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RBCs & Its Clinical 
Implications 
Dr. Amit T. Suryawanshi 
Oral and Maxillofacial Surgeon 
Pune, India 
Contact details :...
Contents 
1. Introduction. 
2. History. 
3. Erythropoiesis. 
4. Morphology of RBCs. 
5. Properties of RBCs. 
6. Functions ...
Introduction 
• Blood is connective tissue of the body in fluid form. 
• Blood is a specialized body fluid 
in humans that...
Composition of Blood 
Blood Cells 45.7 % Plasma 54.3% 
Solid 
6-7% 
Water 
92-93 % 
Gases 
<1 % 
Organic 
Substances 
Inor...
Blood is considered as a fluid of life. Because it 
carries Oxygen from lungs to all parts of the body 
and Carbon dioxide...
Introduction of RBCs 
• RBCs- Red Blood Cells .They are also known as 
Erythrocytes. 
• Red colour of RBCs is due to prese...
History 
• The first person to describe red blood cells was the 
young Dutch biologist Jan Swammerdam, who had 
used an ea...
Normal RBC Count - 
• Avrg RBC count = 4 - 5.5 millions / mm3 
• RBC count in adults male – 5- 5.5 millions /mm3 
• RBC co...
Erythropoiesis 
• Haematopoiesis is the process which includes 
origin, development & maturation of all blood 
cells. 
• W...
Stages & Sites of Erythropoiesis 
• In Fetal life - 
Mesoblastic 
stage 
• First 2 
months of 
i.u. 
• From 
mesenchyme 
o...
In post natal life 
• Upto 5-6 years : Red bone 
marrow of all bones. 
• From 6-20 years : Red 
bone marrow of long 
bones...
In post natal life 
• Only the upper ends of 
the femur & humerus 
contain red bone marrow. 
• Vertebras , ribs, sternum 
...
Erythropoiesis - 
o Blood cells are derived from Pluripotent 
Hemopoetic Stem Cells (PHSC) 
o Growth inducers (GI) like in...
Erythropoietin dependent stages
Iron dependent stages 
CELL 
DIAMETER 
NUCLEUS CYTOPLASM 
15-20 μm Big Very Scanty & basophilic. 
No Hb 
11-16μm Smaller S...
RBC Maturation factors 
1. Vitamin B12 (Extrinsic factor) – 
• Essential for maturation of RBCs 
• Deficiency of Vitamin B...
3. Folic acid – 
• Essential for synthesis of DNA in RBCs. 
• Absence of folic acid causes failure of 
maturation of cells...
Morphology 
• Size : 7.2 μ 
• Shape : Circular , Biconcave 
• Thickness : 2.2 μ, 1 μ 
• Surface area : 120 μm2 
• Volume :...
Advantages of bi-concave shape: 
1. provides large surface area for 
absorption and removal of 
respiratory gases and othe...
Composition 
• Water - 62.5% 
• Hemoglobin - 35% 
• Others - 2.5% 
(glucose, lipids, 
proteins, enzymes, 
vitamin, ions) 
...
Properties of RBCs 
Rouleaux formation Packed cell volume
Specific gravity- 
1.092 – 1.101 
Suspension stability
Functions of RBCs - 
1. Transport of OXYGEN from lungs to the tissues 
2. Transport of CARBON DIOXIDE from tissues to 
the...
5. Blood group determination. 
6. Help to maintain the viscosity of blood.
LIFE SPAN AND FATE OF RBC’S 
• Average life span -- 100-120 days. 
• Spleen -- Graveyard of red blood cells. 
• Daily 10% ...
Hemoglobin 
• Hemoglobin is an oxygen carrying pigment of 
the RBCs. 
• It is a conjugated protein which consists of 
prot...
Functions of Hemoglobin 
1. Transport of OXYGEN from lungs to the 
tissues 
2. Transport of CARBON DIOXIDE from tissues 
t...
HAEMOGLOBIN 
NORMAL VALUES 
• Average hemoglobin (Hb) -- 14 to 16 gm%. 
• At different ages: 
– At birth : 22 – 25 gm% 
– ...
Iron Metabolism- 
• Iron is absorbed for small intestine and 
transported to blood . 
• In blood , Iron combines with β gl...
Synthesis of hemoglobin 
A. 2 succinyl-CoA + 2 glycine Pyrole compund 
B. 4 pyrrole compunds Protoporphyrin IX 
C. Protopo...
Factors for Hemoglobin synthesis 
• Proteins 
• Iron 
• Vitamin C, Riboflavin ,Nicotinic acid , Pyridoxine 
• Copper 
• Co...
Structure of Hemoglobin 
• It is a conjugated protein 
• It consists of 
1. Heme - An Iron containing pigment. 
2. Globin-...
Heme part- Structure 
• It consists of 
1. Iron – Ferrous form(Fe++) 
2. Porphyrin – Pigment part
Globin -Structure 
It consists of 4 polypeptide chains 
1. Two α chains 
2. Two β chains
Types of Normal Hemoglobin 
• There are 2 types of hemoglobin . 
1. Adult Hemoglobin (HbA)- 
- It contains 2 α and 2 β cha...
DESTRUCTION OF HEMOGLOBIN 
– Occurs in Phagocytes of Spleen. 
– Globin is broken into amino acid and 
reused. 
– Heme – It...
CLINICAL 
IMPLICATIONS OF RBC
Clinical disorders related to RBCs 
Broadly classified into 
1. Anemia – Decrease in RBC count and 
Hemoglobin level. 
2. ...
ANEMIA 
• It is defined as a blood cell disorder 
characterized by decreased oxygen carrying 
capacity of blood caused by ...
Classification 
Etiological (Whidby's) classification 
A. Deficiency anemias - 
1. Iron deficiency anemia 
2. Megaloblasti...
C. Haemolytic anemias ( increased destruction of 
rbc) 
1. Hereditary heamolytic anemias 
a. Thalassemia 
b. Sickle cell a...
• Acquired haemolytic anemias 
- Due to direct toxic effect ( eg snake venom, drugs 
, chemicals, etc) 
- In splenomegaly ...
Morphological (Wintrobe’s) classification 
1.Normocytic normochromic anemias 
• Acute post-haemorrhagic anemia 
• Haemolyt...
3. Macrocytic hypochromic anemias- 
• Protein deficiency anemia 
• Megaloblastic anemia 
2.Microcytic hypochromic anemias ...
SIGN & SYMPTOMS 
Considered in two broad categories: 
1. Clinical features common to all anemias. 
2. Certain special clin...
Common Clinical features 
• Typically none in early stages 
• General lassitude 
Cardio-respiratory - 
1. Dyspnoea 
2. Tac...
Oral – 
1. Sore mouth 
2. Oral ulceration 
3. Angular stomatitis 
4. Glossitis 
5. Burning mouth syndrome 
Cutaneous - 
1....
Iron deficiency anemia 
• Most common type of anemia 
• It Develops due to inadequate availibity for 
iron for hemoglobin ...
Clinical features 
PALLOR KOILONYCHIA 
ANGULAR CHEILITIS PAPILLARY ATROPHY OF TONGUE
Megaloblastic anemia 
• Megaloblastic anemia is due to deficiency of 
Maturation factor of RBC i.e. folic acid. 
• DNA syn...
Oral manifestations 
1. Atrophic glossitis 
2. Patchy erythema 
3. Taste alterations 
4. Dysphagia 
5. Burning mouth 
Atro...
Pernicious anemia 
• Cause – 
• It occurs due to atrophy of gastric mucosa 
because of autoimmune destruction of 
parietal...
Oral manifestations 
1. Atrophic glossitis 
2. Patchy erythema 
3. Taste alterations 
4. Dysphagia 
5. Burning mouth 
Atro...
SICKLE CELL ANEMIA 
•It is a congenital anamaly occurs 
due to abnotmal Hb called Hb–S. 
•Molecules of Hb-S polymerize 
in...
Hemolysis in Sickle cell anemia
Oral 
Manifestations 
Pallar of mucosa Delayed erruption of teeth
Other clinical features - 
Jaundice Hand & Foot 
syndrome
THALASSEMIA 
• It is also known as “Cooley’s anemia” . 
• It is caused by inherited anomalies of hemoglobin 
• It is of 2 ...
Clinical features 
1. Saddled nose 
2. Prominent malar 
bone 
3. Retracted upper 
lip 
4. Bimaxillary 
protrusion 
5. Chip...
Radiographic feature 
HAIR ON END APPEARENCE
APLASTIC ANEMIA 
• Aplastic anemia is due to failure of red bone 
marrow . 
• Red bone marrow is replaced by fatty tissues...
Oral manifestations 
ORAL PETECHIAE 
GINGIVAL HYPERPLASIA
Blood Tests
Blood tests 
The routine blood tests are 
1. Complete blood count 
I. RBC count 
II. Blood indices – 
PCV , MCV, MCH, MCHC...
ERYTHROCYTE SEDIMENTATION RATE 
• It is commonly used blood test and is also called 
as a sed rate or BIERNACKI’s REACTION...
• Determination by 
1. Westergreen’s Method 
2. Wintrobe’ s Method 
• Normal Values of ESR 
– Westergreen's Method 
• Adul...
• Variations of ESR 
Pathological - 
• ESR increases in - 
– All Anemias, 
except sickle cell anemia . 
• ESR decreases in...
BLOOD INDICES 
• Importance – Help in diagnosis & typing of Anemias. 
• Different Blood Indices 
1. Packed Cell Volume (PC...
PACKED CELL VOLUME 
• Also called as HEMATOCRIT value 
• It is the fraction of blood composed of 
RBC 
• Procedure- 
• Blo...
• NORMAL VALUES OF PCV – 
Males = 40 to 45%. 
Females = 38 to 42% 
• VARIATIONS IN PCV 
1. PCV increases in 
- Polycythemi...
HEMATOCRIT VALUES
MEAN CORPUSCULAR VOLUME (MCV) 
Average volume of a single red blood cell 
– Normal MCV = 85 - 90 μm3 . 
– VARIATIONS IN MC...
• Decreases in (Microcyte anemia ) 
1. Iron deficiency anemia 
2. Chronic post-haemorrhagic anemia 
3. Thalassemias
MEAN CORPUSCULAR HEMOGLOBIN 
(MCH) 
• Quantity or amount of Hb present in one RBC 
– Normal value of MCH is 30 pg (27 -32p...
• Decreases in (Hypochromic anemia). 
1. Protein deficiency anemia 
2. Megaloblastic anemia 
3. Iron deficiency anemia 
4....
MEAN CORPUSCULAR HEMOGLOBIN 
CONCENTRATION (MCHC) 
• It is the amont of Hb expressed in relation to volume of 
single RBC ...
• Decreases in ( Microcyte anemia ) 
1. Iron deficiency anemia 
2. Chronic post-haemorrhagic anemia 
3. Thalassemias
Peripheral blood smear (PBS) 
o A well prepared & correctly read smear gives 
vast amount of information of RBC 
morpholog...
Management of 
anemia 
Oral Surgeon’s Perspective
Pre operative – 
When patient has to undergo surgery , following 
preoperative measures should be carried out. 
1. Complet...
5. Drugs that induce Hemolysis should be avoided. 
6. Avoidance of elective surgical treatment in patients 
in “crisis” (s...
11. Thorough oral examination of teeth , 
periodontium ,soft tissues should be conducted 
to correct the cause of infectio...
Intra operative - 
1. Gingival bleeding , if present , can be controlled 
with antifibrinolytic agents. 
2. Intramuscular ...
4. GA should be used in caution 
Mostly N2 O + O2 is safe to use. 
(Sickle cell anemia & vitamin B12 
deficiency ). 
5. Pr...
Post operative - 
1. Avoidance of drugs that can cause hemolysis in 
patients with hemolytic anemias 
2. Oral hygiene tech...
Treatment of Anemia 
Physician’s perspective
Treatment of Anemia 
1. Exclude the possibility of hemoglobinopathy 
2. Correct any identified cause of blood loss 
3. Giv...
Polycythemia 
• It is a general term used for 
1. Increased red blood cell count 
2. Increased Hb level. 
Causes- 
1. chro...
• Classified as 
1. Primary polycythemia (Polycythemia vera) 
2. Secondary Polycythemia
Signs & symptoms 
1. Lassitude 
2. Dyspnoea 
3. Dizziness 
4. Headache ,Body 
ache 
5. Itching 
,numbness, 
burning and 
w...
Oral manifestations 
Purplish mucosa Edematous gingiva
Treatment of Polycythemia 
1. Oral surgical procedures in patients with 
polycythemia, should be avoided. 
2. Patient shou...
1. Before performing surgery , threshold levels should 
be obtained .. 
a. Hb = < 16 g/ dL 
b. Hematocrit value = < 47% 
2...
Conclusion 
It is necessary for the oral surgeon to 
have knowledge about RBC related disorders . 
Because , it is mandato...
References 
• Medical Physiology : 11th edition GYTON & 
HALL. 
• Davidson : General Medicine . 
• Burket’s Principle of m...
Thank you
Rbcs & its clinical implications. Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India
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Rbcs & its clinical implications. Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India

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Rbcs & its clinical implications. Dr. Amit Suryawanshi .Oral & Maxillofacial Surgeon, Pune , India

  1. 1. RBCs & Its Clinical Implications Dr. Amit T. Suryawanshi Oral and Maxillofacial Surgeon Pune, India Contact details : Email ID - amitsuryawanshi999@gmail.com Mobile No - 9405622455
  2. 2. Contents 1. Introduction. 2. History. 3. Erythropoiesis. 4. Morphology of RBCs. 5. Properties of RBCs. 6. Functions of RBCs. 7. Lifespan & Fate of RBCs. 8. Hemoglobin & Iron Metabolism. 9. Blood tests & Blood indices . 10. Clinical implications of RBCs. 11. Conclusion.
  3. 3. Introduction • Blood is connective tissue of the body in fluid form. • Blood is a specialized body fluid in humans that delivers oxygen and nutrients to the cells and transports carbon dioxide and metabolic waste products away from the cells. Hence it is called as a “ River of Life ” • Blood and Blood related disorders has got very much importance in patients life ,making it mandatory to learn for Oral Surgeons .
  4. 4. Composition of Blood Blood Cells 45.7 % Plasma 54.3% Solid 6-7% Water 92-93 % Gases <1 % Organic Substances Inorganic Substances Erythrocytes 45 % Leucocytes 0.6 % Thrombocytes 0.1 %
  5. 5. Blood is considered as a fluid of life. Because it carries Oxygen from lungs to all parts of the body and Carbon dioxide from all parts of the body to the lungs. This function of the blood is performed by RBCs. i.e. Red blood Cells which are also known as Erythrocytes . ( Erythros - Red , Cytes – Cells )
  6. 6. Introduction of RBCs • RBCs- Red Blood Cells .They are also known as Erythrocytes. • Red colour of RBCs is due to presence of coloring pigment Hemoglobin. • RBCs play important role in transport of Oxygen from lungs to the tissues and carbon dioxide from tissues to lungs.
  7. 7. History • The first person to describe red blood cells was the young Dutch biologist Jan Swammerdam, who had used an early microscope in 1658 to study the blood. • In 1959, Dr. Max Perutz was able to reveal the structure of hemoglobin .
  8. 8. Normal RBC Count - • Avrg RBC count = 4 - 5.5 millions / mm3 • RBC count in adults male – 5- 5.5 millions /mm3 • RBC count in adults female – 4 – 4.5 millions /mm3 • RBC count in infants - 6-7 million/mm3
  9. 9. Erythropoiesis • Haematopoiesis is the process which includes origin, development & maturation of all blood cells. • Whereas the process by which origin , development and maturation of erythrocytes occur is known as Erythropoiesis.
  10. 10. Stages & Sites of Erythropoiesis • In Fetal life - Mesoblastic stage • First 2 months of i.u. • From mesenchyme of yolk sac Hepatic stage • From 2-6 months • Liver, spleen & lymphoid organs Myeloid stage • From 7-9 month • Red bone marrow, Liver
  11. 11. In post natal life • Upto 5-6 years : Red bone marrow of all bones. • From 6-20 years : Red bone marrow of long bones & all flat bones . • After 20th year : almost red bone marrow of all the long bones is replaced by yellow bone marrow.
  12. 12. In post natal life • Only the upper ends of the femur & humerus contain red bone marrow. • Vertebras , ribs, sternum scapula ,iliac bone also produce red cells continuously. • In case of Bone disorders, RBCs are produced in spleen, liver
  13. 13. Erythropoiesis - o Blood cells are derived from Pluripotent Hemopoetic Stem Cells (PHSC) o Growth inducers (GI) like interleukin-3 and differentiation inducers (DI) play an important role. o Few PHSC are retained throughout life as they are.
  14. 14. Erythropoietin dependent stages
  15. 15. Iron dependent stages CELL DIAMETER NUCLEUS CYTOPLASM 15-20 μm Big Very Scanty & basophilic. No Hb 11-16μm Smaller Still Scanty & basophilic. No Hb 10-12μm Smaller & denser Hb starts to appear, cytoplasm polychromatic 8-10μm Ink spot nucleus Plentiful, eosinophilic cytoplasm. Increase in Hb 8-10μm Absent Some RNA still present 7.2 μm Absent Hb is present in large amount .
  16. 16. RBC Maturation factors 1. Vitamin B12 (Extrinsic factor) – • Essential for maturation of RBCs • Deficiency of Vitamin B12 causes Pernicious Anemia. So it is also called as antipernicious factor . 2. Intrisic Factor of castle- • Produced in Gastric mucosa • Essential for absorption of Vit.B 12
  17. 17. 3. Folic acid – • Essential for synthesis of DNA in RBCs. • Absence of folic acid causes failure of maturation of cells leading to Megaloblastic anemia.
  18. 18. Morphology • Size : 7.2 μ • Shape : Circular , Biconcave • Thickness : 2.2 μ, 1 μ • Surface area : 120 μm2 • Volume : 85-90 μm3
  19. 19. Advantages of bi-concave shape: 1. provides large surface area for absorption and removal of respiratory gases and other substances. 2. Cells can easily squeeze through while passing through capillaries
  20. 20. Composition • Water - 62.5% • Hemoglobin - 35% • Others - 2.5% (glucose, lipids, proteins, enzymes, vitamin, ions) others water haemoglobin
  21. 21. Properties of RBCs Rouleaux formation Packed cell volume
  22. 22. Specific gravity- 1.092 – 1.101 Suspension stability
  23. 23. Functions of RBCs - 1. Transport of OXYGEN from lungs to the tissues 2. Transport of CARBON DIOXIDE from tissues to the lung 3. Buffering action in blood
  24. 24. 5. Blood group determination. 6. Help to maintain the viscosity of blood.
  25. 25. LIFE SPAN AND FATE OF RBC’S • Average life span -- 100-120 days. • Spleen -- Graveyard of red blood cells. • Daily 10% red blood cells, which are senile, get destroyed in normal young healthy adults.
  26. 26. Hemoglobin • Hemoglobin is an oxygen carrying pigment of the RBCs. • It is a conjugated protein which consists of protein combined with an iron containing pigment.
  27. 27. Functions of Hemoglobin 1. Transport of OXYGEN from lungs to the tissues 2. Transport of CARBON DIOXIDE from tissues to the lung 3. Buffering action in blood
  28. 28. HAEMOGLOBIN NORMAL VALUES • Average hemoglobin (Hb) -- 14 to 16 gm%. • At different ages: – At birth : 22 – 25 gm% – After 3 months : 18 – 20 gm% – After1 year : 17 gm% – In adult males : 14 – 17 gm% – In adult females : 12 – 16 gm%
  29. 29. Iron Metabolism- • Iron is absorbed for small intestine and transported to blood . • In blood , Iron combines with β globulin to form Transferrin • Iron is stored in large quantities in RE cells and Hepatocytes as Ferritin. • In RBCs , Iron is stored in Fe++ form .
  30. 30. Synthesis of hemoglobin A. 2 succinyl-CoA + 2 glycine Pyrole compund B. 4 pyrrole compunds Protoporphyrin IX C. Protoporphyrin IX + Fe++ Heme D. Heme + globin Hemoglobin
  31. 31. Factors for Hemoglobin synthesis • Proteins • Iron • Vitamin C, Riboflavin ,Nicotinic acid , Pyridoxine • Copper • Cobalt and nickel
  32. 32. Structure of Hemoglobin • It is a conjugated protein • It consists of 1. Heme - An Iron containing pigment. 2. Globin- Protein
  33. 33. Heme part- Structure • It consists of 1. Iron – Ferrous form(Fe++) 2. Porphyrin – Pigment part
  34. 34. Globin -Structure It consists of 4 polypeptide chains 1. Two α chains 2. Two β chains
  35. 35. Types of Normal Hemoglobin • There are 2 types of hemoglobin . 1. Adult Hemoglobin (HbA)- - It contains 2 α and 2 β chains 2. Fetal Hemoglbin (HbF)- -It contains 2 α and 2 γ chains
  36. 36. DESTRUCTION OF HEMOGLOBIN – Occurs in Phagocytes of Spleen. – Globin is broken into amino acid and reused. – Heme – Its tetrapyrrole ring is opened up to form BILIVERDIN. – Its oxidation produces BILIRUBIN
  37. 37. CLINICAL IMPLICATIONS OF RBC
  38. 38. Clinical disorders related to RBCs Broadly classified into 1. Anemia – Decrease in RBC count and Hemoglobin level. 2. Polycythemia – Increase in RBC count and Hemoglobin level.
  39. 39. ANEMIA • It is defined as a blood cell disorder characterized by decreased oxygen carrying capacity of blood caused by reduction in red blood cell count or hemoglobin content or both.
  40. 40. Classification Etiological (Whidby's) classification A. Deficiency anemias - 1. Iron deficiency anemia 2. Megaloblastic anemia 3. Pernicious anemia B. Blood loss anemias - 1. Acute post- hemorrhagic anemia (accidents) 2.Chronic post- hemorrhagic anemia
  41. 41. C. Haemolytic anemias ( increased destruction of rbc) 1. Hereditary heamolytic anemias a. Thalassemia b. Sickle cell anemia c. Hereditary spherocytosis d. Glucose 6-phosphate dehydrogenase deficiency (G6PD)
  42. 42. • Acquired haemolytic anemias - Due to direct toxic effect ( eg snake venom, drugs , chemicals, etc) - In splenomegaly - In paroxysmal nocturnal haemoglobinuria( PNH) D. APLASTIC ANEMIA (failure of bone marrow) E. Anemia due to chronic diseases (tuberculosis, chronic infections, malignancies )
  43. 43. Morphological (Wintrobe’s) classification 1.Normocytic normochromic anemias • Acute post-haemorrhagic anemia • Haemolytic anemias • Aplastic anemia • Anemia in chronic diseses. 2.Macrocytic normochromic anemia • Pernicious anemia (Addison’s anemia)
  44. 44. 3. Macrocytic hypochromic anemias- • Protein deficiency anemia • Megaloblastic anemia 2.Microcytic hypochromic anemias • Iron deficiency anemia • Chronic post-haemorrhagic anemia • Thalassemias
  45. 45. SIGN & SYMPTOMS Considered in two broad categories: 1. Clinical features common to all anemias. 2. Certain special clinical features for different types of anemias.
  46. 46. Common Clinical features • Typically none in early stages • General lassitude Cardio-respiratory - 1. Dyspnoea 2. Tachycardia 3. Murmurs 4. Palpitations 5. Angina Pectoris
  47. 47. Oral – 1. Sore mouth 2. Oral ulceration 3. Angular stomatitis 4. Glossitis 5. Burning mouth syndrome Cutaneous - 1. Pallor 2. Brittle Nails 3. Koilonychia
  48. 48. Iron deficiency anemia • Most common type of anemia • It Develops due to inadequate availibity for iron for hemoglobin synthesis . • Causes – 1. Loss of blood 2. Decreased intake or poor absorption of iron 3. Increased demand in conditions like growth and pregnancy
  49. 49. Clinical features PALLOR KOILONYCHIA ANGULAR CHEILITIS PAPILLARY ATROPHY OF TONGUE
  50. 50. Megaloblastic anemia • Megaloblastic anemia is due to deficiency of Maturation factor of RBC i.e. folic acid. • DNA synthesis is impaired so cells are megaloblastic but immature .
  51. 51. Oral manifestations 1. Atrophic glossitis 2. Patchy erythema 3. Taste alterations 4. Dysphagia 5. Burning mouth Atrophic glossitis
  52. 52. Pernicious anemia • Cause – • It occurs due to atrophy of gastric mucosa because of autoimmune destruction of parietal calls. • Hence , it leads to decreased production of intrinisic factor and poor absorption of vitamin B12 .( Maturation factor )
  53. 53. Oral manifestations 1. Atrophic glossitis 2. Patchy erythema 3. Taste alterations 4. Dysphagia 5. Burning mouth Atrophic glossitis
  54. 54. SICKLE CELL ANEMIA •It is a congenital anamaly occurs due to abnotmal Hb called Hb–S. •Molecules of Hb-S polymerize into long chains and precipitate inside the cell. •Hence RBCs attain “ Sickle” or “Crescent” shape & become more fragile leading to hemolysis
  55. 55. Hemolysis in Sickle cell anemia
  56. 56. Oral Manifestations Pallar of mucosa Delayed erruption of teeth
  57. 57. Other clinical features - Jaundice Hand & Foot syndrome
  58. 58. THALASSEMIA • It is also known as “Cooley’s anemia” . • It is caused by inherited anomalies of hemoglobin • It is of 2 types 1. α thalesemia 2. Β thalesemia
  59. 59. Clinical features 1. Saddled nose 2. Prominent malar bone 3. Retracted upper lip 4. Bimaxillary protrusion 5. Chipmunk facies
  60. 60. Radiographic feature HAIR ON END APPEARENCE
  61. 61. APLASTIC ANEMIA • Aplastic anemia is due to failure of red bone marrow . • Red bone marrow is replaced by fatty tissues • Causes – 1. Repeated exposure to X-rays & Gamma rays 2. Due to bacterial toxins , quinine , gold salts
  62. 62. Oral manifestations ORAL PETECHIAE GINGIVAL HYPERPLASIA
  63. 63. Blood Tests
  64. 64. Blood tests The routine blood tests are 1. Complete blood count I. RBC count II. Blood indices – PCV , MCV, MCH, MCHC 2. ESR 3. Blood smear 4. Retuculocyte count
  65. 65. ERYTHROCYTE SEDIMENTATION RATE • It is commonly used blood test and is also called as a sed rate or BIERNACKI’s REACTION. • Procedure – 1. Blood is mixed with an anticoagulant and allowed to stand on a vertical tube. 2. RBCs settle down due to gravity leaving supernatant layer of clear plasma above .And the rate at which RBCs settle down is called as ESR . • It is the length of clear supernatant plasma measured in mm at the end of 1 hr.
  66. 66. • Determination by 1. Westergreen’s Method 2. Wintrobe’ s Method • Normal Values of ESR – Westergreen's Method • Adult Males = 0 – 15 mm in 1 hr • Adult Females= 0 - 20 mm in 1 hr
  67. 67. • Variations of ESR Pathological - • ESR increases in - – All Anemias, except sickle cell anemia . • ESR decreases in - – Polycythemia – Sickle cell anemia
  68. 68. BLOOD INDICES • Importance – Help in diagnosis & typing of Anemias. • Different Blood Indices 1. Packed Cell Volume (PCV) 2. Mean Corpuscular Volume (MCV) 3. Mean Corpuscular Hemoglobin (MCH) 4. Mean Corpuscular Hemoglobin Concentration (MCHC)
  69. 69. PACKED CELL VOLUME • Also called as HEMATOCRIT value • It is the fraction of blood composed of RBC • Procedure- • Blood is mixed with anticoagulant & filled in wintrobe’s tube upto 100mm mark . • And tube is typically centrifuged at 3000 RPM for 30 minutes OR at 10,000 rpm for 1 minute
  70. 70. • NORMAL VALUES OF PCV – Males = 40 to 45%. Females = 38 to 42% • VARIATIONS IN PCV 1. PCV increases in - Polycythemia 2. PCV decreases in -All types of anemia.
  71. 71. HEMATOCRIT VALUES
  72. 72. MEAN CORPUSCULAR VOLUME (MCV) Average volume of a single red blood cell – Normal MCV = 85 - 90 μm3 . – VARIATIONS IN MCV- • Increases in (Macrocyte anemia ) - 1. Pernicious anemia 2. Megaloblastic anemia
  73. 73. • Decreases in (Microcyte anemia ) 1. Iron deficiency anemia 2. Chronic post-haemorrhagic anemia 3. Thalassemias
  74. 74. MEAN CORPUSCULAR HEMOGLOBIN (MCH) • Quantity or amount of Hb present in one RBC – Normal value of MCH is 30 pg (27 -32pg) –Increases or remains normal in 1. Pernicious anemia
  75. 75. • Decreases in (Hypochromic anemia). 1. Protein deficiency anemia 2. Megaloblastic anemia 3. Iron deficiency anemia 4. Thalassemia
  76. 76. MEAN CORPUSCULAR HEMOGLOBIN CONCENTRATION (MCHC) • It is the amont of Hb expressed in relation to volume of single RBC . • Normal value of MCHC is 30 % • Increases in (Macrocyte anemia ) - 1. Megaloblastic anemia
  77. 77. • Decreases in ( Microcyte anemia ) 1. Iron deficiency anemia 2. Chronic post-haemorrhagic anemia 3. Thalassemias
  78. 78. Peripheral blood smear (PBS) o A well prepared & correctly read smear gives vast amount of information of RBC morphology. o They are stained by polychromatic stain such as Wright’s stain o Variation in shape, size & Hb concentration & the presence of abnormal cells is noted
  79. 79. Management of anemia Oral Surgeon’s Perspective
  80. 80. Pre operative – When patient has to undergo surgery , following preoperative measures should be carried out. 1. Complete blood count with differential 2. Consultation with physician if lower values of Hb are obtained . (<10gm/dL ) 3. Severity of anemia & its correction should be evaluated before surgical intervention. 4. Possible blood tranfusions , if severe.
  81. 81. 5. Drugs that induce Hemolysis should be avoided. 6. Avoidance of elective surgical treatment in patients in “crisis” (sickle cell anemia) 7. Elimination of oral sources of infection should be done. 8. Administration of antibiotic prophylaxis , if necessary 9. GA should be administered only when Hb is 10 gm/dL or more . 10. Short appointments should be given and that too in the morning (Sickle cell anemia)
  82. 82. 11. Thorough oral examination of teeth , periodontium ,soft tissues should be conducted to correct the cause of infection .(Aplastic anemia ) 12. Oral rinses with chlorhexidene 0.2% in aquous solution will reduce the chances of infection.
  83. 83. Intra operative - 1. Gingival bleeding , if present , can be controlled with antifibrinolytic agents. 2. Intramuscular inj. and Nerve blocks should be avoided because of risk of bleeding. 3. Intraligamantary anesthesia can be used safely in extraction procedures .
  84. 84. 4. GA should be used in caution Mostly N2 O + O2 is safe to use. (Sickle cell anemia & vitamin B12 deficiency ). 5. Prevent dehydration using Normal saline I.V. during operation. Primary closure
  85. 85. Post operative - 1. Avoidance of drugs that can cause hemolysis in patients with hemolytic anemias 2. Oral hygiene techniques have to be done. 3. Recommendation of prophylactic antibiotics if poor wound healing 4. Prescribe Acetaminophen , codein , oxycodone as an analgesics because salicylates can induce acidosis.
  86. 86. Treatment of Anemia Physician’s perspective
  87. 87. Treatment of Anemia 1. Exclude the possibility of hemoglobinopathy 2. Correct any identified cause of blood loss 3. Give oral iron therapy 4. Correct identified vitamin deficiency with oral folic acid & Vit. B12 by injection. 5. Treat malaria with effective antimalarial drugs( in sickle cell anemia & thalessemia ) 6. If evidence of hemolysis, review the drug treatment, & stop the drugs if possible 7. Check if the patient is on marrow suppressing drugs and stop if possible
  88. 88. Polycythemia • It is a general term used for 1. Increased red blood cell count 2. Increased Hb level. Causes- 1. chronic hypoxia 2. smoking 3. fluid loss 4. hypertension & obesity
  89. 89. • Classified as 1. Primary polycythemia (Polycythemia vera) 2. Secondary Polycythemia
  90. 90. Signs & symptoms 1. Lassitude 2. Dyspnoea 3. Dizziness 4. Headache ,Body ache 5. Itching ,numbness, burning and weakness in hands, feet. Facial plethora • Urticaria
  91. 91. Oral manifestations Purplish mucosa Edematous gingiva
  92. 92. Treatment of Polycythemia 1. Oral surgical procedures in patients with polycythemia, should be avoided. 2. Patient should have CBC with differential before surgery. 3. If Hb levels are found increased , Physician’s concern should be taken and patient should undergo treatment for the same.
  93. 93. 1. Before performing surgery , threshold levels should be obtained .. a. Hb = < 16 g/ dL b. Hematocrit value = < 47% 2. Intraoperatively, patients require special attention to hemostasis. 3. If emergency surgery is required venesection is performed & blood is replaced with equal amount of colloid until a satisfactory hematocrit is reached.
  94. 94. Conclusion It is necessary for the oral surgeon to have knowledge about RBC related disorders . Because , it is mandatory to find the etiology of the RBC disorders by letting the patient undergo Blood tests or by consulting with General physician for medicinal treatments before performing any surgical procedure to prevent further complications during & after surgery .
  95. 95. References • Medical Physiology : 11th edition GYTON & HALL. • Davidson : General Medicine . • Burket’s Principle of medicine . • Articles- 1. Dental managemenotf idiopathic aplastic anemia: report of a case . 2. Managing the dental patient with sickle cell anemia: a review of the literature • Tuft university manual – Rx of Medically compromised patients
  96. 96. Thank you

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