Physical Evaluation of the Dental PatientDr. Nelson L. RhodusDiplomate, American Board of Oral MedicineMorse Alumni Distinguished ProfessorDirector of Oral MedicineUniversity of Minnesota

Clinical laboratory testingRelevant to dentistryIndicationsSigns and symptoms of diseaseHigh risk groupsConfirm clinical diagnosisCategories of lab testsDiagnosticScreening

THE DIAGNOSTIC PROCESS

Clinical laboratory testingLab tests used frequently by DDS

CBC( complete blood count)HemoglobinHematocritRBC, WBCDifferential WBC

Clinical laboratory testingLab tests used frequently by DDS

Bleeding studiesPT( INR): Prothrombin TimePTT ( INR): Partial Thromboplastin TimeBT: Bleeding timePlatelet count

Clinical laboratory testingLab tests used frequently by DDSFasting blood glucose( 126 mg %)Hb A 1 C

Infectious diseases:HBV, HCV, HIV, other

Clinical laboratory testingLab tests used frequently by DDS

DDS should have a working concept of WNL( range)Errors in testingClinical scenario MOST IMPORTANT!May need to repeat test in light of clinical impression

Clinical laboratory testingLab tests used frequently by DDSCBC : RBC4.6 - 6.2 million /cc- male4.2 - 5.4 million/cc- femaleErythrocytopenia=Decrease= AnemiasFe, B-12, folate, pernicious, sickle cellErythrocytosis= Increase= Polycythemia dehydration, infection-fever

Clinical laboratory testingLab tests used frequently by DDSCBC : Hemoglobin ( Hb)Oxygen-carrying capacity13.5- 18.0 g/100cc- males11.5- 16.4 g/100cc - females

Clinical laboratory testingLab tests used frequently by DDSCBC : Hematocrit ( Hct)Volume of RBCs per 100 cc of blood40 - 52 %- males35- 47 %- females

Clinical laboratory testingLab tests used frequently by DDSCBC : mean corpuscular hemoglobin( MCH)Average Hb content of each RBC 27-32 pg

Clinical laboratory testingLab tests used frequently by DDSCBC : erythrocyte sedimentation rate ( ESR)= aggregated RBCsWNL < 20 mm/hr.InflammationIncrease= tissue destruction

Clinical laboratory testingLab tests used frequently by DDSCBC : WBC5,000 - 10,000 / ccLeukocytosis= increased WBC infection, RF, allergies, necrosis, exercise, pregnancy, stress, drugs, LEUKEMIALeukopenia= decreased WBChypovolemia, early leukemia, drugs, radiation, blood dyscrasias

Clinical laboratory testingLab tests used frequently by DDSCBC : differential WBCNeutrophils( segmented) = 50-70% Neutrophils( band) = 0- 5%Lymphocytes=25-40%Monocytes= 4-8%Eosinophils= 1- 4%Basophils= 0- 1%

Clinical laboratory testingLab tests used frequently by DDSCBC : differential WBCLEUKEMIASAcute lymphocytic( lymphoblastic) leukemiaAcute myelogenous leukemiaChronic lymphocytic( lymphoblastic) leukemiaChronic myelogenous leukemia

Clinical laboratory testingLab tests used frequently by DDSCBC : differential WBCLYMPHOMASHodgkins, non- Hodgkins, Burkitts

Clinical laboratory testingNeutrophilic leukocytosis: bacterial infections, inflammatory disorders, drug reactions, leukemiaLymphocytosis: bacterial infections, viral infections, leukemiaEosinophilic leukocytosis: allergic reactions

Clinical laboratory testingBLOOD CHEMISTRYSMA-12/60

Clinical laboratory testingBLOOD CHEMISTRYBONE METABOLISMCalcium, Phosphorous, Alkaline phosphatase

Clinical laboratory testingBLOOD CHEMISTRYBONE METABOLISMCalcium, Phosphorous, Alkaline phosphataseHyperparathyroidism, Multiple myelomaPagets disease, fibrous dysplasiaOsteoporosis , Cancer

Clinical laboratory testingBLOOD CHEMISTRYBONE METABOLISMCalcium9.0-10.5 mg%Hypocalcemia: hypoparathyroidism, Vit. D deficicency, preganancy, diuretics

Clinical laboratory testingBLOOD CHEMISTRYBONE METABOLISMPhosphorus3.0- 4.5 mg%Hyperphosphatemia: hypoparathyroidism, renal disease, hyperthyroidism, hypervitaminoisis DHypophosphatemia: hyperparathyroidism, malabsorption, Vit. D deficiency

Clinical laboratory testingBLOOD CHEMISTRYBONE METABOLISMAlkaline phosphatase25 - 115 Units/LElevated: hyperparathyroidism, Pagets, sarcomas, metastatic carcinoma, growth

Clinical laboratory testingBLOOD CHEMISTRYRENAL FUNCTION TESTSBUN ( blood urea nitrogen)Uric AcidCreatinine

Clinical laboratory testingBLOOD CHEMISTRYRENAL FUNCTION TESTSBUN ( blood urea nitrogen)8-18 mg%Uric acid2.4-7.5 mg %Increased: Chronic renal failure, chemo-Tx, lymphoproliferative disease, gout , acidosis

Clinical laboratory testingBLOOD CHEMISTRYRENAL FUNCTION TESTSCreatinine0.6-1.2 mg%Increased: Chronic renal failure, CHF, acromegaly, dehydration, diabetes, shock

Clinical laboratory testingBLOOD CHEMISTRYLIVER FUNCTION TESTSLDH: lactate dehydrogenaseAST: aspartate aminotransferaseALT: alanine aminotransferase( SGPT)Alkaline phosphataseBilirubin, Protein, Albumin

Clinical laboratory testingBLOOD CHEMISTRYLIVER FUNCTION TESTSLDH: lactate dehydrogenase50-240 Units/LALT0-40 Units/L

Clinical laboratory testingBLOOD CHEMISTRYLIVER FUNCTION TESTSLDH and ALT increased:MI, liver disease, mononucleosis, renal disease, anemia, pancreatitis, skeletal muscle damage

Clinical laboratory testingBLOOD CHEMISTRYLIVER FUNCTION TESTSBilirubin02.-1.5 mg %liver disease: hepatitis, cirrhosis, drug toxicities

Clinical laboratory testingBLOOD CHEMISTRYLIVER FUNCTION TESTSTotal protein5.6-8.4 g %Albumin= 3.4- 5.4 g %Globulins= 2.2-3.0 g %liver disease: cirrhosis, chronic infections,Multiple myeloma

Clinical laboratory testingBLOOD CHEMISTRYBLOOD GLUCOSE70-100 mg %Fasting > 126 mg % = diabetesIncreased : corticosteroids, catecholamines, growth hormone, CHF, diuretics

Clinical laboratory testingBLOOD CHEMISTRYSERUM CHOLESTEROL

Normal control of bleedingVascular phasePlatelet phaseCoagulation phase

bleeding problemsInheritedAcquiredDrug therapy

Detection of the patient with bleeding problemsProthrombin time( PT ) or International Normalized Ratio (INR)Partial thromboplastin time (PTT)Thrombin time (TT)Bleeding time (BT)Platelet count

Prothrombin time (PT)activated by tissue thromboplastintests extrinsic and common pathwaysrun with a control ( variable with lab : therefore: INR)normal= 11-15 secondsprolonged time = abnormal ( significant for dentistry > 2.5, 3.0, 3.5...)

Activated partial thromboplastin time (PTT)Contact activator( kaolin)tests the intrinsic and common pathwaysrun with a controlnormal= 25-35 secondsprolonged ( 2.5, 3.0, 3.5...)= abnormal

Thrombin time(TT)activated by thrombintests the ability to form a solid clotrun with a controlnormal= 9-13 secondsprolonged( 2.5, 3.0, 3.5,...) = abnormal

Ivy bleeding time (IBT)tests vascular and platelet statusImmediate factors in control of bleedingnormal = 1-6 minutesabnormal = prolonged time

Platelet counttests numbers of platelets present to form clotnormal= 140,000 to 400,000 / ccbleeding problems < 50,000/cc

Thrombocytopeniaplatelet count ~ 50,000 ( with or without platelet replacement)< 50,000 = bleeding problem

Bleeding disordersNonthrombocytopenic purpurasvascular wall alterationsplatelet function disorderThrombocytopenic purpurasPrimary ( genetic)secondary( acquired: drugs, diseases)Disorders of coagulationinherited, acquired

Microbiological examSample collection ( bacterial, fungal, etc.)LesionTransport mediaClinical information: site, nature, differential diagnosisID organismAntimicrobial sensitivity : long-term Rx, diabetes, immunosuppressed, refractory to TxClosely follow course of TX

Diabetes mellitus Detection and managementDr. Nelson L. RhodusDirector of Oral MedicineUniversity of Minnesota

CytologyExfoliative cytology ( Oral CDx)= brush biopsy.. PAP smear

Scrape off surface of lesion to BM if possibleUseful for : HSV, Candidiasis, pemphigus, some bacteria, cellular atypia

Exfoliative cytologyOral CDx ( brush biopsy)some, limited clinical diagnostic value( decide to Bx)irregular epilthelial cells (not flat)enlarged, irregular size and shape of nucleihyperchromatic nuclei

ORAL CANCERDETECTIONCLINICAL vs. DEFINITIVE DIAGNOSISHISTOPATHOLOGY ..MUST !!lesion with MODERATE DEGREE of clinical suspicion ...BIOPSYlesion with HIGH DEGREE of clinical suspicion...REFER

Leukoplakia to SCCAmean age 63; F = M time to transformation = 7.2 yearsprecedent dysplasia= 17%17 % WITH Bx-proven dysplasia >>> SCCA in 3 yrs.

BiopsyExcisional- entire lesion is removedIncisional- portion of large lesionPunchFine-needle aspirationOral pathologistClinical information to pathologist

Toludine blueOra-scanbinds to DNA93 % accurate = adjunctuptake= high yield + marginsfalse + ves

Candida speciesseveral common species in oral cavityCandida may proliferate with immunosuppressionincrease in Candida counts with decreased salivary flowassociated with diabetes, hematologic abnormalities and several other disorders including Sjogrens syndrome

DiascopyDetects blood in a blisterform lesionPress on lesion with a glass microscope slideIf color blanches= blood-filledOxidized vs. reduced blood

FNAsalivary glandslymph nodes22 gauge needle + 10 - 20 ml syringecytology

Asdvanced laboratory techniquesDNA testing( microarray, RT-pcr, etc.)Cytogenetics, chromosomalViral testingELISA, enzyme assaysImmunofluorescenceAntibodiesSalivary scintigraphyMRI, CT , etc.

Candidiasis53% in SCCA ; 31 % in WNLchronic fungi : epithelial adhesionimmunoincompetencehigher correlation with leukoplakias to SCCA transformation (61%)