Dr. Pradeep Daniel Gainneos .

R
PG Student
Dept. of Pedodontics
 Introduction
• Dyscrasia (or dyskrasia) is a concept from ancient Greek medicine,
meaning bad mixture.

• The concept of dyscrasia was developed by the Greek physician Galen

(130–199 AD), who elaborated a model of health and disease as a structure
of elements, qualities, humors, organs, and temperaments.

• Health was understood in this perspective to be a condition of harmony or

balance among these basic components, called Eucrasia.

• Disease was interpreted as the disproportion of bodily fluids or four

humours: phlegm, blood, and yellow and black bile. The imbalance was
called Dyscrasia.
BLOOD

Blood is a bodily fluid that delivers necessary

substances such as nutrients and oxygen to the cells and
transports metabolic waste products away from the cells.
 Erythrocytes or RBCs
• Circular, biconcave cell.
• Doesn’t contain a nucleus, ribosomes,
or mitochondria.
• Contains Hb which is interwoven in
the stroma.
• The functions of RBCs include:
– Carriage of O2 from the lungs to
peripheral tissues.
– Carriage of CO2.
• Approx. 5 x 106 /cumm
• Approx. life span- 120 days.
 Haemoglobin
• Present in RBCs.
• Required for:
• O2 transport
• CO2 transport
• Acts as a blood buffer
• Each molecule has 2
ingredients-
– haem and globin.
• Haemoglobin is a
conjugated protein.
 Leucocytes or WBCs
• Leukos= white + cytes= cells
• Their fundamental job is to:
– Provide defence against:
• Bacteria
• Viruses
• Fungi
• Parasites
– Remove debris(dead cells) and
foreign protein.
– Produce chemicals that produce
inflammation.
 Platelets
• Platelets are only about 20% of
the diameter of red blood cells.
• The normal platelet count is
150,000-350,000 per microliter of
blood, but since platelets are so
small, they make up just a tiny
fraction of the blood volume.
• The principal function of platelets
is to prevent bleeding.
 Functions of blood
• Transports gases, nutrients, waste, cells
and hormones throughout the body.
• Transports O2, CO2, nutrients,
hormones and wastes.
• Regulates pH, temperature and water
content of cells.
• Protects against blood loss through
clotting.
• Protects against disease through
phagocytic white blood cells and
antibodies.
Classification of Blood Dyscrasias

Blood
dyscrasias

Disorders of
Disorders of Disorders of
hemostatic
blood cells haemoglobin
mechanisms

Red cell White cell Haem Globin Bleeding Coagulation

disorders disorders disorders disorders disorders disorders
RED CELL DISORDERS
 RED CELL DISORDERS
• Disorders of RBCs numbers
– Anaemias
– Polycythemia
• Disorders in the RBC membrane
– Hereditary Spherocytosis
Anaemia
 Iron Deficiency Anaemia
• Most common anaemia.
• Microcytic hypochromic type of anaemia.
• Women are affected 4 times more frequently than men.

CAUSES
• Nutritional Deficiencies
• Chronic Blood loss
• Malaria
 Systemic features
• None in the early stages

• Cardiorespiratory
– Dyspnoea
– Tachycardia
– Palpitations

• Cutaneous
– Pallor
– Koilonychia- spoon shaped nails
 Oral Manifestations
• Angular stomatitis
• Atrophic glossitis
• Ulceration
• Palatal pallor
 General Management
• Administration of 300 mg ferrous sulphate orally, 3 times daily
for 10 days.

• Mild gastrointestinal intolerance is the side effect.

• Takes 10 to 20 days for the hematocrit to normalize.

• Parenteral administration reserved for patients who do not

respond to oral therapy.
 Dental Considerations
• Local Anesthesia adequate for pain control.

• Atrophic glossitis – soreness of tongue with depapillation or

colour change- best known sign of severe anaemia.

• Candidiasis may be a presenting feature caused by candida

albicans which may be promoted by anaemia itself.
 Periodontal Manifestations
• CP patients with Iron deficiency anemia exhibited a higher
gingival index, bleeding on probing, probing pocket depth, and
increased % of sites with a clinical attachment loss (CAL) of
≥6 mm than normal CP patients.

• In patients with significant anaemia, elective periodontal

surgical procedures should be avoided, as they may cause
bleeding problems and also poor wound healing.
 Vitamin B12 Deficiency Anaemia
CAUSES
o Auto immune - Pernicious Anaemia (due to atrophy of
gastric mucosa).
o Poor Intake - specially in vegetarians.
o Malabsorption
o Congenital
o Gastrectomy
o Ileal disease
o Drugs (rare)
• Colchicine
• Neomycin
 General Features
• Slow to develop because liver stores last upto 3 years.
• Commonly seen features are:
– Weakness
– Fatigue
– Light-headedness
– Rapid heartbeat
– Rapid breathing
– Pale color to the skin
– In addition, neurological symptoms particularly paresthesia of
the extremities may develop.
 Oral Manifestations
• A physically normal, sore or burning tongue can be caused by
early Vitamin B12 deficiency.

• Tongue may appear fiery or beefy red and the tip and margins
show papillary atrophy.

• Candidiasis can be precipitated by anaemia.

• Apthous stomatitis occasionally presenting feature.

• Marked pallor of the gingiva.

 Dental Considerations
• Local anaesthesia satisfactory.

• Conscious sedation- Nitrous oxide is contraindicated.

• General anaesthesia should be postponed until the low

haemoglobin has been remedied.
 Folic Acid Deficiency Anaemia
Folic acid is needed by the body to
 Synthesize and breakdown amino
acids

 Synthesize DNA / RNA

 Essential for the maturation of

erythrocytes.

• Laboratory picture is that of

megaloblastic anaemia.
CAUSES:
• Mostly dietary deficiency
• Malabsorption
– Coeliac disease and Crohn’s disease

• Increased demands
– Pregnancy
– Patients under going long term renal dialysis

• Drugs
– Alcohol- interferes with metabolism and absorption of folic acid.
– Barbiturates
– Phenytoin
 General Features
Folate deficiency leads to anaemia
 Fatigue
 Dizziness
 Feeling cold
 Irritability
 Headache
 Difficulty breathing
 Pale skin
GI symptoms such as
 Nausea, vomiting
 Abdominal pain
 Diarrhea especially after meals
• Anorexia also is common.
• In combination with the above symptoms, may lead to marked
weight loss.
 Oral Manifestations
• In early deficiencies
– Soreness of tongue without depapillation or colour change

• In severe anaemia
– Atrophic Glossitis is the best known sign

• Angular Stomatitis is also a well known sign

 General Management
• Oral folic acid (1 mg tablet daily) is effective in reversing
megaloblastic anaemia caused by folate deficiency.

• If the underlying cause of deficiency is irreversible (e.g.

intestinal disease), maintenance therapy is necessary.

• The patient should be given education emphasizing the origin

of the dietary deficiency.
 Dental Considerations
• Local anaesthesia is satisfactory.

• Conscious sedation can be given if the haemoglobin level is

only moderately depressed and supplemental oxygen can be
given.

• General Anaesthesia should be postponed until the low

haemoglobin has been remedied.
 Aplastic anaemia
• Pancytopenia with a non functioning bone marrow.
• Rare disease causing leucopenia, thrombocytopenia and refractory
anaemia.

CAUSES
• Idiopathic
• Chemicals such as benzene
• Drugs
• Hepatic viruses
• Irradiation
 General features
Features of anaemia
– Purpura – usually the first manifestation

– Suseptibility to infection

– Suseptibility to bleeding
 Oral manifestations
• Ulceration

• Haemorrhagic tendencies

• Suseptibility to infections

• Oral lichenoid reactions

 General Management

First line treatment for aplastic anemia consists of

immunosuppressive drugs, typically either anti-lymphocyte

globulin or anti-thymocyte globulin, combined with corticosteroids

and cyclosporine.
 Dental Considerations
• Treatment modifications need to take into consideration:
• Anaemia
• Haemorrhagic tendencies
• Susceptibility to infections
• Effects of corticosteroid therapy
• Hepatitis B and other viral infections

• Local anaesthesia is satisfactory.

• Conscious sedation and general anaesthesia should be avoided.
• Gingival enlargement is a complication of cyclosporine therapy.
 Polycythemia
• Polycythemia may be defined as an abnormal increase in the
erythrocyte count in the peripheral blood, usually accompanied
by an increase in hemoglobin.

• Opposite of anaemia

• RBC count and Hb concentration both rise.

Polycythemia can be:

• Primary aka Polycythemia Vera

– Due to malignant changes in erythrocyte producing cells.

• Secondary
– Where there is an excess need of RBCs for survival. E.g.
at high altitudes, COPD and cyanotic heart diseases.
 Systemic features
• Headache

• Dizziness

• Vertigo

• Tinnitus

• Hemorrhages

• Ruddy cyanotic skin seen on the face and extremities

• Splenomegaly is a common finding on physical examination.

 General Management
• Goal of medical therapy is to reduce erythroid over production and
to lower blood viscosity.
• When the hematocrit rises above 60%, blood is removed usually
about 500 ml initially, by phlebotomy every 2 to 3 days until
hematocrit is controlled.
• Thereafter, maintenance therapy consists of long term phlebotomy
or myelosuppressive therapy.
• Long term myelosupression by chemo therapy or irradiation is
efficient.
 Oral manifestations
• Facial plethora (red florid complexion) is a cardinal sign
particularly evident around the ears, nose and lips.

• Oral mucosa may have cyanotic or purplish appearance.

• Bleeding tendencies are evident as

 Petechiae

 Hemorrhages

 Prolonged bleeding following extractions or periodontal surgery.

 Periodontal Manifestations
• The gingivae appears congested and edematous and
may bleed spontaneously because of hyperviscosity
and hypertension.

• Gingival enlargement may be seen.

DISORDER IN RBC MEMBRANE
 Hereditary Spherocytosis
• Also known as Minkowski– Chauffard
syndrome
• Intrinsic defect in RBC membrane that
renders it spheroidal, less deformable and
vulnerable to spleenic sequestration and
destruction.
• Mutations disrupt vertical interactions
between spectrin meshwork and intrinsic
membrane proteins.
 General features
• Signs and symptoms are highly variable

• They may include:

– Mild pallor

– Intermittent jaundice

– Splenomegaly.
 Oral Manifestations
• Manifest in the mucosa as deposition of blood pigments during
episodes of jaundice or in acute infections.

• Severe dental infection may trigger an attack requiring

hospitalisation.
 General Management
• Splenectomy is frequently performed and is invariably
successful in correcting the haemolysis of erythrocytes.

• Gall Bladder is also removed if symptomatic or diseased.

(affected in about half of the patients).
DISORDERS OF Hb
 Haemoglobinopathies
• They are genetically determined disorders of haemoglobin
production.

• Each of the haemoglobin peptide (globin) chains has a unique

amino acid sequence that can be altered as a result of DNA
mutations.

• Haemoglobinopathies are mostly seen in non – caucasians.

 Sickling Disorders
• It is an autosomal recessive disorder.

• Erythrocytes distort into cresent or sickle shape.

• HbS haemoglobin present instead of HbA.

• 2 α chains are as usual but in the β chains, in position 6, valine

replaces glutamic acid.

• Sickling of RBCs leads to stasis, hemolysis and

microthrombosis of blood.
 General Features
6 main problems:
• Painful Crises
– Usually due to infarction brought on by infection, dehydration,
hypoxia, acidosis or cold.
– Form mainly in spleen, bones and joints, brain, kidney, lungs, retinae
and skin.
• Haematological crises
– Caused by parvovirus infection.
– Can be: haemolytic, aplastic or sequestration.
• Chronic Anaemia
• Chronic hyperbilirubinaemia
• Infections- pnuemococci, meningococci, haemophilus and
salmonellae
• Sequestration syndromes
 Oral Manifestations
• Pallor of the oral mucosa.

• Slow tooth development and eruption.

• Hypoplasia of enamel.
Radiographically,
– “Step ladder” trabecular pattern

– Lamina Dura is more distinct

– Calcified pulp canals

– Hypercementosis may be seen.

 General Management
• Painful and febrile crises of sickle cell anemia are managed
with analgesics, sedatives, bed rest and fluids.

• When vaso- occluson develops, transfusion therapy is

advocated.

• Whole blood or packed cells are used to increase the

erythrocyte count and to promote tissue oxygenation.
 Dental Considerations
• Sickle cell anaemia with Hb less than 11 gm/dl presents a hazard for
general anaesthesia.

• Local anaesthesia is the preferred mode for pain control.

• Conscious sedation can be used safely.

• Preferable to avoid prilocaine which in overdose may cause

Methaemoglobinaemia.

• Aspirin is best avoided - may cause acidosis in large doses.

• Prophylactic antibiotics should be given and infections may be treated

vigorously.

• Elective surgery should be carried out in the hospital and the anaemia
should be corrected pre operatively with the Hb brought upto 10gm/dl.
 Thalassaemias
• These are autosomally dominant, inherited disorders in which either alpha
or beta globin chains are synthesized at a low rate, thereby lessening the
production of Hb A.
• Characterized by hypochromic microcytic anaemia.
• They may be
– Severe - major thalassemia
– Mild - minor thalassemia

• May affect
– Alpha chain - alpha thalassemia
– Beta chain - beta thalassemia
 Beta- Thalassemia
• Results from depressed production of beta chains.

• Homozygous beta thalassemia (Cooley’s anaemia or

thalassemia major) is characterized by:
– Increasingly severe anaemia

– Hepatosplenomegaly

– Skeletal Abnormalities

• Heterozygotes for beta thalassemia may be asymptomatic.

 Oral manifestations
• Marked overdevelopment of maxilla and mandible.

• The osseous changes cause

– Prominent cheekbones,

– Sunken root of the nose,

– Labial inclination of the maxillary incisor,

– Inadequate lip seal.

• These lead to the description “chipmunk” or “rodent facies”.

• The oral mucosa may be pale due to anaemia or yellow tinged

due to jaundice.
 General Management
• Treatment includes blood transfusions to temporarily control anemia.

• Repeated transfusions accelerate development of electromyocardial

instability.

• Iron chelating agents have been used to improve serum iron balance in these
patients.

• In select cases, splenectomy may be helpful.

• Prognosis for thalassemia major is unfavorable and no successful therapy is

available.

• Death usually occurs early.

• Thalassemia minor often requires no specefic therapy unless haemoglobin

levels drop.
 Dental Considerations
• Patients undergoing repeated transfusions are at a risk of
Hepatitis B, C and HIV carriage.

• Since splenectomy results in an immune defect, it is prudent to

cover surgical procedures with prophylactic anti - microbials.

• Local anaesthesia is safe.

• Conscious sedation may be given with oxygen levels not less

than 30%.

• General anaesthesia may be complicated by enlargement of the

maxilla (difficulty in entubation).
 Periodontal Considerations
• Severe gingivitis is evident if the patient is subjected to
splenectomy.

• The colour of gingiva sometimes tends to be dark due to high

ferritin levels in the blood.

• Periodontitis, gingivitis etc. are very dangerous foci of

infection in these immune impaired individuals.
WBC DISORDERS
 Leukaemias
• Leukemias are potentially lethal diseases in which there is
neoplastic proliferation of bone marrow WBCs.

• They are classified by:

– Clinical course - acute or chronic

– Cell of origin - lymphoblast or non lymphoblast

• Dental management of such patients is often complicated by

bleeding tendencies and susceptibility to infection.
 Acute Lymphoblastic Leukemia
• Most common malignant disease of children.

• Usually in childhood but can affect any age group.

CAUSES
• Ionizing radiation

• Exposure to benzene
 Clinical features
• Anaemia

• Lymphadenopathy

• Splenomegaly

• Infections

• Fever

• Bruising

• Bleeding tendencies
 Oral manifestations
• Oral bleeding and petechiae are typical manifestations
• Oral pallor
• Gingival swelling
• Mucosal or gingival ulceration
• Pericoronitis
• Cervical lymphadenopathy
• Oral and Peri-oral Herpetic infections
• Candidiasis caused by Candida albicans
 General Management
• Treatment of choice is with prednisolone.

• Other anti leukemic agents like anthracycline

antibiotic are added if needed.
 Dental considerations
• Preventive oral health care is essential and conservative dental
treatment may be possible.

• Surgery should be deferred except in emergencies .

• Regional local anaesthetics contra indicated if there is severe

haemorrhagic tendencies.

• Conscious sedation is usually possible.

• Anaemia is a contradiction to general anaesthesia however iv

sedation may be used.
 Dental considerations
• Because of dangers of infection and hemorrhage, desmopressin or
platelet or blood infusions may be needed pre operatively.

• Antibiotic coverage should be started pre operatively and continued

till the wound heals.

• Any extraction sockets should not be packed as they predispose to

infection.

• Aspirin and other NSAIDs should not be given since they can
aggravate bleeding.
 Acute Myeloid Leukemia
Most common leukemia in adults

CLINICAL FEATURES
• Anaemia
• Lymphadenopathy
• Splenomegaly
• Infections
• Fever
• Bruising and bleeding tendencies
• Night sweats
• Lethargy
• Weight loss
 Oral manifestations
• Oral bleeding and petechiae are typical manifestations

• Mucosal pallor

• Mucosal or gingival ulceration

• Pericoronitis

• Cervical lymphadenopathy

• Gingival swelling - occurs due to abnormal response to dental

plaque
 General Management
• Less responsive to therapy and continues to be lethal for the
majority affected.

• Remission is the result of intensive treatment with cytosine

arabinoside, together with anthracycline antibiotic,
daunorubicin and sometimes methotrexate.
 Dental considerations
• Preventive oral health care is essential and
conservative dental treatment may be possible.

• Surgery should be deferred except in emergencies.

• Antibiotic coverage should be started pre operatively

and continued till the wound heals.
 Chronic Lymphocytic Leukemia
• Primary disease of older persons.
• The cause of CLL remains unknown.

CLINICAL FEATURES
• Many are asymptomatic.
• In others,
– Fatigue
– Fever
– Weight loss
– Anorexia
– Lymphadenopathy
– Haemorrhage
 Oral manifestations
• Gingival bleeding

• Oral petechiae

• Oral ulceration

• Herpes simplex infection may occur

• Candidiasis is common

• Bleeding tendencies

• Liability to infections
 General Management
• The chemotherapeutic agent used in the treatment of CLL is
the alkylating agent - chlorambucil.

• This agent may be given with prednisone, especially if

autoimmune hemolytic anemia and thrombocytopenia are
present.

• This therapy reduces nodal and spleen size and improves the
quality of life.
 Dental considerations
• Local anaesthesia is satisfactory.

• Conscious sedation may been given.

• General anaesthesia should be carried out in a hospital.

 Chronic Myeloid Leukemia
• Most dramatic white cell disorder.
• Proliferation of myeloid cells in the bone marrow, peripheral
blood and other tissues.

CLINICAL FEATURES
– Anaemia
– Weight loss
– Joint pains
– Splenomegaly
– Hepatomegaly
– Rarely lymphadenopathy
 Oral manifestations
• Pallor of mucosa due to anaemia

• Disturbance of taste

• Xerostomia

• Oral hemorrhages

• Swelling of salivary glands

 General Management
• Treatment of CML is with the alkylating agent - busulfan or
with hydroxyurea.

• These cytotoxic drugs reduce peripheral blood counts and

spleen size, making the patient less symptomatic.
 Dental considerations
Treatment planning should take into consideration:
• Bleeding tendencies

• Liability to infection

• Anaemia

• Susceptibility to hepatitis B, C and HIV infection.

 Periodontal Considerations
• Periodontal manifestations consist of leukemic infiltration, gingival bleeding.

• Their expression is more common in acute forms of leukemia than in chronic

forms.

LEUKEMIC INFILTRATION
– Leukemic cells can infiltrate the gingiva and less frequently the alveolar bone.

– Gingival infiltration results in leukemic gingival enlargement.

– Clinically, the gingiva appears:

 Bluish red and cyanotic

 Rounding and tenseness of the gingival margin

 Increase in size, mostly in the interdental papilla & partially covering the crowns of the teeth.
BLEEDING

• Gingival hemorrhage is a common finding in leukemic

patients.

• It is caused by the thrombocytopenia resulting from

replacement of bone marrow cells by leukemic cells and from
the inhibition of normal stem cell function by leukemic cells
 Leukemic gingival enlargement
• Most important oral sign of leukemia.
• True enlargement occurs in acute leukemia and seldom in
chronic leukemia.
• It may be
— diffuse or marginal
— localized or generalized.
• Normal contours of gingiva are lost.
• It may appear as
― A diffuse enlargement
― An oversized extension of the margins
― A discrete tumor like interproximal mass
• Stippling is replaced by spongy, swollen tissue that tends to
peel away from the teeth and bleed easily.
• The consistency is moderately firm, bit there is a tendency
towards friability.
• Progressive disease produces purple, shiny and hemorrhagic
gingiva.
• Purpuric features like petechial lesions and ecchymosis are
common.
 LYMPHOMAS
• Malignant lymphomas are solid neoplastic growths of lymphoid
cells that arise in reticuloendothelial and lymphoid tissue.
• They spread to distant lymphoid sites, such as liver, spleen and bone
marrow.
• Originate in the lymph nodes but can arise extra nodally.
• Several types of malignant lymphomas occur, however those of
primary interest are
– Hodgkin’s Lymphoma
– Non – Hodgkin’s Lymphoma
– Burkitt’s Lymphoma
 Hodgkin’s Lymphoma
• It is a neoplastic disorder originating in lymphoid tissue.

• The disease classically begins as a painless, enlarging mass

that appears in the neck or mediastinum of adults.

• Initially arises at a single site and subsequently spreads to

contiguous lymphoid structures.

• Characterized by a neoplastic proliferation of large multi

nucleated reticulum cells known as Reed Stenberg Cells.
 General Features
• Progressive painless swelling of the cervical lymph nodes.

• Generalized itching

• Cyclic elevations of body temperature

• Chills and night sweats

• Weight loss
 Non-Hodgkin’s Lymphoma
• Heterogenous collection of 10 different malignant
lymphoid diseases.

• Produce numerous atypical lymphocytes that

obliterate normal lymph nodal architecture.
 General Features
• Painless lymphadenopathy – presenting feature.

• Enlarged lymph nodes are firm, rubbery and mobile.

• Rapid nodal growth may impair lymphatic drainage, resulting

in lymphedema, pain, parasthesia and skin infiltrations.
 Oral Manifestations
• Lymphoid tissue of Waldeyer’s Ring frequently involved site.

• Infiltration results in non tender enlargements of tonsillar

tissue or the posterior palate.

• The surface of these swellings may be erythematous, ulcerated

or necrotic.
• When palate is the sole site of primary lymphoma, it is
sometimes referred to as lymphoproliferative disease of the
palate.

• The enlargement is slow growing, soft, spongy and relatively

painless.

• The surface is non ulcerated and often lumpy, with red surface
telangiestasia.

• As the disease progresses the colour changes from pink to

bluish purple
 Periodontal Manifestations
• In rare cases, oral Non- Hodgkins Lymphoma can mimic other,
more common disorders and can appear as a gingival mass.

• Lymphomas of the gingiva are frequently treated for months as

a pulpal or periodontal problem before the correct diagnosis is
made.
 Dental Considerations
• Preventive dental measures are most important in patients with lymphoma.

• Generally speaking, patients in a state of remission can receive routine dental

care.

• However, patients with acute signs or symptoms of lymphoma should receive

only conservative emergency dental care.

• When invasive procedures are required in the patient with lymphoma,

bleeding time determination and consultation with oncologist are
recommended.

• Patient undergoing chemotherapy or radiation therapy should be observed for

xerostomia or radiation caries.
DISORDERS OF HAEMOSTASIS
 Haemostasis
Normal Haemostasis depends on a complex interaction of
the blood vessels, platelets, fibrin coagulation and deposition and
fibrinolytic proteins.

• Heamostasis consists of 3 reactions:

– Primary- vascular phase

– Secondary- platelet phase

– Tertiary- coagulation phase

• All of which occur at the same time.

 Primary Haemostasis
• Primary haemostasis is by vasoconstriction after injury.
• This reduces the outflow of escaping blood after injury.
• Circulating platelets are exposed to subendothelial collagen, which
causes the release of intra- cytoplasmic granules that stimulate
platelet aggregation and helps to form the soft primary plug.

Abnormalities in primary haemostasis

– Abnormal platelet number or function
– Abnormal von willebrand factor
 Secondary Haemostasis
• The aggregation of platelets is the second phase of
haemostasis.
• Therefore it is also known as ‘the platelet phase’.

Abnormalities in secondary haemostasis

– Defects in the coagulation cascade cause more serious bleeding than do
defects of primary haemostasis.
– They include bleeding into cavities (chests, joints, cranium).
 Tertiary Haemostasis
• It is the third and final phase.

• It is divided into 2 pathways:

 The extrinsic pathway

 The intrinsic pathway

 Bleeding Disorders
CAUSES

• Defects in haemostasis, leading to bleeding disorders can

comprise:
– Platelet activation and function

– Anti – thrombin function

• The more common causes include

– Warfarin- which interferes with clotting factor production

– Vitamin K blockage

– Aspirin – one tablet of which impairs platelet function for almost 1 week.
 General Features
• Deep haemorrhage into muscles, joints or skin.

• Bleeding from and into mucosae and skin (‘bruising’)

- suggests purpura.
 Oral Manifestations
• Localized Oral Purpura

• Blood blisters are occasionally seen, typically in older persons

in the absence of obvious trauma.

• These blood blisters are often in the palate and may sometimes
be 1 cm or more in diameter and after rupture may leave a sore
area for a time.
PLATELET DISORDERS
 Platelet Disorders
• Platelet disorders may be the result of
– Alteration in platelet numbers,
 Decreased (thrombocytopenia)
 Increased (thrombocythemia),

– Altered platelet function (thrombocytopathia).

• Platelet disorders may be:

– Quantitative - Thrombocytopenic purpura
– Qualitative - Disorders of platelet function
Causes
– Failed platelet production
– Thrombocytopenia
– von Willebrand’s disease.
– Excessive platelet Destruction
– Idiopathic Thombocytopenic Purpura
– Abnormal platelet Function
– Abnormal platelet Regulation
 Thrombocytopenic Purpura
• Thrombocytopenia is a bleeding disorder characterised by a
platelet count below the normal range.

• Reduced counts may be due to:

– Failure of platelet production

– Disordered platelet distribution

– Increased platelet destruction.

• It may be:
 Auto- immune or Idiopathic

 Drug induced
Idiopathic Thrombocytopenic Purpura

• Also known as auto–immune thrombocytopenic

purpura.

• It is one of the most common causes of

thrombocytopenia.

• It is auto immune and can lead to purpura and

prolonged bleeding.
 Drug Induced Thrombocytopenic
Purpura
• Reactions of drugs or toxins resulting in a low platelet count
and bleeding tendency.

• Common offenders are:

– Quinidine

– Quiunine

– Sulfonamides

– Heavy alcohol consumption.

 General Features
• Abrupt appearance of petechial hemorrhages.

• Purpura

• Bruises after trauma

• Petechiae cover extensive surface area appearing rash like, but

are tender and do not itch.

• Located chiefly on arms, lower leg, upper chest and neck.

• In severe cases - mucosal bleeding of the GIT may occur.

 Oral Manifestations
• Petechiae

• Ecchymoses

• Post operative haemorrhage.

• Submucous purpura may be conspicous and sometimes seen

as “blackcurrant jelly” blood blisters.
 Dental Considerations
• Regional local anaesthetic block injections can be given.

• Major surgery requires platelets more than 75x 109 /l.

• Conscious sedation can be given.

• General anaesthesia can be given under strict monitoring in an

hospital.

• Avoid aspirin and other NSAIDs.

 Periodontal Considerations
• Gingiva is soft, swollen and friable.

• Bleeding occurs on the slightest provocation and is difficult to

control.

• The severity of the gingival condition is dramatically

alleviated by removal of the local factors.
 CONGENITAL COAGULATION DEFECTS

• Most important hereditary bleeding disorders include:

– von Willibrand’s disease

– Haemophilia A and B
 Haemophilia
• X linked disorder resulting from a deficiency in clotting factor
VIII (Hemophilia A or classic) or factor IX (Hemophilia B or
Christmas Disease) .

• Affects males, females are carriers.

• 3 forms of hemophilia are seen:

– Severe – < 1% of normal factor VIII

– Moderate – 1 - 5%

– Mild – 5 - 25%
 General Features
• Characterized by severe, persistent bleeding.
• Hemorrhage into soft tissue, muscles, organs and joints.
• Clinically these are prominent as hematomas and
hemarthroses.
• Excessive bleeding after trauma.
• Intractable oozing or rapid blood loss one hour or more after
injury.
• Sometimes spontaneous bleeding.
 Oral Manifestations
• Petechiae

• Ecchymoses

• Spontaneous gingival bleeding can occur

• Prolonged massive bleeding even from simple tooth

exfoliation or extraction.

• Associated with anaemia induced pallor and pseudoaphthae.

 Dental considerations
• Local anaesthetic injections or surgery can be followed by persistent
bleeding for days.
• The hemorrhage cannot be controlled by pressure alone.
• Bleeding tendency may be aggravated by NSAIDs.
• In all but severe haemophiliacs, non surgical dental treatment can
usually be carried out under antifibrinolytic cover.
• Extractions and dentoalveolar surgery should be carefully planned. A
factor VIII level between 50 and 75% is required.
• Mild hemophiliacs requiring such surgeries can be managed usually
without factor replacements. Desmopressin and tranexamic acid are
primary alternative.
• Post operative suturing is desirable. Vicryl sutures are most preferred
 Periodontal considerations
• Periodontal health is of critical importance for the hemophiliac for 2
primary reasons:
o Hyperemic gingival contribute to spontaneous and induced gingival
bleeding.

o Periodontitis is leading cause for tooth morbidity necessitating extractions.

• In all but severe hemophiliacs, scaling can be carried out without LA.

• Periodontal surgery requires LA and factor VIII replacement to a level

between 50 to 75%
 von Willebrand’s disease
• Due to inherited deficiency in vWF.

• Most common inherited bleeding disorders.

• Affects both males and females.

 General Manifestations
• Generally, bleeding manifestations are mild.

• Epistaxis

• Bleeding from the mucous membrane

• Purpura of mucous membrane and skin

• Menorrhagia in females
 Oral Manifestations
• Gingival bleeding is the most common finding - in about 30%
to 40% of the diseased.

• Uncontrollable bleeding during dental procedures like gingival

manipulation and pulpectomy.
 Dental Considerations
• Aspirin and NSAIDs should be avoided.

• Local infilteration anaesthesia should generally be used.

• Nerve block anaesthesia is generally contra indicated because injections

delivered into loose alveolar tissue (highly vascular regions) may produce
bleeding or a dissecting hematoma that could obstruct the patient’s airway.

• Conscious sedation can be given, but care must be taken not to damage the
vein.

• General anaesthesia must be given in hospital.

• Intubation is a possible hazard because of the risk of submucosal bleeding

in the airway.
 Periodontal Considerations
• Gingival haemorrhage is more common than in haemophilia.

• Even minor gingival manipulation can lead to uncontrollable

bleeding.

• Cryoprecipitate or other anti fibrinolytic agents should be

administered to minimize bleeding.

• Post operative diet should be soft and semi solid to minimize

trauma to the gingiva.
GUIDELINES FOR ORAL HEALTH CARE
OF PATIENTS WITH HEMATOLOGIC
DISEASE
Guidelines for Hemorrhagic Dental Procedures
• Should be avoided when patients conditions are poorly
controlled.
• Provide prophylactic antibiotics to prevent infection when
open wounds are present.
• Obtain pre operative CBC, DLC, platelet count, bleeding time,
PT and APTT. Any abnormal values mandate a consultation.
• Oral surgical procedures should be done only if absolutely
necessary and in a hospital setting.
• Single dental extractions should be performed as opposed to
multiple extractions.
• Pay meticulous attention to good technique and primary
closure.
 Guidelines for Dental Emergencies
• Pallative emergency treatment only.
• Dental infections should be treated aggressively with
antibiotics and drainage.
• Surgical procedures should be avoided until control of disease
can be assessed with blood profiles.
• Non – Aspirin or Non- NSAID containing drugs should be
prescribed as post operational analgesics.
• If the patient comes back with bleeding-
 Debride the wound site and remove any clot.
 Control the bleeding by packing the socket with absorbable
microfibrillar collagen or thrombin soaked gauze.
 Conclusion
• Recording a proper history including past medical and dental history and
family history of the patient, helps the clinician in better management of
patients with bleeding disorders.
• It not only helps in reaching to a proper diagnosis of the patient’s condition
but also in forming a holistic treatment plan that is beneficial for the
patient.
• Knowledge of the signs and symptoms, both oral and systemic of these
diseases enable the clinician in diagnosing cases in which the patient does
not have any information about the presence of such disease
 References
1. Chaudhuri - Concise medical physiology, IV edition.

2. Harsh Mohan - Essential Pathology for Dental Students, 4th

Edition

3. Guyton and Hall - Textbook of Medical Physiology, 11th ed

4. Carranza’s Clinical Periodontology, X edition.