hematologic dx Flashcards
anemia
Reduction in the oxygen carrying capacity of RBCs; deficiency in red blood cells or of hemoglobin in the blood
anemia classifeid by:
cause and morphology
anemia causes
- Blood Loss
- Inadequate production
- Excess destruction
anemia morph
- Normocytic
- Microcytic
- Macrocytic
anemia lab test
shorthand?
** CBC (Complete Blood Count): **
* Hb
* Hematocrit*
* WBC
* Platelet
* RBC indices*
anemic Hb values
<13.5 g/dL (men) or <12.0 g/dL (women)
anemic hematocrit values
<41.0% (men) or <36.0% (women)
RBC indices*
- MCV (mean corpuscular volume)= size
- MCH (mean cell hemoglobin)= color
- RDW (red cell distribution width)= sixe distribution
- MCHC (mean cell hemoglobin concentratio
- Microcytic anemias
– Iron Deficiency Anemia
– Thalassemias
macrocytic anemias
– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency
normocytic anemias
– Hemolytic Anemia
– Sickle Cell Anemia
Iron Deficiency Anemia
* cells app?
* More common in?
* Causes:
* Labs:
- 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
- Folate Deficiency, cell size?
– stored in the body?
– Deficiency during pregnancy?
– Labs:
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
Cobalamin (B12) Deficiency
* Deficiency of?
* dental office agent of etiology? effects?
– Labs:
– AKA Pernicious Anemia, macrocytic
* Deficiency of intrinsic factor which is necessary for B12 absorption
– Nitrous Oxide:
* Irreversible inactivation of B12
* Neurologic symptoms
– Labs: Serum B12
systemic presentation of anemia
signs and symptoms
– Symptoms: Fatigue, weakness, palpitations, SOB, angina, tingling of fingers and toes
– Signs: pallor, splitting and spooning of fingernails
oral manifestations of anemia
– Atrophic glossitis with loss on tongue papillae, redness or cheilosis
– Mucosal pallor
anemia pts and dental tx
–Generally tolerate routine dental treatment well unless severe
severe anemia pts
- Severe anemia (cardiopulmonary symptoms)
–Defer routine dental care
–Pulse oximeter and supplemental oxygen
–Avoid strong narcotics
what should be avoidied in pts with b12 def
NO
What is important to determine in anemic pts?
- Important to find the cause!
–GI bleed, chronic inflammation pancytopenia
Sickle Cell Anemia
* inheritance?
* RBC sickling in what environments?
* results on hemodynamics?
- 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
Sickle Cell Anemia
* Systemic Signs and Symptoms:
– Result of?
– skin app?
– ulceration where?
– Cardiac?
– Delays in?
– Pain where/ why?
– crisis?
– Result of chronic anemia and small blood vessel occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac: Cardiac failure and Stroke
– Delays in growth and Development
– Pain: Abdominal (splenomegly) and Bone (aseptic necrosis)
– Sickle cell crisis
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
* Oral Manifestations
–Mucosal?
–Papilla?
–Delayed?
–Aseptic bone and pulpal?
– bone?
–Neuro?
–Mucosal pallor or jaundice
–Papillary atrophy
–Delayed tooth eruption
–Aseptic bone and pulpal necrosis
–Osteomyelitis
–Neuropathy
radiogrpahic findings with sickle cell
- Increased widening and decreased number of trabeculations
- Generalized osteoporosis (thinning of the inferior border of the mandible)
- Trabeculations and lamina dura appear more prominent
- “Stepladder” trabeculae
- “Hair on end
sickle cell pt dental care
– non-crisis states
– appt length?
– Emphasis on? infections?
– 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
sickle cell anesthetic
* Avoid what LA
* Epinephrine concentration?
* May consider using LA without?
- Avoid prilocaine
- Epinephrine 1:100,000-no stronger concentration
- May consider using LA without epinephrine
sickle cell O2 in appt
– Monitor oxygen saturation, when using nitrous oxide, provide oxygen at greater than 50% with high flow rates
with major surgical operations what should be done with sickle cell pts
Abx prophylaxis
pain control with sickle cell
Pain management: consult their primary care or hematologist (opioid contract)
Aplastic Anemia
* Causes
* Treatment
- Bone marrow failure resulting in pancytopenia
- Causes:
– Chemotherapy and radiation
– Autoimmune diseases
– Toxic chemicals (benzene)
– Viral
– Medications (methotrexate)
– Inherited (Fanconi anemia) - Treatment– Hematopoietic cell transplant
Aplastic Anemia oral manifestationa due to anemia
- Atrophic glossitis with loss on tongue papillae, redness or cheilosis
- Mucosal pallor
aplastic anemia oral manifestations due to thrombocytopenia
- Petechia, spontaneous or prolonged bleeding
aplastic anemia oral manifestations due to neutropenia
- Infection – Viral, fungal, bacterial
- Ulceration
Aplastic Anemia & Bone Marrow Failure dental management:
* Thorough?
* Discussion with?
* Defer?
*setting?
- Thorough medical history
- Discussion with oncologist: Current status and goals
- Defer routine care
- Dental office vs hospital *
Aplastic Anemia & Bone Marrow Failure labs
* CBC
* Platelet: may require platelet transfusion due to
thrombocytopenia
* ANC-may require antibiotic prophylaxis for neutropenia (<500)
Aplastic Anemia & Bone Marrow Failure
* Confirm patient is?
* Local hemostatic measures when pt is?
- Confirm patient is afebrile
- Local hemostatic measures for patients with thrombocytopenia
- Thrombocytopenia
–Causes
–result
–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
- Petechia
- Spontaneous gingival bleeding
- Prolonged bleeding after procedures
Thrombocytopenia
– Dental Management:
* Thorough?
* routine dental care?
* CBC?
* Discussion with?
* Avoid?
* Local measures?
- Thorough medical history
- May defer routine dental care
- CBC
- Discussion with patient’s MD
- Avoid block injections
- Local hemostatic measures
thrombocytopenia med hx
– Cause of thrombocytopenia (acute cause? chronic cause?)
– Bleeding history, transfusion history
CBC results with thrombocytopenia
– Recent (<24 hours)
– Platelet >50,000 for most dental procedures reduces risk
– Higher for invasive surgical procedures (ex. multiple extractions)
thrombocytopenia MD discussion
– Platelet transfusions, timing
– Dental office vs hospital (<50,000 more appropriate in hospital setting)
- Von Willebrand Disease
commonality?
– Missing or defective VWF (clotting protein)
* Required for platelet adhesion
– Most common inherited clotting disorder (1%
US population)
VWD types
– Type 1 (20-50% normal levels), Type 2 (qualitative), Type 3 (quantitative, severe symptoms)
VWD signs and symptoms
– SS: epistaxis, petechia, ecchymosis, excessive/prolonged bleeding from invasive procedures, hemarthrosis
VWD tx
Tx: DDAVP (desmopressin)
- Von Willebrand Disease
–Dental Management
- Thorough medical history/bleeding history and physical exam
- Discussion with patient’s MD
- Avoid block injections
- Local hemostatic measures
Von Willebrand Disease Discussion with patient’s MD
– Confirm history and severity of disease
– DDAVP, aminocaproic acid
– Dental office vs hospital
- Hemophilia types/inheritence/severity?
–Hemophilia A (Factor 8 deficiency) and B (Factor 9 deficiency)
* X-linked recessive
–Severity
* Mild 6%-30% (A) or 49% (B), moderate 1%-5%, severe <1%
SS of hemophilia
prolonged or spontaneous
bleeding, ecchymosis, hemarthrosis
hemoplhilia tx
factor infusions, DDAVP (A)
- Hemophilia
–Dental Management
- Thorough medical history/bleeding history and physical exam
- Discussion with patient’s hematologist
- Avoid block injections
- Local hemostatic measures
- Hemophilia discussion with MD
– Confirm history and severity of disease
– Dental office vs hospital
– Factor infusions, aminocaproic acid
Plavix (clopidogrel)
–agent for?
–Reduce risk of?
–Increased risk of?
–Antiplatelet agent
–Reduce risk of MI and stroke
–Increased risk of bleeding and bruising
- Plavix (clopidogrel)–Dental Management
- Medication list to evaluate bleeding risk
– Other anticoagulants - Local measures– Low risk of bleeding far outweighs interrupting Plavix treatment
- Coumadin (warfarin)
– mech?
– For patients with?
– Common side effect:
– Vitamin K antagonist
– For patients with Afib, heart failure, prosthetic heart valves, stroke/MI history…
– Common side effect: bleeding
warfarin monitoring
* PT/INR goals:
* Higher in patients with?
- PT/INR goals: 2.0-3.0
- Higher in patients with prosthetic heart valves (3.0-3.5)
antidote for warfarin
K
- Coumadin (warfarin)
–Dental Management
- Dental procedures are generally considered low risk of bleeding
- Review INR (within 24 hours) (<3)
- Local hemostatic measures
- Medications interactions
dental tx bleeding with warfarin
- 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
warfarin med intreactions
– Many medication interactions due to narrow therapeutic range
– Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers
- Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors
–Direct inhibitor of?
–Class of? - Alternative to?
– effective?
lab monitoring?
–Reversal?
–cost?
–Direct inhibitor of factor Xa and thrombin
–Class of newer anticoagulants
* Alternative to warfarin
–Highly effective
–No lab monitoring
–Reversal agent
–More expensive
- DOAC and Direct Thrombin Inhibitors
–Dental Management
- No lab monitoring
- Bleeding risk for dental procedures seems to be low
- Local hemostatic measures
good local measures for bleeding pts
gauze, gelfoam, cellulose, thrombin, tranexamic acid, amicar
Hematologic Malignancies
- Leukemia
- Lymphoma
- Myeloma
Leukemia
* Cancer of?
* Affects?
* Proliferation of WBCs which can be? Or?
- 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 classes
- Lineage: Myeloid vs Lymphoid
- Timing: Acute vs Chronic
common leukemias
- Acute Myeloid (AML)
- Chronic Myeloid (CML)
- Acute Lymphocytic (ALL)
- Chronic Lymphocytic (CLL)
acute forms more likely to be symptomatic
Leukemia causes
- Radiation
- Chemotherapy
- Genetic
- Down syndrome
leukiemia diagnosis
- CBC
- Blood smear
- Molecular studies
leukemia tx
- 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
Leukemia oral manifestations
- Leukemia infiltrate
- Spontaneous gingival bleeding
- Oral ulceration (neutropenic ulcer, mucositis)
- Infection: Viral, fungal, bacterial
- Lymphadenopathy (chronic)
leukemia dental management
* dx unknown/suspected?
* If Dx known:
- Urgent referral to PCP or emergency room for leukemic infiltrate-CBC, smear, flow cytometry
- If Dx known:
- Thorough medical history
- Discussion with oncologist
1. * Current status and goals (comprehensive vs. palliative)
1. * Dental office vs hospital
1. * Timing of dental care-not on active chemotherapy for routine care
important labs of leukemia
* CBC
* Platelet: may require platelet transfusion due to
thrombocytopenia
* ANC-may require antibiotic prophylaxis for neutropenia (<500)
leukemia
* Confirm patient is?
* Local hemostatic measures?
- Confirm patient is afebrile
- Local hemostatic measures for patients with thrombocytopenia
Lymphoma
- Cancer of lymphoid organs and tissues
forms of lymphoma
HL and NHL
- Hodgkin Lymphoma
*cell? - demo?
- LAD?
- LN feel?
- > 50% affect where?
- Hodgkin Lymphoma
- Reed-Sternberg cell
- Young adults
- LAD
- Non-tender, firm
- > 50% affect mediastinal or neck
nodes
- Non Hodgkin Lymphoma (NHL)
- Median Age:
- B-symptoms?
- Over how many types?
- Median Age: 67
- B-symptoms: Fever, night sweats (drenching),
weight loss (unintentional >10%) - Over 20 types
Lymphoma causes
- Autoimmune diseases
- Hepatitis C
- EBV
- Sjogren syndrome
lymphoma diagnosis/staging
- Bone marrow or lymph node biopsy
- MRI for staging
lymphoma tx
- Chemotherapy
- Radiation
- Immunotherapy
- Stem cell transplant
- Watching
Lymphoma oral manifestations
* LAD?
* Extranodal involvement?
* radiographic lesions?
* Infection?
- LAD (Waldeyers ring, neck)
- Extranodal involvement:
1. Oral Ulceration
1. Localized infiltrate
1. Osteolytic radiographic lesions - Infection: Viral, fungal, bacterial
lymphoma tc related oral manifestations
- Head and Neck Radiation (lymphomas in head and neck region only):
1. * Hyposalivation
1. * Trismus
1. * 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
lymphoma discussion with oncologist:
* Current?
* setting?
* Timing of dental care?
- Current status and goals (comprehensive vs. palliative)
- Dental office vs hospital
- Timing of dental care: not on active chemotherapy for routine care
lymphoma labs of interest
* CBC
– Platelet: may require platelet transfusion due to thrombocytopenia
– ANC-may require antibiotic prophylaxis for neutropenia (<500)
lymphoma
– Confirm patient is?
– Local hemostatic measures?
– Confirm patient is afebrile
– Local hemostatic measures for patients with thrombocytopenia
Multiple Myeloma
- Cancer of plasma cells
– Prevents normal production of antibodies
MM s/s
– Hypercalcemia
– Renal damage
– Anemia
– Bone pain
– Infection
MM tx
– Chemotherapy (RVD)
– Bisphosphonates
– Hematopoietic Stem Cell Transplant
Multiple Myeloma
* Oral Manifestations
– Plasmacytoma
– Lytic bone lesions
– Infection: Viral, fungal, bacterial
tx related MM oral manifestations
nn?
bone?
radiographic findings?
- Neuropathy
- MRONJ (IV Zometa)
- Radiographic:
1. – Thick lamina dura
1. – Persistent extraction site
1. – Sclerosis
1. – Sequestra
1. – Fracture
Multiple Myeloma
* Dental Management, dx related
- Soft tissue swelling, radiographic findings
- Infection management
- Pre-bisphosphonate exam
MM Medication related management
what should be provided?
- MRONJ
– Bisphosphonate history (number of doses, active)
– Chlorhexidine rinses
– Oral Hygiene
– Antibiotic regimen
– Sequestration
MM 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
Hematopoetic Stem Cell Transplant
- 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
Indications for Stem Cell Transplant
- Leukemia
- Lymphoma
- Multiple Myeloma
- Aplastic anemia
- Fanconi anemia
- Sickle Cell
Pre-Transplant Evaluation (hematopoetic)
Pre-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 hyposalivation=caries - Patient education about home care
- If planned correctly, pre-transplant evaluation + patient compliance=dental maintenance
Dental Screening Pre-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
Oral Manifestations HSCT (hemo stem cell transplant)
* Mucus mem?
* Bleeding?
* Infection?
* Medication side effects?
* Graft versus host disease?
* Increased risk 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
Hematopoietic Cell Transplant
* Dental Management After Transplant
med hx, clinical exam, consult, CBC, medications
– 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)**
Hematopoietic Cell Transplant
* Dental Management After Transplant
med hx, clinical exam, consult, CBC, medications
– 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)**
