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Dental Management of the Medically Complex Patient > Hematologic Diseases > Flashcards

Hematologic Diseases Flashcards

1
Q

what is anemia

A

a reduction in the oxygen carrying capacity of RBCs
- deficiency in the RBCs or of hemoglobin in the blood

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2
Q

what are the classifications of anemia based on

A
  • causes: blood loss, inadequate production, excess destruction
  • morphology: normocytic, microcytic, macrocytic
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3
Q

what is the lab test for anemia

A

CBC

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4
Q

what values are looked at in the CBC to diagnose anemia

A
  • Hb
  • hematocrit
  • RBC indices
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5
Q

what is the Hb for men and women with anemia

A
  • men: less than 13.5 g/dL
  • women: less than 12.0 g/dL
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6
Q

what is the hematocrit for men and women with anemia

A
  • less than 41% for men
  • less than 36% for women
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7
Q

what are the RBC indices for anemia

A
  • MCV
  • MCH
  • RDW
  • MCHC
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8
Q

what types of anemia fall under microcytic anemia

A
  • iron deficiency anemia
  • thalassemias
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9
Q

what types of anemia fall under macrocytic anemia

A
  • pernicious anemia
  • folate deficiency
  • B12 deficiency
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10
Q

what types of anemia fall under normocytic anemia

A
  • hemolytic anemia
  • sickle cell anemia
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11
Q

describe iron deficiency anemia

A
  • microcytic anemia
  • more common in womena of childbearing age and children
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12
Q

what are the causes of iron deficiency anemia

A
  • blood loss
  • poor iron intake
  • poor iron absorption
  • increased demand for iron
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13
Q

what are the types of macrocytic (megaloblastic) anemias

A
  • folate deficiency
  • cobalmin (B12) deficiency
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13
Q

what are the labs for iron defieciency anemia

A
  • serum iron
  • ferritin
  • TIBC
  • transferrin
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14
Q

describe folate deficiency and the labs for it

A
  • 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
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15
Q

describe cobalmin (b12) deficiency and what labs are needed to dx

A
  • pernicious anemia: deficiency of intrinsic factor which is necessary for B12 absorption
  • nitrous oxide: irreversible inactivation of B12, neurologic symptoms
  • labs: serum B12w
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16
Q

what are the systemic symptoms and signs of anemia

A
  • symptoms: fatigue ,weakness, palpitations, SOB, angina, tingling in fingers and toes
  • signs: pallor, splitting and spooning of fingernails
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17
Q

what are the oral manifestations of anemia

A
  • atrophic glossitis with loss of tongue papillae, redness or cheilosis
  • mucosal pallor
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18
Q

what is the dental management for anemia

A
  • generally tolerate routine dental care well
  • severe anemia (cardiopulm symptoms): defer routine care, pulse oximeter and supplemental O2, avoid strong narcotics
  • avoid long N2O exposure in patients with B12 deficiency
  • identifying signs and symptoms of anemia- find the cause
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19
Q

what might be the causes of anemia

A
  • GI bleed
  • chronic inflammation
  • pancytopenia
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20
Q

describe sickle cell anemia

A
  • autosomal recessive inherited disorder
  • RBC sickling in low O2 or low blood pH environments
  • erythrostasis, increased blood viscosity, reduced blood flow, vascular occlusion, hypoxia -> more sickling
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21
Q

what are the systemic signs and symptoms of sickle cell anemia

A
  • 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
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22
Q

what is sickle cell crisis and what are the causes

A
  • prolonged (hours- days) severe pain which may require hospitalization for pain management
  • causes: infection, higher altitude (hypoxia), dehydration, trauma
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23
Q

what are the oral manifestations of sickle cell anemia

A
  • mucosal pallor or jaundice
  • papillary atrophy
  • delayed tooth eruption
  • aseptic bone and pulpal necrosis
  • osteomyelitis
  • neuropathy
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24
Q

what are the radiographic manifestations of sickle cell anemia

A
  • radiographically:
  • increased widening and decreased number of trabeculations
  • generalized osteoporosis ( thinning of inferior border of the mandible)
  • trabeculations and lamina dura appear more prominent
  • stepladder trabeculae
  • hair on end
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25
Q

what is the dental management for sickle cell anemia

A
  • routine dental care during non-crisis states
  • keep appointments short to reduce stress
  • emphasiss on OH instructions to reduce risk of infection - if infection occurs use IM or IV antibiotics
  • anesthetic: avoid prilocaine, epinephrine 1:100,000- no stronger concentration. may consider using LA without epi
  • monitor oxygen saturation when using NO, provide oxygen at greater than 50% with high flow rates
  • AB prophylaxis for majro surgical proceudres
  • pain management: consult their primary care or hematologist
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26
Q

what is aplastic anemia and the tx

A
  • bone marrow failure resulting in pancytopenia
  • tx: hematopoietic cell transplant
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27
Q

what are the causes of aplastic anemia

A
  • chemotherapy and radiation
  • autoimmune diseases
  • toxic chemicals (benzene)
  • viral
  • medications (methotrexate)
  • inherited (fanconi anemia)
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28
Q

what are the oral manifestations of aplastic anemia

A
  • anemia: atrophic glossitis with loss of tongue papillae, redness or cheilosis, mucosal pallor
  • thrombocytopenia: petechia, spontaneous or prolonged bleeding
  • neutropenia: infectsion (viral, fungal, bacterial), ulceration
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29
Q

what is the dental management for aplastic anemia and bone marrow failure

A
  • thorough med history
  • discussion with oncologist
  • defere routine care
  • labs: CBC, platelets may require transfusion, ANC - may require AB prophylaxis
  • confirm pt is afebrile
  • local hemostatic measures for patients with thrombocytopenia
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30
Q

what are the bleeding disorders

A
  • platelet disorders
  • inherited coagulation disorders
  • medication related bleeding disorders
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31
Q

what are the platelet disorders

A
  • thrombocytopenia
  • Von Willebrand Disease
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32
Q

what dx for thrombocytopenia

A
  • low platelet levels - CBC
  • normal - 150,000-400,000
  • severe: less than 50,000
  • prolonged bleeding
  • petechia
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33
Q

what are the causes of thrombocytopenia

A
  • decreased production
  • destruction
  • medications
  • blood loss
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34
Q

what are the oral manifestations of thrombocytopenia

A
  • petechia
  • spontaneous gingival bleeding
  • prolonged bleeding after procedures
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35
Q

what is the dental management for thrombocytopenia

A
  • thorough med hx
  • cause of thrombocytopenia
  • may defer routine dental care
  • CBC- recent less than 24 hours, platelets more than 50,000
  • discussion with patients MD
  • avoid block injections
  • local hemostatic measures
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36
Q

describe Von Willebrand disease and prevalaence and types

A
  • missing or defective VWF required for platelet adhesion
  • most common inherited clotting disorder (1% of US population)
  • type 1 (20-50% normal levels), type 2 (qualitative), type 3 (quantitative, severe symptoms)
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37
Q

what are the signs and symptoms and tx for VW disease

A
  • S/S: epistaxis, petechia, ecchymosis, excessive/prolonged bleeding from invasive procedures, hemarthrosis
  • tx: DDAVP (desmopressin)
38
Q

what is the dental management for VW disease

A
  • thorough med history
  • discussion with patients MD
  • avoid block injections
  • local hemostatic measures
39
Q

what are the inherited coagulation disorders

A
  • hemophilia
40
Q

what are the types of hemophilia

A
  • A - factor 8 deficiency
  • B - factor 9 deficiency
41
Q

what is the inheritence pattern for hemophilia

A

X- linked recessive

42
Q

what is the severity of hemophilia

A
  • mild 6-30% (A) or 49% (B), moderate 1-5%, severe less than 1%w
43
Q

what are the signs and symptoms of hemophilia and the tx

A

prolonged or spontaneous bleeding, ecchymosis, hemarthrosis
- tx: factor infusions, DDAVP (A)

44
Q

what is the dental management for hemophilia

A
  • thorough med hx
  • discussion with patients hematologist
  • avoid block injections
  • local hemostatic measures
45
Q

what are the medications that cause bleeding disorders

A

plavix and coumadin and direct oral anticoagulations (DOAC) and direct thrombin inhibitors

46
Q

what does plavix do

A
  • antiplatelet agent
  • reduce risk of MI and stroke
  • increased risk of bleeding and bruising
47
Q

what is the dental management for plavix

A
  • medication list to evaluate bleeding risk
  • local measures- low risk of bleeding far outweighs interrupting plavix treatment
48
Q

what is coumadin used for

A
  • vitamin K antagonist
  • for patients with Afib, heart failure, prosthetic heart valves, stroke/MI history
49
Q

what is the common SE of coumadin

A

bleeding

50
Q

what is the monitoring for coumadin

A
  • PT/INR goals: 2-3
  • higher in patients with prosthetic heart valves (3-3.5)
51
Q

what is the antidote for coumadin

A

vitamin K

52
Q

what are the dental management for coumadin

A
  • dental procedures are generally considered low risk of bleeding
  • thromboembolic risk vs procedural bleeding risk
    -review INR within 24 hours: needs to be 2-3
  • local hemostatic measures
  • medications: many medication interactions due to narrow therapeutic range
  • avoid cytochrome P -450 inhibitors and inducers
53
Q

describe the DOAC and direct thrombin inhibitors

A
  • direct inhibitors of factor Xa and thrombin
  • class of newer anticoagulants- alternative to warfarin
  • highly effective
  • no lab monitoring
  • reversal agent
  • more expensive
54
Q

what is the dental management for DOAC and direct thrombin inhibitors

A
  • no lab monitoring
  • bleeding risk for dental procedures seems to be low
  • local hemostatic measures
55
Q

what are the topical hemostatic agents used to control bleeding

A
  • gauze
  • gelfoam
  • cellulose
  • thrombin
  • tranexamic acid
  • amicar
56
Q

what are the hematologic malignancies

A
  • leukemia
  • lymphoma
  • myeloma
57
Q

what is leukemia

A
  • cancer of WBCs
  • affects bone marrow and circualting blood
  • proliferation of WBCs which can be non functional or overtime overcrowd/suppress normal marrow production
58
Q

what is the classification of leukemia

A
  • lineage: myeloid vs lymphoid
  • timing: acute vs chronic
59
Q

what are the types of leukeima

A
  • acute myeloid (AML)
  • chronic myeloid (CML)
  • acute lymphocytic (ALL)
  • chronic lymphocytic (CLL)
60
Q

what are the causes of leukemia

A
  • radiation
  • chemotherapy
  • genetic
  • down syndrom
61
Q

how is leukemia dx

A
  • CBC
  • blood smear
  • molecular studies
62
Q

what is the tx for leukemia

A
  • chemotherapy
  • radiation
  • targeted therapy
  • hematopoietic stem cell transplant
63
Q

what are the signs and symptoms of leukemia

A
  • fatigue, malaise, petechiae, ecchymoses, fever
  • related to functional or treatment related neutropenia and thrombocytopenia
64
Q

what are the oral manifestations of leukemia

A
  • leukemia infiltrate
  • spontaneous gingival bleeding
  • oral ulceration (neutropenic ulcer, mucositis)
  • infection (viral, fungal , bacterial)
  • lymphadenopathy (chronic)
65
Q

what is the dental management of leukemia

A
  • urgent referral to PCP or emergency room for leukemic infiltrate
  • thorough med hx
  • discussion with oncologist
  • labs: CBC
  • confirm pt is afebrile
  • local hemostatic measures for pt with thrombocytopenia
66
Q

lymphoma is the cancer of:

A

lymphoid organs and tissues

67
Q

what are the types of lymphoma

A
  • hodgkin lymphoma
  • non hodgkin lymphoma
68
Q

describe hodgkin lymphoma

A
  • reed-sternberg cell
  • young adults
  • LAD: non-tender, firm, more than 50% affect mediastinal or neck nodes
69
Q

describe non hodgkin lymphoma

A
  • median age:67
  • B- symptoms: fever, night sweats (drenching), weight loss ( unintentional more than 10% of the time)
  • over 20 types: diffuse large B-cell, follicular
70
Q

what are the causes of lymphoma

A
  • autoimmunde diseases
  • hep C
  • EBV
  • Sjogren syndrome
71
Q

what is the dx of lymphoma

A
  • bone marrow or lymph node biopsy
  • MRI for staging
72
Q

what is the tx for lymphoma

A
  • chemotherapy
  • radiation
  • immunotherapy
  • stem cell transplant
  • watching
73
Q

what is the B-cell NHL classification

A
  • precursor -> naive -> follicular -> post GC -> plasma cell
74
Q

what are the oral manifestations for lymphomas

A
  • LAD (waldeyers ring, neck)
  • extranodal involvement: oral ulceration, localized infiltrate, osteolytic radiographic lesions
  • infection: viral, fungal, bacterial
  • treatment related: head and neck radiation: hyposalivation, trismus, osteonecrosis
75
Q

what is the dental management for lymphoma

A
  • similar to leukemia but risk for neutropenia and thrombocytopenia is lower and generally treatment related
  • thorough med hx
  • discussion with oncologist
    = labs: CBC
  • confirm pt is afebrile
  • local hemostatic measures
76
Q

multiple myeloma is cancer of:

A

plasma cells- prevents normal production of antibodies

77
Q

what are the signs and symptoms and tx for multiple myeloma

A
  • S/S: hypercalcemia, renal damage, anemia, bone pain, infection
  • tx: chemotherapy, bisphosphonates, hematopoietic stem cell transplant
78
Q

what are the oral manifestations of multiple myeloma

A
  • plasmacytoma
  • lytic bone lesions
  • infections: viral, fungal, bacterial
  • treatment related: neuropathy, MRONJ, radiographic (thick lamina dura, persistent extraction site, sclerosis, sequestra, fracture_
79
Q

what is the dental management for multiple myeloma

A
  • disease related management: soft tissue swelling, radiographic findings, infection management, pre-bisphosphonate exam
  • medication related: MRONJ ( bisphosphonate hx, chlorhexidine rinses, OH, AB regimen, sequestration) and surgical procedures ( informed consent, as atraumatic as possible, post surgical instructions such as AB rinses and prophylaxis, re-eval after procedures)
80
Q

what are hematopoetic stem cell transplants and what are they used for

A
  • infusion of stem cells to restablish hematopoietic function in patients whose bone marrow or immune system is damaged or defective
  • treatment for solid or hematologic malignancies or other hematologic disorders
81
Q

what are the indications for hematopoetic stem cell transplants

A
  • leukemia
  • lymphoma
  • multiple myeloma
  • aplastic anemia
  • fanconi anemia
  • sickle cell anemia
82
Q

what is included in the pre transplants evaluation

A
  • history and physical
    -blood workup
  • restaging studies
  • infectious disease testing
  • PPD, chest XR, EKG
  • dental screening***
  • fertility
83
Q

what are the dental screnning goals in the pre transplant evaluation

A
  • remove active foci of infection and limit potential foci of infection
  • dentition to be stable for at least 12 months
  • patient education about home care
  • if planned correctly, pre transplant evaluation + patient compliance = dental maintenance
84
Q

what needs to be done in the dental screening pre -HSCT

A
  • comprehensive hard and soft tissue exam
  • full mouth series of radiographs
  • tx: scaling and prophylaxis, removal of caries (restorations, endo therapy, extractions),
  • extraction of all hopeless teeth and 3rd molars with hx of pericoronitis
  • caries risk assessment and need for adjuncts
  • dental management based on primary disease
85
Q

what are the graft types

A
  • autologous
  • allogenic
  • syngenic
86
Q

describe autologous grafts, pros, cons, and indications

A
  • receive own bone marrow or PBSC, “stem cell rescue”
  • pros: no HLA matching, no GVHD, immune suppression
  • cons: contamination of cells, no graft vs tumor, higher risk of relapse
  • indications: lymphoma, mulitple myeloma
87
Q

describe allogenic grafts, pros, cons, indicatison

A
  • donor: relative, unrelated
  • pros: graft free from tumor, graft versus tumor, lower risk of relapse
  • cons: matching, GVHD, higher risk of complication
  • indications include: leukemia, MDS, aplastic anemia, high grade lymphoma
88
Q

describe syngenic grafts

A

receive bone marrow or PBSC from identical twin

89
Q

what are the phases of transplant

A
  • collection
  • preparative regimen
  • stem cell infusion
  • engraftment
90
Q

what are the donor sources for hematopoietic stem cell transplants

A
  • bone marrow
  • peripheral blood
  • cord blood
91
Q

what are the oral manifestations of HSCT

A
  • mucositis: acute, resolves after engraftment
  • bleeding: petechiae, ecchymosis, hematoma
  • infection: viral, fungal , bacterial
  • medication side effect/toxicities: gingival hyperplasia, oral ulceration
  • graft versus host disease: mucosal, salivary hyposalivation, caries
  • increased risk of oral cancer
92
Q

what is the dental management after transplant

A
  • thorough med hx
  • thorough clinical exam
  • discussion with oncologist
  • labs: CBC, ANC
  • medications: bactrim causes myelosuppression, avoid meds that are cytochrome P450 inhibitors for pateints on immunosuppressants with low therapeutic index such as tacrolimus and fluconazole
93
Q
A

Dental Management of the Medically Complex Patient (13 decks)

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