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Dental Care for Patients with Bleeding Disorders in the Era of New Therapies

Dec 19, 2025 by “Bobby” Duc Tran, MD, MSc Chief Medical Officer, Hemophilia of Georgia Adjunct Associate Professor, Department of Hematology, Emory University

Introduction

Dental professionals are increasingly likely to encounter patients with bleeding disorders, particularly as advances in treatment have improved life expectancy and quality of life. These conditions, whether inherited or acquired, pose unique challenges in dental care due to the risk of prolonged bleeding, hematomas, and complications such as retropharyngeal hemorrhage. This article outlines key concepts, treatment options, and collaborative strategies that enable dental teams to confidently care for patients with inherited and acquired bleeding disorders.

Hemostasis involves three key steps: vasoconstriction, platelet plug formation, and fibrin clot formation. Vasoconstriction reduces blood flow at the injury site, while platelets form a temporary plug. For larger injuries, clotting factors—primarily thrombin (Factor IIa)—activate a cascade that results in a stable fibrin clot [1]. Bleeding disorders disrupt one or more of these steps.

 

Inherited Bleeding Disorders

Hemophilia is an X-linked inherited disorder that primarily affects males. Severity is determined by clotting factor activity:

  • Severe hemophilia (<1% activity) often causes spontaneous joint and muscle bleeds.
  • Moderate (1–5%) and mild (6–50%) cases usually present with bleeding after trauma or surgery [2,3].

Von Willebrand disease (VWD), the most common inherited bleeding disorder, affects both sexes and varies in severity [4].

  • Type 1 involves a mild quantitative deficiency of von Willebrand factor (VWF).
  • Type 2 results from qualitative defects.
  • Type 3 is marked by near-complete absence of VWF.

Platelet disorders such as Glanzmann’s thrombasthenia and Bernard-Soulier syndrome and rare clotting factor deficiencies also exist, though these are far less common.

Hemophilia has seen the greatest advancements in treatment. Early management relied on whole blood transfusions, often requiring hospitalization. The 1970s brought home infusions, but the community was devastated in the 1980s when contaminated blood products transmitted HIV and hepatitis C. This tragedy spurred the development of recombinant factors and, more recently, gene therapy [5,6,7,8].

Today, patients may be managed with standard or extended half-life factor products, subcutaneous non-factor therapies, or gene therapies that aim for long-term correction. Many receive prophylactic therapy, while others require treatment only before procedures. For dental professionals, the primary goal is to ensure factor levels are raised to a safe range—typically 50–100%—prior to invasive care.

 

Clotting Disorders Related to Medications

Many patients present with bleeding risk secondary to anticoagulant or antiplatelet therapy.

Anticoagulants:

  • Direct oral anticoagulants (DOACs) such as factor Xa inhibitors (apixaban, rivaroxaban, and edoxaban) and direct thrombin inhibitor (dabigatran) and traditional agents like warfarin can increase bleeding risk [10].
  • Evidence shows that for many dental procedures, these medications can safely be continued. For example, patients on DOACs undergoing simple extractions or restorations usually experience manageable bleeding controlled with local measures [9].
  • Warfarin is considered safe for most dental procedures if the INR is ≤3.5 [11].

Reversal agents are available but are typically restricted to hospital settings and may not be universally stocked.

  • Warfarin: vitamin K and prothrombin complex concentrate.
  • DOACs: idarucizumab for dabigatran; andexanet alfa for factor Xa inhibitors.
  • Timing and access to these agents are critical when urgent reversal is required.

Antiplatelet therapy:

  • Consultation with the prescribing physician is recommended before making any changes [12].
  • In rare cases of uncontrollable bleeding where local measures fail, platelet transfusion may be considered.

 

Practical Dental Approach

1. Comprehensive Assessment

Management begins with a detailed medical history and discussion of prior bleeding events, current medications, and past surgical outcomes. If a patient does not have a bleeding disorder diagnosis but has an extensive bleeding history or unusual bleeding issues with dental care, then the dental team should strongly recommend follow-up for work up wth primary care provider or hematologist.

2. Preventive Care

Emphasis on preventive dentistry—including fluoride, sealants, and early interventions—reduces the need for invasive procedures [13].

3. Preoperative Planning

  • Consult with the patient’s hematologist when necessary.
  • Confirm prophylactic therapy, clotting factor levels, or timing of anticoagulant dosing.
  • Review all medications and supplements [14,15].

4. Adjunctive Therapies

Desmopressin (DDAVP) stimulates the release of VWF and FVIII, effective in mild hemophilia and some VWD cases.

Antifibrinolytics (tranexamic acid, aminocaproic acid) help stabilize clots, especially in mucosal tissues, and are valuable postoperatively.

5. Local Measures

  • Use anesthetics with epinephrine to promote vasoconstriction.
  • Favor minimally invasive techniques, such as flapless extractions and conservative suturing.
  • Apply hemostatic agents like Surgicel, Avitene, or fibrin sealants directly to surgical sites [15].

 

Community Collaboration

In Georgia, Hemophilia of Georgia (HoG) provides critical support [16]. HoG serves as a hemophilia treatment center (HTC), delivering comprehensive care. The organization funds other HTCs in Georgia, facilitates access to bleeding disorder medications, and coordinates care between hematology and dental teams.

When a dental procedure is planned, HoG works with the treating dentist and hematologist to ensure safe treatment, deliver factor products if needed, and provide follow-up support. This model of collaboration exemplifies how dental professionals, when integrated into the care team, can make a profound impact on patient outcomes.

 

Conclusion

Dentists play an essential role in the multidisciplinary care of patients with bleeding disorders. By maintaining current knowledge of evolving therapies, applying meticulous preventive and surgical strategies, and collaborating with subspecialty teams such as hematology, dental professionals can provide safe and effective treatment. With continued advancements in factor replacement, non-factor therapies, and gene-based treatments, clinical outcomes for individuals with bleeding disorders are improving greatly. Dental professionals remain integral to this progress, contributing significantly to the safe and effective management of these patients.


 

References

1. Nacca CR, Shah KN, Truntzer JN, Rubin LE. Total knee arthroplasty in a patient with hypofibrinogenemia. Arthroplast Today. 2015 Nov 6;2(4):177-182. doi: 10.1016/j.artd.2015.10.004. PMID: 28326424; PMCID: PMC5247511.

2. Schramm W. The history of haemophilia - a short review. Thromb Res. 2014 Nov;134 Suppl 1:S4-9. doi: 10.1016/j.thromres.2013.10.020. Epub 2014 Feb 7. PMID: 24513149..

3. Mazepa MA, Monahan PE, Baker JR, Riske BK, Soucie JM; US Hemophilia Treatment Center Network. Men with severe hemophilia in the United States: birth cohort analysis of a large national database. Blood. 2016 Jun 16;127(24):3073-81.

4. Du P, Bergamasco A, Moride Y, Truong Berthoz F, Özen G, Tzivelekis S. Von Willebrand Disease Epidemiology, Burden of Illness and Management: A Systematic Review. J Blood Med. 2023 Mar 2;14:189-208. doi: 10.2147/JBM.S389241. PMID: 36891166; PMCID: PMC9987238.

5. Hewson ID, Daly J, Hallett KB, Liberali SA, Scott CL, Spaile G, Widmer R, Winters J. Consensus statement by hospital based dentists providing dental treatment for patients with inherited bleeding disorders. Aust Dent J. 2011 Jun;56(2):221-6. doi: 10.1111/j.1834-7819.2011.01328.x. PMID: 21623817.

6. Manco-Johnson MJ, Abshire TC, Shapiro AD, Riske B, Hacker MR, Kilcoyne R, Ingram JD, Manco-Johnson ML, Funk S, Jacobson L, Valentino LA, Hoots WK, Buchanan GR, DiMichele D, Recht M, Brown D, Leissinger C, Bleak S, Cohen A, Mathew P, Matsunaga A, Medeiros D, Nugent D, Thomas GA, Thompson AA, McRedmond K, Soucie JM, Austin H, Evatt BL. Prophylaxis versus episodic treatment to prevent joint disease in boys with severe hemophilia. N Engl J Med. 2007 Aug 9;357(6):535-44. doi: 10.1056/NEJMoa067659. PMID: 17687129.

7. Ozelo MC, Yamaguti-Hayakawa GG. Impact of novel hemophilia therapies around the world. Res Pract Thromb Haemost. 2022 Apr 12;6(3):e12695. doi: 10.1002/rth2.12695. PMID: 35434467; PMCID: PMC9004233.

8. Pier Mannuccio Mannucci; New therapies for von Willebrand disease. Hematology Am Soc Hematol Educ Program 2019; 2019 (1): 590–595. 

9. Lusk KA, Snoga JL, Benitez RM, Sarbacker GB. Management of Direct-Acting Oral Anticoagulants Surrounding Dental Procedures With Low-to-Moderate Risk of Bleeding. J Pharm Pract. 2018 Apr;31(2):202-207. doi: 10.1177/0897190017707126. Epub 2017 May 16. PMID: 28506106.

10. Chen A, Stecker E, A Warden B. Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges. J Am Heart Assoc. 2020 Jul 7;9(13):e017559. doi: 10.1161/JAHA.120.017559. Epub 2020 Jun 15. PMID: 32538234; PMCID: PMC7670541.

11. Weltman NJ, Al-Attar Y, Cheung J, Duncan DP, Katchky A, Azarpazhooh A, Abrahamyan L. MANAGEMENT OF DENTAL EXTRACTIONS IN PATIENTS TAKING WARFARIN AS ANTICOAGULANT TREATMENT: A SYSTEMATIC REVIEW. J Can Dent Assoc. 2015;81:f20. PMID: 26679334.

12. Ockerman A, Bornstein MM, Leung YY, Li SKY, Politis C, Jacobs R. Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2020 Jan;49(1):90-98. doi: 10.1016/j.ijom.2019.06.002. Epub 2019 Jun 24. PMID: 31248706.

13. Brewer A, Correa M. Guidelines for Dental Treatment of Patients with Inherited Bleeding Disorders. WFH Guidelines. 2006.

14. Stanford Medicine. Medications and Herbs That Affect Bleeding. https://med.stanford.edu/content/dam/sm/ohns/documents/Sinus%20Center/Stanford_Medication_and_Herbs.pdf. Accessed on 9/10/2025.

15. Abed H, Ainousa A. Dental management of patients with inherited bleeding disorders: a multidisciplinary approach. Gen Dent. 2017 Nov-Dec;65(6):56-60. PMID: 29099367.

16. Hemophilia of Georgia website. http://www.hog.org. Accessed on 9/10/2025.