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Dental Mgmt of Medically Compromised Pts > Hematologic Diseases > Flashcards

Hematologic Diseases Flashcards

1
Q

_____: Reduction in the oxygen carrying capacity of
RBCs; deficiency in red blood cells or of
hemoglobin in the blood

A

anemia

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2
Q 
Classification of \_\_\_\_\_\_
– Causes 
• Blood Loss
• Inadequate production
• Excess destruction 
– Morphology
• Normocytic
• Microcytic
• Macrocytic
A

anemia

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3
Q 
Lab Test for anemia: 
\_\_\_\_\_\_\_\_ (\_\_\_\_ \_\_\_\_ \_\_\_\_) 
• Hb*
• Hematocrit*
• WBC
• Platelet
• RBC indices*
A

CBC (Complete Blood Count)

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4
Q

Concentration of hemoglobin

A

Hb for CBC test

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5
Q

Packed cell volume

A

Hematocrit for CBC test

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6
Q

_____ _______ withinn the CBC

  • MCV (mean corpuscular volume)
  • MCH (mean cell hemoglobin)
  • RDW (red cell distribution width)
  • MCHC (mean cell hemoglobin concentration)
A

RBC indicies

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7
Q

The following are examples of what size type of Anemia??
– Iron Deficiency Anemia
– Thalassemias

A

microcytic

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8
Q

The following are examples of what size type of Anemia??

– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency

A

Macrocytic

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9
Q

The following are examples of what size type of Anemia??

– Hemolytic Anemia
– Sickle Cell Anemia

A

normocytic

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10
Q

______ _____ 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
A

Iron Deficiency Anemia

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11
Q

____ ______ 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

A

Folate Deficiency

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12
Q

______ ______ 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

A

Cobalamin (B12) Deficiency

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13
Q

___ ____ is contradindicated for pts with B12 definiency because it causes the Irreversible inactivation of B12

A

Nitrous Oxide

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14
Q

________ Manifestations of Anemia

– Symptoms: Fatigue, weakness,
palpitations, SOB, angina, tingling of fingers and toes
– Signs: pallor, splitting and
spooning of fingernails

A

systemic

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15
Q

_______ manifestations of Anemia

– Atrophic glossitis with loss on
tongue papillae, redness or cheilosis
– Mucosal pallor

A

Oral

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16
Q

t/f: anemic pts Generally tolerate routine dental treatment well

A

true

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17
Q

t/f: Severe anemia (cardiopulmonary symptoms)
– Defer routine dental care
– Pulse oximeter and supplemental oxygen
– Avoid strong narcotics

A

true

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18
Q

______ _____ _____:

• Autosomal recessive inherited
disorder
• RBC sickling in low oxygen or low
blood pH environments
• Erythrostasis, increased blood
viscosity, reduced blood flow,
vascular occlusion, hypoxiamore
sickling
A

Sickle Cell Anemia

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19
Q

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

A

Sickle Cell Anemia

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20
Q

the following are oral manifestations of which disease??

– Mucosal pallor or jaundice
– Papillary atrophy
– Delayed tooth eruption
– Aseptic bone and pulpal necrosis 
– Osteomyelitis
– Neuropathy
A

Sickle Cell Anemia

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21
Q

What are the radiohgraphic findings of Sickle Cell Anemia

A

• Increased widening and
decreased number of
trabeculations

  • “Stepladder” trabeculae
  • “Hair on end”
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22
Q

– 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

A

Dental Management of sickle cell anemia

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23
Q

– 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)

A

Dental Management of Sickle cell anemia

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24
Q

this type of anemia is Bone marrow failure resulting in

pancytopenia (decrease in all three blood cell types)

A

Aplastic anemia

25
Q

How do you treat aplastic anemia?

A

– Hematopoietic cell transplant

26
Q

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

A

aplastic anemia

27
Q

_____________

– Low platelet levels (CBC)
• Normal: 150,000-400,000 • Severe: <50,000
– Causes: decreased
production, destruction, medications, blood loss
– Prolonged bleeding, petechia

A

Thrombocytopenia

28
Q

Oral manifestations of ______

• Petechia
• Spontaneous gingival bleeding
• Prolonged bleeding after
procedures

A

Thrombocytopenia

29
Q

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

A

true

30
Q

t/f: avoid block injections for pts with Thrombocytopenia

A

true

31
Q

– 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)

A

Von Willebrand Disease

32
Q

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.

A

true

33
Q 
\_\_\_\_\_\_\_ 
– 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)
A

Hemophilia

34
Q 
–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
A

Plavix (clopidogrel)

35
Q 
– 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
A

Coumadin (warfarin)

36
Q

–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

A

Coumadin (warfarin)

37
Q 
\_\_\_\_\_\_ meds:
–Direct inhibitor of factor Xa and thrombin
–Class of newer anticoagulants 
• Alternative to warfarin
–Highly effective
–No lab monitoring
–Reversal agent
–More expensive
A

Direct Oral Anticoagulants (DOAC) and Direct

Thrombin Inhibitors

38
Q

The following are used as _____:

  • Gauze
  • Gelfoam
  • Cellulose (surgicel and oxycel)
  • Thrombin
  • Tranexamic acid
  • Amicar
A

Local hemostatic agents

39
Q

What 3 hematologic diseases are nerve blocks contraindicated?

A

VWD
Thrombocytopenia
Hemophilia

40
Q 
• 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
A

Leukemia

41
Q 
• Causes Include: 
• Radiation
• Chemotherapy
• Genetic
• Down syndrome
• Diagnosis
• CBC
• Blood smear
• Molecular studies
• Treatment
• Chemotherapy
• Radiation
• Targeted therapy
• Hematopoietic stem cell 
transplant
A

Leukemia

42
Q 
• 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)
A

Leukemia

43
Q

• 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

A

Leukemia

44
Q 
• 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
A

Lymphoma

45
Q
  • 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
A

Lymphoma

46
Q 
• 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
A

Lymphoma

47
Q

• 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

A

Lymphoma

48
Q 
• 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
A

Multiple myeloma

49
Q

Which hematologic disease shows punched out radiolucencies?

A

Multiple myeloma

50
Q 
• 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
A

Multiple myeloma

51
Q 
• 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
A

Multiple myeloma

52
Q

• 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

A

Hematopoetic Stem Cell Transplant

53
Q

________ 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 hyposalivationcaries
• Patient education about home care
• If planned correctly, pre-transplant evaluation + patient
compliance=dental maintenance

A

Pre-Transplant

54
Q

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

A

Dental Screening Pre-HSCT

55
Q

___ graft:

Your Own bone marrow

A

Autologous

56
Q

___ graft:

Someone else’s bone marrow

A

Allogeneic

57
Q

___ graft:

Twin’s bone marrow

A

Syngenic

58
Q 
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
A

Oral Manifestations HSCT

59
Q

• 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)

A

After transplant

Dental Mgmt of Medically Compromised Pts (12 decks)

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