Dentists guide to medical conditions, medications and complications 2nd edition

Second Edition

Dentist’s Guide

to Medical Conditions,
Medications & Complications

Kanchan Ganda, M.D.


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Dentist’s Guide to Medical
Conditions, Medications,
and Complications

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Dentist’s Guide to
Medical Conditions,
Medications, and
Complications
Second Edition

Kanchan M. Ganda, M.D.

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This edition first published 2013
First edition published 2008.

C

2013 by John Wiley & Sons, Inc.

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Library of Congress Cataloging-in-Publication Data
Ganda, Kanchan M., author.
[Dentist’s guide to medical conditions and complications]
Dentist’s guide to medical conditions, medications, and complications /
Kanchan M. Ganda. – Second edition.
p. ; cm.
Revised edition of: Dentist’s guide to medical conditions and complications /
Kanchan M. Ganda. 2008.
Includes bibliographical references and index.
ISBN 978-1-118-31389-3 (softback : alk. paper) – ISBN 978-1-118-31390-9 (epdf) –
ISBN 978-1-118-31391-6 (epub) – ISBN 978-1-118-31392-3 (emobi)
I. Title.
[DNLM: 1. Stomatognathic Diseases–complications. 2. Dental Care for Chronically Ill.
3. Medical History Taking. 4. Pharmaceutical Preparations, Dental–administration & dosage.
5. Pharmaceutical Preparations, Dental–contraindications. 6. Stomatognathic Diseases–drug
therapy. WU 140]
RK55.S53
617.6 026–dc23
2013003815
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may
not be available in electronic books.
Cover image: C webphotographeer

Cover design by Maggie Voss
Set in 9.5/12pt Palatino by Aptara R Inc., New Delhi, India
1 2013

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Dedication

This book is dedicated to all my students, past and present; to my late parents, Amrit
Devi and Roop Krishan Dewan; and to my family, for all their encouragement and loving support.

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Contents

Acknowledgments

xii

Introduction: Integration of Medicine in Dentistry

xiv

Section I:

Patient Assessment

1

1.

Routine History-Taking and Physical Examination

3

2.

History and Physical Assessment of the Medically Complex
Dental Patient

24

Section II:

Pharmacology

3.

Essentials in Pharmacology: Drug Metabolism, Cytochrome P450
Enzyme System, and Prescription Writing

35

Local Anesthetics Commonly Used in Dentistry: Assessment,
Analysis, and Associated Dental Management Guidelines

54

Pain Physiology, Analgesics, Opioid Dependency Maintenance
Therapies, Multimodal Analgesia, and Pain Management
Algorithms

67

Odontogenic Infections, Antibiotics, and Infection Management
Protocols

110

Antifungals Commonly Used in Dentistry: Assessment, Analysis,
and Associated Dental Management Guidelines

150

Antivirals Commonly Used in Dentistry: Assessment, Analysis,
and Associated Dental Management Guidelines

155

4.
5.

6.
7.
8.

Section III:
9.

33

Acute Care and Stress Management
Management of Medical Emergencies: Assessment, Analysis, and
Associated Dental Management Guidelines

159
161

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viii

Contents

10.

Section IV:
11.
12.
13.
14.

Oral and Parenteral Conscious Sedation for Dentistry: Assessment,
Analysis, and Associated Dental Management Guidelines
Hematopoietic System

183
199

Complete Blood Count: Assessment, Analysis, and Associated
Dental Management Guidelines

201

Red Blood Cells Associated Disorder: Anemia: Assessment,
Analysis, and Associated Dental Management Guidelines

209

Red Blood Cells Associated Disorder: Polycythemia: Assessment,
Analysis, and Associated Dental Management Guidelines

222

Red Blood Cells Associated Disorder: Hemochromatosis:
Assessment, Analysis, and Associated Dental Management
Guidelines

225

Section V:

Hemostasis and Associated Bleeding Disorders

15.

Primary and Secondary Hemostasis: Normal Mechanisms, Disease
States, and Coagulation Tests: Assessment, Analysis, and
Associated Dental Management Guidelines

231

Platelet Disorders: Thrombocytopenia, Platelet Dysfunction, and
Thrombocytosis: Assessment, Analysis, and Associated Dental
Management Guidelines

243

Von Willebrand’s Disease: Assessment, Analysis, and Associated
Dental Management Guidelines

250

Coagulation Disorders: Common Clotting Factor Deficiency
Disease States, Associated Systemic and/or Local Hemostasis
Adjuncts, and Dental Management Guidelines

254

Anticoagulants: Assessment, Analysis, and Associated Dental
Management Guidelines

262

16.

17.
18.

19.

Section VI:
20.
21.
22.
23.
24.

Cardiology and Renal Disease

229

273

Rheumatic Fever: Assessment, Analysis, and Associated Dental
Management Guidelines

275

Infective Endocarditis and Current Premedication Prophylaxis
Guidelines

279

Hypertension and Target Organ Disease States: Assessment,
Analysis, and Associated Dental Management Guidelines

288

Cerebral Circulation Diseases TIAs and CVAs: Assessment,
Analysis, and Associated Dental Management Guidelines

300

Coronary Circulation Diseases, Classic Angina, and Myocardial
Infarction: Assessment, Analysis, and Associated Dental
Management Guidelines

302

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Contents

25.

ix

Congestive Heart Failure: Assessment, Analysis, and Associated
Dental Management Guidelines

311

Cardiac Arrhythmias: Assessment, Analysis, and Associated
Dental Management Guidelines

315

27.

Peripheral Circulation Disease

318

28.

Renal Function Tests, Renal Disease, and Dialysis: Assessment,
Analysis, and Associated Dental Management Guidelines

319

26.

Section VII:
29.

Pulmonary Diseases

331

Pulmonary Function Tests and Sedation with Pulmonary Diseases:

Assessment, Analysis, and Associated Dental Management
Guidelines

333

Upper Airway Disease: Allergic Rhinitis, Sinusitis, and
Streptococcal Pharyngitis: Assessment, Analysis, and Associated
Dental Management Guidelines

337

Asthma and Airway Emergencies: Assessment, Analysis, and
Associated Dental Management Guidelines

341

32.

Chronic Bronchitis and Smoking Cessation

348

33.

Emphysema: Assessment, Analysis, and Associated Dental
Management Guidelines

356

Chronic Obstructive Pulmonary Disease: Assessment, Analysis,

and Associated Dental Management Guidelines

358

Obstructive Sleep Apnea: Assessment, Analysis, and Associated
Dental Management Guidelines

365

Tuberculosis: Assessment, Analysis, and Associated Dental
Management Guidelines

367

30.

31.

34.
35.
36.

Section VIII:
37.

Section IX:
38.
39.
40.
41.

Clinical Pharmacology

Prescribed and Nonprescribed Medications: Assessment, Analysis,
and Associated Dental Management Guidelines
Endocrinology

375
377
383

Introduction to Endocrinology and Diabetes: Assessment,
Analysis, and Associated Dental Management Guidelines

385

Thyroid Gland Dysfunctions: Assessment, Analysis, and
Associated Dental Management Guidelines

403

Adrenal Gland Disease States: Assessment, Analysis, and
Associated Dental Management Guidelines

408

Parathyroid Dysfunction Disease States: Assessment, Analysis,
and Associated Dental Management Guidelines

417

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x

Contents

42.

Growth Hormone Dysfunction and Endocrine Tissues of the
Reproductive System

Section X:
43.

Seizure Disorders
Classic Seizures: Assessment, Analysis, and Associated Dental
Management Guidelines

Section XI:
44.

Gastrointestinal Conditions and Diseases
Gastrointestinal Disease States and Associated Oral Cavity
Lesions: Assessment, Analysis, and Associated Dental
Management Guidelines

Section XII:
45.

Hepatology

46.

47.

Infectious Diseases

Human Immunodeficiency Virus, Herpes Simplex and Zoster,
Lyme Disease, MRSA Infection, and Sexually Transmitted Diseases

Section XV:
48.

Postexposure Prevention and Prophylaxis

Needle-Stick Exposure Protocol and CDC Recommendations for
Dental Health-Care Providers Infected with the Hepatitis B Virus

Section XIV:

Oral Lesions and Dentistry
Therapeutic Management of Oral Lesions in the
Immune-Competent and the Immune-Compromised Patient in the
Dental Setting

Section XVI: The Female Patient: Pregnancy, Lactation, and
Contraception
49.

Pregnancy, Lactation, and Contraception: Assessment and
Associated Dental Management Guidelines

Section XVII:
and Muscles
50.

439
447

449

467
493
495
503
505
539

541

565
567

Rheumatology: Diseases of the Joints, Bones,
587

Classic Rheumatic Diseases: Assessment and Associated Dental
Management Guidelines

Section XVIII: Oncology: Head and Neck Cancers, Leukemias,
Lymphomas, and Multiple Myeloma
51.

437

465

Liver Function Tests, Hepatitis, and Cirrhosis: Assessment,
Analysis, and Associated Dental Management Guidelines

Section XIII:

433

Head and Neck Cancers and Associated Dental Management
Guidelines

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589

625
627


Contents

Section XIX:

52.

Transplants

663
683

Organ Transplants, Immunosuppressive Drugs, and Associated
Dental Management Guidelines

Section XXI:
54

661

Psychiatric Conditions: Assessment of Disease States and
Associated Dental Management Guidelines

Section XX:
53.

Psychiatry

xi

Common Laboratory Tests

685
695

Comprehensive Metabolic Panel and Common Hematological
Tests

697

Appendix: Suggested Reading

699

Index

743

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Acknowledgments

I wish to sincerely thank Bruce J. Baum, D.M.D., Ph.D., Chief of the Gene Therapy
and Therapeutics Branch at the National Institute of Dental and Craniofacial Research
in Bethesda, Maryland. He was instrumental in mentoring me and motivating me to
publish my work, which is now in its second edition. Dr. Baum’s vision for dentistry
and his confidence that my work would make a difference has been and continues to
be very humbling.
Thanks to my former deans at Tufts University School of Dental Medicine—Lonnie
Norris, D.M.D, M.P.H., and Dean of Curriculum, Nancy Arbree, D.D.S., M.S.—for making my vision of integrating medicine into the dental curriculum a reality. I was given
the flexibility to create a medicine curriculum for our students and integrate this education through all the four years of dental curriculum.
My very sincere thanks to Huw F. Thomas, B.D.S., M.S., Ph.D., our current dean at Tufts University School of Dental Medicine, and to Mark Nehring,
M.Ed., D.M.D., M.P.H., the chair of the Department of Public Health and Community Services at Tufts University School of Dental Medicine (my former chair),
for their tremendous support in ensuring a rapidly processed sabbatical, so I

could complete the second edition of my book. Additionally, I am very grateful to my colleagues Diana Esshaki, D.M.D., M.S., and Patrick McGarry, D.M.D.,
for their unconditional support in efficiently executing all responsibilities while I
was away.
To all the past and present medicine course speakers and rotation directors, specialists in their respective fields of medicine, this unique dental education would have
been incomplete without your active participation, dedication, and support. I wish to
acknowledge and thank you all for your efforts and endless support.
I also would like to thank my D’14 student Ms. Jaskaren K. Randhawa for her unflagging support and help with the proofing of the material.
I’d like to thank my daughter Kiran, for patiently providing me with around-theclock technical support. Also, sincere thanks to my daughter Anjali and my husband,
Om, both of whom are physicians, for enthusiastically participating in our numerous
discussions during which they offered their insights about patient care.
This finest quality second edition would not have been possible without the assistance of my very talented project manager, Ms. Shikha Sharma of Aptara, Inc.,
xii

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Acknowledgments

xiii

New Delhi, India. Her professionalism, very friendly personality, expertise, attention to
detail made it a very pleasurable experience indeed; she is someone who went above
and beyond every step of the way. I am delighted to have been linked with such a
talented and knowledgeable individual and I am so extremely satisfied with the final
product she created!
Last but not least, I wish to thank all my students, who have been my constant source
of inspiration. I never could have experienced the joy of teaching without their active
participation and endurance in the learning of medicine!
Kanchan Ganda, M.D.

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Introduction: Integration of
Medicine in Dentistry

Dental care today holds many challenges for the dental practitioner. Patients are living
longer, often retaining their own dentition, have one or more medical conditions, and
routinely take several medications.
Along with excellence in dentistry, the practicing dentist has the dual task of staying
updated with the current concepts of medicine and pharmacology. They should rightfully be called the “Physician of the Oral Cavity.”
The integration of medicine in the dental curriculum has become a necessity, and
this integration must begin with the freshman class, so the students can gain maximum
benefit and the chance to gain credibility. The integration of medicine is best achieved
when done in a case-based or problem-based format and correlated with the basic sciences, pharmacology, general pathology, oral pathology, and dentistry. There needs to
be a true commitment and constant reinforcement of the integration in all the didactic
and clinical courses.
The integration of medicine, pharmacology, and medically complex patient care is
best achieved when done in a pyramidal process, through the four years of dental education.
The foundation should instill a basic knowledge of:
1.
2.
3.
4.

Standard and medically complex patient history-taking and physical examination.
Symptoms and signs of highest-priority illnesses, along with the common laboratory tests evaluating those disease states.
Anesthetics, analgesics, antibiotics, antivirals, and antifungals used in dentistry.
Prescription writing.

“Normal” patient assessment, when stressed in the first year, prepares students to
better understand the changes prompted by disease states during the second year of
their education, when didactic and clinical knowledge of highest-priority illnesses, associated diagnostic laboratory tests, and the vast pharmacopeia used for the care of those
diseases is included. Case-based scenarios should be used to solidify this information.
The progressive learning up to the end of the second year prepares the student to
“care” for the patient “on paper.” With the start of the clinical years, the student is prepared to apply this knowledge toward “actual” patient care, which occurs typically during the third and fourth years of education.
xiv

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Introduction

xv

During the third year, the student should participate in medical and surgical clinical
rotations in a hospitalized setting and complete a Hospital Clerkship Program where
the student is exposed to head-and-neck cancer care, emergency medicine, critical care,
anesthesia, hematology, oncology, transplants, cardiothoracic surgery, and so on. This
exposure will widen the student’s knowledge, broaden clinical perception, and further
enhance the link between medicine and dentistry.
During the clinical years, the students should complete faculty-reviewed medical
consults for all their medically compromised patients, prior to dentistry. This patientby-patient health status review will help correctly translate their didactic patient-care
knowledge in the clinical setting.
The text is a compilation of materials needed for the integration of medicine in dentistry. It is a book all dental students and dental practitioners will appreciate both as a
read and chair-side.
This text provides information on epidemiology, physiology, pathophysiology, laboratory tests evaluation, associated pharmacology, dental alerts, and suggested deviations in the use of anesthetics, analgesics, antibiotics, antivirals, and antifungals for each
disease state discussed.
The student will greatly benefit from the sections detailing history-taking and physical examination; highly expanded clinical and applied pharmacology of dental anesthetics, analgesics, antibiotics, antivirals, and antifungals; stress management; and management of medical emergencies in the dental setting.

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I

Patient Assessment

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1

Routine History-Taking and
Physical Examination

GENERAL OVERVIEW
Patient Interview Introduction
The primary job of the dental student starting clinical work is to learn to conduct a
patient workup thoroughly and efficiently. The heart of every patient workup is a set
pattern done in a sequential order of data collection and analysis.

Patient Workup Sequential Pattern
The sequential pattern of patient workup consists of the following:
1.

2.
3.

History and physical examination.
Laboratory data collection and analysis.
Diagnostic and therapeutic plan formulation.

The first step, the patient interview, or the history, is probably the single most important task in the diagnostic patient workup because of its importance in diagnosis and in
the development of a good doctor-patient relationship. The provider should demonstrate a professional manner that will put the patient at ease. During the interview,
always listen carefully to the patient. Use interrogation sparingly, or use it later to aid a
communicating patient, or to restrict the rare patient who has a tendency to ramble!

Patient Interview Practical Points
Keep your appearance neat and clean. This will help gain your patient’s trust. Always
introduce yourself when meeting a patient and refer to the patient as “Mr. John Doe”
or “Miss Jane Doe.” Do not use first names during the initial encounter. Exchange a few
brief pleasantries because moving forward, this will help both you and the patient feel
comfortable and at ease with one another.
Dentist’s Guide to Medical Conditions, Medications, and Complications, Second Edition. Kanchan M. Ganda.
C 2013 John Wiley & Sons, Inc. Published 2013 by John Wiley & Sons, Inc.

3

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4

Section I: Patient Assessment

Always have a friendly and sincere interest in your patient’s problem(s). Always be
courteous, respectful, and confidential and show a continued interest while you are with
the patient.

Physical Examination Practical Points
Prior to the start of the physical examination let the patient know that you are going to
take the pulse and blood pressure and examine the head and neck area. This heads-up
will enable the patient to understand that you will be touching him or her. Your attentive
and respectful ways will enhance a good doctor-patient relationship.
The physical examination is an art that is learned by constant repetition. There are
many styles and methods for conducting the general examination, and every clinician
will ultimately choose one examination sequence to go by. Most clinicians, however,
prefer the head-to-foot order. When examining any area of the body, it is usually best to
follow an orderly sequence of inspection, palpation, percussion, and auscultation. This
sequential routine ensures thoroughness.
The physical examination should always be conducted and assessed in the context of
the patient’s dental and medical history. The range of “normal” varies from patient to
patient.
The student needs to become familiar with the use of the stethoscope and the blood
pressure cuff. Fumbling with your equipment or the technique during patient examination will cause you embarrassment. The student also needs to practice the head-andneck exam techniques often on friends or family members to get a good sense of the
normal.

History-Taking and Physical Examination: Broad Conclusions
After the history and physical examination is completed, you should, in most cases, be
able to answer the following questions:

r
r
r
r

r

The disease states that exist in the patient and whether the patient’s problems are
acute or chronic.
The organ systems that may be involved.
The differential diagnosis of the patient’s problems.
The laboratory tests that will be needed for the evaluation of the disease states.
Confirmation or exclusion of a diagnosis and/or whether to follow the course of a
disease state.

HISTORY-TAKING DETAILS
The purpose of medical history and physical examination is to collect information from
the patient, to examine the patient, and to understand the patient’s problems. Traditional history-taking has several parts, each with a specific purpose. In order to achieve
maximum success, the medical history must be accurate, concise, and systematic.
The following is a standard outline in sequential order of the different components
of history-taking. The introductory materials in the health history consist of collecting
several types of information from the patient.

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Chapter 1: Routine History-Taking and Physical Examination

5

Data Collection
The following information is obtained in all patients to gain a basic understanding of
the patient:
Date of the visit:
Name:

(last)
(first)
Home address:
Business address:

Record number:

(middle)
Home phone:
Business phone:

Occupation:

Cell phone:

Date of birth:

Sex: M/F/Transgender/Other
Marital status: S/M/D/W/Partnership
Height:
Weight:
Referred by:

Chief Complaint
The chief complaint states in the patient’s own words the reason for the visit, for example, “I have a toothache” or “I need a root canal.”

Present History
Present history lists, in clear, chronological order, the details of the problem or problems
for which the patient is seeking care. You will determine by interrogation a timeline of
the following:

1.
2.
3.
4.
5.
6.

When did the patient’s problem(s) begin?
Where did the problem(s) begin?
What kinds of symptoms did the patient experience?
Has the patient had any treatment for the problem(s)?
Has the treatment had any positive or negative effect on the patient’s condition?
Has the patient’s lifestyle been affected by the problem(s)?

Past History
The past history gives you an insight about the health status of the patient until now.
Check with the patient for the presence or absence of diseases by eliciting the symptoms
and signs associated with the disease states. It is best to access the disease states with
the patient in alphabetical order to ensure you address each disease state and do not
miss anything. Use interrogation to check for the following disease states:

Anemia
Determine the presence or absence of the nutritional, congenital, and acquired or chronic
disease-associated anemias.

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6

Section I: Patient Assessment

Bleeding Disorders
Determine the presence or absence of the congenital and acquired types of bleeding
disorders.

Cardiorespiratory Disorders
Determine whether the patient has a history of angina, myocardial infarction, transient ischemic attacks (TIAs), cerebrovascular attacks (CVAs/strokes), hypertension,
rheumatic heart disease, asthma, tuberculosis, bronchitis, sinusitis, and chronic obstructive pulmonary disease (COPD).

Drugs/Medications
Determine the patient’s current medications. Check for prescribed, herbal, and overthe-counter (OTC) medications. Determine whether the patient is currently on corticosteroids or has been on them, by mouth or by injection, for two weeks or longer within the
past two years. Check if the patient has known allergies to any drugs, such as NSAIDS,
aspirin, codeine, morphine, penicillin, sulpha antimicrobials, bisulfites, metabisulfites,
or local anesthetics.

Endocrine Disorders
Check for diabetes, hyperthyroidism, hypothyroidism, parathyroid disorders, and pituitary and adrenal disorders (Addison’s disease or Cushing’s syndrome).

Fits or Faints
Check for the presence of different kinds of seizures: grand mal epilepsy, petit mal
epilepsy, temporal lobe or psychomotor epilepsy, or localized motor seizures.

Gastrointestinal Disorders
Check for oral ulcerations, esophagitis, gastritis, peptic ulcerations, Crohn’s disease,
celiac disease, ulcerative colitis, diverticulitis, polyps, and hemorrhoids.

Hospital Admissions
Determine the cause or causes for admission and also check if the patient had any history of accidents or injuries. Determine whether the patient was given any anesthesia,
either local or general, during the hospital admission. Furthermore, determine whether

there were any complications during the hospital admission due to the anesthesia or
due to the medical/surgical condition for which the patient was admitted. Determine
whether the patient was given a blood transfusion during hospitalization.

Immunological Diseases
ă
Check for lupus, Sjogrens
syndrome, rheumatoid arthritis, and polyarthritis nodosa.

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Chapter 1: Routine History-Taking and Physical Examination

7

Infectious Diseases
Check for infectious diseases of childhood: measles, mumps, chicken pox, streptococcus pharyngitis, rheumatic fever, or scarlet fever. Also check for infectious diseases of
adulthood: sexually transmitted diseases (STDs), hepatitis, HIV infection, MethicillinResistant Staphylococcus Aureus (MRSA) infection, and infectious mononucleosis.

Jaundice or Liver Disease
If the patient is jaundiced or has had jaundice, determine the cause. Is it due to viral
hepatitis, alcoholic hepatitis, or gallstones? Determine whether there is any history of
gallbladder dysfunction. Check whether there is any indication of improper liver function.

Kidney Disorders
Determine whether there is any indication of kidney dysfunction, renal stones, urinary
tract infections, renal disease, renal failure, or renal transplant.

Likelihood of Pregnancy

Determine the date of the patient’s last menstrual period (LMP) and whether the patient
is pregnant. Always let the patient know that prior to dental radiographs, you need to
know if the patient is pregnant. You need to also know the pregnancy status, as there
are certain anesthetics, analgesics, and antibiotics that are contraindicated during pregnancy.

Musculoskeletal Disorders
Check for osteoporosis and other causes of impaired bone metabolism, Paget’s disease, osteoarthritis, rheumatoid arthritis, psoriatic arthritis, gout, muscular dystrophy,
polymyositis, and myasthenia gravis.

Neurological Disorders
Check for cranial nerve disorders, headaches, facial pains, migraine, multiple sclerosis, motor neuron disease, transient ischemic attacks (TIAs), or cerebrovascular accidents (CVAs) associated neurological deficits, Parkinson’s disease, and peripheral neuropathies.

Obstetric and Gynecological Disorders
Check for conditions or diseases that can lead to spontaneous abortions, miscarriages,
bleeding, or anemia. Also check for any tumors needing chemotherapy or radiotherapy.

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