Hi. This is Dr. Amit T. Suryawanshi. Oral & Maxillofacial surgeon from Pune, India. I am here on slideshare.com to share some of my own presentations presented at various levels in the field of OMFS. Hope this would somehow be helpful to you making your presentations. All the best.

1. RBCs & Its Clinical
Implications
Dr. Amit T. Suryawanshi
Oral and Maxillofacial Surgeon
Pune, India
Contact details :
Email ID - amitsuryawanshi999@gmail.com
Mobile No - 9405622455

2. Contents
1. Introduction.
2. History.
3. Erythropoiesis.
4. Morphology of RBCs.
5. Properties of RBCs.
6. Functions of RBCs.
7. Lifespan & Fate of RBCs.
8. Hemoglobin & Iron Metabolism.
9. Blood tests & Blood indices .
10. Clinical implications of RBCs.
11. Conclusion.

3. Introduction
• Blood is connective tissue of the body in fluid form.
• Blood is a specialized body fluid
in humans that delivers oxygen and nutrients to
the cells and transports carbon dioxide and
metabolic waste products away from the cells.
Hence it is called as a “ River of Life ”
• Blood and Blood related disorders has got very
much importance in patients life ,making it
mandatory to learn for Oral Surgeons .

4. Composition of Blood
Blood Cells 45.7 % Plasma 54.3%
Solid
6-7%
Water
92-93 %
Gases
<1 %
Organic
Substances
Inorganic
Substances
Erythrocytes
45 %
Leucocytes
0.6 %
Thrombocytes
0.1 %

5. Blood is considered as a fluid of life. Because it
carries Oxygen from lungs to all parts of the body
and Carbon dioxide from all parts of the body to the
lungs.
This function of the blood is performed by RBCs.
i.e. Red blood Cells which are also known as
Erythrocytes . ( Erythros - Red , Cytes – Cells )

6. Introduction of RBCs
• RBCs- Red Blood Cells .They are also known as
Erythrocytes.
• Red colour of RBCs is due to presence of coloring
pigment Hemoglobin.
• RBCs play important role in transport of Oxygen
from lungs to the tissues and carbon dioxide
from tissues to lungs.

7. History
• The first person to describe red blood cells was the
young Dutch biologist Jan Swammerdam, who had
used an early microscope in 1658 to study the
blood.
• In 1959, Dr. Max Perutz was able to reveal
the structure of hemoglobin .

8. Normal RBC Count -
• Avrg RBC count = 4 - 5.5 millions / mm3
• RBC count in adults male – 5- 5.5 millions /mm3
• RBC count in adults female – 4 – 4.5 millions /mm3
• RBC count in infants - 6-7 million/mm3

9. Erythropoiesis
• Haematopoiesis is the process which includes
origin, development & maturation of all blood
cells.
• Whereas the process by which origin ,
development and maturation of erythrocytes
occur is known as Erythropoiesis.

10. Stages & Sites of Erythropoiesis
• In Fetal life -
Mesoblastic
stage
• First 2
months of
i.u.
• From
mesenchyme
of yolk sac
Hepatic
stage
• From 2-6
months
• Liver, spleen
& lymphoid
organs
Myeloid
stage
• From 7-9
month
• Red bone
marrow,
Liver

11. In post natal life
• Upto 5-6 years : Red bone
marrow of all bones.
• From 6-20 years : Red
bone marrow of long
bones & all flat bones .
• After 20th year : almost
red bone marrow of all
the long bones is replaced
by yellow bone marrow.

12. In post natal life
• Only the upper ends of
the femur & humerus
contain red bone marrow.
• Vertebras , ribs, sternum
scapula ,iliac bone also
produce red cells
continuously.
• In case of Bone disorders,
RBCs are produced in
spleen, liver

13. Erythropoiesis -
o Blood cells are derived from Pluripotent
Hemopoetic Stem Cells (PHSC)
o Growth inducers (GI) like interleukin-3 and
differentiation inducers (DI) play an important
role.
o Few PHSC are retained throughout life as they
are.

15. Erythropoietin dependent stages

16. Iron dependent stages
CELL
DIAMETER
NUCLEUS CYTOPLASM
15-20 μm Big Very Scanty & basophilic.
No Hb
11-16μm Smaller Still Scanty & basophilic.
No Hb
10-12μm Smaller &
denser
Hb starts to appear,
cytoplasm polychromatic
8-10μm Ink spot nucleus Plentiful, eosinophilic
cytoplasm. Increase in
Hb
8-10μm Absent Some RNA still present
7.2 μm Absent Hb is present in large
amount .

17. RBC Maturation factors
1. Vitamin B12 (Extrinsic factor) –
• Essential for maturation of RBCs
• Deficiency of Vitamin B12 causes Pernicious Anemia.
So it is also called as antipernicious factor .
2. Intrisic Factor of castle-
• Produced in Gastric mucosa
• Essential for absorption of Vit.B 12

18. 3. Folic acid –
• Essential for synthesis of DNA in RBCs.
• Absence of folic acid causes failure of
maturation of cells leading to
Megaloblastic anemia.

19. Morphology
• Size : 7.2 μ
• Shape : Circular , Biconcave
• Thickness : 2.2 μ, 1 μ
• Surface area : 120 μm2
• Volume : 85-90 μm3

20. Advantages of bi-concave shape:
1. provides large surface area for
absorption and removal of
respiratory gases and other
substances.
2. Cells can easily squeeze through
while passing through capillaries

21. Composition
• Water - 62.5%
• Hemoglobin - 35%
• Others - 2.5%
(glucose, lipids,
proteins, enzymes,
vitamin, ions)
others
water
haemoglobin

22. Properties of RBCs
Rouleaux formation Packed cell volume

23. Specific gravity-
1.092 – 1.101
Suspension stability

24. Functions of RBCs -
1. Transport of OXYGEN from lungs to the tissues
2. Transport of CARBON DIOXIDE from tissues to
the lung
3. Buffering action in blood

25. 5. Blood group determination.
6. Help to maintain the viscosity of blood.

26. LIFE SPAN AND FATE OF RBC’S
• Average life span -- 100-120 days.
• Spleen -- Graveyard of red blood cells.
• Daily 10% red blood cells, which are senile, get
destroyed in normal young healthy adults.

27. Hemoglobin
• Hemoglobin is an oxygen carrying pigment of
the RBCs.
• It is a conjugated protein which consists of
protein combined with an iron containing
pigment.

28. Functions of Hemoglobin
1. Transport of OXYGEN from lungs to the
tissues
2. Transport of CARBON DIOXIDE from tissues
to the lung
3. Buffering action in blood

29. HAEMOGLOBIN
NORMAL VALUES
• Average hemoglobin (Hb) -- 14 to 16 gm%.
• At different ages:
– At birth : 22 – 25 gm%
– After 3 months : 18 – 20 gm%
– After1 year : 17 gm%
– In adult males : 14 – 17 gm%
– In adult females : 12 – 16 gm%

30. Iron Metabolism-
• Iron is absorbed for small intestine and
transported to blood .
• In blood , Iron combines with β globulin to
form Transferrin
• Iron is stored in large quantities in
RE cells and Hepatocytes as Ferritin.
• In RBCs , Iron is stored in Fe++ form .

31. Synthesis of hemoglobin
A. 2 succinyl-CoA + 2 glycine Pyrole compund
B. 4 pyrrole compunds Protoporphyrin IX
C. Protoporphyrin IX + Fe++ Heme
D. Heme + globin Hemoglobin

32. Factors for Hemoglobin synthesis
• Proteins
• Iron
• Vitamin C, Riboflavin ,Nicotinic acid , Pyridoxine
• Copper
• Cobalt and nickel

33. Structure of Hemoglobin
• It is a conjugated protein
• It consists of
1. Heme - An Iron containing pigment.
2. Globin- Protein

34. Heme part- Structure
• It consists of
1. Iron – Ferrous form(Fe++)
2. Porphyrin – Pigment part

35. Globin -Structure
It consists of 4 polypeptide chains
1. Two α chains
2. Two β chains

36. Types of Normal Hemoglobin
• There are 2 types of hemoglobin .
1. Adult Hemoglobin (HbA)-
- It contains 2 α and 2 β chains
2. Fetal Hemoglbin (HbF)-
-It contains 2 α and 2 γ chains

37. DESTRUCTION OF HEMOGLOBIN
– Occurs in Phagocytes of Spleen.
– Globin is broken into amino acid and
reused.
– Heme – Its tetrapyrrole ring is opened up
to form BILIVERDIN.
– Its oxidation produces BILIRUBIN

38. CLINICAL
IMPLICATIONS OF RBC

39. Clinical disorders related to RBCs
Broadly classified into
1. Anemia – Decrease in RBC count and
Hemoglobin level.
2. Polycythemia – Increase in RBC count and
Hemoglobin level.

40. ANEMIA
• It is defined as a blood cell disorder
characterized by decreased oxygen carrying
capacity of blood caused by reduction in red
blood cell count or hemoglobin content or
both.

41. Classification
Etiological (Whidby's) classification
A. Deficiency anemias -
1. Iron deficiency anemia
2. Megaloblastic anemia
3. Pernicious anemia
B. Blood loss anemias -
1. Acute post- hemorrhagic anemia
(accidents)
2.Chronic post- hemorrhagic anemia

42. C. Haemolytic anemias ( increased destruction of
rbc)
1. Hereditary heamolytic anemias
a. Thalassemia
b. Sickle cell anemia
c. Hereditary spherocytosis
d. Glucose 6-phosphate dehydrogenase
deficiency (G6PD)

43. • Acquired haemolytic anemias
- Due to direct toxic effect ( eg snake venom, drugs
, chemicals, etc)
- In splenomegaly
- In paroxysmal nocturnal haemoglobinuria( PNH)
D. APLASTIC ANEMIA (failure of bone marrow)
E. Anemia due to chronic diseases
(tuberculosis, chronic infections, malignancies )

44. Morphological (Wintrobe’s) classification
1.Normocytic normochromic anemias
• Acute post-haemorrhagic anemia
• Haemolytic anemias
• Aplastic anemia
• Anemia in chronic diseses.
2.Macrocytic normochromic anemia
• Pernicious anemia (Addison’s anemia)

45. 3. Macrocytic hypochromic anemias-
• Protein deficiency anemia
• Megaloblastic anemia
2.Microcytic hypochromic anemias
• Iron deficiency anemia
• Chronic post-haemorrhagic anemia
• Thalassemias

46. SIGN & SYMPTOMS
Considered in two broad categories:
1. Clinical features common to all anemias.
2. Certain special clinical features for different
types of anemias.

47. Common Clinical features
• Typically none in early stages
• General lassitude
Cardio-respiratory -
1. Dyspnoea
2. Tachycardia
3. Murmurs
4. Palpitations
5. Angina Pectoris

48. Oral –
1. Sore mouth
2. Oral ulceration
3. Angular stomatitis
4. Glossitis
5. Burning mouth syndrome
Cutaneous -
1. Pallor
2. Brittle Nails
3. Koilonychia

49. Iron deficiency anemia
• Most common type of anemia
• It Develops due to inadequate availibity for
iron for hemoglobin synthesis .
• Causes –
1. Loss of blood
2. Decreased intake or poor absorption of iron
3. Increased demand in conditions like growth
and pregnancy

50. Clinical features
PALLOR KOILONYCHIA
ANGULAR CHEILITIS PAPILLARY ATROPHY OF TONGUE

51. Megaloblastic anemia
• Megaloblastic anemia is due to deficiency of
Maturation factor of RBC i.e. folic acid.
• DNA synthesis is impaired so cells are
megaloblastic but immature .

52. Oral manifestations
1. Atrophic glossitis
2. Patchy erythema
3. Taste alterations
4. Dysphagia
5. Burning mouth
Atrophic glossitis

53. Pernicious anemia
• Cause –
• It occurs due to atrophy of gastric mucosa
because of autoimmune destruction of
parietal calls.
• Hence , it leads to decreased production of
intrinisic factor and poor absorption of
vitamin B12 .( Maturation factor )

54. Oral manifestations
1. Atrophic glossitis
2. Patchy erythema
3. Taste alterations
4. Dysphagia
5. Burning mouth
Atrophic glossitis

55. SICKLE CELL ANEMIA
•It is a congenital anamaly occurs
due to abnotmal Hb called Hb–S.
•Molecules of Hb-S polymerize
into long chains and precipitate
inside the cell.
•Hence RBCs attain “ Sickle” or
“Crescent” shape & become
more fragile leading to hemolysis

56. Hemolysis in Sickle cell anemia

57. Oral
Manifestations
Pallar of mucosa Delayed erruption of teeth

58. Other clinical features -
Jaundice Hand & Foot
syndrome

59. THALASSEMIA
• It is also known as “Cooley’s anemia” .
• It is caused by inherited anomalies of hemoglobin
• It is of 2 types
1. α thalesemia
2. Β thalesemia

60. Clinical features
1. Saddled nose
2. Prominent malar
bone
3. Retracted upper
lip
4. Bimaxillary
protrusion
5. Chipmunk facies

61. Radiographic feature
HAIR ON END APPEARENCE

62. APLASTIC ANEMIA
• Aplastic anemia is due to failure of red bone
marrow .
• Red bone marrow is replaced by fatty tissues
• Causes –
1. Repeated exposure to X-rays & Gamma rays
2. Due to bacterial toxins , quinine , gold salts

63. Oral manifestations
ORAL PETECHIAE
GINGIVAL HYPERPLASIA

64. Blood Tests

65. Blood tests
The routine blood tests are
1. Complete blood count
I. RBC count
II. Blood indices –
PCV , MCV, MCH, MCHC
2. ESR
3. Blood smear
4. Retuculocyte count

66. ERYTHROCYTE SEDIMENTATION RATE
• It is commonly used blood test and is also called
as a sed rate or BIERNACKI’s REACTION.
• Procedure –
1. Blood is mixed with an anticoagulant and
allowed to stand on a vertical tube.
2. RBCs settle down due to gravity leaving
supernatant layer of clear plasma above .And
the rate at which RBCs settle down is called as
ESR .
• It is the length of clear supernatant plasma
measured in mm at the end of 1 hr.

67. • Determination by
1. Westergreen’s Method
2. Wintrobe’ s Method
• Normal Values of ESR
– Westergreen's Method
• Adult Males =
0 – 15 mm in 1 hr
• Adult Females=
0 - 20 mm in 1 hr

68. • Variations of ESR
Pathological -
• ESR increases in -
– All Anemias,
except sickle cell anemia .
• ESR decreases in -
– Polycythemia
– Sickle cell anemia

69. BLOOD INDICES
• Importance – Help in diagnosis & typing of Anemias.
• Different Blood Indices
1. Packed Cell Volume (PCV)
2. Mean Corpuscular Volume (MCV)
3. Mean Corpuscular Hemoglobin (MCH)
4. Mean Corpuscular Hemoglobin Concentration
(MCHC)

70. PACKED CELL VOLUME
• Also called as HEMATOCRIT value
• It is the fraction of blood composed of
RBC
• Procedure-
• Blood is mixed with anticoagulant & filled in
wintrobe’s tube upto 100mm mark .
• And tube is typically centrifuged at 3000 RPM
for 30 minutes OR at 10,000 rpm for 1 minute

71. • NORMAL VALUES OF PCV –
Males = 40 to 45%.
Females = 38 to 42%
• VARIATIONS IN PCV
1. PCV increases in
- Polycythemia
2. PCV decreases in
-All types of anemia.

72. HEMATOCRIT VALUES

73. MEAN CORPUSCULAR VOLUME (MCV)
Average volume of a single red blood cell
– Normal MCV = 85 - 90 μm3 .
– VARIATIONS IN MCV-
• Increases in (Macrocyte anemia ) -
1. Pernicious anemia
2. Megaloblastic anemia

74. • Decreases in (Microcyte anemia )
1. Iron deficiency anemia
2. Chronic post-haemorrhagic anemia
3. Thalassemias

75. MEAN CORPUSCULAR HEMOGLOBIN
(MCH)
• Quantity or amount of Hb present in one RBC
– Normal value of MCH is 30 pg (27 -32pg)
–Increases or remains normal in
1. Pernicious anemia

76. • Decreases in (Hypochromic anemia).
1. Protein deficiency anemia
2. Megaloblastic anemia
3. Iron deficiency anemia
4. Thalassemia

77. MEAN CORPUSCULAR HEMOGLOBIN
CONCENTRATION (MCHC)
• It is the amont of Hb expressed in relation to volume of
single RBC .
• Normal value of MCHC is 30 %
• Increases in (Macrocyte anemia ) -
1. Megaloblastic anemia

78. • Decreases in ( Microcyte anemia )
1. Iron deficiency anemia
2. Chronic post-haemorrhagic anemia
3. Thalassemias

79. Peripheral blood smear (PBS)
o A well prepared & correctly read smear gives
vast amount of information of RBC
morphology.
o They are stained by polychromatic stain such
as Wright’s stain
o Variation in shape, size & Hb concentration &
the presence of abnormal cells is noted

80. Management of
anemia
Oral Surgeon’s Perspective

81. Pre operative –
When patient has to undergo surgery , following
preoperative measures should be carried out.
1. Complete blood count with differential
2. Consultation with physician if lower values of Hb
are obtained . (<10gm/dL )
3. Severity of anemia & its correction should be
evaluated before surgical intervention.
4. Possible blood tranfusions , if severe.

82. 5. Drugs that induce Hemolysis should be avoided.
6. Avoidance of elective surgical treatment in patients
in “crisis” (sickle cell anemia)
7. Elimination of oral sources of infection should be
done.
8. Administration of antibiotic prophylaxis , if
necessary
9. GA should be administered only when Hb is 10
gm/dL or more .
10. Short appointments should be given and that too in
the morning (Sickle cell anemia)

83. 11. Thorough oral examination of teeth ,
periodontium ,soft tissues should be conducted
to correct the cause of infection .(Aplastic
anemia )
12. Oral rinses with chlorhexidene 0.2% in aquous
solution will reduce the chances of infection.

84. Intra operative -
1. Gingival bleeding , if present , can be controlled
with antifibrinolytic agents.
2. Intramuscular inj. and Nerve blocks should be
avoided because of risk of bleeding.
3. Intraligamantary anesthesia can be used safely in
extraction procedures .

85. 4. GA should be used in caution
Mostly N2 O + O2 is safe to use.
(Sickle cell anemia & vitamin B12
deficiency ).
5. Prevent dehydration using Normal saline I.V.
during operation.
Primary closure

86. Post operative -
1. Avoidance of drugs that can cause hemolysis in
patients with hemolytic anemias
2. Oral hygiene techniques have to be done.
3. Recommendation of prophylactic antibiotics if poor
wound healing
4. Prescribe Acetaminophen , codein , oxycodone as an
analgesics because salicylates can induce acidosis.

87. Treatment of Anemia
Physician’s perspective

88. Treatment of Anemia
1. Exclude the possibility of hemoglobinopathy
2. Correct any identified cause of blood loss
3. Give oral iron therapy
4. Correct identified vitamin deficiency with oral folic acid &
Vit. B12 by injection.
5. Treat malaria with effective antimalarial drugs( in sickle
cell anemia & thalessemia )
6. If evidence of hemolysis, review the drug treatment, &
stop the drugs if possible
7. Check if the patient is on marrow suppressing drugs and
stop if possible

89. Polycythemia
• It is a general term used for
1. Increased red blood cell count
2. Increased Hb level.
Causes-
1. chronic hypoxia
2. smoking
3. fluid loss
4. hypertension & obesity

90. • Classified as
1. Primary polycythemia (Polycythemia vera)
2. Secondary Polycythemia

91. Signs & symptoms
1. Lassitude
2. Dyspnoea
3. Dizziness
4. Headache ,Body
ache
5. Itching
,numbness,
burning and
weakness in
hands, feet.
Facial plethora
• Urticaria

92. Oral manifestations
Purplish mucosa Edematous gingiva

93. Treatment of Polycythemia
1. Oral surgical procedures in patients with
polycythemia, should be avoided.
2. Patient should have CBC with differential
before surgery.
3. If Hb levels are found increased ,
Physician’s concern should be taken and
patient should undergo treatment for the
same.

94. 1. Before performing surgery , threshold levels should
be obtained ..
a. Hb = < 16 g/ dL
b. Hematocrit value = < 47%
2. Intraoperatively, patients require special
attention to hemostasis.
3. If emergency surgery is required venesection is
performed & blood is replaced with equal amount
of colloid until a satisfactory hematocrit is reached.

95. Conclusion
It is necessary for the oral surgeon to
have knowledge about RBC related disorders .
Because , it is mandatory to find the
etiology of the RBC disorders by letting the
patient undergo Blood tests or by consulting with
General physician for medicinal treatments
before performing any surgical procedure to
prevent further complications during & after
surgery .

96. References
• Medical Physiology : 11th edition GYTON &
HALL.
• Davidson : General Medicine .
• Burket’s Principle of medicine .
• Articles-
1. Dental managemenotf idiopathic aplastic
anemia: report of a case .
2. Managing the dental patient with sickle cell
anemia: a review of the literature
• Tuft university manual – Rx of Medically
compromised patients

97. Thank you