hematological disorders and its management in periodontal setup

1. HEMATOLOGICAL
DISORDERS
Presented By
Dr. M. Shiva Shanker
Ist Year Post Graduate Student ,
Dept of Periodontics, Mamata Dental College.

2. Contents
 Introduction
 Classification of Blood disorders
 Medical diagnosis
 Significance of bleeding disorders in treatment of
periodontal disease
 Management of periodontal patient with bleeding
disorders
 Post operative measures
 Conclusion
 References

3. INTRODUCTION
 Blood cells play an essential role in the
maintenance of a healthy periodontium. Disorders
of blood cells or blood forming organs can have a
profound effect on the periodontium.
 Gingival and periodontal disturbances associated
with blood dyscrasias must be viewed in terms of
fundamental interrelationships between the oral
tissues and the blood cells and blood forming
organs rather than in terms of a simple association
of dramatic oral changes with hematologic
disease.

4.  “Bleeding disorders are
haematological conditions
characterized by functional
impairment of hemostatic process”

5. CLASSIFICATION
CELLULAR DEFECTS
RED BLOOD CELL DISORDERS
 Anemia
 Erythrocytosis /
Polycythemia
WHITE BLOOD CELL
DISORDERS
 Neutropenia
 Agranulocytosis
 Leukemia
PLATELET DISORDERS
 Thromobocytopenia
 Thromobocytosis
COAGULATION DEFECTS
 Haemophilia A or factor
VIII deficiency disease
 Haemophilia B or factor IX
deficiency
 Autosomal Von Willbrands
disease
Approach to the diagnosis and
classification of blood diseases Imelda
Bates and Barbara J. Bain

6. RBC Disorders
 Erythrocyte disorders do not
profoundly effect the periodontium.
However Aplastic anemia, a bone
marrow disorder characterized by
marked reduction in heamopoitic
tissue, has been associated with
severe periodontal destruction.
Kosuke Oyaizu et al JOP 2005;76:1211-1216

7. Iron deficiency anemia
 Due to deficiency of iron
 Oral manifestations
 Atrophic glossitis,
mucosal pallor, and
angular cheilitis.
 Atrophic glossitis,
flattening of the tongue
papillae, resulting in a
smooth and
erythematous tongue
may mimic migratory
glossitis.

8. Megaloblastic anemia
 Due to deficiency of vitamin B12
and/or folic acid
 Cracked lips, sore tongue as in of
pernicious anemia
Pernicious anemia
 due to the lack of intrinsic factors
Oral manifestation
 Glossitis is most common
 Beefy red tongue
 Atrophy of tongue
Schilling's test is a medical
investigation used in patients with
vitamin B12 deficiency.

9.  Cobalamin deficiency is usually
treated by parenteral administration
of cyanocobalamin (intramuscularly or
subcutaneously, 1000 μg/week for 1
month and monthly thereafter) or
hydroxocobalamin in the same dose
every 1–3 months intramuscularly

10. SICKLE CELL ANEMIA
 Occurs due to gene mutation, consisting of
substitution of the amino acid glutamic acid by
valine 6th position on the β-haemoglobin chain.
 The normal biconcave discoid shape of RBC is
distorted, generally presenting a sickle like shape.
 This results down to anemia and hypertophic bone
marrow.
 dentofacial deformities-decreased densities and
coarse trabecular pattern

11.  There was a coarse trabecular pattern
of “staircase” shape (present mainly in the
interproximal bone because of trabeculae that
formed horizontal rows),
 presence of projections similar to “hair strands”
due to secondary formation of bone tissue as
compensation for resorption that occurred during
bone marrow expansion
 Gingival enlargement, firm to palpation, generaly
found in the lower arch on both sides. (repeated
hemorrhage episodes followed by fibrous tissue
repair formation)
 According to most of literature available, SCD does
not appear to predispose to periodontal
complications

12. APLASTIC ANEMIA
 Bone marrow disorder
 Marked reduction in heamopoitic
tissue
 Severe periodontal destruction
 Petechia spots, spontaneous gingival hemorrhage
 frank hematomas of the mucosa, pharnyx and
gingiva
 Lack of inflammation development of ulceration
 Blood transfusion, if there is secondary infection
antibiotics should be given
Periodontal treatment in severe aplastic anemia, JOP 2005,
76,1211-1216.

13. POLYCYTHEMIA
 It was first described in 1892 by Vasquez
 Increased in circulating RBCs due to over
production by the bone marrow, but also platelets
& white blood cells.
 Primary polycythemia is usually associated with a
gene mutation, the cause of which is unknown.
 2. Secondary polycythemia is usually associated
with increased erythropoietin production variously
a. in response to low blood oxygen level
b. from an erythropoietin-secreting tumour.

14.  Signs and symptoms
orofacial signs
a. purplish or red areas on the
i. cheeks
ii. gingiva
iii. lips
iv. oral mucosa
v. tongue
b. spontaneous bleeding of the gingiva

15. confirmed by bone marrow sampling
Treatment
phlebotomy
 a. may increase the number of platelets
 b. does not reduce the size of an enlarged liver or
spleen
 2. medications to reduce the risk of blood clot.
b. chemotherapy to reduce the number of red blood
cells produced by the bone marrow

16.  A.R. Pradeep in 2011 has conducted a study to
determine the association between anemia and
chronic periodontitis and has stated that the
chronic periodontitis may lead to anemia and
provides evidence that non-surgical periodontal
therapy can improve the anemic status of patients
with chronic periodontitis with greater
improvement in females.

17. THALASSEMIA
 The term Thalassemia was first used by Wipple
and Bradford in 1932, derived from greek
word“thlassa” meaning sea and “haemia” meaning
blood.
 Also called as cooley’s anaemia, Mediterranean
anaemia & erythroblastic anaemia
 Either α or β gobulin gene may be affected. The
resultant RBC have decreased haemoglobin and
are thin and have shortened life span.
Types:
 α-thalassemia
 β-thalassemia
 thalassemia major where the patients is
homozygous

18.  Enlargement of the upper jaw (chipmunk face)
 Migration and spacing of upper anterior teeth
 Varying degrees of malocclusion (overbite, open
bite)
 Teeth may be discoloured, with short crowns and
roots
 Higher rate of dental decay
 Pale gums and mucosa / lining of the mouth (due
to anaemia)
 Sore or burning tongue (due to folate deficiency)
 Painful swelling of salivary glands and dry mouth
 Tooth bearing bone may have a ‘chickenwire-like’
radiological appearance

20. TREATMENT
 Transfusion
 Chelation therapy
 Bone marrow transplantation

21. WBC DISODERS
Neutropenia
 Cyclic neutropenia
 Benign familial neutropenia
 Severe familial neutropenia
 Chronic idiopathic neutropenia
Agranulocytosis
LEUKEMIA
DISODERS OF WBC FUNCTION
 Chediak-Higashi syndrome
 Lazy leukocytes syndrome
 Leukocytes adhesion defeciency
 Papillon- lefever syndrome

22. NEUTROPENIA
 Characterized by decrease or absence of
circulating polymorphonuclear leukocytes
Cyclic neutropenia
 Characterized by cyclic depletion of
polymorphonuclear leukocytes number
 This cyclic depression is due to mutations in
ELANE gene.
 Periodontal manifestation-Gingival inflammation,
Gingival ulceration, Periodontal attachment loss &
bone loss

23. Familial neutropenia
 Inherited as an autosomal dominant
trait
 Fiery red erythematous gingiva often
hyperpastic & alveolar bone loss.
Chronic idiopathic neutropenia
 Persistant gingivitis- edematous &
hyperplastic

24. LEUKEMIA
 Diffuse replacement of the bone
marrow with proliferating leukemic
cells.
 Abnormal number and forms of
immature WBCs in the circulating
blood
 Widespread infiltrates in the liver,
spleen, lymph nodes and other body
sites.

25. CLASSIFICATION OF
LEUKEMIA
leukemia
Acute
Lymphoid Myeloid
Chronic
Lymphoid Myeloid

26. Factors implicated in the causation
 Radiation, chemical injury, genetic factors,
immune deficiency, & viral infection
Periodontal manifestation
 Leukemic infiltration
 Bleeding
 Oral ulceration & infection
Treatment – chemotherapy,
Radiation therapy, bone marrow
Transplantation.

27. Classification of gingival lesions in
Leukemia
Category 1
 concerned with direct leukemic infilteration and induces
gingival enlargement
 Seen in acute monocytic & chronic lymphocytic leukemia
Category 2
 Deals with direct drug toxicity by chemotherapeutic agents.
Category 3
 Comprises the detrimental effect of graft versus host
reaction.
Category4
 Involves secondary effects of depression of marrow or
lymphoid tissue
Barrett PA 1984

28. Chediak-Higashi
syndrome
 autosomal recessive disorder
 Defect – abnormalities in cytoplasmic
granules results in impaired killing of
microorganism
 Severe gingivitis,extensive loss of
alveolar bone , premature loss of
teeth deciduous and permanent

29. Lazy leukocyte syndrome
 microbial infections, neutropenia, defective
chemotactic response.
 susceptible to aggressive periodontitis.
Leukocyte adhesion deficiency
 autosomal recessive disease.
 LAD- combination of cell surface receptor defect
on granulocytes, lymphocytes, monocytes
(Springer TA 1987).the receptors Mac-1,LAF-1 &
p150,95 are involved.
 Fiery red gingiva,gingival tissue bleeds
readily,severe bone loss results in loss of
deciduous teeth as soon as they erupt.

30. Papillon- lefever
syndrome
 Rare autosomal recessive
disease
 Hyperkeratosis of the palms
and soles (either diffuse or
localized)
 Generalized rapid destruction
of the periodontal attachment
apparatus.
 some patients suffering from
PLS exhibit cellular immune
defect with decreased
chemotactic and phagocytic
function of neutrophils and
other granulocytes

31. Down’s syndrome
 Chromosomal abnormality
 Mental deficiency & growth
retardation.
 Periodontal disease prevalence is
100% in Down syndrome.

32.  The main factor involved in this early periodontal
destruction is thought to be the compromised
immune system of people with Down’s syndrome
 It results in reduced chemotaxis, diminished
phagocytic ability, defective oxidative response,
deficient T-cell function and abnormal bactericidal
activity of polymorphonuclear leukocytes
Loesche WJ 1972.

33. Dental management
 Advice regarding the use of fluoride toothpaste
and supplements.
 Advice regarding the use of antimicrobial agents
such as chlorhexidine gluconate gel.
 Appropriate dietary management.
 Use of syrup-free medications.
 Dental visits as often as 3 months for review and
professional support.

34. Platelet disorders
Thrombocytopenia
 Reduced platelet count
 Lack of platelet production
 Increased loss of platelets
 Petechie and hemorrhagic vesicles occur in the
oral cavity
 Gingiva – swollen, soft, friable
 Bleeding occurs spontaneously or on slight
provocation.

35. VASCULAR DISODERS
 Hereditary vascular disorders are associated with
syndromes & are characterized by blood vessel
developmental abnormality.
 Hereditary hemorrhagic telangiectasia
 Ehler-Danlos syndrome

36. COAGULATION DISODERS
 Three disorders account for 95% of congenital
disorders of blood coagulation.
 These include haemophilia A or factor VIII
deficiency disease
 Haemophilia B or factor IX deficiency
 Autosomal Von Willbrands disease.
Blood principles and practice of hematology, L Williams, 2003,
1103-1130.

37. MEDICAL DIAGNOSIS
 Medical history
 Physical examination
 Laboratory evaluation.
Dental management of the classic hemophiliac with inhibitors,
oral surgery oral med oral pathol 1983, 145-8.

38. SIGNIFICANCE OF BLEEDING DISODERS IN
TREATMENT OF PERIODONTAL DISEASE
 Illness, along with pharmacotherapy, may
contribute to the tendency for excessive bleeding.
 Polypharmacia and medical conditions found in an
ageing population are the main reasons to
reconsider treatment approaches in patient with
bleeding disorders and periodontal disease.
 A detailed knowledge of intraoperative and post
operative hemostatic measures under challenging
hemorrhagic situations is considered a priority for
the dental professional.

39. MANAGEMENT OF PERIODONTAL
PATIENT WITH BLEEDING DISODERS
Pre-operative precautions
 Preoperative managements start with thorough
medical history focusing on previous bleeding
history of the patient & medical condition
associated with bleeding
 First patient diagnosed with chronic renal failure
should be managed the day after dialysis
 Second, patient lacking vit k
 Third,the management of patients on
anticoagulant therapy

40. INR values Treatment
4.0 or greater No surgical treatment until INR is
reduced
3.5- 4.0 Emergency minor surgical
procedure only, simple extraction,
incision & drainage. Avoid block
anesthesia injections; use of local
hemostasis
3.0-3.4 Minor surgical procedures, simple
extractions,gingivoplasty avoid
block anesthesia injections;use of
local hemostasis
2.5-2.9 Multiple extractions, single bone
impaction,quadrant periodontal
surgery or SRP
Avoid block anesthesia
injections;use of local hemostasis
1.5-2.4 Full mouth extraction, multiple
bony impactions, gingivectomy,
multiple quadrant flap surgery,
avoid block anesthesia
injections;use of local hemostasis

41.  Unfractionated heparin should be interrupted 4 to
6 hrs before the surgical procedure, resumed 12
to 18 hrs after the dental procedures.
 Patients taking aspirin should discontinue the
medication at least 3 days, and up to 7 days,
before the surgical procedure.
 Preventive dental care for the patient with known
bleeding disorders has to be intensive & should
include regular dental visits, frequent professional
tooth cleaning, oral hygiene reinforcement,
fluoride supplement & mouth rinses, a low sugar
diet and annual radiographic examination.
 Dental care professional must be familiar of the
pathology of the inherited bleeding disorders, and
the dental procedure should be carried out in a
facility in which the necessary equipment's and
biological products are available
General medicine and surgery for dental practioners, BDJ 2003 305-10

42. INTRA-OPERATIVE ACTIONS
 Inherited platelet disorders leading to bleeding or
increased risk for bleeding are managed
systemically with platelet transfusion.
 Factor enhancement: Intravenous infusion of the
deficient coagulation factors starts 1hr before the
procedure in order to achieve a level that is 30%
above the normal plasma concentration of this
particular factors.
 Antifibrinolysis: These are the drugs which inhibit
Plasminogen activation & dissolution of clot.
 Local hemostatics: Thrombin, 0.1% adrenaline
solution soaked in the sterile guage, Astringents
such as tannic acid
Antithrombotic agents implications in dentistry, oral surgery oral
med oral pathol oral radio endod 2002: 544-551

43. POST-OPERATIVE
MEASURES
 Rinsing is prohibited on the day of the surgery and
the healing site must be left undisturbed.
 specific attention must be given to the tongue
movements interfering with healing and food
intake.
 Liquids and high protein diet are strongly
recommended.
 The use of antifibrinolytic mouthwash is highly
recommended the day after the periodontal
treatment. The regimen may comprise rinsing with
10ml of 4.8-5% tranexamic acid solution four
times a day for 2 minutes.

44. CONCLUSION
 All blood cells play a role in the maintenance of a
healthy periodontium.
 Comparable oral changes occur in more than one
form of blood dyscrasia and secondary
inflammatory changes produce a wide range of
variation in the oral signs.

45.  References:
 Text book of periodontology, Carranza, 10th edition,
influence of systemic disorders and stress on the
periodontium, Pg no: 291-299.
 Periodontal medicine B C Deckar Pg no: 227-241.
 Pathologic basis of disease, robbins and cotran, 8th edition
 Text book of physiology, Guyton.
 Bleeding disorders and periodontology, perio 2000, 44:211-
233, 2007.
 Periodontal treatment consideration for cell transplant and
organ transplant patients, perio 2000, 44:82-102, 2007.
 Periodontal treatment in severe aplastic anemia, JOP 2005,
76,1211-1216.
 The effectiveness of a preventive regimen on the periodontal
health of patients undergoing chemotherapy for leukemia
and lymphoma,JCP, 1991, 18:346-347.
 Periodontal implications: medically compromised patients,
review, Annals of periodontology, 1,1,2006
 The glycosylated hemoglobin assay for diabetes: its value to
the periodontist, JOP 1989, 60:640-642.