7. Clinical Considerations (Hematology) Pt. II

Question 1

Disorders of Red Blood Cells

Vitamin B12 and Folate deficiency
• Vitamin B12 (cobalamin) and folic acid are needed for RBC formation.
• Risk factors for folate deficiency include poor ____, alcoholism, history of ____ disorders, and pregnancy (especially during the third trimester).
• Pernicious anemia is caused by a deficiency of ____, a substance secreted by the gastric parietal cells that is necessary for absorption of vitamin B12.
• Most patients with pernicious anemia have ____ with decreased intrinsic factor and hydrochloric acid secretion.

Answer 1

diet
malabsorption
intrinsic factor
chronic atrophic gastritis

Question 2

Disorders of Red Blood Cells

Vitamin B12 and Folate deficiency

• ____ patients are at an increased risk of developing vitamin B12 deficiency because their digestive tracts have been altered.
• In healthy adults, ____ (released by the parietal cells in the stomach) binds with vitamin B12 in the duodenum. The binded vitamin B12 is then absorbed in the ____.
• In patients who have had gastric bypass surgery, most of the stomach and duodenum are bypassed, ____ the breakdown of vitamin B12 and its binding with intrinsic factor.

Answer 2

bariatric
intrinsic factor
ileum

limiting

Question 3

Disorders of Red Blood Cells
G6PD deficiency
• Glucose-6-phosphate dehydrogenase (G6PD) is a ____ enzyme that prevents oxidative damage to cells by promoting detoxification of ____.
• G6PD is expressed in all tissues; however, when the enzyme is abnormally low, this biochemical process is markedly reduced in ____, rendering these cells strongly vulnerable to oxidative stress.
• In G6PD deficiency, hemolysis can be precipitated by diverse factors, such as ____ drugs, infectious diseases, and ingesting ____.

Answer 3

cytoplasmic X chromosome-linked
free radicals

RBC

oxidative
fava beans

Question 4

Disorders of Red Blood Cells

G6PD deficiency
• Patients with G6PD deficiency exhibit an increased incidence of drug sensitivity with ____ (sulfamethoxazole), aspirin, and ____ being the prime offenders.
• Dental ____ may accelerate the rate of hemolysis in patients with this type of anemia.

Answer 4

sulfonamides
chloramphenicol
infection

Question 5

Disorders of Red Blood Cells

Sickle cell anemia
• In patients with sickle cell anemia, distortion of the RBC into a sickled shape results from ____ or ____ blood pH.
• Cellular rigidity and membrane damage occur, and ____ sickling is the result. The net effects of these changes are ____, increased blood viscosity, reduced ____, hypoxia, increased adhesion of RBCs, vascular ____, and further sickling.

Answer 5

deoxygenation
decreased
irreversible
erythrostasis
blood flow
occlusion

Question 6

Disorders of Red Blood Cells

Sickle cell anemia
• Complications of sickle cell anemia can occur at any age, but patients in the following age groups are more likely to manifest certain complications:

Birth to 20 years of age: Painful events, ____, acute ____ syndrome (fever, chest pain, wheezing, cough, and hypoxia), acute anemia, and infection.

From 20 to 40 years of age: ____ of hip and shoulder joints, leg ulcers, priapism, liver disease, and gallstones

Older than 40 years of age: Pulmonary ____, nephropathy, proliferative retinopathy, and cardiac enlargement, heart murmurs, and sudden death from arrhythmias.

Answer 6

stroke
chest

osteonecrosis
hypertension

Question 7

Disorders of Red Blood Cells
Sickle cell anemia
• Patients with sickle cell anemia can receive ____ dental care during non-crisis periods; however, ____ and complicated procedures should be avoided.
• The goal during routine care is to ____ a crisis

Answer 7

routine
long
prevent

Question 8

Disorders of Red Blood Cells

Sickle cell anemia
• Appropriate restorative and preventive dental care are important because oral infection can precipitate a ____. If infection occurs, it must be treated quickly.
• For routine dental care, appointments should be ____ to minimize stress.
• The use of ____ in the local anesthetic is controversial because some believe it may impair circulation and cause vascular occlusion. However, the ____ of a vasoconstrictor outweigh the risk of local impairment of circulation.
• ____ and dehydration should be prevented.

Answer 8

crisis
short
epinephrine
benefits
hypoxia

Question 9

Disorders of Red Blood Cells
Sickle cell anemia
• ____ can be used, with at least ____% oxygen concentration provided.
• ____ must be used with extreme caution.
• ____ should be avoided because suppression of the respiratory center by these agents leads to hypoxia and acidosis, which may precipitate an acute crisis.

Answer 9

nitrous oxide
50
intravenous
opiates

Question 10

• What kind of anemia does he have?
• His MCV is low so it is a ____ anemia
• What are the types of microcytic anemias? ____ deficiency, Thalassemia, Anemia of
____ disease, ____
• When I was rotating in hematology we would get really excited about serum ferritin levels
• What I want you guys to know is “that they can run lab tests to determine which one of
these it is”. Not important for you guys to know
• This patient came back with iron deficiency anemia

Answer 10

microcytic

iron
chronic
sideroblastic

Question 11

• So why did he lose conciseness? Why did he fall?
• Whats syncope? Fainting
• Whats happening with the brain? Not getting enough oxygen so global cerebral
____. Thats why he loss conciseness. He has anemia so his oxygen carrying capacity is very ____ and also is hypotensive and tachycardia which indicates ____ depletion so that puts you at risk for orthostatic hypotension (standing up too quickly and fainting)

Answer 11

hypoperfusion
low
volume

Question 12

• Hemorrhagic shock is probably class ____ stage. His blood pressure was decreased and his heart rate increased. He probably loss 1.5L of blood which was due to an upper GI bleed

Answer 12

III

Question 13

Disorders of White Blood Cells
• Disorders of white blood cells (WBCs) in dental patients can substantially influence clinical decision making as well as the delivery of care because WBCs constitute the primary ____ against microbial infections and are critical for mounting an immune response.
• Defects in WBCs can manifest as delayed ____, infection, or mucosal ____ and, in some cases, may be fatal.

Answer 13

defense
healing
ulceration

Question 14

Disorders of White Blood Cells
• Leukocytes (WBCs) respond to an inflammatory process or injury.
• Normal levels of WBCs for are ____/uL
• ____ is an increase in the number of circulating WBCs and ____ as a reduction in the number of circulating WBCs.
• In a complete blood count (CBC), the differential measures the ____ of the various types of white cells present.
• The differential usually includes ____, bands, eosinophils, ____ and lymphocytes.

Answer 14

4300-10800
leukocytosis
leukopenia
percentage
neutrophils
monocytes

Question 15

Disorders of White Blood Cells
• A thorough ____ for evidence of WBC disorders is essential in all patients who present for dental treatment.
• Patients with leukemia or lymphoma may be at risk for catastrophic outcomes if the disease is not detected before dental treatment is started.
• Patients with leukemia whose disease has not been diagnosed may experience serious ____ complications after surgical procedures, may have altered ____ of surgical wounds, and are prone to postsurgical ____.

Answer 15

assessment
bleeding
healing
infection

Question 16

Disorders of White Blood Cells

• Specific questions regarding blood disorders and cancer in family members, weight loss, fever, swollen or enlarged lymph nodes, and bleeding tendencies should be asked.
• Examination of the head, neck, and mouth should include a thorough inspection of the oropharynx, head, and cervical and ____ lymph nodes.
• ____ examination is important for identifying abnormalities suggestive of invasive neoplasms.
• ____ films also provide insight into potential osteolytic lesions associated with WBC disorders.

Answer 16

supraclavicular
cranial nerve
panoramic

Question 17

Disorders of White Blood Cells
• A patient who displays the classic signs or symptoms of leukemia, lymphoma, or multiple myeloma should be promptly referred directly to a ____.
• Screening laboratory tests should include a ____ with differential (total and differential WBC counts, hemoglobin, hematocrit, platelet count) and a ____ for cell morphologic study.
• If screening tests are ordered by the dentist and one or more results are abnormal, the patient should be promptly referred for ____ evaluation and treatment.

Answer 17

physician
CBC
smear
medical

Question 18

Leukemia
Disorders of White Blood Cells
• Leukemia is cancer of the WBCs that affects the ____ and ____ blood. It involves exponential proliferation of a clonal ____ or ____ cell and occurs in both ____ and chronic forms.
• Acute leukemia is a rapidly progressive disease that results from accumulation of ____, nonfunctional WBCs in the marrow and blood. Chronic leukemias have a ____ onset, which allows production of ____ numbers of more mature, ____ cells.

Answer 18

bone marrow
circulating
myeloid
lymphoid
acute

immature
slower
larger
functional

Question 19

Leukemia
• Four types of leukemia:
Disorders of White Blood Cells
  • \_\_\_\_ (AML)
• \_\_\_\_ (ALL)
• \_\_\_\_ (CML)
• \_\_\_\_(CLL

Answer 19

acute myelogenous leukemia
acute lymphocytic leukemia
chronic myelogenous leukemia
chronic lymphocytic leukemia

Question 20

Leukemia – Clinical considerations
• Patients with leukemia are prone to develop gingival ____, ulceration, and oral infection.
• It is caused by infiltration of atypical and ____ WBCs . It occurs in up to ____% of those with acute leukemia and 10% of those with chronic leukemia.
• A localized mass of leukemic cells is known as a ____. These extramedullary tumors have been observed in the ____ tissues (maxilla, palate) and ____ tissues (gingiva, tongue, oral mucosa) of the maxillofacial complex.

Answer 20

enlargement
immature
granulocytic sarcoma
chloroma
hard
soft

Question 21

Leukemia – Clinical considerations
• The gingiva is boggy and ____ easily and is exacerbated by thrombocytopenia.
• Due to granulocytopenia, at least one third of patients have recurrent ____, nonhealing wounds, oral ulcerations, and fever.
• Enlargement of the ____, lymph nodes, spleen, and gingiva occurs as a result of leukemic infiltration of these tissues.
• Oral ____ is extremely important and invasive procedures (extractions, biopsies) should be ____ if possible.

Answer 21

bleeds
infections
tonsils
hygiene
avoided

Question 22

Lymphoma
Disorders of White Blood Cells
• Lymphoma is cancer of the ____ organs and tissues that presents as discrete tissue masses.
• Lymphomas are classified by ____ type (B cell, T cell, MALT, plasma cell), ____ (small or large cell, cleaved or noncleaved nucleus), and ____ behavior (of low, intermediate, and high grade);
• There are over 20 types, but the 2 main categories are ____, and ____.
• The initial signs of these diseases often occur in the mouth (____) and in the ____ region.

Answer 22

lymphoid
cell
appearance
clinical
hodgkin lymphoma
non-hodgkin lymphoma

waldeyer ring
H+N

Question 23

Lymphoma
Disorders of White Blood Cells
• Hodgkin lymphoma presents most commonly as a painless mass or a group of firm, nontender, enlarged lymph nodes, often affecting the ____ nodes or the ____ nodes (in >50% of cases).
• Non-Hodgkin lymphoma is marked by enlarged lymph nodes, fever, and weight loss.

In contrast with Hodgkin lymphoma, which often begins with a ____ focus of tumor, NHL usually is ____ when first detected.
• About 20% to 40% of lymphomas develop ____ of lymph nodes and are termed ____ lymphomas

Answer 23

mediastinal
neck

single
multifocal
outside

extranodal

Question 24

Lymphoma
Disorders of White Blood Cells
• Lymphomas are the ____ most common malignant lesions in the maxillofacial region (behind ____ + ____ neoplasms),
• In the maxillofacial region these are frequently found in the ____ glands or intraoral ____

Answer 24

third
SCCa
salivary
salivary
mucosa

Question 25

Disorders of White Blood Cells

• Multiple myeloma is a lymphoproliferative disorder that results from overproduction of cloned malignant ____ cells that results in multiple tumorous masses scattered throughout the skeletal system.
• Malignant plasma cells secrete monoclonal ____ and various cytokines.
• Monoclonal gammopathy of undetermined significance (MGUS), consisting of increased numbers of ____ cells with no other ____ manifestations, may precede MM.

Answer 25

plasma
immunoglobulins
plasma
clinical

Question 26

Disorders of White Blood Cells

Multiple myeloma
• The disease consists of ____ and myeloma cell proliferation, ____ production, bone resorption, and bone marrow ____.
• Resorption of bone leads to release of calcium and serum ____.
• Bone marrow replacement leads to ____, leukopenia, thrombocytopenia, and eventually a decrease in plasma ____.
• Increased plasma ____ contributes to altered ____ function, excessive bleeding, renal impairment, and neuropathy.

Answer 26

plasma
immunoglobulin
replacement

hypercalcemia
anemia
immunoglobulins

viscosity
function

Question 27

Disorders of White Blood Cells

Multiple myeloma
• Patients with MM may have ____ lesions, soft tissue lesions, and soft tissue deposits of amyloid.
• Dental radiographs may show “____” lesions or mottled areas that represent areas of tumor.
• An ____-like protein is found sometimes in oral soft tissues.

Answer 27

jaw
punched-out
amyloid

Question 28

Disorders of White Blood Cells

Multiple myeloma
• Patients are often treated with ____ to prevent hypercalcemia and bone resorption -> These patients are at risk for ____ with dental procedures.

Answer 28

IV bisphosphonates

MRONJ

Question 29

Disorders of White Blood Cells
• When a patient presents with a diagnosis of a WBC disorder it is important to understand the diagnosis as well as the stage of treatment.
• Pretreatment care should include oral ____ instructions that emphasize the importance of meticulous plaque removal. Caries and infection should be eliminated before ____ is begun.

Answer 29

hygiene

chemotherapy

Question 30

Disorders of White Blood Cells
• Patients who are undergoing chemotherapy or radiotherapy are susceptible to many oral complications, including ____, neutropenia, infection, excessive ____, graft-versus-host disease (GVHD), and alterations in ____ and development.

Answer 30

mucositis
bleeding
growth

Question 31

Dental management - Mucositis
• Patients who are undergoing chemotherapy or radiotherapy are susceptible to many oral complications, including ____, neutropenia, infection, excessive bleeding, ____, and alterations in growth and development.
• Mucositis usually begins ____ days after initiation of chemotherapy and resolves after ____ of chemotherapy.
• Affected mucosa becomes ____, raw, and tender.
Breakdown of the epithelial barrier produces oral
____ that may become secondarily infected.

Answer 31

mucositis
graft-versus-host disease
7 to 10
cessation
red
ulcerations

Question 32

Dental management - Mucositis
• The treatment of mucositis is ____.
• Oral ____ should be maintained to minimize
infection complications.
• A ____ (____ free) can be used to clean the surface of the ulcers.
• A topical ____ mouth rinse and systemic analgesics makes the mouth more comfortable so the patient can maintain their nutrition.

Answer 32

palliative
hygiene
mouth rinse
alcohol
anesthetic

Question 33

Dental management - Neutropenia
• Oral infection is less of a problem in patients with ____ leukemia than in those with ____ leukemia because the cells are more mature and functional in chronic leukemia. However, in the ____ stages of both CML and CLL, infection can become a serious complication.

• Because of ____, signs of infection are often masked in patients with leukemia. The swelling and erythema usually associated with oral infection are often less ____.

Answer 33

acute
chronic
later
neutropenia
distinctive

Question 34

Dental management - Neutropenia
• ____ infections (bacterial, fungal, and viral) are common with ____ being the most common. This should be treated with topical and sometimes parenteral ____.
• ____ virus infection is also common. To prevent recurrence ____ antiviral agents are given to HSV antibody– positive patients who are undergoing chemotherapy.

Answer 34

opportunistic
candidiasis
antifungals
recurrent herpes simplex
prophylactic

Question 35

Disorders of White Blood Cells
• ‘____ clot’ or ‘____ clot’: Disorganized clot with incomplete fibrin formation, rich in erythrocytes.
• Generally the result of ____ hemorrhage characterized by slow, oozing ____ red blood.
• Remember, upon vessel injury, platelets adhere into vWF in subendothelial tissue → aggregate → primary hemostatic plug. Platelets stimulate the plasma coagulation factors, which leads to the generation of a fibrin clot.
• If this process is disturbed (platelet deficiency, etc.) you can see a disorganized clot form.

Answer 35

liver
currant jelly
venous
dark