“A pint of sweat saves a gallon of blood”- George S.

Patton 1

Blood Disorders
• Normal Blood: 55% plasma & 45% formed elements (44% RBCs + 1%WBC)

• Adult blood cells originate in bone marrow

• Plasma: has 90% water & 10% plasma proteins, inorganic salts, gases

• RBC: transport hemoglobin (Hb), its value reflects anemic state- Hb is low or pathologic
condition if Hb is high

• WBC: are phagocytic, immunologic & an important component of the inflammatory process

• Platelets (thrombocytes): active in blood clotting mechanism & clot dissolution after healing

1) Anemia: are classified based on following criteria

Cause of anemia:
• Blood loss: Acute- blood loss from trauma or disease & Chronic- such as iron-deficiency
anemia
• Increased hemolysis or destruction of RBCs: Hereditary- such as sickle cell disease &
Acquired- such as drugs, infections, physical or chemical agents, antibody-mediated
anemia- erythroblastosis fetalis

Diminished production of RBCs:

a) Nutritional deficiency: can be either because of insufficient dietary intake or defect in
absorption in the GI tract
Examples are- pernicious anemia (B12 absorption deficiency), iron-deficiency anemia,
celiac disease (sprue)
b) Bone marrow failure: Aplastic anemia- can be inherited; etiology unknown. Can be
caused by injury to bone marrow by medications, radiation, chemotherapy or infection.
Aplastic anemias occur in combination with neutropenia and thrombocytopenia
because of decrease in all cells formed in the bone marrow.
 Consult with physician to determine of pre-medication is necessary

Chronic disease:
a) Second most prevalent anemia after iron-deficiency anemia
b) Many chronic diseases are associated with anemia

Genetic blood disorders:

a) Thalassemia- defect in synthesis of hemoglobin

Dental Considerations for Anemia

• Watch for medical history
 “A pint of sweat saves a gallon of blood”- George S. Patton 2

CLINICAL SIGNS:
• Extraoral signs: Pale skin, nails, weakness, malaise. easy fatigability, dyspnea on slight
exertion, faintness, brittle nails (“spooning of nails”- loss of convexity)
• Intraoral signs: pale buccal mucosa, glossitis with loss of filiform papillae, painful
burning sensations (glossodynia), angular cheilitis
TREATMENT:
• Depends on the type of Anemia
• Medication- Oral ferrous iron tablets for iron-deficiency anemia; ***liquid prep for
children may stain teeth, encourage use of straw for administration. Vitamin B12
injections daily for Pernicious anemia. Folic acid supplements for Folate-deficiency
anemia
• Nutritional counseling- inform patients about the food sources for Iron, Vitamin B 12
and Folic acid. For example, Vit. B12 is obtained mostly from animal sources and
fortified foods such as meat, clams, liver, fortified breakfast cereals, fish, poultry, milk,
cheese and eggs.
• Folic acid deficiency in pregnant females can cause neural tube defects in fetus. Spina
bifida (Myelomeningocele) is a severe condition that affects nerve formation in spinal
cord  paralysis in infants.

2) Sickle cell disease:

Definition- It is a Genetic, autosomal recessive condition resulting from a defective Hb molecule
• RBCs take the shape of a “sickle” after defective Hb molecule loses oxygen
• Affects 10% of African American population & Caucasians of Mediterranean origin
• “sickle cell trait”- carriers; have fewer symptoms unless exposed to extreme conditions
like high altitudes, dehydration
• A prenatal diagnosis can be done with 100% accuracy and genetic counseling is
encouraged
CLINICAL SIGNS & SYMPTOMS:
• Anemia starts within the first 6 months of life
• Life span of RBCs reduces from 90-120 days to 10-15 days
• RBCs are brittle so break apart easily  oxygen deprivation and fatigue
• RBCs get stuck in the chest, abdomen or joints  pain
• Bone marrow produces increased number of reticulocytes to counteract the anemia of
sickle cell disease
• Vaso-occlusion (blockage) causes dactylitis
• Mortality is due to repeated episodes of vaso-occlusion infarctions  stroke and
organ damage
 “A pint of sweat saves a gallon of blood”- George S. Patton 3

• Life expectancy is 30 years

TREATMENT:
• For hypoxia, dehydration and acidosis  oxygen & fluids are administered
• Pain relief with opioids without depressing breathing
• Antibiotics – treat acute infections
• Regular Blood transfusions
• Stem cell transplant maybe an option
ORAL IMPLICATIONS:
• Dental pulp necrosis & enamel hypo mineralization
• Osteomyelitis of mandible
• Protrusion of maxilla & mandible
• Pallor of buccal mucosa & numb chin syndrome (mental nerve neuropathy)
• Facial & dental pain
APPOINTMENT MANAGEMENT: Thoroughly review medical history
• Consult with primary physician for disease control and some patient’s may require
premedication*** due to susceptibility to infections and bacteremia
• Stress- reduction protocol to prevent sickle cell crisis & implement preventive program
• Avoid long complicated appointments; anesthesia with low dose of vasoconstrictor to
avoid vaso-occlusion of RBCs

3) Polycythemias:
Definition: Polycythemia is an increase in number and concentration of RBCs, above normal
level.
TYPES: primary and secondary polycythemia
1. Primary Polycythemia or Polycythemia Vera is a neoplasm (cancer) caused by a genetic
mutation in which bone marrow makes too many RBCs. Also, blood viscosity increases,
affecting oxygen transport to tissues.
2. Secondary Polycythemia is usually associated with increased erythropoietin production in
response to low blood oxygen level.
OCCURENCE:
• Diagnosed at an average of age 60
• Affects men more than women
• Develops slowly
Primary Polycythemia or Polycythemia Vera

SIGNS & SYMPTOMS:

 “A pint of sweat saves a gallon of blood”- George S. Patton 4

• Increase bleeding risk with spontaneous bleeding of gingiva.

• Bruise easily result in submucosal petechia and hematoma formation.
• Risk of blood clot formation leading to a heart attack, stroke, and pulmonary embolism.
• Migraines, vertigo and fatigue
• Purple or red areas on the oral mucosa, gingiva, lips or tongue
TREATMENT:
• Chemotherapy
• Phlebotomy to reduce number of blood cells and decrease total blood volume, making
easier for blood to function.
• Low dose of aspirin to reduce risk of blood clots. (<100mg/daily)
• Medications:
• Hydroxyurea (Doxia, Hydrea): help decrease blood cells
• Ruxolitinib (Jakafi): destroy cancer cells and it used to treat people who don’t
respond or can not take Hydroxyurea

Secondary Polycythemia
• Increase of RBC production can result from hypoxia from common conditions that lead
to oxygen shortage in the blood like:
• high altitudes
• emphysema
• chronic obstructive pulmonary disease
• tobacco smoking.
• Develops in response to lack of oxygen in tissues.
• Associated with heart and lung diseases.
TREATMENT:
• Requires treatment of the underlying cause

Oral Health Considerations for Polycythemia

• Primary and secondary polycythemia are associated implications for oral healthcare
• Dental hygienist should consult with primary care physician or hematologist to
obtain clearance for implementing procedures and requirement for
premedication
• Blood tests may be required before oral healthcare
• Pay attention to medical and dental history
• Short appointments, observe tissue after procedures and document
• Explain and give appropriate advice to patient that bleeding may occur days after
the appointment
• Instruct patient to self-check mouth for new signs or symptoms and reporting
changes
• Primary and secondary polycythemia may initially present:
 “A pint of sweat saves a gallon of blood”- George S. Patton 5

• with spontaneous bleeding from the purplish or red areas on the tongue,
cheeks, lips and gums
• poor oral hygiene, including inflamed gingiva and periodontal disease
4) Bleeding or coagulation disorders:
• Blood clotting or hemostasis is the body’s mechanism for stopping injured blood vessels
from forming clots.
• Bleeding disorders have in common the tendency to spontaneous moderate to
excessive bleeding caused by:
a. Trauma
b. Surgical procedure
c. DH therapy
• Types of Disorders of Coagulation
Acquired Disorders
• Vitamin K deficiency
• Liver disease
• If liver not functioning properly, clotting factor may be altered
• Anticoagulation drugs
• Heparin, Coumadin (Warfarin), Aspirin
Hereditary Disorders
• Hemophilia
• Caused by low levels or complete absence of a blood protein essential for clotting
• Etiology: mutation or deletion of factor VIII or IX in the gene
• Treatment: drugs to decrease bleeding or infusion of platelets
• Management: If uncontrolled bleeding, stop treatment

Questions?

1. Which of the following is NOT a characteristic of sickle cell anemia?

a. Inherited blood disorder found mostly in African-Americans
b. Individuals can experience weakness, fatigue and joint pain
c. RBC are circular in shape
d. All of the above

2. Which of the following is NOT a cause of iron-deficiency anemia?

A. Chronic blood loss
B. Deficiency in iron intake
C. Increase iron requirement
D. Normal bone marrow function

3. Which of the following is characterized by an abnormal increase in RBCs?

a. Leukopenia
 “A pint of sweat saves a gallon of blood”- George S. Patton 6

b. Polydipsia
c. Thrombocytopenia
d. Polycythemia
 “A pint of sweat saves a gallon of blood”- George S. Patton 7

References
Olga, A. I., & Joan, A. P. (2018). Oral Pathology for the Dental Hygienist with General Pathology
Introductions (7th ed.). St. Louis, Missouri, USA: Elsevier.

Polycythemia Vera. (2017, February 8). Retrieved November 23, 2018, from Mayoclinic:
https://www.mayoclinic.org/diseases-conditions/polycythemia-vera/diagnosis-treatment/drc-
20355855

Wilkins, E. M., Wyche, C. J., & Boyd, L. D. (2017). Clinical Practice of the Dental Hygienist (12th ed.).
Philadelphia, PA, USA: Wolters Kluwer.