Ebook Dental management of the medically compromised patient (9/E): Part 1

TA B L E O F C O N T E N T S
Dental Management: A Summary, xiii

19 Allergy, 330

PART I  Patient Evaluation and Risk
Assessment, 1

20 Rheumatologic Disorders, 345

1 Patient Evaluation and Risk
Assessment, 2

PART II  Cardiovascular Disease, 18
2
3
4
5
6

21 Organ Transplantation, 370

PART VIII  Hematologic and
Oncologic Disease, 389
22 Disorders of Red Blood Cells, 390

Infective Endocarditis, 19

23 Disorders of White Blood Cells, 402

Hypertension, 38

24 Acquired Bleeding and

Hypercoagulable Disorders, 428

Ischemic Heart Disease, 53
Cardiac Arrhythmias, 70

25 Congenital Bleeding and

Heart Failure (or Congestive Heart
Failure), 86

26 Cancer and Oral Care of Patients With

PART III  Pulmonary Disease, 100
7 Pulmonary Disease, 101
8 Smoking and Tobacco Use
Cessation, 128

9 Sleep-Related Breathing Disorders, 138

PART IV  Gastrointestinal
Disease, 150

Hypercoagulable Disorders, 457
Cancer, 480

PART IX  Neurologic, Behavioral,

and Psychiatric Disorders, 515
27 Neurologic Disorders, 516
28 Anxiety and Eating Disorders, 544
29 Psychiatric Disorders, 561
30 Drug and Alcohol Abuse, 581

10 Liver Disease, 151

Appendices, 596

11 Gastrointestinal Disease, 176

A Guide to Management of Common
Medical Emergencies in the Dental
Office, 597

PART V  Genitourinary Disease, 192
12 Chronic Kidney Disease and
Dialysis, 193

13 Sexually Transmitted Diseases, 210

PART VI  Endocrine and Metabolic
Disease, 229
14 Diabetes Mellitus, 230
15 Adrenal Insufficiency, 255
16 Thyroid Diseases, 268
17 Women’s Health Issues, 288

PART VII  Immunologic Disease, 308

18 AIDS, HIV Infection, and Related
Conditions, 309

B

Guidelines for Infection Control in
Dental Health Care Settings, 606

C Therapeutic Management of Common
Oral Lesions, 623

D Drug Interactions of Significance in
Dentistry, 639

E

Drugs Used in Complementary and
Alternative Medicine of Potential
Importance in Dentistry, 645

Index, 655


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DENTAL
MANAGEMENT
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Compromised Patient

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2015v1.0


LITTLE AND FALACE’S

DENTAL

MANAGEMENT
of the Medically

Compromised Patient
Ninth Edition

James W. Little, DMD, MS
Professor Emeritus
University of Minnesota
School of Dentistry
Minneapolis, Minnesota; Naples, Florida

Craig S. Miller, DMD, MS
Professor of Oral Diagnosis and Oral Medicine
Provost Distinguished Service Professor
Department of Oral Health Practice
Department of Microbiology, Immunology and Genetics
The University of Kentucky College of Dentistry and College of Medicine
Lexington, Kentucky

Nelson L. Rhodus, DMD, MPH
Morse Distinguished Professor and Director
Division of Oral Medicine, Oral Diagnosis and Oral Radiology
University of Minnesota
School of Dentistry and College of Medicine
Minneapolis, Minnesota


3251 Riverport Lane
St. Louis, Missouri 63043

LITTLE AND FALACE’S DENTAL MANAGEMENT OF
THE MEDICALLY COMPROMISED PATIENT, NINTH EDITION

ISBN: 9780323443555

Copyright © 2018 by Elsevier, Inc. All rights reserved.
Previous editions copyrighted 2013, 2008, 2002, 1997, 1993, 1988, 1984, and 1980.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic
or mechanical, including photocopying, recording, or any information storage and retrieval system,
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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein. In
using such information or methods they should be mindful of their own safety and the safety of
others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, 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 practitioners, relying on their
own experience and knowledge of their patients, 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 authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of any methods, products,
instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Names: Little, James W., 1934- author. | Miller, Craig S., author. | Rhodus,
  Nelson L., author.
Title: Little and Falace’s dental management of the medically compromised
  patient / James W. Little, Craig S. Miller, Nelson L. Rhodus.
Description: Ninth edition. | St. Louis, Missouri : Elsevier, Inc., [2018] |
  Preceded by Little and Falace’s dental management of the medically
  compromised patient / James W. Little … [et al.]. 8th ed., c2013. |
  Includes bibliographical references.
Identifiers: LCCN 2017025872 (print) | LCCN 2017027016 (ebook) | ISBN
  9780323443951 (Ebook) | ISBN 9780323443555 (pbk. : alk. paper)
Subjects: | MESH: Dental Care | Dental Care for Chronically Ill | Oral Manifestations
Classification: LCC RK55.S53 (ebook) | LCC RK55.S53 (print) | NLM WU 29 | DDC
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We dedicate this ninth edition to our role model and close friend:
Dr. Selverio “Sol”/“Bud” Silverman, Jr., MA, DDS

In 2014, we lost our dearest colleague:
Each of us in dentistry has been truly blessed by Dr. Silverman:
As a professor of oral medicine at University of California, San Francisco (UCSF) School of
Dentistry, for many years, Silverman headed one of UCSF’s oral medicine clinics and was an
advocate for prevention and early detection of oral cancer as well as AIDS. Silverman was a
diplomat of the American Board of Oral Medicine, past president of the Board, and past
President of the American Academy of Oral Medicine (AAOM). Dr. Silverman was a
consultant to the American Dental Association Council on Scientific Affairs and a national
spokesperson for the Association. He published more than 300 scientific articles, chapters in
textbooks, and monographs. He received the prestigious Margaret Hay Edwards medal
from the American Association for Cancer Education for outstanding contributions.
UCSF Enumeration on October 16, 2006, yet practiced until his death.
Deceased August 14, 2014, at 88 years of age.
Dr. Selverio Silverman, Jr., gave back so much to oral medicine profession worldwide and encouraged
others around the world and as well as his fellow oral medicine colleges and students at UCSF’s oral
medicine clinics yearly, stressing each to become an active member in AAOM. Filled with pride and
love, Bud exchanged his family stories over the years with each of us. “Bud” was a very well-rounded
doctor and family man who was filled with pride and love of both his family and his profession.
Oral medicine educators, doctors, students, and AAOM members should never tire
of challenging each other academically because change makes for evolving changes,
and teaming up with each other professionally makes for the very best for oral medicine
worldwide. Giving is better than receiving always.
Thanks, “Bud,” for giving each of us your very best.
Dear friend, you shall always be missed.
Dr. “Bud” Silverman, Jr., has written the Foreword for this textbook for the prior last five editions.
This book serves as a textbook as well as a must-have reference book for every dental office in the
United States as well as throughout the world.
Dr. Sol Silverman, Jr., and Dr. James W. Little were best friends for the past 45+ years. Their world
was carved with the same great values, yet they practiced and taught oral medicine more than 3250

miles apart. Jim and Bud were tethered via phone as they dedicated their lives to oral medicine
through their teachings, research, and their own publications and textbooks. Each authored oral
medicine textbooks as well as massive publications. Each had the total support and love of each of
their own families, their own university workplace, and fellow members of the AAOM. Bud and
Jim shared their love of sports by playing tennis, golf, and pick-up basketball into their 80s. They
kept young by enjoying their daily playtime with their college kids and all their AAOM friends.
“Bud” Silverman is missed daily by each of us involved with oral medicine.
Dr. James W. Little


This page intentionally left blank


F O R E WO R D

It has been said that dental offices of the past were often
located upstairs, on second floors, to screen out those
who were too infirm to undergo dental treatment. Patients
able to climb the flight of stairs to the office were considered fit enough to treat.
Largely because of modern medical care, people today
are living and working with medical conditions that in
the past might have been disabling or even unsurvivable.
Statistics from 2012 show that roughly half of noninstitutionalized U.S. adults had one or more of 10 chronic
medical conditions (hypertension, coronary heart disease,
stroke, diabetes, cancer, arthritis, hepatitis, weak or failing
kidneys, current asthma, or chronic obstructive pulmonary
disease). Almost a quarter (24.3%) had one of these
conditions, 13.87% had two, and 11.7% had three or
more. Approximately one fourth of U.S. adults have more
than one chronic illness.1

As one might expect, the incidence of chronic illness
increases with age. A total of 69.5% of U.S. adults age
55 to 64 years had one or more of six chronic conditions (arthritis, current asthma, cancer, cardiovascular
disease, chronic obstructive pulmonary disease, and
diabetes), 37.1% had two or more, and 14.4% had three
or more. For ages 65 years and older, the percentages
increase to 85.6%, 56.0%, and 23.1%, respectively.
Women were more affected than men in all age groups
(2008 data).2
Prescription medication is a mainstay of modern health
care, and all age groups use them. A total of 14.1% of
children younger than age 12 years, 17.3% age 12 to 29
years, and almost 20% of adults age 20 to 59 years use
a prescription medication. Of adults age 60 years and
older, roughly a quarter take one or two prescription
medications, and almost four of 10 people (36.7%) take
five or more prescription medications.3 Almost one quarter
of U.S. adults older than 65 years have three or more
chronic illnesses, and more than one third take five or
more medications.
Nowadays, many patients no longer have “a doctor.”
Instead, a patient may see multiple doctors for his or
her various conditions, such as a cardiologist for coronary artery disease, an endocrinologist for diabetes, a
rheumatologist for arthritis, an oncologist for cancer, a
psychiatrist for depression—the list can go on and on.
This can make medical consultation challenging for the
dentist because each specialist focuses on his or her
own area and cannot be expected to be knowledgeable
about the details of dental diseases and treatments. The
dentist cannot expect simply to request a “clearance”

from one of the patient’s physicians, who may not have a
thorough understanding of what the proposed treatment
entails.
It is therefore essential that the dentist understand how
patients’ dental diagnoses and planned treatment relate
to their medical diagnoses and treatment. For example,
some patients may take anticoagulants or have bleeding
disorders that affect dental surgical options and require
special considerations in treatment planning. Medical
treatments such as head and neck radiation therapy or
antiosteoclast medications may impair healing after dental
infections or dental surgical procedures, and failure to
appreciate and take into account such relationships may
put patients at risk for serious complications. Some medical
conditions, if unstable, may pose a risk of intraoperative
medical emergency during dental treatment and may
require modification of treatment planning and delivery.
Organ and hematopoietic transplant recipients are an
increasingly large group of patients, and among their
considerations is the potential for opportunistic infections
and malignancies, which can occur in the oral cavity as
well as elsewhere. Certain medical problems may themselves adversely affect dental health, such as a patient
with physical or cognitive impairment that precludes
effective dental hygiene or a patient whose illness or
medication produces such profound xerostomia that caries
cannot be controlled.
Medications that a patient is taking may create the
potential for interactions that must be considered when
the dentist wishes to prescribe or administer a drug.

In addition, therapeutic effects of medications, such as
anticoagulation, or adverse effects, such as xerostomia
or mucosal reactions, may bear on dental management.
Advanced age, or renal, hepatic, or other diseases that
alter drug uptake, metabolism, clearance, or response
may require dosage adjustments. Furthermore, each new
drug creates the potential for known or as yet unknown
drug interactions and side effects, and adverse effects
of older medications continue to be discovered with
ongoing use.
These are just a few examples of common conditions
that can impact dental management. Although the most
complex and seriously ill patients may require specialists
to provide their dental care, no dentist will be able to
avoid treating patients with medical problems altogether,
and all dentists must be prepared for them. This book,
which has been thoroughly updated in the present edition,
provides an excellent overview of pathophysiology and
treatment of a broad range of common medical conditions

vii


viii

FOREWORD

that will provide the dentist with understanding of the
interrelationships between patients’ dental and medical
care, as well as information on recommended modifications of treatment delivery. Competency in this critical

and complex area of dentistry is essential to the safe
and effective provision of dental care to an increasingly
large part of our population. Its importance cannot be
overstated.
John C. Robinson, MA, DDS, FAAOM
Santa Rosa, California

REFERENCES
1. Ward BW, Schiller JS, Goodman RA. Multiple chronic
conditions among US adults: a 2012 update. Prev Chronic
Dis 2014;11:130389.
2. CDC/National Center for Health Statistics. National
Health Interview Survey. />health_policy/adult_chronic_conditions.htm.
3. Gu Q, Dillon CF, Burt VL. Prescription drug use
continues to increase: U.S. prescription drug data for
2007-2008. NCHS data brief, no 42. Hyattsville, MD,
2010, National Center for Health Statistics.


P R E FAC E

The need for a ninth edition of Dental Management of
the Medically Compromised Patient became apparent
because of the continued, ever-increasing flow of new
knowledge and changing concepts in medicine and
dentistry.
The purpose of the book remains to give dental providers an up-to-date, concise, factual reference work describing the dental management of patients with medical
problems. The more common medical disorders that may
be encountered in a dental practice continue to be the
focus. This book is not a comprehensive medical reference

but rather a book containing enough core information
about each of the medical conditions covered to enable
readers to recognize the basis for various dental management recommendations. Medical problems are organized
to provide a brief overview of the basic disease process,
epidemiology, pathophysiology and complications, signs
and symptoms, laboratory and diagnostic findings, and
currently accepted medical therapy of each disorder.
This is followed by a detailed explanation and recommendations for specific dental management and oral
considerations.
The accumulation of evidence-based research over the
years has allowed us to provide specific dental management
guidelines that should benefit those who read this text.
This includes practicing dentists, practicing dental hygienists, dental graduate students in specialty or general
practice programs, and dental and dental hygiene students.
In particular, the text is intended to give dental providers
an understanding of how to identify a significant medical
issue, ascertain the severity and stability of the disorder,
and make dental management decisions that afford the
patient the utmost health and safety.
An important feature of the book is access to the Evolve
Resources for the ninth edition. These continue to be
available at and include Evolve
Student and Evolve Instructor Resources. Instructions for
activating these resources are included. Working with our
publisher, Elsevier, it is our goal to provide more information online via Evolve each year. This will allow dentists,
dental hygienists, and students easy access to current
information.
The “Dental Management: A Summary” at the front
of the book is a very important resource because it is
specific and to the point and serves as a current overview.

This resource provides readers with a quick reference
review with annotation of the corresponding chapter.
We are extremely pleased to welcome three experts
who serve as contributing authors for this ninth edition:

Dr. Alexander Ross Kerr, clinical professor, Oral and
Maxillofacial Pathology, Radiology, and Medicine, New
York University, College of Dentistry; Dr. Eric T. Stoopler,
associate professor and director of the Postdoctoral Oral
Medicine Program, School of Dental Medicine, University
of Pennsylvania, School of Dental Medicine; and Nathaniel
Simon Treister, chief, Division or Oral Medicine and
Dentistry, Brigham and Women’s Hospital and DanaFarber Cancer Institute and assistant professor of Oral
Medicine, Harvard School of Dental Medicine. Each of
these authors made important contributions to this edition
and reinvigorated our knowledge base. We are pleased
and proud to have these authors as a part of our team.

NEW TO THIS EDITION
A number of major changes have been made in this ninth
edition. Near the front of most chapters, a clear statement
has been made in red type regarding the complications
that may occur. Chapter 1 presents the dental management
and risk assessment process that is used as an important
framework throughout the book. The Eighth Report of
the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure was
added and explained in Chapter 3. Chapter 17 has been
expanded and renamed “Women’s Health Issues.” It
includes in-depth discussions of osteoporosis, osteonecrosis,

and drugs used during pregnancy and breastfeeding. The
2012 report of the American Dental Association/American
Academy of Orthopaedic Surgeons on dental management
of invasive dental procedures for patients with knee and
hip replacements was added to Chapter 20. Chapter 21
was completely rewritten with new tables and figures
added. In Chapters 28 and 29, we made the decision not
to use The American Psychiatric Association fifth edition
of Diagnostic and Statistical Manual of Mental Disorders
(DSM) that was published in 2013. The authors are aware
of the implications of applying the new fifth edition of
the DSM. We decided to postpone the application. This
was based on the need to see how well accepted it becomes.
Thus, in this ninth edition the fourth edition of the DSM
is used.
All remaining chapters have been updated where
necessary, and new dental considerations appear for steroid
supplementation, antibiotic prophylaxis, and patients
taking bisphosphonates. Some chapters have been provided
with new color figures, boxes, and tables. Continued
emphasis has been placed on the medications used to
treat medical conditions. Dosages, side effects, and drug

ix


x

Preface

interactions with agents used in dentistry—including those
used during pregnancy and breastfeeding—are discussed
in detail. Emphasis also has been placed on having
contemporary equipment and diagnostic information to
assess and monitor patients with moderate to severe
medical disease.
Our sincere thanks and appreciation are extended to
those many individuals who have contributed their time

and expertise to the writing and revision of this text.
These include but are not limited to Brian Loehr, Jolynn
Gower, Diane Chatman, and Kathy Falk as head of the
Dental Division at Elsevier.
James W. Little
Craig S. Miller
Nelson L. Rhodus


CONTENTS

Dental Management: A Summary, xiii
PART I

Patient Evaluation and Risk Assessment, 1
1 Patient Evaluation and Risk Assessment, 2

PART II

Cardiovascular Disease, 18
2 Infective Endocarditis, 19

3 Hypertension, 38
4 Ischemic Heart Disease, 53
5 Cardiac Arrhythmias, 70
6 Heart Failure (or Congestive Heart Failure), 86

PART III

Pulmonary Disease, 100
7 Pulmonary Disease, 101
8 Smoking and Tobacco Use Cessation, 128
9 Sleep-Related Breathing Disorders, 138

PART IV

Gastrointestinal Disease, 150
10 Liver Disease, 151
11 Gastrointestinal Disease, 176

PART V

Genitourinary Disease, 192
12 Chronic Kidney Disease and Dialysis, 193
13 Sexually Transmitted Diseases, 210

PART VI

Endocrine and Metabolic Disease, 229
14 Diabetes Mellitus, 230
15 Adrenal Insufficiency, 255
16 Thyroid Diseases, 268

17 Women’s Health Issues, 288
xi


xii

Contents

PART VII

Immunologic Disease, 308
18 AIDS, HIV Infection, and Related Conditions, 309
19 Allergy, 330
20 Rheumatologic Disorders, 345
21 Organ Transplantation, 370

PART VIII Hematologic and Oncologic Disease, 389
22 Disorders of Red Blood Cells, 390
23 Disorders of White Blood Cells, 402
24 Acquired Bleeding and Hypercoagulable Disorders, 428
25 Congenital Bleeding and Hypercoagulable Disorders, 457
26 Cancer and Oral Care of Patients With Cancer, 480

PART IX

Neurologic, Behavioral, and Psychiatric Disorders, 515
27 Neurologic Disorders, 516
28 Anxiety and Eating Disorders, 544
29 Psychiatric Disorders, 561
30 Drug and Alcohol Abuse, 581

Appendices, 596
A Guide to Management of Common Medical Emergencies in the
Dental Office, 597

B Guidelines for Infection Control in Dental Health Care Settings, 606
C Therapeutic Management of Common Oral Lesions, 623
D Drug Interactions of Significance in Dentistry, 639
E Drugs Used in Complementary and Alternative Medicine of Potential
Importance in Dentistry, 645

Index, 655


Dental Management:
A Summary
This table presents several important factors to be considered in the dental management of medically
compromised patients. Each medical condition is outlined according to potential problems related to
dental treatment, oral manifestations, prevention of problems, and complications potentially impacting
on dental treatment.
This table has been designed for use by dentists, dental students, graduate students, dental hygienists,
and dental assistants as a convenient reference work for the dental management of patients who have
medical diseases discussed in this book.

xiii


• Oral petechiae may be found in
patients with IE.

ORAL MANIFESTATIONS

• Identify patients at greatest risk for
adverse outcomes of IE, including patients
with:
• Prosthetic cardiac valves
• A history of previous IE
• Certain types of congenital heart
disease (i.e., unrepaired cyanotic
congenital heart disease, including
patients with palliative shunts and
conduits, completely repaired
congenital heart disease for the first 6
months after a procedure, or repaired
congenital heart disease with residual
defect)
• Cardiac transplantation recipients who
develop cardiac valvulopathy
• Prescribe antibiotic prophylaxis only for
at-risk patients, as listed, who undergo
dental procedures that involve
manipulation of gingival tissue or the
periapical region of teeth or perforation of
the oral mucosa.*
• If prophylaxis is required for an adult,
have the patient take a single dose 30
minutes to 1 hour before the procedure:
• Standard (oral amoxicillin 2 g)
• Allergic to penicillin (oral cephalexin
2 g, oral clindamycin† 600 mg, or

azithromycin or clarithromycin
500 mg)
• Unable to take oral medications
(intravenous [IV] or intramuscular
[IM] ampicillin, cefazolin, or
ceftriaxone)
• Allergic to penicillin and unable to
take oral medications (IV or IM
clindamycin phosphate, cefazolin, or
ceftriaxone)
• See Chapter 24 for management of
potential bleeding problems associated
with anticoagulant therapy.

PREVENTION OF PROBLEMS

*It is of interest that in Great Britain, they had to return to antibiotic prophylaxis for patients considered not to be at risk.
†
Cephalexin should not be used in patients with a history of anaphylaxis, angioedema, or urticaria with penicillins.

1. Dental procedures that involve
the manipulation of gingival
tissues or the periapical region of
teeth or perforation of the oral
mucosa can produce bacteremia.
Bacteremias can also be
produced on a daily basis as the
result of toothbrushing, flossing,
chewing, or the use of toothpicks
or irrigating devices. Although it

is unlikely that a single dental
procedure–induced bacteremia
will result in IE, it is remotely
possible that it can occur.
2. Patients with mechanical
prosthetic heart valves may have
excessive bleeding after invasive
dental procedures as the result of
anticoagulant therapy.

Infective Endocarditis (IE)
Chapter 2

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Encourage the maintenance of optimal oral hygiene in all
patients at increased risk for IE.
• Provide antibiotic prophylaxis only for patients with the
highest risk for adverse outcomes of IE.
• Provide antibiotic prophylaxis for all dental procedures,
except:
• Routine anesthetic injections
• Taking of radiographs
• Placement of removable prosthodontic or orthodontic
appliances
• Adjustment of orthodontic appliances
• Shedding of deciduous teeth or bleeding from trauma to
the lips or oral mucosa
• For patients selected for prophylaxis, perform as much dental

treatment as possible during each coverage period.
• A second antibiotic dose may be indicated if the appointment
lasts longer than 6 hours or if multiple appointments occur
on the same day.
• For multiple appointments (on different days), allow at least
10 days between treatment sessions so that penicillin-resistant
organisms can “clear” from the oral flora. If treatment
becomes necessary before 10 days have passed, select one of
the alternative antibiotics for prophylaxis.
• For patients with prosthetic heart valves who are taking
anticoagulants, the dosage may have to be reduced on the basis
of international normalized ratio (INR) level and the degree of
invasiveness of the planned procedure (see Chapter 24).
• Detection of patients with hypertension and referral to a
physician if poorly controlled or uncontrolled. Defer elective
dental treatment if blood pressure (BP) is ≥180/110 mm Hg.
• For patients who are being treated for hypertension, consider
the following:
• Take measures to reduce stress and anxiety.
• Avoid the use of erythromycin or clarithromycin in
patients taking a calcium channel blocker.
• Avoid the long-term use of nonsteroidal antiinflammatory
drugs (NSAIDs).
• Provide oral sedative premedication or inhalation sedation
(or both).
• Provide local anesthesia of excellent quality.
• For patients who are taking a nonselective beta blocker, limit
epinephrine to ≤2 cartridges of 1 : 100,000 epinephrine.
• Avoid epinephrine-containing gingival retraction cord.
• For patients with upper-level stage 2 hypertension, consider

intraoperative monitoring of BP and terminate appointment if
BP reaches 180/110 mm Hg.
• Make slow changes in chair position to avoid orthostatic
hypotension.

TREATMENT PLANNING MODIFICATION(S)

xiv
DENTAL MANAGEMENT: A SUMMARY


1. Thyrotoxic crisis (thyroid storm)
may be precipitated in patients
with untreated or incompletely
treated thyrotoxicosis by:
a. Infection
b. Trauma
c. Surgical procedures
d. Stress
2. Patients with untreated or
incompletely treated
thyrotoxicosis may be very
sensitive to actions of
epinephrine and other pressor
amines; thus, these agents must
not be used. After the patient is
well managed from a medical
standpoint, these agents may be
administered.
3. Thyrotoxicosis increases the risk

for hypertension, angina,
myocardial infarction (MI),
congestive heart failure, and
severe arrhythmias.
4. Radioactive iodine complications
5. Antithyroid agents:
propylthiouracil, methimazole

Hyperthyroidism (Thyrotoxicosis)
Chapter 16

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Osteoporosis may occur.
• Periodontal disease may be more
progressive.
• Dental caries may be more
extensive.
• Premature loss of deciduous teeth
and early eruption of permanent
teeth may occur.
• Early jaw development may be
noted.
• Tumors found at the midline of
the posterior dorsum of the
tongue must not be surgically
removed until the possibility of
functional thyroid tissue has been
ruled out by 131I uptake tests.

• Acute—salivary gland swelling,
pain, loss of taste
• Radioactive drug-induced:
Chronic sialoadenitis—
xerostomia, pain, and dental
caries
• Sore throat, fever, mouth ulcers

ORAL MANIFESTATIONS

• Detection of patients with thyrotoxicosis
by history and examination findings
• Referral for medical evaluation and
treatment
• Avoidance of any dental treatment for
patient with thyrotoxicosis until good
medical control is attained; however, any
acute oral infection will have to be dealt
with by antibiotic therapy and other
conservative measures to prevent
development of thyrotoxic crisis; suggest
consultation with patient’s physician
during management of acute oral infection
• Avoidance of epinephrine and other
pressor amines in untreated or
incompletely treated patients
• Recognition of early stages of thyrotoxic
crisis:
• Severe symptoms of thyrotoxicosis
• Fever

• Abdominal pain
• Delirious, obtunded, or psychotic
• Initiation of immediate emergency
treatment procedures:
• Seek immediate medical aid.
• Cool with cold towels, ice packs.
• Hydrocortisone (100–300 mg)
• Monitor vital signs.
• Start cardiopulmonary resuscitation
(CPR) if needed.
• Manage pain and xerostomia as
described in Appendix C.
• Possible agranulocytosis; refer to
physician for evaluation and stopping
the antithyroid medication.

PREVENTION OF PROBLEMS

Continued

• When under good medical management, the patient may
receive any indicated dental treatment.
• If acute infection occurs, the physician should be consulted
regarding management.

TREATMENT PLANNING MODIFICATION(S)

DENTAL MANAGEMENT: A SUMMARY

xv

5. Chronic fibrosing (Riedel)—
usually euthyroid

1. Acute suppurative—patient has
acute infection; antibiotics are
required.
2. Subacute painful—period of
hyperthyroidism
3. Subacute painless—up to
6-month period of
hyperthyroidism
4. Hashimoto—leads to severe
hypothyroidism

Thyroiditis
Chapter 16

1. Untreated patients with severe
hypothyroidism exposed to
stressful situations such as
trauma, surgical procedures, or
infection may develop
hypothyroid (myxedema) coma.
2. Untreated hypothyroid patients
may be highly sensitive to
actions of narcotics, barbiturates,
and tranquilizers.
3. May have comorbidities:

hypercholesterolemia, or bleeding
issues

Hypothyroidism
Chapter 16

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• None

• See earlier under Hypothyroidism.

• Tongue may be enlarged.

• None

• Include in differential diagnosis for jaw
pain; see earlier under Hyperthyroidism.
• See earlier under Hyperthyroidism.

• Pain may be referred to
mandible.
• None

• Detection and referral of patients
suspected of being hypothyroid for
medical evaluation and treatment
• Avoidance of narcotics, barbiturates, and
tranquilizers in untreated hypothyroid

patients
• Recognition of initial stage of hypothyroid
(myxedema) coma:
• Hypothermia
• Bradycardia
• Hypotension
• Epileptic seizures
• Initiation of immediate treatment for
myxedema coma:
• Seek immediate medical aid.
• Administer hydrocortisone
(100–300 mg).
• Provide CPR as indicated.

• None

Increased tongue size
Delayed eruption of teeth
Malocclusion
Gingival edema

PREVENTION OF PROBLEMS

• Usually none

•
•
•
•

ORAL MANIFESTATIONS

• In hypothyroid patients under good medical management, any
indicated dental treatment can be performed. See above for
uncontrolled disease.
• None

• Avoid elective dental care if possible until symptoms of
hyperthyroidism have cleared.
• Avoid elective dental care if possible until symptoms of
hyperthyroidism have cleared.

• Postpone elective dental care until infection has been treated.

• In hypothyroid patients under good medical management,
indicated dental treatment may be performed.
• In patients with a congenital form of disease and severe
mental retardation, assistance with hygienic procedures may
be needed.

TREATMENT PLANNING MODIFICATION(S)

xvi
DENTAL MANAGEMENT: A SUMMARY


• Usually none

2. Levothyroxine suppression after
surgery and radioiodine ablation

is the usual treatment for
follicular carcinomas. The
patient may have mild
hyperthyroidism and may be
sensitive to actions of pressor
amines.
3. Patients with multiple endocrine
neoplasia-2 (MEN2) may have
symptoms of hypertension,
hypercalcemia, or both.
4. Anaplastic carcinomas may be
treated by external irradiation,
chemotherapy, or both. See
problems listed in summaries for
Chapter 26.
• See oral complications listed in
summaries for Chapter 26.

• Patients with MEN2 can develop
cystic lesions of the jaws related
to hyperparathyroidism.

• Usually none; metastasis to the
oral cavity is rare.
• Postradiation-induced chronic
sialadenitis, xerostomia, risk for
root caries.

ORAL MANIFESTATIONS

1. Usually none

Thyroid Cancer
Chapter 16

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Manage complications of radiation
therapy and chemotherapy as described in
summaries for Chapter 26.

• Examine for signs and symptoms of
thyroid cancer:
• Hard, painless lump in thyroid
• Dominant nodule in multinodular
goiter
• Hoarseness, dysphagia, dyspnea
• Cervical lymphadenopathy
• Nodule that is affixed to underlying
tissues
• Patient usually euthyroid
• Patients found to have thyroid nodule(s)
should be referred for fine-needle
aspiration biopsy.
• Consult with patient’s physician regarding
permissible degree of hyperthyroidism in
patients treated with thyroid hormone.

PREVENTION OF PROBLEMS

• Prognosis is poor with anaplastic carcinoma.

Continued

• Care with the use of epinephrine is indicated in patients made
to be hyperthyroid as part of their cancer treatment regimen.

• For most patients, the dental treatment plan is not affected
unless the cancer treatment includes external irradiation or
chemotherapy. See summaries for Chapter 26.
• Patients with anaplastic carcinoma have a poor prognosis,
and complex dental procedures usually are not indicated.

TREATMENT PLANNING MODIFICATION(S)

DENTAL MANAGEMENT: A SUMMARY

xvii


• Paresthesias
• Loss of papillae on dorsum of
tongue
• In rare cases, infection and
bleeding complications
• In patients with dysphagia,
increased incidence of carcinoma
of oral and pharyngeal areas
(Plummer-Vinson syndrome)

ORAL MANIFESTATIONS

1.Infection
2.Bleeding
3. Delayed healing

Pernicious Anemia
Chapter 22

1. Accelerated hemolysis of red
blood cells

• Paresthesias of oral tissues
(burning, tingling, numbness)
• Delayed healing (severe cases),
infection, bald red tongue,
angular cheilosis
• Petechial hemorrhages

• Usually none

Glucose-6-Phosphate Dehydrogenase (G-6-PD) Deficiency
Chapter 22

1. Usually none
2. In rare cases, severe leukopenia
and thrombocytopenia may
result in problems with infection
and excessive loss of blood.

Iron Deficiency Anemia
Chapter 22

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Detection and medical treatment (early
detection and treatment can prevent
permanent neurologic damage)

• Control infection.
• Avoid drugs such as certain antibiotics or
that contain aspirin or acetaminophen,
which may increase risk for hemolytic
anemia.
• Be aware that these patients also often
have increased sensitivity to the actions of
sulfa drugs and chloramphenicol.

• Detection and referral for diagnosis and
treatment
• Recognition that in women, most cases are
caused by physiologic process—
menstruation or pregnancy
• Recognition that in men, most cases are
the result of underlying disease—peptic
ulcer, carcinoma of colon, other—requiring
referral to the patient’s physician

PREVENTION OF PROBLEMS

• None indicated when the patient is under medical care

• Usually none unless anemia is severe; then perform only
procedures to meet urgent dental needs.

• Usually none indicated

TREATMENT PLANNING MODIFICATION(S)

xviii
DENTAL MANAGEMENT: A SUMMARY


1. Sickle cell crisis

Sickle Cell Anemia
Chapter 22

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Atypical trabecular pattern
• Delayed eruption of teeth,
growth abnormalities
• Hypoplasia of teeth
• Pallor of oral mucosa
• Jaundice of oral mucosa
• Bone pain

• Osteoporosis

ORAL MANIFESTATIONS

• Consult with patient’s physician to ensure
that condition is stable.
• Institute aggressive preventive dental care.
• Avoid any procedure that may produce
acidosis or hypoxia (avoid long,
complicated procedures).
• Drug modifications:
• Avoid excessive use of barbiturates and
narcotics because suppression of the
respiratory center may occur, leading to
acidosis, which can precipitate acute
crisis. Use benzodiazepine instead.
• Avoid excessive use of salicylates
because “acidosis” may result, again
leading to possible acute crisis; codeine
and acetaminophen in moderate dosage
can be used for pain control.
• Avoid the use of general anesthesia
because hypoxia can lead to
precipitation of acute crisis.
• Nitrous oxide may be used, provided
that 50% oxygen is supplied at all
times; it is critical to avoid diffusion
hypoxia at the termination of nitrous
oxide administration. For nonsurgical
procedures, use local without

vasoconstrictor; for surgical procedures,
use 1 : 100,000 epinephrine in
anesthetic solution.
1. Aspirate before injecting.
2. Inject slowly.
3. Use no more than two cartridges.
4. It is necessary to prevent infection. Use
prophylactic antibiotics for major surgical
procedures.
5. If infection occurs, manage aggressively,
with the use of:
a. Heat
b. Incision and drainage
c. Antibiotics
d. Corrective treatment (e.g., extraction,
pulpectomy)
6. Avoid dehydration in patients with
infection and in patients who are receiving
surgical treatment.

PREVENTION OF PROBLEMS

Continued

• Usually none unless symptoms of severe anemia are present;
then only urgent dental needs should be met.

TREATMENT PLANNING MODIFICATION(S)

DENTAL MANAGEMENT: A SUMMARY

xix


1.Infection
2.Bleeding
3. Delayed healing
4. Mucositis

Leukemia
Chapter 23

1.Infection

Cyclic Neutropenia
Chapter 23

1.Infection

• Gingival swelling or enlargement
• Mucosal or gingival bleeding
• Oral infection

• Periodontal disease
• Oral infection
• Oral ulceration similar to
aphthous stomatitis

• Oral ulcerations
• Periodontitis

• Necrotic tissue

• Oral infection
• Pallor of mucosa

2.Infection

Agranulocytosis
Chapter 23

• Gingival bleeding
• Petechiae
• Ecchymosis

ORAL MANIFESTATIONS

1.Bleeding

Aplastic Anemia
Chapter 22

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Referral for medical diagnosis, treatment,
and consultation
• Complete blood count to determine risk
for anemia, bleeding, and infection
• Antibiotics, antivirals, and antifungals
provided during chemotherapy to prevent

opportunistic oral infection
• Chlorhexidine rinses or bland rinses to
manage mucositis

• Antibiotics should be given to prevent
infection.
• Serial WBC counts should be performed to
identify the safest period for dental
treatment (i.e., when the WBC count is
closest to normal level).

• Referral for medical diagnosis and
treatment
• Drug considerations—some antibiotics
(macrolides, penicillins, and
cephalosporins) used for oral infections
are associated with higher incidence of
agranulocytosis. Avoid these antibiotics if
possible.

• Referral for medical diagnosis and
treatment
• Medical consultation to determine current
status of the patient under medical
treatment
• Some drugs (anticonvulsants, antithyroid
drugs, select antidiabetic agents, diuretics,
and sulfonamides) are associated with
higher incidence of aplastic anemia.

PREVENTION OF PROBLEMS

• Inspect head, neck, and radiographs for undiagnosed or latent
disease (e.g., retained root tips, impacted teeth) and infections
that require management before chemotherapy.
• Eliminate infections before chemotherapy.
• Extractions should be performed at least 10 days before
initiation of chemotherapy.
• Implement plaque control measures and chlorhexidine during
chemotherapy.
• Use prophylactic antibiotics if WBC count is less than
2000/µL or neutrophil count is less than 500/µL (or 1000/µL
at some institutions).
• Platelet replacement may be required (if platelet count is
<50,000/µL) when invasive dental procedures are performed.

• Modifications not required when the WBC count
(neutrophils) is normal.
• If the WBC count (neutrophils) is depressed severely,
antibiotics should be provided to prevent postoperative
infection.

• During periods of low white blood (WBC) counts, provide
emergency care only. Treatment should include the use of
antimicrobial agents and supportive therapy for oral lesions
(see Appendix C for specific treatment regimens).

• Antimicrobial agents and supportive therapy are needed for
oral infection (see Appendix C for specific treatment
regimens).

• During periods of low blood count (platelets, neutrophils, red
blood cells), provide emergency care only.

TREATMENT PLANNING MODIFICATION(S)

xx
DENTAL MANAGEMENT: A SUMMARY


•
•
•
•
•

Soft tissue tumors
Osteolytic jaw lesions
Amyloid deposits in soft tissues
Unexplained mobility of teeth
Exposed bone

ORAL MANIFESTATIONS

1. Increased risk for infection
2. Risks of infection and excessive
bleeding in patients receiving
chemotherapy
3. Minor risk of osteonecrosis in
patients treated by radiation to

the head and neck region
(usually does not occur because
radiation dosage seldom exceeds
50 Gy)
4. Hyposalivation and xerostomia
may occur in patients treated by
irradiation (>25 Gy) to the head
and neck region.
5. Non-Hodgkin lymphoma may be
found in patients with AIDS;
hence, transmission of infectious
agents may be a problem.

• Extranodal oral tumors in
Waldeyer ring or osseous soft
tissues
• Xerostomia in patients treated by
radiation; some of these patients
prone to osteonecrosis
• Burning mouth or tongue
symptoms
• Petechiae or ecchymoses if
thrombocytopenia present
because of tumor invasion of
bone marrow
• Cervical lymphadenopathy
• Mucositis in patients treated by
radiation therapy or
chemotherapy

Lymphomas: Hodgkin Disease, Non-Hodgkin Lymphoma, Burkitt Lymphoma
Chapter 23

1. Excessive bleeding after invasive
dental procedures
2. Risk of infection because of
decrease in normal
immunoglobulins
3. Risks of infection and bleeding
in patients who are being treated
by irradiation or chemotherapy
4. Risk of osteonecrosis of the jaws
in patients who are taking
bisphosphonates (especially
intravenously) as well as other
antiangiogenic medications

Multiple Myeloma
Chapter 23

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• Patients with generalized
lymphadenopathy, extranodal tumors, and
osseous lesions must be identified and
referred for medical evaluation and
treatment.
• The dentist can biopsy extranodal or
osseous lesions to establish a diagnosis;

patients with lesions involving the lymph
nodes should be referred for excisional
biopsy.
• Medical history should identify patients
with diagnosed disease; medical
consultation is needed to establish current
status. (See sections on chemotherapy and
radiation therapy on management and
prevention of medical complications.)
• Before invasive procedures, a complete
blood count should be obtained to
determine risks for bleeding and infection.
• Patients who have been treated by
irradiation to the chest area may develop
acute and chronic cardiovascular
complications such as arrhythmias or
valvular heart disease. Medical
consultation is needed to confirm their
current status.

• Patients with oral soft tissue lesions or
osseous lesions should have them biopsied
by the dentist or should be referred for
diagnosis and treatment as indicated.
• Medical history should identify patients
with diagnosed disease; medical
consultation is needed to establish current
status. (See sections on chemotherapy and
radiation therapy on prevention and
management of medical complications.)

• Be aware of and take precautions for
medication-related osteonecrosis of the
jaws.

PREVENTION OF PROBLEMS

Continued

• Patients in terminal phase should receive only supportive
dental treatment.
• Patients under “control” may receive any indicated treatment;
however, complex restorative treatment may not be indicated
in cases with a poor prognosis.
• Platelet replacement may be needed for patients with
thrombocytopenia. (See sections on radiation therapy and
chemotherapy for treatment plan modifications.)
• Consider prophylactic antibiotics if the WBC count is less
than 2000/µL or the neutrophil count is less than 500 (or
1000/µL at some institutions).

• For patients in terminal stage, provide supportive dental care
only.
• With the newer therapies, the long-term prognosis has been
greatly improved, so complex dental procedures may be
considered. If thrombocytopenia or leukopenia is present,
special precautions (platelet replacement, antibiotic therapy)
are needed to prevent bleeding and infection when invasive
dental procedures are performed.
• Patients may be bleeders because of the presence of abnormal
immunoglobulin M macroglobulins, which form complexes

with clotting factors, thereby inactivating the clotting factors.
(See sections on chemotherapy and radiation therapy for
treatment plan modifications.)

TREATMENT PLANNING MODIFICATION(S)

DENTAL MANAGEMENT: A SUMMARY

xxi


ORAL MANIFESTATIONS

PREVENTION OF PROBLEMS

• Excessive bleeding after dental
procedures

• Screen patients with the following (if
results of one or more tests are abnormal,
refer for diagnosis and medical treatment):
• Prothrombin time
• Activated partial thromboplastin time
• Thrombin time
• Platelet count
• Avoid use of aspirin and related drugs.

1. Prolonged bleeding
2. Infection in patients with bone
marrow replacement or

destruction
3. A medical emergency can result
from stress in patients being
treated with steroids.

• Spontaneous bleeding
• Prolonged bleeding after certain
dental procedures
• Petechiae
• Ecchymoses
• Hematomas

• Identification of patients to include the
following:
• History
• Examination findings
• Screening tests—platelet count
• Referral and consultation with a
hematologist
• Correction of underlying problem or
replacement therapy before surgery
• Local measures to control blood loss (e.g.,
splint, Gelfoam, thrombin)
• Prophylactic antibiotics may be considered
in surgical cases to prevent postoperative
infection if severe neutropenia is present.
• Additional steroids should be used for
patients being treated with steroids, if
indicated (see section on adrenal
insufficiency).

• Aspirin, other NSAIDs, and aspirincontaining compounds are not to be used;
acetaminophen (Tylenol) with or without
codeine may be used if analgesia is
required.

Thrombocytopenia (Primary or Secondary) Caused by Chemicals, Radiation, or Leukemia
Chapter 24

1. Excessive blood loss after
surgical procedures, scaling,
other manipulations

Bleeding Problem Suggested by Examination and History Findings But Lack of Clues to Underlying Cause
Chapter 24

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

• In general, dental procedures can be performed if the platelet
count is 30,000/µL or higher.
• Extractions and minor surgery can be performed if the
platelet count is 50,000/µL or higher.
• Major oral surgery can be performed if the platelet count is
80,000/µL to 100,000/µL or higher.
• Platelet transfusion is needed for patients with platelet counts
below the above values.
• Patients with severe neutropenia (500/µL or less) may require
antibiotics for certain surgical procedures (1000/µL at some
institutions).
• In children with primary thrombocytopenia, many will

respond to steroids with increase in platelets to levels,
allowing dental procedures to be performed.

• None unless test result(s) abnormal; then manage according
to the nature of the underlying problem once diagnosis has
been established by the physician.

TREATMENT PLANNING MODIFICATION(S)

xxii
DENTAL MANAGEMENT: A SUMMARY


ORAL MANIFESTATIONS

PREVENTION OF PROBLEMS

• Excessive bleeding after scaling
and surgical procedures
• Petechiae
• Ecchymoses
• Hematomas

• Identification of patients should include
the following:
• History
• Clinical findings
• Screening tests—none reliable
• Consultation with a hematologist should
be obtained.

• Local measures should be used to control
blood loss: splints, Gelfoam, Oxycel, and
surgical thrombin (see Table 24.6).
• Prevention of allergy if causative and if the
antigen is identified

• Surgical procedures must be avoided in these patients unless
the underlying problem has been corrected or the patient has
been prepared for surgery by a hematologist and the dentist is
prepared to control excessive loss of blood through local
measures: splints, thrombin, microfibrillar collagen, Gelfoam,
Oxycel, ε-aminocaproic acid (Amicar) (see Table 24.6).

TREATMENT PLANNING MODIFICATION(S)

1. Excessive bleeding after dental
procedures that result in soft
tissue or osseous injury

•
•
•
•

Excessive bleeding
Spontaneous bleeding
Petechiae
Hematomas

• Identification of patients with such

disorders should include:
• History
• Examination findings
• Screening laboratory tests—
prothrombin time (prolonged) in liver
disease, platelet count (low if
hypersplenism present)
• Consultation and referral should be
provided.
• Preparation before the dental procedure
may include vitamin K injection by the
physician and platelet replacement if
indicated.
• Local measures are used to control blood
loss (see Table 24.6).
• For patients with liver disease, avoid or
reduce dosage of drugs metabolized by the
liver.
• Do not use aspirin, other NSAIDs, or
aspirin-containing compounds.

Continued

• No dental procedures should be performed unless the patient
has been prepared on the basis of a consultation with a
hematologist.

Acquired Disorders of Coagulation (Liver Disease, Broad-Spectrum Antibiotics, Malabsorption Syndrome, Biliary Tract Obstruction, Heparin, Other Agents or Factors)
Chapter 24

1. Prolonged bleeding after surgical
procedures or any insult to
integrity of oral mucosa

Vascular Wall Alterations (Scurvy, Infection, Chemical, Allergic, Autoimmune, Other Agents or Factors)
Chapter 24

POTENTIAL MEDICAL PROBLEM
RELATED TO DENTAL CARE

DENTAL MANAGEMENT: A SUMMARY

xxiii