DENTAL CONSIDERATIONS IN

HEMATOLOGICAL DISORDERS

Presented by: Madiha Shanam

Mariya Fatma
BDS-Final Yr)
(Batch-2016-17)
RED BLOOD CELL DISORDERS
RBC is biconcave in shape. RBC count in males is 4.5-6 million cu mm
of blood and in females is 4-5.5 million cu mm of blood. RBC contain
35% of Hb which is red in color. The life span of RBC is 120 days.
Following are the disorders of RBC which are covered.
 Erythrocytosis: Polycythemia Vera

 Anaemia: Iron Deficiency Anemia & Anemia of Chronic Inflammation

Plummer Vinson syndrome

 Macrocytosis: B12 and Folate deficiency anemia

 Hemolysis: Paroxysmal nocturnal hemoglobinuria

Glucose-6-phosphate dehydrogenase deficiency
 Hemoglobinopathies: Sickle cell disease

Thalassemias
ERYTHROCYTOSIS : POLYCYTHEMIA VERA

 Also known as “polycythemia rubra vera”, “Osler's disease”, “Vaquez's disease”

and “erythemia”
 There is an uncontrolled proliferation of the erythroid stem cells leading to excess
of erythroid cell mass in the body (RBC). There is accompanying increase in the
granulocyte and megakaryocytic elements though to a lesser degree.
 PV manifest intraorally with erythema of mucosa, glossitis and erythematous,
edematous gingiva
 Marked purplish red discoloration is seen in head and neck.

Oral Health Considerations

 Poorly controlled patients are at an increased risk for both thrombotic and
hemorrhagic due to blood hyperviscosity and concurrent qualitative and
quantitative platelet alterations.
ANEMIA :
IRON DEFICIENCY ANEMIA (IDA) AND ANEMIA OF
CHRONIC INFLAMMATION (ACI)

 IDA is defined as a reduction in total body iron to an extent that iron stores are
fully exhausted and some degree of tissue iron deficiency is present. It may occur
as a consequence of low dietary intake, impaired absorption, or excessive iron
loss.
 ACI also known as anemia of chronic diseases, ACI is observed in autoimmune
diseases, acute and chronic infection, malignancies and chronic kidney disease. In
ACI, the utilization of existing iron stores is impaired, resulting in iron
sequestration.
Clinical and Oral Manifestations:
 Pallor of conjunctivae, lips, and oral mucosa, brittle nails, palmer creases.

 Glossitis and stomatitis are recognized oral manifestations of anemia.

 Other signs and symptoms of anemia includes angular chelitis, pale oral mucosa,
PLUMMER-VINSON SYNDROME
Also known as Paterson-Kelly syndrome
It is a rare syndrome characterized by the classic triad of dysphagia, iron deficiency
anemia and upper esophageal webs
Oral manifestations includes glossitis, glossopyrosis, glossodynia and angular
cheilitis
Barium swallow test is done to diagnose oesophageal webs(thin projections on ant.
wall)
Oral Health Cosiderations:
Routine dental care should be deferred in those patients whose Hb is <11 g/ dL or
those manifest sign and symptoms such as shortness of breath, abnormal heart rate
or oxygen saturation less than 91% until their health status improves
Dentists should be aware that anemia places a patient at increased risk of ischemic
heart disease.
MACROCYTOSIS:
B12 AND FOLATE DEFICIENCY ANEMIA
 Due to decreased intake, impaired
absorption and increased requirements
Clinical and Oral Manifestations :
 Fatigue, decreased mental concentrations,
weakness
 Includes beefy red tongue with smooth or
patchy area of erythema, soreness or a
burning sensation affecting the tongue,
lips, buccal mucosa and other mucosal
sites. Paresthesia and taste alterations
have been reported
 Hunter's glossitis showing fiery red
appearance in megaloblastic anemia
HEMOLYSIS: PAROXYSMAL NOCTURNAL
HEMOGLOBINURIA
 PNH is a rare acquired condition characterized by bone marrow failure, hemolytic
anemia, thrombosis, and smooth muscle dystonia.
 Clinical manifestations includes fatigue, pain, esophageal spasm, erectile
dysfunction and platelet activation
Glucose-6-Phosphate Dehydrogenase
Deficiency
G6PD deficiency is inherited as an X-linked
hemolytic anemia caused by mutations in the
G6PD gene and more than 400 mutational
variants have been defined.
Clinical Manifestations:
The vast majority of individuals with G6PD
deficiency remain clinically asymptomatic
throughout their lives.
Characteristic signs and symptoms of fatigue,
flank pain, anemia, and jaundice are evident.
Oral Health Considerations:
 Patients with G6PD deficiency can tolerate the delivery of all the necessary
dental care. Medications known to induce a hemolytic crisis should be promptly
managed. G6PD patients should maintain excellent oral hygiene and comply with
routine recall visits so as to prevent oral and periodontal infection.

HEMOGLOBINOPATHIES:
Sickle Cell Disease
It is a chronic hemolytic blood disorder characterized by abnormal Hb
which under low oxygen tension, results in sickling of cell. It is a
severe genetic disorder of Hb synthesis. It is autosomal dominant.
Clinical and Oral Manifestations: Acute complications of SCD
include acute chest syndrome, aplastic crisis, fever/sepsis,
osteomyelitis, pain, priapism, splenic sequestration and stroke.
Chronic conditions of SCD include asthma, avascular necrosis, gall
bladder disease, hepatic dysfunction, leg ulcers, nephropathy,
pulmonary hypertension and silent infarcts.
Oral findings includes mucosal pallor, delayed eruption, discolored and
depapillated tongue and increased periodontitis.
Oral Health Considerations:
 SCD is not associated with increased periodontal disease, mandible osteomyelitis
precipitating a sickle cell crisis is reported
 Amoxicillin was the most common antibiotic,& perceived the higher risk of
infectious complications was highest for extractions, followed by restorative
treatment and tooth polishing
 for patients deemed low risk, simple surgical procedures may be accomplished in
the out patient setting.
 Pain management may be chalanging and usually consists of anti inflammatory
agents, opioid/ nonopioid analgesics and proper hydration. For patients deemed
at moderate or high risk, dental therapy should be rendered in a hospital setting
where appropriate medical support is readily available.
Thalassemias
The thalassemias are a group of inherited autosomal recessive disorders of Hb
synthesis characterized by a disturbance of either alpha or beta Hb chain
production.
ALPHA THALASSEMIA : There is reduction or absence of alpha chain synthesis. Alpha
chains of Hb are required not only for HbA but also foe HbF, which is the main
haemoglobin type in fetal life and result in intrauterine death of fetus.
BETA THALASSEMIA : There is reduction or absence of beta chains. Hemolysis not
primarily due to lack of beta globin chains but it is because of the free alpha chains
which form insoluble aggregates that precipitate within the RBCs and cause
damage to the cell membranes.
Clinical and Oral Manifestations
 Patients with α- thalassemia trait are asymptomatic.

 Clinical manifestations include anemia, splenomegaly with jaundice, growth

retardation in children, infections, leg ulcers, gall stones, folic acid deficiency and
drug induced hemolysis
 Characteristics craniofacial deformities include a Class 2 skeletal base
relationship with a short mandible, a reduced posterior facial height, increased
anterior facial proportions, chipmunk facies, spiky shaped and short roots,
taurodontism, attenuated lamina dura, enlarged bone marrow spaces, small
maxillary sinuses, absence of inferior alveolar canal, thin cortex of mandible,
gingivitis a periodontitis.
Oral Health Considerations
 Splenectomized patients are more susceptible to developing postsplenectomy sepsis from
encapsulated bacteria. Prevention of postsplenectomy sepsis includes immunization against
bacteria, antibiotic prophylaxis and antibiotic treatment for fever and malaise.
 Consideration to provide antimicrobial prophylaxis for manipulative dental care is
recommended.
WHITE BLOOD CELLS DISORDERS
 Quantitative Leukocyte Disorders: Granulocytosis
Agranulocytosis
 Qualitative Leukocyte Disorders: Chediak-Higashi Syndrome

 Leukemia: Acute Lymphocytic Leukemia

Acute Myeloid Leukemia

Chronic Myeloid Leukemia
Chronic Lymphocytic Leukemia
 Lymphoma: Hodgkin’s Lymphoma

Non-Hodgkin’s Lymphoma
Burkitt’s Lymphoma
 Multiple myeloma

These topics will be covered under headings of:

*Clinical Features
*Oral Manifestations & Dental Considerations.
QUANTITATIVE LEUKOCYTE DISORDERS
 Granulocytosis: Large number of granulocytes in blood.
Commonly associated with increase in neutrophils. Total WBC
count >11,000/µL with ANC>7,700/µL.
Causes- Infection, burns, MI, metabolic conditions,
neoplasia.
 Agranulocytosis: Reduced number of
neutrophils.ANC<1,000/µL.
Causes-EBV infection, drugs( carbamazepine), autoimmune
disorders.
Oral Health Considerations-) Prophylactic antibiotics e.g.-
Oral Amoxicillin adult-2 g child-50 mg/kg or if unable to take
oral medication Ampicillin adult-2 g IM or IV child-50 mg/kg IM
or IV have been recommended for patients with hematologic
malignancy (ANC<1,000/µL) 30-60 mins. prior to dental
extraction.
Physician consultation is recommended for guidance on
management of severely neutropenic patients.
QUALITATIVE LEUKOCYTE DISORDERS
 Chediak-Higashi Syndrome: Rare autosomal recessive
immunodeficiency disorder. Characterised by partial
occuloalbinism with photophobia, easy bruisability, bleeding.
Oral Health Considerations- Periodontal destruction with
inflammation.
When oral surgical procedures are planned excessive
operative blood loss should be anticipated.
Intramuscular injections should be avoided.
Patient should be encouraged to bring sun glasses to dental
appointments.
LEUKEMIA
Results from proliferation of clone of abnormal hematopoietic cells with impaired
differentiation ,regulation and programmed cell death.
ACUTE: Acute Myeloid Leukemia
Acute Lymphoid Leukemia
CHRONIC: Chronic Myeloid Leukemia
Chronic Lymphocytic Leukemia
 Acute Leukemia: Flu- like symptoms, lymphadenopathy, bone pain, joint
pain,petechial skin and posterior palate hemorrhages, ecchymosis, gingival
enlargement, gingival bleeding, gingival ulcerations.
Oral Health Considerations-Pre chemotherapy dental assessments.
Maintenance of oral hygiene.
Management of periodontal infections.
Palliative treatment for mucositis.
Application of mouth wash with non-alcoholic solution of chlorhexidine 0.12%.
Topical application of povidone iodine followed by swish and swallow with nystatin
5,00,000 units.
Fluconazole to reduce oropharyngeal candidiasis.
Absorbable gelatin or collagen sponge, topical thrombin can be used to control
gingival bleeding.
Physician consultation should be made.
 Chronic Leukemia:Fever,night sweats, weight
loss,lymphadenopathy,anemia,thrombocytopenia,
bleeding,exfoliative cheilitis,infections with herpes and
candida followed by hemorrhagic lesions and mucositis. Oral
symptoms are rare in CML.
Oral Health Considerations-CLL is indolent chronic
hematologic malignant disease that has a prognosis
compatible with relatively normal dental treatment planning.
Patient with severe thrombocytopenia <50,000/µL might
require platelet transfusion prior to dental surgery.
LYMPHOMA
 Hodgkin’s Lymphoma: Lymphadenopathy,
fever, night sweat, weight loss.
Oral Health Considerations-Patients receiving
radiotherapy have risk of developing xerostomia.
Topical Fluoride varnish, gel or fluoride
toothpaste are given.
Risk of osteoradionecrosis in inferior border and
angle of mandible.
Physician consultation for assessing radiation
induced valvular disease risk and need for
prophylactic antibiotics and ischemic risks and
benefits of sedative agents and limitation of
epinephrine in LA.
 Non-Hodgkin’s Lymphoma- Lyphadenopathy,
hepatosplenomegaly, fever, weight loss, night sweat, extra
nodal presentation of GIT, skin, bone marrow, thyroid,
CNS,gingival swelling.
Toothache results in dental extraction an rapid growth of
tumours from non-healing extraction site.
Nerve invasion lead to paresthesia or anesthesia of related
oral mucosal tissue.
Non healing ulceration in surrounding mucosa, erosive
mucosal lesion resembling vesico bullous disease.
Acute complications include mucositis, viral & bacterial
infections and hemorrhagic lesion.
Long term NHL survivors treated with chemotherapy may
present with enamel discolorations & root malformations.
Oral Health Considerations- Non alcoholic chlorhexidine
mouthwash, topical application of iodopovidone for
mucositis.
Topical antimicrobials like tobramycin (0.3%) for bacterial
infections e.g.. antibiotic lozenges with Polymyxin-E and
tobramycin .
 Burkitt’s Lymphoma: Endemic & Sporadic forms.
Endemic refers to cases in African children- all EBV associated
involving bones of the jaw & other facial bones as well as
kidney, GIT, ovaries & other extra nodal sites.
Sporadic refers to cases in American patients- most commonly
involved site is abdomen( ileocecal area) .
Swelling of jaw including jaw tumours resulting in tooth mobility
and pain. Intraoral swelling of maxilla and mandible and anterior
open bite.
Oral Health Considerations-Due to mucositis, a soft toothbrush or
sponge toothbrush with alcohol-free mouth rinse can be used.
Topical gel (lidocaine) or 15% of benzydamine hydrochloride (15
ml three times per day during the chemotherapy cycles) may be
prescribed to reduce discomfort and pain.
To prevent fungal infections ( eg. oral candidiasis), topical anti-
fungal agents (Nystatin suspension 100,000 U/ml) may be
prescribed 4 times per day for 2 weeks. Viral infections are also
common (mainly herpes simplex), and anti-viral agents may be
prescribed (200 mg Acyclovir three times per day)
MULTIPLE MYELOMA
It is a plasma cell neoplasm characterized by
bone marrow plasmacytosis , complications
of bone diseases with skeletal destruction,
renal failure, anemia & hypercalcemia.
Tumours of jaw, pain, swelling, paresthesia of
inferior alveolar and mental nerve, tooth
mobility. Osteolytic lesions ranging from
asymptomatic to pathologic fracture.
Oral Health Considerations-
Osteonecrosis of jaw, resulting in
symptomatic exposed nonhealing areas of
the maxilla and mandible, is increasingly
recognized as a serious complication of long
term iv bisphosphonate therapy.
MANAGEMENT OF BISPHOSPHONATE ASSOCIATED ONJ