Lincoln B. Taylor, DDS, MS, Arthur J. Nowak, DMD, Roger H.
Giller, MD,
Paul S. Casamassimo, DDS, MS
Sickle cell anemia: A review of the dental concerns and a retrospec-
tive study of dental and bony changes
ickle cell anemia (homozygous
This paper is a review of the me&
SS disease) is a hereditary
ical concerns pertlnent to dental
hemolytic disease. Eight per-
care and a preliminary study of den-
cent of American Blacks are silent car-
tal findings of the sickle cell anemia
riers of the sickle hemoglobin gene.
(SS) patient. The dental characteris-
These individuals have one normal
tics observed in 21 dental patients
gene and one mutant sickle hemo-
with SS are described. Radiographic
globin gene, a condition referred to as
findings included “stepladder” tra-
sickle trait. Approximately 1 in 500
beculae pattern (70%),enamel
American Blacks inherit two defective
hypomineralization (24%),calcified
sickle hemoglobin genes and manifest
canals (5%),increased overbite ( 3 0
the clinical disorder of sickle cell ane-
80%),and increased ovetjet (56%).
mia.’,*
Comparisons are made with other
The distortion of the erythrocyte
studies of the sickle cell patient, and
into a sickle shape is the result of low
the need for further study Is suggest-
oxygen tension (oxygen partial pres-
ed.
sure of 50 to 60 mm Hg), which caus-
es partial crystallization of the
Hemoglobin S and realignment of the
defective hemoglobin molecules.3
The distorted sickle cell has increased
cellular rigidity, causing membrane
damage as the cell traverses the
body’s microvasculature. Thus, red
cell life span is shortened due to
hemolysis. Sickling promotes ery-
throstasis, increased blood viscosity,
reduced blood flow velocity, and, in
turn, tissue hypoxia and further sick-
ling4
Sickle cell anemia patients have
many medical problems which can be
induced during dental treatment.
These potential medical complications
increase the need for precautionary
measures during dental treatment. In
contrast, individuals with sickle cell
trait possess a heterozygous genetic
pattern (SA) and may be treated as
normal healthy patients. Individuals
with sickle trait are asymptomatic
carriers of a single recessive sickle
gene and do not experience clinically
relevant sickling except under condi-
38 Special Care In Dentistry, V o l 1 5 No 1 1995
tions of severe hypoxia.
Sickle cell crises are experienced
by SS patients and consist of recur-
rent attacks of pain in the abdomen
and limbs sometimes associated with
fever and the passage of dark or red
urine, weakness, jaundice, pallor, car-
diomegaly, splenomegaly, increased
risk of infections due to loss of
splenic function, and leg ulcers. The
crises are promoted by a number of
factors such as hypoxia, dehydration,
acidosis, and stre~s.’*~,~-”
Frequently, the first manifestation
of SS disease is dactylitis (hand and
foot syndrome): symmetric nonpit-
ting edema of the hands and feet,
accompanied by warmth and tender-
n e s 7 It is most common in children
under the age of 4 years7 Hand and
foot syndrome should alert the clini-
cian to evaluate the patient for under-
lying sickle cell disease.
Infarction of the mandible has
been recognized as part of a painful
crisis9 Abnormal sensation associat-
ed with the mental nerve has been
reported.’O Mental nerve neuropathy
is an oral manifestation which pro-
duces severe pain in the mandible
and usually results in lip
paresthesia.6 Paresthesia of the men-
tal nerve appears to be secondary to a
vascular occlusive episode involving
the inferior alveolar artery at or near
the mental foramen.6The pathologi-
cal basis appears to be nerve com-
pression associated with mandibular
bone involvement, though this is still
~ n c l e a rRecovery
.~ of sensation may
be slow, with the paresthesia lasting
as long as 18 months.6
Bony deformities are commonly
observed in sickle cell disease
patients. Compensatory expansion of
the erythroid (red cell) marrow pro-
duces certain bony changes, such as
overgrowth of the anterior part of the
maxilla with increased angulation
and separation of the incisor teeth.7
Also, distinct bony trabecular pattern
that are usually noted during clinical
and radiographic e~amination.~
Clinicians noting the combined
occurrence of these bony changes
should have the patient evaluated for
hemolytic disorders such as sickle
cell anemia.
Mucosal pallor, delayed eruption,
dental hypoplasia, and radiographic
changes are other common oral find-
ings associated with SS disease.”
Other dental findings observed in
Nigerian sickle cell anemia patients
included the intrinsic opacity of enam-
el, malocclusion (overjet and overbite),
decreased dental caries, and diastema-
ta (gaps between the teeth).12It was
noted, however, that the decrease in
dental caries among the Nigerians was
attributed to the widespread avoid-
ance of sweets or candies, which they
believe weaken their blood.12Also,
Okafor et a1.12did not discuss staining
but rather only mentioned the intrinsic
opacity noted on the cusps of the teeth.
Despite these findings, it should be
noted that there was no sigruficant dif-
ference in dental age between sickle
cell anemia patients and normal
patients.13This is of note, since puber-
ty is commonly delayed in patients
with sickle cell anemia.
A preliminary study involving a
retrospective dental chart review of
all sickle cell anemia dental patients
at the Children’s Hospital in
Columbus, Ohio, was conducted. The
purpose of this study was to deter-
mine if there was any similarity to
the dental findings described in the
Nigerian SS study conducted by
Okafor et al.12
Materials and methods
A retrospective dental chart
review was conducted on all (21)
sickle cell anemia patients (ages 8 to
31 years of age) at the Children’s
Hospital Dental Clinic in Columbus,
Ohio. The data collected from routine
follow-up visits were used to deter-
mine similarities in dental findings.
Information regarding the hemoglo-
bin genotype was obtained from the
medical history reported. No
matched group (control) for age or
sex was considered at the time the
data were collected.
The radiographic features listed in
the results were obtained from peri-
apical and occlusal films. Normally,
the incisors are in contact, with the
upper incisors ahead of the lower by
only the thickness of the upper edges
(ie., 2 to 3 mm overjet is the normal
relati~nship).’~ Thus, abnormal over-
jet is defined as the horizontal dis-
tance of more than 3 mrn.I2
Normally, the lower incisal edges
come into contact with the lingual
surfaces of the upper incisors at or
above the cingulum (i.e., normally,
the overbite is 1 to 2 rnm).I4Okafor et
a l l 2 considered excessive overbite to
be the vertical distance greater than
2.5 mm between the tips of the upper
and lower incisors. This retrospective
study had data recorded as percent-
age coverage for which excessive
overbite is considered to be greater
than 30% relative to the lower incisal
coronal coverage by the upper
incisors.
Results
The Table summarizes dental find-
ings noted on the dental charts of 21
patients with sickle cell anemia. The
21 patients represented all the sickle
cell anemia dental patients at
Children’s Hospital in Columbus,
Ohio. The most prevalent condition
common to these patients was the
radiographic trabeculae “stepladder”
pattern (70%). Other conditions
observed included overjet of 3-10 mm
(56%),overbite of 30-80% (~OYO), cal-
cified canal (5%), and hypomineral-
ization of enamel (24%).The maloc-
clusion does not provide conclusive
evidence that bimaxillary protrusion
is unique to sickle cell patients, since
the black population does tend to
exhibit this characteristic feature.
In some cases, as indicated in the
Table, there was no documentation
or radiographs. Also, there were no
other etiological factors documented
in the records regarding enamel
Special Care In Dentistry, Vol15 No 1 1SSS
hypomineralization (five patients)
and the calcified canal (asymptomatic
tooth #25, coronally). However, the
same patient with the asymptomatic
calcified canal had a cariously
involved tooth (#30) which required
root canal therapy. This tooth had the
apical third of the distal canal calci-
fied.
When considering the presence of
malocclusion with overbite and over-
jet, we noted oral habits as a possible
etiology. Only one patient (mentally
retarded) was shown to have an oral
habit (thumb-sucking) which may
have contributed to the malocclusion.
All the patients were on daily
antibiotics as a precautionary mea-
sure against any subsequent infec-
tions. The regimen was penicillin 250
mg twice daily, and in the case of
allergy to penicillin, erythromycin
250 mg twice daily. Some patients
were also given folic acid and iron
supplements. The accelerated ery-
thropoiesis increases folic acid
requirements in patients with sickle
cell anemia.l” Iron deficiency may
occur, resulting in decreased reticulo-
cyte and hemoglobin levels.16On the
other hand, iron levels in patients
with sickling disorders are often high
and must be monitored due to the
tendency for overloading due to
transfusions and increased dietary
iron absorption.
Pneumonia appeared to be the
most common infection among the 21
patients. There were seven patients
for whom pneumonia had occurred
at some time in their lives. Only two
patients‘ records contained no indica-
tion of their past medical history.
Other medical problems were sinus
infection, gallstone removal (two),
hand-foot syndrome, back pain, joint
pain (two), and abdominal pain.
Discussion
Despite the lack of a matched group
for age and sex, some of the dental
findings in the SS patients in Ohio are
similar to those obtained in the
Nigerian study reported by Okafor et
~ 1 . ’ ~In. that study, clinical evalua-
tions were conducted on 37 consecu-
tive SS patients, aged from 14 to 33
years, on routine follow-up visits.12
39
Table 1. Dental findings of 2 1 subjects at Children’s Hospital, Columbus, Ohio.
Abnormalities
Trabeculae with stepladder
Enamel hypomineralization
Calcified canal
Overbite (30-80‘2,)
Ovejet (3-10 mrn)
‘The denominator represents the total number of patients with documented informa-
tion in each category obtained from their dental records.
Malocclusion in the Nigerian SS
patients was reported to be 35%, in
contrast to 16.6% in controls. The
overjet and overbite occurrence in
our study was 56% and 50%, respec-
tively, despite the lack of documenta-
tion in 5 charts.
Other studies have indicated a
tendency for a more protrusive max-
illa and a more retruded incisors.I7 It
was considered that an increase in
bone marrow activity in patients with
sickle cell disease may explain the
maxillary protrusion. Retrusion of
the anterior teeth is most likely t o be
the result of the increased lip pres-
sure due to the protrusive m a ~ i l l a . ’ ~
Pulp calcificatioo
The presence of peculiar foreign par-
ticles in the dental tubules indicates
infection in the canal.IHAlso, the
presence of denticle-like hardened
bodies as a result of calcification in
the pulp suggests the occurrence of
blood vessel thrombosis.IHThese ~~ ~
findings are not pathognomonic for
sickle cell anemia patients, but sick-
ling has an effect on the aforemen-
tioned changes.In As noted in our
study, 5% of the patients had calci-
fied canals.
Mandibular odeomyelitis
Chronic hemolysis and secondarily
increased erythropoiesis result in
expansion of the bone marrow. The
skeleton is also vulnerable to vaso-
occlusive crises, especially where the
blood supply is relatively limited or
tissue is poorly vascularized.Iy The
40 Specla1 Cam in Dentistry, Vol16 No 1 lo05
Subjects (N = 21) Percentage
11/20‘ 70
5/21 24
1/21 5 These findings are attributed to
8/16 50
9/16 56
lower border of the mandible is
mainly supplied by the periosteal
blood supply, in contrast to the rest
of the mandible-such a s the coro-
noid process, ascending ramus, and
the angle-which are more adequate-
ly supplied by the arteries to the
attached muscles.IYThe inferior alve-
olar artery supplies the teeth and
alveolar process, together with part
of the mandible. An occlusion of the
artery will have its effects mainly in
the alveolar process and teeth. This is
more critical in the molar region than
in the more anterior regions.IYThe
lower anterior teeth are supplied by
anastomoses involving the incisive
and mental branches of the inferior
alveolar arteries from both rieht
” and
left sides, as well as branches of the
facial arteries. Infarction, necrosis,
and osteomyelitis are therefore more
likely to occur in the posterior region
of the mandible.”
Radlographlc features
Radiographic changes in the jaw
occur in 79% to 100% of patients, in
all age groups, and in both the
mandible and maxilla.1H
Radiographic changes in sickle cell
anemia patients are:
(1) a n increase in radiolucency
of the jaws d u e to the
decreased number of trabec-
ulae;
(2) coarse trabecular pattern;
( 3 )thin inferior border of the
mandible;
(4) generalized osteoporosis
commonly caused by salmo-
nella infections;
(5)distinct areas of radiopacity;
and
(6) the stepladder appearance
created in the interdental
alveolar bone by horizontal
rows of trabeculation.”
erythroblastic hyperplasia and
medullary hypertrophy, with the
resultant loss of fine trabeculae and
the formation of larger bone marrow
spaces..’ Expansion o f the red-cell-
producing marrow develops as a
compensatory mechanism for the
underlying hemolytic anemia.
Seventy percent (70%))of the patients
in our study had the stepladder tra-
beculae pattern. This was evident in
the bitewing radiographs around the
first molar region.
Other changes include hyperce-
mentosislHand distinct intact lamina
dura. These changes, although typi-
cal, should not be considered as
definitive diagnostic criteria for sickle
cell anemia. Similar changes may be
seen in normal individuals as well as
in other systemic disorders such as
thalassemia, estrogen imbalance,
hyperparathyroidism, Paget’s dis-
ease, and metabolic bone disease.h
As previously stated, the dental
characteristics given here are not to
be considered as unique diagnostic
features of sickle cell anemia. The
Occurrence of a calcified canal is quite
common even in normal healthy con-
trol subjects and thus is not necessari-
ly a definite feature. A sickle cell ane-
mia patient may have one or more of
the features listed in the Table. If a
combination of features Occurs, the
clinician should be alerted to investi-
gate the patient‘s medical history. In
some instances, the patient may not
alert the clinician to his or her med-
ical condition, since in the patient’s
estimation, the dentist should be con-
cerned only with teeth and not the
patient’s general health. In addition,
it is helpful to realize that certain con-
ditions-such a s intrinsic opacity,
ovejet, and overbite-are the norm
rather than the exception in SS
patients.
The responsibility of the dentist is
to ensure that a proper referral sys-
tem exists for these patients if they
are unable or unwilling to deliver the
necessary dental care. Avoidance by
the dentist does not eradicate the
patient's problem and may have
avoidable medical consequences.
The dentist has no need to fear
treating the sickle cell patient once
medical consultation is sought. When
the patient is in a non-crisis state,
dental treatment within the above-
listed guidelines may be rendered.
During all forms of dental treatment,
care to preserve normal oxygenation
must be taken to avoid systemic sick-
ling complications. Consultation with
an anesthesiologist experienced in
the care of SS patients may be helpful
in this regard.
Preventive dental care is impor-
tant, since oral infection may lead to
osteomyelitis or tissue n e c r ~ s i s . ~
Dental counseling should begin at an
early age and should be maintained
throughout life.7Antibiotic prophy-
laxis is recommended before and
after all dental procedures (including
routine prophylaxis) which are likely
to cause gingival bleeding, because of
the added risk of infection and sys-
temic ba~teremia.'~ Patients with an
acute infection-for example, an
abscess-should receive intramuscu-
lar or intravenous antibiotics instead
of oral medi~ati0n.l~ The parenteral
route will give faster and more con-
sistent blood levels of the antibiotic.
Antibiotic therapy for established
infections should be determined in
consultation with pediatric medical
consultants.
Routine dental treatment may be
rendered during noncrisis periods;
however, therapy during crisis
should be directed toward
palliati~n.~,~,Patients with fevers of
unknown origin should be evaluated
to rule out a possible dental ~ a u s e . ~ , ~ ,patients must be referred to both a
Minimizing physical stress
reduces the risk of a crisis. Thus, care
should be given in consideration of
the manner in which dental treat-
ment should be provided and the
length of treatment. The treatment
options include the traditional dental
setting (1)with only local anesthesia
or (2) under general anesthesia. Sickle
cell anemia patients are categorized
as an ASA 111anesthetic risk.20Dental
treatment for the SS patient is best
performed on an ambulatory basis
with relevant precautions.21Local
anesthesia is more desirable than
general anesthesia when possible,
because local anesthesia has less
potential to lower the oxygenation of
the bl00d.~However, numerous den-
tal appointments and lengthy proce-
dures may be too stressful for the
patient, leading to lack of coopera-
tion, and thus oral rehabilitation
under general anesthesia is more
beneficial under such circumstances.
Oral sedation is an alternative to
help decrease preoperative anxiety
levels prior to local or general anes-
thesia. Low doses should be used;
however, if moderate levels are need-
ed, additional oxygen by nasal can-
nula is suggested.20Similarly, nitrous
oxide sedation must occur with ade-
quate assurance that oxygenation of
the patient is maintained at all times
during the procedure. The use of
nitrous oxide is contr~versial.~
However, if proper oxygenation is
provided and carefully monitored,
nitrous oxide is not contraindicated.
For an adequate margin of safety,
50% oxygen concentration must be
maintained along with high flow rate
and proper ~entilation.',~,~ With any
form of sedation, continuous moni-
toring of oxygen saturations should
be done.
The use of local anesthesia with a
vasoconstrictor is contr~versial.~,~
Some clinicians claim that vasocon-
strictors may impair circulation local-
ly and lead to infarction, while others
maintain that vasoconstrictors have
no effect on the local tissue oxygena-
tion.
For dental treatment with general
anesthesia, all sickle cell anemia
hematologist and an anesthesiologist
who are experienced in the care of
sickle cell anemia patients. The choice
of anesthetic technique is less impor-
tant than the care with which it is
administered. As previously dis-
cussed, important considerations for
the general anesthesia for dental pro-
cedures include:
Special Care In Dentlstry, Vol15 No 1 1995
(1)Hemoglobin levels should
be above 10 gm/100 mL.21
Packed erythrocyte transfu-
sions may be administered
so that an acceptable hemo-
globin level can be obtained,
i.e., 10-12 gm%.
(2) Use of preoxygenation
before induction may mini-
mize the dangers from air-
way obstruction or an unex-
pectedly difficult intubation.
(3) The maintenance of oxy-
genation with the monitor-
ing of oxygen delivery and
oxygen saturation.22
(4) Inhalation of 30-50'/0 oxygen
for at least 4 hours postoper-
atively should guard against
hypoxemia due to hypoven-
t i l a t i ~ nFollowing
.~~ surgery,
complications are more com-
mon than intraoperatively.
Thus, the recovery period is
most critical.
(5) Hydration must be main-
tained during all phases of
the procedure to prevent
hemoconcentration and
resultant s i ~ k l i n g . ~ ~
(6) Further transfusion may be
necessary if reduction in the
HbS level (< 30%) is deemed
advisable to avoid perioper-
, ative sickling problems.22
The extent of the dental
surgery, the length of gener-
al anesthesia required, and
the patient's past history of
sickle-related and other
medical problems should be
considered by the consulting
hematologist and anesthesi-
ologist in making their rec-
ommendations regarding
transfusion.
(7) Temperature hemostasis
should be maintained
aggressively with the aid of
heating blankets, warmed
intravenous fluids, humified
inspired gases, and warm
ambient temperature.22
The guidelines for treatment of SS
patients in the dental office should
include the relevant list above but
also the following:
41
 (1)Schedule dental appoint-
ments during the morning
with minimum treatment for
a brief since stress
and overexertionll are
thought to be contributing
factors in a sickle cell crisis.
(2) Prescribe CNS depressants
judici~usly.~~
(3) Use acetaminophen for treat-
ment of pain, because high
doses of salicylates may
induce acidosis and increase
bleeding4
(4) Avoid elective surgery, such
as the removal of asympto-
matic impacted teethJ5
(5) Ensure appropriate home
fluoride therapy and routine
dental recall visits as in any
general preventive dental
treatment regimen, to mini-
mize undesirable dental pro-
cedure~.~~
Thus, greater awareness of clinical
findings should enable clinicians to
design appropriate prophylactic mea-
sures for those in whom incipient
abnormalities are detected. Sickle cell
anemia patients cannot risk eliminat-
ing dental evaluation, since, in the
event of an oral infection, their health
is greatly compromised compared
with that of the normal healthy per-
son.
Until a completely successful
treatment is identified, sickle cell ane-
mia patients will still have to cope
with the complications and conse-
quences of their disease. The dentist
plays a vital role in the health care
required by these patients and can
provide reassurance to the patients.
Parents have enough of a problem
coping with the disease and need not
be further frustrated by their chil-
dren’s dental care situation. Quality
of life can be enhanced through the
elimination of dental factors which
may trigger a crisis. Thus, through
42 Special Care In Dentistry, Vol15 No 1 1995
educating the parents and providing
both comprehensive and preventive
dental treatments, dentists can
achieve these goals.
Further studies are being pursued
to expand on the findings of Okafor
et a1.12 and this retrospective study.
These studies suggest that there are
some distinct‘changes in both the
dental and bony structures in sickle
cell anemia patients.
Dr. Taylor is assistant professor of pediatric
dentistry, University of Tennessee, Dunn
Dental Building, Memphis, Tennessee. Dr.
Nowak is professor of pediatric dentistry and
pediatrics, University of Iowa, College of
Dentistry, Iowa City, Iowa. Dr. Giller is
associate professor of pediatrics, University of
Colorado School of Medicine, Division of
Hematology, Oncology & Bone Marrow
Transplant, The Children’s Hospital, Denver,
Dr. Casamassimo is professor and chairman
of pediatric dentistry, Children’s Hospital,
Columbus, Ohio.
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