Physical Evaluation of the Dental Patient

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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

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6th edition 2002
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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

CLINICAL EXAM
LABORATORY TESTS
HISTORY
ASSESSMENT
DIAGNOSIS
TREATMENT PLAN
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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
• ErythrocytopeniaDecrease 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 lt 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 WBC hypovolemia, 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
• Hodgkins, non- Hodgkins, Burkitts

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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
• Pagets 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, Pagets, 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 gt 126 mg diabetes
• Increased corticosteroids, catecholamines,
  growth hormone, CHF, diuretics

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Clinical laboratory testing

• BLOOD CHEMISTRY
• SERUM CHOLESTEROL
• lt200 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 gt 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 lt 50,000/cc

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Thrombocytopenia

• platelet count 50,000 ( with or without
  platelet replacement)
• lt 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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cellulitis
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incision and drainage
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Antibiotic culture and sensivitiy testing
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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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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 gtgtgt 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 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 Sjogrens 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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MRI of pleomorphic adenoma of the right parotid
gland
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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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p53 distribution in LP
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Candidiasis

• 53 in SCCA 31 in WNL
• chronic fungi epithelial adhesion
• immunoincompetence
• higher correlation with leukoplakias to SCCA
  transformation (61)