Deficiency anemia and oral manifestations

Deficiency anemia and oral manifestations

Summary :

1. INTRODUCTION 
2. GENERAL INFORMATION ON ANEMIA
3. CLINICAL SIGNS OF ANEMIA
4. BIOLOGICAL SIGNS
5. PATHOPHYSIOPATHOLOGICAL MECHANISM OF ANEMIA
6.  DEFICIENCY ANEMIA:

• DEFINITION 
• IRON DEFICIENCY ANEMIA 
• ANEMIA DUE TO VITAMIN B 12 AND B9 DEFICIENCY

7. Conclusion :
8. INTRODUCTION  :

Anemia is a disease of the red blood cell.

The red blood cell is a biconcave disk with an average diameter of 7.5 µm, a thickness of 2 µm and a surface area of ​​145 µm ² . It is an anucleated cell that contains 70% water, 25% Hb, proteins, enzymes and ions. Its lifespan is limited to 120 days and its main function is the transport of O ₂   via Hb to the tissues. 

2. GENERAL INFORMATION ON ANEMIA  :

  DEFINITION :

The definition of anemia is biological, it corresponds to the reduction in the mass of circulating blood hemoglobin and the interpretation of which must take into account age and sex. 

• Newborn < 13.5 g/dl
•  12 years < 11.5 g/dl
• Adult female < 12 g/dl
• Pregnancy (3rd trimester) < 10g/dl
• Man < 13 g/dl

There are situations of false anemia which correspond to physiological conditions where the decrease in Hb indicates significant hemodilution and this during pregnancy, massive perfusions, splenomegaly with sequestration, generalized edema.

3. CLINICAL SIGNS OF ANEMIA  :

The symptoms of anemia are the consequence of two mechanisms; hypoxemia (reduced capacity of the blood to transport O2 to the tissues) and the activation of adaptation mechanisms.

They are extremely variable depending on: the intensity of the anemia, the speed of its onset, the age of the patient, and their cardiovascular condition.

 The physical sign found is cutaneous-mucosal pallor (proportional to the extent of the deficit) 

 The functional signs found are an anemic syndrome (consequences of hypoxemia) which includes asthenia, headaches, dizziness, ringing in the ears and dyspnea; in addition to the adaptation mechanisms which are responsible for superficial polypnea, tachycardia, palpitations, arterial hypotension, functional heart murmur.

Deficiency anemia and oral manifestations

4. BIOLOGICAL CHARACTERISTICS OF ANEMIA  :

Anemia is defined by: 

• The size of red blood cells (VGM) defines the micro, normo or macrocytic character 
• TCMH and CCMH define hypochromia or normochromia 
•  The reticulocyte rate (young RBCs) which is the index of bone marrow production thus defining the regenerative and non-regenerative nature of the anemia.

Microcytosis is the consequence of abnormal hemoglobin synthesis (iron deficiency, defective globin synthesis, etc.)

Macrocytosis is the consequence of mitotic abnormalities (chemo, DNA synthesis defect due to folate or vitamin B12 deficiency)

5. PHYSIOPATHOLOGICAL MECHANISMS OF ANEMIA  :

Physiological hemolysis is normally compensated by erythropoiesis, this broken balance leads to anemia in the event of:

1. Increased losses: Peripheral (regenerative) anemias
2. Insufficient bone marrow production: Central (aregenerative) anemias 
3. INCREASED LOSSES: 

1.  Hemorrhages :
   • Acute: Causes normocytic or regenerative macrocytic anemia
   • Chronic: repeated bleeding or chronic blood loss causes iron deficiency and aregenerative hypochromic microcytic anemia 
2. Hyperhemolysis: is the exaggerated destruction of red blood cells which is the cause of a highly regenerative anemia related to a cause:

• Corpuscular: Intrinsic due to abnormality of Hb, the membrane or the enzymes of the red blood cell, most often hereditary.
•  Extracorpuscular: this is the aggression of red blood cells by exogenous factors. Most often acquired (infection, toxic agent, mechanical, immunological). 

2. INSUFFICIENCY OF MEDULLARY PRODUCTION:

• Quantitative abnormalities of erythropoiesis:

1.  Bone marrow aplasia: global insufficiency.
2.  Medullary invasion.
3.  Erythroblastopenia. 

• Qualitative abnormalities of dyserythropoiesis 

1. Decreased Hb synthesis (iron deficiency)
2.  DNA synthesis abnormality (folate or vitamin B12 deficiency).
3. Failure to regulate erythropoiesis: renal failure, thyroid failure. 
4. DEFICIENCY ANEMIA 

• Definition :

 These are anemias due to a deficiency in exogenous factors of erythropoiesis => of central origin:

•  iron deficiency => dys-erythropoiesis due to lack of hemoglobin synthesis => microcytosis 
• Antipernicious factor deficiency => dys-erythropoiesis due to DNA synthesis defect 🡺 asynchrony of nucleo-cytoplasmic maturation => megaloblasts and macroocytes   

1. IRON DEFICIENCY ANEMIA (MARTIN DEFICIENCY )  :

1-GENERAL DEFINITION:

• It is a hypochromic hyposideraemic microcytic anemia due to depletion of iron reserves. 

• Insidious onset, spread over several months, therefore “well tolerated” anemia, until the exhaustion of bone marrow reserves.
• It is the most common anemia in the world; in Algeria this is the case in
  •     44% of pregnant women 
  •  30% of children 
  •  14% of infants   

 It is a disorder of erythropoiesis due to a lack of hemoglobin synthesis.

   2-Iron metabolism  :

Iron: exogenous factor essential for erythropoiesis (production of red blood cells)

Contributions: foods: heme iron meat products 30%, non-heme iron; dried vegetables 1-20% 

Requirements: 1-2 mg/day for men, 2-4 mg/day for women 

Losses 1-2 mg/day 

Place of absorption in the duodenum   

 Iron cycle: closed cycle 

Deficiency anemia and oral manifestations

3-Clinic : 

• Clinical signs of anemia.
• Signs of iron deficiency: Hair loss, thinned and very brittle nails, dry lips, angular stomatitis.
• Possibly associated signs suggestive of the cause. 

Oral manifestations during iron deficiency anemia:

Deficiency anemia and oral manifestations

4-Biology :

FNS:   finds frank anemia (often Hb between 6 and 10g/dl), microcytic VGM<80fl hypochromic CCMH<30% TGMH<29 pg, and aregenerative. Often associated with moderate thrombocytosis (increased platelet count) and sometimes neutropenia. 

Serum iron and ferritin are decreased .    

Blood smear: Visible abnormalities are anisocytosis, poikylyocytosis, microcytes, hypochromia, target cells.

5-Etiologies:

• Iron loss through chronic hemorrhages (mainly of gynecological or digestive origin).
• Insufficient intake during unbalanced diet (multiple diets, elderly people, prolonged milk-based diets in infants).
• Increase in uncompensated needs (close pregnancies, premature birth, adolescence)
• Absorption disorders if digestive lesions.

Deficiency anemia and oral manifestations

6-Treatment:

• Oral iron: 200 mg elemental iron/day For 4 to 6 months of continuous treatment.
• Injectable iron : 15 days to 1 month of treatment 

Treatment of etiology 

2. ANEMIA DUE TO FOLATE OR VITAMIN B12 DEFICIENCY:
3. GENERAL DEFINITION:

It is an aregenerative megaloblastic macrocytic anemia related to a deficiency in antipernicious factors; folic acid = vit B9 and vit B12 

• Folate deficiency: is a very common cause in Algeria, linked to an imbalance between intake and needs. 
• VITB12 deficiency less common but increasingly diagnosed 

2. Physiology of anti-pernicious factors  :

Vits B12 and VitB9 are exogenous factors of erythropoiesis, they play a role in DNA synthesis => cell division 

             Needs: reserves:               

 vitB9 = 50-100 micro g / day, *2 in case of pregnancy / VITB9 = 5-10mg (3-4 months)

vitB12 =2-3 microg/day / vit B12 = 3-5 mg (3-4 years)

 Origins: 

Vitb9: liver, vegetables, fruits, eggs 

Vit B12: absent in vegetables, meat, fish and eggs 

  Absorption   :

vitb9: proximal jejunum           

 VIT B 12: terminal ileum associated with intrinsic factor secreted by gastric parietal cells

3-Clinics:

• Clinical signs of anemia with very gradual onset (several months). 
• Signs of deficiency: smooth, depapillated tongue, abdominal pain, diarrhea.
• Signs suggestive of the cause
•  Neurological signs: tingling in the extremities which can lead to paralysis (in case of VITB12 deficiency)

Oral manifestations during anemia:

FAP deficiency anemia manifests itself by:

• Pale mucosa and Hunter glossitis: depapillated and smooth varnished tongue
• At first, very often limited to the front half of the tongue
  •  Tongue is bright red enlarged giving a  swollen  appearance
  • Teeth leave their imprints on the lingual edge 
• It spreads to the entire tongue in a few weeks or months with a characteristic appearance: smooth, shiny tongue on the dorsal surface up to the lingual V on the edges and the ventral surface is dark red, purplish in color, with a thin opaline layer on the edges giving a milky appearance.
• The tongue is less moist and sometimes appears smaller and more pointed. 
• 

4-Biology:

FNS: Finds severe anemia (Hb often < 8g/dl), macrocytic or megalocytic (MCV often > 110fl), normochromic, aregenerative.

Sometimes we can find pancytopenia: erythropenia, leuko-neutropenia, thrombopenia (reduction of the three lines).

Bone marrow aspiration : Finds large erythroblasts called megaloblasts, this is called aregenerative macrocytic megaloblastic anemia.

Folate dosage (serum and erythrocyte)  : low .

VitB12 dosage  : low

 5- Etiologies: 

• Folate deficiency:
  •  Lack of intake: malnutrition. 
  •  Malabsorption: jejunal involvement (celiac disease, bacterial proliferation , small bowel lymphoma).
  •  Excessive use: pregnancy, breastfeeding, hemolysis.
  •  Toxic: Methotrexate, Bactrim, Anti-retrovirals (interference with folic acid metabolism)
• Vitamin B12 deficiency:
  • Malabsorption: Gastrectomy or resection of the terminal ileum.

• Intake deficiencies: strict vegetarian.
• Biermer’s disease: Antibody to gastric parietal cells (site of secretion of intrinsic factor), or Antibody to intrinsic factor. Hence the interest in gastric fibroscopy.

6-Treatment:

          Folic acid: 2 to 4 tablets/day for 2 months

          Vit B12 : 1000 gamma: 1 injection/2 days intramuscularly for 2 months then 1 injection/month in case of gastrectomy or Biermer’s disease.

Treatment of etiology 

VII. CONCLUSION  :

• Deficiency anemias are very common and their diagnosis is easy. 
• The clinic provides guidance and biology confirms it 
• Etiological diagnosis is essential for proper patient care
• The treatment is simple and effective if the etiological treatment is undertaken.  

Good oral hygiene  Regular scaling at the dentist  Dental implant placement Dental x-rays  Teeth whitening  A visit to the dentist  The dentist uses local anesthesia to minimize pain  

Deficiency anemia and oral manifestations