lab investestigations and their implications

Diagnosis and treatment in dentistry are based on clinical examination of the patients. Given that the major oral diseases are of microbial biofilm etiology, it can be expected that performing microbiological analysis on samples collected from the patient could deliver supportive evidence to facilitate the decision-making process by the clinician. Applicable microbiological methods range from microscopy, to culture, to molecular techniques, which can be performed easily within dedicated laboratories proximal to the clinics, such as ones in academic dental institutions. Periodontal and endodontic infections, along with odontogenic abscesses, have been identified as conditions in which applied clinical microbiology may be beneficial for the patient. Administration of antimicrobial agents, backed by microbiological analysis, can yield more predictable treatment outcomes in refractory or early-occurring forms of periodontitis. Confirming a sterile root canal using a culture-negative sample during endodontic treatment may ensure the longevity of its outcome and prevent secondary infections. Susceptibility testing of samples obtained from odontogenic abscesses may facilitate the selection of the apDiagnosis and treatment in dentistry are based on clinical examination of the patients. Given that the major oral diseases are of microbial biofilm etiology, it can be expected that performing microbiological analysis on samples collected from the patient could deliver supportive evidence to facilitate the decision-making process by the clinician. Applicable microbiological methods range from microscopy, to culture, to molecular techniques, which can be performed easily within dedicated laboratories proximal to the clinics, such as ones in academic dental institutions. Periodontal and endodontic infections, along with odontogenic abscesses, have been identified as conditions in which applied clinical microbiology may be beneficial for the patient. Administration of antimicrobial agents, backed by microbiological analysis, can yield more predictable treatment outcomes in refractory or early-occurring forms of periodontitis. Confirming a sterile root canal using a culture-negative sample during endodontic treatment may ensure the longevity of its outcome and prevent secondary infections. Susceptibility testing of samples obtained from odontogenic abscesses may facilitate the selection of the apDiagnosis and treatment in dentistry are based on clinical examination of the patients. Given that the major oral diseases are of microbial biofilm etiology, it can be expected that performing microbiological analysis on samples collected from the patient could deliver supportive evidence to facilitate the decision-making process by the clinician. Applicable microbiological methods range from microscopy, to culture, to molecular techniques, which can be performed easily within dedicated laboratories proximal to the clinics, such as ones in academic dental institutions. Pe

1. Lab investigations

2. INTRODUCTION Evidence shows case history and clinical examination usually reveal most if not all of clinical relevant data Hence there remains a need to confirm our clinical impression Lab investigations supplement rather than replace other methods for gathering information It is a known fact that with the help of lab investigations,some underlying systemic conditions of which the patients are unaware of,are often indentified in dental practice for the first time.

3. Definition Laboratory studies are an extension of physical examination in which tissue,blood,urine or other specimens are obtained from patients and subjected to microscopic, biochemical, microbiological, immunological examination. Information obtained from these investigations help us in indentifying the nature of the disease.

4. CLASSIFICATION: BASED ON WHERE INVESTIGATION IS DONE Chair side investigations Laboratory investigations Acts as a precursor to laboratory investigations Egs: Toluidine blue staining for grading dysplasia,electric pulp testing for tooth vitality, radiographs , Bana Test for detecting the periodonto pathic bacteria in periodontial diseases Significantly higher sensitivity and specificity Egs: glycated haemoglobin estimation, Peripheral smear histology

5. CLASSIFICATION OF LAB TESTS USED IN DENTISTRY HEMATOLOGICAL TESTS CBC: Complete blood count with platelets and WBC differential ESR : Erythrocytic sedimentation rate P.T/I.N.R : Prothrombin time/International narmalised ratio P.T.T : Partial thromboplastin time RENAL TESTS: Serum creatinine Blood urea nitrogen LABORATORY TESTS SIGNS &SYMPTOMS OF DISEASE 2006 KANCHAN GANDA MD LABORATORY TESTS AND SIGNS &SYMPTOMS OF DISEASE 2006 KANCHAN GANDA MD

6. DIABETES TESTS FBS: Fasting blood Sugar PPBS : post pandrial blood sugar HBA1C: HemoglobinAIC HEPATIC SEROLOGY &LIVER FUNCTION TESTS BONE ASSESSMENT TESTS Serum calcium, serum posphorus, alkaline posphates H.I.V/AIDS STATUS ASSESSMENT CD4 count , viral load P.T/I.N.R

7. Blood for hematological investigations can be collected from a peripheral vein ,an artery or capillaries . Venous blood is preferred for most hematological investigations.

8. Collection of blood Peripheral venous blood The upper part of the arm is constricted by applying a tourniquet to hinder the venous return without obstructing the radial pulse The median cubital vein is most commonly used . The vein is fixed by slight traction and the needle ( 20 /21 G ) with the bevel upwards is inserted at an angle of 15 deg to the skin. The needle hub is colored according to its gauge . Blood will flow into the syringe when the needle enters the vein correctly .

9. After collecting the required quantity of blood , the tourniquet is released and the needle is quickly withdrawn .Pressure is applied with cotton wool over the puncture site for 3-5 mins. Blood is transferred to the appropriate containers and the last few drops put on slides for preparing direct peripheral smears .

10. Complications of Venepuncture : syncope , hematoma , bleeding , Thrombophlebitis , thrombosis of vein , transmission of hepatitis, HIV / AIDS . ARTERIAL BLOOD : Sites for collection – Radial artery ( most convenient ) , branchial artery , femoral artery ( largest of the the three )

11. HEMOGLOBIN ESTIMATION The Hb content in a blood sample may be determined by measurement of its color Its power of combining with oxygen or carbon monoxide or by its iron content, The clinical methods for routine purposes are all based on color or light intensity matching techniques.

12. METHODS SAHILI ‘S METHOD ( ACID –HEMATIN ) CYANMETHEMOGLOBIN METHOD ELECTRONIC COUNTERS HALDANE’S CARBOXYHEMOGLOBIN METHOD OXYHEMOGLOBIN METHOD ALKALI –HEMANTIN METHOD

13. Blood cell counts TOTAL RED BLOOD CELL { RBC } COUNT : It is done with the improved Neubauer’s chamber , a cover slip and an RBC pipette. RBC DILUTING FLUID Composition of Hayem’s fluid : Sodium chloride , Sodium sulphate , Mercuric chloride , distilled water to 100 ml.

14. INCREASED POLYCYTHEMIA DECREASED ANEMIA Physiologic : In neonates high altitude after exercise . Hemoconcentration : Burns Dehydration Polycythemia rubra vera Physiologic : Old age , pregnancy , hemodilution Anemia Leukemia

15. HUTICHISON’S CLINICAL METHODS . 21’ST edition

16. TOTAL WHITE BLOOD CELL COUNT (WBC) TLC is done with Neubauer’s chamber and WBC pipette since WBCs are present in much smaller numbers than RBCs the dilution required is much less. It contains a white glass bead inside to facilitate mixing of the blood and diluent .

17. WBC diluting fluid ( Turk’s fluid ) composition : glacial acetic acid 2.0 ml , 1 % gentian violet 1.0 ml ( stains the WBC NUCLEI ) Distilled water to 100 ml

18. Leukocytosis Physiologic – exercise , pregnancy , exposure to cold. Drugs – epinephrine , steroids Pathologic – infection with pyogenic organisms , non-infective inflammations , MI , Pulmonary embolism , acute hemorrhage , uremia , malignant neoplasm's. LEUCOPENIA Starvation and debility Overwhelming infections and toxemia in old people . Infections like typhoid, measles , malaria , kala-azar , hepatitis Hypersplenism . Bone marrow failures – apalstic anemia . Drugs – sulphonamides , chlorpromazine , diuretics .

19. NEUTROPHIL DISORDERS Primary neutrophil disorders characterised by severe periodontal disease, neutropenia(chronic or cyclic),leukocyte adhesion defeciency,chediak-higashi syndrome. Neutrophil abnormalities that occur secondery to underlying systemic diseases and those that are also associated with severe periodontal disease include diabetes,papillon lefevre syndrom,down syndrome,crohn’s disease,AIDS,acute myeliod leukemia

20. Papillon Lefevre Syndrome: Papillon-Lefèvre syndrome(PLS ) is a rare, autosomal recessive disorder. The syndrome is believed to affect 1 to 4 persons per million. TESTS : Complete blood count, blood chemistry, and liver function tests were within normal limits . Immunologic studies revealed low (CD3 + CD4 +) count. Recently, the gene for PLS has been mapped to 11q14-q21.In 1999, Hart et al identified a germline missense and truncating mutations in the gene encoding cathepsin c lysosomal cysteine proteinase that plays an important role in intracellular degradation of proteins in families with PLS. Jayachandran Dorairaj, Sunantha Selvaraj, Mohammed Sadique, Michael Shaw, Sachin Kumar Amruthlal Jain. Papillon Lefevre syndrome: A periodontist approach. IJCRI 201 2;3(7):1 –5. www.ijcasereportsandimages.com

21. Cathepsin C is an enzyme that processes and activates several granule serine proteases critical to immune and inflammatory responses of myeloid and lymphoid cells. cathepsin C gene is that mutations in this gene also results in two closely related conditions: i) Haim­Munk syndrome, and ii) aggressive periodontitis. A common clinical manifestation in all three conditions is the severity and the early onset of periodontal destruction

22. Two new aspects for the pathogenesis of pls have been discovered. First some pts suffering from pls exhibit cellular immune defect with decreased chemo tactic and phagocytic function of neutrophils and other granulocytes Second, some pathogenic micro organisms such as porphyromonasgingivalis,capnocytophaga,peptostreptococus,fusobacterium,spirochetes have been implicated as the causative agents for periodontal problems in pls

23. Erythrocyte Sedimentation Rate { ESR } when anticoagulated blood is allowed to stand undisturbed in a vertical tube , the red cells tend to fall to the bottom forming two layers – the lower red cell layer and the upper plasma layer . It occurs in 3 stages : Stage of aggregation Stage of sedimentation Stage of packing

24. Methods There are 2 common methods of measuring ESR . Westergen’s method Wintrobes method

25. Causes INCREASED DECREASED Physiological : pregnancy TB Inflammatory conditions MI Shock Malignancies hypergammaglobulinemia Physiological : newborns due to polycythemia ,males Congenital spherocytosis Sickle cell disease Allergic states Hypofibrinogenemia

26. Determination Of Platelet Count A peripheral smear prepared from EDTA anticoagulated blood helps to judge roughly whether adequate platelet are presents. Usually , if 2 to 10 platelets per 100 red cells or if clumps of platelets are present , it suggests that they are adequate .

27. Platelet counts can be made by visual counting or electronic counters. METHODS : 1. Direct method 2. Indirect method

28. THROMBOCYTOSIS THROMBOCYTOPENIA During infections , at high altitudes , after severe muscular exercise Immediately after surgery and following bleeding CML Polycythemia vera Myelofibrosis Idiopathic thrombocytosis Congenital : congenital aplastic anemia , rubella infection Wiskott aldrich syndrome Acquired : aplastic anemia , megaloblastic anemia , viral infections , drugs. immune thrombocytopenia , ITP , DIC , vasculitis Causes

29. Determination Of Bleeding Time This test detects abnormal platelet function in vivo. It measures the time taken for a standardized skin wound to stop bleeding . Methods : DUKE’S , IVY’S , Template methods are used .

30. Causes ( prolonged BT ) Thrombocytopenia Platelet function disorders – hereditary & acquired Dysfibrinogenemia , afibrinogenemia Vascular disorders

31. CLOTTING TIME ( CT ) This is the time taken for whole blood drawn from a vein to clot in vitro. The surface of the glass tube initiates the clotting process . This test is sensitive to the factors involved in the intrinsic pathway .

32. Prolonged (CLOTTING TIME ) Deficiency of factor VIII , IX , XI or XII. Afibrinogenemia , dysfibrinogenemia , hypofibrinogenemia Vit K deficiency Liver disease , warfarin therapy

33. PROTHROMBIN TIME ( PT ) It is the time taken for platelet –poor citrated plasma to clot after adding calcium and tissue ( brain ) thromboplastin. NORMAL : 10-14 sec .

34. Prolonged Congenital deficiences of one or more of factors II , V , VII or X . Therapy with coumarin Obstructive jaundice Hemorrhagic disease of the new born Liver disease Fibrinogen deficiency Vit. K deficiency

35. Partial Thromboplastin Time ( PTT ) This test is used to detect defects of coagulation in the intrinsic and common pathways . It is used to monitor heparin pathway. NORMAL : 30-40 sec

36. Prolonged Hemophilia A Christmas disease Von willebraband’s diseases Heparin & oral anticoagulant therapy Hepatic failure Deficiencies in factors II , V or X Presence of acquired inhibitors e.g. . SLE

37. THROMBIN TIME ( TT ) In this test , thrombin is added to citrated plasma and the clotting time noted. This tests the conversion of fibrinogen to fibrin monomers by thrombin

38. Prolonged Hypofibrinogenemia Dysfibrinigenemia Heparin , fibrinogen or fibrin degradation products Chronic liver disease Multiple myeloma Intravascular coagulation

39. www.ccpe-cfpc.com/en/ pdf _files/drug_lists/normal_values

40. www.ccpe-cfpc.com/en/ pdf _files/drug_lists/normal_values

41. www.ccpe-cfpc.com/en/ pdf _files/drug_lists/normal_values

42. Hemophilia DIAGNOSIS : Hemophilia should be suspected in patients presenting with a history of: Easy bruising in early childhood Spontaneous bleeding (particularly into the joints and soft tissue) Excessive bleeding following trauma or surgery.

43. The severity of bleeding manifestations in hemophilia is generally correlated with the clotting factor level DAVIDSON’S PRINCIPLE&PRACTICE OF MEDICINE 21 st edition

44. Management of Hemophilia Administration of desmopressin (DDAVP) can raise F VIII level sufficiently high (2-8 times baseline levels) in patients with mild to moderate hemophilia A .

45. Adjunctive management RICE (rest, ice, compression, and elevation) is an important adjunctive management for bleeding in muscles and joints in addition to increasing factor level with clotting factor concentrates or desmopressin in mild hemophilia Antifibrinolytic drugs (e.g., tranexamic acid, epsilon amino caproic acid) for 5-10 days is effective as adjunctive treatment for mucosal bleeds (e.g., epistaxis, mouth bleed) and is used to decrease the use of coagulation products in dental extractions .

46. Dental Care For persons with hemophilia, good oral hygiene is essential to prevent gingival and periodontal disease. Teeth should be brushed at least twice daily for plaque control. People with bleeding disorders need close cooperation between their physician and their dental practitioner to receive safe, comprehensive dental care.

47. Guidelines for regular dental treatment of persons with bleeding disorders are as follows world federation of Hemophilia may 2006 no 40 Dental appointments for children with bleeding disorders, as well as education in preventive dentistry of children and caregivers, should be started when the baby teeth begin to erupt Deep injections, surgical procedures – particularly those involving bone (extractions, dental implants) – or regional local anesthetic blocks should be performed only after clotting factor level has been appropriately increased.

48. Oral infections should be treated with antibiotics before any surgical procedure is performed. People with mild or moderate hemophilia, non-surgical dental treatment can be carried out under antifibrinolytic cover (tranexamic acid or epsilon aminocaproic acid), but a hematologist must be consulted before other procedures are done. And with mild hemophilia A (FVIII > 5%), scaling and some minor surgery may be possible under desmopressin

49. For those with severe hemophilia, factor replacement is necessary before surgery or regional block injections or scaling Local use of fibrin glue and swish-and-swallow rinses of tranexamic acid before and after dental extractions are safe and cost-effective methods to help control bleeding.

50. Tranexamic acid used topically significantly reduces bleeding. 10 ml of a 5% solution used as a mouth rinse for two minutes, four times daily for seven days is recommended Bleeding can be aggravated by painkillers such as ASA or other NSAIDs such as indomethacin. Paracetamol /acetaminophen and codeine are safe alternative analgesics

51. Screening Tests The following tests may be used to screen a patient suspected to have a bleeding disorder: platelet count, BT, PT, and APTT. Based on these tests, the category of bleeding disorder may be identified These screening tests may not detect abnormalities in patients with mild bleeding disorders and in those with factor XIII (FXIII) deficiency or those with low fibrinolytic inhibitor activity (alpha 2 antiplasmin, PAI-1)

52. INHERITED coagulation disorders 1. Hemophilia A – PTT is prolonged , PT & BT is normal. 2. hemophilia B – PTT is prolonged , PT & BT is normal 3.Von willebrand’s disease – BT , PTT is prolonged , PT & platelet count is normal Carranza’s Clinical Period ontology 11 edition

53. LEUKEMIA Leukemia is a treatable cancer that comes in many forms. Leukemia is the most common cancer diagnosed in children. However, adults account for almost 90% of new cases of leukemia. The rate of new leukemia cases tends to cluster early in childhood, with a gradual rise in cases overall as people age. Leukemia occurs more frequently in males than in female

54. DIAGNOSIS AND TREATMENT Leukemia is diagnosed using several blood tests that are done in a hospital or medical laboratory One blood test is a complete blood count (CBC), which is done both automatically by an automated instrument and manually by a laboratory technician.

55. The blood tests look for Anemia An abnormal increase in the number of lymphoid or myeloid white blood cells, sometimes with an increase in very immature forms of these cells Decrease in clotting components The distribution of blood cell types

56. Bone Marrow Biopsy : A bone marrow examination is also necessary if immature or unusual amounts of cells are found in the blood tests to help confirm a diagnosis The bone marrow biopsy looks for -  An unusual increase in one type of white blood cell  Specific immunological markers (biological markers that can be measured and identify types of cells)  Evidence of damaged chromosomes (chromosome analysis or karyotype) in the bone marrow cells

57. Cytochemistry The cytochemistry of the cells is determined by using special stains that can help identify chemical components in the cells such as enzymes or lipids.  These chemical components are specific to the maturity (level of development) of the cell and the cell path line (type of cells being affected).

58. Flow Cytometry Flow cytometry is an immunofluorescent method that can be used to detect protein surface markers on the cell membrane Cytogenetics The cytogenetics analysis is done to look at the individual chromosomes within the leukemic (white) cell.

59. MILD BLEEDING DISORDERS

60. DENTAL MANAGEMENT OF PATIENTS RECEIVING ANTICOAGULATION OR ANTIPLATELET TREATMENT Antiplatelet & anticoagulant agents have been extensively researched and developed as potential therapies in the prevention & management of arterial and venous thrombosis . These drugs have also been associated with an increase in the bleeding time and risk of postoperative hemorrhage . .. b’coz of this , some dentists still recommend the pt. to stop the therapy for at least 3 days before any oral surgical procedure . Mariele pototski and jose M. Amenabar .dental management of patients receiving anticoagulation or antiplatelet treatment. J oral science .vol 49 , no 4 .253-258, 2007 .

61. INR ( international normalized ratio) was introduced in 1983 by WHO committee on biological standards to assess patients receiving anticoagulation therapy more accurately . The INR is calculated from the ratio of the patient’s PT and control PT , raised to the power of the international sensitivity index value ( ISI ) It is more reliable and sensitive value for determing the level of anticoagulation because it depends on the patient’s blood and on the sensitivity of the thromboplastin reagent and the assigned ISI value. INR = patient PT / mean normal PT .

62. A patient with a normal coagulation profile would have an INR of 1.0 It is recommended that a patient undergoing invasive treatment should have a PT within 1.5 to 2.0 times the normal value and this corresponds to an INR of 1.5 to 2.5 when the ISI is 1.0

63. In patients with anticoagulant therapy , an INR between 2.0 and 3.0 is recommended for most indications . Thus , an INR of 2.5 ( range , 2.0 to 3.0 ) minimizes the risk of either hemorrhage or thromboembolism .

64. DIABETES MELLITUS Blood tests are used to diagnosis diabetes and prediabetes because early in the disease type 2 diabetes may have no symptoms.

65. DIAGNOSIS Any one of the following tests can be used for diagnosis: an  A1C  test, also called the hemoglobin A1c, HbA1c, or glycohemoglobin test a  fasting plasma glucose ( FPG )  test an  oral glucose tolerance test ( OGTT )

66. Adapted from American Diabetes Association ( ADA ) ., standards of medical care in Diabetes- 2012 . Diabetes Care. 2012 ; 35 ( supp 1): S 12

67. National Diabetes information Clearinghouse ( NDIC ) . A service of the institute of Diabetes and Digestive and kidney Diseases ( NIDDK ) , National Institutes of Health ( NIH ).

68. Diabetes is often associated with increased gingival inflammation in response to bacterial plaque . Type2 diabetes has been shown to be a significant risk factor for periodontitis Periodontal destruction was more severe in diabetic pts with greater boneloss and attachmentloss,significantly greater prevalence of deep probing depths. Pts with poorely controlled diabetes often have less favorable response to treatment than those with well controlled diabetes.

69. LIVER FUNCTION TESTS ( LFT ) They are a helpful screening tool, which are an effective modality to detect hepatic dysfunction. Since the liver performs a variety of functions so no single test is sufficient to provide complete estimate of function of liver.

70. CLASSIFICATION of LIVER FUNCTION TESTS A. Tests of the liver’s capacity to transport organic anions and to metabolize drugs- Serum bilirubin, urine bilirubin, urobilinogen etc. B. Tests that detect injury to hepatocytes (serum enzyme tests) – Aminotransferases, alkaline phosphatase, 5 nucleotidase, leucine aminopeptidase etc. C. Tests of the Liver’s biosynthetic capacity- Serum proteins, albumin, prealbumin, serum ceruloplasmin, procollagen III peptide, a 1 antitrypsin, a feto protein, prothrombin time etc

71. Chronic HBV infection MANAGEMENT : Chronically infected persons need medical evaluation every 6–12 months to assess the status of their liver health and their need for antiviral therapy, as well as to screen for liver cancer. Household members should be tested for HBV infection (HBsAg and antiHBs) and given the first dose of hepatitis B vaccine at the same visit If testing indicates the presence of HBV infection, consultation and further care with a physician knowledgeable about chronic hepatitis B is needed.

72. Dental considerations in pt with liver disease The LIVER disease is often associated with a decrease in plasma coagulation concentrations(2,3). Surgery is contraindicated in pts with certain considerations such as acute hepatitis,acute liver failure or alcoholic hepatitits. Based on laboratory test findings and the treatment to be carried out local hemostatic agent (oxidized and regenarated celulose),as well as anti fibrinolytic agents,fresh plasma vit k advisable.

73. Antibiotic prophyloxis is suggested,since liver dysfunction is associated to diminished immune competence. The administration of certain analgesics ,antibiotics and local anesthetics is generally well tolerated by pts with mild to moderate liver disfunction ,modifications necessary in pts with advance stage of liver disease Drugs metabolized in the liver may have to be used with caution or their doses reduced , and certain substances such as erythromycin, metronidazole , tetracyclines must be avoided entirely.

74. HIV Infections HIV diagnostic testing has come a long way since its inception in the early 1980s Current enzyme immunoassays are sensitive enough to detect antibody as early as one to two weeks after infection A variety of other assays are essential to confirm positive antibody screens (Western blot, polymerase chain reaction [PCR]), provide an adjunct to antibody testing (p24 antigen, PCR), or provide additional information for the clinician treating HIV-positive patients (qualitative and quantitative PCR, and genotyping)

75. DIAGNOSTIC TESTS HIV EIA : EIA is commonly used as a screening assay for many infectious diseases, including HIV. These assays are used because they are highly sensitive and generally amenable to automation, facilitating high-volume testing. p24 antigen : p24 antigen tests are also EIA-based and use antibody to capture the disrupted p24 antigen from patient serum. Positive results that are repeatable must be confirmed with a neutralization procedure. Western blot : The Western blot is an immunoblot that allows for the characterization of antibodies to each viral protein.

76. Qualitative PCR : PCR is a method that amplifies viral nucleic acid to allow for its detection in patient specimens. It is a particularly specific and sensitive test which can pick up very small numbers of viral particles. PCR is very useful in the diagnosis of HIV infection in babies born to infected mothers. Quantitative RNA PCR and genotyping : Quantitative RNA PCR must only be used to monitor HIV-positive individuals before or during antiretroviral therapy. It is used in conjunction with CD4 counts and general clinical assessments to ascertain when therapy should be started Can J Infect Dis Med Microbiol Vol 16 No 1 January/February 2005

77. PERIODONTAL ASPECT A REVIEW : Biology and Medicine, 3 (2) Special Issue: 45-52, 2011

78. ELISA / EIA In 1971, Peter Perlmann and Eva Engvall  at Stockholm University in Sweden, and Anton Schuurs and Bauke van Wee men in the Netherlands independently published papers that synthesized this knowledge into methods to perform - EIA/ELISA ELISA – It detects and measures antibodies in the blood that are related to certain infectious conditions. Antibodies are proteins that the body produces in response to harmful substances (antigens).

79. HIV (the virus that causes AIDS) Lyme disease pernicious anemia Rocky Mountain spotted fever Rotavirus Squamous cell carcinoma syphilis toxoplasmosis Varicella zoster virus To Diagnose :

80. Lipid peroxidation levels,total oxidant status and superoxide dismutase in serum, saliva, GCF in chronic periodontitis patients before and after periodontal therapy (D Wei et al in 2010) Lipid peroxidation levels was higher in periodontal region, with total oxidant status and superoxide dismutase increasing both locally and peripherally.nonsurgical therapy can restore and control the subject antioxident capacity by locally and systamically modifying the levels of malondialdehyde(MDA),total oxide status and superoxide dismutase

81. Blood chemistry Bone metabolism Calcium 9.0-10.5mg% hypocalcemia: hypoparathyriodism,vit D deficiency pregnancy,diuretics The reduced ca intake and reduced serum ca levels are associated with increased risk for periodontal disease

82. Phosphorus 3.0-4.5mg% Hyper phosphatemia: hypoparathyriodism, renal disease, hyperthyriodism, hypervitaminosis D Hypophoshatemia : Hyperparathyriodism, malabsorption

83. Alkaline phosphatase : 25-115units/l Elevated: hyperparathyriodism,pagets sarcoma, metastatic carcinoma Decreased: hypo phosphatesia,hypothyriodism,malnutrition

84. Renal function tests BUN(BLOOD UREA NITROGEN) 8-18mg% Decreased BUN Poor nutrition, high fluid intake, liver damage,late pregnancy Uric acid 2.4-7.5mg% Increased: chronic renal failure, chemotherapy, lymphoproliferative disease, gout,acidosis

85. Creatinine 0.6-1.2mg% Increased: chronic renal failure, CHF, Acromegaly,dehydration,diabetis,shock

86. THYRIOD FUNCTION TESTS ENTITY TESTED DISCRIPTION CLINICAL UTILITY TSH THYRIOD STIMULATING HARMONE OR THYROTROPIN BEST THYRIOD FUNCTION SCREENING TEST INTIAL TEST FOR SUSPECTED THYRIOD DISEASE USED TO FOLLOW PTS ON THYRIOD HARMONE THERAPY T4 SERUM TOTAL THYROXIN Used with TSH for monitoring pts with GRAVES disease NEWBORN SCREENING TEST FOR HYPOTHYRIODISM

87. FT4 FREE THYROXINE IS THE METABOLICALLY ACTIVE THYRIOD HARMONE-NOT BOUND TO PROTEIN SHOULD BE ORDERED WHEN TSH IS ABNORMAL TO DETERMINE THYRIOD HYPOFUNCTION OR HYPOFUNCTION FT1 FREE THYROXIN INDEX-MEASURE FREE T4 DETERMINED BY MEASURING FREE THYROXINE LEVEL EITHER THYRIOD BINDING GLOBULIN OR HARMONE BINDING RATIO USED FOR MAKING THE DIAGNOSIS OF THYRIOD DISEASE IN PT WITH PROTEIN ABNORMOLITIES &IN PREGNANT PTS T3 SERUM TOTAL TRIIODOTHYRONINE USED TO DIAGNOSE HYPERTHYRIODISM WHEN TSH IS LOW AND T4 IS STILL NORMAL THYRIOD ANTIBODIES ANTITHYRIOD PEROXIDASE ANTIBODIES ANTIGLOBULIN ANTIBODIES USED TO DIAGNOSE SUSPECTED HUSHIMOTOS THYRIODITIS IN HYPOTHYRIODISM USED TO DIAGNOSE AUTOIMMUNETHYRIODITIS

88. Effect of thyriod disfunction on periodontal status The serum and salivary levels of pro inflammatory cytokines TNF- α and IL-6 represent a well individualized biologic indicator for assessing the possible development of periodontal disease in pts with thyriod disfunction. Hyperthyriodism can induce more periodontal distruction than hypothyriodism,with both thyriod disfunctions having an effect on periodontal tissues through inflammatory mediators such as cytokins

89. Dental treatment modifications may be necessary for dental pts who are under medical management and follow up for a thyriod condition even if there are no comorbid conditions . Stress reduction,awareness of drug side effects or interactions,and vigilance for appearenc of signs or symptoms of harmone toxicity are among the responsibilities of the oral health care provider.

90. Microbiological and serological diagnostic tests for Helicobacter pylori : an overview Different invasive and non-invasive diagnostic tests are available for the diagnosis of H. pylori in the individual patient. Serological testing has been recommended for initial pre-endoscopy or pre-treatment screening in dyspeptic patients.

91. The urease tests provide a simple, rapid and cost-effective method for the detection of H. pylori. Yousfi et al found that the diagnostic yield for detecting H. pylori by the rapid urease test was not adversely affected by the size of the biopsy forceps, while Laine et al showed that increasing the amount of tissue in CLO-tests did significantly hasten the development of positive tests

92. Umeda et al showed that more than 40 % of patients with history of gastritis or peptic ulcers had periodontal pockets (>4 mm). Bruce et al found that periodontal pockets ≥5 mm are associated with increased odds of HP seropositivity.

93. Also, a large epidemiological investigation performed over 10,000 subjects , found a positive link between HP associated gastric infection and periodontal diseases. Periodontitis microenvironment conditions could be favorable for HP multiplication, thus increasing sufficiently to cause gastric infection

94. CONCLUSION The clinician must make decisions that are dependent on the importance of the disease in question. If it is important not to miss a diagnosis, a test with high sensitivity should be chosen. Each and every test should be taken with utmost care for determining the disease status of the individual .

95. REFERENCES Carranza clinical Periodontology 11’th edition . P. J MEHATA’S PRACTICAL MEDICINE . 17 ‘TH EDITION . 2005 . HUTICHISON’S CLINICAL METHODS . 21’ST edition Youri Glupczynski. Microbiological and serological diagnostic tests for Helicobacter pylori: an overview British Medical Bulletin 1998;54 (No. 1): 175-186 C The British Council 1998. Mariele pototski and jose M. Amenabar .dental management of patients receiving anticoagulation or antiplatelet treatment. J oral science .vol 49 , no 4 .253-258, 2007. Stop TB Partnership Retooling Task Force. New Technologies for TB Control: A Framework for their Adoption, Introduction and Implementation. Geneva, World Health Organization ( WHO ), 2007 (WHO/HTM/STB/2007.40

96. Farrugia, A. Guide for the assessment of clotting factor concentrates for the treatment of hemophilia. World Federation of Hemophilia. 2003. Hepatitis B Facts: Testing and Vaccination Immunization, www.vaccineinformation.org B.R. Thapa and Anuj Walia. Liver Function Tests and their Interpretation. Indian Journal of Pediatrics, Volume 74—July, 2007 M . G R E A V E S * and H . G . W A T S O N Approach to the diagnosis and management of mild bleeding disorders. Journal of Thrombosis and Haemostasis, 5 (Suppl. 1): 167–174. Sophie Marbaix1 , Assem Soueidan1 , Maya Romani2 , Guillaume Campard1 , Gilles Amador3 , Zahi Badran1. Helicobacter Pylori and Periodontal diseases: An update and proposal of a multidisciplinary clinical protocol. Open Journal of Stomatology, 2013, 3, 318-322 OJST. M Fearon. The laboratory diagnosis of HIV infections. Can J Infect Dis Med Microbiol 2005;16(1):26-30. National Diabetes information Clearinghouse ( NDIC ) . A service of the institute of Diabetes and Digestive and kidney Diseases ( NIDDK ) , National Institutes of Health ( NIH ).