Case reports

 

Stomatological treatment of patients afflicted with idopathic thrombocytopenic purpura. Case report

 

Ma. del Refugio Islas Granados,* Eduardo de la Teja Ángeles,^§ Alejandro Hinojosa Aguirre^II

 

* Pedodontist at the Naval Medical Center. Mexico City (Centro Médico Naval, D.F.).

^§ Head of the Pediatric Stomatology Department, Stomatologist, (dentist) Pediatrician INP (National Pediatrics Institute).

^II Professor of Pediatric Dentistry, Research and Graduate School, National School of Dentistry, (Facultad de Odontología), National University of Mexico (UNAM). 

Correspondence

 

ABSTRACT

Idiopathic thrombocytopenic purpura (ITP) is the most common acquired hemorrhagic alteration occurring in apparently healthy children who have suffered viral diseases, after application of common vaccines, having been medicated with drugs or received transfusions. ITP undergoes a sudden onset, with a rapid, life threatening development of bleeding (hemorrhage). 90% of cases experience spontaneous remission, or remission after a 3 to 4 week treatment. General clinical manifestations are: petechiae, ecchymosis, hematoma, epistaxis, mucocutaneous hemorrhage, hematuria. Objective: To describe oral manifestations and stomatological management of ITP patients. The present study reports the case of a 4 year old female ITP patient presenting a purpuric condition with more than 100,000 platelets. The case subsides spontaneously without treatment. The patient presents diagnosis of early infancy childhood caries. The case is treated in the conventional manner, with absence of clinical signs and symptoms. Hemostatic measures were taken such as placement of Gelfoam^® (oxidized gelatin sponge) and sutures in the extraction sites. The patient evolved favorably.

Key words: Idiopathic thrombocytopenic purpura (ITP), gingivorragia (bleeding gums), petechiae, ecchymosis.

 

INTRODUCTION

Idiopathic thrombocytopenic purpura is the most common acquired hemorrhagic alteration. Its onset is usual in apparently healthy children after a common viral condition (illness), or after the administration of vaccines, drugs or transfusions.^1-5 It has a sudden onset, and develops a severe life-threatening hemorrhagic clinical condition. 90% of cases experience remission, or remit within a 3 to 4 week treatment.^5-7

Etiology: This condition is the product of a cross reaction incited by viruses, drugs or vaccines.⁷ The condition develops during the one to four week period following exposition to the triggering agent (generally a viral infection). In this period, an antibody aimed at the platelet surface develops. After this bonding, macrophages recognize it as foreign and proceed to its destruction.

Clinical phase: This condition presents a sudden onset in previously healthy children, and develops in a few hours to clinical condition of acute haemorrhage.^5,7,9 Patients with haemorrhage are in a life-threatening position, and require immediate hospitalization. Diagnosis is based upon the presence of three central manifestations:

a) Haemorrhagic phenomena in the skin

b) Spontaneous haemorrhagic mucosa

c) Visceral haemorrhage. 

The main manifestation of spontaneous haemorrhage in the mucosa is the presence of epistaxis and gingivorragia (haemorrhage of the gums).^5,7-11 When there is ecchymosis in the oral mucosa, it is known as damp purpura.

Clinical manifestations: Clinical manifestations of this condition comprise ecchymosis, epistaxis, hematuria, mucocutaneous haemorrhage and occasionally tissue haemorrhage.¹

Stomatognathic manifestations: Hemorrhage in the gums, petechiae or hematoma in mucosa, tongue and palate.^1-5

Laboratory data: Decreased number of platelets. Platelets of normal or slightly augmented size. Prolonged bleeding time, Normal prothrombin and partial thromboplastin times (Table I).^12,13

Treatment: Treatment must be undertaken when platelet count is below 20,000/mm³, or when there are data of diffuse haemorrhage. All other cases must be individually assessed:^12,13 

1) Platelet transfusion due to therapeutic or prophylactic indications.

2) Pharmacological. Steroids are the first line of treatment. Immunoglobulins are advised in life-threatening haemorrhages. Treatment: refractory ITP before surgery and platelet post transfusion to prolong their life. Immunosupressants.¹⁴

3) Splenectomy.¹⁵ 

 

STOMATOLOGICAL MANAGEMENT  

• In acute conditions, treatment must be postponed until the patient is stable. If pain or infection are present, antibiotic and anti inflammatory analgesics must be dispensed.

• Patients requiring urgent treatment must be referred to a hematologist to assess the convenience of a platelet concentrate transfusion^16,17 to elevate amounts to over 50,000 platelet/mm³. The ideal figure to reach is 100,000 platelet/mm³.

• Elective surgery must be postponed until the patient becomes stable. Platelet minimum count to safely perform a surgical procedure is 100,000 per mm³.

• Behavior management with basic techniques for cooperating patients. If the patient does not cooperate and requires extensive dental treatment, assessment must be made of the advisability for oral rehabilitation under general anesthesia in order to avoid accidental traumas and repetitive transfusions due to the risk of developing antibodies.

 

GENERAL PROCEDURES TO BE OBSERVED WITH ITP PATIENTS 

• Short appointments to avoid young children to tire or become anxious.

• Anesthesia with one step vasoconstrictor to avoid damaging small vessels and thus avoid bleeding.

• Use of atraumatic clamps to avoid damaging the gums and thus avoid gingival bleeding.

• In extraction cases, it is necessary to exert sustained pressure, sutures must be applied and a haemostatic agent such as Gelfoam^® must be applied.

• In cases where a prosthesis is needed, it must be perfectly polished to avoid trauma caused by sharp or irregular sites.

• In cases where the patient was prescribed corticosteroids, in dosages which exceed the daily production of cortisol, dosage must be doubled before treatment.

• It is necessary to avoid trauma which might induce bleeding, such as aggressive tooth brushing, misuse of dental floss, toothpicks as well as hard foods, etc.

• It is advised to avoid anti aggregating drugs like those derived from acetylsalicylic acid as well as intra muscular drugs which might induce bleeding. 

These patients do not receive transfusions, for it is considered they could exacerbate general health deterioration. This does not apply to very special, life-threatening cases (Table II).^12,17 

 

CLINICAL CASE

Four year old female patient residing in Mexico City attends the Instituto Nacional de Pediatría (National Pediatrics Institute) on June 2, 2006, due to epistaxis and petechiae. A diagnosis of Idiopathic Thrombocytopenic Purpura was emitted. A relevant aspect of the patient's history was the fact that she presented a purpura clinical picture at 14 months of age, for which she was hospitalized.

The patient was assessed at the Hematology Service, where five hematic cytometry tests were performed at ten days intervals. One of these tests revealed a platelet count of 133,000 mm³. All the others reported normal parameters. Bleeding time was normal, but at the upper range limit. Prothrombin and Thromboplastin times were normal. Tourniquet test was positive, and serological tests for Epstein Barr virus, Cytomegalovirus, and Parvovirus B19 were negative. The patient experienced spontaneous remission of signs and symptoms. A platelet recovery to normal values was observed. The patient was under constant monitoring and her caregivers were advised to immediately bring her to the Emergency room if she ever presented signs or symptoms of bleeding.

The patient was referred to the Stomatology Service due to the fact that she presented pain and swelling in tooth number 74. Upon clinical examination, the patient did not show or inform of bleeding, petechiae or ecchymoses. Intraorally, the patient presented full primary dentition with numerous caries of varied severity (Figures 1 to 3). Tooth number 74 showed extensive caries with apparent communication to the pulp. There was an increased volume in the marginal gingival tissue, and insertion, approximately 1 cm in diameter. Upon palpation there was egress of painful and purulent matter. There was a 3 mm mobility in vestibular-lingual direction. Tooth number 8 presented extensive caries, and was painful to horizontal and vertical percussion. Teeth numbers 55, 54, 64, 65, 75 and 85, presented extensive caries as well as fistulae. Teeth number 52 and 62 presented caries on the palatine and vestibular faces. Tooth number 51 presented caries at the palatine face. Teeth 31 and 41 were erupting, with persistence of primary teeth 71, 81. The rest of the teeth showed no alterations. Hematic cytometry revealed a 183,000 mm3 platelet count.

Stomatological treatment consisted of 10 extractions, 2 steel-chrome crowns and 1 resin (Table III).

CPO index when treatment started (Figures 1, 2 and 3): 11 caries, 0 lost, 0 filled .

CPO index upon completion of treatment (Figures 4, 5 and 6): 0 caries, 8 lost, 3 filled.

At all appointments, lidocaine with 2% epinephrine was administered in one episode. Extractions were performed aiming at avoidance of trauma as much as possible with application of Gelfoam^® at extraction sites, as well as isolated sutures. Therapeutic clindamycin was administered at a ratio of 30mg per kilogram, per day, during 7 days. The patient reacted favorably and showed no complications. 

 

DISCUSSION

Sánchez¹² and Farfán¹³ mention that a clinical picture of purpura manifests itself with a platelet count of 50,000/mm3 or less. The patient presented epistaxis and petechiae with platelet count of 133,000/mm³. In this case the condition remitted spontaneously, without any treatment. Attention protocols^2,5 indicate that the minimum platelet count for dental treatment must be 50,000/mm³ and 100,000/mm³ for minor surgical procedures (extractions). The patient presented a platelet count of 183,000/mm³. For this reason she was treated as a healthy patient. Nevertheless some additional precautions were taken^1-5 such as anesthesia in one episode, placement of Gelfoam^® at the extraction site, application of suture points, as well as maintained pressure. These patients present predisposition to suffer haemorrhage^18-19 when submitted to dental extractions or prophylaxis. Piot¹⁶ recommends the use of fibrin gum, desmopressin and antifibrinolytic agents such as tramexamic acid, Chamate²⁰ and Finucane.¹⁷ Where there is presence of trauma in the oral cavity and the patient in need of dental treatment shows a platelet count lesser than 30,000/mm³, it is advised after consultation with the hematologist, to administer immunoglobulins to increase platelet count. Some patients are refractory to treatment. They receive immunosuppressive drugs.²¹ Splenectomy is considered a last resort, in these patients it is necessary to employ antibiotic prophylaxis.^21-23 

 

CONCLUSIONS

A systematic and orderly assessment of the oral cavity prevents inadvertently missing signs and symptoms such as gum bleeding, petechiae, ecchymoses or hematomas in a patient who is developing a hemorrhagic clinical picture. In these cases it is best to adjourn dental treatment: the dental operator must request laboratory studies such as hematic cytometry with platelet count, as well as coagulation time. The patient must be referred to a specialist to avoid complications such as post extraction haemorrhage.

Preventive treatment is of the utmost importance to avoid dental complications which might aggravate the patient 's general health. Recurrent revisions every three months help avoid complications and also monitor oral manifestations which might be indicative of a reactivation or increase in the condition's severity, which, in turn, might require support care.

 

 REFERENCES

1. Martini MZ et al. Idiopathic Thrombocytopenic purpura presenting as post-extraction hemorrhage. J Contemp Dent Pract 2007; 8 (6): 43-49.         [ Links ]

2. Vaisman B et al. Dental treatment for children with chronic idiopathic thrombocytopaenic purpura: a report of two cases. Int J Paediatr Dent 2004; 14 (5): 355-62.         [ Links ]

3. Hegde RJ et al. Acute idiopathic thrombocytopenic purpura in childhood: a case report. J Indian Soc Pedod Prev Dent 2003; 21 (1): 42-4.         [ Links ]

4. Hunter ML et al. Acute idiopathic thrombocitopaenic purpura in childhood: report of a case presenting in general dental practice. Br Dent J 1997; 183 (1): 27-9.         [ Links ]

5. Castellanos SJL, Díaz GL, Gay ZO. Medicina en odontología. Manejo dental de pacientes con enfermedades sistémicas . 2^a ed. México: El Manual Moderno; 2002.         [ Links ]

6. Huijgens PC. (Hematology and dentistry. Part II. Abnormalities of the vessel wall and blood platelets). Ned Tijdschr Tandheelkd 1996; 103 (2): 42-4.         [ Links ]

7. Colman WR, Rao KA. Hematology/oncology Clinics of North America (Platelets in health and disease) . 1990; 4 (1): 1, 10.         [ Links ]

8. Gernsheimer T. Chronic idiopathic thrombocytopenic purpura: mechanisms of pathogenesis. Oncologist 2009; 14 (1): 12-21.         [ Links ]

9. Little JW y cols. Tratamiento odontológico del paciente bajo tratamiento médico . 5^ta ed. Madrid: Harcourt-Brace; 1998.         [ Links ]

10. Chiarini L, Bertoldi C, Narni F. Management of patients with coagulation disorder in oral and maxillofacial surgery. Management of patients with hypocoagulation caused by primary thrombocytopathy. Minerva Stomatol 1997; 46 (1-2): 61-71.         [ Links ]

11. Henderson JM et al. Management of the oral and maxillofacial surgery patient with thrombocytopenia. J Oral Maxillfac Surg 2001; 59 (4): 421-7.         [ Links ]

12. Sánchez MI y cols. Leucopenia, trombopenia, pancitopenia. Manual de protocolos y actuación en urgencias . Complejo Hospitalario de Toledo. Disponible en: http://www.cht.es/cht/cm/cht/images?locale=es_ES&textOnly=false&idMmedia=8282        [ Links ]

13. Farfán CJM y cols. Hematología. Manual de procedimientos medicoquirúrgicos . Hospital de Pediatría, Centro Médico Nacional Siglo XXI. México: Méndez Editores 1993.         [ Links ]

14. Varghese L et al. Dapsone, danazol, and intrapartum splenectomy in refractory ITP complicating pregnancy. Indian J Med Sci 2008; 62: 452-5.         [ Links ]

15. Burzynski J. New options after first-line therapy for chronic immune thrombocytopenic purpura. Am J Health Syst Pharm 2009; 15 (66): S11-21.         [ Links ]

16. Piot B et al. Management of dental extractions in patients with bleeding disorders. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002; 93 (3): 247-50.         [ Links ]

17. Finucane D et al. Dentoalveolar trauma in a patient with chronic idiopathic thrombocytopenic purpura: a case report. Pediatr Dent 2004; 26 (4): 352-4.         [ Links ]

18. Martínez-Murillo C, Quintana GS. Bases fisiopatológicas y clínicas de las enfermedades hemorrágicas y trombóticas. Manual de hemostasia y trombosis . Prado. México 2001.         [ Links ]

19. Ivanyi L. Inmunological aspects of oral diseases, Boston: MPT 1986.         [ Links ]

20. Chamate et al. Treatment of idiopathic thrombocytopenic purpura. Med Priv 1988; 4 (3): 59-60.         [ Links ]

21. Madero L y cols. Púrpura trombocitopénica idiopática: controversias. BSCP Can Ped 2001; 25 (2): 291-302.         [ Links ]

22. Sánchez-Pérez et al. Splenectomy incidence in specialized care hospital. Rev Med Seguro Soc 2008; 46 (4): 435-8.         [ Links ]

23. Valladares GR, Peña HA. Uso de la esplenectomía como tratamiento de la púrpura trombocitopénica idiopática crónica en los pacientes de la sala de Hemato-oncología Pediátrica del Hospital Materno Infantil desde 1995 hasta junio 2006. Revista Médica de los Postgrados de Medicina UNAH 2007;10 (3): 226-231.         [ Links ]

 

Correspondence address:
Dra. Ma. del Refugio Islas Granados
Guerrero 90-4 Col. Tizapán San Ángel 01090,
Del. Álvaro Obregón México D.F.
Tel: 55 50 89 40
Cel: 044 55 31 71 93 63
E-mail: mariadel33a@hotmail.com 

Note

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