influence of hematological disorder on periodontium

Influence of Hematological disorders on the

Periodontium

Dr Saif KhanAssistant Professor

Dept tof Periodontics & Community Dentistry

Dr Z A Dental College

Aligarh Muslim University, Aligarh,

UP,India-202002

Blood cells play essential role in maintenance of healthy Periodontium

04/11/23 2Dr Saif Khan

• 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


• 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 disorder04/11/23 6Dr Saif Khan

It is essential to diagnose the specific

etiology inorder to address any bleeding or

immunologic disorder appropriately


LeukemiaMalignant 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

Classification

According to lineage of WBC, Leukemia are

classified as

• Lymphocytic

• Myelocytic

– Monocytic04/11/23 9Dr Saif Khan

According to evolution Leukemia can be

– Acute

– Subacute

– Chronic

Acute Leukemia the primitive blast cells are

released in peripheral circulationChronic anemia the abnormal cells are

more mature with normal morphologic characteristics and function when released into the circulation


Histology AML


All leukemic cells tend to displace normal

component of Bone marrow elements with

resulting in decreased production of

RBC Anemia

WBC Leukopenia

Plateletes Thrombocytopenia


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


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


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%)04/11/23 16Dr Saif Khan

• 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


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


Leukemic Gingival Enlargement


Leukemic Gingival Enlargements


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


• 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


• 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


• 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


• 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


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


• 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


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 Ulcer04/11/23 28Dr Saif Khan

• 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


• 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


• 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


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


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)


Sickle Cell Anemia

• Hereditary• Chronic Hemolytic Anemia• Exclusively in Blacks• Presents with

– Pallor– Jaundice– Weakness– Rheumatoid Manifestations– Leg Ulcers

04/11/23 Dr Saif Khan 36

Oral Changes

• Generalised osteoporosis of Jaw

– Stepladder arrangement of trabeculae

• Pallor/Yellowish discoloration

• Periodontal infection may precipitate

Sickle Cell Crisis


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


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


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


Gingival changes represent an

abnormal response to local irritation;

the severity of the gingival condition

is dramatically elevated by removal

of local factors


Leukocyte (Neutrophil) Disorder

Primary neutrophil disorder

– Neutropenia

– Agranulocytosis

– Chediak Higashi Syndrome

– Lazy Leukocyte Syndrome


Secondary Neutrophil Disorder

–Down Syndrome

–Pappilon Lefevre Syndrome

– Inflammatory Bowel Disease


Neutropenia

• Low levels of circulating neutrophils

• Absolute neutrophil count (ANC) less than

1500 cells/µL is considered Neutropenia

• Neutropenia

– Genetic

– Drug Induced

– Viral infection


• Neutropenia is serious , can lead to life

threatening infection which are difficult to control

• It may be

– chronic or cyclic

– Severe or Benign


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


Agranulocytosis

• Generally occurs as Acute disease

• Chronic/Peroidic with recurring neutropenic cycles

(Cyclic Neutropenia)

• Disease onset with fever,malaise,general

weakness and sorethroat


• 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


• 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 04/11/23 Dr Saif Khan 50

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


• Killing of ingested microrganism is delayed

• Aggressive Periodontitis


Lazy Leukocyte syndrome

• Defective chemotaxis response of neutrophils

• Susceptibilty to severe microbial infections

• Abnormal inflammatory response

• Aggressive Periodontitis


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 loss04/11/23 Dr Saif Khan 55

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



• 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


• Periodontal involvement early inflammatory changes-

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


Pappilon Lefevre Syndrome

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


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


influence of hematological disorder on periodontium

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