The paper by Franchesca Fong and colleagues from the Royal London Hospital in this edition of The Journal of Haemophilia Practice fills an important void in the literature regarding the management of dental care in children with inherited bleeding disorders [1]. The vast majority of papers that have been published, and the protocols that have been adopted by haemophilia societies around the world, have concentrated on dental care in the adult population. A number do mention children but this is the first paper from the United Kingdom that concentrates on this particular cohort of patients.

The World Federation of Haemophilia suggests that 'the loss of teeth should be classified as a failure in the provision of adequate dental care' [2]. The exceptions to this are the loss of the deciduous teeth, extractions to facilitate orthodontic treatment, the loss of impacted wisdom teeth and the removal of teeth as a precursor to orthognathic surgery.

The comprehensive care team involves all the specialists concerned with the well-being of the patient. The dental profession is a very important element, but an often forgotten member, of the team. The presence of a suitably qualified dental surgeon at the outpatient clinic reinforces this to medical and nursing staff as well as to patients and their parents. The pathway for the care of these patients involves both primary and secondary care providers. In the area served by the Royal London, access to care within the primary dental care sector became more difficult following the introduction of a new dental services contract in 2006. It is however important to use this sector since adult patients are advised to seek dental care in the primary sector when appropriate.

People with haemophilia now expect a very high standard of care from health care professionals, including dental care. Gone are the days when carious teeth were extracted and all restorative treatment was performed under general anaesthesia due to the fear of administering local anaesthesia. Older patients often expected to be edentulous in early adulthood however younger patients expect to retain their teeth and have the same access to treatment as their peers. Today, children and their parents are given preventive advice from an early age. The paediatric specialist must involve all members of the comprehensive care team but particularly the nursing staff to help with this as they will see the patients when they attend for prophylaxis or the treatment of bleeding episodes. A number of the patients will require orthodontic treatment and co-ordination of this is vital to prevent injury to the soft tissue from the appliances.

The team at the Royal London Hospital has now developed excellent pathways for the management of the children and adults with congenital bleeding disorders. The dental care of the patient during the transition from the paediatric unit to the adult unit is a major challenge in many centres. It can only be hoped that the presence of the dental surgeon at the clinic will promote an easy transition between the units. There are a number of barriers that need to be crossed to make this transition work. The first of these is that the young adult tends to attend clinic on their own and do not always see their teeth as an important part of health care. In addition, adult patients in the UK often find getting NHS care difficult - it is costly and they are required to pay treatment costs according to the scale of fees determined by the government.

I would recommend this article as an excellent base for the development of a patient care pathway in paediatric haemophilia centres. The dental care pathway developed at the Royal London Hospital could easily be modified for use by others. It is to be hoped that the development of such pathways will, in the future, reduce both the problems associated with dental care and the number of patients 'lost to the system' during their transition from paediatric to adult care.