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Blood disorders & nutrition deficiency

Blood disorders & nutrition deficiency. Azmi Darwazeh BDS, MSc, PhD, FFDRCSI Professor in Oral Medicine. Introduction. Blood disorders and nutritional deficiencies have oral manifestations Oral manifestations may appear early in the disease process. Anaemias.

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Blood disorders & nutrition deficiency

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  1. Blood disorders &nutrition deficiency AzmiDarwazeh BDS, MSc, PhD, FFDRCSI Professor in Oral Medicine

  2. Introduction • Blood disorders and nutritional deficiencies have oral manifestations • Oral manifestations may appear early in the disease process

  3. Anaemias • Definition: reduction in the concentration of haemoglobin (Hb) below normal for age and gender • Hb is carried on the RBCs • Reduction in concentration of Hb • Reduction in the number of RBCs • Reduction in the function of RBCs • Alterations in the shape of RBCs

  4. Megaloblastic (macrocytic) anaemias • Deficiency in • Vitamin B12 • Folic acid Crhon’s disease Cealiac disease Intrinsic factor

  5. Megaloblastic (macrocytic) anaemias • Pernicious anemia: vitamin B12 deficiency due to lack of intrinsic factor • Autoimmune • Surgery

  6. Megaloblastic (macrocytic) anaemias • CBC + Blood film • Macrocytic normochromic • Diagnosis may be complicated in case of multiple deficiency

  7. Treatment of vitamin B12 deficiency • Oral vitamin B12 therapy for cases of dietary deficiency (improve diet) • Injections of 1000ug of hydroxocobalamin or cyanocobalamin • Life-long maintenance therapy (1000ug hydroxocobalamine injection every 2 months.

  8. Iron deficiency anaemia - MechanismsIn some patients more than one mechanism may be present • Excessive loss of RBC • Haemorrhage (post-haemorrhagicanaemia) • Excessive destruction (haemolyticanaemia)

  9. Iron deficiency anaemia - MechanismsIn some patients more than one mechanism may be present • Failure of production of RBC • Diminished production with marrow aplasia (aplastic anaemia). • Diminished production with marrow hyperplasia (dyshaemopoieticanaemia e.g. megaloblastic and Fe deficiency anaemia).

  10. Iron deficiency anaemia - MechanismsIn some patients more than one mechanism may be present • Deficiency of • intake of Fe • absorption of Fe • Increased demand on Fe

  11. Iron deficiency anaemia • Microcytic hypochromic • Stages of Fe def. anemia In stores: bone marrow & liver In plasma bound to transferrin Hb bound to RBCs

  12. Stages of iron deficiency • Pre-latent iron deficiency: Body stores of Fe are depleted but circulating Hb. and serum Fe are within normal level • Latent iron deficiency: Body Fe stores are depleted and serum Fe is reduced, but Hb. concentration is not affected • Iron deficiency anaemia: Hb. and serum iron concentration are reduced. Oral symptoms may appear in the second and third of these stages

  13. Management of Fe deficiency anemia • Identification and removal of the underlying cause • Replacement of iron (for months): • Ferrous sulphate 200mg three times daily given after food. • Ferrous gluconate 250 mg/day is a substitute • Infections should be treated

  14. The normal values of CBC must be memorized. • The interpretation of CBC and blood film results must be mastered.

  15. HaemolyticanaemiasSickle cell anaemia • Inherited: autosomal recessive • Sickle cell triat • When HbS loses oxygen sickling of RBCs

  16. Marked regional variations in the prevalence of sickle cell disease and β-thalassemia in Saudi Arabia: Findings from the premarital screening and genetic counseling program Journal of Epidemiology and Global Health, Volume 1, Issue 1, Pages 61-68 Ziad A. Memish, Tariq M. Owaidah, Mohamad Y. Saeedi

  17. SCA – Oral manifestations • Maxillary prognathism • Mandibular prognathism • Osteomyelitis • Peripheral neuropathy • Pulpitis The main concern for the dentist is not the oral features !!

  18. Normocytic anaemias • Failure of RBCs production • Aplastic anaemia • Vitamin C deficiency • Bone marrow malignancies

  19. Oral signs and symptoms in anaemias • Epithelial atrophy • Loss of filliform papillae • Tongue (other sites) soreness • Candidosis • Disturbance of taste sensation • RAS • Gingivitis

  20. Plummer-Vinson (Patterson-Kelly) syndrome Patients are predisposed to the development of postcricoid and oral carcinoma

  21. Management of oral lesion in patients with anaemias and haematinic deficiencies is by treatment of the underlying haematological deficiency

  22. Malignant proliferation of white cells Lymphocytic Acute Leukaemia Monocytic Chronic Myeloid

  23. Oral manifestations of leukaemia Oral symptoms may precede other symptoms • Hyperplastic gingivitis • Spontaneous gingival bleeding • Recurrent attacks of AUG • Oral ulcerations • Infections

  24. Managing the painful symptoms during the late stages of leukaemia • Antiseptic mouth wash • Covering agents

  25. Acute leukaemia manifested as petichealhaemorrhage

  26. Acute leukaemia manifested as oral candidosis

  27. Acute leukaemia manifested as herpetic infection

  28. Oral ulcerations Opportunistic infections

  29. Myelo-dysplastic syndromesSuppression of one or more cell lines in the bone marrow CBC + Smear: An abnormal blood count in an elderly patient should suggest the possibility of a myelodysplastic syndrome Males >60 years old Gingivitis Oral ulcerations

  30. Leukaemia Immune thrombocytopenia Bone marrow suppression

  31. Scurvy • Ascorpic acid (vitamin C) deficiency • Most common single vitamin deficiency • Clinical picture: • Hyperplastic gingivitis and bleeding • Swollen and friable gingiva • False pocketing • Secondary infections • Petichea • 2ry anaemia

  32. Scurvy • Differential diagnosis: leukaemia • Laboratory investigations: • Leukocyte or plasma ascorbic acid levels • Urinary output of ascorbic acid after a test dose • Treatment: • Vitamin C (1 g daily) for few days • Possibility of multiple deficiencies • Quick clinical response

  33. Folate deficiency • Cause: • Malabsorption more than poor dietary intake • Increased demand • High alcohol intake • Medications: e.g. phenytoin Oral manifestations of vitamin B12 and folate deficiency are indistinguishable

  34. Vitamin B12 deficiency • Deficient intake • Deficient absorption • Problems with intrinsic factor (pernicious anemia) • Problem with absorption generally: mal-absorption syndrome

  35. Vitamin B12 deficiency Beefy sore tongue Atrophic tongue and angular cheilitis RAS

  36. Psychological diseases associated with nutritional deficiency • Anorexia nervosa: vomiting and avoidance of food due to a delusion of body image despite the presence of emaciation. • Bulimia nervosa: Patients are usually of normal body weight but indulge in eating binges followed by self-induced vomiting. • Oral features: • Dental erosions • Bilateral parotid enlargement • Manifestations of dietary deficiency

  37. Nutritional deficiency is not always due to inadequate food intake

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