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‫بسم هللا الرحمن الرحيم‬

: ‫مالحظة‬
‫ الدكتور حكى بعرف انو لما ييجيكم دكتور من برا ما بتذكرو اشي بس انا بدي تذكرولي كم‬.1
. ‫معلومة وراح يكونو اسئلة باالمتحان‬
‫ االسنان اهم يعرفو‬bleeding & infection ‫ وحكى انتو كأطباء اسنان بهمكم انو مايصير‬.2
. anemia ‫ اكتر من‬neutropenia ‫عن ال‬
‫ الدكتور كان يقرأ العنوان من الساليد ويحكي هاد مش مهم الكم انا عارف (الدكتور) فأنا كتبت‬.3
‫ والدكتور حكى في‬, ‫الحكي الي حكى جميعو وكتبت معلومات بتوقع أنها مهمة من الساليدات‬
. ‫ الي بحب يقرأ معلومات أكتر وزيادة يقرأ الساليدات‬, ‫االخر انو الي شرحتو هو المهم‬

Always remember : (question in exame)

neutropenia cause mouth ulcer( if patient came to you and he has mouth
ulcer remember neutronpenia and request CBC).

 Acute myloid leukemia can cause gingival hypertrophy .

:To be safe you should know

Neutrophils count
Platlete count
Drugs like: warferin, heparin,asperin

. ‫هون الدكتور حكى المحاضرة هاي رح تكون معلومات عامة‬

Anemia
Reduction in the total number of RBCs, hemoglobin, and/or hematocrit.

According to age and sex female have less hemoglobin level than male bcause
of menses in female and this is normal.

Always remember anemia is not a dagnosis you should know the cause of
anemia .

Anemia could be Presentation for leukemia: patient came and he looks pale
and doctor request CBC and the result (hemoglobin =7, WBCs=50000) and he
has gingival hypertrophy ,so mostly this patient have leukemia .

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In hematology it is important to look at CBC ,the most important thing in CBC
is :
1. White blood cells : (important for dentistry), it decrease the
incidence of infection,so we have what we call deferential
neutrophils ,if we have WBCs =10000 in CBC the deferential
neutrophils is 20% =2000.so absolute neutrophils count = 2000,if
it is less than 2000 you shouldn’t start treatment

‫ اذا بلشتو في المريض مش رايحين‬leukopenic ‫مش الزم تبلشو بالمريض اذا كان‬: ‫بالعربي‬
. ‫تخلصو‬
2. hemoglobin.(not important for dentist).
If patient came and he has hemoglobin =7 it is ok to treat him

3. platelet : you should check platelet count , for safe dental


procedure platelet count should be more than 50000 /cm
(memorize it for future).(Doctor will not ask us about CBC
indices ).

The most common cause of anaemia is iron deficiency .

When we look for CBC we should concentrate on :WBCs, hemoglobin


,platelet, then if patient is anemic we look for MCV.

MCV : Mean Corpuscular Volume

• Macrocytic >100 fl
• Normocytic 80-100 fl
• Microcytic < 80 fl

Doctor say 96 but in slide it is 100.


We have MCH ( mean corpuscular hemoglobin), hemoglobin/RBCs if
it is low we call it hypo chromic.

hypo chromic microcytic anaemia


the most common cause of anemia is iron deficiency and always
microcytic.

Vitamin B12 deficiency:


 we call it megaloblastic anemia ,so if patient came and he has
red sore tongue and MCV high remember B12 & folic acid
deficiency .

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 vitamin B12 deficiency associated with neurological damage
(very imp)

 anemia couldbe symptomatic or asymptomatic ,symptoms include:


1. general weakness
2. palor
3. weak in breath

when we look for patients have anemia we should know if there is


bleeding or bone marrow failure ,because bone marrow responsible for
production of blood cells.
oral manifestation for hematological ‫الدكتور حكى هاي المحاضرة الزم كانت عن ال‬
.patient
. anemia ‫النو انتو مش رح تعالجو مرضى ال‬
:Causes of anemia
.Iron deficiency
B12 and folic acid deficiency. (megaloblastic anemia)
.Hemolytic anemia (instead RBCs live for 120 it lives less)

:Hemolytic anemia
 Jaundice in eye.
 Reticulocyte count to see bone marrow if it is work or not.
 In hemolytic anemia reticulocyte count is high.

Anemia

:Normocytic
: Microcytic :Macrocytic
MCV normal
Megaloblastic
Common in patient
Iron deficiency& anemia(B12&folic
with renal failure
thalasimia acid)
&cancer

If patient have anemia either you start treatment or refer patient to


.internal medicine

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If patient suspected to iron deficiency anemia you should ask female
about menses (if she has heavy menses you can explain iron deficiency
anemia)and male about bleeding ,he may have bleeding tendency and
.epistaxi

We have disease called hereditary hemorrhagic telangiectasia they


.have hematemesis, recurrent epistaxis, we cn see it in tongue

If dentist want to diagnose hereditary hemorrhagic telangiectasia


patient he could diagnose it in patient came with long history of
epistaxis ,iron deficiency anemia ,hematemesis, telangiectasia(dilated
.small arterioles) on finger & tongue (red spot)

:Drugs cause bleeding

 Aspirin : mechanism of action it affect platelet function not count


( doctor say this question in exam) other NSAID affect like
aspirin .

So if platelet function affect may→drugs like aspirin


But if platelet count affect may→leukemia.

Case: 35 years female came with gingival hyper trophy she goes to
dentist then he extracted the teeth after that she has bleeding and
infection, when doctor see CBC
(WBCs=100000,platelet=20000,hemoglobin =7).she is anemic and this
anemia is secondary to bleeding because hemoglobin before extraction
=9.

Test for iron deficiency anemia is ferritin


. If it is low then we have iron deficiency
We have something call acute face reactant which is certain test when
we do it for patient it may increase like C-RP (c reactive protein)if
patient have infection it will be high .so some times ferritin test have
.acute face reactant

If ferritin is low then patient have iron deficiency anemia but if it is


. high patient may normal or have iron deficiency anemia

.Iron deficiency anemia is hypochromic) ‫( قليل الصبغة بالعربي‬

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And RBCs size is small so it is microcytic so we call it :
hypochromic microcytic anemia because most of the cause come with
. iron deficiency other cause may thalassimia

Iron deficiency most common cause for hypochromic microcytic


anemia

Always remember in anemia you should found the cause,because


patient may come with menses or hemorrhoid or hereditary
hemorrhagic telangiectasiaor or esophageal varices bleeding or cancer
colon because of iron deficiency anemia , so in these cases we give
. correction for iron then we should found the underlying cause

Thalassemia
 We have alpha(α) & beta(B) thalassemia .

 The most important is B thalassemia specially when two want to


married ( B

 B_thalassemia similar iron deficiency anemia,both have hypo


chromic microcytic anemia and hemoglobin is low .

When two want to engage they should do this test and some time they
have low MCV but it doesn’t mean the patients have thalassemia , may
have iron deficiency anemia ,so they should do ferritin and if it is low
we give him iron then repeat CBC.

Keep in your mind when we have iron deficiency anemia always


we measure ferritin .

Megaloblastic anemia
 From name mega mean large .

 Patient may have pancytopenia ( allfree cell line is low ),free cell
line mean blood cell(WBCs,RBCs,platelet).

 Always look at MCV if it is high think in megaloblastic anemia.

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 When we talk about megaloblastic anemia we mean folic acid &
B12.

So deficiency in B12 or folic acid lead to→→→ megaloblastic anemia

In megaloblastic anemia patient may come with pancytopenia or


anemia alone.

When we suspected megaloblastic anemia we request CBC, level for


B12 & folic acid ( then we treat patient with B12 & folic acid).

B12 deficiency :

 Anemia is macrocytic
 We call it pernicious anemia
 Body store B12 liver for 3 years ,so patient may have anemia after
3year .
 We treat patient for two reason :
1. hematological → decrease in B12 lead to anemia.
2. neurological →decrease in B12 lead to neurological damage.

Note : you should not treat patient if he has leukemia ,so if you receive
lab report and you found blast cell this will indicate that the patient
has leukemia ( lab report you should concentrate on : blast cell,
neutrophils, platelet ).
. ‫ ألنو إذا بلشتو مش حتخلصو‬leukemia ‫ دائما ً حاولو ما تبلشو في مرضى ال‬: ‫الدكتور‬

some thing call hyper segmentation in We have


phils neutro
as in this )neutrophil nuclei is segmented (
. picture

patient came to you and he complains from If


pain and redness in his tongue and you found hyper segmentation
neutrophils in the lab form so you should think in B12 deficiency;
?why

Because neutrophils hyper segmentation is associated with


.megaloblastic anemia (B12 &folic acid)

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Mouth ulcer

Neutropenia cause candidiasis

Infections

:If patient came to you and he has candidiasis you should think in
1. neutropenia
2. steroids
doctor say: always remember absolute count for neutrophils is =2000 if
less ,you should not start treatment( ‫) ما تبلشو على قولت الدكتور‬.

Pernicious anemia
‫))بالعربي فقر الدم الخبيث‬

 Most important and common cause is B12 deficiency.


 Lack of intrinsic factor.
 Folic acid deficiency; folic acid store in body for 3
months( remember B12 for 3 years).
 Patient 65 years came to your clinic and he has hemoglobin =5, and
he has a lot of other disease, he has red sore tongue so you should
remember B12 deficiency.

If patient has folic acid deficiency it could be result from:


1. Hemolytic anemia.
2. Pregnancy.

So why pregnant women take folic acid?


For two reasons:
1. To prevent deficiency because baby require it.
2. We have disease call neural tubal defect so if folic acid decrease it
will increase the incidence for this disease.

Aplastic anemia
(‫)فقر الدم االتصنعي‬
Bone marrow fail to produce blood cells .
May occur with pancytopenia.

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Low hemoglobin, platelet, RBCs, WBCs .( inthis case you should
not start treatment because if you start you will not stop and may
lose patient.

‫ كمان مرة عاد الجملة الي ضل يكررها طول المحاضرة والي هي دائما ُ قبل ما تبلشو‬: ‫الدكتور‬
‫ ماتبلشو‬high or low ‫ إذا كانو‬CBC (platlet & WBC) ‫بالمريض اتطلعو على ال‬
.‫بالمريض‬

Hemolytic anemia
 Decrease RBCs survival (Normal survival for RBC IS 100-120
days).
Patient comes especially female with low hemoglobin.
 Jaundice and splenomegaly most common features.
MCV may normal or high.
 This patient came same as patient with hepatitis (jaundice) but
liver function test is normal.

In anemic patient the test (in general)is:


 CBC deferential: we look at WBCs, platelet and RBCs count.
 Blood film :
owe look if blast cells ere present then the patient has leukemia.
oif hyper segmentation in neutrophils present then the patient
has megaloblastic anemia,

in case of hemolytic anemia we can see it in blood film but we have


more specific test which is Coomb’s test (direct anti globulin test), if it
is positive we call it autoimmune hemolytic anemia , but if it is not
positive you cant diagnose .

 autoimmune hemolytic anemia: patient has auto anti body (IGg)


against RBCs and this type is more common in female.

Gingival hypertrophy for patients have acute myloid leukemia as in


this picture :

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When you see gingival hypertrophy always suspect acute myloid
leukemia,and you should request CBC deferential ( and remember
doctor say don’t treat patient whith high or low WBCs).

Case : patient 65years old female came to doctor complain from lesion
in here cheek and she has gingival hypertrophy, unfortunatelydoctors
doing asurgery and take biopsy without looking for CBC ,so after
surgery she has problems then doctors request CBC and they see low
WBCs, platelet and hemoglobin befor surgery but doctors don’t care
about that ,so after surgery she has poor healing ,then doctors do test
for bone marrow and they found acute myloid leukemiathen the
patient sudden die ( (‫ هللا يرحمها‬because of infections .
‫ هاي الحالة كانت بمشتشفى الملك عبدهللا وكل الناس بحطو الحق على الدكتور الي عمل العملية‬.

Large tongue cause by:


1. amyloidosis
2. hypothyroidism
3. acromegaly

question in exam:
 decrease in WBCS cause( mouth ulcer, candidiasis, infections).
 Acute myloid leukemia cause gingival hyper trophy .

**************
The end

DONE BY : Mo3ath Abu Hadba


‫المحاضرة كانت من الساليدات وحكي كتير من برا فالي بدو يعرف أكتر عن الموضوع يرجع الى‬
)‫ الساليدات (الدكتورقال انو الي شرحو أهم إشي‬.

Please forgive me for any mistakes…..

My best wishes for all of you…………..

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