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Learn about types of anaemias, including iron deficiency and pernicious anaemia, and explore insights on leukaemias, sickle cell disease, thalassaemias, and haemorrhagic diseases. Discover clinical features, dangers, management, and dental aspects.
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Anaemia • types (etiology): • 1) iron deficiency • most common type • chronic menstrual blood loss, peptic ulcer, haemorrhoids • 2) pernicious anaemia • macrocytic anaemia • +/- neurological disease • folate insufficiency
Anaemia • 3) leukaemia • cause of normocytic anaemia • childhood! • 4) sickle cell trait • 5) thalasaemia
Anaemia • clinical features • tab 22.2, 3, 4 • mucosal disease • glossitis • recurrent aphthae • candidiosis and angular stomatitis
Anaemia • dangers of general anesthesia • any reduction of oxygenation → irreparable brain damage, myocardial infarction → gen. anesthesia should be provided in hospital • lowered resistence to infection • oral candidiosis • osteomyelitis
Sickle cell disease and sickle cell trait • people of African, Afro-Caribbean and Mediterranean or Middle Eastern origin • sickle cell diease = homozygotes • sickle cell trait = heterozygotes • abnormal Hb (HbS) with the risk of haemolysis, anaemia and other effects • in heterozygotes sufficient normal Hb (HbA) is formed to allow normal life
Sickle cell disease and sickle cell trait Sickle cell disease: • complications from polymerisation of deoxygenated HbS (less soluable than HbA) • → chronic haemolysis → chronic anaemia • exacerbation of sickling raises blood viscosity → blocking of capillaries and sickling crisis • tab 22.5 • + abnormal susceptibility to infections (Pneumococcal, Meningococcal) and osteomyelitis
Sickle cell disease and sickle cell trait dental aspects of sickle cell disease and s.c.trait: • Hb ≤ 10g/dl → v. s. homozygote • s.c. trait: gn anaesthesia with full oxygenation s.c. disease: • +/- oral mucosa pale or yellowish due to jaundice • +/- radiographics changes in skull and jaws • prompt atb treatment
Sickle cell disease and sickle cell trait • painfull crisis with analgesics • rigorous dental care necessary due to ↑ susceptibility to infection
The thalassaemias • α-thalassaemias Asians, Africans and Afro-Caribbean • ß-thalassaemias Mediterranean (Greeks) • diminished synthesis of globin chains → resulting relative excess of other chains → precipitation in ery → +/- haemolysis • severity of disease depends on the numbers of affected genes • minor = heterozygotes • major = heterozygotes
The thalassaemias thalassaemia minor: • mild, but persistent microcytic anaemia, otherwise asymptomatic • +/- splenomegaly
The thalassaemias thalassaemia major: • severe hypochromic, microcytic anaemia • great enlargement of liver and spleen • skeletal abnormalities (marrow expansion) • life saving transfusions, but iron depositions in tissues → haemosiderosis → dysfunction of glands and other organs → xerostomia
Leukaemia • leukaemic white blood cells production → supress of other cell lines of the marrow
Leukaemia acute leukaemia • ALL most common leukaemia of children • AML in adults • tab 22.7 • splenomegaly, hepatomegaly, +/- lymphadenopathy • mucosal pallor, abnormal gingival bleeding • tab 22.8
Leukaemia • management: • biopsy of gingival swelling • vigorous oral hygiene to controll the bacterial population before complications develop • extractions avoided, if necessary – blood transfusion, generous atb cover
Leukaemia • chronic leukaemia
Leukopenia and agranulocytosis leukopenia • WBC ≤ 5000³/l • different causes tab 22.10 • chance haematological finding x severe - immunodeficiency
Leukopenia and agranulocytosis agranulocytosis • clinical effects of severe neutropenia: fever prostration, mucosal ulceration • drug induced leukopenias • tab 22.12
Leukopenia and agranulocytosis aplastic anaemia • failure of production of all bone marrow cells (pancytopenia) • systemic and oral effects: purpura, anaemia, susceptibility of infection • cause: unknown, ai, drug induced • management: stop drugs, give atb and transfusions
Haemorrhagic diseases • haemorrhagic diseases = purpura (platelet deffects) and clotting deffects
Haemorrhagic diseases • Investigation of a history of excessive bleeding: • careful history essential tab. 23.1 • most of the haemorrhagical diseases are hereditary! • bleeding for up to 24hrs after an extraction usually due to local causes or a minor defect of haemostasis → more prolonged bleeding is significant
Haemorrhagic diseases • Clinical examination: • signs of anaemia and purpura • examination of the mouth → planning of the operation • haemophilia – all essential extractions carried out at a single operation with fVIII cover • radiographs (to prevent complications)
Haemorrhagic diseases • Laboratory investigations: • tab 23.2 • essential is look for anaemia • blood grouping
Haemorrhagic diseases A) Purpura • typical result of platelet disorders • bleeding time prolonged but clotting function normal (with exception of of vW disease)
Haemorrhagic diseases • general features of purpura: • purpura = bleeding into the skin or mucous membranes causing petechiae or ecchymoses or „spontaneous bruising“ • haemorrhage immediately follows the trauma and ultimately stops spontaneously as a result of normal coagulation • thrombocytopenia = platelets ≤ 100 000 mm³ • spontaneous bleeding uncommon until platelets ≤ 50 000 mm³
Haemorrhagic diseases • typical site palate • +/- excessive gingival bleeding or blood blister • tab 23.3
Haemorrhagic diseases ITP • IgG auto Ab • ↓ number of platelets • children or young adult women • first sign could be profuse gingival bleeding or postextraction haemorrhage • +/- spontaneous bleeding into the skin
Haemorrhagic diseases • management: • corticosteroids • transfusions of platelets • anti…???
Haemorrhagic diseases AIDS • ai thrombocytopenia can be early sign drug associated purpura • aspirin + others interfere with platelet function • others act as haptens → immune destruction of platelets or suppress marrow function • tab 23.4
Haemorrhagic diseases localised oral purpura • sometimes blood blister without haemostatic defect • choking sensation („angina bullosa haemorrhagica“) • rupture → ulcer • systemic purpura should be excluded
Haemorrhagic diseases von Willebrand´s disease • both by prolonged bleeding time and deficiency of fVIII • usually inherited, AD • deficiency of fVIII mild → purpura more common manifestation
Haemorrhagic diseases B) Clotting disorders • tab 23.5
Haemorrhagic diseases Haemophilia A • most common, severe • fVIII deficiency • 6/100 000 • severe haemophilia typically effects in childhood – bleeding into muscles or joints after minor injuries • mild haemophilia (fVIII ≥ 25%) – no symptoms until an injury, surgery or dental extraction
Haemorrhagic diseases • severe and prolonged bleeding can also follow local anaesthetic injections! (inferior dental blocks!)
Haemorrhagic diseases • clinical features: • positive family history • 30% patients negative history! • bleeding starts after a short delay (normal platelet and vascular responses) → persistent bleeding, can continue for weeks • haemarthroses • intracranial haemorrhage! • deep tissue bleeding → obstruction of airways! • HBV, HCV+! • +/- formation of anti fVIII Ab
Haemorrhagic diseases • principles of management: • radiographs (local status, prevention of complications) • admission to hospital • replacement therapy • as much surgical work as possible in one session 23.6 • for dental extraction fVIII level 50-75% • postoperatively: atb, risk of bleeding greatest 4-10 days postoperatively
Haemorrhagic diseases • aspirin and related analgesics avoided! • extractions in mild haemophilia with antifibrinolytic drugs
Haemorrhagic diseases Christmas disease (haemophilia B) • fIX • inherited • more stable → replacement therapy in longer intervals • other the same as in haemophilia A
Haemorrhagic diseases Acquired clotting defects a) vitamin K deficiency • causes: obstructive jaundice, malabsorption • surgary delayed to haemostasis recover • +/- vitamin K
Haemorrhagic diseases b) anticoagulant treatment • coumarin (warfarin) • dental extraction save with INR 2-3 • few teeth extracted in one session, trauma should be minimal, sockets can be sutured • anticoagulation should not be stopped • for large surgery → stopped with agreement of physician • short term: heparin (acts only about 6hrs) → surgery delayed for 12-24hrs
Haemorrhagic diseases c) liver disease • obstructive jaundice • extensive liver damage (viral hepatitis, alcoholism) • haemorrhage can be severe and difficult to control • → vitamin K • antifibrinolytic agents • fresh plasma infusion
Lymphomas • any type of lymphocytes, most frequently B cells • all malignant • Hodgkin + non Hodgkin lymphomas (NHL) • relatively frequently involve cervical lymph nodes x rare in the mouth
Lymphomas A) NHL • adults predominantly affected • nondescript, soft, painless swelling +/- ulcerated • histologically: • + invasion of adjacent tissues • + if traumatised – inflammatory cells can obscure the lymphomatous nature of the tu
Lymphomas • management: • biopsy! • staging!
Lymphomas • Burkitt´s lymphoma • nasopharyngeal (T cell) lymphoma – mlg midline granuloma • MALT! • + local manifestation of gn disease
Cervical lymphadenopathy • dental and periodontal infections most common cause • lymphomas • HIV infection • tab 26.1 • investigation: recent viral illness – lymphadenopathy resolves after some months