HEMATOLOGIC HEMATOLOGIC (BLOOD)(BLOOD) DISEASES DISEASES

Text Reading Assignment:Text Reading Assignment: Chapter 7 - Bleeding DisordersChapter 7 - Bleeding Disorders Chapter 8 - Blood DyscrasiasChapter 8 - Blood Dyscrasias

HEMATOLOGIC HEMATOLOGIC (BLOOD)(BLOOD) DISEASESDISEASES

• Bleeding DisordersBleeding Disorders– Clotting Factor DisordersClotting Factor Disorders– Platelet Function DisordersPlatelet Function Disorders

• ““Blood Dyscrasias” Blood Dyscrasias” (“Formed Elements”)(“Formed Elements”)

– Red Blood Cell (RBC) DisordersRed Blood Cell (RBC) Disorders– White Blood Cell (WBC) DisordersWhite Blood Cell (WBC) Disorders– Platelet DeficienciesPlatelet Deficiencies

HEMATOLOGIC HEMATOLOGIC (BLOOD)(BLOOD) DISEASESDISEASES

• Bleeding DisordersBleeding Disorders– Platelet Function - AssociatedPlatelet Function - Associated– Coagulation Factor - AssociatedCoagulation Factor - Associated

• Platelet DeficiencyPlatelet Deficiency– Thrombocytopenia / ThrombocytopathiaThrombocytopenia / Thrombocytopathia

• Red Blood Cell (RBC) DisordersRed Blood Cell (RBC) Disorders– AnemiaAnemia

• White Blood Cell (WBC) DisordersWhite Blood Cell (WBC) Disorders– LeukopeniaLeukopenia– LeukemiaLeukemia– (Lymphoma)(Lymphoma)

CLINICAL FEATURES OF BLOOD CLINICAL FEATURES OF BLOOD DISORDERSDISORDERS

• Oral Bleeding - Oral Bleeding - See Bleeding ProtocolSee Bleeding Protocol– Petechiae / Easily Bruised (Ecchymoses)Petechiae / Easily Bruised (Ecchymoses)– Bleeding After BrushingBleeding After Brushing– Spontaneous Gingival BleedingSpontaneous Gingival Bleeding– Prolonged After ExtractionsProlonged After Extractions– Excessive From Minor TraumaExcessive From Minor Trauma

• Other Bleeding: Other Bleeding: Epistaxis, Hematemesis, Hemoptysis, Hematuria, MelenaEpistaxis, Hematemesis, Hemoptysis, Hematuria, Melena

• Possible Associated Increased Susceptibility to Infection - Possible Associated Increased Susceptibility to Infection - SeeSee Immunosuppression ProtocolImmunosuppression Protocol– LeukemiaLeukemia

– HIVHIV– Immunosuppression from Chemtherapy for Organ Transplant or Cancer TXImmunosuppression from Chemtherapy for Organ Transplant or Cancer TX

• Oral Swelling &/or UlcerationOral Swelling &/or Ulceration

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

Go To Go To Basic Basic

DiseaseDisease

Clinical BleedingClinical BleedingPetechiaePetechiae Petechiae and EcchymosesPetechiae and Ecchymoses

EcchymosesEcchymoses

Clinical PhotosClinical PhotosBleedingBleeding(and sometimes Swollen)(and sometimes Swollen) Gums Gums

LeukemiaLeukemia HemophiliaHemophilia

LeukemiaLeukemia

LeukemiaLeukemia

Other Clinical Features of Other Clinical Features of Blood DisordersBlood Disorders

UlcerationUlceration Atrophy and Atrophy and PallorPallor

UlcerationUlceration

HEMATOLOGIC HEMATOLOGIC (BLOOD)(BLOOD) DISEASES DISEASES Health History CorrelationHealth History Correlation

Go To Go To Health Health HistoryHistory

HEALTH HISTORYUniversity of the Pacific School of Dentistry

Patient Name: Soc. Sec. No.: Birth Date:

I. CIRCLE APPROPRIATE ANSWER (leave Blank if you do not understand question): 1. Yes No Is your general health good? 2. Yes No Has there been a change in your health within the last year? 3. Yes No Have you been hospitalized or had a serious illness in the last three years?

If YES, why? 4. Yes No Are you being treated by a physician now? For what?

Date of last medical exam? Date of last Dental exam 5. Yes No Have you had problems with prior dental treatment? 6. Yes No Are you in pain now?

II. HAVE YOU EXPERIENCED: 7. Yes No Chest pain (angina)? 18. Yes No Dizziness? 8. Yes No Swollen ankles? 19. Yes No Ringing in ears? 9. Yes No Shortness of breath? 20. Yes No Headaches? 10. Yes No Recent weight loss, fever, night sweats? 21. Yes No Fainting spells? 11. Yes No Persistent cough, coughing up blood? 22. Yes No Blurred vision? 12. Yes No Bleeding problems, bruising easily? 23. Yes No Seizures? 13. Yes No Sinus problems? 24. Yes No Excessive thirst? 14. Yes No Difficulty swallowing? 25. Yes No Frequent urination? 15. Yes No Diarrhea, constipation, blood in stools? 26. Yes No Dry mouth? 16. Yes No Frequent vomiting, nausea? 27. Yes No Jaundice? 17. Yes No Difficulty urinating, blood in urine? 28. Yes No Joint pain, stiffness?

III. DO YOU HAVE OR HAVE YOU HAD: 29. Yes No Heart disease? 40. Yes No AIDS 30. Yes No Heart attack, heart defects? 41. Yes No Tumors, cancer? 31. Yes No Heart murmurs? 42. Yes No Arthritis, rheumatism? 32. Yes No Rheumatic fever? 43. Yes No Eye diseases? 33. Yes No Stroke, hardening of arteries? 44. Yes No Skin diseases? 34. Yes No High blood pressure? 45. Yes No Anemia? 35. Yes No Asthma, TB, emphysema, other lung diseases? 46. Yes No VD (syphilis or gonorrhea)? 36. Yes No Hepatitis, other liver disease? 47. Yes No Herpes? 37. Yes No Stomach problems, ulcers? 48. Yes No Kidney, bladder disease? 38. Yes No Allergies to: drugs, foods, medications, latex? 49. Yes No Thyroid, adrenal disease? 39. Yes No Family history of diabetes, heart problems, tumors? 50. Yes No Diabetes?

IV. DO YOU HAVE OR HAVE YOU HAD: 51. Yes No Psychiatric care? 56. Yes No Hospitalization? 52. Yes No Radiation treatments? 57. Yes No Blood transfusions? 53. Yes No Chemotherapy? 58. Yes No Surgeries? 54. Yes No Prosthetic heart valve? 59. Yes No Pacemaker? 55. Yes No Artificial joint? 60. Yes No Contact lenses?

V. ARE YOU TAKING: 61. Yes No Recreational drugs? 63. Yes No Tobacco in any form? 62. Yes No Drugs, medications, over-the-counter medicines 64. Yes No Alcohol?

(including Aspirin), natural remedies?Please list:

VI. WOMEN ONLY: 65. Yes No Are you or could you be pregnant or nursing? 66. Yes No Taking birth control pills?

VII. ALL PATIENTS: 67. Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form?

If so, please explain:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my healthand/or medication.

Patient’s signature: Date:

RECALL REVIEW:

1. Patient’s signature Date:

2. Patient’s signature Date:

3. Patient’s signature Date:

TESTING FOR BLEEDING TESTING FOR BLEEDING DISORDERSDISORDERS

• PProthrombin rothrombin TTime ime (PT)(PT) (Extrinsic Pathway) (Extrinsic Pathway) DBL N DBL N ~~ > 25 sec.> 25 sec. (N=12-14 sec.)(N=12-14 sec.)

• (Activated)(Activated)PPartial artial TThromboplastin hromboplastin TTime ime ((AAPTT) PTT) (Intrinsic (Intrinsic Pathway) Pathway) DBL N ~ > 50 sec.DBL N ~ > 50 sec. (N=25-35 sec.)(N=25-35 sec.)

• IInternational nternational NNormalized ormalized RRatioatio (INR)(INR) > 3.0 > 3.0 (N=1.0-2.0)(N=1.0-2.0)• Bleeding TimeBleeding Time > 10 min. > 10 min. (N~5 min.)(N~5 min.)• Clotting Time Clotting Time > 10 min.> 10 min. (N = < 5 Minutes)(N = < 5 Minutes)• Platelet CountPlatelet Count as Part of CBC with Differential WBC - as Part of CBC with Differential WBC - < 20 < 20

- 40K - 40K (N=150-500K/mm(N=150-500K/mm33))INR INR == PTR PTR ISI ISI = = (ProThrombinRatio) (ProThrombinRatio) ISI ISI = = (Patient’s PT/ControlPT)(Patient’s PT/ControlPT)ISIISI

ISIISI = = IInternational nternational SSensitivity ensitivity IIndex (for Lab Thromboplastin)ndex (for Lab Thromboplastin)

Normal INR = 1.0-2.0Normal INR = 1.0-2.0

Bleeding TimeBleeding Time

N ~ 5 min.N ~ 5 min.

Clotting TimeClotting Time

N = < 5 MinutesN = < 5 Minutes

PLATELET-ASSOCIATED PLATELET-ASSOCIATED BLEEDING DISORDERSBLEEDING DISORDERS

ThrombocytopeniaThrombocytopeniaThrombocytopathia (Thrombasthenia)Thrombocytopathia (Thrombasthenia)

• Primary or Secondary Deficiency of PlateletsPrimary or Secondary Deficiency of Platelets– 110 / 0 / Idiopathic (Probably Autoimmune) Thrombocytopenic Idiopathic (Probably Autoimmune) Thrombocytopenic

PurpuraPurpura– 2200 / i.e. Leukemia, HIV, Aplastic Anemia / i.e. Leukemia, HIV, Aplastic Anemia

• Altered Platelet Function as in ASPIRIN (and other Altered Platelet Function as in ASPIRIN (and other NSAID’s)NSAID’s)

• von Willebrands diseasevon Willebrands disease• Petechiae are Common FindingPetechiae are Common Finding

Platelet Adhesion, Aggregation Platelet Adhesion, Aggregation and Blood Clottingand Blood Clotting

COAGULATION FACTOR-COAGULATION FACTOR-ASSOCIATED BLEEDING ASSOCIATED BLEEDING

DISORDERSDISORDERS• Hereditary DefectsHereditary Defects

– Hemophilia Hemophilia AA (VII)(VII), , BB (IX)(IX), or , or CC (XI)(XI)– Other: Parahemophilia Other: Parahemophilia (V)(V) and Afibrinogenemia and Afibrinogenemia (I)(I)

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

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

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

Blood DyscrasiasBlood DyscrasiasDiseases of the Formed ElementsDiseases of the Formed Elements• AnemiaAnemia• LeukopeniaLeukopenia• LeukemiaLeukemia• (Thrombocytopenia)(Thrombocytopenia)

Test with Complete Blood Count (CBC) with Differential White Cell Count Test with Complete Blood Count (CBC) with Differential White Cell Count (WBC):(WBC):

RBC Count - Normal = 4.5-5.0 Million RBC’s / 100 mLRBC Count - Normal = 4.5-5.0 Million RBC’s / 100 mLWBC Count - Normal = 4 - 6 Thousand WBC’s / 100 mLWBC Count - Normal = 4 - 6 Thousand WBC’s / 100 mL

Neutrophils ~ 60 - 65 %Neutrophils ~ 60 - 65 %Lymphocytes ~ 30 - 35 %Lymphocytes ~ 30 - 35 %Monocytes ~ 4 - 6 %Monocytes ~ 4 - 6 %Eosinophils ~ 1 - 2 %Eosinophils ~ 1 - 2 %Basophils ~ 0 - 1 %Basophils ~ 0 - 1 %

Platelets = 150 - 600 Thousand / 100 mLPlatelets = 150 - 600 Thousand / 100 mL

ANEMIAANEMIA• Clinical:Clinical: Weakness, Fatigue, Pallor Weakness, Fatigue, Pallor• Decreased Oxygen Carrying Capacity of Decreased Oxygen Carrying Capacity of

BloodBlood• Result of: Decreased Result of: Decreased NumberNumber, , SizeSize, or , or

HgB ContentHgB Content of RBC’s or of of RBC’s or of Defective HgBDefective HgB• Secondary to:Secondary to:

– Nutritional / Iron DefeciencyNutritional / Iron Defeciency– RBC loss or destruction (Chronic Bleeding)RBC loss or destruction (Chronic Bleeding)– Failure of RBC formation (Leukemia)Failure of RBC formation (Leukemia)– Hereditary HgB malformationHereditary HgB malformation

• Oral Features:Oral Features:– PallorPallor– Bald TongueBald Tongue

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

Anemia ClassificationAnemia Classification• Size of RBC’sSize of RBC’s

– Microcytic (Small)Microcytic (Small)– Macrocytic (Large)Macrocytic (Large)– Normocytic (Normal Size)Normocytic (Normal Size)

• Concentration of HgbConcentration of Hgb– Hypochromic (Less)Hypochromic (Less)– Hyperchromic (More)Hyperchromic (More)– Normochromic (Normal)Normochromic (Normal)

• Microcytic / HypochromicMicrocytic / Hypochromic– Chronic Blood Loss, Iron Deficiency, ThalassemiaChronic Blood Loss, Iron Deficiency, Thalassemia

• Macrocytic (Megaloblastic) / HyperchromicMacrocytic (Megaloblastic) / Hyperchromic– Vit B12 (Pernicious) or Folic Acid DeficiencyVit B12 (Pernicious) or Folic Acid Deficiency

• Normocytic / NormochromicNormocytic / Normochromic– Hemolytic, Hemolytic, AplasticAplastic, , MyelophthisicMyelophthisic, Acute Blood Loss, , Acute Blood Loss, Chronic Renal FailureChronic Renal Failure

Determination of RBC IndicesDetermination of RBC Indices• RBC count RBC count (RBC) - (RBC) - # RBC’s / 100 mL of Blood # RBC’s / 100 mL of Blood

• (NORMAL = 4.5-5.0 Million / 100 mL)(NORMAL = 4.5-5.0 Million / 100 mL) • Hematocrit Hematocrit (Hct) - (Hct) - % of (RB) Cells By Volume% of (RB) Cells By Volume

• (NORMAL = 36-45%)(NORMAL = 36-45%) • Hemoglobin Hemoglobin (Hgb) - (Hgb) - mg / 100 ml of Blood mg / 100 ml of Blood

• (NORMAL = 13-15 mg/dL)(NORMAL = 13-15 mg/dL) • MMean ean CCorpuscular orpuscular VVolume olume (MCV)(MCV)

– Hct/RBCHct/RBC - - Normal = 90 (+or- 10) cubic microliterNormal = 90 (+or- 10) cubic microliter

• MMean ean CCorpuscular orpuscular HHemoglobin emoglobin (MCH)(MCH)– Hgb/RBCHgb/RBC - - Normal = 30 (+or- 3) picogramsNormal = 30 (+or- 3) picograms

• MMean ean CCorpuscular orpuscular HHgb gb CConcentration oncentration (MCHC)(MCHC)– Hgb/HctHgb/Hct - - Normal = 33 (+or- 2) %Normal = 33 (+or- 2) %

LEUKOPENIA LEUKOPENIA (Decreased (Decreased Number of WBC’S)Number of WBC’S)

Increased Susceptibility to InfectionIncreased Susceptibility to Infection• Aplastic AnemiaAplastic Anemia

– Failure of Formation of All Blood Cells: Failure of Formation of All Blood Cells: RBC’s, WBC’s and RBC’s, WBC’s and PlateletsPlatelets

• AgranulocytosisAgranulocytosis– Failure of Formation of Failure of Formation of NeutrophilsNeutrophils

• Cyclic NeutropeniaCyclic Neutropenia– Periodic Suppression of Periodic Suppression of NeutrophilNeutrophil Formation Formation

• Associated Oral Ulceration and Infection:Associated Oral Ulceration and Infection:– CandidiasisCandidiasis– HSVHSV

Oral Ulceration and Infection Oral Ulceration and Infection Secondary to Secondary to LeukopeniaLeukopenia or or

LeukemiaLeukemia

LeukemiaLeukemia

LEUKEMIALEUKEMIA• Leukemia - DefinitionLeukemia - Definition

– Malignancies of WBC’s Originating in Malignancies of WBC’s Originating in BONE MARROWBONE MARROW– Expression in Expression in PERIPHERAL BLOODPERIPHERAL BLOOD

• Leukemia - ClassificationLeukemia - Classification– Acute Acute LymphocyticLymphocytic Leukemia Leukemia (ALL)(ALL) - - ChildrenChildren– Chronic Chronic LymphocyticLymphocytic Leukemia Leukemia (CLL)(CLL) - - ElderlyElderly– Acute Acute MyelogenousMyelogenous Leukemia Leukemia (AML)(AML) - - All AgesAll Ages– Chronic Chronic MyelogenousMyelogenous Leukemia Leukemia (CML)(CML) - - AdultsAdults

• Clinical SignificanceClinical Significance– Disease and TreatmentDisease and Treatment Make Patients Anemic and Make Patients Anemic and

More Susceptible to Infection and BleedingMore Susceptible to Infection and Bleeding– Decreased RBC Formation, IneffectiveDecreased RBC Formation, Ineffective Leukocytes (&/orLeukocytes (&/or

Leukopenia)Leukopenia) and and ThrombocytopeniaThrombocytopenia

• Diagnosis by: CBC with Differential and Bone Diagnosis by: CBC with Differential and Bone Marrow BiopsyMarrow Biopsy

Leukemia - Blood Smear

LYMPHOMALYMPHOMA• Cancer of LymphocytesCancer of Lymphocytes• Lymph Nodes or Extranodal Lymph Nodes or Extranodal

Soft Tissue (including mouth) - Soft Tissue (including mouth) - NOTNOT Blood or Bone Marrow Blood or Bone Marrow

• Classified by:Classified by:– Hodgkin’s DiseaseHodgkin’s Disease (with REED-(with REED-

STERNBERG CELLS)STERNBERG CELLS) VS. VS. Non-Non-Hodgkin LymphomaHodgkin Lymphoma

– Type of Lymphocyte: B-cell; T-Type of Lymphocyte: B-cell; T-cell; etc.cell; etc.

– Maturity of Malignant CellsMaturity of Malignant Cells

Non-Hodgkin LymphomaNon-Hodgkin Lymphoma

THE ENDTHE 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 RBC’s / 100 mLWBC Count - Normal = 4 - 6 Thousand WBC’s / 100 mL

Neutrophils ~ 60 - 65 %Lymphocytes ~ 30 - 35 %Monocytes ~ 4 - 6 %Eosinophils ~ 1 - 2 %Basophils ~ 0 - 1 %

Platelets = 150 - 600 Thousand / 100 mL