MANAGEMENT OF PATIENTS WITH HEMOPATHY
I/ INTRODUCTION: The dental surgeon is a health professional whose field of action covers the entire Oro-Facial sphere. This can be the site of a certain number of conditions that can have consequences on the general state of health. Conversely, general pathologies, in particular blood diseases, can present manifestations at the level of the oral cavity. Consequently, it must be examined methodically in all circumstances.
II/ Biological investigation methods:
- The Hemogram: The hemogram corresponds to the quantitative analysis of the formed elements of the blood (cells and platelets). It is a simple and automated test (electronic counters) allowing to quantify the number of white blood cells, red blood cells and platelets.
The blood smear provides a qualitative estimate to establish the blood count and detect possible morphological abnormalities of the cells. The smear is a manual technique.
- Normal adult blood count
Red blood cells
→Hemoglobin: Blood hemoglobin (Hb) corresponds to the amount of hemoglobin contained in 100 ml of blood. It varies according to gender and normal values are:
- in men: 13 to 18 g/dl,
- in women: 12 to 16 g/dl.
→ Red blood cell count: This is the number of red blood cells per mm3 . Normal values are:
- in humans: 4.2 to 5.7 million per microliter,
- in women: 4.0 to 5.3 million per microliter.
→ Hematocrit: This is the distribution (expressed as a %) of red blood cells in relation to plasma, the quantity of white blood cells and platelets not being taken into account because they are in very small quantities). When the hematocrit is equal to 40%, this means that 100 ml of blood contains 40 ml of red blood cells and 60 ml of plasma).
Normal values are:
- in men: 40 to 52%,
- in women: 37 to 46%.
→ The MCV: As the hematocrit corresponds to a volume, if we divide the hematocrit by the number of red blood cells we obtain the average volume of red blood cells. This is the Mean Cell Volume (MCV). It is expressed in µ. This is an average value, the size of the red blood cells can vary (anisocytosis).
The MCV is normally between 80 and 100 µ3 . Below the threshold of 80, we speak of microcytosis and above 100 of macrocytosis .
VGM is currently measured directly by automatic devices during a blood count.
→ The CCMH: The mean corpuscular (or globular) hemoglobin concentration (CCMH) corresponds to the quantity of hemoglobin contained in 100 ml of red blood cells. This parameter is obtained by calculating the ratio between Hemoglobin/Hematocrit. It is expressed in grams/100 ml or in %. Normal values vary between 32 and 36%.
When the CCMH is less than 32% we speak of hypochromia . Above we speak of normochromia . The maximum rate of CCMH is 38% (stoppage of hemoglobin synthesis in the erythroblast from this rate).
→ Mean corpuscular hemoglobin content (MCHC): A less useful parameter, mean corpuscular hemoglobin content (MCHC) is calculated by the ratio of hemoglobin to the number of red blood cells contained in 100 ml of blood. It is normally between 27 and 31 pg/RBC.
→ Reticulocytes: These cells correspond to very young red blood cells, visible only with certain dyes. The number of reticulocytes reflects erythroblastic production. It is expressed as a % with normal values between 0.5 and 1.5% of red blood cells (i.e. 25,000 to 75,000/mm3 ) . This figure allows us to know the regenerative (high reticulocytes) or non-regenerative (low reticulocytes) nature of anemia.
White blood cells:
→ Total leukocyte count: The normal number of leukocytes varies between 4 and 10 G/L. Below 4000/mm3 we speak of leukopenia and above 10000/mm3 of hyperleukocytosis.
→ The leukocyte formula: In the normal state, 5 types of leukocytes are found in the blood. Their rate is often expressed in % but the absolute value is more important.
- Neutrophils play a role in the elimination by phagocytosis of foreign particles, particularly bacteria.
– Normal figures: 2000 to 7500/mm 3
- Eosinophils play a role in allergy and parasite control. – Normal numbers: 100 to 500/mm 3
- Basophils play a role in immediate hypersensitivity. – Normal numbers: 0 to 150/mm 3
- Lymphocytes play a role in cellular and humoral immunity (antibody synthesis). – Normal figures: 1500 to 4000/mm 3
- Monocytes play a role in phagocytosis and immunity. – Normal numbers: 200 to 1000/mm 3
Platelets: Platelets are useful for primary hemostasis (platelet block).
Their usual rate varies from 150,000 to 450,000 /mm3 ( 150 to 450 x 109 / L or 150 to 450 G/L). Below the value of 150 G/L we use the term thrombopenia; above the value of 450 G/L we speak of thrombocytosis (or hyperplaquettosis).
III/ Classification
Hematological diseases can be grouped into four major syndromes.
– hemorrhagic syndrome
– anemic syndrome
– non-proliferative leukocyte syndrome
– proliferative syndrome
A/ Hemorrhagic syndrome
- Primary hemostasis disorder :
Disorders related to platelet disorders.
Disorders related to vascular abnormality.
- Blood clotting disorders :
Hemophilia
Willebrand disease
- Hemostasis disorders first and second ary
- Thrombopenia: this is a decrease in the number of platelets below the threshold of 150,000/mm3 of blood.
- Etiologies:
-Central origin: due to insufficient medullary production
-Peripheral origin:
drugs (NSAIDs, heparin and penicillins)
infectious diseases: HIV, HBV, HCV, EBV, CMV
autoimmune diseases / lupus
- ORAL REPERCUSSIONS:
- Above 80,000 platelets/ mm3 : no signs of bleeding
- Between 80,000 and 50,000 platelets/mm3 : occasional purpura and gingival bleeding
- Between 50,000 and 30,000 platelets/mm3 : purpura, petechiae, oral hematomas and gingival bleeding
- Below 30,000 platelets/mm3 : profuse and locally uncontrollable hemorrhages.
- clinical situations
For thrombocytopenia at 100,000 platelets/ mm3 :
ALL TREATMENTS ARE POSSIBLE WHILE RESPECTING GENERAL PRECAUTIONS
For thrombocytopenia between 50,000 and 100,000 platelets/ mm3 :
- For procedures without risk of bleeding
- Conservative care,
- Prosthetic care,
- Para apical, intraligamenatory or intraseptal anesthesia
- Supragingival scaling.
MANAGEMENT OF PATIENTS WITH HEMOPATHY
GENERAL PRECAUTIONS MUST BE FOLLOWED
- For procedures with moderate hemorrhagic risk
- A localized dental extraction,
- Single implant placement,
- Subgingival scaling and surface planing
GENERAL PRECAUTIONS AND THE LOCAL HEMOSTASIS PROTOCOL MUST BE RESPECTED .
- For procedures with high risk of bleeding:
- Extraction of more than 03 teeth,
- Periodontal surgery, mucogingival cystic enucleation and apical surgery
- extraction of temporary teeth,
- Extractions of teeth with altered periodontium
- Extraction of impacted teeth,
- Biopsies and multiple implant placement)
CARE MUST BE SPECIALIZED AND HOSPITALIZED
For thrombocytopenia below 50,000 platelets/ mm3 :
ANY ACTION IS CONTRAINDICATED AND CARE MUST BE IN HOSPITAL .
- Precautions regarding anesthesia : no special precautions in patients with a platelet count greater than 50,000 platelets/mm3 of blood.
- Precautions regarding prescriptions : the prescription of NSAIDs if necessary must be discussed with the treating physician.
- HEMOPHILIA, WILLEBRAND’S DISEASE: these are pathologies that result from a congenital deficiency in hemostasis factors. The genes coding for factors VIII and IX are located on the X chromosome, which explains why hemophilia mainly affects men.
Willebrand factor and or factor VIII for von Willebrand disease
Factor VIII for hemophilia A
Factor IX for hemophilia B
- Classification :
- For von Willebrand disease:
type 1: quantitative deficit
type 2: qualitative deficit
type 3: severe deficit.
- For hemophilia: it can be: Minor, moderate and severe
- Oral repercussions: depending on the severity of the coagulation factor deficiency, the repercussions can range from the absence of spontaneous bleeding to spontaneous hemorrhages.
- General precautions :
- Contact with the attending physician
- Use a vasoconstrictor
- In case of mucosal bleeding, ensure local compression using compresses impregnated with tranexamic acid and place a non-traumatic gutter.
- Clinical situations:
- for non-invasive procedures: These treatments can be carried out in a practice but while respecting general precautions
- for invasive procedures: discuss the case with the hematologist and ensure possible substitution of the missing factor.
- precautions regarding anesthesia: no loco-regional anesthesia.
- precautions regarding NSAIDs: are contraindicated but if necessary, advice from a hematologist is required.
B/ Anemic syndrome: Anemia is characterized by a decrease in the number of red blood cells, the erythrocyte volume or hematocrit and the amount of hemoglobin present in the circulating blood. The diagnosis of anemia is, by definition, made when:
– the amount of hemoglobin falls below 12g in men, and 11g in women
– hematocrit is less than 40% in men, and 37% in women.
- Risks related to anemia : Bleeding, infection and delayed healing
- Oral manifestations of anemia: Glossitis, cheilitis, petechiae, ulcerations and paresthesias
- Clinical situations
- Low risk patient
- History of corrected anemia and normal hematocrit
- mild anemia not requiring treatment with hematocrit > 40% in men
- anemia associated with chronic disease with hematocrit > 40%. In men
- High risk patient:
- Undiagnosed anemia
- hematocrit < 40%
- associated coagulopathies
Precautions to take:
- Hb safety margin > or equal to 10
- antibiotic prophylaxis and antibiotic therapy / risk of infection.
MANAGEMENT OF PATIENTS WITH HEMOPATHY
C/Leukocyte proliferative disorders/neutropenia
- Leukemias: malignant proliferations of hematopoietic tissues. They are due to chromosomal abnormalities or to irradiation and exposure to certain chemical compounds: we distinguish
- Acute leukemia: cancer of blood stem cells
- Chronic leukemia: B-cell cancer
- Biological situations :
- Mild neutropenia: 1000 to 2000 PNN/mm 3
- moderate neutropenia: 500 to 1000 PNN/mm 3
severe neutropenia: < 500 PNN
- Clinical manifestations:
Paleness of the mucous membranes
viral and drug ulcers
gingival hyperplasia
gingival bleeding
viral and fungal infection
cervical lymphadenopathy
xerostomia
paresthesia
- Clinical situations and CAT
- Comprehensive strategy for care in cases of leukopenia:
Elective care: wait until the count is correct
Urgent care: under antibiotics in times of severe depression
Management of a patient with leukemia :
Contact with the attending physician
hemostasis assessment (even scaling)
prevent post-operative infection with anti-infective prophylaxis
- if PNN < 500 /mm 3:
- 2 g of amoxicillin orally /30 min before the act
then 500 mg every 6 hours for the remainder of the day of the procedure
- or 1g of cephalexin 1 hour before followed by 250 mg every 6 hours / 1 week
- if allergic to beta-lactams:
– 300 mg of clindamycin 1 hour before the act then 150 mg every 6 hours / 7 days.
MANAGEMENT OF PATIENTS WITH HEMOPATHY
Leukemia cases with transplant:
- In patients transplanted less than 3 months ago:
- Pre-operative assessment
- clinical examination and radiological assessment
- only urgent care will be carried out.
- Between 3 months and 1 year:
- Clinical examination
- radiological assessment
- motivation for oral hygiene
- Beyond 1 year:
- in the absence of graft rejection: Routine care will be carried out
- In case of rejection only emergency care will be provided.
MANAGEMENT OF PATIENTS WITH HEMOPATHY
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.