary school

15.6

7.7

x2 7.12
P50.130

Primary school

65.6

48.7

Twice/more than twice a day

21.1

23.1

Once a day

42.1

51.3

x2 1.15

Once/twice a week
University

36.8
2.6

25.6
18.4

P50.561

High school

23.1

50.0

Secondary school

12.8

5.3

Primary school

61.5

26.3

Twice/more than twice a day

17.9

27.8

x2 15.11
P50.002*

Once a day

43.6

41.7

Once/twice a week

28.2

25.0

x2 1.40

Never

10.3

5.6

P50.705

*The statistically significant values which provide the rule P#0.05.

the hemophilia group than in the control group.

Therefore, we thought that higher index results in
children with hemophilia were a consequence of
neglected or insufficient tooth brushing. When caries
are considered, children with hemophilia must be seen
as a high-risk group. In this study, their DMF(T) and
DMF(S) values were significantly higher than in the
control group. The factor that increased the GI values
affected the high prevalence of caries in the study

group. Although the consumption of candies was not

frequent in the haemophilia group, the DMF(T) and
DMF(S) values were found significantly higher; it
might depend on irregular consumption time of the
cariogenic foods. The data gained from the questionnaire and clinic examinations of the study group
disclosed the need for and necessity of preventive
treatments and dental education in patients with
hemophilia.

Table 3. Evaluation of Patients by the Type of Hemophilia

Age

Severe

Moderate

Mild

KruskalWallis test

10.20 2.49

8.92 2.27

9.57 2.41

1.70

0.428

GI
PI

0.41 0.29
0.84 0.36

0.30 0.47
0.99 0.38

0.35 0.33
0.72 0.43

2.06
1.04

0.357
0.594

DMF(T)

2.78 3.11

2.30 2.10

4.45 3.96

1.46

0.483

DMF(S)

3.67 4.36

3.50 4.17

9.00 8.84

1.71

0.425

dmf(t)

3.00 3.74

2.20 3.01

6.00 2.88

7.67

0.022*

dmf(s)

3.71 3.94

4.60 7.52

9.80 8.54

5.99

0.05*

*The statistically significant values which provide the rule P#0.05.

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Journal of Coagulation Disorders

In Northern Ireland, Boyd and Kinirons [10] found

better scores on dental indices in children with
hemophilia. The prevalence of caries experienced and
of untreated caries was lower in the primary and
permanent dentition of patients with hemophilia [10].
Another study by Sonbol et al [4] in the UK, in which
38 children with severe hemophilia were compared
with healthy control subjects, similar results including
lower caries scores were found. On the other hand, a
recent evaluation in Poland demonstrated no significant difference in caries prevalence in 80 children
(aged between 4 and 18 years) with congenital bleeding
disorders. However, worse dental status was seen in
children with severe forms of hemophilia A and von
Willebrand disease compared with other sick children
[11]. Boyd and Kinirons [10] found that the reasons
why the pediatric hemophilic population of Northern
Ireland has less decay and a higher restorative index
was the better motivated patients and parents about
the prognosis and effects of hemophilia on oral tissues,
the importance of attendance for dental treatment, and
dental hygiene habits. Patients with hemophilia
receive a more vigorous dental prevention program
than the general population [10].

CONCLUSION
The results of our study revealed that children with
hemophilia constitute a special group for dental care.
Dental management of patients with hemophilia
should begin with prevention of dental disease. The
parents approach to dental care has an importance to
people with hemophilia in relation to dental care.
Parents should be advised about the significance of
and necessity for oral care. Preventive care should be
delivered as early as possible, and patients should be
recalled for regular dental visits. In this way, the need
for active treatment may be reduced to a minimum
level.
Disclosures: The authors have no financial interests to
disclose related to the contents of this article.

REFERENCES
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related quality of life among young haemophilia patients.
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Oral Surg Oral Med Oral Pathol. 1982;53:363366.
4. Sonbol H, Pelargidou M, Lucas VS, et al. Dental health indices
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9. Newman MG, Takei HH, Carranza FA. Carranzas Clinical
Periodontology. 9th ed. Philadelphia: WB Saunders; 2002:543.
10. Boyd D, Kinirons M. Dental caries experiences of children with
haemophilia in Northern Ireland. Int J Paediatr Dent. 1997;7:
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Parents of participants in the control group showed a

higher tendency for regular dental visits. Low prevalence of regular dental visits in patients with
hemophilia may be related to the low frequency of
the families dental visits. Financial income and
education level in the study group were lower than
those of the control group. The most important issue
related to this study is the serious lack of studies
concerning dental health in children with hemophilia
related with the socio-economic and educational
status of parents. It is considered that the results
found in this study depend closely upon the deficiency
of patient information on the subject, education level
of the families, socio-economic and cultural dissimilarities. There was no difference between the tooth
brushing prevalence of parents in both groups. We
know that the frequency of dental hygiene habits is
directly related to peoples PI level. The children who
were educated by careless parents about dental
hygiene habits do not give the sufficient care and
importance to tooth brushing. So, no difference was
found between the PI level of the study and control
groups. Also, at the deciduous dentition period,
children take their mothers as a role model in dental
hygiene habits; as a result of this situation, there was
no difference between the dmf(t) and dmf(s) levels of
children in the two groups. But at the mixed and
permanent dentition period, children with hemophilia
grow up and become aware of their illness. So they are
afraid of gum bleeding and neglect tooth brushing.
Because of neglected and insufficient tooth brushing,
the DMF(T) and DMF(S) levels of the hemophilia
group become statistically worse than those of the
control group.
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