Hematologic Diseases Flashcards
_____: Reduction in the oxygen carrying capacity of
RBCs; deficiency in red blood cells or of
hemoglobin in the blood
anemia
Classification of \_\_\_\_\_\_ – Causes • Blood Loss • Inadequate production • Excess destruction – Morphology • Normocytic • Microcytic • Macrocytic
anemia
Lab Test for anemia: \_\_\_\_\_\_\_\_ (\_\_\_\_ \_\_\_\_ \_\_\_\_) • Hb* • Hematocrit* • WBC • Platelet • RBC indices*
CBC (Complete Blood Count)
Concentration of hemoglobin
Hb for CBC test
Packed cell volume
Hematocrit for CBC test
_____ _______ withinn the CBC
- MCV (mean corpuscular volume)
- MCH (mean cell hemoglobin)
- RDW (red cell distribution width)
- MCHC (mean cell hemoglobin concentration)
RBC indicies
The following are examples of what size type of Anemia??
– Iron Deficiency Anemia
– Thalassemias
microcytic
The following are examples of what size type of Anemia??
– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency
Macrocytic
The following are examples of what size type of Anemia??
– Hemolytic Anemia
– Sickle Cell Anemia
normocytic
______ _____ Anemia
• Microcytic anemia • More common in women of childbearing age and children • Causes: blood loss, poor iron intake, poor iron absorption, or increased demand for iron • Labs: Serum iron, ferritin, TIBC, transferrin
Iron Deficiency Anemia
____ ______ Anemia
- Macrocytic
– Not stored in the body in large amounts; continual
dietary supply is needed
– Deficiency during pregnancy causes neural tube
defects in the child
– Labs: Serum folate level
Folate Deficiency
______ ______ Anemia
-macrocytic
– Pernicious Anemia
• Deficiency of intrinsic factor which is necessary
for B12 absorption
– Nitrous Oxide
• Irreversible inactivation of B12
• Neurologic symptoms
– Labs: Serum B12
Cobalamin (B12) Deficiency
___ ____ is contradindicated for pts with B12 definiency because it causes the Irreversible inactivation of B12
Nitrous Oxide
________ Manifestations of Anemia
– Symptoms: Fatigue, weakness,
palpitations, SOB, angina, tingling of fingers and toes
– Signs: pallor, splitting and
spooning of fingernails
systemic
_______ manifestations of Anemia
– Atrophic glossitis with loss on
tongue papillae, redness or cheilosis
– Mucosal pallor
Oral
t/f: anemic pts Generally tolerate routine dental treatment well
true
t/f: Severe anemia (cardiopulmonary symptoms)
– Defer routine dental care
– Pulse oximeter and supplemental oxygen
– Avoid strong narcotics
true
______ _____ _____:
• Autosomal recessive inherited disorder • RBC sickling in low oxygen or low blood pH environments • Erythrostasis, increased blood viscosity, reduced blood flow, vascular occlusion, hypoxiamore sickling
Sickle Cell Anemia
The following are systemic Signs and Symptoms what what Disease?
– Result of chronic anemia and small blood vessel
occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac
• Cardiac failure • Stroke
– Delays in growth and Development
– Pain
• Abdominal
• Bone (aseptic necrosis)
– Sickle cell crisis
• Prolonged (hours-days) severe pain which pay require
hospitalization for pain management • Causes: infection, higher altitude (hypoxia), dehydration,
trauma
Sickle Cell Anemia
the following are oral manifestations of which disease??
– Mucosal pallor or jaundice – Papillary atrophy – Delayed tooth eruption – Aseptic bone and pulpal necrosis – Osteomyelitis – Neuropathy
Sickle Cell Anemia
What are the radiohgraphic findings of Sickle Cell Anemia
• Increased widening and
decreased number of
trabeculations
- “Stepladder” trabeculae
- “Hair on end”
– Routine care during non-crisis states
– Keep appointments short to reduce stress
– Emphasis on oral hygiene instructions to reduce risk of infection
• If infection occurs, consider IM or IV antibiotics
Dental Management of sickle cell anemia
– Anesthetic:
• Avoid prilocaine
• Epinephrine 1:100,000-no stronger concentration
• May consider using LA without epinephrine
– Monitor oxygen saturation, when using nitrous oxide, provide
oxygen at greater than 50% with high flow rates
– Antibiotic prophylaxis for major surgical procedures
– Pain management: consult their primary care or hematologist
(opioid contract)
Dental Management of Sickle cell anemia
this type of anemia is Bone marrow failure resulting in
pancytopenia (decrease in all three blood cell types)
Aplastic anemia
How do you treat aplastic anemia?
– Hematopoietic cell transplant
Oral manifestations of ____ ____
– Anemia • Atrophic glossitis with loss on tongue papillae, redness or cheilosis • Mucosal pallor
– Thrombocytopenia
• Petechia, spontaneous orprolonged bleeding
– Neutropenia
• Infection
- Viral, fungal, bacterial
• Ulceration
aplastic anemia
_____________
– Low platelet levels (CBC)
• Normal: 150,000-400,000 • Severe: <50,000
– Causes: decreased
production, destruction, medications, blood loss
– Prolonged bleeding, petechia
Thrombocytopenia
Oral manifestations of ______
• Petechia
• Spontaneous gingival bleeding
• Prolonged bleeding after
procedures
Thrombocytopenia
t/f: Before a treatment of a pt with Thrombocytopenia, it is important to have a recent CBC test with a platelet level of >50,000
true
t/f: avoid block injections for pts with Thrombocytopenia
true
– Missing or defective VWF (clotting protein)
• Required for platelet adhesion
– Most common inherited clotting disorder (1%
US population)
– Type 1 (20-50% normal levels), Type 2
(qualitative) , Type 3 (quantitative, severe
symptoms)
– SS: epistaxis, petechia, ecchymosis,
excessive/prolonged bleeding from invasive
procedures, hemarthrosis
– Tx: DDAVP (desmopressin)
Von Willebrand Disease
t/f: Avoid block injections for pts with Von Willebrand Disease. DO not be afraid to treat these pts. Well controlled pts know how to treat their bleeding.
true
\_\_\_\_\_\_\_ – Hemophilia A (Factor 8 deficiency) and B (Factor 9 deficiency) 1%-5%, severe <1% • X-linked recessive – Severity • Mild 6%-30% (A)or 49% (B), moderate – SS: prolonged or spontaneous bleeding, ecchymosis, hemarthrosis – Tx: factor infusions, DDAVP (A)
Hemophilia
–Antiplatelet agent –Reduce risk of MI and stroke –Increased risk of bleeding and bruising –Dental Management • Medication list to evaluate bleeding risk – Other anticoagulants • Local measures – Low risk of bleeding far outweighs interrupting Plavix treatment
Plavix (clopidogrel)
– Vitamin K antagonist – For patients with Afib, heart failure, prosthetic heart valves, stroke/MI history... – Common side effect: bleeding – Monitoring • PT/INR goals: 2.0-3.0 • Higher in patients with prosthetic heart valves (3.0-3.5) – Antidote • Vitamin K
Coumadin (warfarin)
–Dental Management
• Dental procedures are generally considered low risk of
bleeding
– Thromboembolic risk vs procedural bleeding risk
– Discussion with patients MD for procedures with higher risk of
bleeding
• Review INR (within 24 hours)
– INR: 2.0-3.0 dental treatment
• Local hemostatic measures
• Medications
– Many medication interactions due to narrow therapeutic range
– Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers
Coumadin (warfarin)
\_\_\_\_\_\_ meds: –Direct inhibitor of factor Xa and thrombin –Class of newer anticoagulants • Alternative to warfarin –Highly effective –No lab monitoring –Reversal agent –More expensive
Direct Oral Anticoagulants (DOAC) and Direct
Thrombin Inhibitors
The following are used as _____:
- Gauze
- Gelfoam
- Cellulose (surgicel and oxycel)
- Thrombin
- Tranexamic acid
- Amicar
Local hemostatic agents
What 3 hematologic diseases are nerve blocks contraindicated?
VWD
Thrombocytopenia
Hemophilia
• Cancer of WBCs • Affects bone marrow and circulating blood • Proliferation of WBCs which can be non-functional (blasts) or overtime overcrowd/suppress normal marrow production
Leukemia
• Causes Include: • Radiation • Chemotherapy • Genetic • Down syndrome • Diagnosis • CBC • Blood smear • Molecular studies • Treatment • Chemotherapy • Radiation • Targeted therapy • Hematopoietic stem cell transplant
Leukemia
• Signs and Symptoms • Fatigue, malaise, petechiae, ecchymoses, fever • Related to functional or treatment related neutropenia and thrombocytopenia • Oral Manifestations • Leukemia infiltrate • Spontaneous gingival bleeding • Oral ulceration (neutropenic ulcer, mucositis) • Infection • Viral, fungal, bacterial • Lymphadenopathy (chronic)
Leukemia
• Dental Management
• Urgent referral to PCP or emergency room for leukemic infiltrate-CBC,
smear, flow cytometry
• If Dx known:
• Thorough medical history
• Discussion with oncologist
• Current status and goals (comprehensive vs. palliative)
• Dental office vs hospital
• Timing of dental care-not on active chemotherapy for routine care
• Labs
• CBC
• Platelet: may require platelet transfusion due to
thrombocytopenia
• ANC-may require antibiotic prophylaxis for neutropenia (>500)
• Confirm patient is afebrile
• Local hemostatic measures for patients with thrombocytopenia
Leukemia
• Cancer of lymphoid organs and tissues • Hodgkin Lymphoma • Reed-Sternberg cell • Young adults • LAD • Non-tender, firm • >50% affect mediastinal or neck nodes • Non Hodgkin Lymphoma (NHL) • Median Age: 67 • B-symptoms • Fever, night sweats (drenching), weight loss (unintentional >10%) • Over 20 types • Diffuse Large B-cell (DLBCL) • Follicular
Lymphoma
- Causes Include
- Autoimmune diseases
- Hepatitis C
- EBV
- Sjogren syndrome
- Diagnosis
- Bone marrow or lymph node biopsy
- MRI for staging
- Treatment
- Chemotherapy
- Radiation
- Immunotherapy
- Stem cell transplant
- Watching
Lymphoma
• Oral Manifestations • LAD (Waldeyers ring, neck) • Extranodal involvement • Oral Ulceration • Localized infiltrate • Osteolytic radiographic lesions • Infection • Viral, fungal, bacterial • Treatment related • Head and Neck Radiation (lymphomas in head and neck region only) • Hyposalivation • Trismus • Osteonecrosis
Lymphoma
• Dental Management
– Similar to leukemia but risk for neutropenia and thrombocytopenia is lower and
generally treatment related (chemotherapy, radiation)
– Thorough medical history
– Discussion with oncologist
• Current status and goals (comprehensive vs. palliative)
• Dental office vs hospital
• Timing of dental care-not on active chemotherapy for routine care
– Labs
• CBC
– Platelet: may require platelet transfusion due to thrombocytopenia
– ANC-may require antibiotic prophylaxis for neutropenia (>500)
– Confirm patient is afebrile
– Local hemostatic measures for patients with thrombocytopenia
Lymphoma
• Cancer of plasma cells – Prevents normal production of antibodies • Signs and Symptoms – Hypercalcemia – Renal damage – Anemia – Bone pain – Infection • Treatment – Chemotherapy (RVD) – Bisphosphonates – Hematopoietic Stem Cell Transplant
Multiple myeloma
Which hematologic disease shows punched out radiolucencies?
Multiple myeloma
• Oral Manifestations – Plasmacytoma – Lytic bone lesions – Infection • Viral, fungal, bacterial – Treatment Related • Neuropathy • MRONJ (IV Zometa) • Radiographic – Thick lamina dura – Persistent extraction site – Sclerosis – Sequestra – Fracture
Multiple myeloma
• Dental Management – Disease related management • Soft tissue swelling, radiographic findings • Infection management • Pre-bisphosphonate exam – Medication related • MRONJ – Bisphosphonate history (number of doses, active) – Chlorhexidine rinses – Oral Hygiene – Antibiotic regimen – Sequestration • Surgical Procedures – Informed consent – As atraumatic as possible – Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis – Re-eval after surgical procedures to ensure healing
Multiple myeloma
• Infusion of stem cells to re-establish hematopoietic
function in patients whose bone marrow or immune
system is damaged or defective
• Treatment for solid or hematologic malignancies or other
hematologic disorders
Hematopoetic Stem Cell Transplant
________ Evaluation:
Dental Screening Goals
• Remove active foci of infection and limit potential foci of infection
• Dentition to be stable for at least 12 months
– Urgent care only for 12 months post transplant
– Risk of salivary GVHD and hyposalivationcaries
• Patient education about home care
• If planned correctly, pre-transplant evaluation + patient
compliance=dental maintenance
Pre-Transplant
Screening ______ HSCT
• Comprehensive hard and soft tissue exam
• Full mouth series of radiographs
• Treatment
– Scaling and prophylaxis
– Removal of caries
• Restorations
• Endodontic therapy
• Extractions
– Extraction of all hopeless teeth
& 3rd molars with hx periocoronitis
• Including teeth with questionable or poor prognosis
– Caries risk assessment and need for adjuncts (fluoride)
– Dental management based on primary disease
Dental Screening Pre-HSCT
___ graft:
Your Own bone marrow
Autologous
___ graft:
Someone else’s bone marrow
Allogeneic
___ graft:
Twin’s bone marrow
Syngenic
Oral Manifestations of \_\_\_\_\_\_\_\_ • Mucositis – Acute; resolves after engraftment • Bleeding – Petechiae, ecchymosis, hematoma • Infection – Viral (ex. HSV) – Fungal (ex. candidiasis) – Bacterial • Medication side effect/toxicities – Gingival hyperplasia (cyclosporine) – Oral ulceration (sirolimus) • Graft versus host disease – Mucosal (lichenoid changes) – Salivary-hyposalivation, caries • Increased risk of oral cancer
Oral Manifestations HSCT
• Dental Management ____ HPCT Transplant
– Thorough medical history
• Original diagnosis, date of transplant, immune suppression, GVHD
– Thorough clinical exam
• Hyposalivation, caries, infection, GVHD, oral cancer
– Discussion with oncologist
• Current status and goals (comprehensive vs. palliative)
• Dental office vs hospital
– Labs
• CBC-may require platelet transfusion due to thrombocytopenia
• ANC-may require antibiotic prophylaxis for neutropenia
– Medications
• Immune suppression (dose and length of tx)
• Bactrim-myelosuppression
• Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)
After transplant
