physical evaluation of the dental patient dr. nelson l. rhodus diplomate, american board of oral...
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Physical Evaluation of the Dental Patient
Dr. Nelson L. RhodusDiplomate, American Board of Oral
Medicine
Morse Alumni Distinguished Professor
Director of Oral Medicine
University of Minnesota
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Clinical laboratory testing
Relevant to dentistry Indications
• Signs and symptoms of disease• High risk groups• Confirm clinical diagnosis
Categories of lab tests• Diagnostic• Screening
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THE DIAGNOSTIC PROCESS
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Clinical laboratory testing
Lab tests used frequently by DDS
CBC( complete blood count)• Hemoglobin• Hematocrit• RBC, WBC• Differential WBC
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Clinical laboratory testing
Lab tests used frequently by DDS
Bleeding studies• PT( INR): Prothrombin Time• PTT ( INR): Partial Thromboplastin Time• BT: Bleeding time• Platelet count
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Clinical laboratory testing
Lab tests used frequently by DDS Fasting blood glucose
( 126 mg %)Hb A 1 C
Infectious diseases:HBV, HCV, HIV, other
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Clinical laboratory testing
Lab tests used frequently by DDS
DDS should have a working concept of WNL( range)
Errors in testing Clinical scenario MOST IMPORTANT! May need to repeat test in light of clinical
impression
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Clinical laboratory testing Lab tests used frequently by DDS CBC : RBC 4.6 - 6.2 million /cc- male 4.2 - 5.4 million/cc- female Erythrocytopenia=Decrease= Anemias
Fe, B-12, folate, pernicious, sickle cell Erythrocytosis= Increase= Polycythemia
dehydration, infection-fever
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Clinical laboratory testing
Lab tests used frequently by DDS CBC : Hemoglobin ( Hb) Oxygen-carrying capacity 13.5- 18.0 g/100cc - males 11.5- 16.4 g/100cc - females
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Clinical laboratory testing
Lab tests used frequently by DDS CBC : Hematocrit ( Hct) Volume of RBCs per 100 cc of blood 40 - 52 % - males 35- 47 % - females
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Clinical laboratory testing
Lab tests used frequently by DDS CBC : mean corpuscular hemoglobin
( MCH) Average Hb content of each RBC 27-32 pg
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Clinical laboratory testing
Lab tests used frequently by DDS CBC : erythrocyte sedimentation rate
( ESR)= aggregated RBCs WNL < 20 mm/hr. Inflammation Increase= tissue destruction
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Clinical laboratory testing Lab tests used frequently by DDS CBC : WBC 5,000 - 10,000 / cc Leukocytosis= increased WBC
infection, RF, allergies, necrosis, exercise, pregnancy, stress, drugs, LEUKEMIA
Leukopenia= decreased WBChypovolemia, early leukemia, drugs, radiation, blood dyscrasias
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Clinical laboratory testing Lab tests used frequently by DDS CBC : differential WBC Neutrophils( segmented) = 50-70%
Neutrophils( band) = 0- 5% Lymphocytes = 25-40% Monocytes = 4-8% Eosinophils = 1- 4% Basophils = 0- 1%
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Clinical laboratory testing Lab tests used frequently by DDS CBC : differential WBC LEUKEMIAS Acute lymphocytic( lymphoblastic) leukemia Acute myelogenous leukemia Chronic lymphocytic( lymphoblastic)
leukemia Chronic myelogenous leukemia
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Clinical laboratory testing Lab tests used frequently by DDS CBC : differential WBC LYMPHOMAS Hodgkin’s, non- Hodgkin’s, Burkitt’s
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Clinical laboratory testing Neutrophilic leukocytosis: bacterial
infections, inflammatory disorders, drug reactions, leukemia
Lymphocytosis: bacterial infections, viral infections,
leukemia Eosinophilic leukocytosis:
allergic reactions
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Clinical laboratory testing
BLOOD CHEMISTRY SMA-12/60
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Clinical laboratory testing
BLOOD CHEMISTRY BONE METABOLISM Calcium, Phosphorous, Alkaline
phosphatase
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Clinical laboratory testing BLOOD CHEMISTRY BONE METABOLISM Calcium, Phosphorous, Alkaline
phosphatase Hyperparathyroidism, Multiple myeloma Paget’s disease, fibrous dysplasia Osteoporosis , Cancer
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Clinical laboratory testing BLOOD CHEMISTRY BONE METABOLISM Calcium 9.0-10.5 mg% Hypocalcemia: hypoparathyroidism, Vit. D
deficicency, preganancy, diuretics
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Clinical laboratory testing BLOOD CHEMISTRY BONE METABOLISM Phosphorus 3.0- 4.5 mg% Hyperphosphatemia: hypoparathyroidism, renal
disease, hyperthyroidism, hypervitaminoisis D Hypophosphatemia: hyperparathyroidism,
malabsorption, Vit. D deficiency
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Clinical laboratory testing BLOOD CHEMISTRY BONE METABOLISM Alkaline phosphatase 25 - 115 Units/L Elevated: hyperparathyroidism, Paget’s,
sarcomas, metastatic carcinoma, growth
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Clinical laboratory testing BLOOD CHEMISTRY RENAL FUNCTION TESTS BUN ( blood urea nitrogen) Uric Acid Creatinine
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Clinical laboratory testing BLOOD CHEMISTRY RENAL FUNCTION TESTS BUN ( blood urea nitrogen) 8-18 mg% Uric acid 2.4-7.5 mg % Increased: Chronic renal failure, chemo-Tx,
lymphoproliferative disease, gout , acidosis
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Clinical laboratory testing BLOOD CHEMISTRY RENAL FUNCTION TESTS Creatinine 0.6-1.2 mg% Increased: Chronic renal failure, CHF,
acromegaly, dehydration, diabetes, shock
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Clinical laboratory testing BLOOD CHEMISTRY LIVER FUNCTION TESTS LDH: lactate dehydrogenase AST: aspartate aminotransferase ALT: alanine aminotransferase( SGPT) Alkaline phosphatase Bilirubin, Protein, Albumin
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Clinical laboratory testing BLOOD CHEMISTRY LIVER FUNCTION TESTS LDH: lactate dehydrogenase 50-240 Units/L ALT 0-40 Units/L
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Clinical laboratory testing BLOOD CHEMISTRY LIVER FUNCTION TESTS LDH and ALT increased: MI, liver disease, mononucleosis, renal
disease, anemia, pancreatitis, skeletal muscle damage
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Clinical laboratory testing BLOOD CHEMISTRY LIVER FUNCTION TESTS Bilirubin 02.-1.5 mg % liver disease: hepatitis, cirrhosis, drug
toxicities
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Clinical laboratory testing BLOOD CHEMISTRY LIVER FUNCTION TESTS Total protein 5.6-8.4 g % Albumin= 3.4- 5.4 g % Globulins= 2.2-3.0 g % liver disease: cirrhosis, chronic infections, Multiple myeloma
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Clinical laboratory testing BLOOD CHEMISTRY BLOOD GLUCOSE 70-100 mg % Fasting > 126 mg % = diabetes Increased : corticosteroids, catecholamines,
growth hormone, CHF, diuretics
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Clinical laboratory testing BLOOD CHEMISTRY SERUM CHOLESTEROL <200 mg % Elevated : hypercholesterolemia risk for
ASCVD( MI)
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Normal control of bleeding Vascular phase Platelet phase Coagulation phase
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bleeding problems Inherited Acquired Drug therapy
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Detection of the patient with bleeding problems Prothrombin time( PT ) or
International Normalized Ratio (INR) Partial thromboplastin time (PTT) Thrombin time (TT) Bleeding time (BT) Platelet count
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Prothrombin time (PT) activated by tissue thromboplastin tests
extrinsic and common pathways run with a control ( variable with lab :
therefore: INR) normal= 11-15 seconds prolonged time = abnormal
( significant for dentistry > 2.5, 3.0, 3.5...)
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Activated partial thromboplastin time (PTT)
Contact activator( kaolin) tests the intrinsic and common pathways run with a control normal= 25-35 seconds prolonged ( 2.5, 3.0, 3.5...)= abnormal
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Thrombin time(TT) activated by thrombin tests the ability to form a solid clot run with a control normal= 9-13 seconds prolonged( 2.5, 3.0, 3.5,...) = abnormal
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Ivy bleeding time (IBT) tests vascular and platelet status Immediate factors in control of bleeding normal = 1-6 minutes abnormal = prolonged time
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Platelet count tests numbers of platelets present to form
clot normal= 140,000 to 400,000 / cc bleeding problems < 50,000/cc
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Thrombocytopenia platelet count ~ 50,000 ( with or without
platelet replacement) < 50,000 = bleeding problem
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Bleeding disorders Nonthrombocytopenic purpuras
• vascular wall alterations• platelet function disorder
Thrombocytopenic purpuras• Primary ( genetic)• secondary( acquired: drugs, diseases)
Disorders of coagulation• inherited, acquired
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Microbiological exam Sample collection ( bacterial, fungal, etc.) Lesion Transport media Clinical information: site, nature, differential
diagnosis ID organism Antimicrobial sensitivity : long-term Rx, diabetes,
immunosuppressed, refractory to Tx Closely follow course of TX
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Diabetes mellitus Detection and management
Dr. Nelson L. Rhodus
Director of Oral Medicine
University of Minnesota
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Cytology
Exfoliative cytology ( Oral CDx)= “brush biopsy”…….. PAP smear
Scrape off surface of lesion to BM if possible
Useful for : HSV, Candidiasis, pemphigus, some bacteria, cellular atypia
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QuickTime™ and a decompressor
are needed to see this picture.
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Exfoliative cytology
Oral CDx ® ( “brush biopsy”) some, limited clinical diagnostic
value( decide to Bx) irregular epilthelial cells (not flat) enlarged, irregular size and shape of
nuclei hyperchromatic nuclei
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ORAL CANCERDETECTION
CLINICAL vs. DEFINITIVE DIAGNOSIS
HISTOPATHOLOGY ..MUST !! lesion with MODERATE DEGREE of
clinical suspicion ...BIOPSY lesion with HIGH DEGREE of clinical
suspicion...REFER
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Leukoplakia to SCCA
mean age 63; F = M time to transformation = 7.2 years precedent dysplasia= 17% 17 % WITH Bx-proven dysplasia >>>
SCCA in 3 yrs.
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Biopsy
Excisional- entire lesion is removed Incisional- portion of large lesion Punch Fine-needle aspiration Oral pathologist Clinical information to pathologist
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Toludine blue
Ora-scan® binds to DNA 93 % accurate = adjunct uptake= high yield + margins false + ves
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Candida speciesCandida species
several common species in oral cavity Candida may proliferate with
immunosuppression increase in Candida counts with decreased
salivary flow associated with diabetes, hematologic
abnormalities and several other disorders including Sjogren’s syndrome
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Diascopy
Detects blood in a blisterform lesion Press on lesion with a glass microscope
slide If color blanches= blood-filled Oxidized vs. reduced blood
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FNA
salivary glands lymph nodes 22 gauge needle + 10 - 20 ml
syringe cytology
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Asdvanced laboratory techniques DNA testing( microarray, RT-pcr, etc.) Cytogenetics, chromosomal Viral testing ELISA, enzyme assays Immunofluorescence Antibodies Salivary scintigraphy MRI, CT , etc.
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QuickTime™ and a decompressor
are needed to see this picture.
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Candidiasis
53% in SCCA ; 31 % in WNL chronic fungi : epithelial adhesion immunoincompetence higher correlation with leukoplakias to
SCCA transformation (61%)