|Year : 2017 | Volume
| Issue : 1 | Page : 30-34
Clinical guidelines for periodontal management of idiopathic thrombocytopenic purpura: Current considerations
Neha Bansal1, Manika Jindal2, Narinder Dev Gupta3, Pradeep Shukla1
1 Department of Periodontics and Implantology, Divya Jyoti College of Dental Sciences and Research, Sahibabad, Ghaziabad, Uttar Pradesh, India
2 Department of Periodontics and Implantology, Inderprastha Dental College, Sahibabad, Ghaziabad, Uttar Pradesh, India
3 Department of Periodontics and Community Dentistry, Dr. Ziauddin Ahmad Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
|Date of Web Publication||3-Jul-2017|
K-16, ADA Bank Colony, Pala Road, Aligarh - 202 002, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Idiopathic thrombocytopenic purpura is an acquired platelet disorder reported to have spontaneous hemorrhagic gingiva as one of the earliest manifestations, sometimes as a presenting symptom. It is very important for general dentists to be aware of such conditions as prolonged bleeding may occur as a life-threatening complication during and posttreatment of such patients. They must have a basic insight of the oral findings of thrombocytopenia and should arrange and prepare the necessary assistance in advance. A diligent cooperation among patient, hematologist and dentist are crucial in the management of bleeding disorder patients. This paper provides an overview of thrombocytopenia and current recommendations for its periodontal management. We concluded that thrombocytopenia is not an absolute contraindication for dental procedures; however, the course of treatment should be commanded by the clinical manifestations and the platelet count.
Keywords: Bleeding disorder, idiopathic thrombocytopenic purpura, periodontal management, platelets
|How to cite this article:|
Bansal N, Jindal M, Gupta ND, Shukla P. Clinical guidelines for periodontal management of idiopathic thrombocytopenic purpura: Current considerations. Int J Oral Health Sci 2017;7:30-4
|How to cite this URL:|
Bansal N, Jindal M, Gupta ND, Shukla P. Clinical guidelines for periodontal management of idiopathic thrombocytopenic purpura: Current considerations. Int J Oral Health Sci [serial online] 2017 [cited 2019 May 19];7:30-4. Available from: http://www.ijohsjournal.org/text.asp?2017/7/1/30/209356
| Introduction|| |
Incidences of excessive or abnormal bleeding were first recorded hundreds of years ago. In 1735 a German physician and poet, Paul Gottlieb Werlhof, described the first detailed case of idiopathic thrombocytopenic purpura (ITP), which subsequently becomes known as Werlhof's disease. ITP is an acquired disorder that is characterized by mild to severe thrombocytopenia in the absence of any other abnormalities. It is a condition in which platelet count falls below the 2.5th lower percentile of the normal platelet count distribution (150,000–400,000 cells/μL).
Two major mechanisms involved in pathogenesis of ITP is either increased destruction or decreased production of platelets. Platelet production may be decreased in bone marrow failure syndromes (e.g., aplastic anemia, myelodysplastic syndromes, and chemotherapy induced, drug-induced thrombocytopenia); whereas increased destruction is seen in conditions such as thrombotic microangiopathies and disseminated intravascular coagulation. Other causes include platelet sequestration as in congestive splenomegaly and hemodilution. It may occur as a manifestation of various infections as hepatitis C, human immunodeficiency virus, Epstein–Barr, etc., Helicobacter pylori, etc., and as a side effect of certain drugs such as beta-lactam antibiotics, beta-blockers, tricyclic antidepressants, and selective serotonin reuptake inhibitors. Therefore, health care provider must anticipate the possibility of secondary thrombocytopenia before treating such patients.
Clinically, the thrombocytopenic patients may present with prolonged and spontaneous mucocutaneous bleeding, petechiae (hallmark of platelet defects), easy bruising, purpura, ecchymoses, and subcutaneous hematomas. Most common sites of bleeding are gingiva, oral mucosa, vagina, and skin.
Low platelet count does not always warrant the immediate medical treatment as the patient is usually asymptomatic until platelet count falls below 20–30 × 109/L. Invasiveness of the planned periodontal procedure and the severity of the condition determine the course of management of such patients. In patients with severe bleeding disorders, management goal is to provide standard dental care along with maintenance of hemostasis by local and adjunctive hemostatic measures.
| Oral Findings|| |
Oral symptoms are usually one of the early findings of thrombocytopenia. The minor traumatic events occurring in oral cavity such as chewing and swallowing may cause spontaneous gingival bleeding. Petechiae, ecchymosis, and hematoma are usually spotted in oral mucosa most notably on buccal mucosa and soft palate. Multiple hemorrhagic bullae on sublingual mucous membrane, floor of the mouth, and lateral surface of the tongue have been reported by Byatnal et al. Chronic bleeding may cause brown deposits on teeth due to deposition of blood degradation products as hemosiderin. Thrombocytopenic patients lack effective oral hygiene due to the apprehension of gingival bleeding hence these patients have higher incidence of periodontitis and dental caries. Periodontal disease may lead to other complicated procedures as gingival surgeries and tooth extraction.
| Periodontal Management|| |
Gingival health is of critical importance in thrombocytopenia as the patient is more prone to gingival bleeding. The patient should be motivated for proper oral hygiene maintenance and advised to visits dentist regularly to avoid gingival bleeding and periodontal disease. The patient should be directed to brush teeth twice daily with a soft toothbrush. Dental flossing should be avoided when platelet count is low. Complete periodontal management of thrombocytopenic patient has been shown schematically in [Figure 1].
Before planning any treatment, investigations as complete blood count, bleeding time (BT), clotting time, and prothrombin time (PT) are mandatory to check the hemostatic derangement. In ITP, BT increases while international normalized ratio or PT and activated partial thromboplastin time remains normal.
Less invasive procedures as gingival probing, supragingival scaling, and polishing can be done normally without the likelihood of consequential gingival bleeding. Platelet transfusion is rarely needed if these procedures are done carefully. Scaling and root planing should be performed with fine curettes and scalers. Ultrasonic instrumentation causes less tissue trauma hence preferred in such patients. For severely inflamed tissues, it is recommended to do initial gross debridement along with chlorhexidine mouthwashes to reduce tissue inflammation before deep scaling.
In general, nerve blocks should be avoided because of higher chances of hematoma formation. Local infiltration and intraligamentary anesthesia are preferred in such patients [Table 1]. An anesthetic with a vasoconstrictor should be employed whenever possible. However, vasoconstrictors can increase risk of late bleeding as they can cause rebound vasodilatation.
Treatment depends on platelet count. Minor and major surgery can be carried out safely if platelet count is ≥50,000 cells/μL and ≥80,000 cells/μL, respectively [Table 2]. For invasive procedures such as periodontal surgery, platelet transfusion may be required depending on platelet count [Table 3]. Usually, the platelet transfusion is done 30 min before surgery. Alternatively, oral systemic steroids may increase the platelet levels to safe limits and can be prescribed 7–10 days before surgery.
|Table 3: American Academy of Pediatric Dentistry recommendation for minimum platelet values for performing invasive dental procedures in thrombocytopenic patients|
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Local hemostatic agents (Gelfoam ®, Bleed-X ® [microporous polysaccharide hemispheres], Surgicel ®, fibrin sealant, antifibrinolytic agents, epsilon-aminocaproic acid, Lyostpt ®, Ankaferd Blood Stopper), electrocautery, pressure packing (for at least 30 min) and suturing may be used to stop bleeding and achieve hemostasis. It must be taken care that gauze should be prewetted to prevent the clot from adhering to it. Periodontal packs and stents also provide hemostasis in addition to protect the surgical site, but care should be taken as they can be dislodged by subperiosteal hematoma or severe bleeding. It is recommended that they be worn for 4–7 days.
Antifibrinolytic agents as tranexamic acid may be added to periodontal dressings for intensified effects. Tranexamic acid can be used as mouthwash in 5% concentration. This is not readily available and can be prepared by dissolving 500 mg tablet in 10 ml water to make up a 5% solution. It can be prescribed preoperatively to increase immediate salivary levels and postoperatively for 7–10 days four times a day. For adults, the mouthwash should be swallowed or spitted out after gently swilling inside the mouth for 2–3 min. It has been reported to reduce postoperative bleeding effectively without any other hemostatic measure. It is found to be as effective as factor replacement therapy when used for control of gingival bleeding after oral prophylaxis. It can be given orally in a dose of 15–25 mg/kg (approximately 1 g for adults) 2 h preoperatively, and postoperatively every 6–8 h for 7–10 days.
Other systemically given hemostat agent is desmopressin (DDAVP) which promotes adhesion of platelet to the vessel walls, enhancing clot formation. DDAVP is given 1 h preoperatively intravenously (0.3 μg/kg using 4 μg/ml concentrations) or subcutaneously (0.3 μg/kg using the 15 μg/ml concentrations). Restricted fluid intake is recommended for approximately 24 h after administration of DDAVP.
Medications should be prescribed cautiously in thrombocytopenic patients. Medications that affect platelet function such as aspirin, nonsteroidal anti-inflammatory drugs, and warfarin should be avoided. Prefer use of acetaminophen-containing medications or selective COX-2 inhibitors for pain or fever. As first-line therapy for ITP is corticosteroid so caution must be taken to avoid adrenal insufficiency in patients undergoing dental surgery.
Postoperatively, dentist should allow patient to go home, only after monitoring the bleeding status of surgical site. Patients should be instructed to limit physical exertion, to sit or sleep in a semi-sitting position, and to avoid smoking and alcohol consumption.
| Conclusion|| |
Thrombocytopenia is not an absolute contraindication for dental procedures; however, the course of treatment should be commanded by the clinical manifestations and the platelet count. In thrombocytopenic patients, plaque control and motivation are of key importance in preventing gingival hemorrhage and periodontal diseases. Basic insight of the oral findings and close cooperation between patient, hematologist and dentist is essential in the management of thrombocytopenic patients. With guided treatment protocols, the dental management of ITP patients can be safe and effective.
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There are no conflicts of interest.
| References|| |
Nakhoul IN, Kozuch P, Varma M. Management of adult idiopathic thrombocytopenic purpura. Clin Adv Hematol Oncol 2006;4:136-44, 153.
Provan D, Stasi R, Newland AC, Blanchette VS, Bolton-Maggs P, Bussel JB, et al.
International consensus report on the investigation and management of primary immune thrombocytopenia. Blood 2010;115:168-86.
Aster RH. Pooling of platelets in the spleen: Role in the pathogenesis of “hypersplenic” thrombocytopenia. J Clin Invest 1966;45:645-57.
Konkle BA. Acquired disorders of platelet function. Hematology Am Soc Hematol Educ Program 2011;2011:391-6.
Stasi R. How to approach thrombocytopenia. Hematology Am Soc Hematol Educ Program 2012;2012:191-7.
Izak M, Bussel JB. Management of thrombocytopenia. F1000Prime Rep 2014;6:45.
Byatnal A, Mahajan N, Koppal S, Ravikiran A, Thriveni R, Devi PM. Unusual yet isolated oral manifestations of persistent thrombocytopenia-A rare case report. Braz J Oral Sci 2013;12:233-6.
Schlosser BJ, Pirigyi M, Mirowski GW. Oral manifestations of hematologic and nutritional diseases. Otolaryngol Clin North Am 2011;44:183-203, vii.
Patton LL. Bleeding and clotting disorders. In: Greenberg MG, editor. Burket's Oral Medicine: Diagnosis and Treatment. 10th
ed. Hamilton, ON: BC Decker; 2003. p. 454-77.
Webster WP, Roberts HR, Penick GD. Dental care of patients with hereditary disorders of blood coagulation. In: Rantoff OD, editor. Treatment of Hemorrhagic Disorders. New York: Harper and Row; 1968. p. 93-110.
British Committee for Standards in Haematology General Haematology Task Force. Guidelines for the investigation and management of idiopathic thrombocytopenic purpura in adults, children and in pregnancy. Br J Haematol 2003;120:574-96.
American Academy of Pediatric Dentistry. Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation. Pediatr Dent 2013;35:E185-93.
Kazancioglu HO, Cakir O, Ak G, Zülfikar B. The Effectiveness of a new hemostatic agent (Ankaferd Blood Stopper) for the control of bleeding following tooth extraction in hemophilia: A controlled clinical trial. Turk J Haematol 2013;30:19-24.
Adornato MC, Penna KJ. Hemostatic technique. Using a splint in oral bleeding. N Y State Dent J 2001;67:24-5.
Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management considerations for the patient with an acquired coagulopathy. Part 2: Coagulopathies from drugs. Br Dent J 2003;195:495-501.
Ambados F. Preparing tranexamic acid 4.8% mouthwash. Aust Prescr 2003;26:75.
Ramström G, Sindet-Pedersen S, Hall G, Blombäck M, Alander U. Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 1993;51:1211-6.
Lee AP, Boyle CA, Savidge GF, Fiske J. Effectiveness in controlling haemorrhage after dental scaling in people with haemophilia by using tranexamic acid mouthwash. Br Dent J 2005;198:33-8.
Anderson JA, Brewer A, Creagh D, Hook S, Mainwaring J, McKernan A, et al.
Guidance on the dental management of patients with haemophilia and congenital bleeding disorders. Br Dent J 2013;215:497-504.
Sakariassen KS, Cattaneo M, Vander Berg A, Ruggeri ZM, Mannucci PM, Sixma JJ. DDAVP enhances platelet adherence and platelet aggregate growth on human artery subendothelium. Blood 1984;64:229-36.
Mannucci PM. Desmopressin (DDAVP) in the treatment of bleeding disorders: The first 20 years. Blood 1997;90:2515-21.
Israels S, Schwetz N, Boyar R, McNicol A. Bleeding disorders: Characterization, dental considerations and management. J Can Dent Assoc 2006;72:827.
[Table 1], [Table 2], [Table 3]