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was generalized mild to moderate gingival Ocular Modifications required for blood clotting and are specifi-
inflammation. Probing depths and clinical HPS patients experience ocular complica- cally involved in the secondary aggregation
attachment level ranged from 2-5 mm with tions and sensitivity, such as nystagmus, response. HPS patients can present with
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generalized bleeding upon probing in all photophobia, and general reduction in vi- an absence of delta granules resulting in
four quadrants, as well as class I mobility sual acuity. Previous literature has recom- impaired blood clotting. This complication
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on teeth #8 and 9. In addition, teeth #11 and mended that HPS patients should be given can especially manifest several hours after
25 showed Miller class I recession on the UV-filtering eyewear to accommodate po- injury or surgical procedure, as the formed
facial surfaces. Detectable plaque was seen tential light sensitivity and similar ocular clot is unstable. The only way to confirm the
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particularly on the proximal and lingual complications that may occur under the status of delta granules is by examining pre-
aspects of molars and mandibular incisors. bright lighting of the dental clinic. In cases pared platelets under electron microscope.
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Calculus deposits were clinically detected that demonstrate a more severe presentation Patient platelet numbers are typically nor-
on multiple teeth and were confirmed by the of HPS, these modifications should be im- mal, but their function is impaired. While
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radiographic exam (Figure 5). The patient plemented. a bleeding time test could be beneficial, this
test is insensitive and lacks reproducibility,
Gastrointestinal Modifications therefore it is not recommended. Instead,
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It is common for patients with HPS to also providers can request the newer and more
experience inflammatory bowel disease accurate platelet function analyzer (PFA-
(IBD) or ulcerative colitis (UC). 11-13 Because 100) test to determine the patient’s clot-
IBD may precipitate ulcers and lesions in ting ability. Prothrombin time and partial
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the oral cavity, a thorough intraoral exam thromboplastin time tests would be normal
by the clinician is important to recognize and a complete blood count would not pro-
these lesions. 13, 14 Therefore, the provider vide any information on blood clotting sta-
must recognize that a patient with HPS pre- tus, as HPS affects the quality of platelets,
senting with these lesions in the oral cavi- not the quantity. Currently, there are no clin-
Figure 5. Bitewing radiographs.
ty may also have IBD and should warrant ical practice guidelines for management of
was diagnosed with class I malocclusion further investigation if a diagnosis of IBD bleeding in HPS. Based on the severity of
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and generalized mild periodontitis. Further, has not been made. The presence of IBD the symptoms, the patient should be evalu-
he displayed anterior wear loss without loss or UC can affect a patient’s oral health, as ated by a hematologist. In addition, aspirin
of vertical dimension of occlusion due to previous literature has shown a correlation should be avoided in these patients due to its
supraeruption of the mandibular anterior between the presence of UC, increased rates impact on blood clotting. 4
teeth, corresponding to Turner classification of periodontal diseases, and higher decayed,
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category 2. 9 missing, or filled teeth (DMFT) scores. When a patient presents with a bleeding dis-
Additionally, medication used to treat IBD order, the provider should obtain as much
Treatment Plan may play a role in further suppressing the information as possible prior to initiating
The treatment plan included oral hygiene in- patient’s already compromised immune sys- treatment. Invasive procedures must be ex-
structions, full mouth scaling and root plan- tem. Further, it is important not to prescribe ecuted cautiously, with careful soft tissue
ing and regular maintenance to address his clindamycin or aspirin in patients with GI manipulation. Other tools that may be help-
periodontal condition. The initial treatment conditions because of their significant gas- ful in treating patients with bleeding disor-
was done in two sessions and calculus was trointestinal side effects. None of the afore- ders include hemostatic agents like Surgicel
removed successfully, as confirmed by tac- mentioned intraoral lesions were detected in and Gelfoam, antifibrinolytic mouth rinses,
tile exploration. While bleeding did occur this patient. or stents with tranexamic acid. 4, 19 An ex-
due to the nature of the procedure, hemosta- tra-soft toothbrush is recommended to min-
sis was achieved shortly after treatment was Hemostatic Modifications imize gingival bleeding at home. Previous
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completed. Re-evaluation after six weeks HPS patients can present with thrombocy- literature has demonstrated successful im-
showed significant improvement in the peri- topathy. Delta granules (dense bodies) are plant treatment in patients with HPS, but it
odontal condition, with less bleeding upon
probing and reduced pocket depths. Figures Condition Dental Modification
1 to 5 demonstrate the patient’s condition
before the initiation of treatment. Ocular Considerations Protective eyewear
Bleeding and Hemostatic Clotting ability via PFA-100 test
DISCUSSION Considerations Presence of dense bodies via electron microscopy
HPS is a complex condition that involves Avoid prescribing aspirin
various organ systems and may require Close consultation with hematologist for implant surgery
close oral health monitoring and a wide or tissue augmentation
range of dental treatment modifications.
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The patient presented with mild HPS and Gastrointestinal Considerations Increased frequency of oral ulcers, periodontitis and
did not require modifications for his den- higher DMFT score
tal treatment. However, in order to prevent Avoid prescribing clindamycin
complications, very careful and meticulous Immune Considerations ANC <500 cells/µL indicates antibiotic coverage
scaling and root planing was performed with Increase risk of developing pre-malignant conditions
special attention to avoid soft tissue injury.
He was instructed to use a soft toothbrush Renal Considerations Avoid prescribing NSAIDs
to minimize any potential gingival irritation Pulmonary Considerations Avoid use of rubber dam if breathing is compromised
and bleeding. 10 Patient to be seated upright

Table 1. Conditions associated with HPS and related dental modifications
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