PE

• Identify the bodily system whose function is indicated by each clinical lab test
• Determine severity and level of control of a diagnosed systemic disease
• Determine medical impact on bodily system prior to dental tx
• Signs and symptoms of disease
• Confirm diagnosis

• Low RBC
• Anemias - iron deficiency, pernicious, sickle cell

• High RBC
• Polycythemia vera
• Relative polycythemia (eg dehydration)
• Factitious polycythemia (blood doping, Epo)

• Indicates presence and intensity of an inflammatory process
• Increased in: many but not all infections, acute MI but not with angina, rheumatoid arthritis but not degenerative arthritis, cancer (tissue necrosis)
• Not in mononucleosis

• Iron deficiency anemia
• Low MCV (mean corpuscular value= average volume of each RBC)

• Normal MVC levels
• Can mean sickle cell anemia

• Pernicious anemia
• Greater than normal MCV values

• Low WBC
• Hypovolemia, early leukemia, drugs, radiation, blood dyscrasias

• High WBC
• Infection, allergies, necrosis, exercise, pregnancy, stress, drugs, leukemia

• Looks at neutrophils, lymphocytes, monocytes, eosinophils, and basophil counts
• Eosinophilic= allergies
• Neutrophil leukocytosis = bacterial infections, inflammatory disorders, drug reactions, and leukemia
• Lymphocytosis- bacterial infections, viral infections, leukemia

• Malingnancy
• Too much coagulation

• Cancer chemotherapy
• Radiation therapy
• Blood loss
• Too little coagulation

• >240mg/dL
• Increased risk of ischemic heart disease, cerebrovascular accidents (strokes), peripheral vascular disease

Viral hepatitis, alcoholic hepatitis, toxic (drug related) hepatitis

• Coumadin therapy (for atrial fibrillation, cerebrovascular accidents, peripheral vascular disease)
• Hepatitis

Increased in- hemophilia and heparin (for patients on renal dialysis)

Decreased ejection fraction - heart failure, cardiac valvulopathy (aortic stenosis, aortic insufficiency)

• Normal within 80% of predicted
• Decreased - asthma, COPD

• CVA
• Congestive heart failure
• Ischemic heart disease
• Renal failure
• Retinopathy
• Peripheral arterial disease

• Age
• Gender
• Obesity
• Ethnicity

• 90% of people with hypertension
• No discernable cause
• More common with increased age
• More common among African Americans

• 10% of all people with hypertension
• Directly attributable to a cause - usually renal disease (can be endocrine, meds, or sleep apnea)

• Occipital headaches
• Dizziness
• Palpitations
• Blood in urine
• Dyspnea
• Epitaxis (bloody nose)
• Blurred vision

• Dyspnea (trouble breathing)
• Angina
• Seizure
• Edema

• <1% of all people with hypertension
• Systolic BP above 210 or diastolic >120
• Signs and symptoms affecting the eye, kidney, or brain
• Medical emergency!

• Periodic blood pressure measurements - average at least 2 at least 5 min apart
• Elevated BP over several appointments

• Normal - <120; <80
• Prehypertension - 120-139 OR 80-89
• Stage 1 - 140-159 OR 90-99
• Stage 2 - >160 OR >100

• Low risk patients: <140/90
• High risk patients: <130/80 in patients with diabetes, renal disease, ischemic heart disease, carotid artery disease, CVA, peripheral arterial disease, or abdominal aortic aneurysm

• 30% reduction in incidence of CVA
• 25% reduction in MI
• 50% reduction in congestive heart failure

• Weight reduction (BMI 18-24.9)
• Diet rich in fruits, veggies and lowfat dairy
• Reduce dietary sodium
• Regular aerobic exercise
• Moderation of alcohol consumption
• Quit smoking cigarettes

• Xerostomia from diuretics, calcium channel blockers, and ACE inhibitors
• Lichenoid drug eruption with thiazides and beta blockers
• Gingival hyperplasia due to calcium channel blockers
• Excessive bleeding during oral surgery

• ASA PS I: normotensive or pre-hypertensive under control with lifestyle modifications
• ASA PS II: Pre-hypertensive not controlled, Stage I (with and without control), stage 2 (under control, no target organ damage)
• ASA PS III: Stage 1 or 2 controlled with organ damage, Stage 2 not well controlled, stage 1 or 2 with diabetes mellitus
• ASA PS IV: Malignant hypertension

Atherosclerosis of the coronary arteries

• occur more frequently in the morning within hours of awakening
• increased sympathetic tone
• increased tendency of thrombosis

• Excess plasma lipids
• Macrophages migrate inot the endothelium to form plaques
• Lipids engulfed by macrophages
• Progressive narrowing of lumen
• Plaque rupture
• Release of lipids
• Endothelial damage
• Intravascular thrombi

• Hyperlipidemia: above 240 cholesterol 2x risk; LDL/HDL ratio should be <3, so >6 is high risk
• Markers of inflammation: C-reactive proteins (>3microgram/ml is high risk)
• Hypertension: elevated BP
• Cigarette smoking: >1 pack/day >10years 3-6x risk

• Controllable: alcohol, obesity, physical inactivity, diabetes, stress
• Uncontrollable: age, family hx, sex

• Symptoms - heavy pressure, diffuse pain may radiate (jaw, teeth, arms, back), precipitated by exertion/meals/stress, relieved by rest or nitroglycerin
• Signs - tachycardia, elevated BP, diaphoresis, lasts less than 5 minutes, subsides with rest or nitroglycerin

• Severe angina that lasts for more than 5 minutes; doesn't respond to rest or nitroglycerin
• Symptoms - dizziness, dyspnea, coughing palpations, nausea, vomiting
• Signs - fainting, pallor, diaphoresis, physical and emotional distress, unstable vitals

• NItrates
• Antiplatelet aggregation drugs
• Beta blockers
• Calcium channel blockers
• Coronary artery bypass graft
• Percutaneous transluminal coronary angioplasty
• Stents

• Coronary atherosclerosis
• Angina- mild stable
• MI more than 6 months ago w/surgery, no angina/dyspnea since

• Angina - moderate to severe stable
• MI more than 6 mo ago w/surgery w/stable angina/dyspnea since

• Angina- unstable
• MI less than 6 months ago w/surgery

• Angina radiating to mandible or teeth
• Nitroglycerin causes burning, facial flushing, headache
• Xerostomia due to diuretics, calcium channel blockers, and ACE inhibitors
• Lichenoid drug eruptions with thiazides and beta blockers
• Gingival hyperplasia due to calcium channel blockers
• Asprin and antiplatelet therapy causes excessive bleeding

• Sudden and severe loss of CNS function due to decreased blood flow to part of brain
• Thromboembolic infarcts: most common, due to blood clot, 10% mortality in 30 days
• Hemorrhagic infarcts: 20% of CVAs, wall of cerebral vessel ruptures (aneurysm), hypertensive patients, 40% mortality in 30 days

• Uncontrollable: age, sex, race, family hx, low birth weight, genetics, previous CVA, hx of CV disease, sleep apnea
• Controllable: smoking, physical inactivity or obesity, poor nutrition or diet, drug and alcohol use, oral contraceptives combined with smoking or previous CVA, hypertension (most important), diabetes, atherosclerosis/hyperlipidemia

• TIA
• Ministrokes
• Signs and symptoms last less than 24 hours (usually less than 10 minutes)

• Sudden numbness or weakness
• Sudden dimness or loss of vision
• Sudden dizziness or loss of balance
• Sudden severe headache
• Confusion with difficulty speaking

• Reduce risk factors
• Anticoagulant therapy
• Antiplatelet therapy
• Antihypertensive therapy
• Surgery to remove obstruction
• Rehabilitation

• Slurred speech
• Loss of vision
• Unilateral facial paralysis
• Loss of sensation to oral tissues
• Difficulty swallowing
• Xerostomia from diuretics and ACE inhibitors
• Increased bleeding - from anticoagulant and antiplatelet therapy

• ASA PS II: low risk, CVA over 1 year ago, minor to no neurologic effects, well controlled risk factors
• ASA PS III: moderate risk, CVA less than 1 year ago but not within 6 months, some neurological deficits, moderately well controlled risk factors
• ASA PS IV: high risk, CVA in last 6 months, significant neurological deficits, poorly controlled risk factors

• Type I: Scandinavian ethnic background
• Type II: over 45, overweight (BMI>25), parent/sibling with DM, hypertension, hyperlipidemia, gestational diabetes, physically inactive

• Hyperpituitarism (acromegaly)
• Cushings syndrome
• Chronic pancreatitis
• Carcinoma of pancreas

• Hyperglycemia
• Glucosuria
• Polyuria
• Nocturia
• Polydipsia
• Polyphagia
• Weakness
• Weight loss
• Ketoacidosis
• Microangiopathy - Retinopathy and renal failure
• Macroangiopathy - atherosclerosis
• Peripheral neuropathy
• Autonomic insufficiency
• Susceptibility to infection

• Polyuria
• Polyphagia
• Polydispia
• Weight loss
• Retinopathy/neuropathy may be present but not until later
• Ketoacidosis/renal disease occur less frequently

• FBG: 121-160
• Hb A1C: 7-10%

• FBG: >160
• Hb A1C: 10+%

• ASA PS II: well controlled w/dietary modifications, oral hypoglycemic agents, or insulin and without complications
• ASA PS III: well controlled/moderately well controlled, mild/moderate complications OR poorly controlled w/o complications
• ASA PS IV: severe complications or renal failure

• Xerostomia
• Burning tongue
• Gingivitis and periodontitis
• Caries
• Candidiasis
• Delayed wound healing
• Acetone breath
• Parotid gland swelling
• Lichenoid drug reactions (oral hypoglycemic)

• 45% of adults living in crowded environment
• Oral-fecal route
• Contaminated food, water, poor sanitation
• Person-to-person transmission likely in day care centers and institutions
• Highly infectious
• Incubation 4-6 weeks
• Fecal shedding 10-14 days prior to symptoms through 1st week of symptoms
• Virus can be in saliva and serum
• Fecal shedding can last up to 3 months after onset of symptoms

• Uncommon in developed countries (IV drug users, recipients of blood, hemodialysis, southeast asians, sexually promiscuous, med/dental personnel, group living)
• Underdeveloped countries (mother to child)
• Incubation 6 weeks-6 months
• 5-10% risk for chronic carrier

• Both developed and undeveloped countries
• Almost exclusively spread by blood contact (IV drug use, blood transfusions, hemodialysis, rarely sex or mother to child)
• Incubation 6-7 weeks
• 80-90% risk of chronic carrier

• Must have HepB
• More severe
• IV drug users
• 20-70% chronic carrier

• Most common in developing countries
• Transmitted oral fecal route like hepA
• High mortality in pregnant women (10-20%)
• Incubation 2-8 weeks

• Recently discovered
• 50% of IV drug users
• Sexually transmitted
• Clinical course not typical
• Not cause of liver dysfunction

• HepA: minor childhood illness, 10% cases are asymptomatic, 80% of adults jaundiced
• HepB/C: 60-90% asymptomatic, of those with signs/symptoms 50% jaundiced

• 2-8 weeks post exposure
• Myalgia/arthralgia
• Nausea and vomiting
• Fatigue and malaise
• Fever (low grade except HepA)
• Abdominal pain
• Changes in taste
• Right upper quadrant abdominal pain

• 1-2 weeks after preicteric phase
• Right upper quadrant abdominal pain
• Jaundice
• Nausea and vomiting

• Normal = 7-45
• Hepatitis= 500-10000
• Chronic Hep= <100

• Risk for liver cirrhosis and hepatocellular carcinoma
• Hepatic encephalopathy
• Ascites

• Slowly progressive
• Increased risk of liver cirrhosis in pts over 40 at infection, high alcohol consumption, and males
• Risk for hepatocellular carcinoma
• Hepatic encephalopathy
• Ascites

• Elevated liver function tests
• HepB: positive for HepB surface antigen, viral activity measured, liver ultrasound and biopsy
• HepC: serum HCV RNA, liver ultrasound and biopsy

• hepB surface antigen in blood and active production of virus
• Abnormal liver enzyme tests
• Increased risk for liver cirrhosis (40%) and hepatocellular carcinoma (1-3%)

• HepB surface antigen in blood and low levels of active production of virus
• Normal liver enzyme tests
• Lower risk for liver cirrhosis and hepatocellular carcinoma
• Can become chronic active

• HepA: self limiting, advise pts against handling food or unprotected sex
• HepB: self limiting, pts advised against blood-blood contact, screen sex partners/housemates, monitor for liver failure, monitor for clearance of virus, HepB immune globin
• HepC: interferon alpha tx reduces risk of chronic infection, pts advised against blood-blood contact

• HepB/C Carrier: normal tests mean low risk for developing liver disease or carcinoma, annual tests, pts advised against blood-blood contact
• Chronic active HepB: liver biopsy to detect cirrhosis and carcinoma, interferon alpha + antivirals for 4-6 months , no blood-blood contact
• HepC: interferon alpha + other antivirals for 6-12 months, main cause of liver transplant in US

• Jaundice
• Bleeding, petechial, ecchymoses, hematomas
• Decreased metabolism of meds

• PS I: Hx of HepA/B/C without complications
• PS II: ChronicB/C carrier without elevated ALT/AST, INR<2, no ascites, no hepatic encephalopathy, mildly elevated serum bilirubin (2-3)
• PS III: AcuteA/B/C or Chronic active B/C, moderately elevated ALT/AST (<500), INR <2, no ascites, no hepatic encephalopathy, mildly elevated serum bilirubin (2-3)
• PS IV: Acute hepatitis or Chronic active B/C with severely elevated ALT/AST (>500), INR>2, Ascites, hepatic encephalopathy, elevated serum bilirubin (>5mg/dL)