Section I: Clinical Scenario and Dental Considerations

Clinical Scenario

A 18‐year‐old female patient is referred to your dental clinic from the haematology department regarding her bleeding gums. She is brought to the appointment by her parents and reports that she is feeling depressed about the fact she cannot smile as her teeth and gums are always covered in blood.

Medical History

  • Bernard–Soulier syndrome


  • Tranexamic acid 500 mg thrice daily during the first 3 days of her menstrual cycle
  • Folic acid supplement
  • Vitamin C supplement
  • Iron supplement

Dental History

  • Irregular dental attender due to difficulty with access
  • Last dental visit was 4 years ago
  • Only brushes her teeth once a day as her gums bleed for ~15 minutes after brushing, leaving a bad taste in her mouth

Social History

  • Single, lives with parents
  • Student in final year of high school
  • Poor dietary habits (snacks frequently on sweets and chocolates)
  • Nil alcohol or tobacco consumption reported

Oral Examination

  • Pale mucosa (Figure 11.4.1)
  • Generalised plaque, calculus, gingival inflammation and spontaneous bleeding
  • Generalised tooth surface loss
  • Fissured tongue

Radiological Examination

  • Orthopantomogram undertaken
  • All teeth are present
  • Supernumerary tooth in the upper left quadrant behind wisdom tooth (#29)

Structured Learning

  1. How may the patient’s Bernard–Soulier syndrome be affecting her oral health?
    • It is a rare congenital bleeding disorder (frequency is ~1 per million people)
    • The condition associated with the lack of platelet glycoprotein Ib and characterised by unusually large platelets, reduced platelet adhesion, and thrombocytopaenia
    • Impact on oral health includes:
      • Multiple episodes of spontaneous bleeding gums, exacerbated by toothbrushing, which make it challenging to maintain adequate oral hygiene practices
      • General tiredness resulting from iron deficiency anaemia can lead to general and oral neglect
  2. The patient informs you that she did not go back to her previous dentist due to a bad experience. After scaling was undertaken, the patient had to go to the hospital emergency department as her gums would not stop bleeding and she had to be admitted. What would you do to avoid this happening again?
    • Contact the haematology consultant in charge of the patient
    • Explain what dental treatment is planned and liaise with them to confirm whether it is advisable to proceed
    • Detail the patient’s previous experience when scaling was undertaken

      Figure 11.4.1 (a) Dentition: inflamed, hyperplastic, bleeding gingivae; tooth surface loss. (b) Maxillary arch: occlusal tooth surface loss. (c) Mandibular arch: occlusal tooth surface loss, bleeding gingivae. (d) Tongue: fissured and stained with blood.

    • Confirm what haematological support should be in place to enable treatment
    • Agree the most suitable location for dental care (primary or secondary care)
    • Ensure that there is a plan in place to access haematological support should bleeding still persist
  3. What other factors do you need to consider in your risk assessment?
    • Social
      • Reliance on parents to attend
      • Low self‐esteem due to spontaneous bleeding gingivae
    • Medical
      • Bleeding risk due to bleeding disorder
      • The need for a platelet transfusion and tranexamic acid before and after dental treatment
      • Fatigue from anaemia
    • Dental
      • Excessive gingival bleeding during and after periodontal treatment
      • Inability to maintain her oral health due to excessive bleeding from the gums on toothbrushing
      • Poor dietary habits
  4. When discussing the advanced tooth surface loss, you discover that the persistent bleeding from her gums causes her to feel nauseated when she swallows blood. This makes her vomit several times a day. How would you manage this?
    • Inform the haematologist and advise them that the patient may require more haematological support as her persistently bleeding gums are having an impact not only on her well‐being but also her oral and dental health
    • Dental support is also necessary – dietary analysis, casts to monitor the tooth surface loss, restorative option depends on changes in occlusal vertical dimension
  5. As per the haematologist’s advice, the patient is seen for full mouth debridement in your primary care practice, with perioperative tranexamic acid given orally for 5 days preoperatively and 3 days postoperatively. Following scaling, you note that there is bruising in the floor of the patient’s mouth. What could be the cause and what is the risk?
    • Due to the patient’s increased bleeding risk, trauma from light pressure, including suction, can result in considerable bruising and bleeding
    • The risk is that a sublingual haematoma has formed
    • This is commonly associated with a protruding tongue and respiratory distress
    • If these additional signs are present, this should be treated as an emergency and the emergency services called to secure the airway
  6. The patient returns to you 6 months later requesting braces to straighten her lower teeth. What would you consider?
    • Need to confirm that oral hygiene and general oral health have improved
    • Confirm that the patient is committed to regular dental attendance
    • An orthodontic opinion is required as the lower incisor crowding is severe
    • Space creation to align the anterior teeth may require extraction of posterior teeth and extended fixed orthodontic treatment
    • This is associated with risk, namely bleeding due to dental extractions and potential trauma from the orthodontic appliance
    • The orthodontist will need to liaise closely with the physician and adapt their approach to reduce trauma, namely:
      • Use elastomeric modules to secure arch wires rather than metal ligatures
      • Self‐ligating brackets are generally more comfortable and associated with less plaque accumulationClear aligner therapy (CAT)

General Dental Considerations

Oral Findings

  • Gingival bleeding
  • Blood‐filled bullae (Figure 11.4.2)
  • Palatal petechiae
  • Prolonged bleeding following surgery

Dental Management

  • Thrombocytopenia is not an absolute contraindication for dental procedures

    Figure 11.4.2 Spontaneous blood‐filled bullae (angina bullosa haemorrhagica) have been described in patients with thrombocytopaenia.

  • However, the delivery of dental treatment may need to be modified depending on the associated clinical manifestations, the platelet count and the invasiveness of the proposed dental intervention (Tables 11.4.1 and 11.4.2
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Nov 6, 2022 | Posted by in Implantology | Comments Off on Thrombocytopenia

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