Urine analysis in dentistry

1. URINE
ANALYSIS IN
DENTISTRY
• ASHISH RANGHANI
• PG PART 2
• GDCH, AHMEDABAD
UNDER GUIDANCE OF
DR. J.S SHAH
PROFESSOR AND HEAD
ORAL MEDICINE AND RADIOLOGY
GDCH
DATE- 28/07/2016

2. CONTENTS
1. Processes of Urine Formation
2. Why urinalysis?
3. Collection of urine specimens
4. Types of urine sample
5. Components of urine
6. Urinalysis
7. Physical Examination
Volume ,Color, Odor, Turbidity, Reaction (pH), Specific gravity
8. Biochemical Examination
Proteins, Sugers , Ketone bodies, Bile salts , Bile Pigments, Blood
9. Microscopic Tests
Cells, Crystals ,Casts, Microorganism
10. Urinary changes in Dental Diseases

3. Urine is the
excretory
waste product
formed by the
kidney
It reflects the
overall
metabolic and
kidney
functions of
the body
In normal urine
sample many
substances
such as
glucose,
proteins, amino
acids, are
present in trace
amounts.
Essentials of Medical Physiology Sixth Edition, Sembulingam

4. Processes of Urine Formation
• When blood passes
through glomerular
capillaries, the
plasma is filtered
into the Bowman
capsule. This
process is called
glomerular filtration
Glomerular filtration
• While passing
through the tubule,
the filtrate
undergoes various
changes both in
quality and in
quantity
• Many wanted
substances like
glucose, amino
acids, water and
electrolytes are
reabsorbed from
the tubules
Tubular reabsorption
• Unwanted
substances are
secreted into the
tubule from
peritubular blood
vessels
Tubular secretion
Essentials of
Medical
Physiology Sixth
Edition,
Sembulingam

5. Why urinalysis?
Monitoring
of patients
with
diabetes
General evaluation of health
Diagnosis of disease or disorders
of the kidneys or urinary tract
Diagnosis of other systemic
disease that affect kidney function

6. Collection of urine specimens
• Improper collection-- may invalidate the
results
• Containers for collection of urine should
be wide, clean and dry.
• Analysed within 2 hours of collection else
requires refrigeration.
• All specimens must be properly labeled
• The patient’s name
• The patient’s identification
number
• The date
• The time of collection
• The type of specimen
• The attending physician’s name
• The label should be affixed on
the container, not the lid.

7. Types of urine sample
Sample type Sampling Purpose
Random specimen No specific time
most common, taken
anytime of day
Routine screening
Morning sample First urine in the morning,
most concentrated
Pregnancy test,
microscopic test
Clean catch midstream Discard first few ml,
collect the rest
Culture
24 hours All the urine passed
during the day and night
and next day 1st sample is
collected.
used for quantitative and
qualitative analysis of
substances
Postprandial 2 hours after meal Determine glucose in
diabetic monitoring
Supra-pubic aspired Needle aspiration Obtaining sterile urine

8. Components of urine
textbook of routine urinalysis and body fluids

9. URINALYSIS
1. Volume
2. Color
3. Odor
4. Turbidity
5. Reaction (pH).
6. Specific gravity.
1. Proteins.
2. Sugers.
3. Ketone bodies.
4. Bile salts.
5. Bile Pigments.
6. Blood.
1. Cells.
2. Crystals.
3. Casts.
4. Microorganism
5. Parasites.
6.Contamination
A. Physical
Examination
B. Biochemical
Examination
C. Microscopic Tests

10. PHYSICAL EXAMINATION
• Volume – Normal – 1- 1.5 L /day.
Polyuria >3000ml /
day increased
urination
• Diabetes mellitus &
insipidus,
• Chronic nephritis
• After administration
of certain drugs like
digitalis, salicylates
or diuretics
Anuria <100 ml per
day total suppression
of urination
• Severe hypotension
• Crush injury,
• Mercurial poisoning,
• After a mismatch
transfusion
Oliguria <400ml / day
Decreased urination
• Acute & chronic
glomerulonephritis,
• Shock,
• Congestive cardiac
failure,
• Dehydration

11. APPEARANCE
• COLOUR
• Normal - amber yellow due to the presence of
1. Urobilin
2. Uroerythrin
3. Urochromes
Colorless - Very
dilute urine
• Diabetes
• Polyuria
Yellow orange
(high colored)
• Concentrated
urine
• Excess urobilin
• Bile pigments
• Intake of carrots
Red/ smoky
• RBC
• Myoglobin
• Aniline dyes
• Menstrual
contamination

12. Milky
Pyuria
Fat
Brown black
• Methemoglobin
• Alkaptonuria
• Melanin
Orange
• Bile pigments,Drugs like
• Rifampicin- orange red
• Levodopa -brown to
black
• Amitryptyline - green or
blue-green
• Imipenem–cilastatin -
brown urine
.
-
Cloudy - Phosphates & Carbonates, Urates & Uric acid,
Pus cells, Bacteria, Spermatozoa bacteria, Yeast,
Spermatozoa.

13. Specific Gravity
•It is directly proportional to the concentration
of solute & inversely proportional to the
volume
•Ranges between 1.003 to 1.030

14. LOW SPECIFIC
GRAVITY
HYPOSTHENURIA :indicates dilute
urine, which may be caused by
1. Diabetes insipidus ( can be
as low as 1.001)
2. Drinking excessive amounts
of liquid.
3. Pyelonephritis,
glomerulonephritis
4. Use of diuretics.
HYPERSTHENURIA : indicates very
concentrated urine, which may be
caused by
1. Dehydration
2. Diabetes mellitus
3. Adrenal insufficiency.
4. Toximea of pregnancy (protein
in the urine).
HIGH SPECIFIC
GRAVITY

15. TURBIDITY
Clear and transparent
Freshly
voided
form white precipitate
Pus
cells
gives uniform cloudiness.Bacteria
growth
Red cells
• Gives
turbid
smoky
urine
Mucus
• it forms
bulky
deposits

16. ODOUR OF URINE
After prolonged standingAmmonia smell:
• Rancid : Tyrosinaemia.
Due to urinary infectionFecal smell:
• Mousy order : phenylketonuria
Ketone bodies is seen in diabetesFruity smell
• Maple syrup odour : MSUD
Normal odour Fresh urine has aromatic odor

17. pH
• Normal pH for urine ranges from 4.5 – 8.0 (average pH 6)
• Some foods (such as citrus fruits and dairy products) and
medications (such as antacids) can affect urine pH.
• In a diet high in protein the urine is more acidic, while a diet
high in vegetable material a urine that is more alkaline.
• Tested by:
• litmus paper
• pH paper
• dipsticks

18. pH
CAUSES OF ACIDIC
URINE
1. Acidosis
2. Uncontrolled diabetes
3. Diarrhea
4. Starvation and dehydration
5. Respiratory Acidosis
CAUSES OF ALKALINE
URINE
1. UTI with urease
producing org
2. After Meal
3. Salicylate intoxication
4. Urinary retention due to
obstruction
5. Chronic renal failure
6. Respiratory alkalosis
7. Renal tubular acidosis

19. Chemical examination
• Proteins
• Sugars
• Ketone bodies
• Bilirubin
• Bile salts
• Urobilinogen
• Blood
1. Text book of practicle pathology & microbiology V.H. Talib

20. Tests for proteins
• Principle-proteins are denatured & coagulated on
heating to give white cloud precipitate.
• Method-take 2/3 of test tube with urine, heat only
the upper part keeping lower part as control.
• Presence of phosphates, carbonates, proteins gives
a white cloud formation. Add acetic acid 1-2 drops,
if the cloud persists it indicates it is protein(acetic
acid dissolves the carbonates/phosphates)
HEAT COAGULATION TEST
1. Text book of practicle pathology & microbiology V.H. Talib

21. Other tests
SULPHOSALICYLIC ACID
TEST
• Mix equal volume of
clear urine & 3 to 5%
acid
• Cloudiness indicate
presence of proteins
HELLER’S NITRIC ACID
TEST
• White ring at the point
of contact of conc.
HNO3 and urine
indicate presence of
albumin
Text book of practicle pathology & microbiology v.H. Talib

22. Causes of proteinuria
• Normally there is a very scanty amount of protein
in urine (< 150mg/day)
HEAVY PROTEINURIA
(>3gm/day)
• SLE
• Diabetes mellitus
• Nephrotic syndrome
• Renal vein
thrombosis
MODERATE
PROTEINURIA (1-
3gm/day)
• Multiple myeloma
• Pyelonephritis
• Chronic
glomerulonephritis
• Nephrosclerosis
MILD PROTEINURIA
(<1gm/day)
• Hypertension
• Polycystic kidney
• UTI
• Fever
• Chronic
pyelonephritis
Pathology practicle book, harsh mohan

23. Bence Jones proteins
• These are light chain globulins seen in multiple
myeloma & lymphoma.
• Test- Thermal method(waterbath):
Proteins has unusual property of precipitating at
400 -600c & then dissolving when the urine is
brought to boiling(1000c) & reappears when the
urine is cooled.
1. Text book of practicle pathology & microbiology V.H. Talib

24. Test for sugar
• Blue-green= negative
• Yellow-green=+(<0.5%)
• Greenish yellow=++(0.5-1%)
• Yellow=+++(1-2%)
• Brick red=++++(>2%)
1. Text book of practicle pathology
& microbiology V.H. Talib
• Test-BENEDICT’S TEST(semiquantitative)
• Principle-benedict’s reagent contains cuso4.In the presence of
reducing sugars cupric ions are converted to cuprous oxide which
is hastened by heating, to give the color.
• Method- take 5ml of benedict’s reagent in a test tube, add 8drops
of urine. Boil the mixture.

25. Benedict’s test
• Detects all reducing substances like glucose,
fructose, & other reducing sustances.
• To confirm it is glucose, dipsticks can be used
(glucose oxidase)

26. Causes of glycosuria
• Glycosuria with hyperglycaemia-
1. Diabetes,
2. Acromegaly,
3. Cushing’s Disease,
4. Hyperthyroidism,
5. Drugs Like Corticosteroids.
• Glycosuria without hyperglycaemia-
Renal tubular dysfunction
Text book of practicle pathology & microbiology v.H. Talib

27. KETONE BODIES
• 3 types
Acetone
Acetoacetic acid
β-hydroxy butyric acid
They are products of fat metabolism

28. Rothera’s test
• Principle-acetone & acetoacetic
acid react with sodium
nitroprusside in the presence of
alkali to produce purple colour.
• Method- take 5ml of urine in a test
tube & saturate it with ammonium
sulphate. Then add one crystal of
sodium nitroprusside. Then gently
add 0.5ml of Strong ammonium
hydroxide along the sides of the
test tube.
• Appearance permanganate colored
ring at the junction of the two
fluids indicates a positive test
1. Text book of practicle pathology & microbiology V.H. Talib

29. Causes of ketonuria
• Diabetes
• Non-diabetic causes-
1. High Fever,
2. Starvation,
3. Severe Vomiting/Diarrhea
4. After General Anaesthesia
Text book of practicle pathology & microbiology v.H. Talib

30. Blood in urine
• Test- BENZIDINE TEST
• Method- mix 2ml of benzidine solution with 2ml of
hydrogen peroxide in a test tube. Take 2ml of urine &
add 2ml of above mixture. A blue color indicates +
reaction
Text book of practicle pathology & microbiology v.H. Talib

31. Causes of hematuria
• Acute & Chronic Glomerulonephritis,
• Chronic Passive Congestion Of The Kidney
• Renal TB,
• Leukaemias
• Severe UTI,
• Urinary Calculi
• Benign & Malignant Tumors Of The Kidney
& Urinary Tract
Text book of practicle pathology & microbiology v.H. Talib

32. BILE SALTS
Hay’s test
The test depends on the surface activity of bilirubin
as it lowers the surface tension of urine.
Sprinkle a little of precipitated sulfur powder on the
surface of 2 ml urine. If bilirubin is present, sulfur
powder will sink to the bottom of urine. If bile is
absent, sulfur will remain on the surface of urine.
Text book of practicle pathology & microbiology v.H. Talib

33. Bilirubin
• Test- fouchet’s test.
• Causes
Liver diseases-injury,hepatitis
Obstruction to biliary tract

34. Urobilinogen
• Test- ehrlich test
• 5ml fresh urine + 0.5 ml Ehrilch's reagent, allow to
stand for 5 min →
• pink color on cold → normal trace.
• red color on cold → increased amounts.
• red color after heating → normal traces.
• Causes-hemolytic anemia's
Cause- obstruction to bile flow (obstructive jaundice)

35. Microscopic examination of urine
• A sample of well-mixed urine
(usually 10-15 ml) is
centrifuged in a test tube at
relatively low speed (about
2000-3,000 rpm) for 5-10
minutes which produces a
concentration of sediment
(cellular matter) at the
bottom of the tube.
• A drop of sediment is poured
onto a glass slide, a coverslip
is place over it & observed
under microscope
Urinalysis: a comprehensive review,

36. A variety of normal and abnormal cellular
elements may be seen in urine sediment such as
1. Red blood cells
2. White blood cells
3. Mucus
4. Various epithelial cells
5. Various crystals
6. Bacteria
7. Casts

37. Hematuria is the presence of
abnormal numbers of red cells
in urine due to any of several
possible causes
• Renal stone
• Kidney tumors
• kidney trauma,
• Upper and lower
urinary tract infections,
• Polycystic kidney
WBC in high numbers indicate
inflammation or infection
somewhere along the urinary or
genital tract
• UTI
• Prostatitis
• Chronic pyelonephritis
• Renal stone
• Renal tumours
• Cystitis

38. • The most common type of cast- hyaline casts
• Seen in fever, exercise, damage to the glomerular capillary.
• Red blood cells may stick together and form red blood cell
casts. Such casts are indicative of glomerulonephritis, with
leakage of RBC's from glomeruli, or severe tubular damage
• White blood cell casts
• Their presence indicates inflammation of the kidney.
TYPES OF CAST
Acellular cast
• Hyaline casts
• Granular casts
• Waxy casts
• Fatty casts
• Pigment casts
• Crystal casts
Cellular cast
• Red cell casts
• White cell casts,
• Epithelial cell cast

39. Crystals & amorphous materials

40. URINE ANALYSIS IN DIABETES
• Diabetes mellitus (DM) also known as a group of
metabolic diseases in which there are high blood sugar
levels over a prolonged period.
• This high blood sugar produces the symptoms of
frequent urination, increased thirst, and increased
hunger.
• Untreated, diabetes can cause many complications.
Acute complications include diabetic ketoacidosis and
nonketotic hyper osmolar coma.
• Serious long-term complications include heart disease,
stroke, kidney failure, foot ulcers and damage to the
eyes
A study on abnormal constituents of urine in diabetic patients

41. • In diabetes mellitus mainly glucose and ketone
bodies are elevated
• Glucosuria occurs in mainly during diabetis mellitus
and renal diabetes.
• These ketone bodies are present in the urine this
may be due to diabetic ketoacidosis
• It occurs when the body cannot use sugar (glucose)
as a fuel source because there is little or no insulin.
Fat is used for fuel instead

42. Diagnosis of Multiple
Myeloma
Two of the 4 following criteria are
generally required for diagnosis of
multiple myeloma:
1. Radiographic evidence of osteolytic
bone lesions
2. >20% plasma cells in bone marrow
aspirates or biopsy specimens.
3. Demonstration of monoclonal or
biclonal gammopathy with serum
electrophoresis
4. Demonstration of Bence-Jones
proteinuria
Systemic Lupus
Erythematosus
• Heavy proteinuria (>
3gm/day)
Pathology practicle book, harsh mohan

43. Mercury concentrations in urine
• Urine levels of mercury less than 20 ng/mL are
considered safe.
• The mercury body burden of dental personnel is
normally higher than in the general population.
• This increased body burden is attributed to dental
personnel mixing and applying dental amalgam and
removing amalgam restorations

44. References
1. Text book of practicle pathology & microbiology v.H. Talib
2. Pathology practicle book, harsh mohan
3. Urinalysis in clinical practice, sekhar chakraborty
4. Graff’s textbook of routine urinalysis and body fluids
5. Salma mahaboob, madan mohan rao m, a study on abnormal constituents
of urine in diabetic patients, ujmds 2014, page 64-67
6. Urinalysis: a comprehensive review, jeff Simerville, m.D., Georgetown
university school of medicine, washington, d.C
7. Essentials of Medical Physiology Sixth Edition, Sembulingam