Professional Documents
Culture Documents
Problems in
Dentistry
Commissioning Editor: Alison Taylor
Development Editor: Clive Hewat
Project Manager: Hemamalini Rajendrababu/Bryan Potter
Designer: Charles Gray
Illustration Manager: Merlyn Harvey
Illustrator: Antbits
Medical
Problems in
Dentistry
6th
EDITION
EDINBURGH LONDON NEW YORK OXFORD PHILADELPHIA ST LOUIS SYDNEY TORONTO 2010
Sixth Edition © 2010, Elsevier Limited. All rights reserved.
ISBN 9780702030574
Notice
Knowledge and best practice in this field are constantly changing. As new
research and experience broaden our knowledge, changes in practice,
treatment and drug therapy may become necessary or appropriate. Readers
are advised to check the most current information provided (i) on procedures
featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of the
practitioner, relying on their own experience and knowledge of the patient,
to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions. To the fullest
extent of the law, neither the Publisher nor the Author assumes any liability
for any injury and/or damage to persons or property arising out of or related
to any use of the material contained in this book.
The Publisher
Printed in China
PREFACE
The aim of this book is to provide a basis for the understanding of kidney disease; osteoporosis; Alzheimer disease; pancreatic
how general medical and surgical conditions influence oral health cancer; and even oral cancer) is a prime example.
and oral healthcare. It is particularly relevant to dental professionals In general terms, dental professionals need to develop
and other persons working in the oral healthcare sciences. The strategies to identify patients at risk of medical problems,
reader should thus be able to understand relevant illness identified to assess the severity of those risks and, where necessary,
from the history, physical examination, and investigations; be able recognize the need for help and be able to seek advice from
to present a succinct and, where appropriate, unified list of all a colleague with special competence in the relevant fields.
problems that could influence oral healthcare; and formulate a This text has become one of the most widely used sources of
diagnosis/treatment plan for each problem (appropriate to the information for all dental staff who need to contend with the
level of training). The reader should also be able to communicate increasing variety of medical problems, particularly as they
appropriately with other healthcare providers; to retrieve medical are aware that they face a growing risk of litigation if they
information using the recommended further reading sections and do not keep themselves familiar with current knowledge, in
computer, in a manner that reflects understanding of medical line with the increasing acceptance of the need for continuing
language, terminology, and the relationship among medical professional education and development.
terms and concepts; to refine search strategies to improve The management of patients with these various diseases
relevance and completeness of retrieved items; and to identify and should take into consideration the severity of the condition;
acquire full-text electronic documents available from the internet the type of operative procedure envisioned, and in particular
sites quoted. the amount of trauma, likely distress and time taken; other risk
Though dentistry remains largely a technical subject, there factors; and the healthcare setting (skills/facilities) available.
are a number of reasons why dental professionals should Issues of access and informed consent, and the desirability of
have this basis to their education and training. Dentistry preventive oral healthcare and avoidance of harm, apply to
is a profession and not a trade; medical problems can virtually all situations. The comments and recommendations
influence oral health and healthcare, whilst oral health and herein should be used as guidelines to care, not commandments.
healthcare can influence general health and healthcare; dental Unfortunately, there are very few randomized controlled trials
professionals need to understand patients and their attitudes available to provide evidence for the various practices, and so
to healthcare; they need to communicate at a reasonable many of the recommendations have to be based on consensus.
level with other health professionals and with patients and Since the fifth edition, my co-author for 25 years, Professor Rod
sometimes the media; dental professionals may need to act Cawson, has sadly passed away. Nevertheless, the fact that this
as advocates for patients; and, finally, dental professionals text had become a best-seller and prize-winner, and has provided
themselves can find themselves in need of healthcare. Since probably the most comprehensive coverage available worldwide,
the first edition of this book, the importance of medicine in stimulated me into renewed efforts to keep it abreast of the
dentistry, interactions between medicine and dentistry, and the understanding of diseases and developments in medical and
need for medical knowledge by the whole dental team have all surgical care relevant to the oral healthcare sciences.
radically increased – as has the whole of medicine. I have updated and re-organized the whole text. Key points
The knowledge base of medicine has been extended and have been added in relation to the most important medical
effective new technologies, techniques and drugs have been conditions, and the focus on dentally relevant and changing
developed, many of which have resulted in complications areas has been increased. Much of the material is presented
relevant to oral healthcare. Many patients who would in earlier alphabetically in order to enhance access. This edition is,
times have succumbed, are alive and live to much greater therefore, essentially a complete re-write and the opportunity has
ages, thanks to advances such as public health improvements, been used to remove the arrows inserted in the previous editions.
transplants, pacemakers, radiotherapy and/or potent drugs – and This edition now also includes, for the first time, a number
they need good oral health and may well need oral healthcare. of disorders not previously included, plus alternative and
A wider range of medical problems has thus become relevant to complementary medicine, health promotion, men’s issues
oral healthcare sciences. The world has changed further and the and occupational issues. Included in a number of new
relevance of the book has grown even more, with an increasing areas are autoinflammatory disorders, biological response
number of persons who require special care, and with increasing modifiers, cosmetic procedures, craniofacial transplantation,
travel, not least by dental staff and trainees to developing drug reactions, drug-resistant microbial infections
countries. An ever increasing number of medical conditions also (nosocomial infections, tuberculosis and HIV), IgG4-related
appear to be influenced by dental health and healthcare: the plasmacytic disease, osteomyelitis, osteonecrosis, immune
range of conditions possibly linked to periodontal disease (pre- reconstitution syndrome and transgender issues. New
eclampsia; pre-term and low birthweight babies; endometrio- illustrations have also been added, as well as selected recent
sis; ischaemic heart disease; cerebrovascular disease; aspiration references and up-to-date Internet websites. Eponymous
pneumonia; diabetes mellitus; metabolic syndrome; chronic conditions appear in a separate chapter. National and even v
international guidelines that have been beginning to appear • http://emedicine.medscape.com
PREFACE
vi
CONTENTS
SECTION A: GENERAL 1 24 Trauma and burns 552
2 Medical history and risk assessment 19 25 Age and gender issues 569
4 Signs and symptoms 74 27 Dietary factors and health and disease 597
11 Mucosal, oral and cutaneous disorders 281 35 Transplantation and tissue regeneration 704
17 Allergies 411
20 Immunodeficiencies 451
ix
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SECTION A
GENERAL
Medical emergencies 03
Medical history and risk assessment 19
Perioperative care 45
Signs and symptoms 74
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MEDICAL EMERGENCIES 1
emergencies that may arise. All members of the dental team
KEY POINTS need to know their roles in the event of an emergency. GDC
guidance Principles of dental team working states that dental
• Be prepared
staff who employ, manage or lead a team should make sure that:
• Access to appropriate drugs and equipment
• Training • there are arrangements for at least two people to be avail-
• Who to call able to deal with medical emergencies when treatment is
• Medical history
planned to take place
• all members of staff, not just the registered team members,
know their role if a patient collapses or there is another
kind of medical emergency
The knowledge base of medicine has been extended, and effec-
• all members of staff who might be involved in dealing
tive new technologies, techniques and drugs have been devel-
with a medical emergency are trained and prepared to deal
oped. This has allowed patients, who in earlier times would
with such an emergency at any time, and regularly practise
have succumbed, to remain alive and live to much greater ages;
simulated emergencies together.
such patients may be prone to medical emergencies.
Collapse or other emergencies in the dental surgery are a cause The GDC has stipulated that 10 hours of training and retrain-
for anxiety for all involved Atherton et al., 1999a (Box 1.1). ing in emergency management is a mandatory requirement of
This chapter is limited to the main diagnostic and manage- continuing professional development in every 5-year period.
ment issues in emergency management for easy reference; fuller The most common medical emergencies apart from the
discussion of these conditions can be found in the relevant simple faint are fitting in an epileptic patient, angina pectoris
chapters. In general terms, dental professionals need to develop (ischaemic chest pain), hypoglycaemia in a diabetic patient
strategies to identify patients at risk of such medical emergen- and haemorrhage. Myocardial infarction and cardiopulmonary
cies, to assess the severity of those risks and, where necessary, arrest are more immediately dangerous, but fortunately less
recognize the need for help and be able to seek advice from a common (Box 1.2).
colleague with special competence in the relevant fields. All den- Emergencies are rare, occurring at rates of 0.7 cases per den-
tal staff need to contend with the increasing variety of medical tist per year (Girdler and Smith, 1999) or once every 3–4 years
problems, particularly as they are aware that they face a growing (Atherton et al., 1999b). A medical emergency occurring in dental
risk of litigation if they do not keep themselves familiar with practice is most likely to be the result of an acute deterioration of a
current knowledge, in line with the increasing acceptance of the known medical condition. It may pose an immediate threat to an
need for continuing professional education and development. individual’s life and needs rapid intervention. It is best prevented!
The comments and recommendations herein should be used
as guidelines to care, not commandments. Unfortunately, there
are very few randomized controlled trials available to provide
evidence for the various practices, and so many of the recom-
PREVENTION
mendations have to be based on consensus. Emergency management algorithms are of paramount impor-
Annual theoretical and practical training of all clinical staff is tance and dentists are ultimately responsible for the perfor-
required to manage these rare events effectively. Clinical den- mance of their staff in delivery.
tal staff have an obligation to be conversant with the current Confidence and satisfactory management of emergencies can
Resuscitation Council (UK) guidelines (2006 revised 2008) be improved by the following.
(see Further reading). The UK General Dental Council (GDC),
• Repeatedly assessing the patient whilst undertaking treat-
in Standards for dental professionals and associated supplemen-
ment, noting any changes in appearance or behaviour.
tary guidance (2005; see Useful websites), states that all den-
• Never practising dentistry without another competent
tal professionals are responsible for putting patients’ interests
adult in the room.
first, and acting to protect them. Central to this responsibility
is the need to ensure that they are able to deal with medical
Box 1.2 Likely causes of sudden loss of consciousness
and collapse
Box 1.1 Common emergencies
• Simple faint
• Collapse • Diabetic collapse secondary to hypoglycaemia
• Chest pain • Epileptic seizure
• Shortness of breath • Anaphylaxis
• Mental disturbances • Cardiac arrest
• Reactions to drugs or sedation • Stroke
• Bleeding • Adrenal crisis
3
• Always having accessible the telephone numbers for the • Using the simple intervention of laying the patient supine
emergency procedures: this should be repeated annually. early in the morning session or immediately after lunch is
All dental clinics should have a defined protocol for how likely to prevent hypoglycaemic collapse.
the emergency services are to be alerted. The protocol
should include clear directions for the emergency services All this is particularly important when sedation is used,
to locate and access the clinic and, in a large building, a when there are invasive or painful procedures, or when medi-
member of the team should meet the paramedics at the cally complex individuals are being treated. ‘Forewarned is
main entrance. forearmed’, and dental practitioners must ensure that medical
• Having a readily accessible emergency drugs box and and drug histories are updated at each visit prior to initiating
equipment checked on a weekly basis (Table 1.1 and Figs treatment. It is suggested disease severity should be assessed
1.1–1.3). using a risk stratification system, for example the American
• Taking a careful medical history, assessment of disease Society of Anesthesiologists (ASA) classification (see Chs.
severity, careful treatment scheduling and planning and, 2 and 3). This may help identify high-risk individuals.
in some cases, administration of medication prior to Few emergencies can be treated definitively in the den-
treatment. tal surgery, and the role of the dental team is one of support
Table 1.1 Suggested minimal equipment and drugs for emergency use in dentistry (after Resuscitation Council, 2006).
Oxygen (O2) delivery Portable apparatus for administering oxygen Two portable oxygen cylinders (D size) with pressure
Oxygen face (non-rebreathe type) mask with tube reduction valves and flow meters. Cylinders should
Basic set of oropharyngeal airways (sizes 1, 2, 3 and 4) be of sufficient size to be easily portable but also
Pocket mask with oxygen port allow for adequate flow rates (e.g. 10 L/min, until the
Self-inflating bag valve mask (BVM; 1-L size bag), where staff arrival of an ambulance or the patient fully recovers.
have been appropriately trained A full ‘D’ size cylinder contains 340 L of oxygen and
Variety of well-fitting adult and child face masks for attaching should allow a flow rate of 10 L/min for up to 30
to self-inflating bag minutes. Two such cylinders may be necessary to
ensure the oxygen supply does not fail
Automated external defibrillator (AED) All clinical areas should have immediate access to an AED
(Collapse to shock time less than 3 minutes)
Equipment for administering drugs Single-use sterile syringes (2-ml and 10-ml sizes) and needles Drugs as below
intramuscularly (19 and 21 sizes)
Anaphylaxis Adrenaline (epinephrine) injection 1:1000, 1 mg/ml Intramuscular adrenaline (0.5 ml of 1 in 1000
solution)
Repeat at 5 minutes if needed
Angina Glyceryl trinitratea spray 400 mcg/metered activation Glyceryl trinitrate, two sprays
No corticosteroid is included.
aDo not use nitrates to relieve an angina attack if the patient has recently taken sildenafil as there may be a precipitous fall in blood pressure; analgesics should be
4 used. Where possible, all emergency equipment should be single use and latex free. The kit does not include any intravenous injections
and considered intervention using algorithms that can ‘do no Other agents (e.g. flumazenil) and equipment (e.g. a pulse
harm’. Previously it has been suggested that 20 or more drugs
should be available to the dental surgeon for the management
oximeter) are needed if conscious sedation is administered.
General anaesthesia (GA) must only be undertaken by anaes- 1
of emergencies but this is impractical, may be a source of con- thetists and where advanced life support (ALS) is available.
fusion and, if incorrectly administered, life threatening. The
MANAGING EMERGENCIES
Resuscitation Council (2006) recommendations for equipment
and drugs are detailed in Table 1.1.
MANAGING EMERGENCIES
For all medical emergencies, a structured approach to assess-
ment and reassessment prevents any symptoms and signs being
missed and any incorrect diagnoses being made. The sequence
is best remembered as ‘ABCDE’ (Box 1.3).
Dental staff should be trained in basic cardiopulmonary
resuscitation (CPR) so that, in the event of cardiac arrest, they
should be able to:
EMERGENCY PROCEDURE
• Call for local assistance.
• Assess patient – ABCDE (as Box 1.3) – and give oxygen if
Fig. 1.2 Automatic defibrillator appropriate.
1
• Use acronym MOVE:
caller interrogation and pre-arrival instructions. AMPDS gives
Monitor – reassess ABCDE regularly, attach AED if
a main response category:
appropriate
Oxygen – 15 L/min through non-rebreathe mask • A (immediately life-threatening)
MEDICAL EMERGENCIES
Emergency 1. Call for assistance 2. Give oxygen 3. Other main actions 4. Alert emergency services
Angina Yes Yes Glyceryl trinitrate sublingually Only if no spontaneous recovery after action (3)
Asthma exacerbation Yes Yes Sit patient up and forwards, Only if no spontaneous recovery after action (3)
salbutamol inhaled via spacer
Choking Yes Yes Back slap five times, then Only if no spontaneous recovery after action (3)
abdominal thrust five times
Epileptic fit Yes Yes Protect patient from harm Only if no spontaneous recovery after 5 minutes,
Consider midazolam i.m. persistent altered conscious state or the fit
or sublingually/buccal mucosa characteristics are different to those previously
described
Faint Yes No* Lay patient flat Only if no spontaneous recovery after action (3)
Hypoglycaemia Yes Yes Glucose Only if no spontaneous recovery after action (3)
If unconscious, glucagon i.m.