ha em a tho pathology
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HAEMATOPATHOLOGY
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Anaemias and leukaemias
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Anaemia
types (etiology):
1) iron deficiency
±
most common type ± chronic menstrual blood loss, peptic ulcer,
haemorrhoids
2) pernicious anaemia
± macrocytic anaemia
± +/- neurological disease
± folate insufficiency
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Anaemia
3) leukaemia
± cause of normocytic anaemia
±
childhood! 4) sickle cell trait
5) thalasaemia
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Anaemia
clinical features
tab 22.2, 3, 4
mucosal disease
glossitis
recurrent aphthae candidiosis and angular stomatitis
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Anaemia
dangers of general anesthesia
± any reduction of oxygenation irreparable brain
damage, myocardial infarction gen. anesthesia
should be provided in hospital
lowered resistence to infection
± oral candidiosis
± osteomyelitis
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Sickle cell disease and sickle cell trait
people of African, Afro-Caribbean and
Mediterranean or Middle Eastern origin
sickle cell diease = homozygotes sickle cell trait = heterozygotes
abnormal Hb (HbS) with the risk of
haemolysis, anaemia and other effects in heterozygotes sufficient normal Hb (HbA) is
formed to allow normal life
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Sickle cell disease and sickle cell trait
Sickle cell disease:
complications from polymerisation of
deoxygenated HbS (less soluable than HbA)
chronic haemolysis chronic anaemia
exacerbation of sickling raises blood viscosity
blocking of capillaries and sickling crisis
tab 22.5 + abnormal susceptibility to infections
(Pneumococcal, Meningococcal) and
osteomyelitis
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Sickle cell disease and sickle cell trait
dental aspects of sickle cell disease and s.c.trait:
Hb 10g/dl v. s. homozygote
s.c. trait: gn anaesthesia with full oxygenation
s.c. disease:
+/- oral mucosa pale or yellowish due to
jaundice +/- radiographics changes in skull and jaws
prompt atb treatment
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Sickle cell disease and sickle cell trait
painfull crisis with analgesics
rigorous dental care necessary due to
susceptibility to infection
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The thalassaemias
-thalassaemias Asians, Africans and Afro-
Caribbean
ß-thalassaemias Mediterranean (Greeks)
diminished synthesis of globin chains resulting relative excess of other chains
precipitation in ery +/- haemolysis
severity of disease depends on the numbersof affected genes
minor = heterozygotes
major = heterozygotes
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The thalassaemias
thalassaemia minor:
mild, but persistent microcytic anaemia,
otherwise asymptomatic +/- splenomegaly
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The thalassaemias
thalassaemia major:
severe hypochromic, microcytic anaemia
great enlargement of liver and spleen
skeletal abnormalities (marrow expansion)
life saving transfusions, but iron depositions in
tissues haemosiderosis dysfunction of glands and other organs xerostomia
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Leukaemia
leukaemic white blood cells production
supress of other cell lines of the marrow
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Leukaemia
acute leukaemia
ALL most common leukaemia of children
AML in adults
tab 22.7
splenomegaly, hepatomegaly, +/-
lymphadenopathy mucosal pallor, abnormal gingival bleeding
tab 22.8
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Leukaemia
management:
± biopsy of gingival swelling
±
vigorous oral hygiene to controll the bacterialpopulation before complications develop
± extractions avoided, if necessary blood
transfusion, generous atb cover
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Leukaemia
chronic leukaemia
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Leukopenia and agranulocytosis
leukopenia
WBC 5000³/l
different causes tab 22.10
chance haematological finding x severe -
immunodeficiency
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Leukopenia and agranulocytosis
agranulocytosis
clinical effects of severe neutropenia: fever
prostration, mucosal ulceration
drug induced leukopenias
tab 22.12
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Leukopenia and agranulocytosis
aplastic anaemia
failure of production of all bone marrow cells
(pancytopenia) systemic and oral effects: purpura, anaemia,
susceptibility of infection
cause: unknown, ai, drug induced management: stop drugs, give atb and
transfusions
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Haemorrhagic diseases
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Haemorrhagic diseases
haemorrhagic diseases = purpura (platelet
deffects) and clotting deffects
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Haemorrhagic diseases
Investigation of a history of excessive bleeding:
± careful history essential tab. 23.1
± most of the haemorrhagical diseases are hereditary!
± bleeding for up to 24hrs after an extraction usually
due to local causes or a minor defect of haemostasis
more prolonged bleeding is significant
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Haemorrhagic diseases
Clinical examination:
± signs of anaemia and purpura
± examination of the mouth planning of the
operation
± haemophilia all essential extractions carried out
at a single operation with fVIII cover
± radiographs (to prevent complications)
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Haemorrhagic diseases
Laboratory investigations:
± tab 23.2
± essential is look for anaemia
± blood grouping
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Haemorrhagic diseases
A) Purpura
typical result of platelet disorders
bleeding time prolonged but clotting functionnormal (with exception of of vW disease)
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Haemorrhagic diseases
general features of purpura:
± purpura = bleeding into the skin or mucous
membranes causing petechiae or ecchymoses or
spontaneous bruising ± haemorrhage immediately follows the trauma and
ultimately stops spontaneously as a result of
normal coagulation
± thrombocytopenia = platelets 100 000 mm³ ± spontaneous bleeding uncommon until platelets
50 000 mm³
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Haemorrhagic diseases
± typical site palate
± +/- excessive gingival bleeding or blood blister
± tab 23.3
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Haemorrhagic diseases
ITP
IgG auto Ab
number of platelets children or young adult women
first sign could be profuse gingival bleeding or
postextraction haemorrhage +/- spontaneous bleeding into the skin
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Haemorrhagic diseases
management:
± corticosteroids
± transfusions of platelets
± anti???
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Haemorrhagic diseases
AIDS
ai thrombocytopenia can be early sign
drug associated purpura aspirin + others interfere with platelet
function
others act as haptens immune destructionof platelets or suppress marrow function
tab 23.4
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Haemorrhagic diseases
localised oral purpura
sometimes blood blister without haemostatic
defect choking sensation (angina bullosa
haemorrhagica)
rupture ulcer
systemic purpura should be excluded
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Haemorrhagic diseases
vonWillebrand´s disease
both by prolonged bleeding time and
deficiency of fVIII
usually inherited, AD
deficiency of fVIII mild purpura more
common manifestation
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Haemorrhagic diseases
B) Clotting disorders
tab 23.5
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Haemorrhagic diseases
Haemophilia A
most common, severe
fVIII deficiency 6/100 000
severe haemophilia typically effects in
childhood bleeding into muscles or jointsafter minor injuries
mild haemophilia (fVIII 25%) no symptoms
until an injury, surgery or dental extraction
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Haemorrhagic diseases
severe and prolonged bleeding can also follow
local anaesthetic injections! (inferior dental
blocks!)
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Haemorrhagic diseases
clinical features: ± positive family history
± 30% patients negative history!
± bleeding starts after a short delay (normal platelet and vascular
responses) persistent bleeding, can continue for weeks ± haemarthroses
± intracranial haemorrhage!
± deep tissue bleeding obstruction of airways!
± HBV, HCV+!
± +/- formation of anti fVIII Ab
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Haemorrhagic diseases
principles of management: ± radiographs (local status, prevention of
complications)
± admission to hospital
± replacement therapy
± as much surgical work as possible in one session
23.6
± for dental extraction fVIII level 50-75% ± postoperatively: atb, risk of bleeding greatest 4-10
days postoperatively
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Haemorrhagic diseases
± aspirin and related analgesics avoided!
± extractions in mild haemophilia with
antifibrinolytic drugs
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Haemorrhagic diseases
Christmas disease (haemophilia B)
f IX
inherited more stable replacement therapy in longer
intervals
other the same as in haemophilia A
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Haemorrhagic diseases
Acquired clotting defects
a) vitamin K deficiency
causes: obstructive jaundice, malabsorption surgary delayed to haemostasis recover
+/- vitamin K
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Haemorrhagic diseases
b) anticoagulant treatment coumarin (warfarin)
dental extraction save with INR 2-3
few teeth extracted in one session, traumashould be minimal, sockets can be sutured
anticoagulation should not be stopped
for large surgery stopped with agreementof physician
short term: heparin (acts only about 6hrs)
surgery delayed for 12-24hrs
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Haemorrhagic diseases
c) liver disease
obstructive jaundice
extensive liver damage (viral hepatitis,alcoholism)
haemorrhage can be severe and difficult to
control
vitamin K
antifibrinolytic agents
fresh plasma infusion
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Lymphomas
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Lymphomas
any type of lymphocytes, most frequently B
cells
all malignant
Hodgkin + non Hodgkin lymphomas (NHL)
relatively frequently involve cervical lymph
nodes x rare in the mouth
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Lymphomas
A) NHL
adults predominantly affected
nondescript, soft, painless swelling +/-ulcerated
histologically:
+ invasion of adjacent tissues + if traumatised inflammatory cells can
obscure the lymphomatous nature of the tu
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Lymphomas
management:
± biopsy!
± staging!
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Lymphomas
Burkitt´s lymphoma
nasopharyngeal (T cell) lymphoma mlg
midline granuloma
MALT!
+ local manifestation of gn disease
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Cervical lymphadenopathy
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Cervical lymphadenopathy
dental and periodontal infections most
common cause
lymphomas
HIV infection
tab 26.1
investigation: recent viral illness lymphadenopathy resolves after some months
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Cervical lymphadenopathy
TBC
Mcb tuberculosis + atypical Mcb
clinical features: pathology: granulomas, Mcb Mcb culture
or DNA tests
management: suspicion of TB
C affectednodes should be excised intact
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Cervical lymphadenopathy
Syphilis
lymph nodes enlarged, soft and rubbery
primary or secondary stage Treponema pallidum in a direct smear or by
serological finding
management: atb
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Cervical lymphadenopathy
Cat scratch disease
tab 26.4
pathology: destruction of lymph nodearchitecture, necrosis and lymphocytic
infiltration, formation of histiocytic
granulomas and central suppuration
WS staining
x deep mycoses
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Cervical lymphadenopathy
management: history, clinical features,
exclusion of other causes, disease is mild and
self limiting, +/- suppuration and sinus
formation
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Cervical lymphadenopathy
Lyme disease
transmitted by insects, deer ticks
tab 26.5 management: history + clinical picture
confirmed serologically
atb!
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Cervical lymphadenopathy
Infectious mononucleosis
self-limiting lymphoproliferative disease
tab 26.6 +/- more persistent lymphadenopathy which
may mimic a lymphoma
management: peripheral blood picture(atypical lymphocytes), Paul-Bunnell test, anti
EBV Ab, ampicillin or amoxicilin should be
avoided!
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Cervical lymphadenopathy
AIDS
soon after infection transient glandular fever
like-illness
later +/- wide spread lymphadenopathy (GLS)
AIDS
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Cervical lymphadenopathy
Toxoplasmosis
intestinal parasite of many domestic animals
(cats)
management: serologically, antimicrobial
treatment
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Cervical lymphadenopathy
Mucocutaneous lymph node syndrome
(Kawasaki´s disease)
tab 26.8
management: clinical and ECG finding
aspirin, -globulin