1. 1 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Chapter 9 Oral Manifestations of Systemic Diseases

2. 2 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Outline Outline Endocrine Disorders Endocrine Disorders Blood Disorders Blood Disorders Immunodeficiency Immunodeficiency Oral Manifestations of Therapy for Oral Cancer Oral Manifestations of Therapy for Oral Cancer Effects of Drugs on the Oral Cavity Effects of Drugs on the Oral Cavity Oral Manifestations of Systemic Diseases Oral Manifestations of Systemic Diseases

3. 3 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Systemic Diseases (pg. 288) (pg. 288) Many systemic diseases are reflected in the oral mucosa, maxilla, and mandible. Many systemic diseases are reflected in the oral mucosa, maxilla, and mandible. Mucosal changes may include ulceration or mucosal bleeding. Mucosal changes may include ulceration or mucosal bleeding. Immunodeficiency can lead to opportunistic diseases such as infection and neoplasia. Immunodeficiency can lead to opportunistic diseases such as infection and neoplasia. Bone disease can affect the maxilla and mandible. Bone disease can affect the maxilla and mandible. Systemic disease can cause dental and periodontal changes. Systemic disease can cause dental and periodontal changes. Drugs prescribed for a systemic disease can affect oral tissue. Drugs prescribed for a systemic disease can affect oral tissue.

4. 4 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Systemic Diseases (cont.) Local factors may be involved in the manifestation of systemic disease in oral mucosa. Local factors may be involved in the manifestation of systemic disease in oral mucosa. The mucosa may be more easily injured due to a systemic disease, and mild irritation and chronic inflammation may cause lesions that otherwise would not occur. The mucosa may be more easily injured due to a systemic disease, and mild irritation and chronic inflammation may cause lesions that otherwise would not occur. These may include These may include Endocrine disorders, disorders of red and white blood cells, disorders of platelets and other bleeding and clotting disorders, and immunodeficiency disorders Endocrine disorders, disorders of red and white blood cells, disorders of platelets and other bleeding and clotting disorders, and immunodeficiency disorders

5. 5 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Endocrine Disorders Hyperpituitarism Hyperpituitarism Hyperthyroidism Hyperthyroidism Hypothyroidism Hypothyroidism Hyperparathyroidism Hyperparathyroidism Diabetes Mellitus Diabetes Mellitus Addison Disease Addison Disease

6. 6 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Endocrine Disorders (pg. 288) (pg. 288) The endocrine system consists of a group of integrated glands and cells that secrete hormones. The endocrine system consists of a group of integrated glands and cells that secrete hormones. The secretion is controlled by feedback mechanisms. The secretion is controlled by feedback mechanisms. The amount of hormone circulating in blood triggers factors that control production. The amount of hormone circulating in blood triggers factors that control production. Diseases may result from conditions where too much or too little hormone is produced. Diseases may result from conditions where too much or too little hormone is produced.

7. 7 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hyperpituitarism (pgs. 288-289) (pgs. 288-289) Excess hormone production by the anterior pituitary gland Excess hormone production by the anterior pituitary gland Caused most often by a benign tumor (pituitary adenoma) that produces growth hormone Caused most often by a benign tumor (pituitary adenoma) that produces growth hormone Giantism results if it occurs before the closure of long bones. Giantism results if it occurs before the closure of long bones. Acromegaly results when hypersecretion occurs during adult life. Acromegaly results when hypersecretion occurs during adult life.

8. 8 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Hyperpituitarism (pgs. 288-289) (pgs. 288-289) Affects both men and women, most commonly during the fourth decade of life Affects both men and women, most commonly during the fourth decade of life Patients experience poor vision, light sensitivity, enlargement of hands and feet, and an increase in rib size. Patients experience poor vision, light sensitivity, enlargement of hands and feet, and an increase in rib size. Facial changes Facial changes Enlargement of maxilla and mandible may cause separation of teeth and malocclusion. Enlargement of maxilla and mandible may cause separation of teeth and malocclusion. Frontal bossing and an enlargement of nasal bones may lead to deepening of voice. Frontal bossing and an enlargement of nasal bones may lead to deepening of voice. Mucosal changes Mucosal changes May have thickened lips and macroglossia May have thickened lips and macroglossia

9. 9 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Hyperpituitarism (cont.)

10. 10 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Hyperpituitarism Diagnosis involves measurement of growth hormone. Diagnosis involves measurement of growth hormone. Treatment often includes pituitary gland surgery. Treatment often includes pituitary gland surgery.

11. 11 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hyperthyroidism (Thyrotoxicosis) (pg. 289) (pg. 289) Excess production of thyroid hormone Excess production of thyroid hormone More common in women than men More common in women than men The most common cause is Graves disease The most common cause is Graves disease Graves disease Graves disease Appears to be due to an autoimmune disorder in which a substance is produced that abnormally stimulates the thyroid gland Appears to be due to an autoimmune disorder in which a substance is produced that abnormally stimulates the thyroid gland Other causes include hyperplasia of the gland, benign and malignant tumors of the thyroid, pituitary gland disease, and metastatic tumors. Other causes include hyperplasia of the gland, benign and malignant tumors of the thyroid, pituitary gland disease, and metastatic tumors.

12. 12 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Hyperthyroidism Rosy complexion, erythema of the palms, excessive sweating, fine hair, softened nails Rosy complexion, erythema of the palms, excessive sweating, fine hair, softened nails The patient may have exophthalmos. The patient may have exophthalmos. Anxiety, weakness, restlessness, and cardiac problems may also be associated. Anxiety, weakness, restlessness, and cardiac problems may also be associated.

13. 13 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Hyperthyroidism May lead to premature exfoliation of deciduous teeth in children and premature eruption of permanent teeth May lead to premature exfoliation of deciduous teeth in children and premature eruption of permanent teeth Osteoporosis may affect alveolar bone. Osteoporosis may affect alveolar bone. Caries and periodontal disease may appear and develop more rapidly in these patients. Caries and periodontal disease may appear and develop more rapidly in these patients. Burning tongue also has been reported. Burning tongue also has been reported.

14. 14 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment of Hyperthyroidism May include surgery, medications to suppress thyroid activity, or administration of radioactive iodine May include surgery, medications to suppress thyroid activity, or administration of radioactive iodine

15. 15 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hypothyroidism (pg. 289) (pg. 289) A decreased output of thyroid hormone A decreased output of thyroid hormone Causes include developmental disturbances, autoimmune disease, iodine deficiency, drugs, and pituitary disease Causes include developmental disturbances, autoimmune disease, iodine deficiency, drugs, and pituitary disease Cretinism Cretinism When it occurs in infancy and childhood When it occurs in infancy and childhood Myxedema Myxedema When it occurs in older children and adults When it occurs in older children and adults

16. 16 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hypothyroidism (cont.) Oral manifestations Oral manifestations In infants In infants Thickened lips, enlarged tongue, and delayed eruption of teeth Thickened lips, enlarged tongue, and delayed eruption of teeth In adults In adults Enlarged tongue Enlarged tongue

17. 17 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hyperparathyroidism (pgs. 289-290) (pgs. 289-290) Due to excessive secretion of parathyroid hormone from the parathyroid glands Due to excessive secretion of parathyroid hormone from the parathyroid glands The four parathyroid glands are located near the thyroid gland. The four parathyroid glands are located near the thyroid gland. Parathyroid hormone plays a role in calcium and phosphorous metabolism. Parathyroid hormone plays a role in calcium and phosphorous metabolism. Hyperparathyroidism is characterized by elevated blood levels of calcium (hypercalcemia) and low levels of blood phosphorous (hypophosphatemia). Hyperparathyroidism is characterized by elevated blood levels of calcium (hypercalcemia) and low levels of blood phosphorous (hypophosphatemia).

18. 18 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hyperparathyroidism (cont.)

19. 19 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hyperparathyroidism (cont.) May be the result of hyperplasia of parathyroid glands, a benign tumor of one or more parathyroid glands, or a malignant parathyroid tumor May be the result of hyperplasia of parathyroid glands, a benign tumor of one or more parathyroid glands, or a malignant parathyroid tumor Found in middle-aged adults Found in middle-aged adults Much more common in women than men Much more common in women than men Parathyroid hormone increases the uptake of dietary calcium from the gastrointestinal tract and is able to move calcium from bone to circulating blood when necessary. Parathyroid hormone increases the uptake of dietary calcium from the gastrointestinal tract and is able to move calcium from bone to circulating blood when necessary.

20. 20 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Hyperparathyroidism Mild cases may be asymptomatic, or may have joint pain or stiffness. Mild cases may be asymptomatic, or may have joint pain or stiffness. Lethargy and coma may occur with severe disease. Lethargy and coma may occur with severe disease.

21. 21 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Hyperparathyroidism Well-defined unilocular or multilocular radiolucencies Well-defined unilocular or multilocular radiolucencies Microscopically, they appear to be CGCG (central giant cell granulomas). Microscopically, they appear to be CGCG (central giant cell granulomas). Bone may have a mottled appearance. Bone may have a mottled appearance.

22. 22 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Hyperparathyroidism Measurement of parathyroid hormone blood levels Measurement of parathyroid hormone blood levels May include serum calcium and phosphorous measurements May include serum calcium and phosphorous measurements Treatment is directed at correcting the cause of increased hormone production. Treatment is directed at correcting the cause of increased hormone production. Causes may include tumors, renal disease, and vitamin D deficiency. Causes may include tumors, renal disease, and vitamin D deficiency.

23. 23 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diabetes Mellitus (pgs. 290-294) (pgs. 290-294) A chronic disorder of carbohydrate metabolism characterized by abnormally high blood glucose levels A chronic disorder of carbohydrate metabolism characterized by abnormally high blood glucose levels These result from a lack of insulin, defective insulin that does not work to lower blood glucose levels, or increased insulin resistance due to obesity. These result from a lack of insulin, defective insulin that does not work to lower blood glucose levels, or increased insulin resistance due to obesity.

24. 24 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diabetes Mellitus (cont.)

25. 25 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diabetes Mellitus (cont.) Glucose normally signals beta cells of the pancreas to make insulin. Glucose normally signals beta cells of the pancreas to make insulin. The hormone is then secreted into the bloodstream to facilitate the uptake of glucose into fat and skeletal muscle. The hormone is then secreted into the bloodstream to facilitate the uptake of glucose into fat and skeletal muscle. In the presence of insulin, fat and skeletal muscle cells can use glucose as an energy source. In the presence of insulin, fat and skeletal muscle cells can use glucose as an energy source.

26. 26 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diabetes Mellitus (cont.) Without insulin, tissue is broken down to provide energy and weight loss occurs. Without insulin, tissue is broken down to provide energy and weight loss occurs. A severe hyperglycemia can lead to diabetic coma. A severe hyperglycemia can lead to diabetic coma. Ketone can be produced by the breakdown of fatty acids. Ketone can be produced by the breakdown of fatty acids. Ketoacidosis lowers the pH of blood. Ketoacidosis lowers the pH of blood. Phagocytic activity of macrophages is reduced and neutrophil chemotaxis is delayed. Phagocytic activity of macrophages is reduced and neutrophil chemotaxis is delayed. Collagen production is abnormal. Collagen production is abnormal.

27. 27 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Types of Diabetes Insulin-dependent diabetes mellitus Insulin-dependent diabetes mellitus Type 1 Type 1 Non–insulin-dependent diabetes mellitus Non–insulin-dependent diabetes mellitus Type 2 Type 2

28. 28 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Insulin-Dependent Diabetes Mellitus (pgs. 291-292) (pgs. 291-292) Thought to be an autoimmune disease Thought to be an autoimmune disease Insulin-producing cells of the pancreas are destroyed. Insulin-producing cells of the pancreas are destroyed. 3% to 5% of all diabetic patients have this type. 3% to 5% of all diabetic patients have this type. Can occur at any age, the peak is at 20 Can occur at any age, the peak is at 20 Acute onset with polydipsia (excessive thirst and intake of fluid), polyuria (excessive urination), and polyphagia (excessive appetite) Acute onset with polydipsia (excessive thirst and intake of fluid), polyuria (excessive urination), and polyphagia (excessive appetite)

29. 29 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Insulin-Dependent Diabetes Mellitus (cont.) These patients will require insulin their entire lives. These patients will require insulin their entire lives. The current approach to management of these patients involves multiple insulin injections and proper diet, exercise, and frequent determination of blood glucose levels. The current approach to management of these patients involves multiple insulin injections and proper diet, exercise, and frequent determination of blood glucose levels. But multiple injections of insulin can more readily lead to low blood sugar (hypoglycemia) and insulin shock (severe hypoglycemia). But multiple injections of insulin can more readily lead to low blood sugar (hypoglycemia) and insulin shock (severe hypoglycemia).

30. 30 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Insulin-Dependent Diabetes Mellitus (cont.) New methods of treatment New methods of treatment Nasal spray rather than injection Nasal spray rather than injection Insulin pump Insulin pump A backup may be necessary in case the pump fails A backup may be necessary in case the pump fails Low insulin can lead to ketoacidosis, resulting in nausea, abdominal cramps, disorientation, and fatigue Low insulin can lead to ketoacidosis, resulting in nausea, abdominal cramps, disorientation, and fatigue

31. 31 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Non–Insulin-Dependent Diabetes Mellitus (pgs. 292-294) (pgs. 292-294) Characterized by insulin resistance Characterized by insulin resistance 95% of all diabetic patients have this type of diabetes. 95% of all diabetic patients have this type of diabetes. Usually occurs in patients 35 to 40 years of age or older Usually occurs in patients 35 to 40 years of age or older Many of these individuals are obese Many of these individuals are obese Obesity probably decreases the number of receptors for insulin binding in sensitive tissues like fat or muscle. Obesity probably decreases the number of receptors for insulin binding in sensitive tissues like fat or muscle. Diet and weight reduction may control it in some individuals; others require oral hypoglycemic agents. Diet and weight reduction may control it in some individuals; others require oral hypoglycemic agents.

32. 32 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Non–Insulin- Dependent Diabetes Mellitus (pg. 293) (pg. 293) Atherosclerosis, a thickening of the blood vessel wall from fibrofatty plaques, can lead to impaired circulation, causing impaired oxygenation and nutrition in tissue. Atherosclerosis, a thickening of the blood vessel wall from fibrofatty plaques, can lead to impaired circulation, causing impaired oxygenation and nutrition in tissue. This increases the risk of ulceration and gangrene of the feet, high blood pressure, kidney failure, and stroke. This increases the risk of ulceration and gangrene of the feet, high blood pressure, kidney failure, and stroke. Diabetic retinopathy in the eye can lead to blindness. Diabetic retinopathy in the eye can lead to blindness. The nervous system may be affected. The nervous system may be affected. The person may have decreased resistance to infection. The person may have decreased resistance to infection.

33. 33 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Non–Insulin- Dependent Diabetes Mellitus (cont.)

34. 34 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Complications of Non–Insulin- Dependent Diabetes Mellitus (pgs. 293-294) (pgs. 293-294) Patients may have an increased prevalence of oral candidiasis. Patients may have an increased prevalence of oral candidiasis. Mucormycosis, a rare oral fungal infection that affects the palate and maxillary sinuses, may be seen in uncontrolled or poorly controlled diabetes. Mucormycosis, a rare oral fungal infection that affects the palate and maxillary sinuses, may be seen in uncontrolled or poorly controlled diabetes. Bilateral asymptomatic parotid gland enlargement may occur. Bilateral asymptomatic parotid gland enlargement may occur. Xerostomia may be associated with uncontrolled diabetes mellitus. Xerostomia may be associated with uncontrolled diabetes mellitus. Patients may have an accentuated response to plaque. Patients may have an accentuated response to plaque. Patients may have slow wound healing and increased susceptibility to infection. Patients may have slow wound healing and increased susceptibility to infection.

35. 35 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Complications of Non–Insulin- Dependent Diabetes Mellitus (cont.)

36. 36 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Addison Disease (pg. 294) (pg. 294) Primary adrenal cortical insufficiency Primary adrenal cortical insufficiency In most cases, the cause of destruction of the adrenal gland is unknown – it may be an autoimmune disease. In most cases, the cause of destruction of the adrenal gland is unknown – it may be an autoimmune disease. It may be due to a tumor or tuberculosis. It may be due to a tumor or tuberculosis. To compensate, the pituitary gland increases production of ACTH. To compensate, the pituitary gland increases production of ACTH.

37. 37 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Addison Disease (cont.) Clinical features Clinical features This hormone causes stimulation of melanocytes. This hormone causes stimulation of melanocytes. Bronzing of the skin may occur, as well as melanotic macules on oral mucosa. Bronzing of the skin may occur, as well as melanotic macules on oral mucosa. Treatment Treatment Steroid replacement therapy Steroid replacement therapy

38. 38 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Blood Disorders Disorders of Red Blood Cells and Hemoglobin Disorders of Red Blood Cells and Hemoglobin Disorders of White Blood Cells Disorders of White Blood Cells Bleeding Disorders Bleeding Disorders

39. 39 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Blood Disorders (cont.) (pg. 294) (Box 9-1) (pg. 294) (Box 9-1) The complete blood count examines red blood cells, white blood cells, and platelets. The complete blood count examines red blood cells, white blood cells, and platelets. It provides information about the number of each type of cell, the ratio of types, and the appearance of the cells. It provides information about the number of each type of cell, the ratio of types, and the appearance of the cells.

40. 40 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Disorders of Red Blood Cells and Hemoglobin Anemia Anemia Iron Deficiency Anemia Iron Deficiency Anemia Pernicious Anemia Pernicious Anemia Folic Acid and Vitamin B 12 Deficiency Anemia Folic Acid and Vitamin B 12 Deficiency Anemia Thalassemia Thalassemia Sickle Cell Anemia Sickle Cell Anemia Celiac Sprue Celiac Sprue Aplastic Anemia Aplastic Anemia Polycythemia Polycythemia

41. 41 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Anemia (pgs. 294-295) (pgs. 294-295) A reduction in the oxygen-carrying capacity of blood A reduction in the oxygen-carrying capacity of blood Most often related to a decrease in the number of circulating red blood cells Most often related to a decrease in the number of circulating red blood cells Nutritional anemias Nutritional anemias A deficiency in a substance required for the normal development of red blood cells, commonly vitamins A deficiency in a substance required for the normal development of red blood cells, commonly vitamins Suppression of bone marrow stem cells Suppression of bone marrow stem cells

42. 42 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Anemia (cont.) Clinical features Clinical features Pallor of skin and oral mucosa Pallor of skin and oral mucosa Angular cheilitis Angular cheilitis Erythema and atrophy of oral mucosa Erythema and atrophy of oral mucosa Loss of filiform and fungiform papillae on the dorsum of the tongue Loss of filiform and fungiform papillae on the dorsum of the tongue

43. 43 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Iron Deficiency Anemia (pg. 295) (pg. 295) An insufficient amount of iron is supplied to bone marrow for red blood cell development. An insufficient amount of iron is supplied to bone marrow for red blood cell development. May occur as a result of deficient iron intake, blood loss from heavy menstrual bleeding or chronic gastrointestinal bleeding, poor iron absorption, or an increased requirement for iron in situations such as pregnancy or infancy May occur as a result of deficient iron intake, blood loss from heavy menstrual bleeding or chronic gastrointestinal bleeding, poor iron absorption, or an increased requirement for iron in situations such as pregnancy or infancy Plummer-Vinson syndrome may result from long standing iron deficiency anemia. Plummer-Vinson syndrome may result from long standing iron deficiency anemia. Includes dysphagia, atrophy of the upper alimentary tract, and a predisposition to developing oral cancer Includes dysphagia, atrophy of the upper alimentary tract, and a predisposition to developing oral cancer

44. 44 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Iron Deficiency Anemia (pg. 295) (pg. 295) Often asymptomatic, may have nonspecific symptoms such as weakness and fatigue Often asymptomatic, may have nonspecific symptoms such as weakness and fatigue In severe cases may see angular cheilitis, pallor of oral tissue, and an erythematous, smooth, painful tongue In severe cases may see angular cheilitis, pallor of oral tissue, and an erythematous, smooth, painful tongue

45. 45 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Iron Deficiency Anemia (cont.)

46. 46 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Iron Deficiency Anemia Laboratory tests show a low hemoglobin content and reduced hematocrit. Laboratory tests show a low hemoglobin content and reduced hematocrit. Red blood cells appear smaller than normal (microcytic) and light in color (hypochromic) Red blood cells appear smaller than normal (microcytic) and light in color (hypochromic) Treatment Treatment Dietary supplements Dietary supplements

47. 47 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Pernicious Anemia (pgs. 295-296) (pgs. 295-296) Probably an autoimmune disorder in most situations Probably an autoimmune disorder in most situations May be caused by removal of the stomach, gastric cancer, or gastritis May be caused by removal of the stomach, gastric cancer, or gastritis Caused by a deficiency in intrinsic factor Caused by a deficiency in intrinsic factor Intrinsic factor is secreted by parietal cells in the stomach; it is necessary for absorption of vitamin B 12 Intrinsic factor is secreted by parietal cells in the stomach; it is necessary for absorption of vitamin B 12

48. 48 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Pernicious Anemia (pgs. 295-296) (pgs. 295-296) Weakness, pallor, and fatigue on exertion Weakness, pallor, and fatigue on exertion May see nausea, dizziness, diarrhea, abdominal pain, loss of appetite, and weight loss May see nausea, dizziness, diarrhea, abdominal pain, loss of appetite, and weight loss Angular cheilitis, mucosal pallor, painful atrophic and erythematous mucosa, mucosal ulceration, loss of papillae on the dorsum of the tongue, and burning and painful tongue Angular cheilitis, mucosal pallor, painful atrophic and erythematous mucosa, mucosal ulceration, loss of papillae on the dorsum of the tongue, and burning and painful tongue

49. 49 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Pernicious Anemia (cont.)

50. 50 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Pernicious Anemia Laboratory tests reveal low serum B 12 levels and gastric achlorhydria (lack of hydrochloric acid) Laboratory tests reveal low serum B 12 levels and gastric achlorhydria (lack of hydrochloric acid) Red blood cells have megaloblastic anemia. Red blood cells have megaloblastic anemia. Abnormally large and immature megaloblasts with nuclei Abnormally large and immature megaloblasts with nuclei The Schilling test detects an inability to absorb oral vitamin B 12 The Schilling test detects an inability to absorb oral vitamin B 12 Treatment Treatment Injections of vitamin B 12 Injections of vitamin B 12

51. 51 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Folic Acid and Vitamin B 12 Deficiency Anemia (pg. 296) (pg. 296) From dietary deficiencies From dietary deficiencies Can occur in association with malnutrition Can occur in association with malnutrition May be found with alcoholism or pregnancy May be found with alcoholism or pregnancy

52. 52 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Folic Acid and Vitamin B 12 Deficiency Anemia Oral manifestations are indistinguishable from those of pernicious anemia. Oral manifestations are indistinguishable from those of pernicious anemia.

53. 53 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Folic Acid and Vitamin B 12 Deficiency Anemia Based upon laboratory tests – serum assays of folic acid and vitamin B 12 Based upon laboratory tests – serum assays of folic acid and vitamin B 12

54. 54 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Thalassemia (Mediterranean or Cooley Anemia) (pg. 296) (pg. 296) A group of inherited disorders of hemoglobin synthesis A group of inherited disorders of hemoglobin synthesis An autosomal dominant inheritance pattern An autosomal dominant inheritance pattern The heterozygous form may be mildly symptomatic or asymptomatic. The heterozygous form may be mildly symptomatic or asymptomatic. The homozygous form is associated with severe hemolytic anemia. The homozygous form is associated with severe hemolytic anemia.

55. 55 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Thalassemia (pg. 296) (pg. 296) Yellow skin pallor, fever, malaise, and weakness Yellow skin pallor, fever, malaise, and weakness The face includes prominent cheekbones, depression of the bridge of the nose, a prominent maxilla, and protrusion or flaring of maxillary anterior teeth. The face includes prominent cheekbones, depression of the bridge of the nose, a prominent maxilla, and protrusion or flaring of maxillary anterior teeth. Radiographs may show a salt and pepper pattern. Radiographs may show a salt and pepper pattern. Some trabeculae are prominent, and others are blurred. Some trabeculae are prominent, and others are blurred.

56. 56 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Treatment of Thalassemia Experimental Experimental May include blood transfusions and splenectomy May include blood transfusions and splenectomy Poor prognosis Poor prognosis

57. 57 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Sickle Cell Anemia (pg. 297) (pg. 297) An inherited blood disorder An inherited blood disorder When someone is heterozygous, it is called sickle cell trait. When someone is heterozygous, it is called sickle cell trait. When someone is homozygous, they are much more severely affected. When someone is homozygous, they are much more severely affected. Occurs before age 30 and is more common in women than in men Occurs before age 30 and is more common in women than in men The red blood cells develop a sickle shape when there is decreased oxygen. The red blood cells develop a sickle shape when there is decreased oxygen. This can be triggered by exercise, exertion, administration of a general anesthetic, pregnancy, or even sleep. This can be triggered by exercise, exertion, administration of a general anesthetic, pregnancy, or even sleep.

58. 58 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Sickle Cell Anemia (pg. 297) (pg. 297) The person has weakness, shortness of breath, fatigue, joint pain, and nausea. The person has weakness, shortness of breath, fatigue, joint pain, and nausea. Radiographic Radiographic There is a loss of trabeculation, and large, irregular marrow spaces appear. There is a loss of trabeculation, and large, irregular marrow spaces appear. A hair-on-end pattern may be seen in the skull. A hair-on-end pattern may be seen in the skull.

59. 59 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Sickle Cell Anemia (cont.)

60. 60 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Sickle Cell Anemia (pg. 297) (pg. 297) The sickle-shaped cells may be seen on a blood smear. The sickle-shaped cells may be seen on a blood smear. The number of red blood cells is usually low, as is the hemoglobin content. The number of red blood cells is usually low, as is the hemoglobin content. Treatment is largely supportive, involves administration of oxygen and IV and oral fluid. Treatment is largely supportive, involves administration of oxygen and IV and oral fluid.

61. 61 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Sickle Cell Anemia (cont.)

62. 62 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Celiac Sprue (pgs. 297-298) (pgs. 297-298) A chronic disorder A chronic disorder Sensitivity to wheat gluten Sensitivity to wheat gluten Ingestion causes injury to intestinal mucosa. Ingestion causes injury to intestinal mucosa. This injury may cause malabsorption of nutrients and a resulting anemia. This injury may cause malabsorption of nutrients and a resulting anemia.

63. 63 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Celiac Sprue Symptoms include diarrhea, nervousness, and paresthesia. Symptoms include diarrhea, nervousness, and paresthesia. Painful, burning tongue, atrophy of papillae, and ulceration of oral mucosa Painful, burning tongue, atrophy of papillae, and ulceration of oral mucosa

64. 64 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Celiac Sprue The patient must avoid wheat gluten. The patient must avoid wheat gluten. Oral manifestations resolve when the systemic disease is controlled. Oral manifestations resolve when the systemic disease is controlled.

65. 65 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Aplastic Anemia (pgs. 298-299) (pgs. 298-299) A severe depression of bone marrow activity causes a decrease in all circulating blood cells. – pancytopenia A severe depression of bone marrow activity causes a decrease in all circulating blood cells. – pancytopenia Primary aplastic anemia – the cause is unknown Primary aplastic anemia – the cause is unknown Secondary aplastic anemia – a result of a drug or chemical agent Secondary aplastic anemia – a result of a drug or chemical agent

66. 66 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Aplastic Anemia (cont.)

67. 67 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Aplastic Anemia (pgs. 298-299) (pgs. 298-299) Infection, spontaneous bleeding, petechiae, and purpuric spots Infection, spontaneous bleeding, petechiae, and purpuric spots

68. 68 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Aplastic Anemia (pg. 298) (pg. 298) Leukopenia (decrease in white blood cells) and thrombocytopenia (decrease in platelets) occur. Leukopenia (decrease in white blood cells) and thrombocytopenia (decrease in platelets) occur. Primary aplastic anemia is usually progressive and fatal. Primary aplastic anemia is usually progressive and fatal. Secondary aplastic anemia involves removing the cause. Secondary aplastic anemia involves removing the cause.

69. 69 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Polycythemia Polycythemia Vera Polycythemia Vera Secondary Polycythemia Secondary Polycythemia Relative Polycythemia Relative Polycythemia

70. 70 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Polycythemia (cont.) (pg. 298) (pg. 298) Characterized by an increase in the number of circulating red blood cells Characterized by an increase in the number of circulating red blood cells May be absolute or relative May be absolute or relative The three forms of polycythemia are The three forms of polycythemia are Polycythemia Vera Polycythemia Vera Secondary Polycythemia Secondary Polycythemia Relative Polycythemia Relative Polycythemia

71. 71 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Polycythemia Vera (Primary Polycythemia) (pg. 298) (pg. 298) A neoplastic proliferation of bone marrow stem cells causes an abnormally high number of circulating red blood cells. A neoplastic proliferation of bone marrow stem cells causes an abnormally high number of circulating red blood cells. Unknown cause Unknown cause More common in men than in women More common in men than in women Age of onset usually between 40 and 60 years of age Age of onset usually between 40 and 60 years of age Clinical features Clinical features Headache, dizziness, and itching (pruritus) Headache, dizziness, and itching (pruritus) Thrombi may form. Thrombi may form.

72. 72 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Secondary Polycythemia (pg. 298) (pg. 298) The increase in red blood cells is caused by a physiologic response to decreased oxygen. The increase in red blood cells is caused by a physiologic response to decreased oxygen. A decrease in blood oxygen causes an increase in erythropoietin by the kidneys. A decrease in blood oxygen causes an increase in erythropoietin by the kidneys. May be due to pulmonary disease, heart disease, living at high altitude, or elevation in carbon monoxide May be due to pulmonary disease, heart disease, living at high altitude, or elevation in carbon monoxide

73. 73 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Relative Polycythemia (pg. 298) (pg. 298) Caused by a decrease in plasma volume Caused by a decrease in plasma volume Causes may include diuretics, vomiting, diarrhea, or excessive sweating. Causes may include diuretics, vomiting, diarrhea, or excessive sweating. Most patients are middle-aged white men under physiologic stress, mildly overweight, hypertensive, and heavy smokers. Most patients are middle-aged white men under physiologic stress, mildly overweight, hypertensive, and heavy smokers.

74. 74 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Polycythemia (pg. 299) (pg. 299) The oral mucosa may appear deep red to purple; the gingiva may be edematous and bleed easily. The oral mucosa may appear deep red to purple; the gingiva may be edematous and bleed easily. Submucosal petechiae, ecchymosis, and hematoma formation may be present. Submucosal petechiae, ecchymosis, and hematoma formation may be present.

75. 75 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Polycythemia (pg. 299) (pg. 299) Laboratory testing and measurement of hemoglobin and hematocrit Laboratory testing and measurement of hemoglobin and hematocrit May include removal of causative factors, chemotherapy, and phlebotomy May include removal of causative factors, chemotherapy, and phlebotomy

76. 76 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Disorders of White Blood Cells Agranulocytosis Agranulocytosis Cyclic Neutropenia Cyclic Neutropenia Leukemia Leukemia

77. 77 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Disorders of White Blood Cells (cont.) (pgs. 299-301) (pgs. 299-301) Three groups of white blood cells are found in circulation. Three groups of white blood cells are found in circulation. Granulocytes Granulocytes Neutrophils (PMNs), eosinophils, and basophils Neutrophils (PMNs), eosinophils, and basophils Lymphocytes Lymphocytes Monocytes Monocytes

78. 78 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Agranulocytosis (pg. 300) (pg. 300) A significant reduction in circulating neutrophils A significant reduction in circulating neutrophils Leukopenia – an abnormally low white blood cell count Leukopenia – an abnormally low white blood cell count Neutropenia – a reduction in the number of circulating neutrophils Neutropenia – a reduction in the number of circulating neutrophils

79. 79 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Agranulocytosis (cont.) Can result from a problem in development of neutrophils or accelerated destruction of neutrophils Can result from a problem in development of neutrophils or accelerated destruction of neutrophils Primary – the cause is unknown, may be an immunologic disorder Primary – the cause is unknown, may be an immunologic disorder Secondary – a result of chemicals or drugs Secondary – a result of chemicals or drugs

80. 80 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Agranulocytosis (pg. 300) (pg. 300) Sudden onset of fever, chills, jaundice, weakness, and sore throat Sudden onset of fever, chills, jaundice, weakness, and sore throat Oral infection Oral infection

81. 81 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Agranulocytosis (pg. 300) (pg. 300) Laboratory testing Laboratory testing Marked reduction in WBC count Marked reduction in WBC count Treatment Treatment Transfusions, antibiotics Transfusions, antibiotics Removal of the cause for the secondary form Removal of the cause for the secondary form

82. 82 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Cyclic Neutropenia (pg. 300) (pg. 300) A cyclic decrease in the number of circulating neutrophilic leukocytes A cyclic decrease in the number of circulating neutrophilic leukocytes Discussed on pages 208-209 Discussed on pages 208-209

83. 83 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Leukemia (pgs. 300-301) (Box 9-2) (pgs. 300-301) (Box 9-2) Malignant neoplasms of hematopoietic stem cells Malignant neoplasms of hematopoietic stem cells Characterized by an excessive number of abnormal white blood cells in circulating blood Characterized by an excessive number of abnormal white blood cells in circulating blood Unknown cause; some are investigating oncogenic viruses Unknown cause; some are investigating oncogenic viruses There are many different types categorized as to whether they are acute or chronic. There are many different types categorized as to whether they are acute or chronic.

84. 84 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Acute Leukemias (pgs. 300-301) (pgs. 300-301) Characterized by very immature cells and a rapidly fatal course if not treated Characterized by very immature cells and a rapidly fatal course if not treated Acute lymphoblastic leukemia – involves immature lymphocytes Acute lymphoblastic leukemia – involves immature lymphocytes Primarily affects children and young adults Primarily affects children and young adults Good prognosis Good prognosis Acute myeloblastic leukemia – involves immature granulocytes Acute myeloblastic leukemia – involves immature granulocytes Primarily affects adolescents and young adults. Primarily affects adolescents and young adults. Prognosis is not as good. Prognosis is not as good.

85. 85 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features of Acute Leukemias (pg. 301) (pg. 301) Weakness, fever, enlargement of lymph nodes, and bleeding Weakness, fever, enlargement of lymph nodes, and bleeding

86. 86 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Acute Leukemias Gingival enlargement Gingival enlargement Oral infection Oral infection Bleeding gums, petechiae and ecchymosis Bleeding gums, petechiae and ecchymosis

87. 87 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Acute Leukemias Laboratory findings include elevated white blood cell count, anemia, and low platelet count Laboratory findings include elevated white blood cell count, anemia, and low platelet count Treatment Treatment Bone marrow transplant Bone marrow transplant

88. 88 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Chronic Leukemias (pg. 301) (pg. 301) Slow onset Slow onset Primarily affect adults Primarily affect adults

89. 89 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical Features and Oral Manifestations of Chronic Leukemias Easy fatigability, weakness, weight loss, anorexia Easy fatigability, weakness, weight loss, anorexia Pallor of lips and gingiva, gingival enlargement, petechiae and ecchymosis, gingival bleeding Pallor of lips and gingiva, gingival enlargement, petechiae and ecchymosis, gingival bleeding

90. 90 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Chronic Leukemias High white blood cell count High white blood cell count Treatment Treatment Bone marrow transplant Bone marrow transplant

91. 91 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Bleeding Disorders Hemostasis Hemostasis Purpura Purpura Hemophilia Hemophilia

92. 92 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hemostasis (cont.)

93. 93 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hemostasis (cont.) (pgs. 301-303) (Tables 9-1, 9-2) (pgs. 301-303) (Tables 9-1, 9-2) A cessation of bleeding A cessation of bleeding Circulating platelets adhere to a damaged surface and aggregate to form a temporary clot. Circulating platelets adhere to a damaged surface and aggregate to form a temporary clot. Fibrin binds the platelets Fibrin binds the platelets Fibrin is converted from fibrinogen by a cascade of circulating proteins. Fibrin is converted from fibrinogen by a cascade of circulating proteins. Defects may be caused by abnormalities of either platelets or coagulation factors. Defects may be caused by abnormalities of either platelets or coagulation factors. These may be determined with laboratory tests. These may be determined with laboratory tests.

94. 94 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hemostasis (cont.)

95. 95 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Platelet Count (pgs. 301-302) (pgs. 301-302) To determine the number of platelets To determine the number of platelets Normal is 150,000 to 400,000/mm 3 Normal is 150,000 to 400,000/mm 3 Spontaneous gingival bleeding may occur if the count is less than 20,000/mm 3 Spontaneous gingival bleeding may occur if the count is less than 20,000/mm 3

96. 96 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Bleeding Time (pg. 302) (pg. 302) The adequacy of platelet function The adequacy of platelet function Normal is between 1 and 6 minutes. Normal is between 1 and 6 minutes. Prolonged is greater than 5 or 10 minutes. Prolonged is greater than 5 or 10 minutes.

97. 97 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Prothrombin Time (PT) (pgs. 302-303) (pgs. 302-303) The ability to form a clot The ability to form a clot Normal is usually between 11 and 16 seconds. Normal is usually between 11 and 16 seconds. INR is the ratio of PT to thromboplastin activity. INR is the ratio of PT to thromboplastin activity. Values less than 3 are considered normal. Values less than 3 are considered normal. Patients on anticoagulants may have INR values of 4 to 5. Patients on anticoagulants may have INR values of 4 to 5.

98. 98 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Partial Thromboplastin Time (PTT) (pg. 303) (pg. 303) Measures the other way by which clot formation occurs Measures the other way by which clot formation occurs A normal PTT is usually 25 to 40 seconds. A normal PTT is usually 25 to 40 seconds. Prolongation to 45 or 50 seconds may be associated with bleeding problems. Prolongation to 45 or 50 seconds may be associated with bleeding problems. Over 50 seconds may be severe Over 50 seconds may be severe

99. 99 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Purpura (pgs. 303-304) (pgs. 303-304) A reddish-blue or purplish discoloration of skin or mucosa from spontaneous extravasation of blood A reddish-blue or purplish discoloration of skin or mucosa from spontaneous extravasation of blood May be due to a defect or deficiency in blood platelets May be due to a defect or deficiency in blood platelets Blood may ooze from gingival margins. Blood may ooze from gingival margins.

100. 100 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Thrombocytopenic Purpura (pgs. 303-304) (pgs. 303-304) A bleeding disorder that results from a severe reduction in circulating platelets A bleeding disorder that results from a severe reduction in circulating platelets Idiopathic thrombocytopenic purpura Idiopathic thrombocytopenic purpura If the cause is unknown If the cause is unknown Immune thrombocytopenia Immune thrombocytopenia An autoimmune type of process An autoimmune type of process Secondary thrombocytopenic purpura Secondary thrombocytopenic purpura Often associated with drugs Often associated with drugs

101. 101 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Clinical and Oral Manifestations of Thrombocytopenic Purpura Spontaneous purpuric or hemorrhagic lesions on the skin Spontaneous purpuric or hemorrhagic lesions on the skin Patients bruise easily, may have blood in urine, and have frequent nosebleeds. Patients bruise easily, may have blood in urine, and have frequent nosebleeds.

102. 102 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Thrombocytopenic Purpura Laboratory tests show a significant decrease in platelets. Laboratory tests show a significant decrease in platelets. Treatment Treatment May include transfusions, corticosteroids, and splenectomy May include transfusions, corticosteroids, and splenectomy

103. 103 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Nonthrombocytopenic Purpura (pg. 304) (pg. 304) Bleeding disorders that can result from either a defect in capillary walls or disorders of platelet function Bleeding disorders that can result from either a defect in capillary walls or disorders of platelet function Vitamin C deficiency and infections or chemicals and allergy may be the cause of alterations in vascular walls. Vitamin C deficiency and infections or chemicals and allergy may be the cause of alterations in vascular walls. Drugs, allergy, and autoimmune disease may cause disorders of platelet function. Drugs, allergy, and autoimmune disease may cause disorders of platelet function. Von Willebrand disease is an autosomal dominant disorder of platelet function. Von Willebrand disease is an autosomal dominant disorder of platelet function.

104. 104 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Nonthrombocytopenic Purpura Spontaneous gingival bleeding, petechiae, ecchymoses, and hemorrhagic blisters Spontaneous gingival bleeding, petechiae, ecchymoses, and hemorrhagic blisters

105. 105 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Nonthrombocytopenic Purpura Systemic corticosteroids, splenectomy, and discontinuation of the causative agent Systemic corticosteroids, splenectomy, and discontinuation of the causative agent

106. 106 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Hemophilia (pg. 304) (pg. 304) A disorder of blood coagulation A disorder of blood coagulation Results in severely prolonged clotting time Results in severely prolonged clotting time Due to a deficiency in plasma proteins involved in coagulation Due to a deficiency in plasma proteins involved in coagulation

107. 107 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Types of Hemophilia (pg. 304) (pg. 304) The two most common types are type A and type B. The two most common types are type A and type B. Transmitted as X-linked diseases through an unaffected carrier daughter to a son Transmitted as X-linked diseases through an unaffected carrier daughter to a son Type A Type A Caused by a deficiency of plasma thromboplastinogen or factor VIII Caused by a deficiency of plasma thromboplastinogen or factor VIII Type B Type B Christmas disease Christmas disease Less common, the clotting defect is plasma thromboplastin or factor IX Less common, the clotting defect is plasma thromboplastin or factor IX

108. 108 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Hemophilia Spontaneous gingival bleeding, petechiae, and ecchymosis Spontaneous gingival bleeding, petechiae, and ecchymosis

109. 109 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Diagnosis and Treatment of Hemophilia The bleeding time and PT in hemophilia are normal; the PTT is prolonged. The bleeding time and PT in hemophilia are normal; the PTT is prolonged. Diagnosis involves identifying the missing factor; treatment involves replacing it. Diagnosis involves identifying the missing factor; treatment involves replacing it.

110. 110 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Immunodeficiency (pgs. 304-305) (pgs. 304-305) Can involve the different parts of the immune system either alone or together Can involve the different parts of the immune system either alone or together May involve a deficiency in cell-mediated or humoral immunity May involve a deficiency in cell-mediated or humoral immunity May involve deficiency in phagocytosis May involve deficiency in phagocytosis Divided into Divided into Primary immunodeficiency of genetic origin Primary immunodeficiency of genetic origin Secondary immunodeficiency from another underlying disorder Secondary immunodeficiency from another underlying disorder

111. 111 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Primary Immunodeficiencies (pg. 305) (pg. 305) Of genetic origin Of genetic origin May involve B cells, T cells, or both May involve B cells, T cells, or both Very rare Very rare Bruton disease (X linked congenital agammaglobulinemia) Bruton disease (X linked congenital agammaglobulinemia) DiGeorge syndrome (thymic hypoplasia) DiGeorge syndrome (thymic hypoplasia) Severe combined immunodeficiency Severe combined immunodeficiency

112. 112 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Secondary Immunodeficiencies (Cont.)

113. 113 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Secondary Immunodeficiencies (Cont.) (pg. 305) (Table 9-3) (pg. 305) (Table 9-3) Occur as the result of an underlying disorder Occur as the result of an underlying disorder May be malnutrition, viral infection, cancer, renal disease and Hodgkins disease May be malnutrition, viral infection, cancer, renal disease and Hodgkins disease May occur with immunosuppressive drugs, drugs used along with radiation, chemotherapy May occur with immunosuppressive drugs, drugs used along with radiation, chemotherapy

114. 114 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Therapy for Oral Cancer (pgs. 305-307) (pgs. 305-307) Radiation Therapy Radiation Therapy Chemotherapy Chemotherapy

115. 115 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Oral Manifestations of Therapy for Oral Cancer (cont.) (pg. 305) (pg. 305) Oral cancer can be treated with surgery, radiation therapy, or chemotherapy, or a combination. Oral cancer can be treated with surgery, radiation therapy, or chemotherapy, or a combination.

116. 116 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Radiation Therapy (pgs. 305-306) (pgs. 305-306) The patient often experiences mucositis during radiation therapy. The patient often experiences mucositis during radiation therapy. Mucositis begins about the second week of therapy and subsides a few weeks after its completion. Mucositis begins about the second week of therapy and subsides a few weeks after its completion. It is painful and appears as an erythematous and ulcerated mucosa. It is painful and appears as an erythematous and ulcerated mucosa. The patients may have difficulty eating, pain on swallowing, and loss of taste. The patients may have difficulty eating, pain on swallowing, and loss of taste.

117. 117 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. (pgs. 305-306) (pgs. 305-306) Destruction of major salivary glands may result in xerostomia Destruction of major salivary glands may result in xerostomia The patient is prone to rampant caries and oral candidiasis. The patient is prone to rampant caries and oral candidiasis. They also are prone to osteoradionecrosis. They also are prone to osteoradionecrosis. Radiation Therapy (cont.)

118. 118 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Patients should have an oral evaluation before radiation therapy of the head and neck. Patients should have an oral evaluation before radiation therapy of the head and neck. Potential sources for oral infection and teeth with a questionable prognosis should be removed. Potential sources for oral infection and teeth with a questionable prognosis should be removed. The hygienist can help with The hygienist can help with Fluoride application Fluoride application Patient education Patient education Frequent follow-up appointments Frequent follow-up appointments Radiation Therapy (cont.)

119. 119 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Chemotherapy (pgs. 306-307) (pgs. 306-307) Drugs used for cancer chemotherapy affect basal cells of the epithelium. Drugs used for cancer chemotherapy affect basal cells of the epithelium. Mucositis and oral ulceration are common complications. Mucositis and oral ulceration are common complications. A decrease in all blood cells may occur A decrease in all blood cells may occur Lowered RBC counts can lead to anemia. Lowered RBC counts can lead to anemia. Lowered WBC counts can lead to infections. Lowered WBC counts can lead to infections. Lowered platelets can lead to bleeding problems. Lowered platelets can lead to bleeding problems.

120. 120 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Effects of Drugs on the Oral Cavity (pgs. 307-308) (pgs. 307-308) Blood pressure drugs, antianxiety medications, antipsychotic medications, and antihistamines can cause xerostomia. Blood pressure drugs, antianxiety medications, antipsychotic medications, and antihistamines can cause xerostomia. Prednisone suppresses the immune system and can lead to candidiasis and oral infections. Prednisone suppresses the immune system and can lead to candidiasis and oral infections. Antibiotics may increase risk of candidiasis. Antibiotics may increase risk of candidiasis.

121. 121 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Effects of Drugs on the Oral Cavity (cont.)

122. 122 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Effects of Drugs on the Oral Cavity (cont.)

123. 123 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Effects of Drugs on the Oral Cavity (cont.) Tetracycline can cause tooth discoloration. Tetracycline can cause tooth discoloration. Phenytoin and nifedipine can cause gingival enlargement. Phenytoin and nifedipine can cause gingival enlargement. Cyclosporine may cause gingival enlargement. Cyclosporine may cause gingival enlargement.

124. 124 Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc. Discussion Questions What oral manifestations of systemic diseases may be observed within the oral cavity? What oral manifestations of systemic diseases may be observed within the oral cavity? What disorders of blood cells may be observed within the oral cavity? What disorders of blood cells may be observed within the oral cavity? What effects may immunodeficiency have upon the oral cavity? What effects may immunodeficiency have upon the oral cavity? What oral manifestations may be observed during therapy for oral cancer? What oral manifestations may be observed during therapy for oral cancer? What effects of drugs may be observed within the oral cavity? What effects of drugs may be observed within the oral cavity?