Medical Case: Persistent bleeding after dental extraction
Persistent bleeding after dental extraction is uncommon and usually resolves with local measures. In some cases, however, bleeding may persist.
Case presentation
Peter K, a 41-year-old man, presented to the emergency department with ongoing oral bleeding three days after a dental extraction.
The procedure involved removal of a mandibular molar affected by advanced periodontitis and had been performed under local anesthesia at a private dental clinic. According to the operative report, the extraction was technically uncomplicated, and the patient was discharged with standard postoperative instructions.
Within hours of the procedure, however, the patient developed persistent oozing from the extraction site, requiring repeated gauze compression at home. Over the following two days, bleeding failed to resolve completely and was characterized by intermittent clot disruption, prompting multiple reassessments by the treating dentist.
Several local measures were attempted, including resuturing of the socket and application of topical hemostatic agents. These interventions resulted in only partial and transient control of bleeding.
Because of ongoing bleeding despite repeated local interventions, the patient presented to the emergency department and was admitted for further evaluation and monitoring.
Medical history and initial clinical impression
The patient reported good general health. He denied previous episodes of abnormal bleeding, easy bruising, epistaxis, hemarthroses, or prolonged bleeding after minor trauma. He had undergone prior dental procedures without complications.
There was no known family history of bleeding disorders, and he was not taking anticoagulant or antiplatelet therapy. He denied excessive alcohol intake and had no history suggestive of chronic liver or kidney disease.
On examination, vital signs were stable. Oral inspection revealed slow but continuous bleeding from the extraction socket, associated with gingival edema but without purulent discharge or signs of overt infection. No petechiae, ecchymoses, or other mucocutaneous bleeding manifestations were observed.
At this stage, the clinical picture appeared predominantly locally driven. Inflammation of the socket, delayed clot stabilization, or mechanical disruption of the clot were considered plausible explanations.
Initial laboratory evaluation
Baseline laboratory tests were obtained to exclude common systemic contributors to bleeding:
- Hemoglobin: 12.8 g/dL (mildly reduced compared with the patient’s baseline of 14.5 g/dL);
- Platelet count: 245×109/L (within normal limits);
- Prothrombin time (PT): 12.1 seconds; INR: 1.05 (within reference range);
- Activated partial thromboplastin time (aPTT): 36.4 seconds (institutional reference range: 24–34 seconds).
The modest aPTT prolongation - only 2.4 seconds above the upper limit of normal - was initially interpreted as clinically nonspecific, particularly in the absence of a personal or family bleeding history. On this basis, the working diagnosis remained persistent postoperative bleeding of local origin.
A further attempt at local hemostasis was undertaken, consisting of irrigation of the socket, tight packing with iodoform gauze, and figure-of-eight suturing. Despite these measures, bleeding recurred within hours.
A clinically misleading laboratory profile
At this point, the case began to raise concern.
The bleeding pattern appeared disproportionate to the local findings and refractory to technically adequate local treatment. At the same time, routine coagulation screening offered no definitive systemic explanation. This discordance between the clinical behavior of the bleeding and the apparently reassuring laboratory profile prompted a reassessment of the diagnostic framework.
Repeat laboratory testing confirmed:
- Platelet count: normal;
- PT/INR: within reference range;
- aPTT: persistently prolonged, though only moderately (approximately 50–60 seconds, depending on assay).
Importantly, the degree of aPTT prolongation remained insufficient to clearly account for the severity and persistence of bleeding and did not, in isolation, mandate urgent hematologic intervention according to local protocols.
Several diagnostic hypotheses were considered, including:
- persistent local inflammatory bleeding;
- a subtle platelet function disorder;
- an acquired coagulation abnormality;
- a previously undiagnosed congenital bleeding disorder with limited phenotypic expression.
The absence of a personal or family bleeding history continued to argue against an inherited disorder, reinforcing diagnostic uncertainty.
Correct answer: D. Mild hemophilia A
Given the persistent bleeding and the lack of a satisfactory local explanation, the patient was referred for hematologic evaluation. Coagulation factor assays were performed.
These revealed a marked reduction in factor VIII activity, ranging between 3% and 10% of normal, with normal levels of factors II, V, VII, IX, X, XI, and XII. This pattern was diagnostic of mild hemophilia A.
Retrospective review of previous laboratory data confirmed that aPTT values had at times fallen within the normal range, underscoring the limited sensitivity of aPTT for detecting mild factor VIII deficiency.
Therapeutic intervention and outcome
Following diagnosis, the patient received factor VIII replacement therapy, resulting in rapid and sustained control of bleeding. No further local interventions were required.
The iodoform packing was removed after approximately two weeks without recurrence of hemorrhage. At follow-up, wound healing was complete and no additional bleeding episodes were reported.
Clinical discussion
This case exemplifies a well-recognized diagnostic pitfall in hemostasis: mild hemophilia A may remain clinically silent until adulthood and may not be reliably detected by routine coagulation screening tests.
A critical point of reflection is the patient's negative family history. While hemophilia is a classic X-linked inherited disorder, approximately 30% of cases result from de novo mutations, meaning the absence of affected relatives should never be used to rule out the diagnosis.
Furthermore, the diagnostic utility of the aPTT as a screening tool is inherently limited by the variability of laboratory reagents. The sensitivity of the assay to Factor VIII (FVIII) levels depends heavily on the specific phospholipids and activators used; many modern reagents fail to show significant prolongation until FVIII activity drops below 25–30%. In this patient, an aPTT of 36.4 seconds (just 2.4 seconds above the reference range) was easily dismissed, yet it masked a clinically relevant functional deficiency during a major hemostatic challenge.
Dental extraction represents one of the most common invasive procedures in adults and often serves as the "stress test" that unmasks an underlying coagulation disorder. As emphasized by international guidelines, diagnosis must rely on clinical suspicion and targeted factor assays whenever the bleeding phenotype is disproportionate to the local surgical findings.
Key learning points
- Clinical vs. Laboratory Discordance - Persistent bleeding after dental extraction that fails to respond to technically adequate local measures (suturing, packing) must be investigated for systemic causes, regardless of initial screening results.
- The aPTT "Blind Spot" - A normal or near-normal aPTT does not exclude mild hemophilia A or B. Reagent sensitivity varies significantly, and mild factor deficiencies (5–40%) may not trigger institutional alarm thresholds.
- Genetic Presentation - The absence of a family history of bleeding does not rule out hemophilia, given the high rate of de novo genetic mutations.
- Diagnostic Gold Standard - When clinical suspicion is high, proceed directly to specific factor assays (FVIII, FIX) and von Willebrand factor (vWF) screening, even if the PT and aPTT appear reassuring.
- Multidisciplinary Management - Early hematological consultation is essential to initiate factor replacement therapy, which in this case proved to be the only effective intervention to achieve definitive hemostasis.
- Fan G, Shen Y, Cai Y, Zhao JH, Wu Y. Uncontrollable bleeding after tooth extraction from asymptomatic mild hemophilia patients: two case reports. BMC Oral Health. 2022 Mar 13;22(1):69. doi: 10.1186/s12903-022-02074-9. PMID: 35282827; PMCID: PMC8919556.