A NEMIA AND ITS ORAL
MANIFESTATION
I NTRODUCTION
Anemia is defined as a condition in which the total haemoglobin (Hb) level or number of red blood cells (RBCs) is poorly lowered.
The World Health Organisation (WHO) defines anemia as Hb< 130g/L in men above 15 years, 110 g/L in pregnant women and 110 g/L in pregnant women and <120g/L in non-pregnant women above 15 years of age.
Anemia is a symptom of a wide variety of mild to serious diseases, disorders and conditions.
Anemia is characterized by the reduction in:
1. Red blood cell (RBC) count 2. Hemoglobin content
3. Packed cell volume (PCV
CLASSIFICATION OF ANEMIA
Anemia is classified by three methods:
1. Morphological Classification 2. Etiological Classification.
3.Quantitative Classification.
MORPHOLOGICAL CLASSIFICATION
Depends upon the size and color of RBC.
Size of RBC is determined by mean corpuscular volume(MCV).
Color is determined by mean corpuscular hemoglobin concentration (MCHC).
B Y THIS METHOD , THE ANEMIA IS CLASSIFIED INTO
FOUR TYPES
ETIOLOGICAL CLASSIFICATION
On the basis of etiology anemia is divided into five types:
1. Hemorrhagic anemia 2. Hemolytic anemia
3. Nutrition deficiency anemia 4. Aplastic anemia
5. Anemia of chronic diseases.
SIGNS AND SYMPTOMS OF ANEMIA
➢SKIN AND MUCOUS MEMBRANE:
Colour of the skin and mucous membrane becomes pale.
Paleness is more constant and prominent in buccal and
pharyngeal mucous membrane, conjunctivae, lips, ear lobes, palm and nail bed.
Skin looses the elasticity and becomes thin and dry.
Thinning, loss and early grayness of hair occur. The nails become brittle and easily breakable
➢CARDIOVASCULAR SYSTEM
There is an increase in heart rate (tachycardia) and cardiac output.
Heart is dilated and cardiac murmurs are produced.
The velocity of blood flow is increased.
➢RESPIRATION
There is an increase in rate and force of respiration.
Sometimes, it leads to breathlessness and dyspnea (difficulty in breathing).
Oxygen hemoglobin dissociation curve is shifted to right.
➢ DIGESTION
Anorexia, nausea, vomiting, abdominal discomfort and constipation are common.
In pernicious anemia, there is atrophy of papillae in tongue.
In aplastic anemia, necrotic lesions appear in mouth and pharynx.
➢ METABOLISM
Basal metabolic rate increases in severe anemia.
➢ KIDNEY
Renal function is disturbed.
Albuminuria is common.
➢REPRODUCTIVE SYSTEM
In females, the menstrual cycle is disturbed.
There may be menorrhagia, oligomenorrhea or amenorrhea.
➢ NEUROMUSCULAR SYSTEM
Common neuromuscular symptoms are increased sensitivity to cold, headache, lack of concentration, restlessness, irritability, drowsiness, dizziness or vertigo(especially while standing) and fainting.
Muscles become weak and the patient feels lack of energy and fatigued quite often and quite easily
DIAGNOSIS
Anemia as a laboratory diagnosis
Men Women
Hemoglobin (g/dL) 14-17.4 12.3-15.3
Hematocrit (%) 42-50% 36-44%
RBC Count (106/mm3) 4.5-5.9 4.1-5.1
Reticulocytes 1.6 ± 0.5% 1.4 ± 0.5%
WBC (cells/mm3) ~4,000-11,000 ~4,000-11,000
MCV (fL) 80-96 80-96
MCH (pg/RBC) 30.4 ± 2.8 30.4 ± 2.8
MCHC (g/dL of RBC) 34.4 ± 1.1 34.4 ± 1.1
Symptoms of Anemia
Hemoglobin/Hematocrit Normal or High
Check other
Causes of symptoms e.g. Cardiac Pulmonary
Low
RBC indices
MCV < 80 MCHC < 32
MCV=80-96
MCV > 98 Serum iron and Total
Iron binding capacity of Ferritin
History of acute blood loss Auto immune Hemolytic anemia
Anemia of chronic Diseases Anemia of infection
B12 and folate levels
Low Iron IDA, chronic diseases, Renal diseases
Normal Hb
electrophoresis for Thalassemia.
High Iron BM exam For
Sideroblastic anemia
Low B12 PA, GI problems Severe malnutritio n.
Low folate Folate
malnutrition GI problems Liver
disease
High or Normal Myeloblastic disease
Liver Disease
Clinically Significant Variants
Iron deficiency anemia
Pernicious anemia or Addison’s anemia
Megaloblastic anemia
Sickle cell anemia
Thalassemia
Aplastic anemia
I RON DEFICIENCY ANEMIA
Iron deficiency anemia is the most common type of anemia.
It develops due to inadequate availability of iron for hemoglobin synthesis.
RBCs are microcytic and hypochromic.
Causes of iron deficiency anemia:
i. Loss of blood
ii. Decreased intake of iron
iii. Poor absorption of iron from intestine
iv. Increased demand for iron in conditions like growth and pregnancy.
Features of iron deficiency anemia:
1. Brittle nails,
2. Spoon shaped nails (koilonychias), 3. Brittle hair,
4. Atrophy of papilla in tongue
5. Dysphagia (difficulty in swallowing).
P ERNICIOUS ANEMIA OR A DDISON ’ S ANEMIA
Pernicious anemia is the anemia due to deficiency of vitamin B12.
It is also called Addison’s anemia.
It is due to atrophy of the gastric mucosa because of autoimmune destruction of parietal cells.
The gastric atrophy results in decreased production of intrinsic factor and poor absorption of vitamin B12, which is the maturation factor for RBC.
RBCs are larger and immature with almost normal or slightly low hemoglobin level.
Synthesis of hemoglobin is almost normal in this type of anemia.
So, cells are macrocytic and normochromic/ hypochromic.
Pernicious anemia is common in old age and it is more common in females than in males.
It is associated with other autoimmune diseases like disorders of thyroid gland, Addison’s disease, etc.
Characteristic features of this type of anemia are lemon yellow color of skin (due to anemic paleness and mild jaundice) and red sore tongue.
Neurological disorders such as paresthesia (abnormal sensations like numbness, tingling, burning, etc.), progressive weakness and
ataxia (muscular incoordination) are also observed in extreme conditions.
M EGALOBLASTIC ANEMIA
Megaloblastic anemia is due to the deficiency of another maturation factor called folic acid. Here, the RBCs are not matured.
The DNA synthesis is also defective, so the nucleus remains immature.
The RBCs are megaloblastic and hypochromic.
Features of pernicious anemia appear in megaloblastic anemia also.
However, neurological disorders may not develop.
S ICKLE CELL ANEMIA
Sickle cell anemia is an inherited blood disorder, characterized by sickle shaped red blood cells.
It is also called hemoglobin SS disease or sickle cell disease.
It is common in people of African origin.
Sickle cell anemia is due to the abnormal hemoglobin called hemoglobin S (sickle cell hemoglobin).
In this, α-chains are normal and β-chains are abnormal.
The molecules of hemoglobin S polymerize into long chains and precipitate inside the cells.
Because of this, the RBCs attain sickle (crescent) shape and become more fragile leading to hemolysis
Sickle cell anemia occurs when a person inherits two abnormal genes (one from each parent).
In children, hemolyzed sickle cells aggregate and block the blood vessels, leading to infarction (stoppage of blood supply). The infarction is common in small bones.
The infarcted small bones in hand and foot results in varying length in the digits. This condition is known as hand and foot syndrome.
Jaundice also occurs in these children.
T HALASSEMIA
Thalassemia is an inherited disorder, characterized by abnormal hemoglobin.
It is also known as Cooley’s anemia or Mediterranean anemia.
It is more common in Thailand and to some extent in Mediterranean countries.
Thalassemia is of two types:
1. α-thalassemia 2. β-thalassemia.
In normal hemoglobin, number of α and β polypeptide chains is equal.
In thalassemia, the production of these chains become imbalanced because of defective synthesis of globin genes.
This causes the precipitation of the polypeptide chains in the immature RBCs, leading to disturbance in erythropoiesis.
The precipitation also occurs in mature red cells, resulting in hemolysis.
Α -T HALASSEMIA
α -thalassemia occurs in fetal life or infancy.
In this α-chains are less, absent or abnormal.
This leads to defective erythropoiesis and hemolysis.
The infants may be stillborn or may die immediately after birth.
β-Thalassemia
More common type of thalassemia.
In adults, β-chains are in excess and in children, γ-chains are in excess.
In β-thalassemia, β-chains are less in number, absent or abnormal with an excess of α-chains.
The α-chains precipitate causing defective erythropoiesis and hemolysis.
A PLASTIC A NEMIA
Aplastic anemia is due to the disorder of red bone marrow.
Red bone marrow is reduced and replaced by fatty tissues.
Bone marrow disorder occurs in the following conditions:
I. Repeated exposure to Xray or gamma ray radiation.
II. Presence of bacterial toxins, quinine, gold salts, benzene, radium, etc.
III. Tuberculosis.
IV. Viral infections like hepatitis and HIV infections.
In aplastic anemia, the RBCs are normocytic and normochromic
O RAL HEALTH CONSIDERATIONS
Anemia may be accompanied by common oral symptoms and signs which can present early in the development of the condition, giving particular importance to the observations by dental professionals in contributing to early diagnosis
It commonly include one or more of i. Pallor of the oral mucosa
ii. Glossitis
iii. Glossodynia
iv. Taste disturbance
A PLASTIC ANEMIA
It may increase susceptibility to i. oral infection, which may require
1. antibiotic prophylaxis
2. antibiotic mouthwash
ii. spontaneous or uncontrolled gingival bleeding, which mayrequire 1. antifibrinolytic medications to reduce bleeding risk
2. avoidance of intramuscular injections and nerve-block anesthesia.
P ERNICIOUS ANEMIA
It may be signaled by the common oral symptoms and signs plus i. angular cheilitis
ii. mucositis iii. thrush
iv. recurrent oral ulcer
Sickle cell anemia
(CDHO Advisory) which requires a specialized regimen of oral healthcare.
S ICKLE CELL ANEMIA
The main contraindication for dental treatment with the SCA patient is routine care during a crisis.
Following are a fewguidelines that may be helpful:
1. Schedule dental appointments during the morning with minimum treatment for a brief visit
2. Prescribe CNS depressants judiciously
3. Use acetaminophen for treatment of pain because salicylates may induce acidosis
4. Avoid elective surgery, such as the removal of asymptomatic impacted teeth
5. Incorporate home fluoride therapy and routine dental recall visits into the preventive dental treatment regimen
The dentist should monitor preventive dental care at routine follow up visits.
A three-month recall may be necessary in some cases.
The dentist must be sure that SCA patients are receiving the latest preventive dental measures (e.g., sealants, fluorides, antimicrobial rinses, etc.)
Finally, team approach including the physician, dentist, and patient is vital to the successful dental management of the patient with sickle cell anemia.
Pain medication for the patient suffering with anemia should be limited to
Acetoaminophen
o Exclude pain medication that delay clotting like Aspirin
Ibuprofen
o Must prevent excessive bleeding
o Use of antifibrinolytic drugs must be considered whenever required
C ONCLUSION
Anemia is the most common disorder of the blood with it affecting abouta quarter of people globally.
Anemia goes undetected in many people, and symptoms can be minor or vague.
Appropriate dental care improves a patient’s quality of life by preventing eating difficulties, oral diseases, and esthetic concerns, and facilitates the management of the disease by the hematologist.
Preventive dental care is must for anemic patients of any kind in combinations with appropriate lab investigations and diagnosis before planning of any treatment.
