Oral Health and Systemic Diseases

GDC Learning Outcomes

• General and systemic diseases need to be understood for their impact on oral health.
• Appropriate physiology must be described, and the application explained in patient management.
• Abnormalities of the oral cavity and the rest of the patient need to be recognized, and concerns raised when appropriate.
• A patient's needs must be identified and patients' needs must be referred for advice when required.
• The impact of medical and psychological conditions on the patient must be explained.
• Local referral networks, local clinical guidelines, and policies must be recognized.
• The responsibilities of the dental team must be recognized as an access point to and from wider healthcare.
• All patient care must be underpinned with a preventive approach that contributes to the patient's long-term oral and general health.
• The impact of the patient’s periodontal and general health on the overall treatment plan and outcomes must be explained and taken into account.

Aim of the Session

• The session aims to describe blood disorders and the implications for the dental hygienist/therapist.

Intended Learning Outcomes

• The content will classify blood disorders.
• The content will describe deficiency anaemias.
• Sickle cell disease and thalassemia will be described.
• The main types of leukaemia will be listed.
• The difference between leukaemia, multiple myeloma, and lymphoma will be described.
• How these conditions relate to the work of a dental hygienist/therapist will be explained.

Blood Disorders

• Anaemias are a type of blood disorder.
• Leukaemias are a type of blood disorder.
• Other dyscrasias include multiple myeloma and lymphoma.
• Bleeding disorders like thrombocytopenia/coagulopathies are separate lectures.

Anaemias

• Deficiency anaemias include iron, Vit B12, and folate deficiencies.
• Haemolytic anaemia can be due to inherited haemoglobinopathies like Sickle Cell Disease and Thalassaemia.
• Acquired haemolytic anaemias overlap with anaemia of chronic disease.
• Aplastic anaemia is a type of anaemia.
• Anaemia of chronic disease is a type of anaemia.

Anaemia

• Reduced oxygen-carrying capacity of the blood is present.
• Females have anaemia if below 11.5 g/dl.
• Males have anaemia if below 13.5 g/dl.
• Haemoglobin carries oxygen.
• Reduced haemoglobin or abnormal red blood cells will decrease the oxygen-carrying capacity to the body’s tissues.
• Anaemia is a common condition.

Iron Deficiency Anaemia

• Lack of iron leads to a reduction in red blood cells.
• Cells become smaller, paler, and carry less haemoglobin.
• Causes can include dietary deficiency, chronic blood loss, malabsorption, and pregnancy.

Clinical Features of Anaemia

• Fatigue and lethargy are clinical features.
• Breathlessness is a clinical feature.
• Palpitations are a clinical feature.
• Pallor is a clinical feature.
• Headache is a clinical feature.
• Brittle nails & koilonychia (spoon-shaped nails) can occur.

Clinical Features - Dental

• Pale oral mucosa is a sign.
• Atrophic glossitis is a sign.
• Recurrent aphthous ulcers are a sign.
• Angular cheilitis is a sign.
• Burning mouth syndrome is a sign.

Management of Anaemia

• Check the medical history.
• The underlying cause should be detected and the patient referred to a GP.
• Iron supplements are needed.
• A preventative dental regime is needed.
• Regular maintenance is needed.
• Patients are more prone to infection.

Vitamin B12 Deficiency

• B12 is needed to synthesise DNA & RNA.
• B12 absorption depends on intrinsic factor secretion by parietal cells and the terminal ileum which absorbs the B12-intrinsic factor complex.
• Causes include Diet in meat or dairy - vegans are most at risk, and Impaired absorption due to Crohn's or Pernicious Anaemia.

Vitamin B12 deficiency - Clinical Features

• There is a reduced number of RBC’s and they are larger.
• It develops slowly.
• Patients exhibit usual fatigue, lethargy, breathlessness & pallor.
• Similar dental aspects as other deficiency anaemias include glossitis, recurrent aphthous ulcers, angular cheilitis, burning mouth syndrome and a red beefy tongue.

Vitamin B12 deficiency - Management

• Correct diagnosis is needed.
• B12 must be replaced with regular intra-muscular injections of hydroxocobalamin at regular intervals.
• Preventive dental care and regular recall are important.

Folate (Folic Acid) Deficiency

• It is needed to synthesise DNA & RNA & to build new cells including RBCs.
• It is found in fresh leafy & other vegetables.
• It is absorbed from the small intestine.
• There are virtually no stores in the body.
• Folate deficiency is mostly due to dietary deficiency.

Clinical Features & Management of Folate Deficiency

• Dental aspects are similar to other deficiency anaemias.
• Glossitis, recurrent aphthous ulcers, angular cheilitis and a red beefy tongue are all signs.
• Folate deficiency in pregnancy can result in fetal neural tube defects e.g. spina bifida, cleft lip & palate.
• Treat with folic acid daily by mouth for several months and improve diet.

Haemolytic Anaemias

• Inherited haemoglobinopathies include sickle cell anaemia and thalassaemia.
• Some viral or bacterial infections cause acuired haemolytic Anaemias.
• Medications like penicillin and antimalarial medicines cause Acquired haemolytic Anaemias.
• Blood cancers and some tumours cause Acquired haemolytic Anaemias.
• Autoimmune disorders e.g. lupus, rheumatoid arthritis, ulcerative colitis cause Acquired haemolytic Anaemias.
• An overactive spleen causes Acquired haemolytic Anaemias.
• Mechanical heart valves that may damage red blood cells as they leave the heart cause Acquired haemolytic Anaemias.
• A severe reaction to a blood transfusion causes Acquired haemolytic Anaemias.

Inherited Haemolytic Anaemias

• These are genetically determined disorders of haemoglobin synthesis.
• Sickle Cell Disease, Sickle Cell Trait, Thalassaemia and Thalassaemia Trait are inherited haemolytic anaemias.

Sickle Cell Disease

• Sickle cell disease is an autosomal recessive genetic disease of haemoglobin production associated with intermittent acute crises.
• It is most common in people of African descent.
• Sickled red blood cells are rigid and irregularly shaped, while healthy red blood cells are highly deformable disks.
• It can cause episodes of severe pain and damage to vital organs and death.

Sickle Cell Trait

• A person who inherits the sickle cell gene from one parent and the normal type of that gene from the other parent is said to have sickle cell trait.
• Carriers are healthy and rarely have any health problems related to the trait.
• When two people with SC trait have a child, their child may inherit sickle genes and have SC disease.

Sickle Cell Crisis

• A state of low O2 may be bought on by exercise, stress, dehydration, infection, trauma, and general anaesthetic.
• The misshapen red blood cells clog blood vessels & slow the flow of blood causing anoxia.
• This causes sudden severe pain, clotting, and potentially death.

Clinical Features - Dental

• Papillary atrophy of the tongue occurs.
• Neuropathic pain and altered sensation occurs.
• Aseptic pulp necrosis occurs.
• Osteomyelitis occurs.
• Delayed dental eruption occurs.
• Mucosal pallor due to anaemia occurs.
• Bone pain occurs.
• Fungal infections occur.

Sickle Cell Management by Dental Clinician

• Normal treatment is given for Sickle Cell Trait except to avoid GA.
• Sickle Cell Disease patients are usually treated in specialist centres.
• Preventive care dental regime +++ is important.
• Preventing dental infections is essential.
• Antibiotic prophylaxis is important for invasive dental treatment.
• GA is contra-indicated, but conscious sedation is fine with caution.
• Avoid stress - need good LA for pain control but caution vasoconstrictor.
• Avoid NSAIDs – paracetamol is OK.

Thalassaemia

• It occurs mainly in Mediterranean, Middle/Far Eastern or Asian groups.
• It is characterised by an abnormal amount of haemoglobin.
• It is an inherited disease with genes from both parents.
• Red cells are fewer and more fragile leading to early haemolysis causing anaemia.

Types of Thalassaemia

• Alpha-thalassaemias are mostly found in Asians and have 4 subtypes of varying degrees of severity and the major type is lethal in utero or infancy.
• Beta-thalassaemias are mainly found in Mediterranean & Caribbean and have 2 types: homozygous β-thalassaemia major / heterozygous β-thalassaemia minor.

Symptoms of β-thalassaemia

• Symptoms of Homozygous (major) include chronic anaemia, marrow hyperplasia, skeletal deformities, splenomegaly, cirrhosis, gallstones & iron overload.
• Iron overload causes cardiac problems, liver & pancreatic dysfunction & dry mouth due to deposits in salivary glands.
• With Homozygous Pallor and tiredness
• Heterozygous (minor) is much more common & is usually asymptomatic apart from mild anaemia.

Orofacial Manifestations

• There is a 'Hair on end' appearance on lateral skull x-rays.
• There are prominent maxillae, front bossing (bone marrow expansion).
• Spacing and forward drifting of maxillary incisors occurs.
• There might be painful swelling of parotid salivary glands & xerostomia.

Thalassaemia - Management

• Severe cases are treated in hospital clinics.
• Care with infection control is needed because these patients may have had multiple blood transfusions and may have possibly contracted blood-borne diseases.
• Preventive dental care regimes are needed.

Acquired Haemolytic Anaemias

• These are acquired and NOT inherited.
• Some viral or bacterial infections can cause it.
• Medicines like penicillin and antimalarial medicines can cause it.
• Blood cancers and some tumours can cause it.
• Autoimmune disorders e.g. lupus, rheumatoid arthritis, ulcerative colitis can cause it.
• An overactive spleen can cause it.
• Mechanical heart valves that may damage red blood cells as they leave the heart can cause it.
• A severe reaction to a blood transfusion can cause it.

Aplastic Anaemia

• It occurs when bone marrow is depressed leading to fewer blood cells (all types).
• Causes include idiopathic (autoimmune), genetic, cytotoxic drugs, radiation, certain chemicals, malignancy (leukaemia), viral infection.
• It may rarely be caused by antibiotics, anticonvulsants and sulphonamides.
• It may present with severe bruising, fatigue, pallor, palpitations, dyspnoea.
• Management includes removal of cause and immunosuppressant therapy.

Anaemia of Chronic Disease

• It is characterised by anaemia and evidence of immune system activation.
• It is due to decreased red blood cell production +/- increased haemolysis.
• It is commonly found in people with chronic infections e.g. HIV, autoimmune disorders e.g. rheumatoid arthritis and chronic diseases e.g. liver or kidney disease.
• It is commonly found in people with malignancy, major trauma, major surgery or critical illness and older adults.

Leukaemias

• This is a of malignant proliferation of white blood cell precursors in bone marrow.
• The proliferating immature blast cells crowd out other blood cells formed in bone marrow.
• Results include anaemia, thrombocytopenia, leukopenia and a high risk of infection.
• Risk factors include ionising radiation, chemicals and genetic predisposition, but many causes are unknown.

Classification of Leukaemias

• Acute lymphoblastic leukaemia is a classification.
• Acute myeloid leukaemia is a classification.
• Chronic myeloid leukaemia is a classification.
• Chronic lymphocytic leukaemia is a classification.

Acute Lymphoblastic Leukaemia

• It is most common amongst children, young people, and young adults.
• Large numbers of immature white blood cells are released.
• There is a Drop in red blood cells and platelets.
• It is treated with chemotherapy, antibiotics, blood transfusions, and stem cell transplant.
• Survival rates after treatment are as high as 85% in children but lower in adults.

Acute Myeloid Leukaemia

• This is an aggressive cancer of myeloid cells.
• Bone marrow makes abnormal myeloblasts (a type of white blood cell), red blood cells, or platelets.
• It Affects all ages, but the risk of developing it increases with age.
• It is the most common acute leukaemia affecting adults.
• It is quickly fatal if left untreated.
• It is treated with chemotherapy, radiotherapy, bone marrow transplant and a stem cell transplant.

Chronic Myeloid Leukaemia

• It is rare.
• It mostly affects adults aged 60+.
• It has a slow development.
• It has an increased and unregulated growth of myeloid cells.
• It is treated with tyrosine kinase inhibitors, and sometimes stem cell transplant.
• It has a good outlook but a 'blast crisis' can occur.

Chronic Lymphocytic Leukaemia

• This is the most common leukaemia.
• Produces too many immature lymphocytes.
• It mainly affects over-60s.
• Patients may not need treatment for years.
• It is treated with tyrosine kinase therapy, BCL2 inhibitor therapy, monoclonal antibody therapy, chemotherapy, radiotherapy, immunotherapy.

Common Symptoms of Leukaemia

• Systemic symptoms include weight loss, fever and frequent infections.
• Lung symptoms include easy shortness of breath.
• Muscular symptoms include weakness.
• Bone or joint symptoms include pain or tenderness.
• Psychological symptoms include fatigue and loss of appetite.
• Lymph Node symptoms include swelling.
• Spleen and/or liver symptoms includee Enlargement.
• Skin symptoms include Night sweats, Easy bleeding and bruising, and Purplish patches or spots

Leukaemia - Clinical Features

• Anaemia (fatigue, pallor etc.) occurs.
• Thrombocytopenia (purpura, bleeding tendency) occurs.
• Liability to infection increases.
• Lymphadenopathy occurs.

Leukaemia Clinical Features - Dental

• Cervical lymphadenopathy occurs.
• Ulcers occur.
• Mucosal pallor occurs.
• Gingival hypertrophy (with acute myeloid leukaemia) occurs.
• Spontaneous gingival bleeding occurs.
• Petechial haemorrhages of palate and lips occur.
• Infections (viral, candidal, bacterial) occur.
• Defer dental treatment until remission.
• Chronic illness - get advice from physician.
• Prevention is extremely important.

Other Dyscrasias

• Other dyscrasias exist like myelomas and lymphomas.

Multiple Myeloma

• Cancer sees antibody-producing plasma cells grow in an uncontrolled, invasive manner in bone marrow.
• Cancerous plasma cells produce faulty antibodies (paraprotein), which make it hard for the body to fight infections.
• Eventually multiple holes - osteolytic lesions - form in the bones.
• This can cause bone pain, recurring infection, and kidney damage and fatigue.

Lymphoma

• This affects cells in the lymphatic system
• Lymphocytes grow out of control and collect in lymph nodes, spleen, in other lymph tissues or in neighbouring organs
• Patients commonly present with lymph node enlargement e.g. neck, groin, armpit
• Sometimes intraoral lesions
• Two main types exist including Hodgkin's lymphoma and Non-Hodgkin's lymphoma

Dental Implications

• Radiotherapy or chemotherapy may be used.
• Multiple myeloma patients may be on long-term bisphosphonates, and the risk of osteoradionecrosis should be considered.
• Infections (viral, candidal, bacterial) can occur.
• Defer dental treatment when appropriate.
• It’s important to get advice from a physician.
• Prevention is crucial.

What is the difference between leukaemia, lymphoma and multiple myeloma?

• Patients with blood cancers often have symptoms common to all three forms of the disease. These can include weakness and fatigue, bone pain, infections, fevers and weight loss
• Leukaemia starts in the bone marrow but the cancerous cells are discovered circulating in the blood
• Lymphoma sees the cancerous cells commonly aggregate and form tumours in lymphatic tissues
• Myeloma is a tumour of the bone marrow where the body produces too many plasma cells in the bone marrow which extra cells cause damage to the bone marrow and destroy bone.

Summary

• Blood dyscrasias have been classified.
• Deficiency anaemias have been outlined.
• Haemolytic anaemias including sickle cell disease and thalassemia have been described.
• The main types of leukaemia have been listed.
• The difference between leukaemia, multiple myeloma, and lymphoma has been described.
• How these conditions relate to the work of a dental hygienist/dental therapist has been explained.