Hematologic Diseases Flashcards
what is anemia
a reduction in the oxygen carrying capacity of RBCs
- deficiency in the RBCs or of hemoglobin in the blood
what are the classifications of anemia based on
- causes: blood loss, inadequate production, excess destruction
- morphology: normocytic, microcytic, macrocytic
what is the lab test for anemia
CBC
what values are looked at in the CBC to diagnose anemia
- Hb
- hematocrit
- RBC indices
what is the Hb for men and women with anemia
- men: less than 13.5 g/dL
- women: less than 12.0 g/dL
what is the hematocrit for men and women with anemia
- less than 41% for men
- less than 36% for women
what are the RBC indices for anemia
- MCV
- MCH
- RDW
- MCHC
what types of anemia fall under microcytic anemia
- iron deficiency anemia
- thalassemias
what types of anemia fall under macrocytic anemia
- pernicious anemia
- folate deficiency
- B12 deficiency
what types of anemia fall under normocytic anemia
- hemolytic anemia
- sickle cell anemia
describe iron deficiency anemia
- microcytic anemia
- more common in womena of childbearing age and children
what are the causes of iron deficiency anemia
- blood loss
- poor iron intake
- poor iron absorption
- increased demand for iron
what are the types of macrocytic (megaloblastic) anemias
- folate deficiency
- cobalmin (B12) deficiency
what are the labs for iron defieciency anemia
- serum iron
- ferritin
- TIBC
- transferrin
describe folate deficiency and the labs for it
- 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
describe cobalmin (b12) deficiency and what labs are needed to dx
- pernicious anemia: deficiency of intrinsic factor which is necessary for B12 absorption
- nitrous oxide: irreversible inactivation of B12, neurologic symptoms
- labs: serum B12w
what are the systemic symptoms and signs of anemia
- symptoms: fatigue ,weakness, palpitations, SOB, angina, tingling in fingers and toes
- signs: pallor, splitting and spooning of fingernails
what are the oral manifestations of anemia
- atrophic glossitis with loss of tongue papillae, redness or cheilosis
- mucosal pallor
what is the dental management for anemia
- 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
what might be the causes of anemia
- GI bleed
- chronic inflammation
- pancytopenia
describe sickle cell anemia
- 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
what are the systemic signs and symptoms of sickle cell anemia
- 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
what is sickle cell crisis and what are the causes
- prolonged (hours- days) severe pain which may require hospitalization for pain management
- causes: infection, higher altitude (hypoxia), dehydration, trauma
what are the oral manifestations of sickle cell anemia
- mucosal pallor or jaundice
- papillary atrophy
- delayed tooth eruption
- aseptic bone and pulpal necrosis
- osteomyelitis
- neuropathy
what are the radiographic manifestations of sickle cell anemia
- 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
what is the dental management for sickle cell anemia
- 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
what is aplastic anemia and the tx
- bone marrow failure resulting in pancytopenia
- tx: hematopoietic cell transplant
what are the causes of aplastic anemia
- chemotherapy and radiation
- autoimmune diseases
- toxic chemicals (benzene)
- viral
- medications (methotrexate)
- inherited (fanconi anemia)
what are the oral manifestations of aplastic anemia
- 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
what is the dental management for aplastic anemia and bone marrow failure
- 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
what are the bleeding disorders
- platelet disorders
- inherited coagulation disorders
- medication related bleeding disorders
what are the platelet disorders
- thrombocytopenia
- Von Willebrand Disease
what dx for thrombocytopenia
- low platelet levels - CBC
- normal - 150,000-400,000
- severe: less than 50,000
- prolonged bleeding
- petechia
what are the causes of thrombocytopenia
- decreased production
- destruction
- medications
- blood loss
what are the oral manifestations of thrombocytopenia
- petechia
- spontaneous gingival bleeding
- prolonged bleeding after procedures
what is the dental management for thrombocytopenia
- 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
describe Von Willebrand disease and prevalaence and types
- 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)
what are the signs and symptoms and tx for VW disease
- S/S: epistaxis, petechia, ecchymosis, excessive/prolonged bleeding from invasive procedures, hemarthrosis
- tx: DDAVP (desmopressin)
what is the dental management for VW disease
- thorough med history
- discussion with patients MD
- avoid block injections
- local hemostatic measures
what are the inherited coagulation disorders
- hemophilia
what are the types of hemophilia
- A - factor 8 deficiency
- B - factor 9 deficiency
what is the inheritence pattern for hemophilia
X- linked recessive
what is the severity of hemophilia
- mild 6-30% (A) or 49% (B), moderate 1-5%, severe less than 1%w
what are the signs and symptoms of hemophilia and the tx
prolonged or spontaneous bleeding, ecchymosis, hemarthrosis
- tx: factor infusions, DDAVP (A)
what is the dental management for hemophilia
- thorough med hx
- discussion with patients hematologist
- avoid block injections
- local hemostatic measures
what are the medications that cause bleeding disorders
plavix and coumadin and direct oral anticoagulations (DOAC) and direct thrombin inhibitors
what does plavix do
- antiplatelet agent
- reduce risk of MI and stroke
- increased risk of bleeding and bruising
what is the dental management for plavix
- medication list to evaluate bleeding risk
- local measures- low risk of bleeding far outweighs interrupting plavix treatment
what is coumadin used for
- vitamin K antagonist
- for patients with Afib, heart failure, prosthetic heart valves, stroke/MI history
what is the common SE of coumadin
bleeding
what is the monitoring for coumadin
- PT/INR goals: 2-3
- higher in patients with prosthetic heart valves (3-3.5)
what is the antidote for coumadin
vitamin K
what are the dental management for coumadin
- 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
describe the DOAC and direct thrombin inhibitors
- direct inhibitors of factor Xa and thrombin
- class of newer anticoagulants- alternative to warfarin
- highly effective
- no lab monitoring
- reversal agent
- more expensive
what is the dental management for DOAC and direct thrombin inhibitors
- no lab monitoring
- bleeding risk for dental procedures seems to be low
- local hemostatic measures
what are the topical hemostatic agents used to control bleeding
- gauze
- gelfoam
- cellulose
- thrombin
- tranexamic acid
- amicar
what are the hematologic malignancies
- leukemia
- lymphoma
- myeloma
what is leukemia
- cancer of WBCs
- affects bone marrow and circualting blood
- proliferation of WBCs which can be non functional or overtime overcrowd/suppress normal marrow production
what is the classification of leukemia
- lineage: myeloid vs lymphoid
- timing: acute vs chronic
what are the types of leukeima
- acute myeloid (AML)
- chronic myeloid (CML)
- acute lymphocytic (ALL)
- chronic lymphocytic (CLL)
what are the causes of leukemia
- radiation
- chemotherapy
- genetic
- down syndrom
how is leukemia dx
- CBC
- blood smear
- molecular studies
what is the tx for leukemia
- chemotherapy
- radiation
- targeted therapy
- hematopoietic stem cell transplant
what are the signs and symptoms of leukemia
- fatigue, malaise, petechiae, ecchymoses, fever
- related to functional or treatment related neutropenia and thrombocytopenia
what are the oral manifestations of leukemia
- leukemia infiltrate
- spontaneous gingival bleeding
- oral ulceration (neutropenic ulcer, mucositis)
- infection (viral, fungal , bacterial)
- lymphadenopathy (chronic)
what is the dental management of leukemia
- 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
lymphoma is the cancer of:
lymphoid organs and tissues
what are the types of lymphoma
- hodgkin lymphoma
- non hodgkin lymphoma
describe hodgkin lymphoma
- reed-sternberg cell
- young adults
- LAD: non-tender, firm, more than 50% affect mediastinal or neck nodes
describe non hodgkin lymphoma
- 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
what are the causes of lymphoma
- autoimmunde diseases
- hep C
- EBV
- Sjogren syndrome
what is the dx of lymphoma
- bone marrow or lymph node biopsy
- MRI for staging
what is the tx for lymphoma
- chemotherapy
- radiation
- immunotherapy
- stem cell transplant
- watching
what is the B-cell NHL classification
- precursor -> naive -> follicular -> post GC -> plasma cell
what are the oral manifestations for lymphomas
- 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
what is the dental management for lymphoma
- 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
multiple myeloma is cancer of:
plasma cells- prevents normal production of antibodies
what are the signs and symptoms and tx for multiple myeloma
- S/S: hypercalcemia, renal damage, anemia, bone pain, infection
- tx: chemotherapy, bisphosphonates, hematopoietic stem cell transplant
what are the oral manifestations of multiple myeloma
- plasmacytoma
- lytic bone lesions
- infections: viral, fungal, bacterial
- treatment related: neuropathy, MRONJ, radiographic (thick lamina dura, persistent extraction site, sclerosis, sequestra, fracture_
what is the dental management for multiple myeloma
- 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)
what are hematopoetic stem cell transplants and what are they used for
- 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
what are the indications for hematopoetic stem cell transplants
- leukemia
- lymphoma
- multiple myeloma
- aplastic anemia
- fanconi anemia
- sickle cell anemia
what is included in the pre transplants evaluation
- history and physical
-blood workup - restaging studies
- infectious disease testing
- PPD, chest XR, EKG
- dental screening***
- fertility
what are the dental screnning goals in the pre transplant evaluation
- 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
what needs to be done in the dental screening pre -HSCT
- 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
what are the graft types
- autologous
- allogenic
- syngenic
describe autologous grafts, pros, cons, and indications
- 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
describe allogenic grafts, pros, cons, indicatison
- 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
describe syngenic grafts
receive bone marrow or PBSC from identical twin
what are the phases of transplant
- collection
- preparative regimen
- stem cell infusion
- engraftment
what are the donor sources for hematopoietic stem cell transplants
- bone marrow
- peripheral blood
- cord blood
what are the oral manifestations of HSCT
- 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
what is the dental management after transplant
- 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
