Blood Disorders DTH 24 BMS Student Copy PDF

Blood Disorders Biomedical Sciences Dr Anisha Desai GDC Learning Outcomes 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.6 Describe relevant and appropriate physiology and explain its application to patient management 1.2.4 Recognise abnormalities of the oral ca...

Blood Disorders Biomedical Sciences Dr Anisha Desai GDC Learning Outcomes 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.6 Describe relevant and appropriate physiology and explain its application to patient management 1.2.4 Recognise abnormalities of the oral cavity and the rest of the patient and raise concerns where appropriate 1.5.4 Identify where patients’ needs may diCer from the treatment plan and refer patients for advice when and where appropriate 1.7.2 Explain the impact of medical and psychological conditions in the patient 1.7.9 Recognise local referral networks, local clinical guidelines and policies 1.10.1 Recognise the responsibilities of the dental team as an access point to and from wider healthcare 1.10.3 Underpin all patient care with a preventive approach that contributes to the patient’s long- term oral health and general health 1.11.2 Explain and take account of the impact of the patient’s periodontal and general health on the overall treatment plan and outcomes Aim of the Session Describe blood disorders and the implications for the dental hygienist/therapist Intended Learning Outcomes At the end of this session, you should be able to: Classify blood disorders Describe deSciency anaemias Describe sickle cell disease and thalassemia List the main types of leukaemia Describe the diCerence between leukaemia, multiple myeloma and lymphoma Explain how these conditions relate to the work of a dental hygienist/therapist Blood Disorders Anaemias Red blood cells not working correctly Leukaemias Cancers of white blood cells Other dyscrasias e.g. multiple myeloma, lymphoma Bleeding disorders (separate lecture) - Thrombocytopenia/ Coagulopathies Anaemias Anaemias DeSciency anaemias o Iron deSciency o Vit B12 deSciency o Folate deSciency Haemolytic anaemia o Haemoglobinopathies (inherited)  Sickle Cell Disease  Thalassaemia o Acquired haemolytic anaemias (overlaps with anaemia of chronic disease) Aplastic anaemia Anaemia of chronic disease Anaemia A condition in which there is reduced oxygen carrying capacity of the blood obelow 11.5 g/dl for females obelow 13.5 g/dl for males Haemoglobin is needed to carry oxygen and if you have too few or abnormal red blood cells, or not enough haemoglobin, there will be a decreased capacity of the blood to carry oxygen to the body’s tissues. Common condition Source: https://www.pedhemeoncpmk.com/uploads/6691/Sles/Iron% 20deSciency%20anemia.pdf Iron DeSciency Anaemia De2nition: a condition where a lack of iron in the body leads to a reduction in the number of red blood cells Cells: become smaller, paler and carry less haemoglobin Causes: oDietary deSciency oChronic blood loss oMalabsorption oPregnancy Source:https://medlib.am/anemia/ Clinical Features Fatigue, lethargy Breathlessness Palpitations Pallor Headache Brittle nails & koilonychia (spoon-shaped nails) Source: https://ckdexplained.co.uk/functions-of-kidney-5-blood-cells-anaemia-and-epo/ Clinical Features - Dental Pale oral mucosa Atrophic glossitis Recurrent aphthous ulcers Angular cheilitis Source: https://link.springer.com/chapter/10.1007/978-3-031-08198-9_14 Burning mouth syndrome Source: Source: https://quizlet.com/611535178/oral-exa https://quizlet.com/528334540/lecture-23-throat-infections-ii-dash-car m-picturesSndings-dash-cards/ ds/ Management Check medical history Detect underlying cause – ref to GP Iron supplements Preventative dental regime Regular maintenance Patients are more prone to infection Source: https://archealthnutrition.co.uk/products/ferrous-fumara te-210mg-iron-supplement-tablets-84s-vegetarian Vitamin B12 deSciency B12 needed to synthesise DNA & RNA B12 absorption depends on: oIntrinsic factor secretion by parietal cells oTerminal ileum which absorbs the B12-intrinsic factor complex Causes: oDiet: Found in meat, dairy – vegans most at risk oImpaired absorption: Crohn's, Pernicious Anaemia Vitamin B12 deSciency - Clinical Features Cells: reduced number of RBC’s and they become larger Develops slowly Usual fatigue, lethargy, breathlessness & pallor Dental aspects similar to other deSciency anaemias oGlossitis oRecurrent aphthous ulcers oAngular cheilitis oBurning mouth syndrome oRed beefy tongue Source: https://stanfordmedicine25.stanford.edu/ the25/tongue.html Vitamin B12 deSciency - Management Correct diagnosis Replacement of B12 (cobalamin) with regular intra-muscular injections of hydroxocobalamin at regular intervals Preventive dental care and regular recall Source: https://facesconsent.com/shop/product/hydroxo cobalamin-inj-1mgml-x-1 Folate (Folic Acid) DeSciency Needed to synthesise DNA & RNA & to build new cells including RBCs Found in fresh leafy & other vegetables Absorbed from small intestine Virtually no stores in body Folate deSciency mostly due to dietary deSciency Clinical Features & Management Dental aspects similar to other deSciency anaemias o Glossitis o Recurrent aphthous ulcers o Angular cheilitis o Red beefy tongue Folate deSciency in pregnancy can result in fetal neural tube defects e.g. spina biSda, cleft lip & palate Treat with folic acid daily by mouth for several months and improve diet Source: https://kineticptgreenville.com/spina-biSda/ Haemolytic Anaemias Inherited oHaemoglobinopathies Sickle cell anaemia Thalassaemia Acquired oSome viral or bacterial infections oMedicines e.g. penicillin, antimalarial medicines oBlood cancers and some tumours oAutoimmune disorders e.g. lupus, rheumatoid arthritis, ulcerative colitis oAn overactive spleen oMechanical heart valves that may damage red blood cells as they leave the heart oA severe reaction to a blood transfusion Inherited Haemolytic Anaemias Genetically determined disorders of haemoglobin synthesis oSickle Cell Disease oSickle Cell Trait oThalassaemia oThalassaemia Trait Sickle Cell Disease Autosomal recessive genetic disease of haemoglobin production associated with intermittent acute crises Most common in people of African descent Healthy red blood cell - highly deformable disk Sickled red blood cell - rigid and irregularly shaped Can cause episodes of severe pain, damage to Source: https://vitrosens.com/what-is-sickle-cell-disease/ 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 Healthy as carriers, rarely having 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 Source: https://web.iitd.ac.in/~sdeep/Elias_Inorg_lec_10.pdf 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 dow of blood causing anoxia This causes sudden severe pain, clotting and potentially death Clinical Features - Dental Papillary atrophy of tongue (A) Neuropathic pain and altered sensation (B) Aseptic pulp necrosis (C) Osteomyelitis (D) Delayed dental eruption Mucosal pallor due to anaemia Bone pain Fungal infections Sickle Cell Management by Dental Clinician Sickle Cell Trait normal treatment except avoid GA Sickle Cell Disease patients often treated in specialist centres Preventive care dental regime +++ Preventing dental infections essential Antibiotic prophylaxis for invasive dental treatment GA contra-indicated (conscious sedation Sne with caution) Avoid stress – need good LA for pain control but caution vasoconstrictor Avoid NSAIDs – paracetamol OK Thalassaemia Occurs mainly in Mediterranean, Middle/Far Eastern or Asian groups Characterised by abnormal amount of haemoglobin Inherited disease with genes from both parents Red cells: fewer and more fragile leading to early haemolysis causing Source: https://travocure.com/thalassemia-and-what-you-can-do/ anaemia Types of Thalassaemia Alpha-thalassaemias: oMostly found in Asians o4 subtypes of varying degrees of severity oMajor type is lethal in utero or infancy Beta-thalassaemias: oMainly Mediterranean & Caribbean o2 types: homozygous β-thalassaemia major / heterozygous β- thalassaemia minor Symptoms of β-thalassaemia Homozygous (major): oChronic anaemia, marrow hyperplasia, skeletal deformities, splenomegaly, cirrhosis, gallstones & iron overload oIron overload causes cardiac problems, liver & pancreatic dysfunction & dry mouth due to deposits in salivary glands oPallor and tiredness Heterozygous (minor): oMuch more common & usually asymptomatic apart from mild anaemia Orofacial Manifestations ‘Hair on end’ appearance on lateral skull x-rays Prominent maxillae, front bossing (bone marrow expansion) Spacing and forward drifting of maxillary incisors May get painful swelling of parotid salivary glands & xerostomia Thalassaemia - Management Severe cases treated in hospital clinics Care with infection control as these patients may have had multiple blood transfusions and may have possibly contracted blood borne diseases Preventive dental care regimes Acquired Haemolytic Anaemias Acquired, NOT inherited Some viral or bacterial infections Medicines e.g. penicillin, antimalarial medicines Blood cancers and some tumours Autoimmune disorders e.g. lupus, rheumatoid arthritis, ulcerative colitis An overactive spleen Mechanical heart valves that may damage red blood cells as they leave the heart A severe reaction to a blood transfusion Aplastic Anaemia Occurs when bone marrow is depressed leading to fewer blood cells (all types) Causes: idiopathic (autoimmune), genetic, cytotoxic drugs, radiation, certain chemicals, malignancy (leukaemia), viral infection May rarely be caused by antibiotics, anticonvulsants and sulphonamides May present with severe bruising, fatigue, pallor, palpitations, dyspnoea Managed by: Removal of cause Immunosuppressant therapy Source: https://cfch.com.sg/aplastic-anaemia/ Anaemia of Chronic Disease Characterised by anaemia and evidence of immune system activation Due to decreased red blood cell production +/- increased haemolysis Commonly found in the following conditions: o chronic infections e.g. HIV o autoimmune disorders e.g. rheumatoid arthritis o chronic diseases e.g. liver or kidney disease o malignancy o major trauma o major surgery or critical illness o older adults Leukaemias Leukaemias 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 in anaemia, thrombocytopenia, leukopenia, high risk of infection Risk factors ionising radiation, chemicals, genetic predisposition, many causes unknown Source: https://www.abc.net.au/health/library/stories/2004/10/18/1830091.htm ClassiScation of Leukaemias Acute lymphoblastic leukaemia Acute myeloid leukaemia Chronic myeloid leukaemia Chronic lymphocytic leukaemia Source: https://link.springer.com/chapter/10.1007/978-3-030-69921-5_8 Acute Lymphoblastic Leukaemia Most common in children, young people, young adults Large numbers of immature white blood cells released Drop in red blood cells and platelets Treated with chemotherapy, antibiotics, blood transfusions, stem cell transplant Survival rates after treatment as high as 85% in children, lower in adults Acute Myeloid Leukaemia Aggressive cancer of myeloid cells Bone marrow makes abnormal myeloblasts (a type of white blood cell), red blood cells, or platelets ACects all ages, but risk of developing increases with age Most common acute leukaemia aCecting adults Quickly fatal if left untreated Treated with chemotherapy, radiotherapy, bone marrow transplant, stem cell transplant Chronic Myeloid Leukaemia Rare Mostly aCects adults aged 60+ Slow development Increased and unregulated growth of myeloid cells Treated with tyrosine kinase inhibitors, and sometimes stem cell transplant Outlook good But ‘blast crisis’ can occur Chronic Lymphocytic Leukaemia Most common leukaemia Too many immature lymphocytes produced Mainly aCects over-60s May not need treatment for years Treated with tyrosine kinase therapy, BCL2 inhibitor therapy, monoclonal antibody therapy, chemotherapy, radiotherapy, immunotherapy Source: https://www.rituxanhycela.com/patient/cll/what-is-cll/stages.html Common Symptoms of Leukaemia Source: https://thedailyguardian.com/childhood-leukaemia-understanding-the-causes-prevalence-and-treatment- of-the-disease/ Leukaemia - Clinical Features Anaemia (fatigue, pallor etc.) Thrombocytopenia (purpura, bleeding tendency) Liability to infection Lymphadenopathy Source: https://commons.wikimedia.org/wiki/File:Cervical_lymphaden opathy_right_neck.png Leukaemia Clinical Features - Dental Cervical lymphadenopathy Ulcers Mucosal pallor Gingival hypertrophy (with acute myeloid leukaemia) Spontaneous gingival bleeding Petechial haemorrhages of palate, lips Infections (viral, candidal, bacterial) Defer dental treatment until remission Chronic illness - get advice from physician Prevention++++ Source: Other Dyscrasias Multiple Myeloma Cancer in which 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 Sght infections Eventually multiple holes - osteolytic lesions - form in the bones Get bone pain, recurring infection, Source: kidney damage and fatigue https://www.gponline.com/test-knowledge-multiple-myeloma/haematology/a rticle/1058866 Lymphoma ACects 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: oHodgkin's lymphoma oNon-Hodgkin's lymphoma Dental Implications Radiotherapy or chemotherapy Multiple myeloma patients may be on long-term bisphosphonates (consider risk of osteoradionecrosis) Infections (viral, candidal, bacterial) Defer dental treatment when appropriate Source: Get advice from physician https://www.semanticscholar.org/paper/Bisphosphonate-related-osteon ecrosis-of-the-jaw%3A-Ruggiero-Mehrotra/34d0df0a4eec666157a74a4 e05ce2ea63b476c87 Prevention++++ What is the diCerence between leukaemia, lymphoma and multiple myeloma? Patients with blood cancers often have symptoms common to all three forms of the disease: 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 - the cancerous cells commonly aggregate and form tumours in lymphatic tissues Myeloma - tumour of the bone marrow. The body produces too many plasma cells in the bone marrow. These extra cells cause damage to the bone marrow and destroy bone. Summary ClassiSed blood dyscrasias Outlined deSciency anaemias Described haemolytic anaemias including sickle cell disease and thalassemia Listed the main types of leukaemia Described the diCerence between leukaemia, multiple myeloma and lymphoma Explained how these conditions relate to the work of a dental hygienist/ dental therapist Further Reading Orofacial manifestations of hematological disorders https://journals.lww.com/ijdr/fulltext/2011/22030/orofacial_manifestation s_of_hematological.18.aspx Orofacial manifestations of sickle cell disease: implications for dental clinicians https://www.nature.com/articles/s41415-021-2601-3?proof=t%2525C2% 2525A0 Sickle cell anemia in dentistry: manifestations and management https://ijmdc.com/fulltext/51-1578043152.pdf Dental Treatment in Patients with Leukemia https://onlinelibrary.wiley.com/doi/full/10.1155/2015/571739 References World Health Organization (2024) Anaemia. Available at: https://www.who.int/health-topics/anaemia#tab=tab_1 [Accessed: 7 November 2024]. Waugh, A. and Grant, A. (2018) Ross & Wilson Anatomy And Physiology In Health And Illness. 13th ed. Elsevier. Scully C (2014) Scully’s Medical Problems in Dentistry 7th ed. Churchill Livingstone. Scully C, Diz Dios P, Kumar N (2006) Special Care in Dentistry – Handbook of Oral Healthcare. Churchill Livingstone.