The Saudi Journal for Dental Research (2016) 7, 6972

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sa
www.sciencedirect.com

CASE REPORT

Aplastic anemia presenting as bleeding of gingiva:

Case report and dental considerations
Arpita Rai a,*, Vanita Vaishali b, Venkatesh G. Naikmasur
Atul Sattur c

c,1

, Ansul Kumar d,

Department of Oral Medicine and Radiology, Faculty of Dentistry, Jamia Millia Islamia, New Delhi 110025, India
College of Dental Sciences and Hospital, Indore, India
c
Department of Oral Medicine and Radiology, S.D.M. College of Dental Sciences & Hospital, Dharwad, Karnataka 580 009, India
d
Dr. RML PGIMER Hospital, New Delhi, India
b

Received 10 April 2015; accepted 18 April 2015

Available online 27 April 2015

KEYWORDS
Aplastic anemia;
Pallor;
Petechiae;
Hematoma;
Gum bleeding

Abstract The article describes a case of aplastic anemia in a 44-year-old male patient which presented as spontaneous bleeding of gums. Though bleeding of gums is a very common complaint
encountered in a dental clinic, bleeding of gums due to systemic causes is an infrequent nding.
Patient from blood dyscrasias may present in a dental ofce with bleeding of gums as sole or the
rst complaint. The acknowledgment of the patients underlying condition is the responsibility of
the dentist for pertinent referral and further management.
2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
Aplastic anemia is a serious and often fatal hematologic disorder characterized by hypoplastic bone marrow and peripheral
pancytopenia. Aplastic anemia is a rare, non contagious and
potentially life threatening disorder caused by destruction of
pluripotent stem cells in the bone marrow with an annual
* Corresponding author. Tel.: +91 8802536376.
E-mail addresses: arpitadoc@gmail.com (A. Rai), drvnmasur@
gmail.com (V.G. Naikmasur), docansul@gmail.com (A. Kumar).
1
Fax: +91 8362467612.
Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

incidence of 2 to 6/1,000,000.1 In contrast to the term aplastic

anemia, suggesting suppression of erythropoietic cell lines, all
cell lines may be affected in this disorder.2 Depending on
affected cell lines, aplastic anemia is associated with not only
fatigue, but also bleeding due to thrombocytopenia and recurrent infections due to neutropenia.3 The diagnosis aplastic
anemia is conrmed by hypocellularity of the bone marrow.
The remaining cells are morphologically unaffected without
malignant inltration.
Aplastic anemia is classied as acquired or congenital. The
congenital type is rare and usually associated with Fanconis
anemia and dyskeratosis congenita.4 In more than 50% of
the acquired cases of aplastic anemia, the cause is unknown.
Potential triggers for the onset of aplastic anemia include
T-cell mediated auto-immune disease, iatrogenic agents, viral
infection and pregnancy.1 This notion is supported by the
similar incidence of aplastic anemia in men and women.1 It

http://dx.doi.org/10.1016/j.sjdr.2015.04.004
2352-0035 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

70
is more common in Asian countries than in the United States
and Europe with about 60007000 new diagnosis reported
annually worldwide. It can appear at any age but is most commonly diagnosed in children aged 25 years, young adults
between 20 and 25 years and adults aged 5560 years.5
A wide array of disorders of red cells and hemostasis
encountered in internal medicine has manifestations in the oral
cavity and the facial region. These manifestations must be
properly recognized if the patient must receive appropriate
diagnosis and referral for treatment. Though bleeding of gums
is a very common complaint encountered in a dental clinic,
bleeding of gums due to systemic causes is an infrequent nding. Patients from blood dyscrasias may present in a dental
ofce with bleeding of gums as the sole or the rst complaint.
Acknowledgment of the patients underlying condition is the
responsibility of the dentist for pertinent referral and further
management.

A. Rai et al.

Figure 1 Clinical photograph of the patient showing extreme

pallor of lower palpebral conjunctiva.

2. Case report
A 44-year-old patient reported to the Department of Oral
Medicine and Radiology with complaints of bleeding of gums
for the duration of 1 month. Bleeding of gums was spontaneous and continuous. Greater frequency of bleeding was
noticed in the early mornings. Bleeding occurred from all
quadrants of the mouth and the patient reported that about
one cup of blood per day was oozing from the gums. The
patient reported a negative history of rectal bleeding, hemoptysis or hematemesis. The patient had visited a local physician
20 days back and had been prescribed antibiotics (metronidazole, albendazole), vitamin C supplement and a multivitamin.
He also gave a history of acid peptic disease for the past
25 years. Patient reported a history of easy bruising and
reported ecchymosis and petechiae on arms, legs and buttocks.
On examination, extreme pallor of lower palpebral conjunctiva
(Fig. 1), nail beds (Fig. 2) and palms was evident. Ecchymotic
patches were present on the left lower limb, right arm and dorsogluteal region bilaterally. Intra oral examination revealed
generalized pallor of the oral mucosa. There was presence of
multiple hematomas on the oral mucosa, one on the right buccal mucosa (Fig. 3), two on the left buccal mucosa and two on
the upper labial mucosa (Fig. 4). The hematomas were bluish
red, approximately 23 mm in size and non-tender. The tongue
showed pallor and three hematomas were present on the dorsal
surface (Fig. 5). Pallor of hard and soft palate was marked.
Generalized gingival recession was evident with oozing of
blood from the gingiva which was more evident in the lower
anterior region (Fig. 6). There was collection of blood in the
lower vestibule. On manipulation, there was accentuated
bleeding of gingiva (Fig. 7).
Panoromic radiograph revealed generalized extensive alveolar bone loss. Hemogram of the patient revealed pancytopenia with RBC count of 1.92 millions/mm3 and hemoglobin
was 6.6 gm%. Total leukocyte count was 1100 cells/mm3
(P40%, L60%, M0%, E0%, B0%). ESR was raised to
92 mm in the 1st hour. Bleeding time was more than 15 min,
though the Clotting time was 4.30 min. Platelet count had
reduced to 19,000 cells/mm3. The peripheral smears revealed
anisopoikilocytosis in relation to red blood cells. There was
reduction in the number of white blood cells with a shift to
the left. There was also a reduction in the number of platelets.

Figure 2 Clinical photograph of the patient showing pallor of

nail beds.

Figure 3 Intra-oral photograph showing oral hematoma on the

right buccal mucosa in relation to the line of occlusion in the
molar region which is approximately 2 mm in size.

Aplastic anemia presenting as bleeding of gingiva

Figure 4 Intra-oral photograph showing two hematomas on the

upper labial mucosa. The lesion on the right side is formed by
coalescing of multiple small lesions.

Bone marrow aspiration cytology was advised to the patient

which revealed bone marrow aplasia (Fig. 8). The diagnosis
of aplastic anemia was established and the patient was referred
to a higher center for further investigation and management.
Oral hygiene instructions were given to the patient. The
patient was also advised to use tranexamic acid mouthwash
to control spontaneous gingival bleeding. Further management of chronic periodontitis was synchronized with platelet
transfusions received by the patient.
3. Discussion
Aplastic anemia is a rare hematologic disease characterized by
a hypoplastic bone marrow and peripheral pancytopenia. A
pancytopenia is diagnosed when two of three criteria are
met: a neutrophil count of less than 0.5 109 cells/L, a platelet
count less than 20 109 cells/L and a reticulocyte count less
than 1%. When the neutrophil count is less than 0.2 109,
the disease is then characterized as severe.1
Oral manifestations are common in patients with aplastic
anemia and are directly associated with pancytopenia. These

Figure 5 Intra-oral photograph showing three hematomas on

the dorsum of the tongue.

71
manifestations include petechial hemorrhages, gingival swelling and spontaneous bleeding, ulceration, pallor and severe
periodontal disease.4,68 Gingivitis and periodontitis have been
reported in 36.36% of the patients with Fanconis anemia
which is not associated with the lower platelet count but is
attributed to poor oral hygiene.9 Cases of advanced or rapidly
progressive periodontitis have been reported to occur with prolonged neutropenia and may be due to several qualitative and
quantitative neutrophil defects, including neutropenia, agranulocytosis and leukocyte adhesion deciency.6 In addition,
thrombocytopenia can induce compromised clotting, so surgical intervention should be delayed until the patient is controlled with platelet administration.4 Gingival bleeding is
another common manifestation associated with decreased platelet level seen in aplastic anemia patients.7 Oral traumatic and
petechial hemorrhagic lesions have been associated with the
decreased platelet level.8 Brennan6 describes the risk factors
associated with oral manifestations of aplastic anemia and suggests that the level of thrombocytopenia is not necessarily
indicative of the degree of petechial hemorrhaging. These
lesions most likely result from the thrombocytopenia-induced
clotting disorder, which causes excessive bleeding after minor
trauma associated with normal oral functioning.
In patients rst choice therapy for aplastic anemia is
allogenic stem cell transplantation with a 5-year survival of
7080%.10 Graft rejection and graft-versus host disease remain
serious risks, but can be contained by careful patient management. A supportive therapy with erythrocyte and platelet
transfusions is a widely used, reasonable alternative. The benet of transfusions to prevent bleeding should be weighed
against the likelihood of developing HLA antibodies and
hemochromatosis.11 In case the patient responds insufciently
to supportive therapy, immune-modulating treatment based
on a short course of anti-thymocyte globulin or anti-lymphocyte globulin and several months of cyclosporin to modulate
the patients immune response may be tried. The prognosis
of the immune-modulating treatment is relatively high, with
5-year survival rates of up to 75%.12
Little research has been published about gingival bleeding
in aplastic anemia. In fact, only case reports and series with
small sample sizes are available. The present case exemplies
the role of the oral physician in diagnosing one of the critical

Figure 6 Intra-oral photograph showing gingival recession with

oozing of blood from the gingival sulcus.

72

A. Rai et al.
treatment on the day of platelet transfusion.13 To reduce the
risk of uncontrolled bleeding during major dental treatments,
the patients should take antibrinolytics. These agents may
decrease bleeding, particularly oral mucosal bleeding, in
patients with thrombocytopenia by stabilization of thrombi.4
Jones et al have reported a case of idiopathic aplastic anemia
which was treated with a combination of modalities including
initial platelet transfusion, oral hygiene instruction, dental prophylaxis and systemic aminocaproic acid.14 Patients with
aplastic anemia are more susceptible to infection; therefore,
dental treatment should be postponed until the patients white
blood cell count rises to a normal level.15 Dentists should consider prescribing antibacterial mouthwash and oral antibiotics
before dental procedures. Since chronic periodontitis is a focus
of infection and considered a potential risk for systemic infection in patients with aplastic anemia, it would be prudent to
treat this condition in consultation with a hematologist.
Conict of interest
None.

Figure 7 Intra-oral photograph showing accentuated bleeding

o gingiva on manipulation.

Figure 8
marrow.

Photomicrograph showing the hypocellular bone

conditions like aplastic anemia through its oral manifestation.

Any signs of excessive bleeding, or a poor response to the standard treatment of infections and oral ulcerations, should be
investigated to rule out a possibility of pancytopenia.
Correlation of the oral presentation of spontaneous and
remarkable gingival bleeding with intra-oral hematomas,
ecchymotic patches elsewhere in the body and severe pallor
led to the suspicion of pancytopenia. Further investigations
in the form of hemogram and bone marrow aspiration cytology conrmed the diagnosis of aplastic anemia. Early referral
of the patient for specialized care will undoubtedly be of considerable value to the patient in the management of this potentially fatal disease.
Dental management of patients of aplastic anemia requires
interdisciplinary care with the consultation of the treating dentist with hematologist. It is advisable to perform dental

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