CASE REPORT

Case history
A 29-year-old female patient, resident of Nishat, Srinagar, reported to the Department of Periodontics and Oral Implantology, Government Dental College, Srinagar with the complaints of recurrent bleeding and swelling of gums. Medical history revealed that she was a known case of vWD. She had a history of cholecystectomy and right ovarian cystectomy 9 years back. The patient was previously on oral contraceptives as medication for menorrhagia. She underwent diagnostic hysteroscopy with endometrial ablation with roller ball to cure menorrhagia 5 years back, and since then, she has had no menstrual bleeding. The patient was hypertensive for the last 5 years and was on medication for that. The patient also complained of frequent urinary tract infections.
Family history revealed consanguineous marriage between her parents. Pedigree analysis of the family revealed that the patient's father, mother, maternal and paternal uncles, and one of her three brothers were also suffering from vWD.
Past dental history revealed extraction of six teeth in the past and there was history of blood transfusions before each extraction which were continued even after the extractions till the bleeding stopped, i.e. six times in a month.

General and extraoral examination
The patient had overall normal physical and mental development. Extraoral examination revealed the presence of pallor, anemia, and grade I clubbing of finger nails.

Intraoral examination
The soft tissue examination of the gingiva revealed spontaneous bleeding on slightest provocation. Red, soft, edematous gingiva was present with loss of stippling. There was generalized gingival enlargement. Rest of the oral mucosa including palate and tongue were normal on inspection and palpation. There was caries in relation to 24, 26, and 28. Grade III calculus and extrinsic stains were present because of absence of tooth brushing due to the fear of uncontrolled gingival bleeding during the same.

Radiographic examination
Orthopantomogram examination of the patient revealed no significant findings except the carious involvement of few teeth.

Laboratory investigations
The macroscopic urine examination was normal and microscopic examination revealed the presence of occasional pus cells and epithelial cells. No red blood cells, no casts, and no crystals were present. Table 1 shows the list of various laboratory investigations carried out to reach at the diagnosis of the disease.
Table 1  List of laboratory investigations carried out

Diagnosis
In view of the above findings, the patient was diagnosed to be suffering from either type 2A or 2B vWD. The cause of gingival bleeding could thus be attributed to vWD primarily, but gingival enlargement appears to be due to hormonal treatment (intake of oral contraceptives) for menorrhagia and local factors primarily.

Dental management
On her first dental visit, Plaque index (by Silness and Loe) and Gingival index (by Loe and Silness) were recorded. The scores were found to be on the higher side and were noted as the baseline periodontal parameters. On the same day, supragingival plaque removal was done with extreme caution taking care not to touch the gingiva. Betadine irrigation was done meticulously (supragingivally). The patient was prescribed chlorhexidine mouthwash twice a day. On her second visit, thorough consultation was taken from a physician. Various hematological and other laboratory investigations were carried out. Supragingival scaling was done and the patient was given oral hygiene instructions. On her subsequent visits, again oral prophylaxis was carried out and oral hygiene instructions were reinforced. Conservative treatment of various carious lesions was carried out.
As per physician's consultation, further gingivectomy was planned to treat gingival enlargement. The surgery was performed in the Department of Periodontics, Government Dental College, Srinagar. Since the patient was suffering from type 2 vWD, she was treated prior to the surgery with factor VIII replacement. Tranexamic acid was given before and for 7 days after surgery. The surgery was carried out under local anesthesia and the procedure was performed quadrant-wise. Gelfoam was used as local therapy to control bleeding during the procedure. Postoperative instructions were given and the patient was recalled after 24 h to examine for signs of bleeding. The patient was prescribed acetaminophen for pain control and antibiotics for infection control. The patient was kept on chemical plaque control and was instructed not to do toothbrushing in the surgical area for at least 4 weeks. Additional doses of factor VIII replacement were given postoperatively as needed. Regular follow-up appointments were fixed and the patient was kept under strict observation for signs of bleeding, infection, or delayed healing in future. Patient's general health and oral hygiene were apparently normal on subsequent follow-ups. At 1 month postoperatively, the plaque and gingival indices were recorded again and the results showed great improvements compared to the baseline scores.