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
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Represents the % of packed RBCs inRepresents the % of packed RBCs inwhole bloodwhole blood
41-50 36-45
MF
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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
Hypoproliferative anemiasHypoproliferative anemias
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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Blood loss anemiasBlood loss anemias
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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Blood loss anemiasBlood loss anemias
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
Disorders of the hemoglobinDisorders of the hemoglobin
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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
Disorders of the hemoglobinDisorders of the hemoglobin
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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.
Hypoproliferative anemiasHypoproliferative anemias
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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
Hypoproliferative anemiasHypoproliferative anemias
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%)
Hypoproliferative anemiasHypoproliferative anemias
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
Sickle cell anemiaSickle cell anemia
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
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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Physical and Oral ManifestationsPhysical and Oral Manifestations
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
Sickle cell anemiaSickle cell 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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The endThe end
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