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Introduction Erythrocytes are produced from the bone marrow from pleuripotent stem cells via immature cells (reticulocytes). Reticulocytes retain their organelles and nuclear remnants and still have the ability to divide and are released into the blood when the demand is high. Erythropoietin produced in the kidneys stimulates erythrocytes production when the O 2 level is low.

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Mature erythrocytes contain only haemoglobin which carry O 2 and CO 2 between the lungs and the tissues. Haemoglobin production requires iron, protoporphyrin and globin chains. Haemoglobin is a heterogenous group of proteins consisting of 4 globin chains and 4 haem groups. In an adult, the normal haemoglobins are HbA, HbA 2 and HbF.


ANAEMIA Haemoglobin level lower than what is normal for the age and sex. Prepubertal Hb < 11 g/dl Adult female Hb < 11.5 g/dl Adult male Hb < 13.5 g/dl Anaemia impairs the O 2 carrying capacity of the blood, it is not a disease but a manifestation of many diseases.

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CLASSIFICATION OF ANAEMIA Based on the size of the RBC Microcytic anaemia is when the mean corpuscular volume (MCV) is less than 78fl. This is the most common and usually due to iron deficiency. Normocytic anaemia is when the RBC size is normal (MCV 79 – 98fl) This is usually due to chronic diseases like leukaemia, liver disease, renal failure and sickle cell disease.

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Macrocytic anaemia is when the MCV is > 99fl. Usually arise from vitamin B12 or folate deficiency. Folate and B12 deficiency can arise from increased demand as in pregnancy or malignancy or as a result of alcoholism. Some drugs deplete folate and B12 such as methotrexate. Macrocytic anaemia may also arise from liver disease and myxedema.

Causes of Anaemia:

Causes of Anaemia Poor Intake of Hematinics Socioeconomic factors Diet fads Impaired absorption Small bowel disease Increased demand Pregnancy haemolysis Impaired erythropoiesis Aplastic anaemia Leukeamia Drugs Heamolystic anaemias Sickle cell disease Blood loss (commonest) Menorrhagia GIT lesion (ulcers, CA) Trauma

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CLINICAL FEATURES Asymptomatic in the early stages. Pallor of the conjunctiva, oral mucosa or the skin. Tiredness, dyspnoea, tachycardia or murmurs and may worsen angina and heart failure.

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GENERAL MANAGEMENT OF ANAEMIA Establish the precise nature though lab studies- Hb content, MCV etc. Replace Hb with haematinics, blood transfusion or erythropoietin. Erythropoietin is indicated in the treatment of anaemia of renal failure and cytotoxic therapy.

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DENAL ASPECTS OF MANAGEMENT LA is sufficient for pain control. Conscious sedation should be used only when oxygen is available to supplement. Deep sedation carries the risk of hypoxia. Avoid N 2 O if vitamin B12 deficiency is suspected. N 2 O can interfere with B12 metabolism and neurologic function if administered for more than 12 hours.

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Anaemia should be corrected preoperatively if GA is indicated. Elective surgery under GA should not be carried out if the Hb is less than 10 g/dl. The myocardium may not be able to respond to increased demands for oxygen if adequate oxygenation is not ensured. In an emergency, blood transfusion can be used to correct the anaemia. Diuretics should be administered to prevent volume overload. Some anaemias may cause oral ulcers, glossitis or angular stomatitis and will be discussed with the specific anaemias.


DEFICIENCY ANAEMIAS IRON DEFICINECY ANAEMIA Common in this environment due to malnutrition, malaria and chronic blood loss. Manifest as impaired exercise capacity and koilonychia. Treated with ferrous sulphate 200mg tds. Ferrous salt is preferable to the ferric salts as they are better absorbed in the gut.

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Presents in the mouth as a sore, physically normal tongue even before haematologic parameters fall below the normal levels. Severe anaemia is a cause of atrophic glossitis. Rarely, may be associated with Plummer-Vinson syndrome (glossitis, dysphagia and iron deficiency anaemia). Candidosis may be precipitated or aggravated by anaemia.

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Angular cheilitis may be a feature though this is more commonly due to candidiasis. Aphthous stomatitis may also be associated with iron deficiency anaemia. VITAMIN B12 DEFICIENCY In addition to general features of anemia, this may present with neurologic symptoms of paraesthesia of the extremities. Oral features are similar to Iron def anaemia apart from association with Plummer Vinson syndrome.

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FOLATE (FOLIC ACID) DEFICIENCY No body stores and usually due to inadequate intake. Deficiency in pregnancy associated with cleft deformities. Sore, physically normal tongue, atrophic glossitis and angular cheilitis are oral features.


HAEMOLYTIC ANAEMIAS May be due to - Inherited abnormalities of formation (haemoglobinopathies) - Inherited abnormal structure (G6PD deficiency) - Damage to erythrocytes (autoimmune, drug induced or infective) Increased erythrocyte destruction leads to billirubin overproduction and jaundice. Spleen may be enlarged, reticulocyte and uric acid levels will be raised.

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DENTAL MANAGEMENT OF SICKLING DISORDERS. Important to recognize and diagnose the condition. For patients with sickle cell disease (HbSS), LA is preferred. Avoid prilocaine (may cause methaemoglobinaemia if used excessively). Aspirin in large doses may cause acidosis which can precipitate a crisis. Best avoided.

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Conscious sedation and relative analgesia are safe, avoid benzodiazepines which can depress respiration. For treatment under GA, correct anaemia preoperatively. Exchange blood transfusion is occasionally indicated. Prophylactic antibiotics should be given for surgical procedures and infections should be treated aggressively.

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Orodental features of SCD include - painful infarcts in the jaws which present like and may be construed as toothache. - dense radiopacities in the jaws and skull- stepladder trabecular pattern. - Osteomyelitis may occur in the mandible. - Neuropathies including lip anaesthesia. - Hypercementosis. - Bone marrow hypertrophy may lead to enlarged maxilla and increased overjet and overbite

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Bossing of the skull and hair on end trabecular pattern, tower skull appearance. Enamel hypomineralisation and calcified pulp canals.

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