Physical Evaluation of the Dental Patient Dr. Nelson L. Rhodus Diplomate, American Board of Oral Medicine Morse Alumni Distinguished Professor Director of Oral Medicine University of Minnesota
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
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%)