|Year : 2017 | Volume
| Issue : 3 | Page : 137-142
Correlation between hemoglobin concentration and hematocrit values in patients with temporomandibular joint ankylosis and nonankylosed patients
Daniel Otasowie Osunde1, Benjamin Idemudia Akhiwu2, Kevin U Omeje3, Olushola I Amole3, Akinwale A Efunkoya3
1 Department of Dental Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria
2 Department of Dental and Maxillofacial Surgery, Faculty of Dentistry, Jos University Teaching Hospital, University of Jos, Jos, Nigeria
3 Department of Oral and Maxillofacial Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Submission||08-Dec-2016|
|Date of Acceptance||24-Apr-2017|
|Date of Web Publication||6-Oct-2017|
Benjamin Idemudia Akhiwu
Department of Dental and Maxillofacial Surgery, Faculty of Medical Sciences, Jos University Teaching Hospital, University of Jos, Jos
Source of Support: None, Conflict of Interest: None
Background: Temporomandibular joint (TMJ) ankylosis causes distortion of the anatomy of the upper airway resulting in some form of airway obstruction. Aim: The aim of this study was to determine the relationship between TMJ ankylosis and hemoglobin and hematocrit levels. Settings and Design: This was a prospective comparative study of all consecutive patients with TMJ ankylosis who presented to the Oral and Maxillofacial Unit of the Teaching Hospital from January 2010 to December 2012. Materials and Methods: Information obtained included age, gender, types of ankylosis, etiology, duration of ankylosis as well as the hemoglobin and hematocrit values which were compared with age- and sex-matched nonankylosed patients. P ≤ 0.05 was considered statistically significant. Results: Twenty patients aged 10–35 years (mean 20.8 ± 5.53) comprising 55.0% males and 45.0% females participated in the study. Bony ankylosis was the most common presentation (75.0%) while trauma (55.0%) was the most common etiologic factor. The mean duration of ankylosis was 9.05 ± 5.43. The mean hemoglobin concentration was 13.49 ± 1.67 and the mean hematocrit was 39.35 ± 5.63. There was a positive correlation between the duration of ankylosis and the hemoglobin concentration (r = 0.471, df = 17, P= 0.042) as well as the hematocrit values (r = 0.457, df = 17, P= 0.049). Both hematological parameters were found to be significantly higher than the values in the nonankylosed patients with a mean difference of 1.57 g/dl (P = 0.001) and 6.28% (P = 0.0001) for hemoglobin concentration and hematocrit values, respectively. Conclusion: Patients with TMJ ankylosis have higher values of hemoglobin concentration and hematocrit values than the nonankylosed individuals and these findings can be explored for the clinical benefit of patients.
Keywords: Ankylosis, hematocrit, hemoglobin concentration, temporomandibular joint
|How to cite this article:|
Osunde DO, Akhiwu BI, Omeje KU, Amole OI, Efunkoya AA. Correlation between hemoglobin concentration and hematocrit values in patients with temporomandibular joint ankylosis and nonankylosed patients. J Health Res Rev 2017;4:137-42
|How to cite this URL:|
Osunde DO, Akhiwu BI, Omeje KU, Amole OI, Efunkoya AA. Correlation between hemoglobin concentration and hematocrit values in patients with temporomandibular joint ankylosis and nonankylosed patients. J Health Res Rev [serial online] 2017 [cited 2022 Sep 26];4:137-42. Available from: https://www.jhrr.org/text.asp?2017/4/3/137/216062
| Introduction|| |
Temporomandibular joint (TMJ) ankylosis is an extremely disabling affliction that causes problems with mastication, digestion, speech, appearance, and access to routine dentistry. It also has an impact on the psychological development of the patient, especially as it relates to inability to open the mouth. In addition, there is distortion of the anatomy of the upper airway resulting in some form of airway obstruction. The extent of mouth opening limitation varies with the type of ankylosis depending on whether it is fibrous, bony (in which it is worst), complete, or incomplete. The inability to open the mouth, especially in patients with complete bony TMJ ankylosis, may be comparable with patients placed on Maxillo - mandibular fixation (MMF) Studies have shown that patients placed on MMF have reduced pulmonary functions, especially the functional vital capacity, owing to upper airway obstruction., It is assumed that a similar scenario also exists in patients with inability to open the mouth arising from ankylosis of the TMJ.
Few authors have reported on the breathing difficulty associated with chronic upper airway obstruction in patients with ankylosis of the TMJ.,, TMJ ankylosed patients may be in a state of relative hypoxia analogous to high-altitude climbers and the body responds to this hypothetical condition by gradually increasing the concentration of hemoglobin, which carries oxygen in red blood cells (RBCs) for tissue perfusion. Thus, we hypothesized that patients with TMJ ankylosis may have higher hemoglobin concentrations and packed cell volume than the nonankylosed individuals.
While the literature is replete with published reports on TMJ ankylosis with majority geared toward restoration of function and prevention of reankylosis,,,,, there is no previous study on hematological profiles of patients with TMJ ankylosis, to the best of the authors' knowledge. The aim of this study was to determine if there was any relationship between patients with TMJ ankylosis and hemoglobin concentration/hematocrit values and to channel the information obtained toward better patient management.
| Materials and Methods|| |
The study was a prospective comparative study of all consecutive patients with TMJ ankylosis who presented to the Oral and Maxillofacial Unit of the Teaching Hospital from January 2010 to December 2012. Ethical Clearance (ethical clearance number - NHREC/21/08/2008/AKTH/EC/1399) was obtained from the Hospital Ethics Committee.
Informed consents were obtained from the recruited participants and assents from children below the age of consent after adequate explanation. All patients with clinical and radiologic evidence of ankylosis who consented to the study were recruited. However, patients with a history of sleep apnea, chronic obstructive airway diseases as well as cigarette smokers were excluded from the study. Also excluded were patients who showed any clinical feature suggestive of dehydration and patients with hemoglobinopathy (sickle cell disease or thalassemias) and active malaria.
The information obtained included the age, gender, types of ankylosis, etiology, and duration of ankylosis. Then, all patients had their maximum interincisal distance (measured in millimeters using a cleft measuring ruler) and the diameter of their pharynx determined. The hemoglobin concentration and hematocrit values were also assessed for all the patients who participated in the study.
The blood for the hematologic parameters in all the patients was obtained by the same coresearcher. After explaining the procedure to the patient, each patient was made to either sit comfortably in a chair or lie comfortably in a bed, after which the researcher washed his hands and then gloved; a suitable site for venepuncture was selected. A tourniquet was then placed 3–4 inches above the selected puncture site after which the researcher palpates for a vein. When a vein is selected, the area was cleansed in a circular motion, beginning at the site and working outward. The area is then allowed to air dry. The patient is asked to make a fist, after which the patient's arm is grasped firmly using the thumb to draw the skin taut and anchor the vein, the needle is swiftly inserted through the skin into the lumen of the vein. The needle should form a 15°–30° angle with the arm surface. Then, 5 ml of blood is drawn and placed into a heparinized sample bottle. The tourniquet is removed and the needle pulled from the patient's arm. A gauze is placed on the puncture site while applying adequate pressure to avoid formation of a hematoma. The sample is then analyzed in the laboratory.
To determine the hematocrit values, a capillary tube is three quarters filled with well-mixed, venous blood. One end of the tube is sealed with clay. The filled tube is placed in the microhematocrit centrifuge, with the plugged end away from the center of the centrifuge. Centrifuge is preset to a speed of 10,000 rpm for 5 min. Then, the tube is placed in the microhematocrit reader and read.
While to determine the hemoglobin concentration, blood is taken from the heparinized sample bottle and the test is performed by an automated cell counter. In this assay, all forms of hemoglobin are converted to the colored protein cyanomethemoglobin and measured by a colorimeter.
The size of the pharynx was evaluated indirectly by measuring the distance between the angles of the mandible, with the neck in an extended position. The distance between one mandibular angle stretching across the upper part of the neck anteriorly to the contralateral angle was evaluated using a flexible centimeter tape. These measurements were standardized and carried out by one of the investigators.
The hematological values and the distance between the angles of the mandible in the TMJ ankylosed patients were compared with those of nonankylosed, age- and sex-matched apparently healthy patients, who presented to the maxillofacial surgery clinic during the period of study.
Data obtained were analyzed using the Statistical Package for Social Sciences (SPSS version 13 Chicago IL, SPSS Inc.). Comparative statistics was done using Chi-square test or Student's t-test as appropriate. Whereas multivariate analysis was carried out to determine the variables accounting for the difference in hematocrit and hemoglobin concentration in the two group. A P ≤ 0.05 was considered statistically significant.
| Results|| |
A total of twenty patients with TMJ ankylosis, comprising males 11.0 (55.0%) and females 9.0 (45.0%) who met the inclusion criteria were enrolled into the study. The ages ranged from 10 to 35 years, mean 20.8 ± 5.53, and the difference between the mean ages of male and females was not statistically significant (t = 0.826, P= 0.420). They all presented with bony type of TMJ ankylosis. Trauma (55.0%) and cancrum oris (40.0%) were the most common etiologic factors. The duration of ankylosis ranged from 1 to 18 years (mean, 9.05 ± 5.43) [Table 1].
|Table 1: Demographics and clinical characteristics of patients with temporomandibular joint ankylosis|
Click here to view
The hemoglobin concentration ranged from 11.9 to 16.2 g/dl (mean, 13.49 ± 1.67) while the hematocrit values ranged from 34.0% to 48.0% (mean, 39.35 ± 5.63) and there was no gender difference with respect to both parameters of hemoglobin concentration (P = 0.095) and hematocrit values (P = 0.114). There was a positive correlation between the duration of ankylosis and the hemoglobin concentration (r = 0.471, df = 17, P= 0.042) and hematocrit value (r = 0.457, df = 17, P= 0.049), respectively.
Corresponding age- and sex-matched controls were also recruited for the study. The baseline demographic parameters in patients with TMJ ankylosis and the nonankylotic controls are shown in [Table 2]. There was equitable distribution of the parameters between both groups (P > 0.05). There was, however, a statistically significant difference between the mean dimensions of the pharyngeal width in the controls and ankylosed patients (16.2 ± 1.52 cm vs. 10.08 ± 0.98 cm) (P < 0.0001). Both hematological parameters were found to be significantly higher than the values in the nonankylosed patients with a mean difference of 1.57 g/dl (P = 0.001) and 6.28% (P = 0.001) for hemoglobin concentration and hematocrit values, respectively [Table 3].
|Table 3: Hemoglobin concentration and hematocrit values in ankylosed versus nonankylosed patients|
Click here to view
Multivariate analysis of the variables shows that age and gender had no effect on the values of hematocrit and hemoglobin concentration between the ankylotic and not ankylotic groups [Table 4].
|Table 4: Multivariate analysis of variables accounting for differences in hematocrit and hemoglobin concentration in ankylotic and nonankylotic groups|
Click here to view
| Discussion|| |
This study evaluated the level of hemoglobin concentration and the hematocrit values in patients with TMJ ankylosis and in nonankylosed controls. Our study question was: Is there a significant difference in the hemoglobin and hematocrit levels between patients with TMJ ankylosis and those without restriction of mouth opening?
To adequately answer this question, the study designed was prospective and comparative between age- and sex-matched patients with TMJ ankylosis and those without. Patients were recruited consecutively as they presented, this was to enable us remove bias and they were age and sex matching to improve precision and eliminate confounding factors. Comparative statistics using Chi-square test or Student's t-test were appropriate was carried out to ensure that there was no statistically significant difference in gender and age between the two study groups as well as to determine if the difference in hemoglobin and hematocrit levels between the ankylosed and nonankylosed was significant. After which the multivariate analysis was carried out to determine the variables accounting for the difference in hematocrit and hemoglobin concentration in the two group. All these factors were to help improve the strength of the study.
The results of this study showed a significant difference in the levels of hemoglobin concentration with a mean difference of 1.57 g/dl, between ankylosed patients and the nonankylosed controls. A similar significant difference was observed with respect to the hematocrit value between patients with TMJ ankylosis and the nonankylosed patients (mean difference = 6.28%). Although the reasons for this observed difference are not known, it is likely, however, that the high levels of hemoglobin concentrations and the hematocrit values observed in patients with TMJ ankylosis could be due to compensatory mechanisms aimed at delivering enough oxygen to the tissues. Patients with TMJ ankylosis have been reported to have some degree of airway obstruction due to the morphological defect in the mandible (retrognathia), relative macroglossia, and alteration of the normal anatomy of the upper airway.,, In addition, in a growing child, TMJ ankylosis leads to shortening of mandibular rami and narrowing of space between the angle of the mandible as well as sub-atmospheric intrapharyngeal pressure and hypotonicity of oropharyngeal muscles thereby resulting in narrowing of the oropharyngeal airway. All these mechanisms lead to increased airway resistance, airway obstruction, and consequently reduced pulmonary functions. In the present study, all of the patients presented with bony ankylosis, with a maximum interincisal distance <5 mm.
In a morphologically distorted airway, normal flow of air in and out of the lungs may be altered which may result in relative hypoxia. This situation may be analogous to people living in high altitude where the oxygen tension may be lower than the normal atmospheric values. The normal bodily response to this kind of scenario is through increase in the blood levels of endogenous erythropoietin (EPO) and this stimulates increase in RBCs production. One of the most extensively studied systemic adaptations to hypoxia is the stimulation of RBC production. There has been reported associations between reduced atmospheric oxygen pressure and elevated RBC numbers in the blood of animals and humans.,, The hypoxic induction of EPO serves as a paradigm of oxygen-dependent gene regulation, and the search for the transcription factor that mediates this induction led to the discovery of the hypoxia-inducible factor (HIF) as a key mediator of cellular adaptation to low oxygen. An experimental evidence suggested that HIF promotes erythropoiesis through coordinated cell type-specific hypoxia responses, which include increased EPO production in the kidney and liver, enhanced iron uptake and utilization as well as changes in the bone marrow microenvironment that facilitate erythroid progenitor maturation and proliferation.
This study has demonstrated a raise in hematocrit and hemoglobin values obtained in patients with TMJ ankylosis. Multivariate analysis of the variables shows that age and gender had no effect on the values of hematocrit and hemoglobin concentration between the ankylotic and not ankylotic groups. The observed changes are being accounted for solely by differences in anatomy of the upper oropharyngeal structures in the two treatment groups.
The clinical relevance of this study is that this study has demonstrate that patients with ankylosis can comfortably be good candidates for autologous blood transfusion, especially as large volumes of blood loss are anticipated in complex surgical procedures involving excision of the ankylotic mass, orthognathic surgery, raising of temporalis fascia flaps as interposition material or distraction osteogenesis, especially in our setting, where voluntary blood donation is nonexisting or inadequate.
In the light of these findings, we would recommend that patients with TMJ ankylosis should as part of their treatment protocol, especially in environments, where blood for transfusion is not readily available act as autologous donors for their own treatment. This would help ensure that they have enough blood to be transfused as blood loss is generally expected in the surgery. In addition, the risk of transfusion-related reactions and infections which are possible occurrences in multiple blood transfusions are eliminated.
The limitation of this study may be the relatively small sample size. More research is needed with a larger study population to validate the result of the present study.
Suggested line of the future research could include an attempt to study the molecular mechanisms that may have accounted for this significant rise in hemoglobin and hematocrit values of patients with TMJ ankylosis. In addition, sleep study on ankylosed patients to determine if airway obstruction occurs during sleep should be carried out. This may throw further light into the pathophysiologic mechanisms of the observed changes in hematologic parameters.
| Conclusion|| |
Patients with TMJ ankylosis were found to have higher values of hemoglobin concentration and hematocrit values than the nonankylosed individuals. This information could be used to putgood use in the subsequent management of these patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Brkic Z, Pijevcevic V, Petronijevic M. Oral rehabilitation of patient with temporomandibular joint ankylosis caused by ankylosing spondilitis: A case presentation. Vojnosanit Pregl 2017;74:374–377. [Doi: 10.2298/VSP1505522189].
Zanaty O, El Metainy S, Abo Alia D, Medra A. Improvement in the airway after mandibular distraction osteogenesis surgery in children with temporomandibular joint ankylosis and mandibular hypoplasia. Paediatr Anaesth 2016;26:399-404.
Amuwha GO, Saheeb BD. Pulmonary function of adult Nigerians placed on intermaxillary fixation. J Maxillofac Oral Surg 2009;8:43-6.
Felstead AM, Revington PJ. Surgical management of temporomandibular joint ankylosis in ankylosing spondylitis. Int J Rheumatol 2011;2011:854167.
Alday LE, Vega PJ, Heller A. Congenital ankylosis of the temporomandibular joint: Resultant upper airway obstruction and cor pulmonale. Chest 1979;75:384-6.
Prabhakar AR, Rai KK, Bedi S. Management of congenital bilateral temporomandibular joint ankylosis with secondary mandibular hypoplasia. J Pediatr Surg 2008;43:e27-30.
Storz JF. Evolution. Genes for high altitudes. Science 2010;329:40-1.
Movahed R, Mercuri LG. Management of temporomandibular joint ankylosis. Oral Maxillofac Surg Clin North Am 2015;27:27-35.
Yan YB, Liang SX, Shen J, Zhang JC, Zhang Y. Current concepts in the pathogenesis of traumatic temporomandibular joint ankylosis. Head Face Med 2014;10:35.
Dongmei H, Minjie C, Yatting Q, Lingzbi L. Traumatic temporomandibular joint ankylosis: Our classification and treatment experience. J Oral Maxillofac Surg 2011;69:1600-7.
Ko EC, Chen MY, Hsu M, Huang E, Lai S. Intraoral approach for arthroplasty for correction of TMJ ankylosis. Int J Oral Maxillofac Surg 2009;38:1256-62.
Wahal R. Temporo-mandibular joint ankylosis - The difficult airway. J Oral Biol Craniofac Res 2015;5:57-8.
Shah FR, Sharma KR, Hilloowalla RN, Karandikar AD. Anaesthetic considerations of temporomandibular joint ankylosis with obstructive sleep apnoea: A case report. J Indian Soc Pedod Prev Dent 2002;20:16-20.
Zhong R, Liu H, Wang H, Li X, He Z, Gangla M, et al.
Adaption to high altitude: An evaluation of the storage quality of suspended red blood cells prepared from the whole blood of Tibetan plateau migrants. PLoS One 2015;10:e0144201.
Blanchard KL, Acquaviva AM, Galson DL, Bunn HF. Hypoxic induction of the human erythropoietin gene: Cooperation between the promoter and enhancer, each of which contains steroid receptor response elements. Mol Cell Biol 1992;12:5373-85.
[Table 1], [Table 2], [Table 3], [Table 4]