Introduction Chairside investigations Lab investigations Saliva as a diagnostic tool Conclusion

1. Investigations for
Oro-Mucosal Lesions

2. References
 Scully C: Oral & Maxillofacial Medicine
 Burket- Oral Medicine (8th ed.)
 Govindrao Gomes – Oral medicine 2nd ed.
 Siddheswaran V, Adyanthaya R, Shivanna V. Pulse oximetry: A diagnostic instrument in
pulp vitality testing- An invitro study. Worl Jou Dent, Jul- Sept 2011;2(3):225-230
 Samraj RV, Indira R, Srinivasan MR, Kumar A. Recent advances in pulp vitality.
endodontology 2003;15:14-19
 Sridharan G, Shankar AA. Toluidine blue: A review of its chemistry and clinical utility. J
Oral Maxillofac Pathol. 2012 May-Aug; 16(2): 251–255.
 Nagaraju K, Prasad S. et al. Diagnostic efficiency of toluidine blue with Lugol’s iodine
in oral premalignant and malignant lesions. Indian J Den Res 2010; 21(2):218-213
 Agarwal A, Ammanagi R, Keluskar V. Oral Lumenoscopy: An adjuvant in early screening
of oral cancer. JIAOMR, Apr-Jun 2011;23(2):124-127

3. References
 Chen A, Wai Y et al . Using the modified Schirmer test to measure mouth dryness. JADA,
Feb 2005; 136: 164-170
 Ge-fei Du et al. Rose bengal staining in detection of oral precancerous and malignant
lesions with colorimetric evaluation: A pilot study. Int. J. Cancer: 120, 1958–1963 (2007)
 Thirugnana Sambandham et al. The Application of Vizilite in Oral Cancer. Journal of
Clinical and Diagnostic Research. 2013 January, Vol-7(1): 185-186.
 Neha Vashist et al. Chemiluminescence and Toluidine Blue as Diagnostic Tools for
Detecting Early Stages of Oral Cancer: An invivo Study. Journal of Clinical and Diagnostic
Research. 2014 Apr, Vol-8(4): ZC35-ZC38.

4. Contents
 Introduction
 Chairside investigations
 Lab investigations
 Saliva as a diagnostic tool
 Conclusion

5. Introduction
Diagnosis –
• It is the correct determination, discriminative estimation, and logical
appraisal of conditions found during examination as evidenced by
distinctive marks, signs and symptoms.
• Investigations can be performed to confirm or refute a clinical
suspicion.
• They can also be performed as a part of a screening process.

6. Terminologies
 Sensitivity
 Specificity
 Predictive value
Points to remember
1. No harm to patient
2. Informed consent
3. Skilled operator

7. Investigations
Vitality tests
Vital stains
Skin testing
Biopsy
Vizilite and Others
Salivary testing

8. Vitality Tests
1. Percussion
2. Thermal tests
3. Anesthetic test
4. Test cavity
5. Electric pulp test
6. Transillumination
7. Ultraviolet light
8. Laser Doppler Flowmetry
9. Pulse Oximetry
10. Xenon Radioisotope
11. Plethysmography
12. Optical Reflectance Method

9. 6. Transillumination
Dental unit light is turned off and only the fiber optic light used.
Placed sequentially on all sides of the tooth.
If a crack is present in the dentin, the light will be interrupted at that crack ;
dark line is visible.
The dentin on the opposite side of the crack from the light source will be
darker in color.
If multiple cracks are observed, endodontic treatment is indicated followed by
a full coverage restoration.

10. 7. Ultraviolet light
Foreman reported that
Teeth with necrotic pulps and teeth with endodontic treatment did not
fluoresce when exposed to UV light while
Teeth with vital pulps fluoresced normally.
He cautioned that lighting in the operatory needed to be suppressed fully
observe any changes in the tooth color.

11. 8. Laser Doppler Flowmetry
Introduced in the early 1970s.
Initially, it was suggested for use in measuring blood flow in the
retina.
Employs a beam of infrared (780 to 820 nm) or
near infrared (632.8 nm) light, directed into the tissue
by optical fibers.
Light source Photodetector
Red light is emitted from a light source, if the light beam is scattered off
stationary tissue or cells, there is no shift in light spectrum. If however,
the light hits a moving cell in blood vessel, there is a shift in the light
spectrum of scattered light according to the Doppler principle

12. 9. Pulse Oximetry
The probe consists -
Two light emitting diodes,
A red and
A infrared
Advantages
• A direct measurement of pulpal circulation ; real measure of pulp vitality.
• Completely objective
• Disadvantages:
• Requires use of the monitor, which is large as well as expensive.
• No specific probes for correctly adapting to the human teeth.

13. 10. Xenon Radioisotope
To differentiate between vital and pulpless teeth :
Initial count above the 200 to 300 counts ; found in pulpless teeth
Disadvantages
Use of radioactive isotopes - expensive
The methods involve the introduction of the isotope in the blood stream, which
is a difficult procedure in everyday practice, thus making the method non-
feasible in clinical practice.

14. 11. Plethysmography
Depicts changes in tissue opacity
Pulsatile variations in the blood circulation of the dental pulp can be recorded
Preliminary tests showed that vital and nonvital pulps reflected the radiation
differently.

15. 12. Optical Reflectance Method
The device consists of
Two light-emitting diodes (LED),
An optical receiver, and
Computer
• Radiation at red (660nm) and near infra red (650nm) wavelengths are directed
through a thin probe.
• The beam is directed to the tissue and reflected back.
• Plethysmography is used to measure the pulse rate.
• Reflected radiation is related to plethysmogram using a computer.
• Vital and non-vital pulps reflected radiation differently.

16. Vital stains
1. Toluidine blue staining
2. Lugol’s iodine test
3. Acridine binding method
4. KOH Test
5. Rose Bengal Staining

17. Toluidine blue
Principle - Metachromasia is a phenomenon whereby a dye may absorb light
at different wavelengths depending on its concentration and surroundings
and it has the ability to change its color.

18. Procedure
Rinsing of the mouth twice with water for 20 s to remove debris.
1% acetic acid is then applied for 20 s. This is followed by 1% TB application
for 20 s when a mucosal lesion was seen or given as rinse when no obvious
lesion was detected.
Again, 2 rinses with 1% acetic acid were performed to reduce the extent of
mechanically retained stain.
Finally the mouth is rinsed with water.
The interpretation is based on the color

19. Lugol’s Iodine Test
 Combination with toluidine blue
 Mechanism
Reaction with glycogen
To visualize the mucogingival junction in the mouth
Also used for screening of premalignant lesions.

20. Acridine Binding Method
• Abnormally high uptake of acriflavine was exhibited by cells taken from the
buccal mucosa of subjects with squamous cell cancer
• Cotton tipped applicators – rubbed over mucosa
• Applicators are broken
• Cells detached from applicators and stained
• Results are recorded as the per cent of the dye taken up from the acriflavine
solution by each sample of 50,000 cells.

21. KOH test
• Test for candidiasis
• Quick, inexpensive fungal test to differentiate dermatophytes and candida albicans
associated disorders from other skin disorders like psoriasis and eczemas.
Procedure :
• Scrapings are taken from the infected area of patient.
• Placed directly onto a microscope slide and covered with 10% or 20% KOH
• The slide is left for 5 – 15 mins.
• The slide is gently heated to speed up the action of the KOH.
• Adding calcofluor-white stain to the slide will cause the fungi to become fluorescent,
making them easier to identify under fluorescent microscope.
• Place the slide under microscope.

22. Rose Bengal Staining
• Eye is anesthetized topically with propaine 0.5%.
• It is a vital stain taken up by dead and degenerating
cells that have been damaged by the reduced tear
volume.
• This test is particularly useful in early stages of
conjunctivitis sicca and keratoconjunctivitis sicca
syndrome.

23. Mouth rinse with distilled water to clean the lesions for 1 minute
Applications of solution of RB with cotton tip for 2 minutes
Mouth rinse with distilled water to remove excess RB solution for 1
minutes
Oral examination of the location, size, morphology and surface
characteristics of sites stained
The staining results of oral lesions to be compared with a shade guide
Staining result of a lesion was classified as 1, 2, 3 or 4 according to the shade
tabs.
Staining results of 3 and 4 were regarded as RB positive staining, while staining
results of 1 and 2 were regarded as RB negative staining
Ge-fei Du et al. Rose bengal staining in detection of oral precancerous and malignant lesions with colorimetric
evaluation: A pilot study. Int. J. Cancer: 2007

24. Diascopy
• Technique of applying pressure to a suspected vascular lesion to visualize the
evacuation of coloration
• Facilitate the differentiation of a small vascular lesion from a pigmented lesion.
• To determine if skin redness is due to blood within vessels ( erythema ) or
extravasated into the skin ( petechiae , purpura ) .
• The former will blanch with pressure , the latter will not .

25. Nikolsky’s sign
It is elicited in blistering diseases to determine whether
the epidermis is adherent to the underlying dermis.
Auspitz sign
When the thick white scale of psoriasis is carefully scraped
away from the surface of a plaque, tiny bleeding points
may be seen in the underlying epidermis .
It is typical, but not diagnostic, of psoriasis .

26. Oral Lumenoscopy
• Based on property of tissue reflectance
• Neoplastic epithelial cells tend to have an altered nuclear - cytoplasmic ratio.
Dehydration with acetic acid highlights this nuclear density
• The phenomenon can be further amplified by replacing conventional lighting with
diffuse blue-white chemiluminescent illumination.
Steps for using Oral Lumenoscopy System :
• Ask the patient to rinse with 1% acetic acid for 30-60 seconds
• Dim the lights in the room or use the eyewear provided by to facilitate the examination
• Apply the toluidine blue marking system to lesion visible under lumenoscopy
illumination.
• Lesions stained with toluidine blue can be viewed clearly even without the
lumenoscopy device.

27. Advantages :
• It is an easy to use, noninvasive, chair-side test
• Single use material, can be conveniently disposed
• Easily storable
• Can be used for patient education and motivation
Disadvantages :
• Detect only a small percentage of mucosal abnormalities, e.g. potentially malignant
disorders
• It cannot discriminate between progressive and the non-progressive counterparts of
tumor
• Not economical

28. Schirmer’s Test
• Assessing the function of the lacrimal gland
• Measuring the amount of wetting on a strip of filter paper placed in the
lower eyelid over 5 minutes.
Modified Schirmer’s Test
Performed with color bar

29. Slit Lamp Test
• Procedure involves the use of an instrument called a slit-lamp, which provides
a three-dimensional view of the eye.
Indications :
• Diagnosing conditions including cataracts, dry eye syndrome, diabetic
retinopathy, glaucoma.
• Also performed to monitor the progress of disease.
Procedure:
• Patient is asked to sit facing the slit-lamp and keep their head still by resting
their chin upon the chin rest attached to the instrument and placing their
forehead against the head support.
• The optometrist will then shine a thin, bright light into the eye and look
through the magnified lens to examine the front structures of the eye.

30. • It will take about 15 to 20 minutes for the eyes to dilate, but once they're
dilated the slit lamp procedure can be performed again, this time to examine
the back of the eye.
• The eyes will remain sensitive to light for a few hours after being dilated, so
sunglasses should be worn outside.

31. Skin Testing
Prick tests
Intradermal
Patch tests

32. Prick tests
Indications :
• Rhinitis / allergic conjunctivitis;
• Asthma;
• Food reactions such as those manifested by anaphylaxis, immediate acute urticaria, or
acute flare of eczema;
• Suspected latex allergy
Not routinely indicated :
• Nonspecific rash without allergic / atopic characteristics;
• Food intolerance without allergic features (e.g. irritable bowel syndrome);
• Reactions to respiratory irritants (smoke, fumes, perfumes etc.); and
• Screening for allergy in the absence of symptoms (e.g. family history of allergy).

33. Drugs that interfere with the skin prick test response
• First generation antihistamines usually have a short duration of action whereas second
generation act for longer; the duration of suppression of skin test reactivity is variable
between different drugs and individuals.
• Antidepressants have antihistamine activity and may need to be withheld for 1-2
weeks or more.
• Prolonged topical corticosteroids have been shown to reduce skin reactivity.
• Topical moisturisers do not reduce prick test reactions but may cause extracts to run or
disperse which creates a practical difficulty.

34. • Drop then prick - A drop of allergen will be applied from the dropper bottle
onto the skin prior to pricking the skin. The drop on the tip of the dropper
can be touched on the skin to transfer the liquid but the actual tip of the
dropper should not touch the skin.
• Dip then prick - The allergen extract is placed into small wells in a multi-well
tray. The dropper is dipped into the allergen extract, withdrawn, and then
applied to the skin with firm pressure
. Stallergenes prick lancet Lancets

35. Method of recording skin prick test results:
• A chart is kept and the wheal (and flare) size in mm recorded next to each
allergen name.
• Wheal diameter in recorded in numerical form and not qualitative marking
(e.g. +, ++) as the primary reported result.
• A wheal of 3mm or greater is taken to indicate the presence of specific IgE to
the allergen tested.
• It will vary with different allergens, extracts from different sources, and
different populations.

36. Patch test
• It is intended to produce a local allergic reaction on a small area of the
patient's back, where the diluted chemicals are placed.
Mechanism :
• When skin is exposed to an allergen, the antigen presenting cells phagocytoze and
break it into smaller pieces.
• This is where a substance is recognized by immune cells in the skin.
• Presents it to CD4+ T-cell, or T-helper cell.
• The T-cell, if it recognizes the substance as dangerous, expands in number
• When the skin is again exposed to the antigen, the memory T-cells in the skin recognize
the antigen and produce cytokines thus starting a complex immune cascade leading to
skin inflammation, itching, and the typical rash of contact dermatitis.

37. Interpretation of results :
• The dermatologist or allergist completes a record form at the second and third
appointments (usually 48 and 72/96 hour readings).
• The result for each test site is then recorded. One system used is as follows:
Negative (-)
Irritant reaction (IR)
• Equivocal / uncertain (+/-)
• Weak positive (+)
• Strong positive (++)
• Extreme reaction (+++)

38. Intradermal
Intradermal testing may be used in the diagnosis of:
• Immediate allergy to beta-lactam drugs, other drugs where validated protocols exist;
and
• Immediate hypersensitivity to some vaccines.
Interpretation of intradermal tests:
• The optimal time for reading the reaction depends upon the pharmacological agent
used for the test and the type of immunological reaction to be observed.
• Intradermal tests for the detection of DTH are read at 48h
• The lepromin test is read at four weeks and depends on the formation of a granuloma

39. Tuberculin Test :
• More than 10 mm in diameter - a positive response
• Less than 5 mm is considered as negative.
• A positive test does not indicate active infection.
• A negative tuberculin test indicates non-exposure or decreased or absent
delayed hypersensitivity to M. tuberculosis.
Lepromin Test :
• It is a prognostic test that is very helpful in classifying leprosy.
• The response after intradermal injection is typically biphasic, with an Early
Fernandez and a Late Mitsuda reaction

41. Candidin Test :
• Hypersensitivity towards Candida albicans is universal.
• Hence, a test cannot be used to diagnose the infection.
• Compared with healthy controls, reactivity to candidin is significantly reduced
in patients with AIDS
• The test dose of 0.1 mL Candin is injected intradermally on the forearm
intended to elicit an induration response in excess of 5 mm at 48h after
injection in immunocompetent persons with cellular hypersensitivity to the
antigen.

42. BIOPSY
• Process of surgically removing tissue from patient for histopathological
examination.
Excisional biopsy
Incisional biopsy
Fine needle
Punch
Oral CDx

43. Clinical Diagnosis Type of biopsy
Leukoplakia/erythroplakia
Incisional or punch biopsy of area with
suspicion
Consider multiple biopsies if extensive
lesion
Mucosal lichen planus
Incisional biopsy of a representative
area
Bullous lesions (pemphigus
pemphigoid etc)
Incisional or punch biopsy of
unaffected mucosa close to bulla or
erosion plus fresh tissue specimen
Mucocoele Careful excision biopsy
Fibroepithelial polyp, Pyogenic
granuloma, epulis
Excisional biopsy
Minor salivary gland tumour
Palate: Deep incisional biopsy
Upper lip: Excisional biopsy
Major salivary gland tumour FNAC/FNCB (seek advice)

44. Excisional Biopsy
• Excisional biopsy is the complete removal of a lesion to confirm the clinical
diagnosis.
• This is appropriate only if the lesion is almost certainly benign.
• Small , pedunculated , exophytic lesions in accessible areas are excellent
candidates for excisional biopsy.
• An ellipse is traced around the lesion, with the blade angled toward the
centre of the lesion
• This produces a wedge-shaped specimen that is deepest under the centre of
the lesion.

45. Incisional Biopsy
Sample of tissue should be collected from the area that has been most severely
and significantly affected.
In cases of epithelial dysplasia, the severity of the epithelial changes or the
presence of carcinoma will be correlated with the clinical appearance.
The anterior tip of the ellipse is gently lifted with tissue forceps, and the base is
severed.

47. Punch biopsy :
• It is rarely necessary in oral cavity as most of the oral
lesions are easily accessible.
• With this technique, the surgical defect that is
produced is small and does not require suturing.
• A sharpened hollow tube of several millimeters in
diameter is rotated until underlying bone or muscle
is reached.
• The tissue is then removed in the same manner as in
incisional or excisional biopsy.

48. Exfoliative Cytology
• Exfoliative cytology is the microscopic examination of shed
cells from an epithelial surface.
Pap stain involves 5 dyes in 3 solutions.
• Haematoxylin stains cell nuclei.
• OG-6 stains the keratin
• EA comprises three dyes EA-36, EA-50, EA-65
• Eosin Y stains the superficial epithelial squamous cells,
nucleoli and red blood cells.
• Light Green SF yellowish stains the cytoplasm of other cells

49. INDICATIONS
• Evaluation of extensive mucosal lesion
• Follow up for patients
• Fragile patient’s medical status
CONTRAINDICATIONS
• Does not give notion of extent of invasion.
• Degree of differentiation of malignancy cannot be identified
• Reduced reliability of technique

50. ADVANTAGES
• Painless, bloodless, noninvasive, quick, economical
• Suitable in patients with systemic disease
• Guards against false negative Biopsy
• Useful for mass screening
• Has potential for early detection of malignant lesions
DISADVANTAGES
• Relatively less information than histological slides
• Suitable only for epithelial cells
• Interpretation requires skilled and experienced cytopathologist
• Tumor grading cannot be assessed

51. APPLICATIONS
• Early detection and control of oral cancer
• Assessment of nutritional iron deficiency, oral candidiasis and viral infections
• Forensic dentistry
• Predicting the cellular response of a tumour to irradiation

52. Fine Needle Aspiration Cytology
It is microscopy of the examination of an aspirate obtained by inserting a fine
needle into the lesion.
Painless and safe procedure for rapid diagnosis.
INDICATIONS
 In all lesions thought to contain fluid or any intraosseous lesion before
surgical exploration.
 A fluctuant mass in the soft tissues to determine its contents.
 Any radiolucency in the bone of the jaw should be aspirated to rule out a
vascular lesion.

53. Procedure
• Needle positioning : First needle is positioned within the targeted tissue
• Application of negative pressure : Plunger is pulled to apply negative pressure.
Needle is moved back and forth within the targeted tissue to obtain a greater
field
• Releasing of negative pressure: Negative pressure is then released while the
needle remains within the targeted tissue
• Withdrawing the needle: Needle is withdrawn and then the defumed air is
drawn in the syringe and the aspirate is blown onto the slide
• Fixing: Fixing is done in 95% alcohol

54. Dentigerous Cyst Clear pale, straw colored fluid
Odontogenic keratocyst Dirty, creamy white viscoid suspention
Periodontal cysts Clear, pale yellow straw colored fluid
Infected cyst Pus or brownish fluid, seropurulant
Gingival cysts Clear fluid
Solitary bone cyst Serous or sanguineous fluid, blood or empty cavity
Stafne’s bone cyst Empty cavity will yield air
Dermoid cyst Thick sebaceous material
Vascular cyst walls Fresh blood
Arterial or arteriovenous malformation Bright red blood,pulsatile pushes plunger

55. Oral CDx brush biopsy
• Indications:
• White or red spots, chronic ulcerations, mucosal lesions with an abnormal epithelial
surface
• Small, benign abnormality that have been routinely watched and not suspicious enough
to warrant referral for biopsy
• Contraindications :
• Lesions with intact normal epithelium
• Fibromas, mucoceles, hemangiomas, submucosal masses, pigmented lesions
• Highly suspicious lesions (immediate scalpel biopsy)
• Lesions with obvious etiology: herpes, aphthous ulcerations, trauma ulcerations,
trauma

56. Procedure :
• The oral biopsy brush is firmly pressed against lesion
and rotated
• The brush is then rotated onto the enclosed glass slide
• The sample is then fixed
• Drying for 15 minutes.
• Dry slide in then placed into the supplied slide holder,
placed back into the box, and shipped to the lab for
analysis.
• A specimen smear is prepared from the sample and
analyzed at the CDx laboratory
• Aid of a proprietary high speed computer system which
assists a specially trained pathologist

57. Benefits of the OralCDx Brush Biopsy:
• Highly accurate, noninvasive chair-side biopsy
• Requires no topical or local anesthesia
• Samples a larger area than scalpel biopsy
• Achieves a complete transepithelial biopsy tissue specimen
• As sensitive as a scalpel biopsy in ruling out oral dysplasia and carcinoma

58. Vizilite
 It is a screening device that may help
the clinician more easily visualize
suspicious lesions
Kit contains :
 Chemiluminescent device
 30 ml acetic acid
 Light stick holder / retractor

59. ViziLite Procedure
Steps :
 Patient rinses with 1% acetic acid for 1 minute
 Activate device by bending outer capsule to break inner vial
( A diffuse chemiluminescent blue / white light
Average wavelength 490 - 510 nm )
 Shake capsule to mix contents
 Insert capsule into retractor unit
 Dim room lighting
 Visually inspect oral cavity using device
 Discard materials

60. How ViziLite Works
Normal epithelial cells absorbs the blue light and appears dark
Abnormal cells having a higher N:C ratio reflect light and appear more
acetowhite, brighter, sharper with more distinct margins when viewed under
Vizilite's diffuse low-energy wavelength light.

61.  Vizilite can assist a dentist or hygienist in identifying an abnormality in the oral
cavity
 In 2002, Vizilite ( Zila Pharmaceuticals, Phoenix, AZ ) became the first FDA -
approved adjunct technology to conventional head and neck examination for
improving visualization of early lesions.
Vizilite
Helps to delineate the
margins precisely
Doesn’t guide much in
selection of the most
characteristic site for biopsy
within the already existing
lesion.
Toulidene Blue
TB gives a more precise
localized area which retains
the dye and helps us in
selecting the most
characteristic site for biopsy
in a much better way

62. ViziLite Plus with Toluidene Blue630
 ViziLite Plus with TBlue630 is an
oral lesion identification and
marking system
 Used as an adjunct to the
conventional head and neck
examination.
 Comprised of -
Chemiluminescent light source
(ViziLite) to improve the
identification of lesions and
Blue phenothiazine dye to mark
those lesions identified by
ViziLite.

63. Velscope
Most effective component of comprehensive patient care, the VELSCOPE is
introduced as part of the intra and extra-oral examination
After discussing about the examination with the patient, VELSCOPE blue
excitation light is illuminated into the oral cavity.
Abnormal tissue typically appears as an
irregular, dark area that stands out against
the green fluorescence pattern of
surrounding healthy tissue.

64. VELSCOPE mechanism

67. BACTERIAL & FUNGAL
SMEARS
Swabbing mouth to obtain
sample of oral bacteria.
Scraping of lesion
Applying oral sample to surface of agar.
Placed directly on a microscope slide

68. ORAL CAVITY & SINUS
EXAMINATION
INVESTIGATIONS
1. Maxillary sinus Transillumination
Biopsy
2. Oral cavity
A. Odontogenic infections
B. Odontogenic tumours
WBCs count, ESR, Biopsy, Gram staining,
Montoux test
Biopsy

69. ORAL CAVITY INVESTIGATIONS
C. Vesiculo-bullous lesions Tzanck smear
Immunofluorescent antibody test
D. Bone diseases
• Fibrous dysplasia
• Cherubism
• Paget’s disease
Serum alk.phosphatase
 Biopsy
Serum alk.phosphatase
Urinary hydroxyproline
E. Oral cancer Toluidine blue staining
Lugol’s iodine test
Direct fluorescent imaging
Biopsy
F. Cysts of jaw Aspiration

70. PROCEDURE ADVANTAGES DISADVANTAGES
Biopsy Definitive diagnosis Invasive
Brush biopsy Simple
Non-invasive
False- negative results
Bacteriological
smear & culture
Simple No correlation between
causal organism & disease
Fungal smear Simple As above
Viral culture Simple Require special facilities
DNA studies PCR used Require special facilities
Blood Simple Low detection rate
Serology Specific Undetected
Retrospective

71. Blood investigations
• Erythrocyte studies
• Leucocyte studies
• Tests for assessing hemostasis

72. Complete blood count
• Total red cell count
• Hemoglobin concentration
• Hematocrit or packed-cell volume
• Red cell indices (MCV, MCH, MCHC)
• Total white cell count
• Differential white cell count
• Red blood cell distribution width (RDW)
• Platelet count
• Mean platelet volume (MPV)

73. Red blood cells
• Total red cell count
• Hemoglobin concentration
• Hematocrit
• Red cell indices (MCV, MCH, MCHC)
• Red blood cell distribution width (RDW)
White blood cells
• Total white cell count
• Differential white cell count
Platelets
• Platelet count
• Mean platelet volume(MPV)

74. Test Normal value
Total RBC count 4-5.5 million/mm3 of blood
Total WBC count 4-10,000/mm3 blood
Differential WBC count Neutrophils 43-77%
Lymphocytes 17-47%
Mononcytes 0-9%
Eosinophils 0-4%
Basophils 0-2%
Hemoglobin concentration 14-18 gm/dL for males
12-16 gm/dL for females
Hematocrit 40-50%
Platelet count 150,000-450,000/mm3 blood
Sedimentation rate 0-20 mm/hr
Bleeding time <5-6 minutes
Prothrombin time 12-15 seconds

75. Red blood cells
Test Name Normal Range
(SI units)
Increased Decreased
1. Red Blood cell
count
4.5-5.5 × 106/ mm3 Polycythemia, fluid
loss, diuretics,
diarrhea, burns
Anemia
2. RBC indices Macrocytosis Microcytosis
a) Mean corpuscular
volume(MCV)
Adult: 80-93 um2 Vitamin B12 & folate
deficiency
Iron deficiency
anemia,
thalassemia
b) Mean corpuscular
hemoglobin (MCH)
27.5 - 33.2 pg Hyperchromia Hypochromic
anemia
c) Mean corpuscular
hemoglobin
concentration
(MCHC)
33.4 - 35.5% Hyperchromia Hypochromic
anemia

76. Red blood cells
Test Name Normal Range(SI units)
Hemoglobin Adult male: 14.0-18g/dL
Adult female: 12-16 g/dL
Hematocrit Adult male: 42-50%
Adult female: 36-45%

77. Peripheral blood smear
• Normocytic
• Microcytic
• Macrocytic
• Normochromic
• Hypochromic
• Hyperchromic
• Reticulocytosis
• Anisocytosis
• Poikilocytosis
• Spherocytosis

78. RBC size
• Anisocytosis
• Macrocytes
• Microcytes
RBC shape
• Poikilocytosis
• Spherocytosis
Immature red and white cells

79. RBC size
• Anisocytosis
• Macrocytes
• Microcytes
RBC shape
• Poikilocytosis
• Spherocytosis
Immature red and white cells

80. Erythrocyte sedimentation rate
(ESR)
• Introduction
• Two main methods
Westergren method
Wintrobe Method.
• Procedure

81. ESR
Test Normal Range Increased Decreased
Erythrocyte
Sedimentation
Rate(ESR)
Adults (Westergren
method):
Males: <15 mm/hr
Females: <20 mm/hr
Children
(Westergren
method):
Newborn: 0 to 2
mm/hr
Neonatal to puberty:
3 to 13 mm/hr
• Inflammation
• Pregnancy
• Rheumatoid
arthritis
• Polycythemia
• Sickle cell
anemia
• Hereditary
spherocytosis
• Congestive
heart failure

82. White blood cells
Test
Name
Normal Range Increased
(Leukocytosis)
Decreased
(Leukopenia)
Total White
Blood Cell
Count
4000-11000/mm3 • Physiologic
leukocytosis
• Acute & chronic
infections
• Leukemia
• Infuenza,
measles
• Cyclic
neutropenia
• Drug induced
• Typhoid
• Bone marrow
faliure
• Total White Blood Cell Count
• Differential White Blood Cell Count

83. Differential leukocyte count (DLC)
Leukocyte
type
Normal
%
Absolute
count
[/Cubic
mm]
Low count High count
Neutrophils 50-70 3000-6000 • Malignant
neutropenia
• Aplastic anemia
• Lymphocytic
leukemia
• Myelogenous
leukemia
• Acute
infectious
diseases
• Erythroblasto
sis foetalis
Lymphocytes 20-40 1500-3000 • Aplastic anemia
• Myelogenous
leukemia
• Chronic
infections
• Mumps
• Lymphocytic
leukemia

84. Leukocyte
type
Normal
%
Absolute
count
[/Cubic
mm]
Low count High count
Monocytes 0-7 300-500 • Aplastic
anemia
• Monocytic
leukemia
• Malaria
• Tuberculosis
Eosinophils 0-5 50-250 • Aplastic
anemia
• Typhoid fever
• Parasitic
infestations
• Allergy
• Eosinophilic
leukemia
Basophils 0-1 <50 • Stress
• Pregnancy
• Bone marrow
related
conditions:
leukemia or
lymphoma

85. Platelets
Test
Name
Normal
Range
Increased
(Thrombocytosis)
Decreased
(Thrombocytopeni
a)
Platelet
count
150,000-
450,000/mm3
• Polycythemia vera
• Essential
thrombocythemia
• Myelofibrosis
• Acute rheumatic
fever
• Thrombocytopenic
purpura
• Acute & chronic
leukemias
• Aplastic anemia
• Hemolytic jaundice

86. Tests for assessing hemostasis
• Fibrin degradation products
• Torniquet test
Test Normal Range
Bleeding time 1-6 min ( Ivy’s test)
1-3 min (Duke’s test)
PT 11-13sec
INR 1.0
aPTT 15-35sec
Thrombin time 9-13sec
Von Willebrand’s antigen 60-150%vWF activity
Coagulation factor assays 60-100% Factor activity

87. SALIVARY GLANDS
PROCEDURE ADVANTAGES DISADVANTAGES
Sialometry Simple, rapid No information about
individual gland volume
Sialochemistry Viral infections, drug
screening, hormone levels
Variable results
Blood tests Simple
Systemic disease
Fail to reflect local disease
Sialography Gross structural damage Time-consuming
Painful
Salivary gland biopsy Definitive diagnosis Invasive
Facial palsy/salivary fistula

88. Saliva as a Diagnostic Tool
Advantages
• Non-invasive
• Individuals with limited training
• No special equipment
• Valuable for children and
older adults
Uses
1. Oral diseases
2. Systemic diseases
Hereditary
Autoimmune diseases
Malignancy
Infectious diseases
3. Drug monitoring

89. Saliva Investigations
PROCEDURE ADVANTAGES DISADVANTAGES
Sialometry Simple, rapid No information about
individual gland
volume
Sialochemistry Viral infections, drug
screening, hormone
levels
Variable results

90. Lactobacillus Count Test
• Estimates the number of bacteria in saliva
• Colonies – Tomato Peptone Agar
Technique
• Collection of saliva
• Spreading on agar plate
• Incubation
• Results
Interpretation –
• Immune <103
• Slight 103 - 5000
• Medium 5000 – 104
• High >104

91. Snyder Test
• Measures ability of microorganisms in saliva – responsible for formation of
acids
Technique
• Collection of saliva
• Snyder media
• Mixing of media with saliva
• Results
Interpretation –

92. S. Mutans in saliva
Saliva samples obtained – Tongue blades
Incubation – Mitis Salivarius Bacitracin Agar
> 105 - High caries activity

93. Buffer capacity
• Collection of saliva – 10ml of saliva
• Adjusting pH of saliva to 7 – Addition of acid or base at room temperature
• Results – Level of lactic acid is recorded again to adjust the pH to 6
• Interpretation –
• Low buffer capacity < 0.45 ml
• High buffer capacity = or > 0.45 ml

94. Swab test
• Sampling of oral flora by swabbing buccal surface of teeth
• Placement in snyder media
• Incubation – 48 hrs.
• pH recorded

95. Point-of-care testing
• To move salivary diagnostics out of the laboratory and into clinical practice to allow
for more timely diagnosis of the disease.
• Can be rapidly performed directly at the dental clinic
• Allows therapy to begin immediately and thus improving the quality of care delivered.
• Problems like patient follow-up is averted.
• Also lowers overall costs

96. Lab-on-a-chip
• A newer generation of POC technology is under development.
• It seeks to integrate and automate all the complexities of a laboratory procedure into
a device the size of a computer chip.
• Measures the amount of multiple biomarkers in a small saliva sample.
• Provides rapid, simple, inexpensive, and accurate measurements directly from saliva

97. Saliva testing for periodontal disease
• Traditional method to diagnose periodontal disease relies on measuring pocket depth
and clinical attachment loss, and evaluating radiographs for bone loss.
• Do not predict periodontal disease in its earliest state.
• Untreated periodontal disease can lead to systemic disorders such as cardiovascular
disease and diabetes.
• Researchers have been investigating ways to detect periodontal disease in its
preclinical phase using genetic, microbial, and protein biomarkers.

98. • Oral DNA Labs offer two salivary tests that evaluate for periodontal disease.
• My Perio Path is a DNA test that uses saliva to determine an individual's risk for
periodontal disease by identifying the specific bacterial pathogens (microbial
biomarkers) associated with the disease.
• My Perio ID uses saliva to determine a patient's genetic susceptibility for periodontal
disease by testing for a genetic biomarker.
• Researchers have reported that high levels of the inflammatory biomarker C-reactive
protein (CRP) have been associated with chronic and aggressive periodontal disease.

99. • Interleukin (IL) 1β is a proinflammatory cytokine that stimulates the induction of adhesion
molecules and other mediators which in turn facilitate and amplify the inflammatory response.
• Its levels correlated significantly with periodontal parameters
• Moreover, combined levels of Il-1β and matrix metalloproteinase (MMP)-8 increased the risk of
experiencing periodontal disease by 45 folds.
• MMP-8 is not only an indicator of disease severity, but also disease activity.
• MMP-1 (interstitial collagenase) also appeared to be activated in periodontitis.
• Additionally, higher levels of other MMPs, including MMP-2, MMP-3 and MMP-9,were also
reported in the saliva of patients affected by periodontitis.

100. • The University of Michigan developed a rapid POC device, known as an integrated microfluidic
platform for oral diagnostics
• This handheld, pocket-sized test determines the amount of the enzyme matrix
metalloproteinase-8 (MMP-8) in saliva, in less than 10 minutes.
• The use of saliva-based diagnostics appears promising for future application to diagnose
periodontal disease and to predict periodontal treatment outcomes.
• In the near future, clinicians will be able to assess periodontal disease with a rapid chairside
saliva test

101. • Benefit of using saliva as a diagnostic tool for OSCC is that it contains the exfoliated cells in the
oral cavity, which allow for the screening and identification of potential biomarkers for oral cancer.
• Biopsies take up to seven days for results, saliva-based diagnostic technology has the potential to
decrease the wait time to less than one hour.
• The University of California, Los Angeles (UCLA) Collaborative Oral Fluid Diagnostic Research
Laboratory, led by Dr. David Wong, developed a POC device used to detect oral cancer in saliva.
• Oral fluid nanosensor test (OFNASET), is a POC, automated, and easy-to-use integrated system
that uses electrochemical detection of salivary proteins and nucleic acids
• Can measure up to eight different biomarkers in a single test in less than 15 minutes.
• The OFNASET will screen for the risk of oral cancer to allow for only test-positive patients to be
referred for biopsies.

102. • New POC testing will allow for the diagnosis of oral diseases right at the patient's chairside.
• Salivary diagnostics will expand the role of both dentists and dental hygienists and will allow
for substantial involvement of the patient in decision- making and self-care.
• Salivary diagnostic testing not only presents the clinician with the ability to provide a higher
standard of care for patients; it also can help increase the patient's understanding of the
overall value of comprehensive care and subsequently facilitate positive behavioral changes.

103. OraQuick test (HIV antibodies detection test)
• First FDA - approved oral swab in-home test
• An oral swab test not requiring blood.
• This test detects HIV infection if used 3 months after a risk event. That's because
OraQuick tests for HIV antibodies, and it takes your body up to 3 months to produce
these antibodies at levels that can be detected by this test.
• HIV antibodies from oral fluid are collected using the swab.
• Once the device is inserted in to the test tube, the oral fluid mixes with the liquid and
travels up the test stick.

104. If C-line turns dark it
confirms the test is working
properly.
If no C-Line appears, the test
is not working.
If only C-Line appears, the
test is negative.
HIV antibodies collecting at
the T-Line indicate the test is
positive.

105. Conclusion
Laboratory tests are among the most important aspects of modern medicine given that a
large percentage of health care decisions, from diagnosis through therapy and
prognosis, are derived from clinical laboratory tests.
Lab tests are important tools that help the health care provider and the patient to keep track
of their health status. There are no tests that can detect “health”; rather laboratory tests
are used as a predictor or marker for disease.
Laboratory studies alone rarely establish the nature of illness, but when interpreted in
conjunction with history and physical examination, they frequently establish or confirm a
diagnostic impression.