Influence of Hematological
disorders on the
Periodontium

Dr Saif Khan
Assistant Professor
Dept tof Periodontics & Communi...
Blood cells play essential role in
maintenance of healthy Periodontium

10/21/13

Dr Saif Khan

2
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Dr Saif Khan

3
• Comparable oral changes occur in more than one
form of blood dyscrasia
• Secondary inflammatory changes produce wide
ran...
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Dr Saif Khan

5
• Abnormal Gingival Bleeding or from other areas of
oral mucosa that is difficult to control may suggest
some underlying H...
It is essential to diagnose the specific
etiology inorder to address any bleeding or
immunologic disorder appropriately

1...
Leukemia
Malignant neoplasia of WBC precursors
Charcterised by
1.Replacement of Bone marrow with proliferating
cells
2.Abn...
Classification
According to lineage of WBC, Leukemia are
classified as
• Lymphocytic
• Myelocytic
– Monocytic

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D...
 According to evolution Leukemia can be
– Acute
– Subacute
– Chronic

 Acute Leukemia the primitive blast cells
are rele...
Histology AML

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Dr Saif Khan

11
All leukemic cells tend to displace normal
component of Bone marrow elements with
resulting in decreased production of
RB...
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Dr Saif Khan

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Aleukemic Leukemia
• Patients have normal blood counts while
leukemic cells primarily reside in Bone marrow.
• The periphe...
Periodontium in Leukemia

• Oral and Periodontal manifestation of
Leukemia consists of
– Leukemic infiltration
– Bleeding ...
Leukemic infiltration
• Leukemic cells infiltrate gingiva and less
frequently alveolar bone
• Gingival infiltration result...
• Leukemic gingival enlargement is not
found in edentulous patients or in patients
with chronic leukemia
• Leukemic gingiv...
Clinical features
• Gingiva appears Bluish-red and Cyanotic
• Rounding and Tenseness at Gingival Margin
• Increase in ging...
Leukemic Gingival Enlargement

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Dr Saif Khan

19
Leukemic Gingival Enlargements

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Microscopically
• Dense,diffuse infiltration of predominantly
immature leukocytes in attached & marginal
gingiva
• Normal ...
• Cellular accumulation is denser in entire
reticular connective tissue layer
• Pappillary layer contains comparatively fe...
• Epithelium presents with variety of changes and
may be thinned or Hyperplastic
• Degeneration associated with intercellu...
• Microscopic picture of marginal gingiva
differs from other gingival locations
• Consists of notable inflammatory compone...
• Periodontal ligament and alveolar bone may also
be involved in acute and subacute leukemia
• Periodontal ligament may be...
Bleeding
• Oral bleeding has been seen in 17.7% patients
with Acute Leukemia and 4.4% in patient
with Chronic leukemia
• G...
• Caused by Thrombocytopenia by replacement
of Bone marrow cells by leukemic cells
• Also by inhibition of stem cell funct...
Oral ulceration and Infection
• Granulocytopenia (dimnished WBC count) results
from the displacement of normal bone marrow...
• Gingiva is peculiar bluish red, is sponge like and friable,
and bleeds persistently on slightest provocation or even
spo...
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Dr Saif Khan

30
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Dr Saif Khan

31
• Secondary oral changes superimposed on oral
tissues altered by blood dyscrasia

• Systemic toxic effects, loss of apetit...
• In chronic leukemia clinical oral changes
suggesting hematologic disturbances are rare

• Gingival biopsy in patient wit...
Anemia
• Deficiency in the quantity or quality of the
blood
• Manifested by reduction in the number of
erythrocyte and the...
Anemias are classified according to
cellular morphology and hemoglobin content
1. Macrocytic Hyperchromic anemia (Pernicio...
Sickle Cell Anemia
•
•
•
•

Hereditary
Chronic Hemolytic Anemia
Exclusively in Blacks
Presents with
– Pallor
– Jaundice
– ...
Oral Changes

• Generalised osteoporosis of Jaw
– Stepladder arrangement of trabeculae

• Pallor/Yellowish discoloration
•...
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Dr Saif Khan

38
Thrombocytopenia
• Reduced platelet count either due to
– lack of platelet production or
– increased platelet destruction
...
Etiology of Thrombocytopenia
• Aplasia of Bone Marrow
• Displacement of Megakaryocyte in marrow
• Leukemia
• Replacement o...
Thrombocytopenia is characterised by

• Low platelet count
• Prolonged clot retraction & bleeding time
• Normal or slightl...
Gingival changes represent an
abnormal response to local irritation;
the severity of the gingival condition
is dramaticall...
Leukocyte (Neutrophil) Disorder
Primary neutrophil disorder
– Neutropenia
– Agranulocytosis
– Chediak Higashi Syndrome
– ...
Secondary Neutrophil Disorder
–Down Syndrome
–Pappilon Lefevre Syndrome
–Inflammatory Bowel Disease

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Dr Saif Kh...
Neutropenia
• Low levels of circulating neutrophils
• Absolute neutrophil count (ANC) less
than 1500 cells/µL is considere...
• Neutropenia is serious , can lead to life
threatening infection which are difficult to control
• It may be
– chronic or ...
Agranulocytosis
• Reduction in No. of circulating
Granulocytes
• Severe Ulcerative infections of oral
mucosa,Skin, GIT and...
Agranulocytosis
• Generally occurs as Acute disease
• Chronic/Peroidic with recurring neutropenic cycles
(Cyclic Neutropen...
• Ulceration in oral cavity,oropharynx & throat is
characteristic
• Mucosa exhibits isolated necrotic patches
• Black and ...
• Gingival Hemorrhage, Necrosis, Increased
Salivation and Fetid Odor
• Cyclic Neutropenia gingival changes recur with
recu...
Chediak Higashi Syndrome
• Genetically transmitted disease
• Melanocytes, Platelets & Phagocytes affected
• Causes partial...
• Killing of ingested microrganism is delayed
• Aggressive Periodontitis

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Lazy Leukocyte syndrome
•

Defective chemotaxis response of
neutrophils
• Susceptibilty to severe microbial infections
• A...
Leukocyte Adhesion Deficiency
(LAD)
• Very rare genetic disorder
• Inherited disease-primary immunodeficiency
diagnosed at...
Pappillon Lefevre Syndrome

• Inherited follows Autosomal Reccesive
disorder
• Parents not affected both parents must carr...
• PLS characterised by
– Hyperkeratotic skin lesion
– Severe destruction of Periodontium
– Calcification of Dura

• Cutane...
• Periodontal involvement
changes-

early inflammatory

bone loss

• Primary teeth are lost by 5-6 years of age
• Permanen...
Pappilon Lefevre Syndrome

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Dr Saif Khan

59
Down Syndrome

• Congenital disease caused by chromosomal
abnormality
• Trisomy 21
• Mental deficiency and growth retardat...
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61
Down syndrome

• Deep Periodontal pocket & substantial plaque
accumulation
• Poor PMN chemotaxis and phagocytosis
• Diseas...
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Dr Saif Khan

63
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Influence of hematological disorder on periodontium

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Influence of hematological disorder on the periodontium

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Influence of hematological disorder on periodontium

  1. 1. Influence of Hematological disorders on the Periodontium Dr Saif Khan Assistant Professor Dept tof Periodontics & Community Dentistry Dr Z A Dental College Aligarh Muslim University, Aligarh, UP,India-202002
  2. 2. Blood cells play essential role in maintenance of healthy Periodontium 10/21/13 Dr Saif Khan 2
  3. 3. 10/21/13 Dr Saif Khan 3
  4. 4. • Comparable oral changes occur in more than one form of blood dyscrasia • Secondary inflammatory changes produce wide range of variation in oral signs • Hemorrhagic tendencies occur when normal hemostatic mechanisms are disturbed 10/21/13 Dr Saif Khan 4
  5. 5. 10/21/13 Dr Saif Khan 5
  6. 6. • Abnormal Gingival Bleeding or from other areas of oral mucosa that is difficult to control may suggest some underlying Hematologic disease or Blood dyscrasia • Hemorrhagic tendencies occur when normal Hemostatic mechanisms are disturbed • Petechiaes and eechymosis of soft palate may suggest underlying bleeding disorder Dr Saif Khan 10/21/13 6
  7. 7. It is essential to diagnose the specific etiology inorder to address any bleeding or immunologic disorder appropriately 10/21/13 Dr Saif Khan 7
  8. 8. Leukemia Malignant neoplasia of WBC precursors Charcterised by 1.Replacement of Bone marrow with proliferating cells 2.Abnormal number & form of immature WBCs in circulating blood 3.Infiltration in liver, spleen, lymph nodes and other body sites
  9. 9. Classification According to lineage of WBC, Leukemia are classified as • Lymphocytic • Myelocytic – Monocytic 10/21/13 Dr Saif Khan 9
  10. 10.  According to evolution Leukemia can be – Acute – Subacute – Chronic  Acute Leukemia the primitive blast cells are released in peripheral circulation  Chronic anemia the abnormal cells are more mature with normal morphologic characteristics and function when released into the circulation 10/21/13 Dr Saif Khan 10
  11. 11. Histology AML 10/21/13 Dr Saif Khan 11
  12. 12. All leukemic cells tend to displace normal component of Bone marrow elements with resulting in decreased production of RBC Anemia WBC Leukopenia Plateletes Thrombocytopenia 10/21/13 Dr Saif Khan 12
  13. 13. 10/21/13 Dr Saif Khan 13
  14. 14. Aleukemic Leukemia • Patients have normal blood counts while leukemic cells primarily reside in Bone marrow. • The peripheral blood does not contains any Leukemic or malignant cell 10/21/13 Dr Saif Khan 14
  15. 15. Periodontium in Leukemia • Oral and Periodontal manifestation of Leukemia consists of – Leukemic infiltration – Bleeding or Hemorrhage – Oral Ulcerations – Infections • The expression of above signs are more common in Acute & Subacute form of leukemia than Chronic 10/21/13 Dr Saif Khan 15
  16. 16. Leukemic infiltration • Leukemic cells infiltrate gingiva and less frequently alveolar bone • Gingival infiltration results in Leukemic Gingival enlargement • Highest incidence of leukemic gingival enlargement is found in patients with – Acute Monocytic Leukemia (66.7%) – Acute Myelocytic-monocytic leukemia (18.7%) – Acute Myelocytic leukemia (3.7%) 10/21/13 Dr Saif Khan 16
  17. 17. • Leukemic gingival enlargement is not found in edentulous patients or in patients with chronic leukemia • Leukemic gingival enlargement consists of – Infiltration of Gingival Corium by leukemic cells – Increased gingival thickness, periodontal pocket formation, bacterial plaque accumulation and secondary inflammation 10/21/13 Dr Saif Khan 17
  18. 18. Clinical features • Gingiva appears Bluish-red and Cyanotic • Rounding and Tenseness at Gingival Margin • Increase in gingival size at interdental papilla covering the crown of teeth 10/21/13 Dr Saif Khan 18
  19. 19. Leukemic Gingival Enlargement 10/21/13 Dr Saif Khan 19
  20. 20. Leukemic Gingival Enlargements 10/21/13 Dr Saif Khan 20
  21. 21. Microscopically • Dense,diffuse infiltration of predominantly immature leukocytes in attached & marginal gingiva • Normal connective tissue component of gingiva is replaced by leukemic cells • Mitotic figures indicative of ectopic haemopoiesis may be seen • Nature of cell infiltrate depends on type of leukemia 10/21/13 Dr Saif Khan 21
  22. 22. • Cellular accumulation is denser in entire reticular connective tissue layer • Pappillary layer contains comparatively few leukocytes • Blood vessels are distended and contain predominantly leukemic cells • RBCs are reduced in number 10/21/13 Dr Saif Khan 22
  23. 23. • Epithelium presents with variety of changes and may be thinned or Hyperplastic • Degeneration associated with intercellular and intracellular edema and leukocyte infiltration with diminished surface keratinization 10/21/13 Dr Saif Khan 23
  24. 24. • Microscopic picture of marginal gingiva differs from other gingival locations • Consists of notable inflammatory component in addition to leukemic cells • Scattered foci of plasma cells and lymphocytes with edema and degeneration are common findings • Inner layer of marginal gingiva is usually ulcerated with marginal necrosis and pseudomembrane formation 10/21/13 Dr Saif Khan 24
  25. 25. • Periodontal ligament and alveolar bone may also be involved in acute and subacute leukemia • Periodontal ligament may be infiltrated with mature and immature leukocytes • Marrow of alveolar bone exhibits localised area of necrosis, thrombosis of blood vessels, infilation with mature and immature leukocytes • Replacement of fatty marrow with fibrous tissue 10/21/13 Dr Saif Khan 25
  26. 26. Bleeding • Oral bleeding has been seen in 17.7% patients with Acute Leukemia and 4.4% in patient with Chronic leukemia • Gingival hemorrhage is common in leukemic patients • Bleeding gingiva can be early sign of gingivitis 10/21/13 Dr Saif Khan 26
  27. 27. • Caused by Thrombocytopenia by replacement of Bone marrow cells by leukemic cells • Also by inhibition of stem cell function by leukemic cells or their products • Bleeding may be side effect of Chemotherapeutic agents used to treat leukemia 10/21/13 Dr Saif Khan 27
  28. 28. Oral ulceration and Infection • Granulocytopenia (dimnished WBC count) results from the displacement of normal bone marrow cells by leukemic cells • Discrete, Punched –out ulcers penetrating deeply into submucosa and covered by a firmly attached white slough • Recurrent Herpetic oral ulcers • Atypical Oral Ulcer 10/21/13 Dr Saif Khan 28
  29. 29. • Gingiva is peculiar bluish red, is sponge like and friable, and bleeds persistently on slightest provocation or even spontaneously in leukemia patients • Acute gingival necrosis • Pseudomembrane formation • NUG 10/21/13 Dr Saif Khan 29
  30. 30. 10/21/13 Dr Saif Khan 30
  31. 31. 10/21/13 Dr Saif Khan 31
  32. 32. • Secondary oral changes superimposed on oral tissues altered by blood dyscrasia • Systemic toxic effects, loss of apetite, nausea, blood loss from persistent gingival bleeding and constant gnawing pain • Eliminating or reducing local factors (dental plaque 10/21/13 Dr Saif Khan 32
  33. 33. • In chronic leukemia clinical oral changes suggesting hematologic disturbances are rare • Gingival biopsy in patient with chronic leukaemia may reveal typical gingival inflammation without any suggestion of a hematologic disturbance 10/21/13 Dr Saif Khan 33
  34. 34. Anemia • Deficiency in the quantity or quality of the blood • Manifested by reduction in the number of erythrocyte and the amount of hemoglobin • Anemia results from – Blood loss – Defective blood formation – Increased RBC destruction 10/21/13 Dr Saif Khan 34
  35. 35. Anemias are classified according to cellular morphology and hemoglobin content 1. Macrocytic Hyperchromic anemia (Pernicious Anemia) 2. Microcytic Hypochromic anemia (Iron deficiency anemia) 3. Sickle cell anemia 4. Normocytic Normochromic anemia (Hemolytic &Aplastic anemia) 10/21/13 Dr Saif Khan 35
  36. 36. Sickle Cell Anemia • • • • Hereditary Chronic Hemolytic Anemia Exclusively in Blacks Presents with – Pallor – Jaundice – Weakness – Rheumatoid Manifestations – Leg Ulcers 10/21/13 Dr Saif Khan 36
  37. 37. Oral Changes • Generalised osteoporosis of Jaw – Stepladder arrangement of trabeculae • Pallor/Yellowish discoloration • Periodontal infection may precipitate Sickle Cell Crisis 10/21/13 Dr Saif Khan 37
  38. 38. 10/21/13 Dr Saif Khan 38
  39. 39. Thrombocytopenia • Reduced platelet count either due to – lack of platelet production or – increased platelet destruction – Increased loss • Purpura is – purplish appearance of skin or mucous membrane that occurs as a result of decreased platelets • Thrombocytopenic purpura may be – Idiopathic (Werlhof’s disease) or – secondary to some known etiologic factor 10/21/13 Dr Saif Khan 39
  40. 40. Etiology of Thrombocytopenia • Aplasia of Bone Marrow • Displacement of Megakaryocyte in marrow • Leukemia • Replacement of marrow by tumour • Destruction of marrow by irradiation, radium or by drugs- Benzene, Aminopyrene, Arsenical Agents 10/21/13 Dr Saif Khan 40
  41. 41. Thrombocytopenia is characterised by • Low platelet count • Prolonged clot retraction & bleeding time • Normal or slightly prolonged clotting time • Petechiae and Hemorrhagic vesicle occur in the palate, tonsillar pillar and buccal mucosa • Spontaneous Bleeding in gingivae 10/21/13 Dr Saif Khan 41
  42. 42. Gingival changes represent an abnormal response to local irritation; the severity of the gingival condition is dramatically elevated by removal of local factors 10/21/13 Dr Saif Khan 42
  43. 43. Leukocyte (Neutrophil) Disorder Primary neutrophil disorder – Neutropenia – Agranulocytosis – Chediak Higashi Syndrome – Lazy Leukocyte Syndrome 10/21/13 Dr Saif Khan 43
  44. 44. Secondary Neutrophil Disorder –Down Syndrome –Pappilon Lefevre Syndrome –Inflammatory Bowel Disease 10/21/13 Dr Saif Khan 44
  45. 45. Neutropenia • Low levels of circulating neutrophils • Absolute neutrophil count (ANC) less than 1500 cells/µL is considered Neutropenia • Neutropenia – Genetic – Drug Induced – Viral infection 10/21/13 Dr Saif Khan 45
  46. 46. • Neutropenia is serious , can lead to life threatening infection which are difficult to control • It may be – chronic or cyclic – Severe or Benign 10/21/13 Dr Saif Khan 46
  47. 47. Agranulocytosis • Reduction in No. of circulating Granulocytes • Severe Ulcerative infections of oral mucosa,Skin, GIT and Genitourinary tracts • Drug Idiosyncrasy MC cause of Agranulocytosis – Aminopyrene, Barbiturates & their deivative, Benzene ring derivative, Sulfonamide, Gold salts and Arsenical agents 10/21/13 Dr Saif Khan 47
  48. 48. Agranulocytosis • Generally occurs as Acute disease • Chronic/Peroidic with recurring neutropenic cycles (Cyclic Neutropenia) • Disease onset with fever,malaise,general weakness and sorethroat 10/21/13 Dr Saif Khan 48
  49. 49. • Ulceration in oral cavity,oropharynx & throat is characteristic • Mucosa exhibits isolated necrotic patches • Black and grey in color demarcated from adjacent uninvolved areas • Absence of inflammatory reaction caused by lack of granulocytes is striking feature 10/21/13 Dr Saif Khan 49
  50. 50. • Gingival Hemorrhage, Necrosis, Increased Salivation and Fetid Odor • Cyclic Neutropenia gingival changes recur with recurrent exacerbation of disease • Aggressive periodontitis has been seen in cyclic neutropenia • D/D -ANUG, Diptheria, NOMA, Acute Necrotizing infection of tonsil 10/21/13 Dr Saif Khan 50
  51. 51. Chediak Higashi Syndrome • Genetically transmitted disease • Melanocytes, Platelets & Phagocytes affected • Causes partial Albinism, Mild Bleeding & Recurrent infections • Neutrophils contains abnormal large giant Lysosome that can fuse with phagosome but their ability to release their content is impaired 10/21/13 Dr Saif Khan 51
  52. 52. • Killing of ingested microrganism is delayed • Aggressive Periodontitis 10/21/13 Dr Saif Khan 52
  53. 53. 10/21/13 Dr Saif Khan 53
  54. 54. Lazy Leukocyte syndrome • Defective chemotaxis response of neutrophils • Susceptibilty to severe microbial infections • Abnormal inflammatory response • Aggressive Periodontitis 10/21/13 Dr Saif Khan 54
  55. 55. Leukocyte Adhesion Deficiency (LAD) • Very rare genetic disorder • Inherited disease-primary immunodeficiency diagnosed at birth • Failure to express cell- surface integrin (CD18) which is necessary for leukocytes to adhere to the vessel wall at site of infection • Frequent RTI,Otitis media.primary and permanent tooth affected early tooth loss 10/21/13 Dr Saif Khan 55
  56. 56. Pappillon Lefevre Syndrome • Inherited follows Autosomal Reccesive disorder • Parents not affected both parents must carry the gene for the disease to manifest in offspring • M=F predilection • Very Rare ;1-4 cases/million 10/21/13 Dr Saif Khan 56
  57. 57. • PLS characterised by – Hyperkeratotic skin lesion – Severe destruction of Periodontium – Calcification of Dura • Cutaneous & Periodontal Changes before 4 yrs of age • Skin lesions- Hyperkeratosis, Icthyiosis of localised areas on palms, soles,kness and elbows 10/21/13 Dr Saif Khan 57
  58. 58. • Periodontal involvement changes- early inflammatory bone loss • Primary teeth are lost by 5-6 years of age • Permanent teeth erupt normally but are lost within because of Severe Destructive periodontal disease • By 15 years patient is completely edentulous except third molars • No significant alterations have been found in peripheral blood lymphocytes and PMNs 10/21/13 Dr Saif Khan 58
  59. 59. Pappilon Lefevre Syndrome 10/21/13 Dr Saif Khan 59
  60. 60. Down Syndrome • Congenital disease caused by chromosomal abnormality • Trisomy 21 • Mental deficiency and growth retardation • Prevalance of periodontal disease in Down syndrome is 100% in patients younger than 30yrs 10/21/13 Dr Saif Khan 60
  61. 61. 10/21/13 Dr Saif Khan 61
  62. 62. Down syndrome • Deep Periodontal pocket & substantial plaque accumulation • Poor PMN chemotaxis and phagocytosis • Disease progresses rapidly • Acute necrotizing lesions are frequent • Increased P intermedia in children with Down syndrome 10/21/13 Dr Saif Khan 62
  63. 63. 10/21/13 Dr Saif Khan 63

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