Blood Disorders

People with neutropenia have low levels of white blood cells called neutrophils, which provide the first line of defense against bacterial infections. Neutropenia can be caused by medications that stop neutrophils from being produced or from maturing in the bone marrow. Various diseases such as HIV/AIDS also can cause neutropenia.

If you have neutropenia, you are more likely to get infections, including bacterial infections in your mouth. However, you may have no or few signs of infection because the neutrophils that cause redness and inflammation are not available to do so. This means the classic signs of infection are less obvious to your dentist. It also means that infections such as periodontal (gum) disease and oral ulcers can get worse rapidly.

People with severe neutropenia can have deep ulcers in their mouths. They may not be accompanied by inflammation, but often are painful.

Because people with neutropenia are more susceptible to bacterial infections, they sometimes are given antibiotics before major dental treatment. Whether your dentist decides to do this depends on the severity of the neutropenia. A normal neutrophil count is between 3,000 and 6,000 cells. Generally, if your neutrophil count is less than 1,000, you will need antibiotics before dental treatment. In certain cases, antibiotic therapy may be continued for several days after dental treatment. Since neutropenia can affect your blood counts frequently, give your dentist a copy of your blood test results.

People with polycythemia vera have abnormally high numbers of red blood cells. Because of this, they are more likely to form blood clots. They can have purplish or red discoloration of the tongue, cheeks, lips and gums.

Primary polycythemia vera is a disorder of red blood cells. Secondary polycythemia vera usually occurs in response to a lack of oxygen. Your body senses that your oxygen level is low and makes up for it by making more red blood cells, which carry oxygen. Heavy smokers, people with emphysema and people who move to a very high altitude may have secondary polycythemia.

People with primary polycythemia vera usually are treated by a dental specialist rather than a general dentist to minimize complications such as bleeding and the formation of blood clots. Your dentist probably will require a blood test to see if certain blood levels, such as hemoglobin and hemotocrit, are normal. If specific blood tests are not normal, your dentist will need to consult with your physician before you get dental treatment.

Anemia is a reduction of a blood element called hemoglobin, an oxygen-carrying molecule in the blood. Anemia can be caused by blood loss, fluid overload, increased destruction of red blood cells, decreased production of red blood cells, nutritional deficiencies or defects in the hemoglobin molecule itself. Other types of anemia include iron-deficiency anemia, aplastic anemia, sickle cell anemia, pernicious anemia and thalassemia.

People with anemia can have tissue in their mouths that appears abnormally pale. Their tongues can become smooth, and X-rays sometimes show bony changes in their jaws.

People with certain types of anemia, such as aplastic anemia, are more susceptible to infection, and the dentist should consider prescribing an antibiotic mouthwash rinse and/or oral antibiotics before dental procedures. Before major dental treatment, people with this condition should receive medications called antifibrinolytic drugs to reduce the risk of uncontrolled bleeding. During treatment, the dentist will avoid intramuscular injections and nerve-block anesthesia because they can lead to bleeding problems.

If you have sickle cell anemia, plan routine dental care during non-crisis periods and keep the appointments short. A blood test to check certain elements, such as hemoglobin and hemotocrit, should be obtained and evaluated by the treating medical doctor and dentist prior to dental treatment. In addition, people with sickle cell anemia often have heart murmurs and may need antibiotics prior to dental treatment.

Anyone with a chronic anemia, such as thelassemia, may heal very slowly after dental procedures. If you have a chronic anemia, talk to your dentist to see if any special procedures or precautions are necessary. Since this type of disease can affect your blood counts, give your dentist a copy of your blood test results.

People with hemophilia lack some important proteins (also known as factors) that help the blood to clot. Hemophiliacs experience more episodes of oral bleeding than healthy people. They can have more dental problems than healthy people because of poor oral hygiene and home care. Episodes of oral bleeding can discourage hemophiliacs from taking good care of their teeth.

Before dental treatment that might cause bleeding, hemophiliacs may need factor-replacement therapy to increase the amount of clotting factor in the blood. If you need factor replacement for dental procedures, you may need to have your treatment in a hospital. However, some people can administer the factors themselves. Talk to your medical doctor and dentist about your condition to decide should request that blood tests be done before treatment to help determine your risk of uncontrolled bleeding.

Your dentist should use caution when giving you a block injection — a type of local anesthetic injection in your lower jaw — or should avoid this type of injection altogether. Sometimes, a block injection can cause a hematoma, a swelling bruise under the skin. Generally, aspirin or nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen (Motrin, Advil and others), should not be taken by people with bleeding diseases because these drugs can make it harder for blood to clot.

If you need extensive dental surgery, you may need to be treated in an operating room while under general anesthesia.

In most cases, restorative and prosthodontic therapy, endodontic therapy and orthodontics are safe. Clotting drugs and other measures can be used to minimize bleeding. People with braces should avoid cuts from brackets, wires and bands. Some experts suggest that fixed orthodontic appliances are better than removable appliances. However, the goal is to decrease the chances that chronic tissue irritation can cause bleeding.

Oral surgery procedures pose the greatest risk of hemorrhage (severe bleeding), but the risk still is relatively low. Some experts note that delayed bleeding after tooth extraction occurs in only 8% of hemophiliac patients. Still, oral surgery should only be done if it is necessary. It is very important that you and your dentist take precautions. Here are some things to do:

Replace missing coagulation factors, up to 50% to 100% of normal.

Replace coagulation factors after surgery as necessary.

Use careful surgical techniques and hemostatic (clotting) agents and techniques (pressure packs, vasoconstrictors, topical drugs, surgical stents and absorbable materials).

Use antifibrinolytic drugs after surgery, such as Amicar (aminocaproic acid), which prevent the breakdown of blood clots.

Eat a diet of soft foods.

Platelets help the blood to clot. People without enough platelets have a higher risk of uncontrolled bleeding. Two of the most common platelet disorders are idiopathic thrombocytopenic purpura and thrombotic thrombocytopenic purpura.

People with platelet disorders can have more cavities, more teeth that need restoring and more severe gum disease — all because of poor oral hygiene. People may be afraid that their gums will bleed when they brush their teeth so they don't practice good oral hygiene. However, tooth cleaning, even in the dentist's office, does not have to cause significant bleeding.

A normal platelet count is between 150,000 and 400,000 cells. People with platelet levels below 20,000 run the risk of unprovoked bleeding and should have dental treatment in a hospital with a platelet transfusion. Since this type of disease can affect your blood counts, give your dentist a copy of your blood test results.

People with platelet levels between 20,000 and 60,000 should be treated by a dental specialist trained in oral medicine, hospital dentistry or oral surgery. These specialists will use surgical techniques and products (pressure packs, vasoconstrictors, topical drugs, surgical stents, sutures and absorbable materials) to reduce the risk of uncontrolled bleeding. A platelet infusion also may be necessary.

For people with platelet levels above 60,000, restorative and prosthodontic therapy (fillings, dentures, etc.), endodontic therapy (root canal treatment) and orthodontics generally are safe if cautionary procedures are followed. Generally, aspiring or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil and others) should not be taken by people with bleeding diseases because these drugs can make it harder for blood to clot. In addition, your dentist should use caution when giving you a block injection — a local anesthetic injection in your lower jaw — or should avoid this type of injection. It can result in a hematoma, a swelling bruise under the skin.

People with braces should avoid cuts from brackets, wires and bands. Some experts suggest that fixed orthodontic appliances are better than removeable appliances. However, the goal is to decrease the chance of chronic tissue irritation that can cause bleeding.