Card Set Information
S5 pt 1
What 3 categories of disease cause anemia?
1. blood loss
2. RBC production
3. destroy RBC
What are tests for anemia?
: low 40's (lower for females)
What are 3 classes of anemia?
: loss/decrease prod
: Fe (hypochrom)
: (B12, folate)
What are the intraoral signs of anemia?
red, sore, smooth tongue(atrophy papillae)
esophageal webs and dysphagia
What are therapies for microcytic anemia?
Fe replacement: ferrous sulfate(uncomplicated, 3-8weeks), deferoxamine(chelating, acute)
What enzyme converts homocysteine to methionine?
hydroxocobalamin to methylcobalamin
What enzyme is necessary for folates role in DNA synthesis?
DHF reductase (DHF->THF) (di->tetra)
What is diff in clinical presentations of B12 and folic acid def?
: pallor, anemia, fatigue, glossitis
: neuro (myelin synthesis)
Exposure to what compound results in megaloblastic anemia?
NO: inhibit methionine synthase
What are the causes of folic acid deficiency?
malabsorption, overcooking, maternal, hepatic(alcohol)
: phenytoin, oral contraceptives, antimalarials
DHF reductase inhibitors(cancer, autoimmune)
: methotrexate, trimethoprim
leucovorin counteracts DHF reductase inhibitors
What are the classes of antithrombic drugs?
: warfarin(coumadin), pradaxa, heparin (thrombin inhibitor)
: aspirin, clopidogrel, dipyridamole
3. thrombolytic (fibrinolytic):
What is the difference between low and high conc of heparin?
: accelerate antithrombin III (1000x) inactivating 9,10,12
: hep/antithrIII binds thrombin itself
all parenteral admin
What is the heparin antagonist?
What are the indirect anitcoags?
inibit reduction of Vit K (necessary for gamma carboxylation of 2,7,9,10)
: antimicrobials, barbituates (inc met), NSAIA (sensitize)
what does vit K do?
cofactor in gamma carboxylation of glutamic acid residues of clotting factors 2,7,9,10
What drugs are platelet inhibitors?
: (cyclooxygenase)TXA2 inhibitor
: ADP receptor antagonist (no agg)
: vasodilation, PDEase inhib->inc CAMP, less agg
What are fibronolytic drugs?
: lyses fibrin, degrades factors 5,8
: t-PA (3 hour window) adheres fibrin, absorbs and cleaves plasminogen
: activates circualting plasminogen
: (exotoxin) binds and kinda activates plasminogen
: streptokinase & acylated plasminogen
: MI, pulm emb, DVT
How long should pt on aspirin or coumarin stop b4 procedure?
: 5 days, start 1 day after
: INR (international normalized ratio) 2.5 (5 bad, 1 avg)
: 6 hours or reverse w protamine, restart after clot formed
Which blood disorder pts are of particular concern for dentist?
: drug, chemo, cyclic neutropenia
lekemias & lymphomas
: dysfunctional WBC
What are important lab values to asses hematologic status?
: infection (osteomyleitis after extractions, antibiotic prohy)
What precautions should be done for pt on chemo?
done befor chemo/radio
CHX, antifungal rinses
treat during intervals
early after diagnosis
What does aPTT assess?
partial thromboplastin time (30+-5 seconds)
: 1,2,5,8,9,10,11,12 (8 most imp)
What test is used to assess LMWH levels?
What are thrombophila causes?
def of protein C, S or antithrombin
: inflammation (TF)
Consequences of DIC?
: depleted factors, platelets
: organ failure (infarcs)
What does PT assess?
: 13 secs+-1
: 1,2,5, 7*, 10
: international normalized ratio = pt PT/mean lab PT adj w/ international sensitivity
Describe platelet ranges.
<5,000 GI or cerebral hemmorhage
<20,000 spontaneous bleeding
>50,000 needed for surgical hemostasis
life span 10 days
What is bleeding time evaluate?
qualitative platelet function & vascular integrity
40mm Hg BP cuff and incision blotted every 30 secs
5 min +- 2 (longer 9.5 if aspirin)
What is PFA-100?
main test: platelet ability to aggregate to collagen-epi & collagen-ADP
What is are other qualitative platelet tests?
: agg w/ ADP, collagen, Arachidonic acid, or EPI
: bind fibrinogen
Heriditary coagulation disorders?
v, VIII def
Protein C def
antithrombin III def
: TF, cell lysis
: endothelial damage, hypotension/stasis shock
Acquired coag disorders?
Vit K def
drug-induced hemmorhage, platelet
idiopathic or thrombotic thrombocytopenic purpura
vWF is carrier for Factor VIII (inc half life and conc)
low plasma vWF released from endothelium and platelets
types (I, IIA, IIB, III)
bleeding persists (usually diagnosed via dental)
: desmopressin (DDAVP)
: viral factor VIII-vWF, cryoprecipitate(disease tx), antifibronlytics
no aspirin/NSAIDS, acetomenophin& opiods OK
coagulation adjuncts should be available
What are some antifibrinolytics?
plasminogen activator inhibitors
rinses of tranexamic acid
Is aspirin a dental procedure concern?
not really, NEVER stop for pts w/ Coronary artery stents
How many half lifes will NSAIDS be cleared?
4: 94% clearance
What are plavix(clopidogrel) and prasugrel(effient) dental concerns?
less bleeding problems than aspirin
do not D/C
never for stents
if D/C need 6 days
X linked recessive (males only, female carriers)
: (VIII def) 80%
: (IX def) 15%
early hemostasis may bleed late
watch out for Deep IM injections (IAN)
: replace factors & antifibrinolytics, no aspirin/NSAIDs
For hemophilia what levels of VIII do you need for dental surgery?
80-100% for major oral
use advate or cryoprecipitate
What does coumadin do?
: competitive antagonist of vit K (epoxide reductase) 2, 7, 9, 10
: DVT, post pulm emb, A-fib, Post MI/CVA, prosthetic valves
asses PT/INR usually ok <3
What are the aids to coagulation?
: geleini, collagin, collagen-like
What should acetaminophen be limited to for pts on coumadin?
What are the dental concerns for heparin and LMWH?
won't typically see hep
: against Xa (enoxaparin) DVT, pulmonary embolus
delay dental tx if possiible, consult MD
useful as bridge D/C coumadin and start lovenox
NHL is what % of new cancers?
6th most common cause cancer death
What are the mechanisms of lymphomagensis?
: (H. pylori, Chlamydia psittaci, EBV(burkitts), HTLVI (Tcell) HTLV-V (cutaneous T-cell), Hep C
: wiskott-aldrich, organ, AIDS, age
Clincal behavior classifications of lymphoma?
: indolent, incurable, years life expectancy (CLL,hairy cell)
: very aggressive, potentially curable, weeks life expectancy (ALL, burkitts)
Clinical features of lymphomas?
lymphadenopathy (may fluctuate), cytopenia, hepatosplenomegaly, fever, night swears, weight loss
What is a waldeyer's ring a sign of?
What does a biopsy for NHL evaluate?
morphology and nodal architecture
: reveal monoclonal
What are important chromosomes involved with NHL?
bcl-2 (14,18 trans follicular lymphoma)
cyclin D1 (mantle cell)
What is counterintuitive about indolent lymphoma treatement?
stage III (both sides diaphragm) and IV(marrow) are highly curable
wait til symptomatic to treat
What is the most common indolent lymphoma?
follicular (bcl-2 absent) germinal center B-Cell
translocation (14,18) fuses bcl-2 and IgH constitutively expressed
What is rituximab?
immunotherapy- monoclonal CD20 (B-cells) Ab
Does immediate treatement prolong survival of Follicular cell lymphoma?
What is Diffuse large B-cell lymphoma(DLBCL)?
most common aggressive lymphoma
usually symptomatic, extranodal, germinal center B-cell
rapidly enlarging mass(nodal)
What is the treatment course for DLBCL?
What is Burkitt's lymphoma?
abdominal, rapidly growing mass/tumor
c-myc oncogene linked with Ig genes
What is hodgkin's disease?
highly curable, not as common, Reed-Sternberg cells(giant B cells (popcorn), some w/EBV genomes)
more common for rich, young(>50 bimodal)
Pel-Ebstein fever(relapsing high-grade)
painful to drink alcohol
: cervical->mediastinum or axilla
: ABVD, BEACOPP
: adriamycin, bleomycin, vinblastine, dacarbazine
sensitive to Radiation
What is a thick buffy coat a sign of?
too many WBCs and platelets
neoplastic, unregulated accumulation or proliferation of WBCs
: cell line, maturatation, chronic, acute
What are the granulocytes?
BEN, baso, eosin, neutro
What are the agranulocytes?
active tyrosine kinase
anemic symtpoms (splenomegaly)
all stages of myeloid(B,E,N), giant platelets
low leukocyte alkaline phosphotase
high B12 binding
What is philadelphia chromosome?
abnormal 9-22 translocation
BCR-ABL on 22 w always active tyrosine kinase
What are CML treatments?
marrow transplants, chemo
no tx for blast crises
What are features of acute leukemias?
generally unknown causes
block of maturation, many immature blasts
blasts in periphery, inc buffy coat, pancytopenia (mature) hypercellular, monotonous marrow
AML increase w/age, ALL decrease then increase
anemia, thrombo, neutorpenia
3-6 months survival
translocation are favorable
diploid, -Y is most common (intermediate prognosis)
Which leukemia presents w gum hyperplasia?
induction: cleared but could come back, follow w/ consolidation or transplant
M3- acute promyelocytic
DIC (from granules release)
t(15,17) 90% treatable w/ vitamins
What are the features of ALL?
most common of children (peak 3-4 yr old)
adults usually relapse
marrow and blood lymphoblasts
70% cureable in children(chemoradiation)
: big no cytoplasm
: large w/more cytoplasm
: burkitts, big w/ vacuoles
What are oral complications of acute leukemias?
leukemic infiltration-> gum hyperplasia
: moncytic leukemias
: chemo, radiation, neutropenia
: abcess, herpes, candida
: peticea, gingival
graft vs host
: mucostis, infection, secondary tumors
small mature lymphocytes in blood
hypercellullar marrow w mature small lymphocytes
treat only if symptomatic
Painless lymph nodes
proliferating neoplastic PLASMA cells (crowds out other cells->pancytopenia)
clonal and produce monoclona Abs (found in blood and urine)
proliferate in marrow and cause skeletal destruction (radiolucent xrays)
Rouleaux formation of RBCs (stuck in rows)
excess bleeding light chains
Multiple myeloma tx?
Which marker indicates stem cells?
What is usually the most histocompatible relative?
What endothelial secretions inhibit platelet aggrigation?
what is the catalyst of fibrinogen?
Describe the intrinsic pathway.
12, 11, 9 (8) 10, V (prothrombin), 1 fibrinogen 13
all factors in blood
: damaged surface
What sets off the extrinsic pathway?
tissue factor from fibroblast membranes (trauma)
initiatesclotting transient because VIIa is inhibited
What factor is typically used to speed clottiing?
what does thrombin do?
cleave thrombin receptor (activates platelets)
cleave V adn VIII
limit by cleaving Va and VIIIa
what else do platelets do?
release growth factors that facilitate healing
what are the natural clotting limiters?
thombomodulin (protein C & S) hydolize Va, VIIIa
antithrombin & 2a and 10a & heparin- antithrombin inactive protease complex
Role of vit k?
2,7,9, 10, C, S
glutamate residues (gamma carboxylation)
coumadin (oral) (K blocker)
what is a tPA drug name?
What are D-dimes?
biproducts of plasmin breakdown of clots
What are some embryological milestones of hematopoiesis?
: yolk sac stem cells
: migrate to liver (some in spleen, lymphoid dev in nodes and thymus
: migrate to bone marrow (func after 7 mo)
: cord blood w/hematopoietic stem cells
2 wks postpartum
: hematopoiesis shifts to marrow
What hormone controls RBC production?
: kidney, O2
: Fe, B12, Folate
normal bone marrow
proerythroblast->basophilic eb->polychromatic eb-> normoblast
What is a reticulocyte?
immature RBC, no nucleus, reticular(mesh) rRNA (methylene blue)
What is the protein of the cytoskeleton of RBC?
What are normal lab ranges for erythron for males and females?
name, male, female (lower numbers)
: 4.4-5.9, 3.8-5.2
: 13-18, 12-16
: 40-52, 35-47
: 0.5-1.5%, 0.025-0.105/mm3
What are the normal ranges of RBC indices?
: avg volume 80-100
MCHC= avg Hg/volume 31-36
: avg weight 27-34
What are the presentations of iron deficiency anemia?
most common (cause chronic blood loss, menorrhagia, intesinal)
Fe absorbed in duodenum (malabsorbtion sprue, celiac)
: transport protein
no active Fe excretion
ferritin(best indicator) & hemosiderrin
: storage protein
dimple is 1/2 cell when should be 1/3rd
: desire to eat nonedible
What is pica?
desire to eat non-edible, consequence of Fe def anemia
What are oral presentations of anemia?
atrophic mucositis of upper aero-digestive tract
What are the causes of anemia of chronic disease?
: TB, osteomyelitis
: rheumatoid arthritis, regional enteritis
: lymphoma, carcinoma
All increase IL which inhibit rls of Fe from stores and decrease erythropoeitin response
What are the causes of megaloblastic anemia?
B12 and folic acid deficiency
req for DNA synth, delay nuclear maturation w respect to cytoplamic elements
(hypercelluar) megaloblasts in marrow, macrocytic RBC & hypersegmented neutrophils in blood
What is the function of folic acid?
C1 fragment tranfer
: deoxyurdilate+ c1 frag--> thymidilate
What causes folic acid deficiency?
diet, alcohol, metabolic needs, drugs (anticonvulsants, antimicrobials, methotrexate)
: celiac, sprue
What is the function of B12?
cofactor in thymidilate synthesis, cofactor in methylmalonyl CoA to Succinyl CoA
What is required to absorb B12?
: cofactor of gastric parietal cells)
receptor in terminal ilial
: transport protein
What is pernicious anemia?
deficient(autoimmune) intrinsic factor (B12)
What are some causes of B12 deficiency?
pernicious, malabosbtion, competition (tapeworm), diverticulosis
rarely dietary or hereditary
poikilocytes & megoblastc marrow
Describe the classifications of hemolysis.
: intrinsic deficient
What are the byproducts of hemoglobin after hemolysis?
: transerrin back to bone marrow
: indirect, unconjugated bilirubin
: digested to AA