WBC Disorders Lectures 3 & 4 PDF

WBCs disorders lectures 3 and 4 A ssis ta n t professor Sameer Alkhawaja  L3. WBC 1 white blood cell WBCs provide the primary defense against microbial infections and are critical for meninting an immune response. Defects in...

WBCs disorders lectures 3 and 4 A ssis ta n t professor Sameer Alkhawaja  L3. WBC 1 white blood cell WBCs provide the primary defense against microbial infections and are critical for meninting an immune response. Defects in WBCs can manifest as 1.delayed healing 2.Infection 3. mucosal ulceration. 1.WBCs make up approximately 1% of the total blood volume in ahealthy adult. performed. 2.WBCs that circulate in the peripheral blood account for only 5% of the total WBC  WBC 2 The number of circulating WBCs normally 1.ranges from 4400 to 11,000/micro L in adults 2..normal differential count consists of: Neutrophils, 50% to 60%; Eosinophils, 1% To 3% Basophils, less than 1% Lymphocytes, 20% to 34%; (T lymphocytes , B lymphocytes, Natural killer cells). Monocytes, 3% to 7%  WBC…. 3 The primary function of WBC neutrophils is to defend the body against certain infectious agents (primarily bacteria) through phagocytosis and enzymatic destruction. Eosinophils and basophils are involved in inflammatory allergic reactions. Eosinophils also combat infection by parasites  Leukocytosis leukocytosis is defined as an increase in the number of circulating WBCs to more than 11,000/micro.L physiologic leukocytosis:- Exercise, pregnancy emotional stress Pathologic leukocytosis can be caused by infection, neoplasia necrosis.  Leukocytosis Pyogenic infections increase the number of neutrophils. Tuberculosis, syphilis, and viral infections increase the numbers of lymphocytes. Protozoal infections associated with an increase in the numbers of monocytes. Allergies and parasitic infections increase the numbers of circulating eosinophils.  leukopenia leukopenia as a reduction in the number of circulating WBCs (less than 4400/micro.L Leukopenia Result from Infection (viral ). Drug chemotherapy  pancytopenia Pancytopenia is reduction in all blood element (WBC ,RBC ,PLATLATE ) Due to bone marrow suppression Cause of pancytopenia :- 1.Aplastic anemia 2.chemotherpy  Leukemia and Lymphoma Patients with leukemia or lymphoma are gravely ill if they are not properly identified and do not receive appropriate medical care. Patients are usually immunosuppressed because of the disease or treatment. Hence, they are prone to develop a serious infection and often bleed easily because of thrombocytopenia.  Leukemia…1 Leukemia Leukemia (cancer of the WBCs) is characterized by a great increase in the numbers of circulating immature leukocytes. Leukemia affects the bone marrow and circulating blood. occurs in both acute and chronic forms..  Leukemia…2 Myeloproliferative disorders Acute myeloid leukemia: immature neoplastic malignancy of myeloid cell Chronic myeloid leukemia: mature neoplastic malignancy of myeloid cells Lymphoproliferative disorders Acute lymphoblastic leukemia: immature neoplastic malignancy of lymphoid cells Chronic lymphocytic leukemia: mature neoplastic malignancy of lymphoid cells  Leukemia…3 Leukemia occurs in all race. at any age, more common in men. Leukemia is much more common in adults than in children, more than half of all cases occurring after age 65 years. The most common types of leukemia in adults are acute myeloid leukemia. The most common form of leukemia among people younger than 19 years of age is acute lymphoblastic leukemia  Risk of leukemia Family history large doses of ionizing radiation infection with specific viruses (e.g., Epstein-Barr virus). Cigarette smoking exposure to electromagnetic fields.  Lymphomas…1 Lymphoma is a cancer of the lymphoid organs and tissues Lymphomas are classified by ,. Cell type: Appearance B cell , small cell T cell , large cell Plasma cell Clinical behavior Low grade Intermediate grade high grade  Lymphoma s…2 These diseases are of importance in dental management because initial signs often occur in the mouth and in the head and neck region, and precautions must be taken before any dental treatment is provided Intraoral lymphoma most commonly involves Waldeyer`s ring (soft palate and oropharynx); less often, the salivary glands and mandible are affected. Intraoral lymphomas appear as rapidly expanding (or chronic), unexplained swellings of the head and neck lymph nodes, palate, gingiva, buccal sulcus, or floor of the mouth. The presence of these orofacial abnormalities requires prompt evaluation using a needle, incisional, or excisional biopsy.  Lymphomas …..3 Most Common Types of Lymphomas Hodgkin lymphoma: Non-Hodgkin lymphoma:. Burkitt lymphoma:. Multiple myeloma: in multiple tumorous masses scattered throughout theskeletal system.  Hodgkin lymphoma Other names , Hodgkin's disease is a malignant neoplasm of B-lymphocytes, primarily in lymph nodes. This neoplasm contains a characteristic tumor cell called the Reed-Sternberg cell. Micrograph showing Hodgkin lymphoma (Field stain) Specialty Hematology and oncology Symptoms Fever, night sweats, weight loss, non painful enlarged lymph nodes Risk factors Epstein–Barr virus, family history, HIV/AIDS Diagnostic method Lymph node biopsy Treatment Chemotherapy, radiation therapy, stem-cell transplant ,immuno therapy Prognosis Five-year survival rate 88% (US) Frequency 574,000 (affected during 2015) Deaths 23,900 (2015) Named after Thomas Hodgkin Reed–Sternberg cells are large (30–50 microns) and are either multinucleated or have a bilobed nucleus with prominent eosinophilic inclusion-like nucleoli (thus resembling an "owl's eye" appearance  Non-Hodgkin lymphoma Non-Hodgkin lymphoma: includes all types of lymphoma except Hodgkin's lymphomas. B or T cell malignant neoplasms, many types and locations; most are of B cell lineage  Burkitt lymphoma. Burkitt lymphoma: aggressive non- Hodgkin B cell lymphoma involving bone and lymph nodes. Multiple myeloma: overproduction of malignant plasma cells that results in multiple tumorous masses scattered throughout theskeletal system. END OF 1ST LECTURE  Q1 MEDICIN WHAT ARE COUNTER ACTING HORMON OF INSULIN  Dental management in Leukemia Leukemic patients whose disease has not been diagnosed may experience:- 1.serious bleeding problems after any surgical 2.procedure problems with the healing of the surgical wounds 3.Postsurgical infection Thus , it is important for the dentist to identify these patients before starting any treatment..  diagno sis Questions regarding blood disorders and cancer in family members, weight loss, fever, enlarged lymph nodes, and bleeding tendencies should be asked. After the history is complete, clinical examination is mandatory. Examination of the head, neck, and mouth should include athorough inspection of the oropharynx, head, and cervical and supraclavicular lymph nodes. The dentist should be aware that an enlarged supraclavicular node is highly suggestive of malignancy. Cranial nerve examination is important for identifying abnormalities suggestive of invasive neoplasms. Panoramic films (OPG) , total and differential WBC counts, hemoglobin and platelet count.  Treatment Planning Modifications Three phases of medical therapy: (1)Pre-treatment assessment and preparation (2) Oral health care during medical therapy. (3) Post-treatment management.  Pre-treatment Assessment….1 The goal is to minimize or eliminate oral diseases before the start of chemotherapy. The dentist must know : The specific diagnosis The severity of the disorder The type of medical treatment, for example, a patient who is receiving only palliative treatment is not a good candidate for extensive restorative or prosthodontic procedures that require months for completing  Pre-treatment Assessment….2 Pretreatment (before chemotherapy)care should include oral hygiene instructions,like using fluoride gels, encouraging a non-cariogenic diet, eliminating mucosal and periodontal disease and eliminating any source of mucosal injury plaque removal. Caries elimination. If pulpal disease is present, the dentist may recommend root canal therapy or extraction of teeth.. Inspection of radiographs for undiagnosed disease, retained root tips, impacted teeth is important for clearing the oral cavity. Extraction should be considered if 1.periodontal pocket depths are greater than 5 mm, 2.periapical inflammation is present, 3.the tooth is nonfunctional 4.partially erupted (as with third molars 5.Guidelines for extraction in patients before chemotherapy include scheduling a minimum of 3 weeks between the time of extraction and initiation of chemotherapy or radiotherapy. 6.avoid invasive procedures if the platelet count is less than 50,000/micro L.  Oral Complications during Medical Therapy 1. Mucositis Chemotherapyaffects epithelial cells that have high replication rates, specially in young patients Thus ,younger persons greater prevalence of havea mucositis usually begins 7 to 10 days after initiation of chemotherapy and resolves after cessation of chemotherapy. irritation  Mucositis: Affected mucosa becomes red, raw, and tender. Breakdown of the epithelial barrier produces oral ulcerations that may become secondarily infected source of systemic infection. Antiseptic rinses (e.g., chlorhexidine) used to promote healing of oral ulcerations. use of topical anesthetic and systemic analgesics makes the mouth more comfortable. A thin layer of Orabase is useful in protecting ulcers from surface  Neutropenia and Infection: Patients who have neutropenia develop acute gingival inflammation and mucosal ulcerations. Chronic neutropenia contributes to severe destruction of the periodontium with loss of attachment when oral hygiene is less than optimal. Periodontal therapy that include instruction on oral hygiene, frequent scaling,and antimicrobial therapy can reduce the adverse effects associated with this disorder.  Oral infection is less of a problem in patients with chronic leukemia than in those with acute leukemia because the cells are more mature and functional in chronic leukemia. However, in the later stages, an infection can become a serious complication. Splenectomy due to massive splenomegaly may also increase the risk of infection. 2.Opportunistic infections (bacterial, fungal, and viral) are common in leukemic patients because of neutropenia signs of infection are often masked in patients with leukemia 1.swelling and erythema usually associated with oral infection are often less marked. 2.In these patients, severe infection can occur with minimal clinical signs, which can make clinical diagnosis more difficult. 3.When an oral infection develops in such patients, a specimen of exudate should be sent for culture and antibiotic  Opportunistic infections A common opportunistic infection is acute pseudomembranous candidiasis; should be treated with one of the antifungal medications. Infrequently, unusual oral fungal infections (mucormycosis) occur, or fungal septicemia may originate from the oral cavity. These patients require potent systemic antifungal like fluconazole or amphotericin B. Another common infection in patients receiving chemotherapy (Herpes Simplex Virus) antiviral agents. Herpetic lesions tend to be larger and take longer to heal than herpetic lesions found in non leukemic patients to prevent a recurrences ) are prescribed to HSV antibody- acyclovir positive patients who are undergoing chemotherapy.  3.Bleeding Small or large areas of submucosal hemorrhage may be found in the leukemic patient. These lesions result from minor trauma (e.g., tongue biting) and are related to thrombocytopenia. Leukemic patients also may report spontaneous and severe gingival bleeding that is aggravated by poor oral hygiene. The dentist should make efforts to improve oral hygiene and should use local measures to control bleeding. A gelatin sponge with thrombin or microfibrillar collagen can be placed localy Plat late count should be at least 50,000/microliter before  4.Growth and Development Chemotherapy during childhood can affect the growth and development of the teeth and facial bones. This effect is not observed in adults. Restricted growth of the jaws leads to micrognathia , retrognathia , or malocclusion Damage to the teeth that occurs at the time of chemotherapy can manifest as shorten or blunted roots ,dilacerations , calicification abnormalities, pulp enlargement, microdontia,  Post-treatment Management…1 Patients who have WBC disorders and are in a state of remission can receive most indicated dental treatment Patients who have advanced disease and a limited prognosisas occurs in many cases of leukemia, should receive emergency care only. In Hodgkin lymphoma, the spleen may be involved and surgically removed. Subsequently, the patient is at risk for bacterial infection. The risk for such infection is greatest during the first 6 months after splenectomy. Antibiotic prophylaxis should be provided for invasive procedures during the first 6 months after splenectomy  Up to 80% of patients with Multiple Myeloma are presented with osteopenia, osteolysis, and pathologic fractures. Patients bisphosphonates drugsoften are that inhibit treated ; with An osteoclastactivity. infrequent adverse effect of bisphosphonates is osteonecrosis of the jaws. The greatest risk for this complication is associated with the use of intravenous bisphosphonates for at least 1 year. The condition often is triggered by the extraction of a painful tooth or teeth, most commonly a mandibular posterior tooth.  Post-treatment Management…2 The typical presenting lesion is a severely painful and unexpected nonhealing extraction socket or exposed area of bone. However, the necrotic bone may be asymptomatic for weeks and may be noticed only on routine examination. Treatment is directed toward controlling and limiting progression by means of local debridement (bone and wound irrigation with antiseptics), together with suitable antibiotics.  develop patients:- (1) Treat infections early. Nonsurgical approaches are preferable to surgical Limit the extraction to as few as possible and to one quadrant. Wait two months before performing surgery in a different quadrant. Provide antibiotic coverage during the extraction and healing period END