923866 PRD Primary Dental JournalVol. xx no.

xx Month xxxx

Key words Learning Objectives Authors

Acquired bleeding disorders, congenital
bleeding disorders, normal haemostasis,
anticoagulant drug therapy, bone
marrow disorders
•• To have a sound understanding of
acquired and congenital bleeding
disorders
•• To recognise and manage dental
patients with bleeding disorders safely
in a primary care setting
•• To provide advice on when to refer
patients with bleeding disorders to
specialist care
Sukina Moosajee BDS MSc
M SCD RCSEd, PGCert (CE) FHEA
Consultant in Special Care Dentistry
Department of Community Special Care Dentistry,
Kings College Hospital NHS Foundation Trust,
Denmark Hill
Sobia Rafique BDS MFDS MSc SCD
MSND Consultant Special Care
Dentistry
Department of Community Special Care Dentistry,
Kings College Hospital NHS Foundation Trust,
Denmark Hill

Sukina Moosajee, Sobia Rafique

Prim Dent J. 2020;9(2):47-55

Dental management of patients

with acquired and congenital
bleeding disorders
Abstract
In an age when people are living longer and medical interventions are
continually becoming more advanced, clinicians will need to be aware of
systemic disorders and treatments that may cause complications in the dental
setting. The Office for National Statistics’ projections state that 26% of the UK
population will be aged over 65 years by 2041.1 Therefore, clinicians may often
encounter patients who complain of prolonged bleeding following certain
procedures, most commonly dental extractions. In the majority of cases, the
cause is often a local one, which can be managed using simple local measures.
However, poor management can lead to potentially fatal consequences.
The aim of this paper is to update clinicians on the dental management of
patients with acquired or congenital bleeding disorders, and on how to decide
the most appropriate setting for safe dental care. Patient safety in the NHS is a
national priority with ever greater measures being put into place to avoid patient
harm. Whilst most patients can be successfully treated in primary care, for the
provision of safe dental treatment, the clinician may need to make a decision
regarding referral to specialist services for all dental treatment, or share care
between primary care and specialist services for selected procedures.

Normal haemostasis haemostasis have been disregarded in

Haemostasis is the process whereby
bleeding from a site of tissue damage is
arrested by the transformation of blood
from its fluid state into a thrombus.2
Modern models of haemostasis
recognise that it is a complex,
simultaneous process involving the
vascular endothelium, reflex
vasoconstriction, platelet plug formation,
coagulation and fibrinolysis.3 Distinct
primary, secondary (intrinsic and
extrinsic) and tertiary models of
favour of a cell-based, step wise model
consisting of overlapping stages of
initiation, amplification and
propagation.3
A bleeding disorder arises if there is a
problem in any part of the haemostatic
pathways. It can be acquired or
congenital. There are many acquired
medical conditions for which patients may
be taking medication causing an
increased bleeding tendency. For

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Vol. 9 N o . 2 J un e 2020 journals.sagepub.com/home/PRD 47

 Dental management of patients with acquired and
congenital bleeding disorders
Tabl e 1
Antiplatelet drugs prescribed in the UK
Drug name(s) Drug group
Aspirin Cyclo-oxygenase (COX)
inhibitor
Clopidogrel Adenosine diphosphate
(ADP) receptor antagonist
Prasugrel
Dipyridamole Adenosine uptake
inhibitor
Ticagrelor P2Y12 receptor antagonist
example, patients with a replacement
heart valve may be taking anticoagulants,
or patients that have had organ
transplants may be on corticosteroids.
There are several acquired medical
conditions that can directly affect normal
haemostasis, including:
•• Liver disease
•• Renal disease
•• Bone marrow disorders
•• Immune disorders
•• Other relevant acquired conditions
Congenital bleeding disorders are
present from birth. They are a group of
disorders that share the inability to form
a proper blood clot. This results in
extended bleeding following injury,
surgery, trauma and menstruation.
Bleeding may also occur spontaneously
with no known or identifiable cause.4
Acquired bleeding disorders
resulting from antiplatelet or
anticoagulant drug therapy
Antiplatelet drugs may be prescribed for
the primary and secondary prevention of
cardiovascular disease, the management
of acute myocardial and cerebral
ischaemia, and long term management
of transient ischaemic attacks or
ischaemic stroke.5 Antiplatelet drugs
prescribed in the United Kingdom (UK)
are shown in Table 1.5,6 They are
prescribed alone or in combination with
other antiplatelet or anticoagulant
48 Pr i ma r y De n ta l J ou r n a l
Mechanism of action
Irreversible inhibition of COX results in
reduction of thromboxane A2
Competitive inhibition of ADP binding
to platelet receptors, blocks
amplification of platelet aggregation
Reduction of ADP-induced aggregation
Prevents ADP-mediated P2Y12
dependent platelet activation and
aggregation
drug(s), and inhibit platelet aggregation
and thrombus formation.5
Anticoagulant drugs prescribed in the
UK are shown in Table 2.7-13 They may
be prescribed alone or in combination
with other antiplatelet or anticoagulant
drug(s). They inhibit the synthesis or
function of clotting factors required to
form a stable fibrin clot.
Dental management of
patients with acquired
bleeding disorders resulting
from antiplatelet or
anticoagulant drug therapy
Dental procedures unlikely to cause
bleeding include routine conservative,
restorative and orthograde endodontic
procedures requiring buccal,
intraligamental and intrapapillary local
anaesthesia, supragingival scaling,
prosthodontic procedures and fitting and
adjustment of orthodontic appliances.
These procedures may be carried out
without measuring the INR, withdrawing
heparin therapy or altering Direct Oral
Anticoagulant (DOAC) regimes.8
The INR does need to be checked, and
heparin or DOAC therapy may need to
be altered prior to dental procedures
that are likely to cause bleeding. These
include extractions, surgical procedures,
inferior alveolar block and lingual
infiltration, local anaesthetic injections
and deep periodontal scaling.8
Indication(s)
Primary and secondary prevention of
cardiovascular disease (CVD), acute
ischaemic events
Long term management of ischaemic stroke
or transient ischaemic attack (TIA)
Secondary prevention of CVD, acute
ischaemic events, long term management
of ischaemic stroke or TIA
Secondary prevention of CVD, long term
management of ischaemic stroke or TIA
Secondary prevention of CVD, acute
ischaemic events
Patients should be treated early in the
day and week, atraumatically and using
local haemostatic measures (local
anaesthesia with a vasoconstrictor,
gauze pressure packs, absorbable
haemostatic packing, sutures). Written
post-operative instructions and
emergency contact details should be
provided.8
A patient taking warfarin with an INR
below 4.0 can usually be treated in
primary care without altering their
anticoagulant regime. The INR should be
measured, ideally within 24 hours prior
to the procedure. For patients with a
stable INR, it is acceptable for it to be
measured within 72 hours prior to the
procedure.13 For INR results above 4.0,
and for those which are erratic or
fluctuant, liaison with the clinician
responsible for anticoagulation therapy
is required.8
A patient on a DOAC may need to
alter their drug regime in conjunction
with the clinician responsible for
anticoagulation, depending on the drug
being taken and the patient’s renal
clearance. Morning doses of apixaban,
edoxaban and dabigatran may need to
be omitted. For patients taking
rivaroxaban in the morning, the dose
should be delayed. For patients taking
rivaroxaban in the evening, no
alteration of the drug regime is required.
DOACs can be recommenced four hours
 Tabl e 2
Anticoagulant drugs prescribed in the UK
Drug name(s) Drug group
Warfarin Vitamin K antagonist
Phenindione
Acenocumarol
Dabigatran Direct Acting Oral
Anticoagulant (DOAC)
Rivaroxaban DOACs
Apixaban
Edoxaban
Unfractionated Heparin
heparin
Dalteparin Low molecular weight
heparins
Enoxaparin
Tinzaparin
post-operatively, assuming satisfactory
haemostasis is achieved.8
For patients on injectable anticoagulants
(e.g. heparins), liaison with the clinician
responsible for anticoagulation is
required.8
Patients taking single or dual
antiplatelet drugs can be managed
routinely in primary care. Local
haemostatic measures are sufficient to
manage any bleeding tendency
associated with these drugs after
surgical procedures. Seeking specialist
advice or referral is recommended for
patients taking triple antiplatelet
therapy, or combinations of antiplatelet
and anticoagulant therapy.8
The Scottish Dental Effectiveness
Programme (SDCEP) has produced a full
guide summary algorithm to help with
decision making.8 It is a key reference
source for dental team members who
treat patients taking antiplatelet or
anticoagulant drug therapy.
Vol. 9 N o . 2 J un e 2020
Mechanism of action
Antagonises vitamin K, which is
required for the synthesis of
clotting factors II, VII, IX, X,
protein C and protein S
Direct thrombin (factor IIa)
inhibitor
Factor Xa inhibitors
Inhibition of antithrombin III,
inhibition of factors IXa, Xa,
XIa, XIIa, prevention of
activation of factors V and VIII
Inhibition of factor Xa
Acquired bleeding disorders
arising from medical
conditions
Liver Disease
The liver plays a major role in
haemostasis as:
•• It produces coagulation factors
that are vital for clotting
•• It produces thrombopoietin,
a glycoprotein hormone which
regulates platelet production by
the bone marrow
•• Failure of normal liver can lead to
malabsorption of Vitamin K which is
required for the synthesis of blood
clotting factors
Both the Prothrombin Time (PT) and
Activated Partial Thromboplastin Time
(APTT) are prolonged in chronic liver
disease and severe bleeding can occur
after dental extractions.8,9 Every day
more than 40 people die from liver
disease.10 There are numerous causes of
liver disease, including alcohol misuse,
Indication(s)
Pulmonary embolus (PE), deep vein thrombosis
(DVT), mitral stenosis or regurgitation,
symptomatic thrombophilias, antiphospholipid
syndrome (APS), paroxysmal nocturnal
haemoglobinuria (PNH), atrial fibrillation,
cardioversion, mural thrombus, dilated
cardiomyopathy, arterial grafts, coronary
thrombosis, artificial cardiac valves
PE and DVT, prophylaxis of venous
thromboembolism (VTE prophylaxis), atrial
fibrillation,
PE and DVT (rivaroxaban), VTE prophylaxis,
atrial fibrillation
Haemodialysis, VTE prophylaxis, venous
thromboembolism during pregnancy, acute
coronary syndromes, PE and DVT
Haemodialysis, VTE prophylaxis, venous
thromboembolism during pregnancy, prevention
of thrombosis in patients with solid tumours,
acute coronary syndromes, PE and DVT
hepatitis, autoimmune disease and
obesity.
Dental management of bleeding
tendencies caused by acquired liver
disease
•• Liver function tests and clotting
screens should be carried out prior to
invasive dental treatment, such as
extractions11
•• Patients at risk of Vitamin K
malabsorption may require oral or
intravenous Vitamin K beforehand,
and it is important to liaise with the
patient’s physician
•• Patients with jaundice may require a
preoperative infusion of fresh frozen
plasma,11 consultation with the
patient’s physician is essential
•• Local haemostatic measures should
always be used (see Table 3)12-14
Renal disease
Chronic renal failure is an irreversible
condition which occurs after progressive
kidney damage. It results in depression
49
 Dental management of patients with acquired and
congenital bleeding disorders

Tabl e 3

Local haemostatic measures

1. Local anaesthetic:
• Use local anaesthetic with a vasoconstrictor.
• Avoid regional nerve blocks where possible. If necessary, then ensure an aspirating syringe is always used.

2. Minimise trauma:
• As with all extractions the aim is to minimise trauma as much as possible.

3. Haemostatic agents:
• Consider the use of a haemostatic resorbable dressing following an extraction such as oxidised regenerated cellulose
(Surgicel®), synthetic collagen or gelatine sponge to promote and stabilise clot formation by providing a mechanical matrix.

4. Suture:
• Suture the socket with resorbable sutures to achieve primary closure where possible and then apply pressure to socket with a
gauze pack until haemostasis is achieved.

5. Post-operative instructions:
• Give clear post-operative instructions to the patient both verbal and written.

6. Tranexamic acid mouthwash:

• The use of tranexamic mouthwash post operatively is not routinely advocated in patients on warfarin as it is expensive, difficult
to obtain and when used in combination with other haemostatic measures, provides little additional reduction in post-operative
bleeding.
• However, tranexamic acid mouthwash maybe useful as an antifibrinolytic agent for patients with congenital and other acquired
bleeding disorders.

of the glomerular filtration rate

Table 4
persisting over 3 months or more.
Patients with chronic renal failure may Signs of chronic renal failure
require dialysis. Where patients are on
haemodialysis, heparin is added to the General signs Oral signs
dialysis circuit to facilitate the process.
Patients on other forms of dialysis are Anaemia as kidneys produce erythropoietin Loss of lamina dura
not treated with heparin.9 Clinicians
Bruising due to decreased thromboxane production Osteolytic lesions
need to be aware of signs and
which impairs conversion of prothrombin to thrombin
symptoms of renal failure, especially in
patients who have a history of poorly Bleeding from mucous membranes due to platelet Secondary hyperparathyroidism
controlled hypertension or diabetes abnormality and defective Von Willebrands Factor leading to giant cell lesions
(see Table 4).
Skin pigmentation and pruritus due to excess urea Halitosis
Haemostasis is impaired in patients with
chronic renal failure due to: Anorexia, nausea, vomiting, diarrhoea Metallic taste

•• Impaired platelet production as
thrombopoietin hormone which
stimulates megakaryocytes mature
into platelets is produced in the
kidney’s proximal convoluted
tubulular cells13
•• Impaired platelet adhesion due to
defective von Willebrand factor
(vWF) as glomerular endothelial cells
express vWF
•• A decrease in platelet factor 3
(thromboxane) which impairs
CNS effects such as confusion, coma and fits due to Dry mouth
metabolic disturbances
Oral ulceration/pale mucosa due
to anaemia
conversion of prothrombin to Dental management of bleeding
thrombin tendencies caused by acquired renal
•• Vasodilation from raised prostacyclin disorders
levels (PG1)14 •• The renal physician or haematologist
•• The use of heparin in haemodialysis9 should be consulted

50 Pr i ma r y De n ta l J ou r n a l
 Tabl e 5

Bone marrow disorders

Bone marrow disorder Disorder results from: Treatment Bleeding tendency caused by:

Myeloproliferative Disorders Increased production of one or more Spontaneous recovery Decreased production of platelets
(rare) precursor cell lines resulting in Bone marrow transplant Can transform to leukaemia
inhibition of other cells Immunosuppressive treatment From immunosuppressive
treatment

Myelodysplastic syndrome Abnormal cell production leading to Spontaneous recovery Decreased production of platelets
(rare) underproduction of normal cells Bone marrow transplant Can transform to leukaemia
Immunosuppressive treatment From immunosuppressive
treatment

Myelofibrosis Fibrosis due to abnormal precursor Hydroxyurea and bisulphan Decreased production of platelets
(rare) cells stimulating fibroblasts Splenectomy Can transform to leakaemia

Leukaemia Malignant neoplasm of Chemotherapy Decreased production of platelets

(2% of all cancers in the UK)
haematopoietic stem cells that can Radiotherapy from disease and from treatment
infiltrate bone marrow and enter
Bone marrow transplant
circulation
4 main types

Lymphoma Neoplastic transformation of normal Chemotherapy Bone marrow infiltration causes

(non-Hodgkins more common B or T cells in lymphoid tissue thrombocytopenia
than Hodgkins; 4% of all 2 main types
cancers in the UK)

Graft versus host disease Severe complication that can follow High dose corticosteroids Liver involvement
bone marrow transplant Thrombocytopenia
From corticosteroid treatment

Multiple myeloma
(1% of all cancers in the UK)
Malignant disease of bone marrow Chemotherapy Bone marrow infiltration leading
plasma cells Bone marrow transplant to thrombocytopenia
hyperviscosity leading to further
bleeding tendency Association
with renal failure

•• Invasive dental treatment should not
be carried out on the same day as
dialysis due to the use of heparin
•• Bleeding tendencies should be
excluded prior to administering a
nerve block injection or carrying out
invasive dental treatment
•• Local haemostatic measures (see
Table 3) are essential
To avoid post-operative bleeding, once
local measures have been used,
desmopressin (DDAVP), which can be
taken intra-nasally chairside, may help
with haemostasis for up to 4 hours and
can be prescribed by the patient’s
specialist unit.14
Bone marrow disorders
The bone marrow produces
haematopoetic stem cells. Normally, only
mature cells are released from the bone
marrow into the circulation. Any disorder
causing an abnormality in the production
of immature precursor cells or mature
cells can cause a bone marrow disorder.
Normal function can be disrupted by
infections, such as tuberculosis, or
malignancies, such as leukaemia (see
Table 5).15
Dental management of bleeding
tendencies caused by bone marrow
disorders
The main points to consider are:
•• Extreme caution with invasive dental
procedures, including inferior dental
block local anaesthetics
•• Prior consultation with the patient’s
haematologist or physician is
essential
•• Local haemostatic measures must
always be used (see Table 3)
•• For patients with haematological
malignancies, the timing of the

Vol. 9 N o . 2 J un e 2020 51
 Dental management of patients with acquired and
congenital bleeding disorders

Tabl e 6

Immune disorders causing bleeding tendencies

Disorder Cause Management Cause of bleeding tendency

Idiopathic Post viral infection Corticosteroids Immune destruction of platelets causes

thrombocytopenic purpura Pregnancy Immunosuppressant medication thrombocytopenia (platelet count,
(ITP) / autoimmune 150 x 109/l)
Idiopathic Splenectomy
thrombocytopenic purpura
In conjunction with other
autoimmune disorders

Human immunodeficiency Infection with HIV Anti-viral therapy Impaired haematopoiesis, immune
Virus (HIV) disease mediated thrombocytopenia, altered
coagulation, co-existing disease
(e.g viral hepatitis, haemophilia,
opportunistic infection, malignancy),
side effect of antiviral therapy

Systemic Lupus Multisystem autoimmune disease Non-steroidal anti-inflammatory Thrombocytopenia can be a

Erythematosus (SLE) Autoantibodies to dsDNA and
phospholipids
drugs, hydroxychloroquine,
biological therapies (e.g. anti-
TNFα agents, anti-CD20 agents,
rituximab)
complication of SLE
Corticosteroid therapy
Anticoagulant medication

Antiphospholipid Autoantibodies to phospholipids Antiplatelet or anticoagulant Thrombocytopenia Antiplatelet and/

Syndrome (APS) medication or anticoagulant medication

Tabl e 7

Causes of splenomegaly
Haematological Hepatic Autoimmune Infective

Myeloproliferative Cirrhosis SLE Chronic malaria

Myelofibrosis Portal hypertension Rheumatoid arthritis Endocarditis

Leukaemias Sarcoidosis Typhoid

Lymphomas Tuberculosis

procedure is important. Invasive depending on their platelet levels. Immune disorders

dental procedures should be carried
out when the patient is in remission
and between chemotherapeutic
regimes when the cell count and
platelet count is optimal
•• A thorough dental assessment is
essential prior to treatment
commencing so that any teeth with
poor prognosis can be removed
avoiding fatal complications
•• Patients with thrombocytopenia may
require platelet transfusions prior to
invasive dental treatment,
Full blood and platelet counts
should be checked before surgery,
with minimum counts of:
•• At least 30 x 109/l for regional
dental block anaesthesia
•• At least 50 x 109/l for minor oral
surgery
•• At least 75 x 109/l for major
surgery16
•• Local haemostatic measures and the
use of DDAVP and tranexamic acid
can reduce the need for platelet and
factor transfusions
Disorders of the immune system can
affect haemostasis due to immune
destruction of platelets, effects on vessel
walls and the effects of drugs taken to
control the disorders. These are shown in
Table 6.17-20
Disorders of the spleen
The spleen acts as a storage site for red
blood cells and platelets enabling rapid
mobilisation when necessary.
Splenomegaly usually occurs secondary
to other disorders and can result in

52 Pr i ma r y De n ta l J ou r n a l
 Tabl e 8

Causes of acquired thrombocytopenia

Decreased platelet production Splenic sequestration Other

Leukaemia Cirrhosis with congestive splenomegaly Idiopathic thrombocytopenia purpura (ITP)

Lymphoma Myelofibrosis with splenomegaly HIV

Aplastic anaemia Drugs (Heparin)

Myelodysplasia Disseminated intravascular coagulation (DIC)

Chronic alcoholism Thrombotic thrombocytopenia purpura

Vitamin B12 deficiency

Folic acid Deficiency

Tabl e 9

Classification and clinical features of haemophilia A and haemophilia B

Factor level Signs and symptoms

< 1% of normal (1 iu/dL) (Severe) Spontaneous, recurrent haemarthroses and haematomas

Severe bleeding after injury or surgery

1-5% of normal (1-5 IU/dL) (Moderate) Prolonged bleeding after relatively minor trauma
Spontaneous bleeding may occur rarely

>5% to <40% of normal (5-40 IU/dL) (Mild) Abnormal bleeding after haemostatic challenge (for example
tooth extraction, trauma or surgery)

bleeding problems due to sequestration
of platelets causing thrombocytopenia
(see Table 7).
Other causes of acquired thrombocyto-
penia are shown in Table 8.18
Dental management of
bleeding disorders caused by
immune system and splenic
disorders
The main points to consider are similar
to the previous sections:
•• Prior to any invasive dental
procedures, consult the patient’s
physician and check the
patient’s full blood and platelet
count
•• If the patient is on anticoagulants,
then manage as described earlier
•• Always use local haemostatic
measures (see Table 3)
Congenital bleeding disorders
Congenital bleeding disorders are
present from birth. Von Willebrand
Disease (vWD) is the most common
congenital bleeding disorder.19 It is
defined by the UK Haemophilia Centre
Doctors Organisation (UKHCDO) as
‘a bleeding disorder predominantly
attributable to reduced levels of von
Willebrand factor (vWF) activity’.20 Von
Willebrand factor is a complex
glycoprotein which is essential for platelet
adhesion to damaged vascular
endothelium, and acts as a carrier
molecule for clotting factor VIII (FVIII).21,22
The inheritance pattern is autosomal,
therefore both males and females are
affected. Bleeding symptoms typical of
vWD include bleeding after minor
injury, surgical bleeding,
mucocutaneous bleeding, menorrhagia,
epistaxis, bleeding after tooth
extraction, gastrointestinal bleeding,
gingival bleeding, oral mucosal
bleeding, and postpartum
haemorrhage.22 Internal bleeding,
bleeding into muscles and bleeding into
joints may occur in severe disease.
Patients with vWD may be managed
with tranexamic acid, desmopressin/
DDAVP or vWF containing plasma-
derived concentrates.22,23
The haemophilias are congenital
bleeding disorders resulting from a
deficiency of FVIII (haemophilia A) and
clotting factor IX (FIX) (haemophilia B).24
The inheritance pattern is usually X-linked
recessive, affecting males born to carrier
females, although new, spontaneous
genetic mutations can produce sporadic
disease with no family history.25 Female
carriers may have sufficiently low levels
of FVIII or FIX to be classified as having
haemophilia.26 Table 9 shows the
classification and clinical features of
haemophilia.26,27,28

Vol. 9 N o . 2 J un e 2020 53
 Dental management of patients with acquired and
congenital bleeding disorders

Tabl e 10

Dental procedures requiring haemostatic cover in patients with congenital

bleeding disorders
Procedures that do not require factor Procedures that do require factor haemostatic cover
haemostatic cover (e.g. tranexamic acid, (e.g. tranexamic acid, DDAVP, factor replacement
DDAVP, factor replacement therapy) therapy)

Local anaesthesia Buccal, intra-ligamentous and intra-papillary Regional nerve blocks (inferior alveolar, posterior-
infiltrations. Treatment can be carried out superior alveolar). Lingual and floor of mouth
safely in primary care. infiltrations. Treatment can be carried out safely in
primary care.

Restorative dentistry Routine conservative dentistry, crown and

bridge work, endodontic treatment. Treatment
can be carried out safely in primary care.

Periodontal treatment Periodontal probing, supragingival scaling Subgingival scaling, periodontal probing and
and polish in patients with mild disease and supragingival scaling in patients with severe disease
with good gingival health. Treatment can be and/or where gingival health is poor. Refer patients with
carried out safely in primary care. severe disease or complications to specialist services.

Prosthetic dentistry Construction and of full or partial dentures.

Treatment can be carried out safely in
primary care.

Extractions and oral surgery All dental extractions and minor oral surgery
procedures. Local haemostatic measures should be used.
Post-operative hospital admission may be required for
patient with severe disease or complications. Refer to
specialist services.

Patients with congenital bleeding
disorders are cared for in
Comprehensive Care Centres (CCCs) or
Haemophilia Centres (HCs). DDAVP is
the treatment of choice in mild
haemophilia A, and symptomatic
carriers of haemophilia A. Where factor
concentrate is required, recombinant
FVIII is the treatment of choice in
haemophilia A and recombinant FIX in
haemophilia B.23 A complication of
treatment with factor concentrate is the
development of inhibitors, antibodies
that interfere with the effect of
transfused factor concentrates. In these
patients, “by-passing therapies” are
used to manage acute bleeds; these
include recombinant FVIIa (rFVIIa,
NovoSeven®), and FEIBA® (Factor
Eight Inhibitor Bypassing Activity).23
Patients who received plasma-derived
factor concentrates prior to 1985 may
have become infected with blood-borne
viruses, including hepatitis B virus,
hepatitis C virus and HIV.27 The clinical
manifestations (e.g. chronic liver
disease, thrombocytopenia) and
medical management of these
transfusion transmitted infections can
increase bleeding severity in patients
with congenital bleeding disorders.
Dental management of patients with
congenital bleeding disorders
As severe complications may arise
after dental treatment in patients with
congenital bleeding disorders,
close liaison is required between
haematology and dental teams caring
for these patients. Preventive advice
should be delivered according to
evidence-based guidelines.28 When
providing dental treatment for patients
with congenital bleeding disorders,
care should be taken to reduce
accidental damage to the oral mucosa,
e.g. careful placement of saliva
ejectors, radiograph holders and films,
rubber dam clamps and matrix bands.
Also ensure restorations and removable
prosthesis have no sharp surfaces.
The prescription of non-steroidal anti-
inflammatory drugs should be avoided
as this can worsen any bleeding
tendency due to the inhibition of
platelet function.26 Where haemostatic
cover is required for dental procedures
(see Table 9), dental appointments
should be scheduled as close to the time
of administration of haemostatic cover
as possible. Patients with severe disease
and/or complications may require
post-operative admission in CCCs/HCs
for monitoring and management of any
bleeding complications.26
Table 10 shows which dental procedures
require haemostatic cover.
Conclusion
It is important for the dental clinician to
be able to recognise medical conditions
and treatments that may cause serious
and possibly fatal bleeding
complications. This paper outlines many
of these conditions. Through a detailed
risk assessment and treatment planning,
the clinician can provide safe dental
treatment and use a shared care
approach when necessary.

54 Pr i ma r y De n ta l J ou r n a l
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Care Dentistry: Part 2. Dental
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