g.

Dental management of haematologic disorders – anaemia

Introduction

-Erythrocytes are produced from the bone marrow from pleuripotent stem cells via immature
cells (reticulocytes).
-Reticulocytes retain their organelles and nuclear remnants and still have the ability to divide
and are released into the blood when the demand is high.

-Erythropoietin produced in the kidneys stimulates erythrocytes production when the oxygen
level is low.
-Mature erythrocytes contain only haemoglobin which carry oxygen and carbon dioxide
between the lungs and the tissues.

-Haemoglobin production requires iron, protoporphyrin and globin chains.

-Haemoglobin is a heterogenous group of proteins consisting of 4 globin chains and 4 haem
groups.
-In an adult, the normal haemoglobins are HbA, HbA2 and HbF.

ANAEMIA (Source: Owotade FJ. 18)

-Haemoglobin level lower than what is normal for the age and sex.

-Prepubertal Hb<11 g/dl

-Adult female Hb<11.5 g/dl
-Adult male Hb<13.5 g/dl
-Anaemia impairs the oxygen carrying capacity of the blood, it is not a disease but a
manifestation of many diseases.

Classification of anaemia (Source: Owotade FJ. 18) -Based on the size of the RBC

-Microcytic anaemia is when the mean corpuscular volume (MCV) is less than 78 fl.
-This is the most common and usually due to iron deficiency.
-Normocytic anaemia is when the RBC size is normal (MCV 79 – 98 fl)
-This is usually due to chronic diseases like leukaemia, liver disease, renal failure and sickle
cell disease.

-Macrocytic anaemia is when the MCV is >99 fl. 54

-Usually arise from vitamine B12 or folate deficiency. Folate and B12 deficiency can arise
from increased demand as in pregnancy or malignancy or as a result of alcoholism.
-Some drugs deplete folate and B12 such as methotrexate.
-Macrocytic anaemia may also arise from liver disease and myxedema

Causes of Anaemia
-Poor intakes of Hematinic: Socioeconomic factors, diet fads;
-Impaired absorption: Small bowel disease;
-Increased demand: Pregnancy, haemolysis;
-Impaired erythropoiesis: Aplastic anaemia, leukeamia, drugs -Haemolitic anaemias: Sickle
cell disease;
-Blood loss (commonest): Menorrhagia, GIT lesion (ulcers, CA), trauma
Clinical features (Source: Owotade FJ. 18) -Asymptomatic in the early stages.

-Pallor of the conjunctiva, oral mucosa or the skin.

-Tiredness, dyspnoea, tachycardia or murmurs and may worsen angina and heart failure.

General management of anaemia (Source: Owotade FJ. 18) -Establish the precise nature
though lab studies-Hb content, MCV etc.

-Replace Hb with haematinics, blood transfusion of erythropoietin.

-Erythropoietin is indicated in the treatment of anaemia of renal failure and cytotoxic therapy.

Dental aspect of management (Source: Owotade FJ. 18) -Local anaesthesia is sufficient for
pain control.

-Conscious sedation should be used only when oxygen is available to supplement.

-Deep sedation carries the risk of hypoxia.
-Avoid Nitrous oxide (N2O) if vitamin B12 deficiency is suspected. N2O can interfere with
B12 metabolism and neurologic function if administered for more than 12 hours.
-Anaemia should be corrected preoperatively if general anaesthesia (GA) is indicated.
-Elective surgery under GA should not be carried out if the Hb is less than 10 g/dl.
-The myocardium may not be able to respond to increased demands for oxygen if adequate
oxygenation is not ensured.
-In an emergency, blood transfusion can be used to correct the anaemia. Diuretics should be
administered to prevent volume overload.
-Some anaemias may cause oral ulcers, glossitis or angular stomatitis and will be discussed
with the specific anaemias.

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Deficiency anaemias (Source: Owotade FJ. 18)

1. Iron deficiency anaemia

-Common in this environment due to malnutrition, malaria and chronic blood loss.
-Manifest as impaired exercise capacity and koilonychia.
-Treated with ferrous sulphate 200 mg tds. Ferrous salt is preferable to the ferric salts as they
are better absorbed in the gut.
-Present in the mouth as a sore, physically normal tongue even before haematologic
parameters fall below the normal levels.
-Severe anaemia is a cause of atrophic glossitis.
-Rarely, may be associated with Plummer-Vinson syndrome (glossitis, dysphagia and iron
deficiency anaemia).
-Candidosis may be precipitated or aggravated by anaemia.
-Angular cheilitis may be a feature though this is more commonly due to candidiasis.
-Aphthous stomatitis may also be associated with iron deficiency anaemia.

2. Vitamin B12 deficiency

-In addition to general features of anaemia, this may present with neurologic symptoms of
paraesthesia of the extremities.
-Oral features are similar to Iron def anaemia apart from association with Plummer Vinson
syndrome.

3. Folate (Folic Acid) deficiency

-No body stores and usually due to inadequate intake
-Deficiency in pregnancy associated with cleft deformities
-Sore, physically normal tongue, atrophic glossitis and angular cheilitis are oral features

4. Haemolitic anaemias
-May be due to: Inherited abnormalities of formation (haemoglobinopathies), Inherited
abnormal structure (G6PD deficiency), Damage to erythrocytes (autoimmune, drug induced
or infective). -Increased erythrocyte destruction leads to billirubin overproduction and
jaundice.
-Spleen may be enlarged, reticulocyte and uric acid levels will be raised.

DENTAL MANAGEMENT OF SICKLING DISORDERS (Source: Owotade FJ. 18)

-Important to recognize and diagnose the condition.

-For patients with sickle cell disease (HbSS), local anaesthesia (LA) is preferred.
-Avoid prilocaine (may cause methaemoglobinaemia if used excessively).
-Aspirin in large doses may cause acidosis which can precipitate a crisis. Best avoided.
-Conscious sedation and relative analgesia are safe, avoid benzodiazepines which can depress
respiration.
-For treatment under general anaesthesia (GA), correct anaemia preoperatively. Exchange
blood transfusion is occasionally indicated.
-Prophylactic antibiotics should be given for surgical procedures and infections should be
treated aggressively.

Orodental features of SCD include:

-painful infarcts in the jaws which present like and may be construed as toothache.
-dense radiopacities in the jaws and skull-stepladder trabecular pattern.
-Osteomyelitis may occur in the mandible.
-Neuropathies including lip anaesthesia.
-Hypercementosis.
-Bone marrow hypertrophy may lead to enlarged maxilla and increased overjet and overbite.
-Bossing of the skull and hair on end trabecular pattern, tower skull appearance.
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-Enamel hypomineralisation and calcified pulp canals.

h. Dental Treatment in Patients with Leukemia

According to Deliverska EG, Krasteva A. in the oral cavity local symptoms and findings of
leukemia include paleness of the oral mucosa with gingival bleeding that develops into
painless gingival hyperplasia, petechiae, hemorrhages, and ulcerative necrotic lesions (Fig. 4
and Fig. 5).

Once the diagnosis has been made, consultation with the patient physician or oncologist is
mandatory before commencing dental treatment.

The main problems in dental treatment of patients with hematologic malignancies of white
cells are:
• Bleeding tendency
• Increased risk of infection - odontogenic infections and opportunistic infections:

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• Risk of developing osteonecrosis of the jaw

• Anemia
• Corticosteroids treatment - may display evidence of secondary adrenal insufficiency. •
Secondary malignancies

The dentist, and mainly the periodontists and oral pathologist, plays a fundamental role in the
early diagnosis of leukemia knowing that the first symptoms of the disease occur in the oral

cavity with normal or show subtle changes in initial laboratory tests. 13