ESR & PCV
Public Health Significance
Previous year questions
• RBC - red cells / red blood corpuscles / haematids / erythroid
cells / erythrocytes.
• Derived from Greek erythros for "red" and kytos for "hollow
vessel", with -cyte translated as "cell" in modern usage.
• Non-nucleated formed elements in the blood.
• It lacks cytoplasmic organelles such as nucleolus, mitochondria
• The red color of RBC is due to the presence of Hemoglobin
5. HISTORICAL BACKGROUND
• JAN SWAMMERDAM-1658 - Dutch biologist and
microscopist. He called them ruddy globules
• ANTON VAN LEEUWENHOEK-1674- Discovered
Microscope and established its size.
• OTTO FUNKE 1851 - German physiologist was the first
scientist to successfully crystallize hemoglobin. "Blutfarbstoff"
• DR. MAX PERUTZ- 1959 - by use of X-ray crystallography
unravelled the structure of hemoglobin
• MENGHINI-1747- presence of iron in the blood, identified the
red corpuscles as the chief site of iron within the organism.
8. Advantages of Biconcave Shape of RBCs:
• Greater surface area for exchange of gases.
• Flexibilty of RBC
• Minimal tension when the volume of cell alters.
How is the shape maintained?
- a contractile protein
- maintains shape and flexibility of RBC
- Antigen on cell membrane – helps in blood group classification
9. NORMAL COUNT
• Adults males: 4.5 – 6 million cu mm of blood
• Adult females: 4 – 5.5 million cu mm of blood
• At birth: 6.7 million cu mm of blood
• 62.5% water
• 35% Hemoglobin
• 2.5% :
- Sugar – glucose
- Lipids – Cephalin, Cholesterol & Lecithin
- Protein – Glutathion : insoluble protein which acts as a
reducing agent and prevents damage of hemoglobin
- Enzymes – Carbonic anhydrase and catalase
- Ions – Na+, K+, Ca2+, PO4
12. FRAGILITY AND HEMOLYSIS
• Hemolysis- Breakdown of RBC and liberation of hemoglobin.
• Fragility- Susceptibility of RBC to hemolysis or tendency to
• There are 2 types:
1. Osmotic fragility- due to exposure to hypotonic saline.
2. Mechanical fragility- due to mechanical trauma
Physiologic causes of increase count:
• High altitude
Decrease in count: High barometric pressure, Pregnancy, sleep
15. VARIATIONS IN SHAPE
• Crenation: Shrinkage as in hypertonic solutions.
• Spherocytosis: Globular form as in hypotonic conditions.
• Elliptocytosis: elliptical shape
• Sickle cell: Crescent shape
• Poikilocytosis: Flask, hammer or any other unusual shape.
16. VARIATIONS IN SIZE
• Physiological conditions: RBC in venous blood slightly larger
than those in arterial blood.
• Pathological conditions:
1. Microcytes – smaller cells
2. Macrocytes – larger cells
3. Anisocytes – cells of different sizes
17. LIFESPAN AND FATE OF RBC
• Lifespan – 120 days
• Site of destruction:
• The process of origin, development and maturation of
Site of erythropoiesis:
• In fetal life: - Mesoblastic stage
- Hepatic stage
- Myeloid stage
• In newborns, children and adults
19. FIGURE 10.1: Stem cells. L = Lymphocyte, R = Red blood cell, N = Neutrophil, B = Basophil,
E = Eosinophil, M = Monocyte, P = Platelet.
21. • Factors necessary for erythropoiesis:
1. General factors:
2. Maturation factors:
-Vitamin B12 (Cyanocobalamin)
-Intrinsic factor of Castle
• Hb is the iron containing coloring pigment of RBC.
• 95% dry weight of RBC; 30 – 34% wet weight.
• Molecular weight of Hb is 68,000
• Normal value:
-At birth: 25g/dl
-From puberty: 14-16 g/dl
-Adult males: 15g/dl
-Adult females: 14.5g/dl
23. STRUCTURE OF HEMOGLOBIN
• Conjugated protein
• Protein part called Globin and iron containing pigment called
• Heme part is called porphyrin
and is formed by 4 pyrole rings
• Globin is made up of 4
polypeptide chains – 2 alpha and
2 beta chains.
25. ERYTHROCYTE SEDIMENTATION RATE
• Red cells have the property of Rouleaux (piling one on the other)
• Piled red cells are heavier than the individual ones.
• The rate at which the red cells fall is known as ESR.
• Normal values:
Wintrobe’s method: Males: 0 – 9mm/hr
Females: 0 – 20mm/hr
Westergren’s method: Males: 3 – 7mm/hr
Females: 5 – 9 mm/hr
27. Westergren’s method:
• Westergren’s tube is used which is 300 mm long & opened at
both the ends.
• It requires collecting 2 ml of venous blood into a tube
containing 0 .5 ml of sodium citrate. It should be stored no
longer than 2 hours at room temperature
or 6 hours at 4 °C. The blood is drawn into
the tube to the 200 mm mark. The tube is
placed in a rack in a strictly vertical position
for 1 hour at room temperature,
28. Wintrobe’s method:
• The Wintrobe method is performed similarly except that the
Wintrobe tube is smaller in diameter than the Westergren tube
and only 100 mm long.
• EDTA anticoagulated blood without extra diluent
is drawn into the tube, and the rate of fall of red
blood cells is measured in millimeters after 1 hour.
29. PACKED CELL VOLUME
• Hematocrit is the fractional volume of blood that the
• It is a reliable index of red cell population.
• Normal values : Males – 46%
Females – 42%
30. RBC INDICES
• MCV (MEAN CORPUSCULAR VOLUME)
– The average volume of single RBC
PCV per 100ml blood
MCV = 10um3
RBC count (million/cu mm)
Normal range : 78 – 94 um3
RBC with normal volume are called Normocytes
RBC with less then normal volume, Microcytes
RBC with more than normal volume, Macrocytes
31. • MCH (mean corpuscular hemoglobin)
– The average content of Hb in average RBC.
Hb in gm%
MCH = 10pg
RBC count (million/cu mm)
• Normal range: 28 – 32pg
32. • MCHC (mean corpuscular hemoglobin concentration)
– Express the average concentration of hemoglobin per unit
volume of RBC.
– It defined as the ratio of the weight of hemoglobin to
volume of RBC.
Hb in gm%
MCHC = 100
PCV per 100ml blood
Normal range: 33 – 38 gm/100ml of cells
33. DISORDERS OF RBC
• Anemia is defined as Hb concentration in blood below the
lower limit of the normal range for the age and sex of the
• In adults, the lower extreme of normal Hb is taken as 13g/dl
for males and 11.5g/dl for females.
35. MORPHOLOGICAL CLASSIFICATION
• Depends upon the size and color of RBC.
• Size of RBC is determined by mean corpuscular volume
• Color is determined by mean corpuscular hemoglobin
• By this method, the anemia is classified into four types
37. ETIOLOGICAL CLASSIFICATION
• On the basis of etiology, anemia is divided into five types:
1. Hemorrhagic anemia
2. Hemolytic anemia
3. Nutrition deficiency anemia
4. Aplastic anemia
5. Anemia of chronic diseases.
38. IRON DEFICIENCY ANEMIA
• Iron deficiency anemia is the most common type of anemia.
• It develops due to inadequate availability of iron for
• RBCs are microcytic and hypochromic.
39. • Causes of iron deficiency anemia:
i. Loss of blood
ii. Decreased intake of iron
iii. Poor absorption of iron from intestine
iv. Increased demand for iron in conditions like growth and
• Features of iron deficiency anemia:
1. Brittle nails,
2. Spoon shaped nails (koilonychias),
3. Brittle hair,
4. Atrophy of papilla in tongue
5. Dysphagia (difficulty in swallowing).
40. Oral manifestations:
• Pallor of mucosa
• Atrophy of oral mucosa
• Tongue changes – redness, soreness or burning sensation.
Papillae of the anterior two thirds undergo atrophy.
• Angular cheilitis
• Slow healing
• Clinical – Koilonychia, angular cheilitis, depapillation of
• Lab diagnosis – Hb level as low as 4g/100ml. MCV, MCH &
MCHC all are reduced. RBC count slightly reduced or normal.
• Iron supplement: oral ferrous fumerate or ferrous sulphate
300mg three to four times a day for a period of 6 months
• Parenteral route : single dose of iron sorbitol 1.5mg/kg body
42. Oral Health Considerations:
• For dental patients with extremely low Hb levels- physician
• When Hb is less than 8g/dl, GA should be avoided
• Narcotic use should be limited for those with sever anemia as
there is increased rick of ischemic heart disease.
43. PLUMMER VINSON SYNDROME
• Patterson Brown Kelly syndrome / Sideropenic dysphagia
• Characterized by iron deficiency anemia, dysphagia and
esophageal webs or strictures.
• Middle aged women- 4th to 7th decade of life
• Dysphagia, angular cheilitis, sore tongue.
• Patient complains of spasm in throat or food sticking in throat.
• Spoon shaped nails.
45. SICKLE CELL ANEMIA
• First described by Herrick in 1910.
• Severe genetic disorder of hemoglobin synthesis.
• Autosomal dominant
• Abnormal hemoglobin, which under low oxygen tension,
results in sickling of the cell.
• In this, α-chains are normal and β-chains are abnormal.
• Newborn screening is an important starting point for simple
public health strategies such as parental education, penicillin
prophylaxis, immunization and utilization of prenatal testing.
• The HbS solubility test (Sickledex) can be performed in 5mins
for screening of adult hemoglobinopathies.
• Prenatal testing by DNA analysis of amniotic fluid at 14 to 16
weeks can be done to find out alterations and mutations in
47. Clinical Features:
Periods of latency interrupted by periods of acute crisis.
Known sequelae include:
Acute chest syndrome
Chronic leg ulcers
48. Oral Manifestations:
• Enamel hypomineralization
• Increased overjet and overbite
• Calcified canals
• Pallor of oral mucosa and delayed eruption of teeth.
• SCA is not associated with increased levels of gingivitis or
*Periodontal Disease in Sickle Cell Disease Subjects by John M. Crawford. Journal of
Periodontology. March 1988, Vol. 59, No. 3, Pages 164-169
• Regular monitoring of hematological state
• Blood transfusion – cerebrovascular symptoms in early
childhood , recurrent pulmonary thrombosis
• Mild to moderate anemia - Blood transfusion
• Risk of HIV and HEPATITIS infection – transfused patient
• Painful crisis – analgesics
• Incidence of hypoxia and dehydration should be avoided
50. Dental management
• Dental treatment - Directed towards palliative therapy during
• Preventive dental care – antiseptic mouth rinses , topical fluoride
• Antibiotic prophylaxis – penicillin is the drug of choice
• Odontogenic and nonodontogenic infection should be
• Periodontal status - closely monitored
• Thalassemia is an inherited disorder, characterized by
• It is also known as Cooley’s anemia or Mediterranean
• It is more common in Thailand and to some extent in
• Thalassemia is of two types:
52. • In normal hemoglobin, number of α and β polypeptide chains is
• In thalassemia, the production of these chains become
imbalanced because of defective synthesis of globin genes.
• This causes the precipitation of the polypeptide chains in the
immature RBCs, leading to disturbance in erythropoiesis.
• α -thalassemia occurs in fetal life or infancy.
• In this α-chains are less, absent or abnormal.
• In adults, β-chains are in excess and in children, γ-chains are
• This leads to defective erythropoiesis and hemolysis.
• The infants may be stillborn or may die immediately after
• More common type of thalassemia.
• In β-thalassemia, β-chains are less in number, absent or
abnormal with an excess of α-chains.
• Severity ranges from complete lack of symptoms to
• Cooley’s anemia, or thalassemia major is the name for the
most severe form.
55. Oral Manifestations:
• Excessive overgrowth of maxilla
• Oral mucosa has a lemon yellow tint because of chronic
jaundice – hard palate and floor of the mouth.
• Chipmunk facies- Saddle nose, prominent malar bone, retracted
• Poor healing
• Spacing between teeth
• Discoloration of dentin
56. General management
• Blood transfusion
• Iron chelating agents – desferroxamine
• Folic acid supplements
• Splenectomy – severe cases
57. Dental management
• Poor wound healing after any surgical procedure
• Surgery has been used successfully to treat the facial
• HIV and HEPATITIS infections are common in transfused
• Prophylactic antibiotics in splenectomy cases
58. MEGALOBLASTIC (PERNICIOUS) ANEMIA &
VIT B12 (COBALAMIN) ANEMIA
• Occurs due to deficiency of Vit B12 or folic acid or both,
resulting in disordered cell proliferation.
Clinical Features & Oral Manifestations:
• Weakness, anemia, palpitations, diarrhoea
• Paresthesia of finger, toes & also dementia may be observed.
• Burning sensation of tongue, angular cheilitis
• Hunter’s glossitis: Atrophy of filiform and fungiform papillae
leading to smooth fiery red surface of tongue
• Blood tranfusion: when Hb level is less than 4g/dl of blood
• Folic acid supplements:
initial dose - 5 mg orally daily
maintenance dose - 5 mg orally once a week
• Vit B12 therapy:
Initial dose – 1000 mcg , intramuscularly 4 to 6 wks
Maintenance dose – 1000 mcg intramuscularly once every
61. APLASTIC ANEMIA
• A rare disorder characterized by peripheral blood pancytopenia
associated with bone marrow suppression.
• Occurs due to failure of haematopoietic precursor cells in bone
marrow to produce adequate number of all blood cell types.
62. Clinical Features:
• Commonly seen in young adults
• Erythrocyte deficiency: Headaches, pale skin, breathlessness
• Thrombocyte deficiency: Bruising & bleeding. Cerebral
• Leukocyte deficiency: Bacterial and fungal infections are
• Ankle edema, anginal pain, congestive cardiac failure
• Supportive therapy: Antibiotics & transfusion
• Bone marrow transplantation
• Stimulation of haemopoiesis and promote marrow recovery
Androgenic steroids - oxymetholone
Corticosteroids –Prednisolone or methyl prednisolone
Antithymocyte or antilymphocyte globulin combined with
• Abnormal increase in the number of RBCs in the peripheral
blood, usually with increase in Hb level.
o Polycythemia Vera
o Relative Polycythemia
o Secondary Polycythemia
65. POLYCYTHEMIA VERA
• Polycythemia rubra vera / Osler’s disease / Erythremia /
• Uncontrolled proliferation of erythroid stem cells leading to
excess of erythroid cell mass in the body.
• Male predilection – Middle age
• Skin appears flushed, reddened
• Spleen is palpable
66. • Tip of the finger has cyanotic appearance.
• Erythromealgia: Burning sensation with erythema and warmth
in hand and feet.
• Dizziness and blackouts
• Purplish red discoloration
• Swollen bleeding gingiva
• Venesection: done at periodic intervals to remove 500-600ml
of blood. Also called Phlebotomy.
• Radioactive phosphorus: Excellent treatment modality when
the diagnosis is certain.
• Aspirin – given for thrombotic event
68. PUBLIC HEALTH SCENARIO
• Globally, anaemia affects 1.62 billion people, which corresponds
to 24.8% of the population.
• The highest prevalence is in preschool-age children (47.4%), and
the lowest prevalence is in men (12.7%).
• However, the population group with the greatest number of
individuals affected is pregnant women (41.8%).
• In women, anaemia may become the underlying cause of
maternal mortality and perinatal mortality.
69. • Nearly 50 per cent of women of reproductive age and 26 per cent
of men in the age group of 15-59 years are anemic.
• Nine out of ten anemia sufferers live in developing countries,
about 2 billion people suffer from anemia and an even larger
number of people present iron deficiency.
70. Anemia in India
• Infants, Pre-school Children, Adolescents and Women of
Childbearing age, particularly Pregnant Women, are at greatest risk
of developing Iron Deficiency Anaemia.
• The condition has a prevalence rate of 74 percent among pregnant
women in the region ranging from 13.4 percent in Thailand to 87
percent in India.
• According to the NFHS-(III), more than half of women in India
(55%) have anaemia, including 39 % with mild anemia, 15 % with
moderate anemia and 2 percent with severe anaemia.
71. • The survey further revealed that among the states, Assam is the
worst affected with 72% of married women being anaemic,
followed by Haryana (69.7%) and Jharkhand (68.4%).
*Anaemia ‘a silent killer’ among women in India: Present scenario Kawaljit Kaur . Euro J
Zool Res, 2014, 3 (1):32-36
72. Various health programmes:
• The National Nutritional Anemia Prophylaxis Programme
(NNAPP) was launched in 1972 during the 4th five year plan in
India with the aim to curb the prevalence of anemia.
• One of the largest nutritional supplement programmes, the
Integrated Child Development Services (ICDS) scheme was
initiated in 1975 in India to provide nutritious food to pregnant
women and children.
73. • Further, in 1991, the Government of India introduced policies to
control nutritional anemia through promotion of iron rich food
(green leafy vegetables: mustard leaves, bengal gram leaves,
clocasia leaves etc., shepu or sowa, cereals: wheats, ragi, jawar,,
pulses: sprouted pulses, and jaggery), provision of iron and folate
supplements to high risk groups (all pregnant and lactating
women, Intra-Uterine Device (IUD) users, and children between
1-5 years), and identification and treatment to severely anemic
74. • National Rural Health Mission (NRHM), 2005, undertakes
programme once in a month in villages to educate mothers on
health and nutrition.
• In spite of the fact that the Health and Family Welfare
Department in India has policies to provide iron supplement to
pregnant women to prevent maternal anemia, evaluation from
large scale programmes shows that maternal anemia has not
75. • Some plausible reasons are the side effects of the iron pills and
also improper utilization of health service and personal beliefs
(Fox, 1983; Galloway and Mcguire, 1994).
• Prevalence of Iron-Deficiency Anaemia in India: Results from a Large Nationwide
Survey by Ramesh Chellan. Lopamudra Paul. JOURNAL OF POPULATION AND
SOCIAL STUDIES Volume 19 Number 1 July 2010
• Red blood cells play an important role in our health by
carrying fresh oxygen throughout the body.
• Hemoglobin is the protein inside red blood cells that carries
• Most people don't think about their red blood cells unless they
have a disease that affects these cells. Problems with red blood
cells can be caused by illnesses or a lack of iron or vitamins in
the diet. Some diseases of the red blood cells are inherited.
77. • Anemia is the most common disorder of the blood with it
affecting about a quarter of people globally.
• Anemia goes undetected in many people, and symptoms can be
minor or vague.
• Appropriate dental care improves a patient’s quality of life by
preventing eating difficulties, oral diseases, and esthetic
concerns, and facilitates the management of the disease by the
78. • Preventive dental care is must for patients with blood cell
disorders of any kind in combinations with appropriate lab
investigations and diagnosis before planning of any treatment.
• Essentials of medical physiology by Dr.Sembulingam.
• Medical physiology for dental students by Dr G K Pal
• Essential Pathology for dental students by Harsh Mohan 3rd
• Text book of Oral Medicine Ghom 2nd edn
• Human physiology for B.D.S by Prof. A K Jain 3rd edn
• Burket’s Oral Medicine by Greenberg . Glick . Ship . 11th edn
80. PREVIOUS YEAR QUESTIONS
• RBC (10mks)
(MDS Degree examinations March 1994, 2000)
• RBC Morphology & Functions (10mks)
(MDS Degree examination April/May 07 & 2010)
• Iron deficiency anemia (10mks)
(MDS Degree examination Sept 2007)