Influence of Systemic Conditions on the

Periodontium
 Hematologic Disorders and Immune
Deficiencies
 All blood cells play an essential role in the maintenance
of a healthy periodontium.

 White blood cells (WBCs) are involved in inflammatory

reactions and are responsible for cellular defense against
microorganisms as well as for proinflammatory cytokine
release.
 Red blood cells (RBCs) are responsible for gas
exchange and nutrient supply to the periodontal
tissues and platelets and are necessary for normal
hemostasis, as well as recruitment of cells during
inflammation and wound healing.

 Consequently, disorders of any blood cells or blood-

forming organs can have a profound effect on the
periodontium.
 Certain oral changes, such as hemorrhage, may
suggest the existence of a blood dyscrasia.

 However, a specific diagnosis requires a complete

physical examination and a thorough hematologic
study.

 Comparable oral changes occur in more than one form

of blood dyscrasia, and secondary inflammatory
changes produce a wide range of variation in the oral
signs.
 Abnormal bleeding from the gingiva or other areas of
the oral mucosa that is difficult to control is an
important clinical sign suggesting a hematologic
disorder.
 Petechiae and ecchymosis observed most often in the
soft palate area are signs of an underlying bleeding
disorder.
 It is essential to diagnose the specific etiology to
appropriately address any bleeding or immunological
disorder.
 Deficiencies in the host immune response may lead to
severely destructive periodontal lesions.

 These deficiencies may be primary (inherited) or

secondary (acquired), caused by immunosuppressive
drug therapy, or pathologic destruction of the lymphoid
system.
 Leukemia, lymphomas, and multiple myeloma may
result in secondary immunodeficiency disorders.
 Leukocyte (Neutrophil) Disorders
 Disorders that affect production or function of
leukocytes may result in severe periodontal
destruction.
 The PMN (neutrophil) in particular plays a critical
 role in bacterial infections because PMNs are the first
line of defense .
 Quantitative deficiency of leukocytes (neutropenia,
agranulocytosis) are typically associated with a more
generalized periodontal destruction affecting all teeth.
 Neutropenia

 Neutropenia is a blood disorder that results in low

levels of circulating neutrophils.
 it is a serious condition that may be caused by
diseases, medications, chemicals, infections,
idiopathic conditions, or hereditary disorders.
 It may be chronic or cyclic, severe, or benign.
 It affects as many as one in three patients receiving
chemotherapy for cancer
 An absolute neutrophil count (ANC) of 1000 to 1500
cells/μl is diagnostic for mild neutropenia.
 An ANC of 500 to 1000 cells per microliter is
considered moderate neutropenia and an ANC less
than 500 cells/μl is a severe neutropenia.
 Infections are sometimes difficult to manage and may
be life threatening, particularly in severe neutropenia
 Agranulocytosis
 Agranulocytosis is a more severe neutropenia

 It is defined as an ANC of less than 100 cells/μl.

 It is characterized by a reduction in the number of
circulating granulocytes and results in severe
infections, including ulcerative necrotizing lesions of
the oral mucosa, skin, and gastrointestinal and
genitourinary tracts.
 Agranulocytosis has been reported after the
administration of drugs such as aminopyrine,
barbiturates and their derivatives, benzene ring
derivatives, sulfonamides, gold salts, or arsenical agents

 It generally occurs as an acute disease, It may be chronic

or periodic with recurring neutropenic cycles (e.g., cyclic
neutropenia)
 The onset of disease is accompanied by fever, malaise,
general weakness, and sore throat.
 Ulceration in the oral cavity, oropharynx, and throat is
characteristic.
 The mucosa exhibits isolated necrotic patches that are
black and gray and are sharply demarcated from the
adjacent uninvolved areas.
 The absence of a notable inflammatory reaction
caused by lack of granulocytes is a striking feature
 Gingival hemorrhage, necrosis, increased salivation,
and fetid odor are accompanying clinical features.
 Leukemia
 Leukemia is an important disease to understand and
appreciate because of the seriousness of the disease
and the periodontal manifestations.
 The leukemias are malignant neoplasias of WBC
precursors characterized by:
 (1) diffuse replacement of the bone marrow with
proliferating leukemic cells
 (2) abnormal numbers and forms of immature WBCs
in the circulating blood.
 (3) widespread infiltrates in the liver, spleen, lymph
nodes, and other body sites.
 According to the cell type involved, leukemias are
classified as lymphocytic or myelogenous.

 A subgroup of the myelogenous leukemias is

monocytic leukemia.

 The term lymphocytic indicates that the malignant

change occurs in cells that normally form lymphocytes.

 The term myelogenous indicates that the malignant

change occurs in cells that normally form RBCs, some
types of WBCs and platelets.
 According to their evolution, leukemias can be acute, which
is rapidly fatal, subacute, or chronic.

 In acute leukemia, the primitive “blast” cells released into

the peripheral circulation are immature and nonfunctional,
whereas in chronic leukemia the abnormal cells tend to be
more mature with normal morphologic characteristics and
function when released into the circulation.
 All leukemias tend to displace normal components of
the bone marrow elements with leukemic cells,
resulting in reduced production of normal RBCs,
WBCs, and platelets, which leads to anemia,
leukopenia (reduction in number of nonmalignant
WBCs) and thrombocytopenia.
 Anemia results in poor tissue oxygenation, making
tissues more friable and susceptible to breakdown.
 A reduction of normal WBCs in the circulation leads to
a poor cellular defense and an increased susceptibility
to infections.
 Thrombocytopenia leads to bleeding tendency, which
can occur in any tissue but in particular affects the oral
cavity, especially the gingival sulcus
 The Periodontium in Leukemic Patients
 Oral and periodontal manifestations of leukemia may
include leukemic infiltration, bleeding, oral
ulcerations, and infections.
 The expression of these signs is more common in
acute and subacute forms of leukemia than in chronic
forms
 Leukemic Infiltration
 Leukemic cells can infiltrate the gingiva and less
frequently the alveolar bone.
 Gingival infiltration often results in leukemic gingival
enlargement
 A study of 1076 adult patients with leukemia showed
that 3.6% of the patients with teeth had leukemic
gingival proliferative lesions, with the highest
incidence in patients with acute monocytic leukemia
(66.7%), followed by acute myelocytic-monocytic
leukemia (18.7%), and acute myelocytic leukemia
(3.7%).
 Leukemic gingival enlargement is not found in
edentulous patients or in patients with chronic
leukemia.

 Clinically, the gingiva appears bluish red and cyanotic,

with a rounding and tenseness of the gingival margin.
 Bleeding
 Gingival hemorrhage is a common finding in leukemic
patients , even in the absence of clinically detectable
gingivitis.

 Bleeding gingiva can be an early sign of leukemia.

 It is caused by the thrombocytopenia resulting from

replacement of the bone marrow cells by leukemic
cells and from the inhibition of normal stem cell
function by leukemic cells.
 This bleeding tendency can also manifest in the skin
and throughout the oral mucosa.

 petechiae and ecchymosis are often found.

 Oral bleeding has been reported as a presenting sign

in 17.7% of patients with acute leukemia and in 4.4%
of patients with chronic leukemia.

 Bleeding may also be a side effect of the

chemotherapeutic agents used to treat leukemia.
 Oral Ulceration and Infection

 In leukemia, the response to bacterial plaque or other

local irritation is altered

 The cellular component of the inflammatory exudate

differs both quantitatively and qualitatively from that
in nonleukemic individuals in that there is a
pronounced infiltration of immature leukemic cells in
addition to the usual inflammatory cells.

 As a result, the normal inflammatory response may be

diminished
 Granulocytopenia (diminished WBC count) results
from the displacement of normal bone marrow cells by
leukemic cells, which increases the host susceptibility
to opportunistic microorganisms and leads to
ulcerations and infections

 Discrete, punched-out ulcers penetrating deeply into

the submucosa and covered by a firmly attached white
slough can be found on the oral mucosa.
 Acute gingivitis and lesions resembling necrotizing
ulcerative gingivitis are more frequent and severe in
terminal cases of acute leukemia

 The inflamed gingiva in patients with leukemia differs

clinically from that in nonleukemic individuals.

 Gingiva is a peculiar bluish red, is spongelike and

friable, and bleeds persistently on the slightest
provocation or even spontaneously in leukemic
patients.
Good luck