Special Considerations

Aging and Comorbidities

Studies have linked bleeding disorders to osteoporosis, thus it’s critical for dental providers to perform a thorough health history to evaluate for the use of bisphosphonates prior to treatment planning for dental extractions. Patients with bleeding disorders are also twice as likely to have hypertension, requiring dental providers to diligently monitor blood pressure during treatment procedures.⁵⁷ Other common comorbidities include obesity, diabetes, obstructive sleep apnea, and cardiovascular disease. According to the World Health Organization, the incidence of obesity has tripled in the last 30 years, currently affecting 13% of the world's population. In the subgroup of patients with hemophilia, obesity has increased by 20% in adults and 40% in children in the last 10 years and currently affects 43% of adults and 27% of children with hemophilia. This is of particular interest to dental providers when screening for obstructive sleep apnea, as obesity is the most documented risk factor for obstructive sleep apnea.⁵⁸

Temporomandibular Dysfunction

There is scant literature on the relationship between temporomandibular dysfunction, hemophilia and other bleeding disorders. As the temporomandibular joint is a load-bearing joint with a blood supply and can often be a site of a spontaneous bleed for patients with bleeding disorders, all dental providers should screen for temporomandibular pain, crepitus, and associated muscle pain.⁵⁹ If any of these screenings yield a positive result, the patient should be referred to a board-certified orofacial pain specialist for further diagnostic testing and treatment.

Females and Bleeding Disorder Disparities

Women with bleeding disorders present with different symptomology than men. Women are born with more flexible ligaments and joints than men for the purpose of childbearing. That flexibility, in turn, leads to greater laxity in the joints which affects how women experience bleeding disorders. More than 90% of patients seeking treatment for temporomandibular dysfunction are women in their childbearing years.⁶⁰ There is an urgent need for good data on the prevalence of orofacial pain in women with bleeding disorders.

Another issue that affects women with bleeding disorders is iron deficiency due to the hemostatic challenge of menstruation. Iron deficiency presents even greater burdens for women, along with being associated with restless leg syndrome, migraines, fibromyalgia, pagophagia (ice chewing), fatigue, and chronic pain.⁶¹ Dental providers should have the ability to recognize early warning signs of iron deficiency, such as dental caries and periodontal disease in order to allow patients to receive necessary interventions before the longstanding effects of iron deficiency are manifested and to avoid severe complications.⁶²