hematologic dx Flashcards
(106 cards)
1
Q
anemia
A
Reduction in the oxygen carrying capacity of RBCs; deficiency in red blood cells or of hemoglobin in the blood
2
Q
anemia classifeid by:
A
cause and morphology
3
Q
anemia causes
A
- Blood Loss
- Inadequate production
- Excess destruction
4
Q
anemia morph
A
- Normocytic
- Microcytic
- Macrocytic
5
Q
anemia lab test
shorthand?
A
** CBC (Complete Blood Count): **
* Hb
* Hematocrit*
* WBC
* Platelet
* RBC indices*
6
Q
anemic Hb values
A
<13.5 g/dL (men) or <12.0 g/dL (women)
7
Q
anemic hematocrit values
A
<41.0% (men) or <36.0% (women)
8
Q
RBC indices*
A
- MCV (mean corpuscular volume)= size
- MCH (mean cell hemoglobin)= color
- RDW (red cell distribution width)= sixe distribution
- MCHC (mean cell hemoglobin concentratio
9
Q
- Microcytic anemias
A
– Iron Deficiency Anemia
– Thalassemias
10
Q
macrocytic anemias
A
– Pernicious Anemia
– Folate Deficiency
– B12 Deficiency
11
Q
normocytic anemias
A
– Hemolytic Anemia
– Sickle Cell Anemia
12
Q
Iron Deficiency Anemia
* cells app?
* More common in?
* Causes:
* Labs:
A
- Microcytic anemia
- More common in women of childbearing age and children
- Causes: blood loss, poor iron intake, poor iron absorption, or increased demand for iron
- Labs: Serum iron, ferritin, TIBC, transferrin
13
Q
- Folate Deficiency, cell size?
– stored in the body?
– Deficiency during pregnancy?
– Labs:
A
Macrocytic
– Not stored in the body in large amounts; continual
dietary supply is needed
– Deficiency during pregnancy causes neural tube
defects in the child
– Labs: Serum folate level
14
Q
Cobalamin (B12) Deficiency
* Deficiency of?
* dental office agent of etiology? effects?
– Labs:
A
– AKA Pernicious Anemia, macrocytic
* Deficiency of intrinsic factor which is necessary for B12 absorption
– Nitrous Oxide:
* Irreversible inactivation of B12
* Neurologic symptoms
– Labs: Serum B12
15
Q
systemic presentation of anemia
signs and symptoms
A
– Symptoms: Fatigue, weakness, palpitations, SOB, angina, tingling of fingers and toes
– Signs: pallor, splitting and spooning of fingernails
16
Q
oral manifestations of anemia
A
– Atrophic glossitis with loss on tongue papillae, redness or cheilosis
– Mucosal pallor
17
Q
anemia pts and dental tx
A
–Generally tolerate routine dental treatment well unless severe
18
Q
severe anemia pts
A
- Severe anemia (cardiopulmonary symptoms)
–Defer routine dental care
–Pulse oximeter and supplemental oxygen
–Avoid strong narcotics
19
Q
what should be avoidied in pts with b12 def
A
NO
20
Q
What is important to determine in anemic pts?
A
- Important to find the cause!
–GI bleed, chronic inflammation pancytopenia
21
Q
Sickle Cell Anemia
* inheritance?
* RBC sickling in what environments?
* results on hemodynamics?
A
- Autosomal recessive inherited disorder
- RBC sickling in low oxygen or low blood pH environments
- Erythrostasis, increased blood viscosity, reduced blood flow, vascular occlusion, hypoxia= more sickling
22
Q
Sickle Cell Anemia
* Systemic Signs and Symptoms:
– Result of?
– skin app?
– ulceration where?
– Cardiac?
– Delays in?
– Pain where/ why?
– crisis?
A
– Result of chronic anemia and small blood vessel occlusion
– Jaundice, pallor
– Leg ulcers
– Cardiac: Cardiac failure and Stroke
– Delays in growth and Development
– Pain: Abdominal (splenomegly) and Bone (aseptic necrosis)
– Sickle cell crisis
23
Q
sickle cell crisis
A
- Prolonged (hours-days) severe pain which pay require
hospitalization for pain management - Causes: infection, higher altitude (hypoxia), dehydration, trauma
24
Q
Sickle Cell Anemia
* Oral Manifestations
–Mucosal?
–Papilla?
–Delayed?
–Aseptic bone and pulpal?
– bone?
–Neuro?
A
–Mucosal pallor or jaundice
–Papillary atrophy
–Delayed tooth eruption
–Aseptic bone and pulpal necrosis
–Osteomyelitis
–Neuropathy
25
radiogrpahic findings with sickle cell
* Increased widening and decreased number of trabeculations
* Generalized osteoporosis (thinning of the inferior border of the mandible)
* Trabeculations and lamina dura appear more prominent
* “Stepladder” trabeculae
* “Hair on end
26
sickle cell pt dental care
– non-crisis states
– appt length?
– Emphasis on? infections?
– Routine care during non-crisis states
– Keep appointments short to reduce stress
– Emphasis on oral hygiene instructions to reduce risk of infection> If infection occurs, consider IM or IV antibiotics
27
sickle cell anesthetic
* Avoid what LA
* Epinephrine concentration?
* May consider using LA without?
* Avoid prilocaine
* Epinephrine 1:100,000-no stronger concentration
* May consider using LA without epinephrine
28
sickle cell O2 in appt
– Monitor oxygen saturation, when using nitrous oxide, provide oxygen at greater than 50% with high flow rates
29
with major surgical operations what should be done with sickle cell pts
Abx prophylaxis
30
pain control with sickle cell
Pain management: consult their primary care or hematologist (opioid contract)
31
Aplastic Anemia
* Causes
* Treatment
* Bone marrow failure resulting in pancytopenia
* Causes:
– Chemotherapy and radiation
– Autoimmune diseases
– Toxic chemicals (benzene)
– Viral
– Medications (methotrexate)
– Inherited (Fanconi anemia)
* Treatment– Hematopoietic cell transplant
32
Aplastic Anemia oral manifestationa due to anemia
* Atrophic glossitis with loss on tongue papillae, redness or cheilosis
* Mucosal pallor
33
aplastic anemia oral manifestations due to thrombocytopenia
* Petechia, spontaneous or prolonged bleeding
34
aplastic anemia oral manifestations due to neutropenia
* Infection – Viral, fungal, bacterial
* Ulceration
35
Aplastic Anemia & Bone Marrow Failure dental management:
* Thorough?
* Discussion with?
* Defer?
*setting?
* Thorough medical history
* Discussion with oncologist: Current status and goals
* Defer routine care
* Dental office vs hospital *
36
Aplastic Anemia & Bone Marrow Failure labs
*** CBC**
* Platelet: may require platelet transfusion due to
thrombocytopenia
* ANC-may require antibiotic prophylaxis for neutropenia (<500)
37
Aplastic Anemia & Bone Marrow Failure
* Confirm patient is?
* Local hemostatic measures when pt is?
* Confirm patient is afebrile
* Local hemostatic measures for patients with thrombocytopenia
38
* Thrombocytopenia
–Causes
–result
–Low platelet levels (CBC)
* Normal: 150,000-400,000
* Severe: <50,000
–Causes: decreased production, destruction, medications, blood loss
–Prolonged bleeding, petechia
39
* Thrombocytopenia
–Oral Manifestations
* Petechia
* Spontaneous gingival bleeding
* Prolonged bleeding after procedures
40
Thrombocytopenia
– Dental Management:
* Thorough?
* routine dental care?
* CBC?
* Discussion with?
* Avoid?
* Local measures?
* Thorough medical history
* May defer routine dental care
* CBC
* Discussion with patient’s MD
* Avoid block injections
* Local hemostatic measures
41
thrombocytopenia med hx
– Cause of thrombocytopenia (acute cause? chronic cause?)
– Bleeding history, transfusion history
42
CBC results with thrombocytopenia
– Recent (<24 hours)
– Platelet >50,000 for most dental procedures reduces risk
– Higher for invasive surgical procedures (ex. multiple extractions)
43
thrombocytopenia MD discussion
– Platelet transfusions, timing
– Dental office vs hospital (<50,000 more appropriate in hospital setting)
44
* Von Willebrand Disease
commonality?
– Missing or defective VWF (clotting protein)
* Required for platelet adhesion
– Most common inherited clotting disorder (1%
US population)
45
VWD types
– Type 1 (20-50% normal levels), Type 2 (qualitative), Type 3 (quantitative, severe symptoms)
46
VWD signs and symptoms
– SS: epistaxis, petechia, ecchymosis, excessive/prolonged bleeding from invasive procedures, hemarthrosis
47
VWD tx
Tx: DDAVP (desmopressin)
48
* Von Willebrand Disease
–Dental Management
* Thorough medical history/bleeding history and physical exam
* Discussion with patient’s MD
* Avoid block injections
* Local hemostatic measures
49
Von Willebrand Disease Discussion with patient’s MD
– Confirm history and severity of disease
– DDAVP, aminocaproic acid
– Dental office vs hospital
50
* Hemophilia types/inheritence/severity?
–Hemophilia A (Factor 8 deficiency) and B (Factor 9 deficiency)
* X-linked recessive
–Severity
* Mild 6%-30% (A) or 49% (B), moderate 1%-5%, severe <1%
51
SS of hemophilia
prolonged or spontaneous
bleeding, ecchymosis, hemarthrosis
52
hemoplhilia tx
factor infusions, DDAVP (A)
53
* Hemophilia
–Dental Management
* Thorough medical history/bleeding history and physical exam
* Discussion with patient’s hematologist
* Avoid block injections
* Local hemostatic measures
54
* Hemophilia discussion with MD
– Confirm history and severity of disease
– Dental office vs hospital
– Factor infusions, aminocaproic acid
55
Plavix (clopidogrel)
–agent for?
–Reduce risk of?
–Increased risk of?
–Antiplatelet agent
–Reduce risk of MI and stroke
–Increased risk of bleeding and bruising
56
* Plavix (clopidogrel)–Dental Management
* Medication list to evaluate bleeding risk
– Other anticoagulants
* Local measures– Low risk of bleeding far outweighs interrupting Plavix treatment
57
* Coumadin (warfarin)
– mech?
– For patients with?
– Common side effect:
– Vitamin K antagonist
– For patients with Afib, heart failure, prosthetic heart valves, stroke/MI history...
– Common side effect: bleeding
58
warfarin monitoring
* PT/INR goals:
* Higher in patients with?
* PT/INR goals: 2.0-3.0
* Higher in patients with prosthetic heart valves (3.0-3.5)
59
antidote for warfarin
K
60
* Coumadin (warfarin)
–Dental Management
* Dental procedures are generally considered low risk of bleeding
* Review INR (within 24 hours) (<3)
* Local hemostatic measures
* Medications interactions
61
dental tx bleeding with warfarin
* Dental procedures are generally considered low risk of bleeding
– Thromboembolic risk vs procedural bleeding risk
– Discussion with patients MD for procedures with higher risk of bleeding
62
warfarin med intreactions
– Many medication interactions due to narrow therapeutic range
– Avoid cytochrome P-450 inhibitors (ex. fluconazole) and inducers
63
* Direct Oral Anticoagulants (DOAC) and Direct Thrombin Inhibitors
–Direct inhibitor of?
–Class of?
* Alternative to?
– effective?
lab monitoring?
–Reversal?
–cost?
–Direct inhibitor of factor Xa and thrombin
–Class of newer anticoagulants
* Alternative to warfarin
–Highly effective
–No lab monitoring
–Reversal agent
–More expensive
64
* DOAC and Direct Thrombin Inhibitors
–Dental Management
* No lab monitoring
* Bleeding risk for dental procedures seems to be low
* Local hemostatic measures
65
good local measures for bleeding pts
gauze, gelfoam, cellulose, thrombin, tranexamic acid, amicar
66
Hematologic Malignancies
* Leukemia
* Lymphoma
* Myeloma
67
Leukemia
* Cancer of?
* Affects?
* Proliferation of WBCs which can be? Or?
* Cancer of WBCs
* Affects bone marrow and circulating blood
* Proliferation of WBCs which can be non-functional (blasts) or overtime overcrowd/suppress normal marrow production
68
leukemia classes
* Lineage: Myeloid vs Lymphoid
* Timing: Acute vs Chronic
69
common leukemias
* Acute Myeloid (AML)
* Chronic Myeloid (CML)
* Acute Lymphocytic (ALL)
* Chronic Lymphocytic (CLL)
**acute forms more likely to be symptomatic**
70
Leukemia causes
* Radiation
* Chemotherapy
* Genetic
* Down syndrome
71
leukiemia diagnosis
* CBC
* Blood smear
* Molecular studies
72
leukemia tx
* Chemotherapy
* Radiation
* Targeted therapy
* Hematopoietic stem cell transplant
73
Leukemia Signs and Symptoms
* Fatigue, malaise, petechiae, ecchymoses, fever
* Related to functional or treatment related neutropenia and thrombocytopenia
74
Leukemia oral manifestations
* Leukemia infiltrate
* Spontaneous gingival bleeding
* Oral ulceration (neutropenic ulcer, mucositis)
* Infection: Viral, fungal, bacterial
* Lymphadenopathy (chronic)
75
leukemia dental management
* dx unknown/suspected?
* If Dx known:
* Urgent referral to PCP or emergency room for leukemic infiltrate-CBC, smear, flow cytometry
* If Dx known:
* Thorough medical history
* Discussion with oncologist
1. * Current status and goals (comprehensive vs. palliative)
1. * Dental office vs hospital
1. * Timing of dental care-not on active chemotherapy for routine care
76
important labs of leukemia
*** CBC**
* Platelet: may require platelet transfusion due to
thrombocytopenia
* ANC-may require antibiotic prophylaxis for neutropenia (<500)
77
leukemia
* Confirm patient is?
* Local hemostatic measures?
* Confirm patient is afebrile
* Local hemostatic measures for patients with thrombocytopenia
78
Lymphoma
* Cancer of lymphoid organs and tissues
79
forms of lymphoma
HL and NHL
80
* Hodgkin Lymphoma
*cell?
* demo?
* LAD?
* LN feel?
* >50% affect where?
* Hodgkin Lymphoma
* Reed-Sternberg cell
* Young adults
* LAD
* Non-tender, firm
* >50% affect mediastinal or neck
nodes
81
* Non Hodgkin Lymphoma (NHL)
* Median Age:
* B-symptoms?
* Over how many types?
* Median Age: 67
* B-symptoms: Fever, night sweats (drenching),
weight loss (unintentional >10%)
* Over 20 types
82
Lymphoma causes
* Autoimmune diseases
* Hepatitis C
* EBV
* Sjogren syndrome
83
lymphoma diagnosis/staging
* Bone marrow or lymph node biopsy
* MRI for staging
84
lymphoma tx
* Chemotherapy
* Radiation
* Immunotherapy
* Stem cell transplant
* Watching
85
Lymphoma oral manifestations
* LAD?
* Extranodal involvement?
* radiographic lesions?
* Infection?
* LAD (Waldeyers ring, neck)
* Extranodal involvement:
1. Oral Ulceration
1. Localized infiltrate
1. Osteolytic radiographic lesions
* Infection: Viral, fungal, bacterial
86
lymphoma tc related oral manifestations
* Head and Neck Radiation (lymphomas in head and neck region only):
1. * Hyposalivation
1. * Trismus
1. * Osteonecrosis
87
Lymphoma dental management
– Similar to leukemia but risk for neutropenia and thrombocytopenia is lower and generally treatment related (chemotherapy, radiation)
– Thorough medical history
– Discussion with oncologist
88
lymphoma discussion with oncologist:
* Current?
* setting?
* Timing of dental care?
* Current status and goals (comprehensive vs. palliative)
* Dental office vs hospital
* Timing of dental care: not on active chemotherapy for routine care
89
lymphoma labs of interest
*** CBC**
– Platelet: may require platelet transfusion due to thrombocytopenia
– ANC-may require antibiotic prophylaxis for neutropenia (<500)
90
lymphoma
– Confirm patient is?
– Local hemostatic measures?
– Confirm patient is afebrile
– Local hemostatic measures for patients with thrombocytopenia
91
Multiple Myeloma
* Cancer of plasma cells
– Prevents normal production of antibodies
92
MM s/s
– Hypercalcemia
– Renal damage
– Anemia
– Bone pain
– Infection
93
MM tx
– Chemotherapy (RVD)
– Bisphosphonates
– Hematopoietic Stem Cell Transplant
94
Multiple Myeloma
* Oral Manifestations
– Plasmacytoma
– Lytic bone lesions
– Infection: Viral, fungal, bacterial
95
tx related MM oral manifestations
nn?
bone?
radiographic findings?
* Neuropathy
* MRONJ (IV Zometa)
* Radiographic:
1. – Thick lamina dura
1. – Persistent extraction site
1. – Sclerosis
1. – Sequestra
1. – Fracture
96
Multiple Myeloma
* Dental Management, dx related
* Soft tissue swelling, radiographic findings
* Infection management
* Pre-bisphosphonate exam
97
MM Medication related management
what should be provided?
* MRONJ
– Bisphosphonate history (number of doses, active)
– Chlorhexidine rinses
– Oral Hygiene
– Antibiotic regimen
– Sequestration
98
MM surgical procedures
– Informed consent
– As atraumatic as possible
– Thorough post surgical instructions including chlorhexidine rinses and antibiotic prophylaxis
– Re-eval after surgical procedures to ensure healing
99
Hematopoetic Stem Cell Transplant
* Infusion of stem cells to re-establish hematopoietic
function in patients whose bone marrow or immune
system is damaged or defective
* Treatment for solid or hematologic malignancies or other hematologic disorders
100
Indications for Stem Cell Transplant
* Leukemia
* Lymphoma
* Multiple Myeloma
* Aplastic anemia
* Fanconi anemia
* Sickle Cell
101
Pre-Transplant Evaluation (hematopoetic)
102
Pre-Transplant Evaluation:
Dental Screening Goals
* Remove active foci of infection and limit potential foci of infection
* Dentition to be** stable for at least 12 months **
– **Urgent care only for 12 months post** transplant
– **Risk of salivary GVHD** and **hyposalivation**=caries
* Patient education about home care
* If planned correctly, pre-transplant evaluation + patient compliance=dental maintenance
103
Dental Screening Pre-HSCT
* Comprehensive hard and soft tissue exam
* Full mouth series of radiographs
* Treatment
– Scaling and prophylaxis
– Removal of caries
* Restorations
* Endodontic therapy
* Extractions
– Extraction of all hopeless teeth & 3rd molars with hx periocoronitis
* Including teeth with questionable or poor prognosis
– Caries risk assessment and need for adjuncts (fluoride)
– Dental management based on primary disease
104
Oral Manifestations HSCT (hemo stem cell transplant)
* Mucus mem?
* Bleeding?
* Infection?
* Medication side effects?
* Graft versus host disease?
* Increased risk of?
* Mucositis – Acute; resolves after engraftment
* Bleeding– Petechiae, ecchymosis, hematoma
* Infection– Viral (ex. HSV), Fungal (ex. candidiasis), Bacterial
* Medication side effect/toxicities
– Gingival hyperplasia (cyclosporine)
– Oral ulceration (sirolimus)
* Graft versus host disease– Mucosal (lichenoid changes), Salivary-hyposalivation, caries
* Increased risk of oral cancer
105
Hematopoietic Cell Transplant
* Dental Management After Transplant
med hx, clinical exam, consult, CBC, medications
– Thorough medical history: Original diagnosis, date of transplant, immune suppression, GVHD
– Thorough clinical exam: Hyposalivation, caries, infection, GVHD, oral cancer
– Discussion with oncologist: Current status and goals (comprehensive vs. palliative), Dental office vs hospital
– Labs
* CBC-may require platelet transfusion due to thrombocytopenia, ANC-may require antibiotic prophylaxis for neutropenia
– Medications: Immune suppression (dose and length of tx), Bactrim-myelosuppression,** Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)**
106
Hematopoietic Cell Transplant
* Dental Management After Transplant
med hx, clinical exam, consult, CBC, medications
– Thorough medical history: Original diagnosis, date of transplant, immune suppression, GVHD
– Thorough clinical exam: Hyposalivation, caries, infection, GVHD, oral cancer
– Discussion with oncologist: Current status and goals (comprehensive vs. palliative), Dental office vs hospital
– Labs
* CBC-may require platelet transfusion due to thrombocytopenia, ANC-may require antibiotic prophylaxis for neutropenia
– Medications: Immune suppression (dose and length of tx), Bactrim-myelosuppression,** Avoid medications that are cytochrome P450 inhibitors for patients on immunosuppressants with low therapeutic index (ex. tacrolimus and fluconazole)**
