Blood Simple

The human body contains 5 to 6 quarts of blood that run through the body from start to finish in approximately 20 to 30 seconds.¹ Composed of plasma, red blood cells (RBC), white blood cells (WBC), and platelets,^1-5 blood and its circulation perform numerous, essential functions such as providing oxygen and nutrients to tissues and carbon dioxide to the lungs; removing waste products from the kidneys; hormone transportation; and fighting infections.¹ Nine components form the essential make-up of blood (see Table 1). lood or hematologic disorders are complex medical problems that should be reviewed by dental health care professionals prior to treatment. Blood disorders are detected through laboratory testing. For further diagnosis, bone marrow is withdrawn to understand cell origination.¹ The eight categories of general blood disorders include: anemia, bleeding and clotting disorders, transfusion, leukemia, lymphomas, myeloproliferative disorders, plasma disorders, spleen disorders, and white blood cell disorders.¹

Symptoms

Symptoms are often vague and may be attributed to other disorders but the following are telltale signs: a decrease or increase of RBCs (increased anemia and decreased polycythemia); WBCs (increased leucopenia); blood platelets (increased thrombocytopenia); the production of immunerelated proteins (increased multiple myeloma); substance disorders responsible for insufficient blood clotting (excessive bruising, bleeding, or tiny purple/red spots on skin); or abnormal blood clot formations (increased warmth, painful areas in legs, shortness of breath, chest pain, or both).^1,3,4 DIAGNOSIS Blood tests can illustrate the functionality of blood itself. The most common test is the complete blood count test, which measures all cellular components of blood—RBCs, WBCs, and platelets. The complete blood count test identifies the amount of WBCs and platelets in the blood and the level of hemoglobin in the blood.

Four RBC concerns include:

1. The number of RBCs,
   
2. The amount of hemoglobin (the oxygen-carrying protein in RBC)
   
3. The average size of the RBCs, and
   
4. The degree of size variability or shape of the RBCs.

Microscopic evaluations identify the number and specific types of WBCs while platelet counts measure the protective mechanisms for clotting. High counts indicate potential blood clots in small vessels or excessive bleeding.¹ A physician uses the average size and degree of variability from the RBC evaluation to identify the abnormal cell problems associated with various anemias (deficiencies of iron, folic acid, Vitamin B12, etc). Microscopic evaluations identify the number and specific types of WBCs while platelet counts measure the protective mechanisms for clotting. High counts indicate potential blood clots in small vessels or excessive bleeding.¹ Further tests can also determine the reticulocyte count, which tells how many new RBCs are being produced in bone marrow; WBC problems, which signify the inability to fight infection; clotting tests, which determine the platelet number counts; prothrombin time, which determines the clot formation time for plasma coagulation defects; partial thromboplastin time, which determines the required time of clot formation in test plasma versus normal plasma; proteins and other substances, which determine the blood cell production of proteins in blood or urine; and blood typing, which is the evaluation of plasma and RBC for the presence of particular proteins on RBC surfaces with certain antibodies.^1,3

Anemia

Anemia is sometimes referred to as “tired blood” because it is caused by a reduced concentration of hemoglobin or lack of healthy RBCs providing oxygen to the tissues.^1,5 Not enough oxygen in the body’s tissues creates anemia. The three main causes of anemia are heavy loss of RBCs, blood loss, and low production of RBCs. The symptoms of mild anemia are sometimes not noticeable, but may include fatigue, weakness, and pallor. Severe anemia presents with faintness, dizziness, increased thirst, sweating, a weak rapid pulse, and fast breathing.6 Women and people with chronic diseases are at higher risk for anemia because they may experience blood loss or excessive bleeding (menses or gastrointestinal bleeding); reduced production of RBCs (iron deficiency, folic deficiency, or pernicious anemia); or increased destruction of RBCs (hypersplenism, autoimmune destruction).^{1- 8} Anemia is also a risk factor for chronic kidney disease, acute coronary syndrome, geriatrics, or adverse cardiovascular outcomes³ (see Table 2).

Bleeding and Clotting Disorders

Blood clotting or hemostasis is the body’s mechanism for stopping injured blood vessels from forming clots, which can cause serious health problems.^{1-5,7, 9-15} The three main processes of blood clotting include constriction of bleeding vessels, activity of platelets, and activity of blood clotting factors.¹ When the hemostasis system is not functioning correctly, excessive bleeding or clotting can occur. If clotting is not adequate, major blood loss can occur even from a slight injury to blood vessels. When too much clotting occurs, blood vessels can become blocked causing stroke, heart attack, or pulmonary embolism.¹ When blood vessels are damaged and begin excessive bleeding, they constrict in order to reduce the bleeding, while platelets group together to stick to the injured area. This process is called the von Willebrand factor, which creates the glue protein that adheres to the vessel wall, causing collagen and thrombin to plug the damaged area.^1,5,9 Platelets interact with blood proteins to create a fibrin formation, which entraps the platelet accumulations and other substances to form a blood clot (see Table 3).^1,9

Leukemia

Leukemia is caused by WBCs multiplying uncontrollably and becoming cancerous, involving the bone marrow and organs like the spleen and lymph nodes. Most leukemias can be treated and some cured.^1,4,5,7,16

Lymphomas

Lymphomas (see Table 5) are WBC cancers in the lymphatic system and blood forming organs. T or β lymphocytes are involved in regulating the immune system, fighting viral infections, and the production of antibodies. Cancerous locations include lymph nodes, bone marrow, spleen, or other organs.^1-5,18

Myeloproliferative Disorders

These disorders are characterized by the abnormal proliferation of blood producing cells in bone marrow or the forcing out of these cells by fibrous tissues. An overgrowth of noncancerous fibrous tissue in the bone marrow from blood-producing cells may lead to a cancerous condition (leukemia) in some individuals (see Table 6).^1,5,7,8,19

Plasma Cell Disorders

Plasma cell disorders (myelomas) cause an overproduction of one antibody clone, which leads to a higher risk of infections (see Table 7). With overproduction of plasma cells, various tissues and organs, particularly the kidney, are damaged from the antibodies produced. ^{1-5, 7,20} Heavy chain diseases are cancers of the plasma cells where a clone of plasma cells creates abnormal antibodies labeled “heavy chains.”

Spleen Disorders

The spleen is integral to the immune system. Those with a damaged or absent spleen are at risk of developing severe bacterial infections. The spleen has two basic parts: the white pulp that works as an infection fighting system and the red pulp that filters unwanted material in the blood. It may be surgically removed which reduces antibody production and the filtering of blood, impairing the body’s ability to fight infections (see Table 8).^1-4

White Blood Cell Disorders

Normal white blood cells in the bone marrow form two general groups and five subdivisions (granulocytes: neutrophils, eosinophils, and basophils, and agranulocytes: lymphocytes and monocytes) totaling between 4,000 and 11,000 cells per microliter. Disorder occurs when WBC levels fall below or above normal levels.^1,2,5 WBCs are key to fighting infection (see Table 9).

Put Into Practice

General treatment for all patients in the dental office should include a thorough medical history review. When a blood disorder is indicated, the patient should be asked for details and his or her physician/ hematologist should be contacted to learn if any of the planned dental treatment needs to be amended.⁵ Specific questions for patients may include:

1. Do patients have relatives with bleeding problems?²
2. Have they experienced excessive bleeding following surgical procedures or following trauma?
   
3. Do they have coagulation problems when using pain prevention drugs?
   
4. Have they experienced spontaneous bleeding?³

For patients who will be undergoing chemotherapy/radiation, home care education should be stressed since patients will experience decreased immunities. Patients with blood disorders should be encouraged to maintain excellent personal oral health and frequent dental appointments⁵ as healthy tissues reduce the possibility of infections, bleeding, and other potential problems. An ultrasoft toothbrush or power toothbrush with soft bristles should be recommended to cleanse. Flossing and antibacterial mouthrinses are also indicated to reduce infection.^6,21 Undergoing radiation of the head and neck may cause xerostomia, mucositis, and rampant caries so a daily home fluoride treatment should be advised along with remedies for dry mouth.²¹ Patients with blood disorders and those taking anticoagulants should not take aspirin or nonsteroidal anti-inflammatory drugs for pain relief.³ Blood disorders entail a vast arena of medical information to consider for care. A consultation with the patient’s physician will help you provide the most effective and safe dental care to this group of patients.

References

1. Fenkel EP. Blood disorders. Merck Manual Home Edition. Available at www.mercdk.com/mmhe/sec14/ch169/ch169a.html. Accessed July 13, 2007.
2. Crowley L. The hematopoietic and lymphatic systems. In: Crowley L, ed. An Introduction to Human Disease, Pathology and Pathophysiology Correlations. 6th ed. Sudbury, Mass: Jones and Bartlett Publishers; 2004:347-373.
3. Little JW, Falace DA, Miller CS, Rhodus, NL. Bleeding disorders, disorders of red and white blood cells. In: Little JW, Miller C, Rhodus NL, Falace D, eds. Dental management of the Medically Compromised Patient. 6th ed. St. Louis: Mosby; 2002:332-416.
4. Damjanov I. The hematopoietic and lymphoid systems. In: Damajanov I, ed. Pathology for the Health-related Professions. 2nd ed. Philadelphia: W.B. Saunders Co; 2000:209-239.
5. Wilkins EM. The patient with a blood disorder. Clinical Practice of the Dental Hygienist. 9th ed. Philadelphia: Lippincott, Williams & Wilkins; 2005:1057-1071.
6. The Merck Manual Online Edition. Anemia. Available at: www.merck.com/mmhe/sec14/ch172/ch172a.html. Accessed August 18, 2008.
7. Tamparo CD, Lewis MA. Anemias and other red blood cell disorders, leukemias, lymphatic diseases. Diseases of the Human Body. 3rd ed. Philadelphia: F.A. Davis Co; 2000:202-217.
8. MayoClinic.com. Diseases and conditions; Anemia. Available at www.mayoclinic.com/health/anemia/DS00321/DSECTION=8. Accessed July 17, 2007.
9. University of Virginia. Hematology and Blood Disorders—Bleeding/Clotting Disorders. Available at www.healthsystem.virginia.edu/uvahealth/adult_ blood bleeddis.cfin. Accessed July 17, 2007.
10. National Hemophilia Foundation. What is a bleeding disorder? Available at www.hemophilia.org/NHFWeb/MainPgs/MainNHF.asp?menuid=26&contentid=5&r ptname=bleeding. Accessed July 17, 2007.
11. University of Virginia. Hematology and Blood disorders—Hemophilia. Available at www.healthsystem.virginia.edu/uvahealth/adult_blood/hemophi.cfin. Accessed July 17, 2007.
12. University of Virginia. Hematology and Blood Disorders—Idiopathic Thrombocytompenic Purpura. Available at www.healthsystem.virginia.edu/uvahealth/adult_blood/itp.cfin. Accessed July 17, 2007.
13. University of Virginia, Hematology and Blood Disorders—Thrombosis Disorders. Available at www.health system.virginia.edu/uvahealth/adult_blood/thrombo.cfin. Accessed July 17, 2007.
14. United States Department of Health and Human Services. Bleeding Disorders. Available at www.4woman.gov/faq/bleed.htm. Accessed July 17, 2007.
15. United States Food and Drug Administration, Department of Health and Human Services. FDA approves new product to treat Von Willbrand Disease. Availabe at: www.fda.gov/bbs/topics/NEWS/2007/NEW01553.html. Accessed July 18, 2007.
16. Leukemia and Lymphoma Society. Leukemia. Available at: www.leukemia-lymphoma.org/all_page?item_id=7026. Accessed July 17, 2007.
17. Acute Lymphocytic Leukemia (ALL). Available at: www.merck.com/mmhe/sec14/ch176/ch176b.html. Accessed August 18, 2008.
18. Leukemia and Lymphoma Society, Lymphoma. Available at: www.leukemialymphoma.org/all_page?item_id=7030. Accessed July 17, 2007.
19. Leukemia and Lymphoma Society. Myleproliferative disorders. Available at: www.leukemia-lymphoma.org/all_page?item_id=311829. Accessed July 17, 2007.
20. Leukemia and Lymphoma Society, Myeloma. Available at: www.leukemialymphoma.org/all_page?item_id=7032. Accessed July 17, 2007.
21. Kimbrough VJ, Henderson K. Special needs population. In: Oral Health Education. Upper Saddle River, NJ: Pearson Prentice Hall; 2006:75-77.

From Dimensions of Dental Hygiene. September 2008; 6(9):40-43.