HEMATOLOGIC (BLOOD) DISEASES

CBC
WBC count RBC count WBC differential Hemoglobin (HGB) Hematocrit (HCT)
% of volume occupied by RBCs

Red cell indices

Mean cell volume (MCV)
average size of RBC

Mean cell hemoglobin (MCH)

average amount of hemoglobin in an average RBC

Mean cell hemoglobin concentration (MCHC)

average concentration of hemoglobin/unit of volume in an average RBC

Major Determinants of Disease

Blood cells have a short life span & require continuous replacement Most diseases of blood cells feature too many or too few cells because of an imbalance in the production or loss of cells Hemoglobin must be properly assembled & produced for effective O2 transport White blood cells are critical in the defense against infection Diseases of lymphoid cells differ importantly from diseases of myeloid cells Malignancies of myeloid cells are associated with circulation of malignant cells in the blood (leukemia) Malignancies of lymphoid cells are associated with malignant cells in the blood (leukemia) or masses in lymph nodes & other tissue (lymphoma) Most diseases that affect platelets cause a low platelet count

 Diseases of blood frequently affect soft and hard tissues of mouth with different characteristics.

 Oral manifestation of blood disease affect : colour of the mucosa hypertrophy of gingiva mucosal destruction in the form of ulceration ,bleeding and hemorrhage colour of the tooth with red discolouration lymphnode affect the bone with decreased density and enlarged marrow space.

 Every dentist should be familiarized the

wide variety of oral manifestations of the

blood diseases to differentiate from other

diseases.

 Diseases of blood can be classified as follows: (1) Cellular defects (2) Coagulation defects

 (1) Cellular defects:

a) RBC (erythrocytes) Increased : Polycythemia Decreased : Anaemia 1. Pernicious anaemia 2. Aplastic anaemia 3. Thalassemia 4. Sickle cell anaemia 5.Erythroblastosis fetalis. 6. Iron deficiency anaemia.

 b) WBC
Increased
Physiological - leucocytosis Pathological 1. Leukemia 2. Infectious mononucleosis Decreased 1. Leucopenia 2. Agranulocytosis 3. neutropenia

 c. Thrombocytes
Decreased Thrombocytopenic purpura Defective Thrombocytopathic purpura

Blood Dyscrasias
Sites of blood cell formation

HEMATOLOGIC (BLOOD) DISEASES

Bleeding Disorders
Clotting Factor Disorders Platelet Function Disorders

Blood Dyscrasias

(Formed Elements)

Red Blood Cell (RBC) Disorders White Blood Cell (WBC) Disorders Platelet Deficiencies

HEMATOLOGIC (BLOOD) DISEASES

Bleeding Disorders
Platelet Function - Associated Coagulation Factor - Associated

Platelet Deficiency
Thrombocytopenia / Thrombocytopathia

Red Blood Cell (RBC) Disorders

Anemia

White Blood Cell (WBC) Disorders

Leukopenia Leukemia (Lymphoma)

CLINICAL FEATURES OF BLOOD DISORDERS

Oral Bleeding - See Bleeding Protocol
Petechiae / Easily Bruised (Ecchymoses) Bleeding After Brushing Spontaneous Gingival Bleeding Prolonged After Extractions Excessive From Minor Trauma

Other Bleeding: Epistaxis, Hematemesis, Hemoptysis, Hematuria, Melena Possible Associated Increased Susceptibility to Infection - See Immunosuppression Protocol
Leukemia

HIV Immunosuppression from Chemtherapy for Organ Transplant or Cancer TX

Oral Swelling &/or Ulceration

Long Term Immunosuppression carries increased Risk for Malignancy (Especially lymphoma and leukemia)

Clinical Bleeding
Petechiae Petechiae and Ecchymoses

Ecchymoses

Bleeding(and sometimes Swollen) Gums

Leukemia Hemophilia

Clinical Photos

Leukemia

Leukemia

Other Clinical Features of Blood Disorders

Ulceration Atrophy and Pallor

Ulceration

TESTING FOR BLEEDING DISORDERS

Prothrombin Time (PT) (Extrinsic Pathway) DBL N ~ > 25 sec. (N=12-14 sec.) (Activated)Partial Thromboplastin Time (APTT) (Intrinsic Pathway) DBL N ~ > 50 sec. (N=25-35 sec.) International Normalized Ratio (INR) > 3.0 (N=1.0-2.0) Bleeding Time > 10 min. (N~5 min.) Clotting Time > 10 min. (N = < 5 Minutes) Platelet Count as Part of CBC with Differential WBC < 20 - 40K (N=150-500K/mm3) INR = PTR ISI = (ProThrombinRatio) ISI = (Patients PT/ControlPT)ISI Normal INR = 1.0-2.0

ISI = International Sensitivity Index (for Lab Thromboplastin)

Bleeding Time

N ~ 5 min.

Clotting Time

N = < 5 Minutes

Thrombocytopenia Thrombocytopathia (Thrombasthenia)

Primary or Secondary Deficiency of Platelets
10 / Idiopathic (Probably Autoimmune) Thrombocytopenic Purpura 20 / i.e. Leukemia, HIV, Aplastic Anemia

PLATELET-ASSOCIATED BLEEDING DISORDERS

Altered Platelet Function as in ASPIRIN (and other NSAIDs) von Willebrands disease Petechiae are Common Finding

Platelet Adhesion, Aggregation and Blood Clotting

COAGULATION FACTORASSOCIATED BLEEDING DISORDERS

Hereditary Defects
Hemophilia A (VII), B (IX), or C (XI) Other: Parahemophilia (V) and Afibrinogenemia (I)

Liver Disease
Cirrhosis, Hepatitis (I and II) + (VII, IX, and X)

Anti-Coagulant Medication
Coumarin (Warfarin) - Vitamin K Antagonist (II, VII, IX, and X) Heparin - Anti-Thrombin / Plasma Thromboplastin

GI Malabsorption Problems
Fat Soluble Vitamin K Deficiency (Sprue or Biliary Disease)

Diseases of the Formed Elements

Anemia Leukopenia Leukemia (Thrombocytopenia)

Blood Dyscrasias

Test with Complete Blood Count (CBC) with Differential White Cell Count (WBC): RBC Count - Normal = 4.5-5.0 Million RBCs / 100 mL WBC Count - Normal = 4 - 6 Thousand WBCs / 100 mL Neutrophils ~ 60 - 65 % Lymphocytes ~ 30 - 35 % Monocytes ~ 4-6 % Eosinophils ~ 1 - 2 % Basophils ~ 0-1 % Platelets = 150 - 600 Thousand / 100 mL

Anemia
Abnormally low hemoglobin Caused by
decreased numbers of RBCs decreased amount of hemoglobin both

Sign of an underlying condition Diagnose

CBC

 Clinical: Weakness, Fatigue, Pallor Decreased Oxygen Carrying Capacity of Blood Result of: Decreased Number, Size, or HgB Content of RBCs or of Defective HgB Secondary to:
Nutritional / Iron Defeciency RBC loss or destruction (Chronic Bleeding) Failure of RBC formation (Leukemia) Hereditary HgB malformation

ANEMIA

Oral Features:
Pallor Bald Tongue

Possible Association with other Disease: Leukemia, Kidney Disease, etc.

Anemia Classification
Size of RBCs
Microcytic (Small) Macrocytic (Large) Normocytic (Normal Size)

Concentration of Hgb
Hypochromic (Less) Hyperchromic (More) Normochromic (Normal)

Microcytic / Hypochromic
Chronic Blood Loss, Iron Deficiency, Thalassemia

Macrocytic (Megaloblastic) / Hyperchromic

Vit B12 (Pernicious) or Folic Acid Deficiency

Normocytic / Normochromic
Hemolytic, Aplastic, Myelophthisic, Acute Blood Loss, Chronic Renal Failure

RBC count (RBC) - # RBCs / 100 mL of Blood (NORMAL = 4.5-5.0 Million / 100 mL) Hematocrit (Hct) - % of (RB) Cells By Volume (NORMAL = 36-45%) Hemoglobin (Hgb) - mg / 100 ml of Blood (NORMAL = 13-15 mg/dL) Mean Corpuscular Volume (MCV) Hct/RBC - Normal = 90 (+or- 10) cubic microliter Mean Corpuscular Hemoglobin (MCH) Hgb/RBC - Normal = 30 (+or- 3) picograms Mean Corpuscular Hgb Concentration (MCHC) Hgb/Hct - Normal = 33 (+or- 2) %

Determination of RBC Indices

LEUKOPENIA (Decreased Number of WBCS) Increased Susceptibility to Infection

Aplastic Anemia
Failure of Formation of All Blood Cells: RBCs, WBCs and Platelets

Agranulocytosis
Failure of Formation of Neutrophils

Cyclic Neutropenia
Periodic Suppression of Neutrophil Formation

Associated Oral Ulceration and Infection:

Candidiasis HSV

Oral Ulceration and Infection Secondary to Leukopenia or Leukemia

LEUKEMIA
Leukemia - Definition
Malignancies of WBCs Originating in BONE MARROW Expression in PERIPHERAL BLOOD

Leukemia - Blood Smear

Leukemia - Classification
Acute Lymphocytic Leukemia (ALL) Chronic Lymphocytic Leukemia (CLL) Acute Myelogenous Leukemia (AML) Chronic Myelogenous Leukemia (CML) Children Elderly All Ages Adults

Clinical Significance
Disease and Treatment Make Patients Anemic and More Susceptible to Infection and Bleeding Decreased RBC Formation, Ineffective Leukocytes (&/or Leukopenia) and Thrombocytopenia

Leukemia

Diagnosis by: CBC with Differential and Bone Marrow Biopsy

LYMPHOMA
Cancer of Lymphocytes Lymph Nodes or Extranodal Soft Tissue (including mouth) - NOT Blood or Bone Marrow Classified by:
Hodgkins Disease (with REEDSTERNBERG CELLS) VS. NonHodgkin Lymphoma Type of Lymphocyte: B-cell; Tcell; etc. Maturity of Malignant Cells

Non-Hodgkin Lymphoma

THE END

Test with Complete Blood Count (CBC) with Differential White Cell Count (WBC) + Hgb, Hct, and Red Cell Indices: RBC Count - Normal = 4.5-5.0 Million RBCs / 100 mL WBC Count - Normal = 4 - 6 Thousand WBCs / 100 mL Neutrophils ~ 60 - 65 % Lymphocytes ~ 30 - 35 % Monocytes ~ 4-6 % Eosinophils ~ 1 - 2 % Basophils ~ 0-1 % Platelets = 150 - 600 Thousand / 100 mL

Bruch, Treister, 2010. Clinical oral medicine and pathology, p 79.

Bruch, Treister, 2010. Clinical oral medicine and pathology, p 152.

 Oral lymphomas may present before, concomitantly with, or after lymph node expression.