ORAL MEDICINE (OMP301)

REVISION
TOPICS INCLUDED ARE:
REVISION BLOOD DISORDERS OF RELEVANCE TO DENTISTRY

Instructor: Dr.Sahar Abdelraouf

ORAL MEDICINE COURSE IS MAINLY CONCERNED BY:

1) Case history of the disease:

• Oral manifestations (symptoms)
• Medical Hx (general manifestations; knowledge must be present from general medicine)
• Other manifestations: skin, nails, etc …
2) Clinical examination: intraoral and extraoral signs (e.g. skin, nails …etc)

3) Laboratory investigations:
• List them according to each condition

Diagnosis and Dental management

Note that: Knowledge about etiology and pathophysiology of disease from medical
sciences is important as in Oral Medicine we just put an overview of that as a reminder.
https://youtu.be/WvD4p8FkQpY https://youtu.be/Z8WmHK_QDtw

• Definition
• Pathophysiology: watch the above videos given by url
• Clinical manifestation: (general manifestations, oral manifestations,
other manifestations
• Laboratory investigations
• Dental managemet
Discussed in lectures in MIU in detail
Sickle cell anemia: https://youtu.be/fIIJmg_1hv0 Thalassemia: https://youtu.be/oH6SMG3Ykjg

Scheme (detailed for)

Sickle cell diseases
and
Thalassemia
• What is HbA2?and what is the difference between HgA and HgA2?
• HbA (⍺2β2) - HbA2 (⍺2𝛿2)
Normal adult Hb Sickle cell Sickle cell trait Thalassemia Thalassemia
(Normal Hb anemia (β) (major) minor
types in adults) (Absence of
β chain)
HbA 97% HbSS: 80-90% HbSA: 60% HbF (⍺2ɣ2): up HbA:
(defective β2) to 90% considerable
amounts
HbA2 + HbF 3% HbF: 10-20 % Normal Hb HbA2 (⍺2𝛿2): HbF and HbA2:
types in adult: the remainder remainder
remainder %
40%
 Shortened life
span to the ¼ of
normal
 Anemia: general + oral manifest.
Jaundice: yellow sclera
• Delayed eruption of teeth
• Enamel hypoplasia

Expansion of BM • Osteoporosis and osteosclerosis

spaces • Hair on end appearance of skull
• Frontal bossing
• Maxillary overgrowth
• Ladder-like appearance of alveolar
bone – dense LD
• Teeth: (Atypical) odontalgia
• Pain in abdomen/chest/bone
Infarction
• Kidney: hematuria
• Extremities: ulcers
 • Anemia: general + oral manifest.
• Jaundice: yellow skin/sclera
• Hemosiderosis: increase iron overload will
 increase susceptibility to infection
 parotid swelling
 Teeth: discoloration due to iron
deposition
Ashen-gray skin =
(pallor + jaundice + hemosiderosis)
Expansion of BM • Osteoporosis and osteosclerosis
spaces • Hair on end appearance of skull
• Frontal bossing
• Maxillary overgrowth
• Ladder-like appearance of alveolar bone
– dense LD

• Large head
• Short nose with depressed nasal bridge
Thalassemic face • Enlargement of the maxilla
• Forward drifting and spacing of maxillary
(Mongoloid features) incisors
• Anterior open bite
Lab. Sickle cell anemia
Invest.
• Normocytic normochromic anemia
• Increase RDW (reticulocytes increase to
compensate for lost RBCs)
• Increase serum bilirubin
• Decrease Haptoglobin (that bind free Hb
spilling into blood due to RBcs hemolysis)
• Electrophoresis: HBS predominant
• Sickling test: Sickling occurs after sealing fresh • Electrophoresis: HBF predominant
blood in a small chamber of microscopic slide
with a reducing agent.
Thalassemia (major)
• Microcytic hypochromic anemia
• Increase RDW (reticulocytes increase to compensate
for lost RBCs)
• Increase serum bilirubin
• Increase serum bilirubin
• Decrease Haptoglobin (that bind free Hb spilling into
blood due to RBcs hemolysis)
• Increase serum iron
• Decrease serum folate
Problems encountered by dentist in:
Sickle cell anemia:
• Anemia; delayed wound healing, oral lesions causing burning sensation of oral mucosa.
• (Atypical) odontalgia due to
•infarction of bone (mandible)  osteomyelitis
•infarction of pulp  pulpal necrosis
Thalassemia:
• Anemia; delayed wound healing, oral lesions causing burning sensation of oral mucosa.
• Increase susceptibility to infection due to iron overload
1-Patient education: avoid spicy food, vinegar, excessive salty food. Inform the patient that the oral
condition becomes better with control of anemic state.
2- Drugs/precaution during dental treatment:
 Oral surgery:
• For both diseases:
• oral surgery not performed unless level of Hb reaches 7 gm/dl
• if general anesthesia is needed… a specialist must be present.
• proper flap design of oral surgery and minimal trauma to augment wound healing
• antibiotics as prophylaxis in any operation (since infection may precipitate sickling in Sickle cell
anemia, iron overload that enhance bacterial growth in thalassemia)
• never anaesthetize or operate on patient during crisis.
• avoid vasoconstrictor in local anesthesia as it may precipitate crisis.
• avoid drugs which may cause respiratory depression & lead to hypoxia (e.g. Sedatives).
 Sickle cell anemia: Manage pain caused by infarction e.g. pulpal pain (do endodontic treatment)
 symptomatic treatment of intraoral manifestation:
• “burning sensation” (Tantum Verde q.d.s. 10 min. before eating and at bedtime)
• for angular cheilitis: combined antifungal/antibiotic treatment is preferable such as
quadriderm cream.
4- Follow-up: maintain optimum oral hygiene
 Glucose 6 phosphate
dehydrogenase deficiency
(G6PD)-Scheme with
Illustrations
- https://youtu.be/VoBysmk6Qiw

- And here is a general explanation:

Offending oxidant drugs are those drugs
that result in generation of free radicals in
RBCs. Those free radicals are normally
removed in RBCs so not to harm cell itself.
In case of glucose 6 ph dehydrogenase def.,
RBCs are not capable to do that and free
radicals pile up and end by causing early
destruction of RBCs than usual (after about
2 months)
- Dentist: take care of Ibuprofen and aspirin
prescription in such patients
X-linked recessive disorder (appear in males only
https://youtu.be/bZxaGal4V-Q https://youtu.be/SVlV68XVQLg

Scheme (detailed) for

Leukemia (L)
and
Multiple Myeloma (MM)
 Cause : Unknown
may be
Viruses/ Chemicals / Genetic

Neoplastic proliferation

L.: WBCs (Immature MM.: Plasma cell neoplasm

= non-functional) producing ONE TYPE OF Ig (G)
 Malignant proliferation of cells
(Occupy space in BM and deplete nutrients)

Cl. manif. of
= PANCYTOPENIA
Clinical manifestations of pancytopenia:
• Anemia: (general manifestations,: easy fatigue, dyspnea, palpitation ….etc and oral manifestations: atrophy and
pallor of oral mucosa, recurrent oral ulcers, atrophy of tongue and oral mucosa ……etc)
• Leukopenia.: increased susceptibility to infections, recurrent oral ulcer (its size and presence or absence of red
halo depend on extent of decrease in WBCs)
• Thrombocytopenia.: (manifestation may reach up to spontaneous bleeding according to extent of platelets def.)
 General manifestations: Purpura of skin (= petechia and ecchymosis), epistaxis (bleeding from nose)
 Oral and manifestations: Purpura of oral mucosa (= petechia and ecchymosis), bleeding gums and with minor
trauma as with tooth brushing (bleeding to interdental papilla results in its enlargement).
L: Hyperplasia in bone
marrow spaces = Bone pain

Bone pain
Easy fracture
HYPERCALCEMIA
Neurological manifestations:
MM: Multiple myeloma
paresthesia
plasma cells interact with
bone cells and results in
aggressive bone resorption
(osteolytic bone lesions)
 Hepatosplenomegaly
= Lymphadenopathy

L: Malignant cells invading organs/tissues

MM: Light chain ppt in

kidney/invasion by plasma
Renal failure
cells/hypercalcemia
ending up with renal failure
 INCREASED BLEEDING
TENDENCY

Leukemia: Increased clot formation

• Some leukemic cells secrete sustances to activate
clotting factors (in some types of leukemia)
• Hepatomegally: decrease clotting factor
= +
increased bleeding
tendency
formation (DIC)
• Thrombocytopenia

Multiple myeloma:
• Thrombocytopenia
• Abnormal Ig coat platelets = Increased bleeding
tendency
 Cardiac problems Neurological
Cachexia due to increased manifestations
blood viscosity
DIC
by presence of
paraprotein
 Oral Manifest. Leukemia Multiple Myeloma
Features of anemia atrophy and pallor of oral mucosa, recurrent oral ulcers, atrophy of tongue and oral
mucosa ……etc

Features of leukopenia increased susceptibility to infections (e.g. candidiasis), recurrent oral ulcer (its size and
presence or absence of red halo depend on extent of decrease in WBCs) + recurrent
HSV and HZV infection
Increased bleeding tendency Purpura of oral mucosa (= petechia and ecchymosis), bleeding gums and with minor
(thrombocytopenia + other trauma as with tooth brushing (bleeding to interdental papilla results in its
causes) enlargement).
Bone Loss of lamina dura Paresthesia (mental)
Loss of alveolar bone crest Bone pain
Fracture (rare in mandible)
Osteolytic bone lesions: teeth mobility
Tissue invasion by Gingival enlargement Plasma cell lesion
malignant cells Nerve infitration
(Bell’s palsy, neuralgia)
Cerv. Lymphadenopathy
Atypical odontalgia
 Lab. Features Leukemia Multiple Myeloma
Hematological • Normocytic normochromic anemia • Normocytic normochromic anemia
• Decrease platelets • Decrease platelets
• Increased (malignant blast cells) • Neutropenia
• ESR raised
Biochemial • Hypergammaglobulinemia
• Monoclonal IgG
• Bence Jon’s proteins (in urine)
• Hypercalcemia
Radiological • Loss of lamina dura • Osteoporosis
• Loss of alveolar bone crest • Punched out radioloucencies
(osteolytic lesions)
Bone marrow • Abnormal immature blast cells • Malignant plasma cells
biopsy
(confirm diagnosis)
Problems encountered by dentist:
• L. and MM.:
 Anemia; delayed wound healing, oral lesions causing burning sensation of oral mucosa.
 Leukopenia; increased susceptibility to infection, recurrent oral ulcers
 Increased bleeding tendency
 Renal failure
 “Chemotherapy”
• L.: (Atypical) odontalgia, gingival enlargement, DIC in some types of leukemia
• M.: Plasma cell lesion
Dental management:
 Acute leukemia: Surgery is not allowed and only
symptomatic and conservative treatment should be attempted as follow:
 Analgesics, antibiotics and pulp drainage via opened cavity for painful (exposed) teeth.
 Local measures for bleeding gum e.g. absorbable gelatin sponges saturated with thrombin placed
subgingivally after gentle removal of possible etiological factors.
 If surgery is unavoidable so hospitalization and the patient will need blood transfusion first.
1-Patient education: oral hygiene motivation, avoid spicy food, vinegar, excessive salty food.
Inform the patient that the oral condition becomes better with control of malignant blood disorder
2- Drugs/precaution during dental treatment (during remission period of disease):
 Oral surgery:
• oral surgery not performed unless level of Hb reaches 7 gm/dl
• proper flap design of oral surgery and minimal trauma to augment wound healing
• antibiotics as prophylaxis for any surgical procedure
• Antiseptic mouth wash as 0.2% chlorhexidine used among other oral hygiene methods
• BT, PTT and INR should be checked before surgery (INR max.=1.5).
 Manage gingival problems:
• L.: Scaling and wait in remission period, if still enlarged do gingivectomy
• M.: Excision of plasma cell lesion during remission period of disease
 Drugs: prophylactic antiviral and antifungal
 Symptomatic treatment of intraoral manifestation:
• “burning sensation” (Tantum Verde q.d.s. 10 min. before eating and at bedtime)
• for angular cheilitis: combined antifungal/antibiotic treatment is preferable such as
quadriderm cream.
4- Follow-up: maintain optimum oral hygiene to avoid the need for any dental intervention
• Is there any dental consideration considering the renal failure in mm other than working on a
non dialysis day?

Still, here are the important points in dental management of patient undergoing renal dialysis:
Dental procedures are best done the day after dialysis for the following reasons:
• All blood cells will be functioning much better when blood is cleared from urea.
• Patient take heparin on dialysis day. Heparin effect stays for up to 6 hours, so better to
schedule dental procedures on the next day.
• Patient gets exhausted on dialysis day, so better to schedule dental procedures on the
next day.
 Short scheme
Agranulocytosis Cyclic Neutropenia
Hematological •No neutrophils are seen in Cyclic decrease in neutrophils evey 3-
circulation (also no basophils and 5 days every3-4 weeks
eosinophils)
General Severe signs and symptoms of Infection is not significant
manifestations generalized infection (RT, GIT, GUT (short duration of neutropenia)
…etc)
Oral Deep, large, irregular margin, no Clinical appearance is major-
manifestations red halo, floor covered by necrotic aphthous-like with the absence of red
slough, foul odor (FS) (worse than halo
major-aphthous-like)
Severe form of PD + Lymphadenopathy

Lab. Differential leukocytic count Sequential, differential leukocytic

investigations (neutrophil count less than count
100/mm3).
DENTAL MANAGEMENT:

1) Patient education: about the nature of disease and its relation to oral manifestations. Instruct
the patient to maintain optimal oral hygiene. When there’s ulcer in the oral cavity avoid excessive
spicy, salty food …..
2) Removal of the cause : e.g. source of trauma if present. Contact physician as underlying
systemic condition is the cause of oral manifestations.
3) Drugs/precaution during dental treatment:
• Agranulocytosis: Parenteral antibiotics are given to control infection.
• Cyclic neutropenia: Systemic antibiotics are given to control periodontal disease (according to
the case).
• Antibacterial mouth rinse (chlorhexidine e.g. Hexitol).
4) Follow up: to keep optimal oral health condition of teeth and periodontium so to avoid any
surgical treatment as possible.
Pathomechanism of EBV infection: https://youtu.be/28CNEVgF3kE
EBV testing: https://youtu.be/kKPkG1gflfo
Clinical manifestations (General and oral manifestations) EBV testing: https://youtu.be/kKPkG1gflfo
What is the type of aphthous-like ulcers in hematological diseases are (minor/major??)

For example:
• Iron def anemia, vitamin B12 def. anemia … minor aphthous-like ulcers
• Aplastic anemia, neutropenia (including cyclic type) … major aphthous-like ulcers.
As a conclusion, in the absence or decrease in the no. of PMNL which function as first line of
defense and are main cell responsible for inflammatory reaction (seen clinically as red halo), ulcer
becomes secondarily infected resulting in considerable connective tissue destruction and ulcer
becomes large > 1cm in diameter and deep, persists for weeks and lack of red halo (occurs with
major decrease in PMNL) then healing occurs by scar formation simulating major aphthous-like
ulcer.
 TO BE FILLED BY STUDENTS WHILE STUDYING THIS CHAPTERO
Ulcer Ulcer description
BE DSTUDENTS Blood disorders
minor aphthous-like From ulcers chapter Iron def anemia,
ulcers vitamin B12 def.
anemia ….
major aphthous-like Large, deep ulcers Without red halo: With red halo:
ulcers with irreguler Aplastic anemia, Ulcers appearing
margin, coverd by neutropenia during
necrotic slough (if (including cyclic chemotherapy of
extensive gives type) …. malignany blood
foeted odor) diorders
…worse than major
aphthous ulcer
THANK YOU