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ANAEMIA
General aspects
Anaemia is defined as an Hb level below the
norm for the age, gender and ethnic background
of the individual and may be due to:
insufficient red blood cell (RBC) numbers or Hb
content.
Up to puberty, an Hb level below 11.0 g/dL is
the hallmark of anaemia;
the corresponding figure in :
adult females is below 11.5 g/dL, and
in adult males below 13.5 g/dL.
The effect of anaemia is to lower the oxygencarrying capacity of the blood.
Microcytic anaemia
is the most common and is usually
due:
to iron deficiency, or
occasionally to thalassaemia or
chronic diseases.
The mean corpuscular (cell) volume
(MCV) falls below 78 fl.
Macrocytic anaemia
is caused usually by:
vitamin B12 or folate deficiency (not
infrequently in alcoholics); sometimes
by the consumption of folate and vitamin B12 in
chronic haemolysis, pregnancy or malignancy;
and sometimes by drugs
(methotrexate,prazathioprine, cytosine or
hydroxycarbamide).
Macrocytic anaemia may also be caused by liver
disease, myxoedema or, sometimes, aplastic
anaemia.
MCV more than 99 fl.
Elective operations
under GA should not usually be carried out when the Hb is less
than
10 g/dL (male).
Blood
transfusions should be used only when absolutely necessary, if the Hb
concentration has fallen below 7 g/dL, since they may carry the risk of
infection, circulatory overload and allergic reactions.
DEFICIENCY ANAEMIAS
Iron-deficiency anaemia
Vitamin B12 (cobalamin)
deficiency
Folate (folic acid)
deficiency
HAEMOLYTIC ANAEMIAS
Iron-deficiency anaemia
Dental aspects
LA is satisfactory for pain control.
Atrophic glossitis soreness of the
tongue with depapillation or colour
change.
PatersonBrown-Kelly (Plummer
Vinson) syndrome.
Angular stomatitis.
Aphthous-like ulceration.
Staining of the teeth by iron.
Some iron preparations can cause tooth
erosion, as can chewable vitamin C.
Treatment
The cause of the iron deficiency
must be sought and treated.
The best treatment for iron
deficiency is an iron salt such as:
ferrous sulfate 200 mg three
times daily orally, which is better
absorbed than ferric salts.
Ferrous gluconate 250 mg/day
can be given if ferrous sulfate is
not tolerated.
General management
The diagnosis of B12 deficiency
depends on the clinical findings
and low serum B12 levels, together
with autoantibodies against gastric
parietal cells and/or intrinsic factor.
If the patient consumes adequate
vitamin B12 but has clinically
confirmed B12 deficiency,
malabsorption must be present.
Dental aspects
LA is satisfactory.
A physically normal but sore or burning tongue can
be caused by early vitamin B12 deficiency, often
with normal Hb levels.
It is important for these patients to undergo
haematological examination.
As Deficiency of vitamin B12 develops slowly since
liver stores last up to 3 years.
In addition to the usual signs and symptoms of
anaemia, neurological symptoms particularly
paraesthesiae of the extremities develop in about
10%. Early signs include loss of toe positional sense
and diminished perception of the vibration of a
tuning fork. These early neurological changes are
reversible with treatment.
Dental aspects
LA is satisfactory for pain control.
Soreness of the tongue without depapillation
or colour change can be caused by early
deficiencies, often with normal Hb levels.
Atrophic glossitis is the best-known effect of
severe anaemia.
Angular stomatitis is also a well-known sign
but affects only a minority.
Aphthous stomatitis is sometimes.
HAEMOLYTIC ANAEMIAS
General aspects:
Haemolytic anaemia may result from:
inherited abnormalities of Hb formation (the
haemoglobinopathies);
inherited abnormalities of erythrocyte structure or
function (spherocytosis; glucose-6-phosphate
dehydrogenase [G6PD] deficiency); or
from damage to erythrocytes (autoimmune,
druginduced or infective).
Worldwide, malaria is the most common
cause.
Dental aspects
The main principles in patients with sickle cell
disease are to prevent:
trauma, infection, hypoxia, acidosis or dehydration,
all of which can precipitate a crisis.
Infections must be treated early.
Painful crises should be treated promptly with
analgesics, such as diamorphine or pethidine, and
hydration.
Patients with sickle cell anaemia are treated with
hydroxycarbamide (hydroxyurea), which raises the
levels of HbF and iron-chelating agents
(desferrioxamine, deferasirox or deferiprone).
The thalassaemias
Thalassaemias are autosomally dominant
inherited disorders in which either alphaor beta-globin chains are synthesized at a
low rate,
thereby lessening the production of HbA.
Cause excessive erythrocyte fragility and
haemolysis .
Thalassaemias are characterized by a
hypochromic microcytic anaemia.
thalassaemia major
Clinical features Homozygotes for
thalassaemia major suffer from
chronic anaemia, marrow
hyperplasia, skeletal deformities,
splenomegaly, cirrhosis, gallstones
and iron overload.
thalassaemia minor
Heterozygous beta-thalassaemia
(thalassaemia minor or thalassaemia
trait) is common and usually
asymptomatic, except for mild
hypochromic anaemia. Anaemia may
be aggravated by pregnancy or
intercurrent illness.
General management:
Diagnosis of beta-thalassaemia is
confirmed by finding severe
microcytic hypochromic anaemia with
gross aniso- and poikilocytosis,
normal or raised serum iron and
ferritin, and normal TIBC.
There is a great increase in HbF and
some increase in HbA2.
The main treatment measures in betathalassaemia are blood transfusions,
Dental aspects
Hepatitis B or C, or HIV carriage, may be a complication
in repeatedly transfused patients.
Since splenectomy results in an immune defect, it may
be prudent to cover surgical procedures with
prophylactic antimicrobials.
LA is safe.
CS may be given with oxygen levels not less than 30%.
GA induction may be complicated by enlargement of
the maxilla, which may cause difficulties in intubation,
but in any event,
the chronic severe anaemia and often cardiomyopathy
are contraindications.