Proper Use of Clotting Factor Concentrates

Due to the complexity of managing bleeding disorders, communication between the dental provider, patient, and the patient’s hematologist is essential. Once the dentist has established a treatment plan, they must communicate with the hematologist to determine if the patient will require factor replacement prior to, post treatment or both. In addition, the hematology treatment plan must be communicated to the patient or caregiver, as well as the dentist.

Replacement factor is very expensive and there is a risk to the patient of developing antibodies or inhibitors to the factor if unnecessarily prescribed.²⁶ A single dose of factor may cost $5,000-$10,000, and a simple plan may use 1-4 doses of factor. Factor replacement involves either human plasma-derived or human recombinant factor concentrates, some of which may be chemically modified for extended duration. In addition, other therapies include non-factor therapies (i.e. emicizumab, a bispecific antibody that links Factor IX and X and mimics Factor VIIIa’s tenase function), desmopressin (an IV medication), antifibrinolytic drugs, platelets, or fresh frozen plasma depending on the specific bleeding disorder.²⁷ Treatments that do not pose a severe hemostatic challenge, such as restorations, should be completed in as few appointments as possible to minimize unnecessary infusions.

Many patients with bleeding disorders are capable to self-infusing IV medications at home either from a port or a butterfly needle before a procedure. Indeed, some people with severe hemophilia self-infuse factor at home two or three times a week to prevent bleeding. However, some patients may not be able to self-infuse, or they may require medications to be given at an infusion center before going to the dental provider for the dental procedure. Physical impairment from prior bleeding events resulting in arthropathy, IV access difficulty, insurance or cost concerns, and other medical illness can be barriers to self-infusion.

Because of the high costs, logistical barriers, and insurance limitations to obtain bleeding disorder treatments, it can take many weeks (or even months) to obtain the medication necessary to complete an otherwise straightforward treatment plan. However, forgoing such therapy can lead to a traumatic experience from bleeding with a dental procedure that makes the patient hesitant for future dental care. Some patients may already have medications at home, and a procedure(s) could be scheduled once a treatment plan is made.

Figure 6 demonstrates medications community used for patients with bleeding disorders that may be prescribed by the patient’s hematologist/HTC