# The Presence of Periodontitis in Patients with Von Willebrand Disease: A Systematic Review
## 4 Discussion  
The correlation between periodontal health and bleeding disorders has been studied over the years. Studies have proven that hemophilic patients exhibit higher index values of gingival bleeding, plaque accumulation, and increased numbers of teeth affected by carious processes/extractions [20]. Nevertheless, no direct interrelationship has been detected between VWD and periodontal inflammation, as a reaction to the microorganism aggregation [17; 18; 19]. Another important aspect that should be considered is circulating blood cells profiles. [PERSON] and collaborators published a meta-analysis in which they analyzed the hemogram, leukogram, and thrombogram between periodontitis and control patients [21]. They concluded that periodontitis is associated with hematologic changes (high white blood cells, neutrophils, erythrocyte, and low mean platelet volume). Blood cell profiles may be a useful tool for the hematologist to decide in which dental settings a patient should be treated.  
Periodantal treatments in patients with VWD must be performed under specific precautions. The evolution point of the periodontal pathology must be taken into consideration, as well the probing measurements and the oral health status of the patients. Topical substances, such as tranexamic acid, used in the management of bleeding while performing simple supragingival scaling procedures, are indicated in subjects with simple forms of VWD [22]. More evolved expressions of the disease require collaboration with the hematology department in order to initiate a substitute therapy [22]. Maneuvers that imply periodontal nonsurgical or surgical approaches require a minimum 50-75% value of factor VIII before the procedure [22]. Periodantal measures are crucial for maintaining the oral health of patients with VWD and must be initiated as soon as the periodontal status requires. Scaling procedures must be performed at different meetings, in order to prevent important hemorrhages. Inflammation and infection control must be applied, with the help of antibiotics and chlorexcidine gluconate, depending on the type of periodontal pathology [22; 23]. Oral hygiene education and prophylactic measures are as important as therapeutic procedures for patients with VWD, as they all concur in fighting the most important complication, i.e., excessive bleeding [24].  
The professional relationship and collaboration between a dental practitioner and hematologist are very important, given the great risk during dental maneuvers [24; 25]. Treatment protocol must be carefully guided by the hematologist, in order to perform safe therapeutic procedures [24; 25]. Lack of communication in this process can lead to different complications related to delayed and excessive bleeding [24]. Speaking, swallowing, and breathing impediments have also been reported as undesired episodes among hemophilic patients, undergoing dental procedures [25].  
According to our results, the possible susceptibility of patients with VWD to the onset and exacerbation of periodontitis is not relevant as compared with non-VWD periodontal patients. In the literature, there are few works about periodontitis and VWD and this is a limitation of our study; moreover, the test population was only represented by VWD type 1 patients; however, [PERSON] and collaborators included patients with VWD type 2 and 3 [19]. As reported from the literature, the differences are underlined by the concentration of VWF antigen. Nevertheless, VWD patients affected by gingivitis/periodontitis should be treated as periodontitis compromised; the surgical and nonsurgical periodontal therapy must be applied under control in order to reduce bleeding and hemorrhages.