Hematological+disorders

= List the Three Take Away or Big ideas From Carranzaon Hematological Disorders and Periodontal Disease = = D iscuss Each Big Idea = Hematologic disorder- WBC are a part of the inflammatory process and are a part of cellular defense. RBCs are used for gas exchange and nutrient supply to the periodontium, and platelets and are necessary for normal hemostasis as well as recruitment of cells during the inflammatory and wound healing process. Disorders of the blood cells or blood forming organisms have a direct effect on the periodontium. **Leukemia**- is malignanat neoplasia of WBC precursors characterized by (1) diffuse replacement of the bone marrow with proliferating leukemic cells, (2)abnormal numbers and forms of immature WBCs in the circulating blood and (3) widespread infiltrates in the liver, spleen, lymph nodes and other body sites (Carranza, p. 292). Will cause a reduce production of RBCs, WBCs, and platelets and leads to anemia, leucopenia, and thrombocytopenia. Oral and periodontal manifestations of leukemia consist of leukemic infiltration, bleeding, oral ulcerations, and infections. (1) Leukemic infiltration occurs more often in the gingiva then in the surrounding alveolar bone and it can lead to gingival enlargement. (2) Bleeding can be an early sign of leukemia, it is caused by the replacement of bone marrow cells with leukemia cells and from the inhibition of normal stem cell functions. (3) Patients will have an increased risk of infections due to the diminished inflammatory response. The expression of these signs is more common in acute and subacute forms of leukemia then in chronic forms ( Carranza, p. 292)

**Anemia** causes poor tissue oxygenated, making tissues more friable and susceptible to breakdown. According to Carranza (2006), anemia is defined as a deficiency in the quantity or the quality of the blood, manifested by a reduction in the number of erythrocytes and in the amount of hemoglobin. Anemia could be the result of blood loss, defective blood formation, or increased RBC destruction. Furthermore, anemias are classified according to cellular morphology and hemoglobin content as (1) macrocytic hyperchromic anemia (pernicious anemia), (2) microcytic hyperchromic anemia (iron deficiency anemia), (3) sickle cell anemia, or (4) hemolytic or aplastic anemia (Carranza, p.296).

(1) Pernicious anemia: Signs and symptoms of pernicious anemia is usually a triad of symptoms: weakness, sore tongue, and numbness of the extremities. The tongue would appear red, smooth, and shiny due to atrophy of the papillae. However, the gingiva appears pallor and bloodless. Vitamin B12 replacement usually reverses pernicious anemia, minimize its complications, or prevent neurological damage. Patients who have pernicious anemia, their entire mouth including the tongue would be sore;thus, eating would be painful. Advised the patients to stay away from irritating and spicy foods. Recommend mouthwash that does not have alcohol in them such as Biotene or Oasis or rinse with warm saline solution. Pernicious anemia primarily affects people of the northern European ancestry. The onset of the disease usually occurs after age 35 and the incidence increases with age. however, it only affects approximately 2% of elder people over age 60. How do patients prevent pernicious anemia? Recommend and emphasized the importance of vitamin B12 supplements especially patients that are strict vegetarians or follow vegan diets.

(2) Iron deficiency anemia: Iron deficiency anemia is caused by inadequate supply of iron for the formation of RBCs. Iron deficiency anemia may result due to inadequate intake of iron in an individual's diet, loss of blood, hemorrhage from trauma or ulcers, and pregnancy. Iron deficiency anemia is most common in pre-menopausal women, infants, children, adolescents especially adolescent girls. Patients who fall in the category of low socioeconomic are in high risk of iron deficiency anemia because it wold be difficult for them to get a well-balanced diet that includes foods that are rich in iron. Patients who suffers from iron deficiency anemia do not even know they have the disorder because its usually asymptomatic and has a gradual progression. During the severe and advanced stage of the disorder, the patient might develop dyspnea on exertion, fatigue, pallor, inability to concentrate, listlessness, irritability, and headaches. In chronic iron deficiency anemia, nails are described as spoon-shaped and brittle, corners of the mouth have cracks, the tongue are smooth, gingiva appears pallor, patient experiences dysphagia, or may develop pica. Other associated neuromuscular effects are numbness and tingling of the extremities and periodic neuralgic pain. According to Carranza (2006), patients with iron deficiency anemia can also have Plummer-Vinson syndrome that characterizes glossitis and ulceration of the oral mucosa and the oropharynx which induces dysphagia (p.296).

(3) Sickle cell anemia Carranza (2006) describes sickle sell anemia as a hereditary form of chronic hemolyic anemia that occurs almost exclusively in African-Americans. Sickle cell anemia is characterized by pallor, jaundice, weakness, rheumatoid manifestations, and leg ulcers. Oral changes include generalized osteoporosis of the jaws, a stepladder alignment of the trabeculae of the interdental septa, and a yellowish discoloration sometimes pallor of the oral mucosa (p. 296).

(4) Aplastic anemia: Aplastic anemia result from a failure of the bone marrow to produce erythrocytes (Carranza, 2006). Signs and symptoms of aplastic anemia are continuous weakness and fatigue, shortness of breath, headaches, pallor, tachychardia, and finally heart failure. There are oral changes to look for such as pale discoloration of the oral mucosa and increased susceptibility to infection.

**Thrombocytopenia** leads to bleeding tendency which can occur in any tissue but in particular affects the oral cavity, especially the gingival sulcus. Patients may present with leukemic enlargement due to the leukemic calls going into the gingiva. This will occur in the free and attached gingiva. The gums will bleed significantly without the presence of gingivitis. The bone marrow cells are replaced by leukemic cells. The normal inflammatory response will be diminished and the patients will present with oral ulcersa and infections. The lesions are caused by simple trauma to the mouth. Leukocyte (Neutrophil) Disorders- PMN's become affected with this disorder and our first line of defense becomes compromised and this will predispose to peridontal destruction. Severe periodontitis has been observed in individuals with primary neutrophil disorders such as neutropenia, agranulocytosis, and lazy leukocyte syndrome. Agranulocytosis- has a reduction in the number of circulating granulocytes and results in severe infections like ulcerative necrotizing lesions of the oral mucosa. Notable inflammation may be absent because of the lack of granulocytes. Coagulation disorders- Hemophilias A and B and Von Willebrand's disease are the most common inherited coagulation disorders. Hemophilia A is a deficiency in the coagulation factor VIII. Patient's that have less thank 1% or normal factor VIII levels may experience serve bleeding with just the slightest provocation than those with moderate (1%-5% factor VIII) hemophilia. Those patient with the moderate deficiency in factor VIII will have less frequent spontaneous bleeding but will still bleed with minimal trauma. Hemophilia B results in the deficiency of factor XI. The severity also depends on the amount of existing factor XI. There are certain amount of levels of factor XI that must be present in order to perform surgical therapies. Von Willebrand's disease is a result of deficiency of the Von Willebrand factor. The present of this factor mediates the adhesion of platelets to the injured area and is required for hemostasis. Clinical examination should detect petechiae, hemorrhagic vesicles, spontaneous gingival bleeding, and gingical hyperplasia. Patients with these disorders may not have good oral hygiene for the fear of bleeding, for this reason it is essential of expressing the importance to these patients about good oral hygiene.