## 4 Discussion  
In the present study, we analyzed the effects of continual dental support over a period of 5 years on the periodontal status and oral health habits of the patients each year and also investigated the association between them. Periodontal status is affected by aging [12], and we compared subjects at two dentition stages (mixed dentition and permanent dentition) in each year. The results showed that continual dental support improved the periodontal status and oral health habits of children with hemophilia in the mixed dentition stage. However, no change was observed in the permanent dentition stage. Our results suggest  
Figure 5: Associations between oral health habits in young patients with hemophilia. (**A**) Association between dental floss use and daily toothpushing by parents in patients with hemophilia in mixed dentition. There were significant differences, as determined by the analysis of variance with Bonferroni correction. **\(p<0.01\)**. (**B**) Association between dental floss use and the presence of a family dentist in patients with hemophilia in permanent dentition. that continual dental support may contribute to improved periodontal status and oral health habits in hemophilic patients, especially in the mixed dentition stage. Patients with hemophilia require measures to be taken to reduce the risk of oral bleeding. According to the World Federation of Hemophilia (WFH) guidelines, prevention of dental disease is crucial for patients with hemophilia to avoid invasive dental procedures [13]. They also recommend access to regular preventive oral care as part of comprehensive hemophilia care [13]. [PERSON] et al. reported that a multidisciplinary approach by multiple medical disciplines, including dentistry, resulted in a lower gingival index and better oral health in children with hemophilia [14]. Those who are involved in dental support should not only educate patients with hemophilia about the importance of good oral health habits but also provide instruction on how to maintain good oral health. [PERSON] et al. (2022) investigated the oral hygiene of children with bleeding disorders and found an association between the oral hygiene of the primary caregiver and the child [15]. This finding suggests that all health providers, family members, and caregivers surrounding the child have an impact on oral disease; this impact may be more significant during the deciduous and mixed dentition periods when children require help with toothrbushing. It is essential to educate the adults in contact with the child so that they have a high level of awareness about the child's oral hygiene. Previous studies reported that children with hemophilia have poorer periodontal health than healthy children [5; 16; 17; 18]. On the other hand, few studies have reported the effect of continuous dental support. In the present study, several children in the mixed dentition group had a CPI value of 3 (4-5 mm periodontal pockets) at the first visit, and the upper right molars had the highest mean CPI value. With continual dental support, the CPI values of the upper right molars improved, and the CPI values of 3 or higher decreased in each site. In the permanent dentition group, there were CPI values of 3 or higher in each molar region, but no improvement was observed except in the upper right molars. These results suggest that periodontal status is more likely to improve in the mixed dentition group than in the permanent dentition group, with continual dental support for hemophilic patients. Periodontal status is associated with oral health habits [7], and continual dental support for the mixed dentition group, whose periodontal status is more likely to improve, may be necessary for them to maintain good periodontal status. We conducted an annual survey of oral health habits. The questionnaires revealed that continual dental support increased the rate of dental floss use, the frequency of toothrbushing by parents, and the percentage of subjects attending family dentits in the mixed dentition group.