Some Important Concepts

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ANEMIASANEMIAS


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Anemia is defined as a reduction in the oxygen-carrying capacity of the bloodAnemia is defined as a reduction in the oxygen-carrying capacity of the blood

and usually is related to a decrease in number of circulating red blood cells (RBC)and usually is related to a decrease in number of circulating red blood cells (RBC)

or to an abnormality in the hemoglobin (Hb) contained within the RBCsor to an abnormality in the hemoglobin (Hb) contained within the RBCs

AnemiaAnemia

Decreased production of RBCsDecreased production of RBCs

Blood lossBlood loss Usually chronic blood lossUsually chronic blood loss

Increased rate of destruction of RBCsIncreased rate of destruction of RBCs Hemolytic anemiaHemolytic anemia

Iron deficiencyIron deficiency

Pernicious anemia (vit BPernicious anemia (vit B1212 ))

Folate deficiencyFolate deficiency

Some important conceptsSome important concepts


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Represents the % of packed RBCs inRepresents the % of packed RBCs inwhole bloodwhole blood

41-50 36-45

MF


Normal Values:Normal Values:

Men 41.5-50.4%Men 41.5-50.4%

Women 35.9-44.6%Women 35.9-44.6%


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Classification ofClassification ofanemiaanemia by pathogenesisby pathogenesis

SpleenSpleen PeripheralPeripheralFactoryFactory

MaterialsMaterials

FormulaFormula

Hypoproliferative anemiasHypoproliferative anemias

Disorders of HemoglobinDisorders of Hemoglobin

Hemolytic anemiasHemolytic anemiasBlood Loss AnemiasBlood Loss Anemias

Bone MarrowBone Marrow

Destruction of RBCsDestruction of RBCs ChronicChronic


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Classification ofClassification ofanemiaanemia by pathogenesisby pathogenesis

Blood loss anemiaBlood loss anemia

Hemolytic anemiasHemolytic anemias

Disorders of hemoglobinDisorders of hemoglobin


Iron deficiency anemiaIron deficiency anemia

Plummer-Vinson SyndromePlummer-Vinson Syndrome

Glucose 6 phosphate dehydrogenaseGlucose 6 phosphate dehydrogenase

Deficiency (G-6-PD deficiency)Deficiency (G-6-PD deficiency)Drug InducedDrug Induced

Immune mediatedImmune mediated

Sickle cell anemiaSickle cell anemia

ThalassemiaThalassemia

Vitamin B12 DeficiencyVitamin B12 Deficiency

Pernicious anemiaPernicious anemia

Folic acid deficiencyFolic acid deficiency

Aplastic anemiaAplastic anemia


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Blood loss anemiasBlood loss anemias

Iron deficiencyIron deficiencyanemiaanemia

-Most common of all anemiasMost common of all anemias

-30% of the world population30% of the world population

-In U.S. 5-11% of women and 2% of menIn U.S. 5-11% of women and 2% of men

-Southeast AsiaSoutheast Asia High prevalence: Cultural backgroundHigh prevalence: Cultural background

-Causes:Causes:Chronic blood lossChronic blood loss

Malabsorption syndromeMalabsorption syndrome PicaPica

Celiac diseaseCeliac disease

Helicobacter PyloriHelicobacter Pylori


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Iron deficiencyIron deficiency

anemiaanemia

Diagnosis:Diagnosis:

Low hemoglobin levelLow hemoglobin levelMicrocytic hypochromic cells in a peripheral blood smearMicrocytic hypochromic cells in a peripheral blood smearDecrease mean corpuscular value (hemoglobin)Decrease mean corpuscular value (hemoglobin)

Low serum iron levelLow serum iron levelMarkedly reduced serum ferritin levelMarkedly reduced serum ferritin levelHigh serum iron-binding capacityHigh serum iron-binding capacity

GOLD STANDARDGOLD STANDARD Iron stores in bone marrowIron stores in bone marrow


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Iron deficiencyIron deficiencyanemiaanemia

Low number of RBCs, pale and small in sizeLow number of RBCs, pale and small in size

peripheral blood smearperipheral blood smear


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FoodFood Liver, meat, green vegetables, legumes,Liver, meat, green vegetables, legumes,

nuts, egg yolk whole grain or enrichednuts, egg yolk whole grain or enrichedbreads, cerealsbreads, cereals

SupplementsSupplements

VitaminsVitamins Elemental iron in iron supplementsElemental iron in iron supplements Ferrous fumarateFerrous fumarate 33%33%

Ferrous gluconateFerrous gluconate 11.6%11.6%

Ferrous SOFerrous SO44

20%20%

Ferrous sulfate, dessicated 30%Ferrous sulfate, dessicated 30%

Iron interferes with absorption of: tetracyclines, quinolones, levothyroxine, pencillamine, levodopa. Wait 2 hrsIron interferes with absorption of: tetracyclines, quinolones, levothyroxine, pencillamine, levodopa. Wait 2 hrs

between drugs.between drugs.



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G6 PD deficiency anemia

Due to a deficiency of an enzyme in the hexosemonophosphate shunt pathway

Found in 400 M persons worldwide 11% of African Americans (has an association with SCA) Very prominent in persons of Mediterranean origin

Blockage of this pathway allows accumulation ofoxidants in the RBCs with altered cell

membranes and resulting hemolysis Hemolytic episodes can be triggered by infection,drugs and foods (fava beans) Aspirin, dapsone, ascorbic acid, vitamin K

Hemolytic anemiasHemolytic anemias


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SCA falls under a broad entity of diseases known as hemoglobinopathiesSCA falls under a broad entity of diseases known as hemoglobinopathies

Main Problem: Abnormal hemoglobinMain Problem: Abnormal hemoglobin

SCA: autosomal recessive disorder and is characterized by an abnormality inSCA: autosomal recessive disorder and is characterized by an abnormality inthe B-chain of the hemoglobin and an abnormal RBC (trait vs disease)the B-chain of the hemoglobin and an abnormal RBC (trait vs disease)

Mainly affects persons of African or Afro-Caribbean descentMainly affects persons of African or Afro-Caribbean descent

When the red blood cell is subjected to a low oxygen tension the hemoglobin willWhen the red blood cell is subjected to a low oxygen tension the hemoglobin will

form a sickle-shaped crystal within the erythrocyteform a sickle-shaped crystal within the erythrocyte

Sickling may also be precipitated by infection, dehydration, hypoxia, acidosisSickling may also be precipitated by infection, dehydration, hypoxia, acidosis

and results in painful crises due to infarcts caused by stasis of blood flowand results in painful crises due to infarcts caused by stasis of blood flow

(spleen, bones, joints, brian, kidneys, lungs, eyes and skin)(spleen, bones, joints, brian, kidneys, lungs, eyes and skin)

Disorders of the hemoglobinDisorders of the hemoglobin


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When the red blood cell is subjected to aWhen the red blood cell is subjected to a

low oxygen tensionlow oxygen tension the hemoglobin willthe hemoglobin will

form a sickle-shaped crystal within theform a sickle-shaped crystal within the

erythrocyteerythrocyte



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Sickle cell traitSickle cell trait

Normal adult hemoglobin molecule is made of 2 alpha and 2 beta chains:Normal adult hemoglobin molecule is made of 2 alpha and 2 beta chains:

Hemoglobin AHemoglobin A

In patients with SCA the normal molecule is substituted for 75-100% hemoglobin SIn patients with SCA the normal molecule is substituted for 75-100% hemoglobin S

(substitution of the a.a.)(substitution of the a.a.)

In patients with the sickle cell traitIn patients with the sickle cell trait 20-35% of the hemoglobin is S, the rest20-35% of the hemoglobin is S, the rest

is normalis normal hemoglobin Ahemoglobin A

Patients with the trait: usually have aPatients with the trait: usually have a normal life with mild symptoms,normal life with mild symptoms,

except under ABNORMAL low oxygen conditionsexcept under ABNORMAL low oxygen conditions



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Thalassemias Due to a genetic defect in either the - or

-globin chain of hemoglobin resulting indiminished survival of RBCs Common in persons of Mediterranean,

African and Southeast Asian ancestry

-thalassemia treated with bloodtransfusion, folic acid supplement andascorbic acid, and possibly splenectomy

Disorders of hemoglobinDisorders of hemoglobin


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Vitamin B12 deficiencyVitamin B12 deficiency

Vitamin B12 deficiency along with folic acid deficiency falls under theVitamin B12 deficiency along with folic acid deficiency falls under the

group: MEGALOBLASTIC ANEMIASgroup: MEGALOBLASTIC ANEMIAS

Foods of animal origin are the primary dietary sources of Vitamin B12Foods of animal origin are the primary dietary sources of Vitamin B12

Vitamin B12 deficiency takes 2 to 5 years to developVitamin B12 deficiency takes 2 to 5 years to develop storagestorage

Cobalamin is necessary for DNA synthesis and a deficiency preventsCobalamin is necessary for DNA synthesis and a deficiency prevents

the normal cell duplication in the bone marrowthe normal cell duplication in the bone marrow

Production of large erythrocytesProduction of large erythrocytes

Vitamin B12 deficiencyVitamin B12 deficiency seen inseen in MalabsorptionMalabsorption

Strict vegetarians.Strict vegetarians.



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-Pernicious Anemia (PA) is the most common cause of Vitamin BPernicious Anemia (PA) is the most common cause of Vitamin B1212

deficiency and is associated with chronic atrophic gastritis.deficiency and is associated with chronic atrophic gastritis.

-Other conditions than can lead to vitamin BOther conditions than can lead to vitamin B1212 deficiency: gastrectomydeficiency: gastrectomy

-PA develops because atrophic changes in the gastric mucosa resultsPA develops because atrophic changes in the gastric mucosa results

in lack ofin lack of intrinsic factorintrinsic factorproduction, which is necessary for the absorptionproduction, which is necessary for the absorption

of Vitamin Bof Vitamin B1212 from the gutfrom the gut


PerniciousPernicious AnemiaAnemia


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-In 85% of the patients serum antibodies to the gastric parietal cells areIn 85% of the patients serum antibodies to the gastric parietal cells are

notednoted

-Additionally in 50% of patients, serum antibodies to intrinsic factorAdditionally in 50% of patients, serum antibodies to intrinsic factor

have been notedhave been noted

-Other autoimmune conditions: Graves, Hashimoto, AddisonOther autoimmune conditions: Graves, Hashimoto, Addison

-Diagnosis: Shilling test: small amount of radioactive Vitamin B12 orallyDiagnosis: Shilling test: small amount of radioactive Vitamin B12 orally

after 24 hours: amount of radioactive Vit. B12 in the urine (7-30%)after 24 hours: amount of radioactive Vit. B12 in the urine (7-30%)


PerniciousPernicious AnemiaAnemia


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Physical and Oral ManifestationsPhysical and Oral Manifestations

Iron deficiencyIron deficiency anemiaanemia

PallorPallor

- Oral mucosa: Soft palate, tongue and sublingual tissues- Oral mucosa: Soft palate, tongue and sublingual tissues

- Conjunctiva- Conjunctiva

Jaundice is usually not evidentJaundice is usually not evident

Spoon-shaped fingernailsSpoon-shaped fingernails KoilonychiaKoilonychia

Atrophic tongueAtrophic tongue

GlossodyniaGlossodynia

Burning Mouth DisordersBurning Mouth Disorders


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Plummer-Vinson SyndromePlummer-Vinson Syndrome

Type of Iron deficiency characterized by dysphagia and microcytic hypochromic anemiaType of Iron deficiency characterized by dysphagia and microcytic hypochromic anemia

Sore depapillated tongueSore depapillated tongue

XerostomiaXerostomia

Angular stomatitisAngular stomatitis

KoilonychiaKoilonychia

Atrophic changes are not limited to the oral cavityAtrophic changes are not limited to the oral cavity pharynx, upper GIpharynx, upper GI

Pallor fatigue, dyspneaPallor fatigue, dyspnea

DYSPHAGIADYSPHAGIA Muscular degeneration of the esophagusMuscular degeneration of the esophagus

Important: Increased prevalence of oral and pharyngeal carcinomaImportant: Increased prevalence of oral and pharyngeal carcinoma


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Glucose 6-phosphate dehydrogenase deficiencyGlucose 6-phosphate dehydrogenase deficiency

Most common manifestation : JAUNDICEMost common manifestation : JAUNDICE

Jaundice: sclera,Jaundice: sclera, palate and floor of the mouthpalate and floor of the mouth

Radiographic changes: Increase in the trabeculation of the bone (more radiolucent)Radiographic changes: Increase in the trabeculation of the bone (more radiolucent)

Hyperplasia of the erythroid elements of the bone marrowHyperplasia of the erythroid elements of the bone marrow


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Sickle cellSickle cell anemiaanemia

Marked underdevelopmentMarked underdevelopment

Majority of the patients die before 40 years of ageMajority of the patients die before 40 years of age

Hemolytic anemiaHemolytic anemia PallorPallor

JaundiceJaundiceCongestive Heart FailureCongestive Heart Failure

StrokesStrokes

Pain crisisPain crisis

Small InfarctsSmall Infarcts

Increased risk for developing infections with:Increased risk for developing infections with:

-- S. pneumoniaeS. pneumoniae- H. influenza- H. influenza

- Salmonella- Salmonella

-- E. ColiE. Coli


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Hypoplasia of the dentitionHypoplasia of the dentition

Delayed eruptionDelayed eruption

Increased bone trabeculationIncreased bone trabeculation

Dense lamina duraDense lamina dura

Skull film: thick cortexSkull film: thick cortex classical appearance hair on endclassical appearance hair on end

Areas of bone sclerosis in periapical filmsAreas of bone sclerosis in periapical films

Sometimes paresthesia of mental nerveSometimes paresthesia of mental nerve


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ThalassemiaThalassemia

Bone marrow expansionBone marrow expansion Ineffective erythropoiesisIneffective erythropoiesis

Bimaxillary protrusionBimaxillary protrusion

Spacing of the teethSpacing of the teeth

Marked open biteMarked open bite

Prominent malar bonesProminent malar bones

Thin cortical boneThin cortical bone

Discoloration of the teethDiscoloration of the teeth Iron depositIron deposit


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Folic Acid deficiency anemiaFolic Acid deficiency anemia

-PharyngitisPharyngitis

-Ulcerative StomatitisUlcerative Stomatitis

-Angular cheilitisAngular cheilitis

-Difference with pernicious anemia: No neurological symptomsDifference with pernicious anemia: No neurological symptoms


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Vitamin B12 deficiency / pernicious anemiaVitamin B12 deficiency / pernicious anemia

In children Vitamin B12 deficiency often presents with non-specific symptomsIn children Vitamin B12 deficiency often presents with non-specific symptoms

Neurological symptoms: paresthesia, sensory deficit, loss of reflexes, hypotoniaNeurological symptoms: paresthesia, sensory deficit, loss of reflexes, hypotonia

seizures, dementiaseizures, dementia

Abnormal skin pigmentationAbnormal skin pigmentation

Systolic murmursSystolic murmurs

GlossodyniaGlossodynia

Atrophic tongueAtrophic tongue

Tongue hypotonic (advance stage)Tongue hypotonic (advance stage)

Erythema and macular lesions in the dorsum of the tongueErythema and macular lesions in the dorsum of the tongue

Dysphagia and taste aberrationsDysphagia and taste aberrations

BMD: Burning mouth DisorderBMD: Burning mouth Disorder


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Dental Management of Patients withDental Management of Patients with

AnemiaAnemia


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Dental Management of Patients with AnemiaDental Management of Patients with Anemia

1.1. CBC with differential in who patient presents with sign and symptomsCBC with differential in who patient presents with sign and symptomsof anemiaof anemia

1.1. Consultation with primary MD if low hematocrit or hemoglobin is foundConsultation with primary MD if low hematocrit or hemoglobin is found

2.2. Assessment of the severity of the anemia in conjunction with the patient MDAssessment of the severity of the anemia in conjunction with the patient MD

3.3. Possible blood transfusion prior to treatment if anemia is severePossible blood transfusion prior to treatment if anemia is severe

4.4. Avoidance of elective treatment in patient who are in crisisAvoidance of elective treatment in patient who are in crisis

General issues:General issues:

Patients with severe anemia may not tolerate blood loss or hypoxiaPatients with severe anemia may not tolerate blood loss or hypoxia

Patients with anemia may not tolerate certain drugsPatients with anemia may not tolerate certain drugs

Patients with anemia may not handle infection wellPatients with anemia may not handle infection well


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Dental Management of Patients with AnemiaDental Management of Patients with Anemia


Cautious use of nitrous oxide analgesia in patient with sickle cell anemia;Cautious use of nitrous oxide analgesia in patient with sickle cell anemia;

ensure good oxygenation at all timesensure good oxygenation at all times

Avoid respiratory depressantsAvoid respiratory depressants

Avoid aspirin in large doses (to avoid acidosis); acetaminophen or codeineAvoid aspirin in large doses (to avoid acidosis); acetaminophen or codeineare better choicesare better choices

Consider prophylactic antibiotics for surgical proceduresConsider prophylactic antibiotics for surgical procedures

Aggressive management of infectionsAggressive management of infections

G-6-PD DeficiencyG-6-PD Deficiency

Avoid the use of aspirinAvoid the use of aspirin


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Some Important Concepts

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