Post on 15-Apr-2017
ANEMIA
Definition reduction in the level of haemoglobin
levels, which is usually accompanied by a decrease in the number of erythrocytes ( RBC’s), resulting in lowering the O2 capacity of the blood.
Normal Hb concentrations in blood for adults:
Males : 13.5 g/dl Females : 11.5 g /dl
The mean corpuscular volume, or "mean cell volume" (MCV), is a measure of the average red blood cell volume that is reported as part of a standard complete blood count
The hematocrit (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume fraction (EVF) is the percentage of blood volume that is occupied by red blood cells
Causes: 1) chronic blood loss and consequent iron
deficiency, usually in women from heavy menstruation
2) folate and vitamin B12 deficiency ( the 2nd common cause ).
Classification according to RBC size:
In patients with anemia, it is the MCV measurement that allows classification as either a
microcytic anemia (MCV below normal range),normocytic anemia (MCV within normal range) macrocytic anemia (MCV above normal range).
The normal MCV is 78-99 fL, with smaller cells (<78 fL) described as microcytic and larger cells (>99 fL) as macrocytic.
Microcytic anemia : most common usually due to iron deficiency , occasionally to thalassaemia or chronic disease.
Macrocytic anemia: usually caused by vitamin B12 or folate deficiency ( sometimes that is caused by pregnancy, chronic haemolysis, malignancy or some drugs, liver disease , myxoedema or aplastic anemia
Normocytic anemia : chronic disease like leukaemia , chronic inflammatory disease , renal failure , infection, malignancy and sickle cell anemia
Clinical features: early: asymptomatic.
pallor of the oral mucosa and conjunctiva,
tiredness, dyspnoea, tachycardia, murmurs and palpitation.
General management 1) Clinical and laboratory investigation.( MCV, Hb, blood film )
2) Hematinics. ( iron or folic acid)
3) Erythropoietin. (used for anemia in chronic renal failure or cytotoxic therapy)
4) Blood transfusion. ( used only when absolutely nesseccary Hb under 7.0 g/dl)
Dental aspects - some anemias cause oral lesions such as ulcers,
glossitis or angular stomatitis.
-L.A - conscious sedation: only if there is supplemental O2
- Nitrous oxide : contraindicated in B12 def.
- G.A : it is vital to ensure full oxygenation.
- elective operation: Hg more than 10 g/dl. - Preoperatively : raise the hemoglobin level if
necessary by transfusion.
In details
1) Iron deficiency anemia. 2) Vit B12 deficiency. 3) folate deficiency.
Iron deficiency anemia General aspect: Most common cause of anemia in the west, as a result of
nutritional deficiency or chronic blood loss.
Developing countries: malaria and chronic blood loss. Main cause of microcytic anemia.
Clinical features: 1) impaired excersie capacity. 2) koilonychia: "spoon nails." It refers to abnormally
thin nails (usually of the hand) which have lost their convexity, becoming flat or even concave in shape.
General management
Iron salt supplement such as ferrous sulphate, or ferrous gluconate .
Oral iron may need to be given for 3 months or more after the hemoglobin has reached normal levels, to replenish marrow iron stores.
Parenteral iron : intramuscular.
Dental aspects: L.A satisfactory for pain management
Conscious sedation: if full oxygenation is possible.
At early stages: sore tongue can develop if hemoglobin falls beneath the normal value.
Severe anemia: atrophic glossitis, soreness of the tongue with depapillation or colour change.
Dental aspectscont.
Candidosis can be aggravated or precipitated by anemia
Treatment with iron appears to improve the response to antifungal treatment.
Angular stomatitis(affects only minority).
Aphthous stomatitis is sometimes associated with iron deficiency anemia.
Vitamin B12 deficiency General aspects: B12 needed for A.A, DNA/RNA, new cells.
Found in the diet in the meat.
Deficiency of vit B12 is usually due to defect in intrinsic
factor( as a result of pernicious anemia or gastrectomy)
Nitrous oxide is contraindicated if given more than 12 hours, interfere with metabolism of Vit B12.
General aspectscont.
Pernicous anemia: autoantibodies against gastric parietal cells, or to the intrinsic factor.
Clinical features: Deficiency develops slowly(liver stores last up to 3
years) Neurological symptoms: paraesthesiae in the
extremities. Treatment : I.M hydroxycobalamin
Dental aspects: L.A is satisfactory Conscious sedation can be given if the Hb level is
moderately depressed and supplemental oxygen can be given.
Nitrous oxide is theoretically contraindicated.
G.A : if Hb is not low.
Early B12 def: normal or sore or burning tongue. Red sore patches may form on the tongue,(pattern or
red patches without depapillation).
Dental aspectscont.
Candidosis can be aggravated or precipitated by anemia and may be the presenting feature.
Angular stomatitis (uncommon)
Aphthous stomatitis is occasionally the presenting feature.
Folate deficiency Folic acid is needed A.A/ ,DNA/RNA ,new cells
Folic acid is found in fresh leafy and other vegetables.
No body stores of folic acid.
Most folic acid def. is caused by dietary def.
Clinical features: Folate def. in adluts leads to anemia.
In pregnancy folate def. leads to neural tube defects or cleft lip-palate in the fetus.
Effects of folate def. is very similiar to B12 def.
Red cell folate are more reliable than serum folate.
Treatment: folic acid
Dental aspects: L.A, conscious sedation, GA: the same as pernicous
anemia.
No contraindication of nitrous oxide.
Atrophic glossitis is the best known effect of severe anemia.
Angular stomatitis (affects only a minority).
HAEMOLYTIC ANAEMIAS
Inherited abnormality of Hb function
Defected structure or function of erythrocytes
( spherocytosis, G6DP def.)
Damage of erythrocytes ( autoimmune, drug induced, infective)
Clinical features :
Billirubin over production ( Jaundice) Spleen enlargement Increased RBC turnover to cause in the
end an increase in folic acid demand, and macrocytic changes occur
Treatment:
Folic acid Transfusion ( risk of iron overload)
Dental aspects :
LA : safest method of pain control Conscious sedation: given with
supplemental oxygen if nesseccary GA: Contraindecated
* main concern : sickle cell anemia
Sickle cell anemia ( autosomal)
The hemoglobin that is present is HbS
Gross distortion in erythrocyte shape
Might cause vascular occlusion since erythrocytes are stiff
Sickle cell anemia Trait: • Heterozygous • X10 more common than Sickle Cell Disease• Asymptomatic
Sickle cell crises is due to low oxygen tension Sickle cell anemia is most common in
africans, afro-caribbeans and middle eastern Early mortality rates are high
Sickle cell disorder: ( homozygous)
Clinical Features : 1. Painful crises ( mainly due to infarctions
especially in the spleen , bone, kidney , brain, lungs, joints.. Etc)
2. Haematological crises 3. Chronic hyperbillrubenemia 4. Infections ( mostly pneumococci,
meningiococci, heamophilus, salmonella) 5. Chronic anemia6. Sequestration syndromes: chest( gas change
impairment ) , blood, girdle ( bowels)
Management
Family history should be taken Take notice if Hb is less than 9 g/dl Blood film to follow the shape of RBC’s Electrophoresis: 40% Hbs , 60% HbA
Treatment Folic acid should be taken regularly Monitoring of cells Comprehensive care programme Blood transfusion ( usually avoided hep. C,
and HIV)
* * Main cause of death: thrombosis , infection
Prevent trauma, infection, hypoxia, acidosis, dehydration ( to avoid a crises)
Dental aspect GA : investigate all sickling disorders
especially when the Hb is less than 11 then there’s a hazard
Sickle Cell Trait: GA : few problems, full oxygenation should
be given
Dental Aspects cont.Sickle Cell Disease: LA : preferred to stop the pain Avoid prilocain> methaminoglobinemia Avoid asprin > acidosis Use acetaminophens, codiene Conscious sedation : used safely with relative
analgesia Elective surgery : only when hemolysis is
minimal Prophylactic antibiotics: penicillin V ,
clindamycine , should be given before surgery
Oral manifestations Painful infarcts in the jaws (radio opacities )
might be mistaken for osteomyelitis or toothache
Stepladder trabeculae pattern ( in xrays) Skeletal maturation is delayed Crises might be predisposing to osteomyelitis Hypercementosis might be seen Bone marrow hyperplasia leads to enlarged
heamopoietic maxilla with excessive over jet Enamel hypo mineralization and calcified pulp
canals
THALASSEMIA
Thalassemia Autosomal dominant inherited disorder
Alpha and beta globin chains will be produced slowly thus low HbA
Erythrocytes fragility will be due to the excess in the production of the not affected chains
Characterized by microcytic anemia
Found in Mediterranean , middle eastern
Thalassemia is divided into : Sever ( major, homozygous) Mild ( minor , heterozygous)
Alpha thalassemia: ( alpha chain) Beta thalassemia ( beta chain )
Alpha thalassemia
Alpha chain deficient Found in asians No compensatory mechanisms Lethal in utero or infancy due to inability
of carrying Oxygen
Beta thalassemia Mediterranean anemia Beta chains Homozygous : cooley anemia ( major
type) Severe anemia, failure to thrive,
hepatosplenomegaly, skeletal abnormalities
Heterozygous : might be asymptomatic
Clinical features HOMOZYGOUS Chronic anemia Marrow hyperplasia Skeletal defomaties Splenomegaly Cirrhosis Gallstones Iron overload : will damage the heart and
cause death
HETEROZYGOUS: asymptomatic Or mild hypochromic anemia
General managment Severe microcytic anemia ( confirmed) Basophilic stippling of erythrocytes Normal or raised serum iron and ferritin Normal total iron-binding capacity Great increase in fetal Hb Some increase in HbA2
treatment Blood transfusions Folic acid and chelating agents Ascorbic acid Hydroxycarbamide Splenectomy : if hyper- splenism happens
Dental aspects LA: safe Conscious sedation: if oxygen level not
less than 30% GA: complicated by the enlargement of
maxilla in intubation, and it is contraindicated in the presence of severe anemia and cardiomyopathy
Oral manifestations Enlarged maxilla ( chipmunk facies) Hair-on-end appearance due to expantion of
the diploe Less common: parotid swelling , xerostomia
due to iron deposition, sore or burning tongue due to folate deficiency
Pneumatization of the sinuses may be delayed
Spacing of the teeth and forward drift of the maxillary incisors ( ortho might be recommended)
Skicle Cell trait with haemoglobinopathy
SCT with thalassaemia are not usually as ill as those with isolated sickle cell disease
They are at the same level of risk from general anaesthesia as are those with sickle cell disease
Patients with other combined defects should be managed in the same way as those with sickle trait alone
Erythrocyte membrane defects
General and clinical aspects: Hereditary spherocytosis is the main form of
congenital haemolytic anemia in Caucasians Autosomal dominant Characterized by :• Heamolytic anemia • Jaundice• Splenomegaly• Gallstones• Heamochormatosis • Skin infections
General management Splenectomy Folic acid treatment
Dental Aspects: LA is safe, conscious sedation and GA may
be given at optimal oxygenation
Erythrocytic metabolic defects G6PD deficiency : most common
Acquired hemolytic anemias Caused by: Trauma , toxins , complement mediated
lysis and malaria
Aplastic anemia
Pancytopenia with a non-functioning bone marrow , causes leucopenia , thrombocytopenia and refractory anemia
Clinical features Same as normochromic, normocytic or
macrocytic together. Susceptibility to infection and bleeding Purpura is the first manifestation
General management Removal of the cause : • stop chloramphenicol• Bone marrow transplant • Steriods• Blood transfusion
Prognosis is poor and 50% of the patients die within 6 months , usually form haemorrhage or infection.
Dental aspects Take consideration of: Anemia Haemorrhagic tendency Hep. B , and other viral infections
Ulcers Susceptibility to infections Oral lichenoid lesions Sjogren like syndrome Gingival swelling
Fanconi’s anemia Rare autosomal recessive syndrome where 90%
develop bone marrow failure (the inability to produce blood cells) by age 40.
characterized: by: Skeletal defects Hyper pigmentation Pancytopenia
Susceptible to head and neck carcinoma at early age as a result of a genetic defect in a cluster of proteins responsible for DNA repair
Pure red cell aplasia Congenital or acquired , refers to a type of
anemia affecting the precursors to red blood cells but not to white blood cells. the bone marrow ceases to produce red blood cells.
Associated with: thymoma ( tumor of epi. Of thymus) Sometimes chronic mucocutaneous candidosis
Those patients need regular blood transfusions
Anemia caused by bone marrow infiltration
Infiltration by abnormal cells cause normocytic anemia and often leucopenia or thrombocytopenia
Dental care may be complicated by susceptibility to infections, haemorrhage or underlying disease
Anaemia associated with systemic disease
Including: Chronic inflammation ( infection or rheumatoid
arthritis ) Neoplasms ( leukemia) Liver disease
Very rarely: Hypothyroidism Hypopituitarism Hypoadernocorticism Uraemia HIV infection
THE ENDLana Obeidat
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