WBC disorders

• WBCs


  White blood cells that provide the primary defense against microbial infections and are critical for mounting an immune response
• WBC disorders


  • Defects can manifest as delayed healing, infection, or mucosal ulceration
• Detecting WBC abnormalities


  1. History taking

  2. Clinical examination

  3. Screening laboratory tests

  4. Prompt referral to physician for diagnosis and treatment before invasive dental procedures
• WBCs make up approximately 1% of the total blood volume in a healthy adult, but this 1% makes a large difference to health as immunity depends on it</b>
• WBCs that circulate in the peripheral blood account for only 5% of the total WBC mass, but these cells are readily available to help fight invading organisms
• Locations where lymphocytes primarily localize

  • Lymph nodes
  • Spleen
  • Mucosa associated lymphoid tissue (MALT) lining the respiratory and gastrointestinal tracts
• Three groups of WBCs found in the peripheral circulation

  • Granulocytes (90% neutrophils, remainder eosinophils and basophils)
  • Monocytes
  • Lymphocytes (T cells, B cells, Natural killer cells)
• Functions of WBC types

  • Neutrophils: Defend against infectious agents through phagocytosis and enzymatic destruction

  Eosinophils and basophils: Involved in inflammatory allergic reactions

  Eosinophils: Combat infection by parasites
• Normal WBC count range

  4400 to 11,000/micro.L in adults
• Normal differential WBC count

  • Neutrophils: 50% to 60%

  Eosinophils: 1% to 3%

  Basophils: Less than 1%

  Lymphocytes: 20% to 34%

  Monocytes: 3% to 7%
• Leukocytosis


  Increase in the number of circulating WBCs to more than 11,000/micro.L
• Leukopenia


  Reduction in the number of circulating WBCs to less than 4400/micro.L
• Causes of physiologic leukocytosis

  • Exercise

  Pregnancy

  Emotional stress
• Causes of pathologic leukocytosis

  • Infection

  Neoplasia

  Necrosis
• Causes of leukocytosis by cell type

  • Pyogenic infections: Increase neutrophils

  Tuberculosis, syphilis, viral infections: Increase lymphocytes

  Protozoal infections: Increase monocytes

  Allergies, parasitic infections: Increase eosinophils
• Leukopenia and pancytopenia (decreased WBCs and RBCs) are common complications of chemotherapeutic drugs
• Patients with leukocytosis or leukopenia may have bone marrow abnormalities that can cause thrombocytopenia
• Examination of the patient's bone marrow aspirate is important for taking the final diagnosis
• Leukemia


  Cancer of the white blood cells, characterized by a great increase in the numbers of circulating immature leukocytes
• Common types of leukemia

  • Acute lymphoblastic leukemia (ALL)

  Acute myeloid leukemia (AML)

  Chronic lymphoblastic leukemia (CLL)

  Chronic myeloid leukemia (CML)
• Myeloproliferative disorders


  • Acute myeloid leukemia: Immature neoplastic malignancy of myeloid cells

  Chronic myeloid leukemia: Mature neoplastic malignancy of myeloid cells
• Lymphoproliferative disorders


  • Acute lymphoblastic leukemia: Immature neoplastic malignancy of lymphoid cells

  Chronic lymphocytic leukemia: Mature neoplastic malignancy of lymphoid cells
• Leukemia is much more common in adults than in children, with more than half of all cases occurring after age 65 years
• The most common form of leukemia among people younger than 19 years of age is acute lymphoblastic leukemia
• Risk factors for leukemia

  • Family history

  Large doses of ionizing radiation

  Infection with specific viruses (e.g., Epstein-Barr virus)

  Cigarette smoking

  Exposure to electromagnetic fields
• Lymphoma


  Cancer of the lymphoid organs and tissues
• Classification of lymphomas


  • By cell type (B cell, T cell, MALT, plasma cell)

  By appearance (small or large cell)

  By clinical behavior (low, intermediate, and high grade)
• Initial signs of lymphoma often occur in the mouth and head and neck region
• Common types of lymphomas

  • Hodgkin lymphoma: Malignant neoplasm of B-lymphocytes, contains Reed-Sternberg cells

  Non-Hodgkin lymphoma: Malignant neoplasms of B or T cells, many types and locations

  Burkitt lymphoma: Aggressive non-Hodgkin B cell lymphoma involving bone and lymph nodes

  Multiple myeloma: Overproduction of malignant plasma cells resulting in multiple tumorous masses in the skeletal system
• Dental management in leukemia

  Pre-treatment assessment and preparation

  Oral health care during medical therapy

  Post-treatment management
• Pre-treatment assessment and preparation

  Obtain specific diagnosis and severity of disorder

  Determine type of medical treatment

  Provide oral hygiene instructions, fluoride gels, non-cariogenic diet

  Eliminate mucosal and periodontal disease, eliminate sources of mucosal injury

  Perform plaque removal, caries elimination, root canal therapy or extractions as needed

  Inspect radiographs for undiagnosed disease, retained root tips, impacted teeth

  Consider extractions if periodontal pocket depths are great
• Pre-treatment Assessment


  The goal is to minimize or eliminate oral diseases before the start of chemotherapy
• Pre-treatment Assessment


  • The dentist must know the specific diagnosis, the severity of the disorder, and the type of medical treatment
• Patients receiving only palliative treatment


  Not a good candidate for extensive restorative or prosthodontic procedures that require months for completing
• Pretreatment (before chemotherapy) care

  Oral hygiene instructions, using fluoride gels, encouraging a non-cariogenic diet, eliminating mucosal and periodontal disease, eliminating any source of mucosal injury, plaque removal
• Caries elimination


  If pulpal disease is present, the dentist may recommend root canal therapy or extraction of teeth
• Inspection of radiographs


  For undiagnosed disease, retained root tips, impacted teeth to clear the oral cavity
• Extraction


  Consider if periodontal pocket depths are greater than 5 mm, periapical inflammation is present, the tooth is nonfunctional or partially erupted
• Guidelines for extraction before chemotherapy

  • Schedule a minimum of 3 weeks between the time of extraction and initiation of chemotherapy or radiotherapy, avoid invasive procedures if the platelet count is less than 50,000/micro L
• Mucositis


  Chemotherapy affects epithelial cells that have high replication rates, specially in young patients, begins 7 to 10 days after initiation of chemotherapy and resolves after cessation of chemotherapy