Dental Management: A Summary: © 2017, by Elsevier Inc. All Rights Reserved

Dental Management:
A Summary
This table presents several important factors to be considered in the dental man-
agement of medically compromised patients. Each medical condition is outlined
according to potential problems related to dental treatment, oral manifestations,
prevention of these problems, and effects of complications on dental treatment
planning.
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.
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© 2017, by Elsevier Inc. All rights reserved.
Dental Management: A Summary
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Potential Medical Problem

Related to Dental Care Oral Manifestations Prevention of Problems Treatment Planning Modification(s)
Infective Endocarditis (IE)
Chapter 2
1. Dental procedures that involve • Oral petechiae may be • Identify patients at greatest risk for adverse outcomes • Encourage the maintenance of
the manipulation of gingival found in patients with of IE, including patients with: optimal oral hygiene in all patients at
tissues or the periapical region IE. • Prosthetic cardiac valves increased risk for IE.
of teeth or perforation of the • A history of previous IE • Provide antibiotic prophylaxis for
oral mucosa can produce a • Certain types of congenital heart disease (i.e., only those patients with the highest
bacteremia. Bacteremias can unrepaired cyanotic congenital heart disease, risk for adverse outcomes of IE.
also be produced on a daily including patients with palliative shunts and • Provide antibiotic prophylaxis for all
basis as the result of conduits, completely repaired congenital heart dental procedures, except:
toothbrushing, flossing, disease for the first 6 months after a procedure, • Routine anesthetic injections
chewing, or the use of or repaired congenital heart disease with residual • Taking of radiographs
toothpicks or irrigating devices. defect) • Placement of removable
Although it is unlikely that a • Cardiac transplantation recipients who develop prosthodontic or orthodontic
single dental procedure–induced cardiac valvulopathy appliances
bacteremia will result in • Prescribe antibiotic prophylaxis only for at-risk • Adjustment of orthodontic
infective endocarditis (IE), it is patients, as listed, who undergo dental procedures appliances
DENTAL MANAGEMENT: A SUMMARY
remotely possible that it can that involve manipulation of gingival tissue or the • Shedding of deciduous teeth or
occur. periapical region of teeth or perforation of the oral bleeding from trauma to the lips
2. Patients with mechanical mucosa. or oral mucosa
prosthetic heart valves may • If prophylaxis is required for an adult, take a single • For patients selected for prophylaxis,
have excessive bleeding dose 30 minutes to 1 hour before the procedure: perform as much dental treatment as
following invasive dental • Standard (oral amoxicillin 2 g) possible during each coverage period.
procedures as the result of • Allergic to penicillin (oral cephalexin 2 g, oral • A second antibiotic dose may be
anticoagulant therapy. clindamycin* 600 mg, or azithromycin or indicated if the appointment lasts
clarithromycin 500 mg) longer than 6 hours, or if multiple

*NOTE: Cephalexin should not be used in appointments occur on the same day.
patients with a history of anaphylaxis, angioedema, • For multiple appointments, allow
or urticaria with penicillins. at least 10 days between treatment
• Unable to take oral medications (intravenous [IV] sessions so that penicillin-resistant
or intramuscular [IM] ampicillin, cefazolin, or organisms can clear from the oral
ceftriaxone) flora. If treatment becomes necessary
• Allergic to penicillin and unable to take oral before 10 days have passed, select
medications (IV or IM clindamycin phosphate, one of the alternative antibiotics for
cefazolin, or ceftriaxone) prophylaxis.
• See Chapter 24 for management of potential bleeding • For patients with prosthetic heart
problems associated with anticoagulant therapy. 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).
Hypertension
Chapter 3
1. Routine delivery of dental • No oral complications • Detection of patients with hypertension and referral to • For patients with BP <180/110,
care to a patient with severe are due to hypertension a physician if poorly controlled or uncontrolled. Defer and no evidence of target organ
uncontrolled hypertension could itself; however, adverse elective dental treatment if blood pressure (BP) is involvement, any treatment may be
result in a serious outcome such effects such as dry ≥180/110 mm Hg. provided
as angina, myocardial mouth, taste changes, • For patients who are being treated for hypertension, • For patients with BP ≥180/110, defer
infarction, or stroke. and oral lesions may consider the following: elective dental care
2. Stress and anxiety related to be drug-related. • Take measures to reduce stress and anxiety. • For patients with target organ
the dental visit may cause an • Avoid the use of erythromycin or clarithromycin in involvement, refer to appropriate
increase in blood pressure, patients taking a calcium channel blocker. chapter for management
leading to angina, myocardial • Avoid the long-term use of nonsteroidal recommendations
infarction, or stroke. antiinflammatory drugs (NSAIDs).
3. In patients taking nonselective • Provide oral sedative premedication and/or
beta blockers, excessive use of inhalation sedation.
vasoconstrictors can potentially • Provide local anesthesia of excellent quality.
cause an acute elevation in • For patients who are taking a nonselective beta
blood pressure. blocker, limit epinephrine to ≤2 cartridges of
4. Some antihypertensive drugs 1 : 100,000 epinephrine.
can cause oral lesions or oral • Avoid epinephrine-containing gingival retraction
dryness and can predispose cord.
patients to orthostatic • For patients with upper-level stage 2 hypertension,
hypotension. consider intraoperative monitoring of BP, and
terminate appointment if BP reaches 180/110.
• Make slow changes in chair position to avoid
orthostatic hypotension.

Continued
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Dental Management: A Summary—cont’d

Angina Pectoris
Chapter 4
1. The stress and anxiety of a • No oral complications Unstable Angina (major risk) Unstable Angina
dental visit could precipitate are due to angina; • Elective dental care should be deferred; if care • Dental treatment should be limited to
an anginal attack, myocardial however, adverse effects becomes necessary, it should be provided in urgent care only such as treatment of
infarction, or sudden death. such as dry mouth, taste consultation with the physician. Management may acute infection, bleeding, or pain.
2. For patients who are taking a changes, and oral lesions include establishment of an IV line; sedation; Stable Angina
nonselective beta blocker, the may be drug related. monitoring of electrocardiogram, pulse oximeter, • Any indicated dental treatment may
use of excessive amounts of • Excessive bleeding may and blood pressure; oxygen; cautious use of be provided if appropriate
epinephrine could precipitate occur as the result of the vasoconstrictors; and prophylactic nitroglycerin. management issues are considered.
a dangerous elevation in blood use of aspirin or other Stable Angina—intermediate risk
pressure. platelet aggregation • Elective dental care may be provided, with the
3. Patients who are taking aspirin inhibitors. following management considerations:
or other platelet aggregation • For stress/anxiety reduction: Provide oral sedative
inhibitor may experience premedication and/or inhalation sedation if
excessive bleeding. indicated, assess pretreatment vital signs and
4. Questions may arise as to availability of nitroglycerin, and limit quantity
the necessity of antibiotic of vasoconstrictor used.
prophylaxis for patients with • For patients taking a nonselective beta blocker:
a history of coronary artery • Limit epinephrine to ≤2 cartridges of 1 : 100,000

bypass graft, balloon epinephrine.
angioplasty, or stent. • Avoid use of epinephrine-impregnated gingival
retraction cord.
• Avoid anticholinergics.
• Provide local anesthesia of excellent quality and
adequate postoperative pain control.
• If patient is taking aspirin or another platelet
aggregation inhibitor: Excess bleeding usually
is manageable with local measures only;
discontinuation of medication is not recommended.
• Antibiotic prophylaxis is not recommended for
patients with a history of coronary artery bypass
graft (CABG), angioplasty, or stent.
Previous Myocardial Infarction
Chapter 4
1. The stress and anxiety of a • No oral complications Recent Myocardial Infarction (<1 month)—major risk Recent Myocardial Infarction
dental visit could precipitate are due to myocardial • Elective dental care should be deferred; if care • Dental treatment should be limited to
an anginal attack, myocardial infarction; however, becomes necessary, it should be provided in urgent care only, such as treatment of
infarction, or sudden death in adverse effects such as consultation with the physician. acute infection, bleeding, or pain.
the office. dry mouth, taste • Management may include establishment of an IV line; Past Myocardial Infarction
2. Patients may have some degree changes, and oral lesions sedation; monitoring of electrocardiogram, pulse • Any indicated dental treatment
of heart failure. may be drug-related. oximeter, and blood pressure; oxygen; cautious use may be provided, taking into
3. If the patient has a pacemaker, Also, bleeding may be of vasoconstrictors; and prophylactic nitroglycerin. consideration appropriate
some dental equipment excessive because of use Past Myocardial Infarction (>1 month without management considerations.
may potentially cause of aspirin, other platelet symptoms)—intermediate risk
electromagnetic interference. aggregation inhibitors, • Elective dental care may be provided with the
4. In patients who are taking or warfarin (Coumadin). following management considerations:
a nonselective beta blocker, • For stress/anxiety reduction: Provide oral sedative
excessive amounts of premedication and/or inhalation sedation if
epinephrine may cause a indicated, assess pretreatment vital signs and
dangerous elevation in blood availability of nitroglycerin, and limit the quantity
pressure. of vasoconstrictor used.
5. Patients who are taking aspirin • For patients who are taking a nonselective beta
or another platelet aggregation blocker: Limit epinephrine to ≤2 cartridges of
inhibitor or warfarin 1 : 100,000 epinephrine.
(Coumadin) may experience • Avoid use of epinephrine-impregnated gingival
excessive postoperative retraction cord.
bleeding. • Avoid anticholinergics.
6. Questions may arise about • Provide local anesthesia of excellent quality and

necessity of antibiotic adequate postoperative pain control.
prophylaxis for patients with • If the patient is taking aspirin or another platelet
a history of CABG, balloon aggregation inhibitor, excessive bleeding is usually
angioplasty, or stent. manageable by local measures only; discontinuation
of medication is not recommended.
• If patient has a pacemaker or implanted
defibrillator, avoid use of electrosurgery and
ultrasonic scalers; antibiotic prophylaxis is not
recommended for these patients.
• If patient is taking warfarin (Coumadin), the INR
should be 3.5 or less before performance of
invasive procedures.
• Antibiotic prophylaxis is not recommended for

patients with a history of CABG, angioplasty, or
stent.
Continued
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Arrhythmias
Chapter 5
1. The stress and anxiety of dental • No oral complications • Determine the nature, severity, and appropriate High-Risk Arrhythmias
treatment or excessive amounts are due to arrhythmia; treatment of arrhythmia through history and clinical • Dental treatment should be limited to
of epinephrine may induce however, adverse effects findings; if specific diagnosis is unclear, obtain medical urgent care only, such as treatment of
life-threatening arrhythmias such as dry mouth, taste consultation to confirm the following: acute infection, bleeding, or pain.
in susceptible patients. changes, and oral lesions • For high-risk arrhythmia (high-grade All Other Arrhythmias
2. Patients with preexisting may be drug-related. atrioventricular [AV] block, symptomatic • Any indicated dental treatment may
arrhythmia are at increased • Excessive bleeding or ventricular arrhythmia, supraventricular arrhythmia be provided as long as arrhythmia
risk for serious complications bruising may occur as with uncontrolled ventricular rate): is controlled and appropriate
such as angina, myocardial the result of use of 1. Elective dental care should be deferred; if care management issues are considered.
infarction, stroke, heart failure, warfarin (Coumadin). becomes necessary, it should be provided in
or cardiac arrest. consultation with the physician.
3. Patients with a pacemaker or 2. Management may include establishment
a defibrillator may be at risk of an IV line; sedation; monitoring of
for possible malfunction caused electrocardiogram, pulse oximeter, and blood
by electromagnetic interference pressure; oxygen; and cautious use of
from some dental equipment; vasoconstrictors.

some question about the need • For intermediate- and low-risk arrhythmia
for prophylactic antibiotics may (essentially all others):
arise. 1. Elective dental care may be provided with the
4. In patients who are taking following management considerations. Stress/
a nonselective beta blocker, anxiety reduction: provide oral sedative
excessive amounts of premedication and/or inhalation sedation if
epinephrine may cause a indicated; assess pretreatment vital signs; avoid
dangerous elevation in blood excessive use of epinephrine (for patients who

pressure. are taking a nonselective beta blocker, limit
5. Patients with atrial fibrillation epinephrine to ≤2 cartridges of 1 : 100,000
who are taking warfarin epinephrine, avoid the use of epinephrine-
(Coumadin) are at risk for impregnated gingival retraction cord, and
excessive postoperative provide local anesthesia of excellent quality and
bleeding. postoperative pain control).
6. Patients who are taking digoxin 2. For patients who are taking warfarin
are at risk for arrhythmia if (Coumadin), the INR should be 3.5 or less
epinephrine is used; digoxin before any invasive dental procedure; provide
toxicity also is a potential local measures for hemostasis.
problem. 3. For patients with a pacemaker or an implanted
defibrillator, avoid the use of electrosurgery and
ultrasonic scalers; antibiotic prophylaxis is not
recommended for these patients.
4. For patients taking digoxin, avoid use of
epinephrine because of increased risk of
inducing arrhythmia; be observant for signs
of digoxin toxicity (e.g., hypersalivation).
Heart Failure
Chapter 6
1. Providing dental treatment to • No oral complications Symptomatic Heart Failure (NYHA class III or IV) Symptomatic Heart Failure (NYHA
a patient with symptomatic or are caused by heart • Elective dental care should be deferred and medical class III or IV)
uncontrolled heart failure may failure; however, adverse consultation obtained; if care becomes necessary, it • Dental treatment should be limited to
result in worsening of effects such as dry should be provided in consultation with the physician. urgent care only, such as treatment of
symptoms, acute failure, mouth, taste changes, • Management may include establishment of an IV line; acute infection, bleeding, or pain.
arrhythmia, myocardial and oral lesions may sedation; monitoring of electrocardiogram, pulse Asymptomatic/Mild Heart Failure
infarction, cardiac arrest, or be drug-related. oximeter, and blood pressure; oxygen; cautious use of (NYHA class I and II)
stroke. • Digoxin can cause an vasoconstrictors; and possibly, prophylactic • Any necessary dental treatment may
2. Patients with heart failure may enhanced gag reflex. nitroglycerin. be provided.
have difficulty breathing and Asymptomatic/Mild Heart Failure (NYHA class I and II
may not tolerate a supine chair and possibly III)
position. • Elective dental care may be provided with the
3. Heart failure is due to an following management considerations:
underlying condition such as • For stress/anxiety reduction: Provide oral sedative
coronary artery disease or premedication and/or inhalation sedation if
hypertension which may also indicated, and assess pretreatment vital signs.
require special management • For patients who are taking a nonselective beta
considerations. blocker, limit epinephrine to ≤2 cartridges of
4. In patients who are taking 1 : 100,000 epinephrine, avoid the use of
a nonselective beta blocker, epinephrine-impregnated gingival retraction cord,
excessive amounts of and provide local anesthesia of excellent quality
epinephrine may cause a and postoperative pain control.
dangerous elevation in blood • Ensure a comfortable chair position; supine
pressure. position may not be tolerated.

5. The use of epinephrine in • If patient is taking digoxin, avoid the use of
patients who are taking digoxin epinephrine.
may cause arrhythmia. • Avoid the use of nonsteroidal antiinflammatory
6. Digitalis may result in toxicity, drugs (NSAIDs).
so be on the alert.
Continued
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Chronic Obstructive Pulmonary Disease
Chapter 7
1. Aggravation or worsening of • Leukoplakia, • Avoid treating if upper respiratory infection is present. • None
compromised respiratory erythroplakia, or • Use an upright chair position.
function squamous cell carcinoma • Use of local anesthesia is appropriate; minimize the
may develop in chronic use of bilateral mandibular or palatal blocks.
smokers of tobacco. • Do not use a rubber dam in patients with severe
disease.
• Use pulse oximetry to monitor oxygen saturation.
• Use of low-flow oxygen is helpful.
• Do not use nitrous oxide–oxygen sedation in patients
with severe emphysema.
• Low-dose oral diazepam is acceptable.
• Avoid barbiturates, narcotics, antihistamines, and
anticholinergics.
• Usual daily steroid dose may be needed in patients

who are taking systemic steroids for surgical
procedures.
• Avoid macrolide antibiotics (erythromycin,
clarithromycin) and ciprofloxacin for patients who are
taking theophylline.
• Outpatient general anesthesia is contraindicated.
Asthma
Chapter 7
1. Precipitation of an acute • Oral candidiasis is • Identify asthmatic patient by history. • None required.
asthma attack reported with the use of • Determine character of asthma:
a corticosteroid inhaler • Type (allergic or nonallergic)
inhaler without a • Precipitating factors
“spacer,” but it occurs • Age at onset
rarely. • Level of control (frequency, severity of attacks
• Maxillofacial growth can [mild, moderate, severe])
be altered when asthma • How usually managed
is severe during • Medications being taken
childhood. • Necessity for past emergency care
• Baseline forced expiratory volume at 1 second
(FEV1) stable (not decreasing)
• Avoid known precipitating factors.
• Consult with physician for severe persistent asthma.
• Reduce the risk of an attack: Have the patient bring
medication inhaler to each appointment, and
recommend prophylaxis with an inhaler before each
appointment for persons with moderate to severe
persistent asthma.
• Drugs to avoid:
• Aspirin-containing medications
• NSAIDs
• Narcotics and barbiturates
• Macrolide antibiotics (e.g., erythromycin), if the

patient is taking theophylline
• Discontinue cimetidine 24 hours before IV sedation
in patients who are taking theophylline.
• Sulfite-containing local anesthetic solutions may need
to be avoided.
• Usual daily steroid dose may be needed for surgical
procedures in patients who are taking systemic
steroids.
• Premedication (nitrous oxide or diazepam) may be
needed for anxious patients.
• Provide a stress-free environment.
• Use a pulse oximeter.
• Recognize signs and symptoms of a severe or

worsening asthma attack (e.g., difficulty breathing,
tachypnea).
Continued
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DM10

Tuberculosis
Chapter 7
1. Tuberculosis may be contracted • Oral ulceration (rare); • CAVEAT: Many patients with infectious disease cannot • None required.
by the dental health care tongue most common be identified by history or examination; therefore, all
worker from an actively site; ulcer may occur on patients should be approached with the use of
infectious patient. gingiva or palate standard precautions (see Appendix B).
2. Patients and staff may be • Tuberculosis involvement • Patient with active sputum-positive tuberculosis:
infected by a dentist who is of cervical and • Consult with physician before treatment.
actively infectious. submandibular lymph • Treatment is limited to emergency care (older
nodes (scrofula) than 6 years of age.)
• Calcified cervical lymph • Treatment is provided in the hospital setting
nodes may indicate with proper isolation, sterilization, mask, gloves,
previous infection/latent gown, and ventilation.
disease. • For patients younger than 6 years of age, treat
as a normal (noninfectious) patient after
consulting with the physician.
• For patients producing consistently negative

sputum after undergoing at least 2 to 3 weeks of
chemotherapy, treat as a normal patient.
• Patients with a past history of tuberculosis:
• Patients should be approached with caution;
obtain good history of disease and its treatment,
and conduct appropriate review of systems.
• Obtain history of adequate treatment, periodic
chest radiographs, and examination findings to

rule out reactivation.
• Dental treatment should be postponed if:
1. Questionable history of adequate treatment
2. Lack of appropriate medical supervision since
recovery
3. Signs or symptoms of relapse
• If present status is free of clinical disease, patient
should be treated as for a normal patient.
• Patients with recent conversion to a positive result
on tuberculin skin testing (with purified protein
derivative [PPD]):
• Should have been evaluated by the physician to
rule out clinical disease
• May be receiving isoniazid (INH)
prophylactically for 3 to 9 months
• Should be treated as a normal patient when the
physician approves health status
• Patients with signs or symptoms of tuberculosis:
• Should be referred to the physician and should
have treatment postponed
• If treatment is necessary, provide treatment as
for patient with active sputum-positive
tuberculosis (above).
Obstructive Sleep Apnea
Chapter 9
1. Patients with untreated • Large tongue, long soft • Patients should be identified by history and clinical • Patients with obstructive sleep apnea
obstructive sleep apnea are at palate, long uvula, examination and referred to a sleep medicine specialist may undergo any necessary dental
increased risk for hypertension, redundant for diagnosis and treatment planning. treatment.
stroke, arrhythmia, myocardial parapharyngeal tissues, • Signs and symptoms suggestive of obstructive sleep
infarction, and diabetes. large tonsils, retrusive apnea include heavy snoring, witnessed apnea episodes
mandible during sleep, excessive daytime sleepiness, obesity, and
large neck circumference.
• Depending on the diagnosis and severity of the
disease, treatment may include positive airway

pressure, use of oral appliances, or various forms of
upper airway surgery.
Continued
DM11
DM12

Viral Hepatitis Types B, C, D, and E
Chapter 10
1. Hepatitis may be contracted by • Bleeding • CAVEAT: Because most carriers are undetectable by • None required.
the dentist from an infectious • Lichenoid eruptions history, all patients should be treated with the use of
patient. • Unpredictable drug standard precautions (see Appendix B); risk may be
2. Patients or staff may be infected metabolism decreased by the use of hepatitis B vaccine.
by the dentist who has active • For patient with active hepatitis, use the following
disease or is a carrier. procedures:
3. With chronic active hepatitis, • Consult with the physician (to determine status).
the patient may have chronic • Treat on an emergency basis only.
liver dysfunction, which may • For patients with a history of hepatitis, use the
be associated with a bleeding following procedures:
tendency or altered drug • Consult with the physician (to determine status).
metabolism. • Probable type determination:
1. Age at time of infection (type B uncommon
at younger than 15 years of age)
2. Source of infection (if food or water, usually
type A or E)
3. If blood transfusion–related, probably type C
4. If type is indeterminate, assay for hepatitis B
surface antigen (HBsAg) may be considered.
• With patients in high-risk categories, consider
screening for HBsAg or anti–hepatitis C virus.
• If patient is HBsAg- or hepatitis C virus–positive
(carrier status):

• Consult with the physician to determine liver
function status and/or recommendations for
early treatment.
• Minimize the use of drugs metabolized by the
liver.
• Monitor preoperative prothrombin time in
chronic active hepatitis, if invasive/surgical
procedures are planned.
• Needlestick:
• Consult the physician.
• Consider hepatitis B immunoglobulin.
Alcoholic Liver Disease (Cirrhosis)
Chapter 10
1. Bleeding tendencies; • Neglect • Identify alcoholic patients through the following • Because oral neglect is commonly
unpredictable drug metabolism • Bleeding methods: seen in persons who abuse alcohol,
• Ecchymoses • History patients with this history should be
• Petechiae • Clinical examination required to demonstrate interest in
• Glossitis • Detection of odor on breath and ability to care for dentition
• Angular cheilosis • Information from friends or relatives before any significant treatment is
• Impaired healing • Consult with the physician to determine the status of rendered.
• Parotid enlargement liver dysfunction.
• Candidiasis • Perform clinical screening for alcohol abuse with the
• Oral cancer CAGE questionnaire, and attempt to guide patients
• Alcohol breath odor during treatment.
• Bruxism • Laboratory screening should include the following:
• Dental attrition • Complete blood count with differential
• Xerostomia • Aspartate aminotransferase, alanine
aminotransferase
• Platelet count
• Thrombin time
• Prothrombin time
• Minimize the use of drugs metabolized by the liver.
• If screening tests are abnormal, consider
antifibrinolytic agents, fresh frozen plasma, vitamin K,
and platelets, for use during surgery.
• Defer routine care if ascites (encephalopathy), is
present.

Peptic Ulcer Disease
Chapter 11
1. Further injury to the intestinal • Rare—enamel dissolution • Avoid aspirin/other NSAIDs. • Provide as stress-free an environment
mucosa caused by aspirin/other associated with persistent • Avoid corticosteroids. as possible.
NSAIDs regurgitation • Examine oral cavity for signs of fungal overgrowth.
2. Fungal overgrowth during or • Fungal overgrowth
after systemic antibiotic use • Rare—vitamin B
deficiency (glossopyrosis)
with omeprazole use
Inflammatory Bowel Disease
Chapter 11
1. In patients who are being • “Cobblestoning”— • Additional steroids may be needed for surgical • Schedule appointments during
treated with steroids, stress aphthous lesions procedures. remissions.
may lead to serious medical • Pyostomatitis vegetans • Complete blood count is needed to monitor toxic
problems. hematologic effects of drugs.
• If antibiotics are used, monitor for signs or symptoms
DM13
(diarrhea, GI distress) of pseudomembranous colitis.

Continued
DM14

Pseudomembranous Colitis
Chapter 11
1. Fungal overgrowth during or • Rare—fungal overgrowth • Select appropriate antibiotic, dosage, and duration. • Schedule appointments when the
after course of antibiotics • Take precautions with prolonged antibiotic use in the patient is free of disease symptoms.
elderly and those previously affected.
End-Stage Renal Disease
Chapter 12
1. Bleeding tendency • Mucosal pallor • Consult with physician (to determine status). • Major emphasis on oral hygiene and
2. Hypertension • Xerostomia • Pretreatment screening (i.e., platelet count, optimal maintenance care to
3. Anemia • Metallic taste prothrombin time, partial thromboplastin time, eliminate possible sources of
4. Intolerance to nephrotoxic • Ammonia breath odor hematocrit, hemoglobin) for hematologic disorder infection.
drugs metabolized by the • Stomatitis done by dentist or patient’s physician. • No contraindications for routine
kidney • Loss of lamina dura • Closely monitor blood pressure before and during dental care.
5. Enhanced susceptibility to • Bone radiolucencies treatment. • Extensive reconstructive crown and
infection • Bleeding tendency • Adjust dosage/avoid drugs excreted by the kidney and bridge procedures may not be
nephrotoxic drugs when glomerular filtration rate indicated for patients with poor
(GFR) <60 mL/min. prognosis.

• Meticulous attention should be paid to good surgical
technique to minimize the risk of abnormal bleeding
or infection.
• Provide aggressive management of infection.
Hemodialysis
Chapter 12
1. Bleeding tendency • Bleeding • Consultation with physician. • None required.
• •

2. Hypertension Lichenoid eruptions Delay dental treatment for at least 4 hours after
3. Anemia dialysis to avoid heparin effects (potential for excessive
4. Intolerance to nephrotoxic bleeding); best to perform dental treatment on the day
drugs metabolized by the after dialysis.
kidney • Avoid drugs metabolized by kidney or nephrotoxic
5. Bacterial endarteritis of drugs.
arteriovenous fistula secondary • American Heart Association does not recommend
to bacteremia antibiotic prophylaxis for invasive dental procedures.
6. Hepatitis (active or carrier) • Monitor blood pressure closely—avoid placing blood
7. Bacterial endocarditis pressure cuff on the arm containing the shunt used for
8. Collapse of shunt dialysis.
• Avoid intravenous medications in arm with shunt
• Consider corticosteroid supplementation if indicated.
Gonorrhea
Chapter 13
1. Remote possibility of • Rare but varied CAVEAT: Many patients with sexually transmitted disease • None required.
transmission from oral or expression, including cannot be identified by history or examination;
pharyngeal lesions of an generalized stomatitis, therefore, all patients must be approached with the use
infected patient ulceration, and of standard precautions (see Appendix B).
formation of • For patients currently receiving treatment for
pseudomembranous gonorrhea, provide necessary care.
coating of oropharynx • For patients with past history of gonorrhea,
perform the following:
• Obtain a good history of disease and its
treatment.
• Provide necessary care.
• For patients with signs or symptoms suggestive of
gonorrhea:
• Refer to physician for evaluation.
• Provide necessary care after disease treatment has
been initiated.
Syphilis
Chapter 13
1. Syphilis may be contracted by • Chancre • For patients receiving treatment for syphilis: • None required.
the dentist from an actively • Mucous patch • Consult with physician before treatment.
infectious patient. • Gumma • Provide necessary care.
2. Patients or staff may be infected • Interstitial glossitis • Be aware that oral lesions of primary and
by the dentist who has syphilis. • Congenital syphilis secondary syphilis are infectious before initiation of
(associated with antibiotic therapy.

Hutchinson’s incisors • For patients with a past history of syphilis:
and mulberry molars) • Approach with caution; obtain good history of
disease, its treatment, and negative serologic tests
for syphilis test after completion of therapy.
• Treat as normal patient if free of disease.
• For patients showing signs or symptoms suggestive of
syphilis:
• Refer to physician, and postpone treatment.
• The dentist may request/order serologic tests for
syphilis before referral.
• Defer treatment until diagnosis established and
medical treatment provided.

Continued
DM15
DM16

Genital Herpes
Chapter 13
1. Inoculation of oral cavity and • Autoinoculation of type CAVEAT: Many patients with sexually transmitted disease • None usually required; patients prone
potential transmission to dentist 2 herpes to oral cavity cannot be identified by history or examination; to recurrence after dental treatment
(fingers, eyes) therefore, all patients must be approached with the use should be prescribed a systemic
of standard precautions (see Appendix B). antiviral drug for prophylactic use
• Localized genital infection poses no problem; for a few days.
however, be aware of possibility of autoinoculation
to dermal sites and the oral cavity by the patient.

• For oral infection with HSV-1 or HSV-2 postpone
elective dental care until lesion is healing (in scab
phase or when it disappears).
Human Papillomavirus (HPV) Infection
Chapter 13
1. Inoculation of oral cavity and • Benign manifestations: CAVEAT: Many patients with sexually transmitted disease • Discuss risks of transmission and the
potential transmission to fingers papilloma, verruca cannot be identified by history or examination; potential for development of
vulgaris, condyloma therefore, all patients must be approached with the use carcinoma with high-risk types (HPV

acuminatum of standard precautions (see Appendix B). 16, 18, 31, 33, 35). Appropriate
• Specific genotypes • Localized genital infection poses no problem; treatment and follow-up care should
associated with risk for however, be aware of the possibility of be provided.
development of autoinoculation to the oral cavity by the patient.
carcinoma • Oral lesions should be excised and submitted for
histologic examination. HPV typing should be
considered.
Diabetes Mellitus
Chapter 14
1. In patients with uncontrolled • Accelerated periodontal • Detection by the following methods: • In patients with well-controlled
diabetes: disease • History diabetes, no alteration of treatment
a. Infection • Gingival proliferations • Clinical findings plan is indicated unless complications
b. Poor wound healing • Periodontal abscesses • Screening for blood glucose of diabetes are present, such as:
c. Risk for systemic problems • Xerostomia • Referral for diagnosis and treatment • Hypertension
2. Insulin reaction in patients • Poor healing • Monitoring and control of hyperglycemia by • Congestive heart failure
treated with insulin • Infection assessment of blood glucose • Myocardial infarction
3. In diabetic patients, early onset • Oral ulcerations • Monitoring of hemoglobin A1c (A1C) status • Angina
of complications relating to • Candidiasis • For patients receiving insulin (or sulfonylurea • Renal failure
cardiovascular system, eyes, • Mucormycosis drugs), insulin reaction is prevented by the following • Defer orthodontic and prosthodontic
kidneys, and nervous system • Numbness, burning, or methods: care until periodontal disease is well
(angina, myocardial infarction, pain in oral tissues • Eating normal meals before appointments controlled.
cerebrovascular accident, renal • Scheduling appointments in morning or mid- • Avoid periodontal or oral surgery if
failure, peripheral neuropathy morning poor glycemic control.
blindness, hypertension, • Informing the dentist of any symptoms of insulin
congestive heart failure) reaction when they first occur
• Having sugar available in some form in cases of
insulin reaction
• Diabetic patients who develop oral infection may
require increased insulin dosage and consultation with
the physician, in addition to aggressive local and
systemic management of infection (including antibiotic
sensitivity testing).
• Drug considerations include the following:
• Insulin reaction

• Insulin and drug interactions
• Hypoglycemic agents—on rare occasions can cause
aplastic anemia, etc.
• Avoidance of general anesthesia in patients with
severe diabetes
Continued
DM17
DM18

Adrenal Insufficiency (AI)
Chapter 15
1. Inability to tolerate stress • Pigmentation of oral • For routine dental procedures (excluding extractions): • None required.
2. Delayed healing mucous membranes • Patients currently taking corticosteroids—no
3. Susceptibility to infection • Delayed healing additional supplementation generally required; be
4. Hypertension (with prolonged • Possible oral infection sure to obtain good local anesthesia and good
steroid use) postoperative pain control
• Patients with past history of regular corticosteroid
usage; none generally required
• Patients using topical or inhalational steroids—
generally no supplementation required
• With secondary AI, provide usual daily steroid dose
for surgical procedures.
• With primary AI, for extractions or other surgery,
extensive procedures, or extreme patient anxiety, with
local anesthetic include the following:
• Discontinue drugs that decrease cortisol levels (e.g.,
ketoconazole) at least 24 hours before surgery with

consent of the patient’s physician.
• Give 25 mg/day hydrocortisone for minor oral and
periodontal surgery, administered before procedure.
• Give 50-75 mg hydrocortisone at beginning of
moderate oral surgery, and up to 1 day after.
Return to preoperative glucocorticoid dose on
postoperative day 2.

• Give 100-150 mg/day of hydrocortisone at
beginning of major oral surgery or procedures
involving general anesthesia; continue for 2-3 days.
• Monitor blood pressure throughout procedure and
initial postoperative phase.
• Provide good pain control.
Hyperthyroidism (Thyrotoxicosis)
Chapter 16
1. Thyrotoxic crisis (thyroid • Osteoporosis may occur. • Detection of patients with thyrotoxicosis by history • Once under good medical
storm) may be precipitated in • Periodontal disease may and examination findings management, the patient may receive
patients with untreated or be more progressive. • Referral for medical evaluation and treatment any indicated dental treatment.
incompletely treated • Dental caries may be • Avoidance of any dental treatment for patient with • If acute infection occurs, the
thyrotoxicosis by: more extensive. thyrotoxicosis until good medical control is attained; physician should be consulted
a. Infection • Premature loss of however, any acute oral infection will have to be dealt regarding management.
b. Trauma deciduous teeth and with by antibiotic therapy and other conservative
c. Surgical procedures early eruption of measures to prevent development of thyrotoxic crisis;
d. Stress permanent teeth may suggest consultation with patient’s physician during
2. Patients with untreated occur. management of acute oral infection
or incompletely treated • Early jaw development • Avoidance of epinephrine and other pressor amines in
thyrotoxicosis may be may be noted. untreated or incompletely treated patient
very sensitive to actions of • Tumors found at the • Recognition of early stages of thyrotoxic crisis:
epinephrine and other pressor midline of the posterior • Severe symptoms of thyrotoxicosis
amines; thus, these agents must dorsum of the tongue • Fever
not be used; once the patient is must not be surgically • Abdominal pain
well managed from a medical removed until the • Delirious, obtunded, or psychotic
standpoint, these agents may be possibility of functional • Initiation of immediate emergency treatment
administered. thyroid tissue has been procedures:
3. Thyrotoxicosis increases the ruled out by 131I uptake • Seek immediate medical aid.
risk for hypertension, angina, tests. • Cool with cold towels, ice packs.
MI, congestive heart failure, • Hydrocortisone (100-300 mg)
and severe arrhythmias. • Monitor vital signs.
4. Radioactive iodine • Acute—salivary gland • Start cardiopulmonary resuscitation (CPR) if
complications swelling, pain, loss of needed.

taste • Manage pain and xerostomia as described in
• Radioactive drug- Appendix C.
induced: Chronic
sialoadenitis—
xerostomia, pain and
dental caries
5. Antithyroid agents: • Sore throat, fever, mouth • Possible agranulocytosis, refer to physician for
propylthiouracil, methimazole ulcers evaluation and stopping the antithyroid medication.
Continued
DM19
DM20

Hypothyroidism
Chapter 16
1. Untreated patients with severe • Increase tongue size • Detection and referral of patients suspected of being • In hypothyroid patients under good
hypothyroidism exposed to • Delayed eruption of hypothyroid for medical evaluation and treatment medical management, indicated
stressful situations such as teeth • Avoidance of narcotics, barbiturates, and tranquilizers dental treatment may be performed.
trauma, surgical procedures, or • Malocclusion in untreated hypothyroid patients • In patients with a congenital form of
infection may develop • Gingival edema • Recognition of initial stage of hypothyroid disease and severe mental retardation,
hypothyroid (myxedema) coma. (myxedema) coma: assistance with hygienic procedures
2. Untreated hypothyroid patients • Hypothermia may be needed.
may be highly sensitive to • Bradycardia
actions of narcotics, • Hypotension
barbiturates, and tranquilizers. • Epileptic seizures
• Initiation of immediate treatment for myxedema coma:
• Seek immediate medical aid.
• Administer hydrocortisone (100-300 mg).
• Provide CPR as indicated.
Thyroiditis
Chapter 16
1. Acute suppurative—patient has • Usually none • None • Postpone elective dental care until
acute infection, antibiotics are infection has been treated.
required.
2. Subacute painful—period of • Pain may be referred to • Include in differential diagnosis for jaw pain; see • Avoid elective dental care if possible
hyperthyroidism mandible. earlier under Hyperthyroidism. until symptoms of hyperthyroidism
have cleared.
3. Subacute painless—up to • None • See earlier under Hyperthyroidism. • Avoid elective dental care if possible

6-month period of until symptoms of hyperthyroidism
hyperthyroidism have cleared.
4. Hashimoto’s—leads to severe • Tongue may enlarge. • See earlier under Hypothyroidism. • In hypothyroid patients under good
hypothyroidism medical management, any indicated
dental treatment can be performed.
See above for uncontrolled disease.
5. Chronic fibrosing (Riedel’s)— • None • None • None
usually euthyroid
Thyroid Cancer
Chapter 16
1. Usually none • Usually none; metastasis • Examine for signs and symptoms of thyroid cancer: • For most patients, the dental
to the oral cavity is rare. • Hard, painless lump in thyroid treatment plan is not affected unless
• Post-radiation induced • Dominant nodule in multinodular goiter the cancer treatment includes external
chronic sialodenitis, • Hoarseness, dysphagia, dyspnea irradiation or chemotherapy. See
xerostomia, risk for root • Cervical lymphadenopathy summaries for Chapter 26. Patients
caries. • Nodule that is affixed to underlying tissues with anaplastic carcinoma have a
• Patient usually euthyroid poor prognosis, and complex dental
• Patients found to have thyroid nodule(s) should be procedures usually are not indicated.
referred for fine needle aspiration biopsy.
2. Levothyroxine suppression after • Usually none • Consult with patient’s physician regarding permissible • Care with the use of epinephrine is
surgery and radioiodine degree of hyperthyroidism in patients treated with indicated in patients treated with
ablation is usual treatment for thyroid hormone. thyroid hormone.
follicular carcinomas. Patient
may have mild hyperthyroidism
and may be sensitive to actions
of pressor amines.
3. Patients with multiple endocrine • Patients with MEN2 can

neoplasia-2 (MEN2) may have develop cystic lesions of
symptoms of hypertension and/ the jaws related to
or hypercalcemia. hyperparathyroidism.
4. Anaplastic carcinomas may be • See oral complications • Manage complications of radiation therapy/ • Prognosis is poor with anaplastic
treated by external irradiation listed in summaries for chemotherapy as described in summaries for carcinoma.
and/or chemotherapy. See Chapter 26. Chapter 26.
problems listed in summaries
for Chapter 26.
Continued
DM21
DM22

Pregnancy and Lactation
Chapter 17
1. Dental procedures could harm • Exaggeration of • Women of childbearing age: • None, except that major
the developing fetus through periodontal disease, • Always use contemporary radiographic techniques, reconstructive procedures, crown and
effects of: “pregnancy gingivitis” including lead apron and thyroid collar, when bridge fabrication, and significant
a. Radiation • “Pregnancy tumor” performing radiographic examination. operations are best delayed until after
b. Drugs • Tooth mobility • Do not prescribe drugs that are known to be delivery.
c. Stress harmful to the fetus, or whose effects are as yet
2. Supine hypotension in late unknown (see Table 17-3).
pregnancy • Encourage patients to maintain a balanced,
3. Poor nutrition and diet can nutritious diet.
affect oral health. • For pregnant women:
4. Transmission of drugs to infant • Consider contacting the patient’s physician to verify
in breast milk physical status and present management plan; ask
5. Lack of proper oral health care for suggestions regarding patient’s treatment,
during pregnancy could harm especially as it relates to drug administration.
the development of the fetus • Maintain optimal oral hygiene, including
and affect time of delivery. prophylaxis, throughout pregnancy.

• Minimize oral microbial load (consider
chlorhexidine and/or fluoride).
• Avoid elective dental care during the first trimester.
The second trimester and early third trimester are
the best times for elective treatment.
• Do not schedule radiographs during the first
trimester; thereafter, take only those necessary for

treatment, always with the use of a lead apron.
• Avoid drugs known to be harmful to the fetus, or
whose effects are unknown (see Table 17-3).
• In advanced stages of pregnancy (late third
trimester), do not place the patient in the supine
position for prolonged periods; avoid aspirin/other
NSAIDs.
• For lactating mothers:
• Most drugs are of little pharmacologic significance
to lactation.
• Do not prescribe drugs known to be harmful (see
Table 17-3).
• Administer drugs just after breast feeding.
HIV Seropositive Asymptomatic
Chapter 18
1. Transmission of infectious • None in the early stage; • Identification of HIV-infected patient is difficult; • None indicated.
agents to dental personnel and however, increased interview questions should address promiscuous sexual
patients, may include: incidence of certain oral behavior.
a. Human immunodeficiency lesions associated with • Infectious disease control procedures must be used for
virus (HIV) AIDS is found when all patients.
b. Hepatitis B virus (HBV) compared with • Extreme care must be taken to avoid needlestick and
c. Hepatitis C virus (HCV) noninfected persons instrument wounding.
d. Epstein-Barr virus (EBV) (i.e., candidiasis). • All dental personnel should be vaccinated to be
e. Cytomegalovirus (CMV) protected from HBV infection.
2. To date, dental health care • All asymptomatic antibody-positive (for HIV) patients
workers have not been infected may go on to develop AIDS; however, it may take as
with HIV through occupational long as 15 years before a diagnosis of AIDS is made.
exposure; six patients may • The HIV-infected patient’s CD4+ cell count and viral
have been infected by an HIV- titer must be monitored.
infected dentist; thus, risk of • The patient’s immune status, medications, and
HIV transmission in the dental potential for opportunistic infections must be
setting is very low, but the determined and monitored.
potential exists.
3. Persons who are hepatitis
carriers may transmit HBV or
HCV to the unvaccinated or
those lacking antibody.
Continued

DM23
DM24

HIV-Infected, Asymptomatic Patient (CD4+ lymphocyte count less than 500/μL but more than 200/μL)
Chapter 18
1. Transmission of infectious • Oral candidiasis • Use standard precautions in providing care for all • None indicated.
agents to dental personnel and • Hairy leukoplakia patients. • If patient is in “remission” with a
patients: • Persistent • Vaccinate dental personnel for protection from HBV CD4+ count >200/μL, routine and
a. HIV lymphadenopathy infection. complex restorative procedures can
b. Hepatitis B virus • Salivary gland • Identify patients by presence of signs/symptoms be provided.
c. Hepatitis C virus enlargement associated with decreasing CD4+ cell counts; refer for
d. Epstein-Barr virus • With the exception of medical evaluation, counseling, and management.
e. Cytomegalovirus Kaposi sarcoma and • Establish platelet status and immune status of patients
Note: Transmission of HIV to non-Hodgkin lymphoma, with low CD4+ cells (<500/μL) before performing
patients who received care in other lesions listed under invasive dental procedures (see AIDS, next entry).
dental offices has been reported. AIDS may be found with • Inform patients of various support groups available to
Transmission of HBV and HCV increased frequency. help in terms of education and emotional, financial,
has been well documented on legal, and other issues.
numerous occasions. • Identify potential drug-drug interactions.
2. Patients with decreasing

CD4+ lymphocytes may have
significant immune suppression
and be at increased risk for
infection.
3. Patients with decreasing CD4+
lymphocytes may be
thrombocytopenic and hence
potential bleeders.
AIDS (CD4+ lymphocyte count less than 200 μL)
Chapter 18
1. Potential for transmission of • Kaposi sarcoma • Use standard precautions in providing care for all • Patients in advanced stages of disease
infectious agents to dental • Non-Hodgkin’s patients. should receive emergency and
personnel and patients: lymphoma • Vaccinate dental personnel for protection from preventive dental care; elective dental
a. HIV • Oral candidiasis hepatitis B virus. treatment usually is not indicated at
b. Hepatitis B virus • Lymphadenopathy • Through medical history and examination findings, this stage.
c. Hepatitis C virus • Hairy leukoplakia identify undiagnosed cases and refer for medical
d. Epstein-Barr virus • Xerostomia evaluation, counseling, and management.
e. Cytomegalovirus • Salivary gland • Give patients with significant immunosuppression
2. Potential for transmission from enlargement antibiotic prophylaxis for surgical or invasive dental
dental health care workers to • Venereal warts procedures, if neutrophil count is <500/μL.
patients. • Linear gingivitis • Platelet count should be ordered before any surgical
3. Patients with advanced disease erythema procedure is performed; if significant
have significant suppression • Necrotizing ulcerative thrombocytopenia is present, platelet replacement may
of their immune system and periodontitis be needed.
may be at risk for infection • Necrotizing stomatitis • The patient’s immune status, medications (highly
resulting from invasive dental • Herpes zoster active antiretroviral therapy [HAART]), and potential
procedures. • Primary or recurrent for opportunistic infections must be determined and
4. Patients may be bleeders herpes simplex lesions monitored.
because of thrombocytopenia. • Major aphthous lesions • Identify potential drug-drug interactions.
• Herpetiform aphthous
lesions
• Petechiae, ecchymoses
• Others (see Tables 18-5,
18-6)

Continued
DM25
DM26

Allergic Reaction (not severe)
Chapter 19
1. Mild reaction occurring after • Rash, itching • Take careful history and identify patients who are • Do not use agents to which the
patient exposure to known or allergic to agents used in dentistry, and who have a patient is allergic, as identified in the
likely allergenic agent, such as: history of atopic reactions (e.g., asthma, hay fever, medical history.
a. Drugs urticaria, angioneurotic edema). • Before administering local
b. Local anesthetic • Do not use agents to which the patient is allergic, as anesthetics, consider the following:
c. Latex gloves or other rubber identified in the medical history. • Ask the patient about any allergic
products (rubber dam, gutta • For patients with a history of atopic reactions, use reactions to local anesthetic.
percha) care when giving drugs and with use of materials (Most patients who say they are
associated with a high incidence of allergy such as allergic will describe a fainting
penicillin; be prepared to deal with severe allergic episode or a toxic reaction.) If an
reaction. allergic reaction has occurred,
• If patient develops allergic reaction to previously identify the type of anesthetic
unsuspected drug or other material, consider the used, and select one from various
following: chemical groups.
• Nonemergency reaction, no further contact with 1. Inject 1 drop (aspirate first) of
agent—administer diphenhydramine 50 mg up to alternate anesthetic, and wait 5

four times a day, orally or IM. minutes; if no reaction occurs,
• Emergency reaction—with patient in supine proceed with injection of
position with patent airway and supplemental remaining anesthetic.
oxygen, inject 0.3 to 0.5 mL epinephrine 1 : 1000 2. If anesthetic that patient has
IM; support respiration if necessary; check pulse; reacted to cannot be identified,
obtain medical assistance. consider the following
• When prescribing drugs, inform the patient procedures:

regarding signs and symptoms of allergic reactions; a. Refer to allergist for
advise the patient to call the dentist if such a provocative dose testing, or
reaction occurs, or to report to the nearest hospital b. Use diphenhydramine
emergency room. (Benadryl) with epinephrine
1 : 100,000 as local
anesthetic (1% solution,
1-4 mL).
Anaphylaxis
Chapter 19
1. Severe reaction occurring after • May develop itching of • Take careful history and identify patients who are • Do not use agents to which the
patient exposure to known or throat/palate, then skin allergic to agents used in dentistry. patient is allergic, as identified in the
likely allergenic agent, such as: rash and swelling of • Avoid allergens (drugs/other agents). medical history.
a. Drugs tissues in neck • If reaction is severe:
b. Local anesthetic • Identify anaphylactic reaction.
c. Latex gloves or other rubber • Call for medical help; activate EMS.
products (rubber dam, gutta • Place patient in the supine position.
percha) • Check for and maintain open airway.
• Administer oxygen.
• Check vital signs—respiration, blood pressure,
pulse rate, and rhythm.
• If vital signs depressed or absent, inject 0.3-0.5 mL
of epinephrine 1 : 1000 IM into the tongue.
• Provide CPR as indicated.
• Repeat injection of epinephrine if no response is
obtained.
Urticaria (Angioedema)
Chapter 19
1. Nonemergency; edematous • Soft tissue swelling • Identify patients who have had allergic reactions • Do not use agents to which the
swelling of lips, cheek, other through the history and what drug or materials caused patient is allergic, as identified in the
tissue, after contact with the reaction. medical history.
allergen • Avoid the use of antigen in allergic persons.
2. Emergency; edematous swelling • If patient develops allergic reaction to previously
of tongue, pharynx, and larynx unsuspected drug or other material, consider the

with obstruction of airway following:
• Nonemergency reaction, no further contact with
agent—administer diphenhydramine 50 mg up to
4 times a day, orally or IM.
• Emergency reaction—put patient in the supine
position; with patent airway and oxygen, inject 0.3-
0.5 mL epinephrine 1 : 1000 IM; support respiration
if necessary; check pulse; obtain medical assistance.
• For hereditary angioedema, consider use of danazol or
C1 inhibitor concentrate as preventative measure.
• For allergy to penicillin:
• Administer erythromycin or another macrolide

antibiotic.
• In nonallergic person, administer by the oral route
whenever possible—lowest incidence of
sensitization.
• Do not use in topical form.
DM27
Continued
DM28

Rheumatoid Arthritis and Osteoarthritis
Chapter 20
1. Immunosuppression due to • Temporomandibular • Early risk assessment and intervention • Adjust chair position to keep patient
many antiinflammatory joint (TMJ) problems/ • Refer for medical care more comfortable
drugs—steroids, methotrexate, disorders (TMDs) • Ensure patient receives regular medical care • TMD problems and limited jaw
disease-modifying antirheumatic • Xerostomia appointments opening
drugs (DMARDs), biologics • Bleeding • Address and prevent xerostomia
2. Potential for increased • Infections (increased caries rate)
infections due to • Prevention of bleeding problems
immunosuppresion (leukopenia) • Possible corticosteroid
3. Potential bleeding from long- supplementation
term use of aspirin/other • Antibiotic prophylaxis (per previous)
NSAIDs
4. Potential for adrenal
suppression from long-term
corticosteroid use
Joint Replacements
Chapter 20
Dentists have three options for managing dental patients
with prosthetic joint replacements regarding antibiotic
prophylaxis:
1. Potential for late prosthetic 1. Informed consent. • Defer dental care during immediate
joint infection 2. Base clinical decisions on the 2003 ADA/AAOS postoperative period
consensus statement • Use antibiotic prophylaxis for
3. Consultation with the patient’s orthopedic surgeon to patients with prosthetic joint

suggest following the 2003 guidelines until a new joint replacement for invasive dental
consensus statement is approved. If the orthopedist procedures for the first two years
elects to recommend antibiotic prophylaxis for a following the placement of the joint
patient who would not receive it on the basis of replacement and in patients with
the 2003 guidelines, the orthopedist can write the "high risk" conditions: rheumatoid
prescription for the desired antibiotic. arthritis, type 1 diabetes, previous
history of prosthetic joint infection,
malnourishment, hemophilia,
malignancy and severe immune
suppression.
Giant Cell Arteritis
Chapter 20
1. Potential for jaw claudication, • TMD symptoms • Include in differential diagnosis for pain in the • Defer care during sympotomatic
which may be mistaken for temporal region. phase.
TMD symptoms • Refer for medical care.
Systemic Lupus Erythematosus
Chapter 20
1. Potential for end-organ • Infections • No specific recommendations for antibiotic • Prevention of bleeding problems
complications (e.g., heart, renal, • Oral ulcers (stomatitis) prophylaxis, but antibiotics may be necessary if • Possible corticosteroid
skin, immune) • Bleeding patient is immunosuppressed. supplementation
2. Immunosuppression due to • Differential diagnosis
many antiinflammatory drugs
(e.g., steroids, methotrexate,
DMARDs, biologics)
3. Potential for increased
infections due to
immunosuppression
(leukopenia)
4. Potential bleeding from long-
term use of aspirin/other
NSAIDs
5. Potential for adrenal
suppression from long-term
corticosteroid use
Lyme Disease
Chapter 20
1. Potential for facial palsy and • Facial palsy • Differential diagnosis • Defer care during symptomatic phase
paresthesia • Refer for medical care
Sjögren Syndrome
Chapter 20
1. Severe xerostomia, increased • Xerostomia • Differential diagnosis • Frequent prevention recalls and

caries rate, candidiasis, • Increased caries • Multiple fluoride therapy (see Appendix C) prophies
glossitis/stomatitis • Candidiasis • Sialagogues to stimulate salivary flow • Rigid oral hygiene program
2. Salivary gland hypertrophy • Glossitis/stomatitis (see Appendix C) • Close salivary gland monitoring
and potential transformation • Antifungal therapy (lymphoma)
to lymphoma • Increased oral hygiene • Soothing (“Magic”) mouthwash
(see Appendix C)
Intravascular Access Devices (Uldall Catheter, Central IV Line, Broviac-Hickman Device)
Chapter 21
1. High rate of infection, but • None • The Centers for Disease Control and Prevention • Modifications will depend on the
the role of transient dental (CDC) does not recommend antibiotic prophylaxis for reason for the intravascular device.
bacteremias that cause these invasive dental procedures.

infections has not been
established.
Continued
DM29
DM30

Solid Organ Transplantation
Chapter 21
1. Infection from suppression of • Usually none • Dental evaluation and treatment before transplantation • Before transplantation, consider the
immune response by the • Diseases associated with includes the following: following:
following: excessive • Establish stable oral and dental status free of active • For patients with poor dental
a. Cyclosporine immunosuppression dental disease. status, consider extractions and
b. Azathioprine include: • Initiate aggressive oral hygiene program to full dentures.
c. Prednisone • Candidiasis maintain oral health. • For patients with good dental
d. Antithymocyte globulin • Herpes simplex • Arrange medical consultation for patients with status, perform the following:
e. Antilymphocyte globulin • Herpes zoster organ failure before performing needed dental 1. Maintain dentition.
f. Orthoclone (monoclonal • Hairy leukoplakia treatment to establish the following: 2. Establish aggressive oral
antibody), others • Lymphoma 1. Degree of failure hygiene program in the
2. Acute rejection, reversible • Kaposi sarcoma 2. Current status of patient following areas:
3. Chronic rejection, • Aphthous stomatitis 3. Need for antibiotic prophylaxis a. Toothbrushing, flossing
nonreversible, includes the • Squamous cell 4. Need to modify drug selection or dosage b. Diet modification, if
following: carcinoma of lip 5. Need to take special precautions to avoid indicated
a. Graft failure—end-stage • Adverse effects of bleeding c. Topical fluorides
organ failure immunosuppressant 6. If surgery is indicated, access to recent d. Plaque control, calculus
b. Bleeding—liver, kidney drugs include: prothrombin time, partial thromboplastin time, removal
c. Drug overdosage—liver, • Bleeding and white cell count or differential may be e. Chlorhexidine or Listerine
kidney (spontaneous) needed. mouth rinse
d. Death or need for • Infection • Dental treatment after transplantation includes the 3. Treat all active dental
transplantation of heart, • Ulceration following: disease by:

liver • Petechiae • Immediate posttransplantation period (6 months): a. Extraction—nonrestorable
e. Osteoporosis • Ecchymoses 1. Provide emergency dental care only. teeth
f. Drug-induced psychosis • Gingival hyperplasia 2. Continue oral hygiene procedures. b. Endodontics—nonvital teeth
g. Anemia • Salivary gland • Stable graft period: c. Restoration of carious teeth
h. Leukopenia dysfunction 1. Maintain oral hygiene. d. Complex dental prostheses,
i. Thrombocytopenia • Graft failure may 2. Recall every 3 months. other major work deferred
j. Gingival hyperplasia manifest with: 3. Use universal precautions. until after transplantation
k. Adrenocortical suppression • Uremic stomatitis
l. Tumors (listed above) (kidney)
m. Poor healing • Bleeding (liver)
n. Bleeding • Petechiae (liver,
o. Infection kidney)
• Ecchymoses (liver)
5. Schedule medical consultation on the following • For patients with dental status
topics: between the defined extremes:
a. Need for antibiotic prophylaxis 1. Decision to maintain natural
b. Need for precautions to avoid excessive dentition must be made on an
bleeding individual patient basis.
c. Need for supplemental steroids 2. Factors to be considered:
d. Selection of drugs and dosage a. Extent and severity of
6. Examine for clinical evidence of the following: dental disease
a. Organ failure or rejection b. Importance of teeth to
b. Overimmunosuppression (e.g., tumors, patient
infection) c. Cost of maintaining natural
7. Monitor blood pressure at every appointment. dentition
8. If evidence of drug adverse effects, graft d. Systemic status of patient
rejection, or overimmunosuppression is found, and prognosis
refer patient to physician. e. Physical ability to maintain
• Chronic rejection period: good oral hygiene
1. Perform immediate or emergency dental care • After transplantation:
only. • Immediate posttransplantation
2. Follow guidelines for stable graft when period—limit dental care to
treatment is performed. emergency needs.
• Stable graft period—base
treatment plan on needs and
desires of the patient; recall every
3 to 6 months.
• Chronic rejection period—limit
dental care to immediate or
emergency needs.

• Maintain aggressive oral hygiene
program throughout all periods.
• Consult with physician to confirm
patient’s current status and the
need for special precautions.
Continued
DM31
DM32

Heart Transplantation, Special Considerations
Chapter 21
In addition to risk of infection due
to immune suppression:
1. Patient may be on long-term • Usually none • Have physician modify anticoagulation regimen to • The American Heart Association
anticoagulation therapy; • See Chapter 25 achieve prothrombin time 2.5 times normal or less (AHA) has stated that evidence
excessive bleeding may occur (INR, 3.5 or less), if surgical procedures are planned. regarding the need for antibiotic
with surgical procedures. • Consult with physician to establish status of coronary prophylaxis for prevention of
2. Graft atherosclerosis may vessels of transplanted heart; if advanced graft endocarditis in patients with heart
occur, increasing the risk for atherosclerosis is present, manage as described in transplantation is inconclusive.
myocardial infarction. section on coronary atherosclerotic heart disease. • The AHA recommends that
3. No nerve supply exists to • Be aware of signs and symptoms of myocardial prophylaxis be considered for cardiac
the transplanted heart; thus, infarction, other than pain; if these occur, obtain transplant patients who develop
pain will not be symptom of immediate medical assistance for patient. cardiac valvular disease.
myocardial infarction. • Do not use ultrasonic scalers or electrosurgery unit • If prophylaxis is planned, the
4. Some patients require cardiac in patients with a pacemaker. standard amoxicillin regimen of the
pacing; electrical equipment AHA would be appropriate.
may interfere with the

pacemaker.
5. Cardiac valvular disease may
develop.
Liver Transplantation, Special Considerations
Chapter 21
to immune suppression:

1. Drugs that may be toxic to the • See earlier under Solid • Avoid drugs that are toxic to the liver. • The need for prophylactic antibiotics
liver must not be prescribed. Organ Transplantation. • Have the physician modify the anticoagulation for invasive dental procedures in
2. Some patients may be on regimen to achieve an INR of 3.5 or less. patients with stable liver transplants
anticoagulation medication. should be determined on an
3. Excessive bleeding may occur individual basis through medical
with surgical procedures. consultation.
Kidney Transplantation, Special Considerations
Chapter 21
to immune suppression
1. Drugs that may be toxic to the • See earlier under Solid • Avoid drugs that are toxic to the kidney. • The need for prophylactic antibiotics
kidney must not be prescribed. Organ Transplantation. for invasive dental procedures in
patients with stable kidney
transplants should be determined on
an individual basis through medical
consultation.
Pancreas Transplantation
Chapter 21
1. No special considerations • See earlier under Solid • The need for prophylactic antibiotics
beyond those listed above for Organ Transplantation. for invasive dental procedures in
organ transplantation. patients with stable pancreas
transplants should be determined on
an individual basis through medical
consultation.
Bone Marrow Transplantation
Chapter 21
1. Immune suppression and • Mucositis • Avoid dental treatment during conditioning and • If possible, treat active dental disease
pancytopenia resulting from • Gingivitis critical phases of bone marrow transplantation. before transplantation.
conditioning therapy, including: • Xerostomia • Treat all active dental disease prior to bone marrow • Prognosis varies according to reason
a. Total body irradiation • Candidiasis transplantation. for transplantation, source of
b. Cyclophosphamide • Herpes simplex • Observe requirements for antibiotic prophylaxis for marrow to be transplanted, and
c. Busulfan infections invasive dental procedures: techniques used to condition and
2. Problems during conditioning • Osteoradionecrosis • Prophylaxis is indicated if procedures must be maintain the patient; other factors
phase and critical phase (until • Gingival overgrowth performed on an emergency basis during that may affect prognosis include age
transplanted marrow becomes (with cyclosporine) conditioning or critical phases of bone marrow and general health status; complex
functional) include: transplantation. dental prostheses may not be
a. Infection • Need should be determined through medical indicated for many patients.
b. Bleeding consultation. (See earlier under Solid Organ • (See earlier under Solid Organ
c. Poor healing Transplantation for details of hygiene program and Transplantation for other suggested
3. Immune suppression resulting dental management.) treatment planning considerations.)
from maintenance medications (For management of soft tissue
used to prevent graft-versus- complications, see Appendix C.)

host disease and:
a. Cyclosporine
b. Prednisone
c. Methotrexate
4. Problems during maintenance
phase include:
a. Infection
b. Others as listed earlier under
Solid Organ Transplantation
related to medication(s)
being used
5. Graft-versus-host disease and

chronic rejection:
a. Infection
b. Bleeding
Continued
DM33
DM34

Iron Deficiency Anemia
Chapter 22
1. Usually none • Paresthesias • Detection and referral for diagnosis and treatment • Usually none indicated.
2. In rare cases, severe leukopenia • Loss of papillae on • Recognition that in women most cases are caused by
and thrombocytopenia may dorsum of tongue physiologic process—menstruation or pregnancy
result in problems with • In rare cases, infection • Recognition that in men most cases are the result of
infection and excessive loss of and bleeding underlying disease—peptic ulcer, carcinoma of colon,
blood. complications other—requiring referral to the patient’s physician
• In patients with
dysphagia, increased
incidence of carcinoma
of oral and pharyngeal
areas (Plummer-Vinson
syndrome)
Glucose-6-Phosphate Dehydrogenase (G-6-PD) Deficiency
Chapter 22
1. Accelerated hemolysis of red • Usually none • Control infection. • Usually none unless anemia is severe;
blood cells • Avoid drugs such as certain antibiotics, or that contain then, perform only procedures to
aspirin, or acetaminophen, which may increase risk for meet urgent dental needs.
hemolytic anemia.

• Be aware that these patients also often have increased
sensitivity to sulfa drugs and chloramphenicol.
Pernicious Anemia
Chapter 22
1. Infection • Paresthesias of oral • Detection and medical treatment (early detection and • None indicated, once the patient is
2. Bleeding tissues (burning, tingling, treatment can prevent permanent neurologic damage) under medical care.
3. Delayed healing numbness)
• Delayed healing (severe
cases), infection, bald red
tongue, angular cheilosis
• Petechial hemorrhages
Sickle Cell Anemia
Chapter 22
1. Sickle cell crisis • Atypical trabecular • Consult with patient’s physician to ensure that • Usually none, unless symptoms of
pattern condition is stable. severe anemia are present; then, only
• Delayed eruption of • Institute aggressive preventive dental care. urgent dental needs should be met.
teeth, growth • Avoid any procedure that may produce acidosis or
abnormalities hypoxia (avoid long, complicated procedures).
• Hypoplasia of teeth • Drug modifications:
• Pallor of oral mucosa • Avoid excessive use of barbiturates and narcotics,
• Jaundice of oral mucosa because suppression of the respiratory center may
• Bone pain occur, leading to acidosis, which can precipitate
• Osteoporosis 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.
Continued
DM35
DM36

Aplastic Anemia
Chapter 22
1. Bleeding • Gingival bleeding • Referral for medical diagnosis and treatment • During periods of low blood count
• Petechiae • Medical consultation to determine current status of (platelets, neutrophils, red blood
• Ecchymosis the patient under medical treatment cells), provide emergency care only.
2. Infection • Oral infection • Some drugs (anticonvulsants, anthyroid drugs, select • Antimicrobial agents and supportive
• Pallor of mucosa antidiabetic agents, diuretics and sulfonamides) are therapy are needed for oral infection
associated with higher incidence of aplastic anemia. (see Appendix C for specific
treatment regimens).
Agranulocytosis
Chapter 23
1. Infection • Oral ulcerations • Referral for medical diagnosis and treatment • During periods of low blood count,
• Periodontitis • Drug considerations—some antibiotics (macrolides, provide emergency care only.
• Necrotic tissue penicillins, and cephalosporins) used for oral infections Treatment should include the use of
are associated with higher incidence of antimicrobial agents and supportive
agranulocytosis. Avoid these antibiotics if possible. therapy for oral lesions (see
Appendix C for specific treatment
regimens).

Cyclic Neutropenia
Chapter 23
1. Infection • Periodontal disease • Antibiotics should be given to prevent infection. • Modifications not required when the
• Oral infection • Serial white blood cell (WBC) counts should be WBC count (neutrophils) is normal.
• Oral ulceration similar performed to identify the safest period for dental • If the WBC count (neutrophils) is
to that of aphthous treatment (i.e., when the WBC count is closest to depressed severely, antibiotics should
stomatitis normal level). be provided to prevent postoperative
infection.
Leukemia
Chapter 23
1. Infection • Gingival swelling/ • Referral for medical diagnosis, treatment, and • Inspect head, neck, and radiographs
2. Bleeding enlargement consultation for undiagnosed or latent disease
3. Delayed healing • Mucosal or gingival • Complete blood count to determine risk for anemia, (e.g., retained root tips, impacted
4. Mucositis bleeding bleeding, and infection teeth) and infections that require
• Oral infection • Antibiotics, antivirals, and antifungals provided during managment before chemotherapy.
chemotherapy to prevent opportunistic oral infection • Eliminate infections before
• Chlorhexidine rinse/bland rinses to manage mucositis 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 at some institutions).
• Platelet replacement may be required
(if platelet count is <50,000/μL)
when invasive dental procedures are
performed.
Multiple Myeloma
Chapter 23
1. Excessive bleeding after invasive • Soft tissue tumors • Patients with oral soft tissue lesions and/or osseous • For patients in terminal stage,
dental procedures • Osteolytic lesions lesions should have them biopsied by the dentist or provide supportive dental care only.

2. Risk of infection because • Amyloid deposits in soft should be referred for diagnosis and treatment as • Long-term prognosis is poor, so
of decrease in normal tissues indicated. complex dental procedures may not
immunoglobulins • Unexplained mobility of • Medical history should identify patients with be indicated.
3. Risks of infection and bleeding teeth diagnosed disease; medical consultation is needed to • If thrombocytopenia or leukopenia is
in patients who are being • Exposed bone establish current status. (See sections on chemotherapy present, special precautions (platelet
treated by irradiation or and radiation therapy on prevention and management replacement, antibiotic therapy) are
chemotherapy of medical complications.) needed to prevent bleeding and
4. Risk of osteonecrosis of the • Be aware of and take precautions for bisphosphonate- infection when invasive dental
jaws in patients who are taking induced osteonecrosis of the jaws. procedures are performed.
bisphosphonates (especially • Patients may be bleeders because of
intravenously) 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.)
DM37
Continued
DM38

Lymphomas: Hodgkin Disease, Non-Hodgkin Lymphoma, Burkitt’s Lymphoma
Chapter 23
1. Increased risk for infection • Extranodal oral tumors • Patients with generalized lymphadenopathy, extranodal • Patients in terminal phase should
2. Risks of infection and excessive in Waldeyer’s ring or tumors, and osseous lesions must be identified and receive only supportive dental
bleeding in patients receiving osseous soft tissues referred for medical evaluation and treatment. treatment.
chemotherapy • Xerostomia in patients • The dentist can biopsy extranodal or osseous lesions • Patients under “control” may receive
3. Minor risk of osteonecrosis in treated by radiation; to establish a diagnosis; patients with lesions involving any indicated treatment; however,
patients treated by radiation some of these patients the lymph nodes should be referred for excisional complex restorative treatment may
to the head and neck region prone to osteonecrosis biopsy. not be indicated in cases with a poor
(usually does not occur because • Burning mouth or tongue • Medical history should identify patients with prognosis.
radiation dosage seldom symptoms diagnosed disease; medical consultation will be needed • Platelet replacement may be needed
exceeds 50 Gy) • Petechiae or ecchymoses to establish current status. (See sections on for patients with thrombocytopenia.
4. Xerostomia may occur in if thrombocytopenia chemotherapy and radiation therapy on management (See sections on radiation therapy
patients treated by irradiation present because of tumor and prevention of medical complications.) and chemotherapy for treatment plan
to the head and neck region. invasion of bone marrow • Before invasive procedures, a complete blood count modifications.)
5. Non-Hodgkin lymphoma may • Cervical should be obtained to determine risks for bleeding and • Consider prophylactic antibiotics if
be found in patients with AIDS; lymphadenopathy infection. the WBC count is less than 2000/μL,
hence, transmission of • Mucositis in patients • Patients who have been treated by irradiation to or the neutrophil count is less than
infectious agents may be a treated by radiation the chest area may develop acute and chronic 500 (or 1000 at some institutions).
problem. therapy or chemotherapy cardiovascular complications such as arrhythmias or
valvular heart disease. Medical consultation is needed

to confirm their current status.
Bleeding Problem Suggested by Examination and History Findings But Lack of Clues to Underlying Cause
Chapter 24
1. Excessive blood loss after • Excessive bleeding after • Screen patients with the following (if results of one or • None, unless test result(s) abnormal;
surgical procedures, scaling, dental procedures more tests are abnormal, refer for diagnosis and then, manage according to the nature
other manipulations medical treatment): of the underlying problem once
• Prothrombin time diagnosis has been established by the
• Activated partial thromboplastin time physician.
• Thrombin time
• Platelet count
• Avoid use of aspirin and related drugs.
Thrombocytopenia (Primary or Secondary) Caused by Chemicals, Radiation, or Leukemia
Chapter 24
1. Prolonged bleeding • Spontaneous bleeding • Identification of patients to include the following: • In general, dental procedures can be
2. Infection in patients with • Prolonged bleeding after • History performed if the platelet count is
bone marrow replacement or certain dental procedures • Examination findings 30,000/μL or higher.
destruction • Petechiae • Screening tests— platelet count • Extractions and minor surgery can be
3. A medical emergency can result • Ecchymoses • Referral and consultation with hematologist performed if the platelet count is
from stress in patients being • Hematomas • Correction of underlying problem or replacement 50,000/μL or higher.
treated with steroids. therapy before surgery • Major oral surgery can be performed
• Local measures to control blood loss (e.g., splint, if the platelet count is 80,000/μL to
Gelfoam, thrombin) 100,000/μL or higher.
• Prophylactic antibiotics may be considered in surgical • Platelet transfusion will be needed for
cases to prevent postoperative infection if severe patients with platelet counts below
neutropenia is present. the above values.
• Additional steroids should be used for patients being • Patients with severe neutropenia
treated with steroids, if indicated (see section on (500/μL or less) may require
adrenal insufficiency). antibiotics for certain surgical
• Aspirin/other NSAIDs, aspirin-containing compounds procedures (1000 at some
are not to be used; acetaminophen (Tylenol) with or institutions).
without codeine may be used if analgesia is required. • In children with primary
thrombocytopenia, many will
respond to steroids with increase in
platelets to levels allowing dental
procedures to be performed.
Vascular Wall Alterations (Scurvy, Infection, Chemical, Allergic, Autoimmune, Other Agents/Factors)
Chapter 24

1. Prolonged bleeding after • Excessive bleeding after • Identification of patients should include the following: • Surgical procedures must be avoided
surgical procedures or any scaling and surgical • History in these patients unless the underlying
insult to integrity of oral procedures • Clinical findings problem has been corrected, or the
mucosa • Petechiae • Screening tests—none reliable patient has been prepared for surgery
• Ecchymoses • Consultation with the hematologist should be by the hematologist, and the dentist
• Hematomas obtained. is prepared to control excessive loss
• Local measures should be used to control blood loss: of blood through local measures:
splints, Gelfoam, Oxycel, and surgical thrombin (see splints, thrombin, microfibrillar
Table 24-6). collagen, Gelfoam, Oxycel,
• Prevention of allergy if causative, and if the antigen is ε-aminocaproic acid (Amicar) (see
identified. Table 24-6).
Continued
DM39

DM40
Acquired Disorders of Coagulation (liver disease, broad-spectrum antibiotics, malabsorption syndrome, biliary tract
obstruction, heparin, other agents/factors)
Chapter 24
1. Excessive bleeding after dental • Excessive bleeding • Identification of patients with such disorders should • No dental procedures should be
procedures that result in soft • Spontaneous bleeding include: performed unless the patient has been
tissue or osseous injury • Petechiae • History prepared on the basis of a
• Hematomas • Examination findings consultation with the hematologist.
• 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, aspirin-containing
compounds.
Anticoagulation with Coumarin Drugs (Warfarin)
Chapter 24
1. Excessive bleeding after dental • Excessive bleeding • Identify patients who are taking anticoagulants/ • No dental procedures should be
procedures that result in soft • Hematomas coumarin in the following ways: performed unless medical consult has
tissue or osseous injury • Petechiae • History been obtained and level of
• In rare cases, • Screening laboratory test—international normalized anticoagulation is at an acceptable
spontaneous bleeding ratio (INR), prothrombin time (PT) range; the procedure may have to be

• Consultation should be obtained regarding level of delayed by 2-3 days if the dosage of
anticoagulation: anticoagulant has to be reduced.
• If INR is 3.5 or less, most surgical procedures can • Avoid aspirin or aspirin-containing
be performed. compounds. Use acetaminophen
• Dosage of anticoagulant should be reduced if INR (Tylenol) for postoperative pain
is greater than 3.5 (it takes several days for INR to control.
fall to desired level; confirmation should be
obtained by new tests before surgery is completed).
• Patients undergoing major oral surgery should be
managed on an individual basis; in most cases, INR
should be below 3.0 at the time of surgery.
• Low-molecular-weight heparin bridging can be
considered for major surgery.
• ε-Aminocaproic acid (Amicar) rinses, just before
surgery and every hour for 6-8 hours, will aid in
control of bleeding. Local measures should be
instituted to control blood loss after surgery (see Table
24-6).
Disseminated Intravascular Coagulation (DIC)
Chapter 24
1. Excessive bleeding after invasive • Spontaneous gingival • Identification of patients includes the following: • Depending on the cause of DIC, the
dental procedures; in chronic bleeding • History—excessive bleeding after minor trauma; treatment plan should be altered as
form of disease, widespread • Petechiae spontaneous bleeding from nose, gingiva, follows:
thrombosis may occur. • Ecchymoses gastrointestinal tract, urinary tract; recent infection, • With acute DIC—No routine
• Prolonged bleeding after burns, shock and acidosis, or autoimmune disease; dental care until medical
invasive dental history of cancer most often associated with evaluation and correction of cause
procedures chronic form of disseminated intravascular • With chronic DIC—No routine
coagulation (DIC), in which thrombosis rather than dental care until medical
bleeding usually is the major clinical problem evaluation and correction of cause
• Examination findings include the following: when possible; if prognosis is poor
1. Petechiae on the basis of underlying cause
2. Ecchymoses (advanced cancer), limited dental
3. Spontaneous gingival bleeding; bleeding from care is indicated.
nose, ears, and so on. • Avoid aspirin/other NSAIDs,
• Screening laboratory findings include the following: aspirin-containing compounds.
1. Acute DIC—prothrombin time (prolonged), • Do not use ε-aminocaproic acid
partial thromboplastin time (prolonged), (Amicar), tranexamic acid or
thrombin time (prolonged), platelet count desmopression, as these agents
(decreased) may complicate the disorder and
2. Chronic DIC—most tests may be normal, but result in increased bleeding.
fibrin-split products are present (positive result • Acetaminophen with or without
on D-dimer test). codeine can be used for
• Obtain referral and consultation with physician if postoperative pain.
invasive dental procedures must be performed, and
include information on:

• Acute DIC—cryoprecipitate, fresh frozen plasma,
and platelets
• Chronic DIC—anticoagulants such as heparin or
vitamin K antagonists
• Aspirin or aspirin-containing products are prohibited.
• Local measures are used to control bleeding (see Table
24-6).
• Antibiotic therapy may be considered to prevent
postoperative infection.
Continued
DM41
DM42

Disorders of Platelet Release
Chapter 24
1. Excessive bleeding after invasive • Excessive bleeding may • Identification of patient should include the following: • Usually, no modifications are
dental procedures occur after surgery. • History—recent use of aspirin, indomethacin, indicated for patients who have no
• Petechiae, ecchymoses, phenylbutazone, ibuprofen, or sulfinpyrazone; other platelet or coagulation
and hematomas may be presence of other platelet or coagulation disorders disorders.
found when other • Examination—often negative unless signs related to
platelet or coagulation other platelet or coagulation disorders are present
disorders are present. • Screening laboratory tests— partial thromboplastin
time (prolonged)
• Most patients on drugs noted above without an
additional platelet or coagulation problem will not
bleed excessively after surgery.
• Patients with prolonged partial thromboplastin time
should be referred for evaluation before performance
of any surgical procedures.
• Elective surgery can be performed after withdrawal of
drug for at least 3 days and management of other

platelet or coagulation disorders by appropriate
means.
Primary Fibrinogenolysis
Chapter 24
1. Excessive bleeding after invasive • Prolonged bleeding after • Identification of patients should include the following: • Patients with advanced cancer should
dental procedures invasive dental • History—liver disease, cancer of lung, cancer of have treatment limited to emergency
procedures prostate, and heat stroke may cause this condition. dental procedures and preventive

• Jaundice of mucosa • Examination findings to consider: measures; complex dental
• Ecchymoses 1. Jaundice restorations in general are not
2. Spider angiomas indicated; in other patients, once
3. Ecchymoses preparation to avoid excessive
4. Hematomas bleeding has occurred
• Screening laboratory tests: (ε-aminocaproic acid), most dental
1. Platelet count (often normal) treatment can be rendered.
2. Prothrombin time (prolonged)
3. Partial thromboplastin time (prolonged)
4. Thrombin time (prolonged)
• Consultation and referral before any invasive dental
procedure; ε-aminocaproic acid therapy will inhibit
plasmin and plasmin activators.
Low-Molecular-Weight Heparin Therapy: Enoxaparin (Lovenox), Ardeparin (Normiflo), Dalteparin (Fragmin),
Nadroparin (Fraxiparine), Reviparin (Clivarin), Tinzaparin (Innohep)
Chapter 24
1. Used in patients who have • Gingival bleeding • Delay procedure until patient is off the medication. • Usually none needed.
received prosthetic knee or hip • Petechiae • Have physician stop medication and perform surgery
replacement; patient takes • Ecchymoses the next day; once hemostasis is obtained, have the
medication for approximately 2 • In rare cases, excessive physician resume medication.
weeks after getting out of the bleeding after dental • Perform surgery, and manage any excessive bleeding
hospital procedures through local means (preferred if excessive bleeding
2. Complications include the is not anticipated).
following:
a. Excessive bleeding
b. Anemia
c. Fever
d. Thrombocytopenia
e. Peripheral edema
Antiplatelet Drug Therapy: Aspirin, Aspirin Plus Dipyridamole (Aggrenox), Ibuprofen (Advil, Motrin)
Chapter 24
1. Used for prevention of initial or • Gingival bleeding • If no other complications occur, dental procedures • Usually none needed, unless there are
recurrent myocardial infarction • Petechiae and surgery can usually be performed. other medical problems, such as
and stroke prevention • Ecchymoses recent MI or stroke.
2. Complications include: • In rare cases, excessive
a. Excessive bleeding bleeding after dental
b. Gastrointestinal bleeding procedures
c. Tinnitus
d. Bronchospasm

Fibrinogen Receptor Therapy (Glycoprotein [GP] IIb/IIIa inhibitors—Abciximab, Tirofiban): ADP Inhibitors
(clopidogrel [Plavix], ticlopidine [Ticlid])
Chapter 24
1. Used for prevention of • Gingival bleeding • If no other complications occur, dental procedures • Usually none needed, unless there are
recurrent myocardial infarction • Petechiae and surgery may be performed. other medical problems such as
and stroke • Ecchymoses recent MI or stroke.
2. Complications include: • In rare cases, excessive • ADA and AHA issued a statement
a. Excessive bleeding bleeding after dental that dual-antiplatelet treatment
b. Gastrointestinal bleeding procedures (clopidogrel and aspirin) should not
c. Neutropenia • Adverse reactions be discontinued for patients with
d. Thrombocytopenia increase risk for infection stents when receiving invasive dental
(neutropenia) and treatment.

bleeding
(thrombocytopenia).
Continued
DM43
DM44

Congenital Disorders of Coagulation (Hemophilia)
Chapter 25
1. Excessive bleeding after dental • Spontaneous bleeding • Identification of patients includes the following: • No dental procedures should be
procedures • Prolonged bleeding after • History—bleeding problems in relatives, excessive performed unless the patient has been
2. HIV-, HBV-, and HCV-infected dental procedures that bleeding after trauma or surgery prepared on the basis of consultation
patients are potentially injure soft tissue or bone • Examination findings: with the hematologist.
infectious (see Appendix B) • Hematomas 1. Ecchymoses • Avoid aspirin/other NSAIDs, aspirin-
• Oral lesions associated 2. Hemarthrosis containing compounds—use
with HIV infection in 3. Dissecting hematomas acetaminophen (Tylenol) with or
patients who receive • Screening tests—prothrombin time (normal), without codeine.
infected replacement activated partial thromboplastin time (prolonged),
products (most cases thrombin time (normal), platelet count (normal)
occurred before 1986) • Consultation and referral should be provided for
diagnosis and treatment and for preparation before

dental procedures are performed.
• Replacement options include the following:
• Cryoprecipitate (used rarely)
• Fresh frozen plasma (used rarely)
• Factor VIII concentrates, including:
1. Heat-treated concentrate
2. Purified factor VIII

3. Recombinant factor VIII
4. Porcine factor VIII
• For mild to moderate factor VIII deficiency,
consider using:
1. 1-desamino-8-D-arginine vasopressin
(desmopressin) (oral or nasal)
2. ε-Aminocaproic acid (Amicar) rinse or taken
orally
3. Tranexamic acid (Cyklokapron); oral solution
not available in the United States, injectable and
tablets are
4. Factor VIII replacement for some cases
5. Often treated on an outpatient basis
• For severe factor VIII deficiency, alleviate with such
measures as:
• Agents used above for mild to moderate deficiency
• Higher dose(s) of factor VIII
• Patients who are low responders (low antibody
response to FVIII):
• Agents used for mild to moderate deficiency
• Very high dose(s) of factor VIII
• Patients who are high responders (high antibody
response to FVIII):
• No elective surgery
• Agents used for mild to moderate deficiency
• High doses of porcine factor VIII concentrate
• Nonactivated prothrombin/complex concentrate
• Activated prothrombin/complex concentrate
• Plasmapheresis
• Factor VIIa
• Steroids
• In rare cases, plasmapheresis
• Treatment is provided on an outpatient basis in
accordance with results of the consultation (mild to
moderate deficiency, no inhibitors).
• Local measures (e.g., splints, thrombin, microfibrillar
collagen) are used for control of bleeding (see Table
25-6).
• Aspirin/other NSAIDs, aspirin-containing compounds
should be avoided.

Continued
DM45
DM46

von Willebrand Disease
Chapter 25
1. Excessive bleeding after invasive • Spontaneous bleeding • Identification of patients should include: • No invasive dental procedures should
dental procedures • Prolonged bleeding after • History of bleeding problems in relatives and of be performed unless the patient has
dental procedures that excessive bleeding after surgery or trauma, etc. been prepared on the basis of
injure soft tissue or bone • Examination findings to include: consultation with the hematologist.
• Petechiae 1. Petechiae • Most dental procedures including
• Hematomas 2. Hematomas complex restorations can be offered
• Screening laboratory tests— possible prolonged to these patients.
partial thromboplastin time, platelet count may be • Emphasis is on maintaining good
low. oral hygiene, topical fluorides, and
•
Consultation and referral should be provided for diet.

diagnosis and treatment and preparation before dental • Acetaminophen with or without
procedures. codeine may be used for
• Type I and many type II cases require the following: postoperative pain control.
• 1-desamino-8-D-arginine vasopressin
(desmopression and Amicar)
• Local measures (see Table 25-6)
• May be treated on an outpatient basis
• Type III and some type II patients require the

following:
• Fresh frozen plasma
• Cryoprecipitate
• Special factor VIII concentrates (retain vWF)
1. Humate-P
2. Koate HS
• Local measures (see Table 25-6)
• Outpatient treatment is possible on the basis of results
of consultation.
• Avoid aspirin/other NSAIDs, aspirin-containing
compounds.
Radiation-Treated Patients (Radiation to Head and Neck)
Chapter 26
1. Patients treated by irradiation • Mucositis • Before radiation therapy is started, the dentist should • Once radiation treatment has been
tend to develop the following • Candidiasis be involved; after a complete examination, the completed and more than 6000 cGy
problems during and just after • Xerostomia following procedures should be done: used, every effort should be made to
completion of therapy: • Loss of taste • Extract teeth that cannot be repaired. avoid osteonecrosis:
a. Mucositis • Trismus • Extract teeth with advanced periodontal disease. • Teeth should not be extracted.
b. Xerostomia • Sensitivity of teeth • Perform preprosthetic surgery. • Diseased teeth should be
c. Loss of taste • Cervical caries, cuspal • Restore large carious lesions. endodontically treated, if
d. Constricture of muscles and rampant caries • Perform surgeries with adequate time for healing, indicated.
(trismus) • Osteonecrosis or consider hyperbaric oxygen therapy. • Aggressive preventive measures are
e. Secondary infections—viral, • Establish good oral hygiene. needed to prevent periodontal disease
bacterial, fungal (candidiasis) • Start daily prescription strength fluoride application and cervical caries.
f. Tooth sensitivity with the use of a flexible tray. • Most dental procedures other than
2. Chronic problems caused by • Treat endodontically, or extract nonvital teeth. extractions and surgical procedures
radiation therapy include the • Treat chronic tooth and jaw infections. can be done if performed
following: • During radiation treatment, the dentist can be atraumatically and without vascular
a. Xerostomia involved with the following: compromise.
b. Cervical caries • Symptomatic treatment of mucositis
c. Osteonecrosis (see Appendix C)
d. Muscle trismus • Management of xerostomia (see Appendix C)
e. Tooth sensitivity • Prevention of trismus by using mouth opening
f. Loss of taste exercises or physical therapy
• Chlorhexidine rinses for plaque control and an
antifungal if candidiasis develops (see Appendix C)
• Diagnosis and treatment of secondary infection—

candidiasis, others (see Appendix C)
• Continue daily fluoride treatment.
• After radiation treatment, the dentist should ensure
the following:
• Have patient back for frequent recall appointments
(every 3 to 4 months).
• Continue emphasis on good oral hygiene.
• Treat carious lesions when first detected.
• Make every effort to avoid oral infection.
• Manage xerostomia (see Appendix C).
• Manage chronic loss of taste (see Appendix C).
Continued
DM47
DM48

Patients Receiving Chemotherapy for Cancer
Chapter 26
1. Excessive bleeding secondary to • Mucositis • Before starting chemotherapy, the dentist should: • Perform only emergency dental
bone marrow suppression • Excessive bleeding after • Eliminate gross infection in the following areas: treatment during chemotherapy.
(thrombocytopenia) minor trauma • Periapical • On the basis of the prognosis of
2. Prone to infection as a result • Spontaneous gingival • Periodontal underlying disease, consider limiting
of bone marrow suppression bleeding • Soft tissue dental treatment to only immediate
(leukopenia) • Xerostomia • Treat advanced carious lesions. care needs for patients who are being
3. Severe anemia from bone • Infection • Tooth edges are smooth and not sharp. treated in a palliative mode; however,
marrow suppression • Poor healing • Remove appliances. children and adults who are being
4. Thrombocytopenia, leukopenia, • Provide oral hygiene instructions. treated for leukemia may have a very
and anemia are possible • Ensure that in children and young adults, the good prognosis, and any indicated
complications of underlying following issues are addressed: dental treatment may be performed;
cancer. • Mobile primary teeth are removed. also, many patients with lymphoma
• Gingival operculum is removed. may have a good prognosis.
• Adequate time is allowed for healing before
induction.
• During chemotherapy, the dentist should:
• Consult with oncologist before any invasive dental
procedures.
• Perform the following if invasive procedures are

required:
1. Consider antibiotic prophylaxis if WBC is less
than 1000/μL or absolute neutrophil count
(ANC) is less than 500/μL.
2. Consider platelet replacement if platelet count is
less than 50,000/μL.
• Perform culture and antibiotic sensitivity testing of
exudate from areas of infection.
• Control spontaneous bleeding with gauze,
periodontal packing, and soft mouth guard.
• Use topical fluoride for caries control.
• Apply chlorhexidine rinses for plaque and
candidiasis control (see Appendix C).
• Provide symptomatic relief of mucositis and
xerostomia (see Appendix C).
• Be aware of and take precautions for
bisphosphonate-induced osteonecrosis.
• If severe anemia is present, avoid general
anesthesia.
• Consider modifying home care instructions on the
basis of oral status, reduce or stop flossing and
brushing if excessive bleeding or tissue irritation
results; damp gauze can be used to wipe the gingiva
and teeth; solution of water and baking soda can
be used to rinse the mouth to clean ulcerated
tissues.
• Minimize food aversion during chemotherapy—fast
before treatment (4 hours), eat novel nonimportant
food just before treatment, and avoid nutritionally
important foods during posttreatment nausea.
• After completion of chemotherapy:
• Monitor patient until all adverse effects of therapy
have cleared.
• Place patient on dental recall program.
• Antibiotic prophylaxis is not indicated for these
patients on the basis of available evidence; however,
need should be decided on an individual patient

basis following medical consultation.
• Be aware of and take precautions for
bisphosphonate-induced osteonecrosis.
Continued
DM49
DM50

Seizure Disorder (Epilepsy)
Chapter 27
1. Occurrence of generalized • Gingival overgrowth • Identify epileptic patient by history, including: • Maintenance of optimal oral hygiene
tonic-clonic seizure in dental caused by phenytoin • Type of seizure • Surgical reduction of gingival
office (Dilantin) • Age at onset overgrowth, if indicated
2. Drug-induced leukopenia and • Traumatic oral injuries • Cause of seizures • Replacement of missing teeth with
thrombocytopenia (phenytoin, • Drug-induced erythema • Medications fixed prosthesis as opposed to
carbamazepine, valproic acid) multiforme • Regularity of physician visits removable
3. Drug-induced gingival • Degree of control • Metal prosthodontic devices used
overgrowth that affects • Frequency of seizures, last seizure instead of porcelain when possible
periodontal health • Precipitating factors • Protect patient during a seizure,
• History of seizure-related injuries manage airway, and discontinue
• Well-controlled—normal care can be provided. treatment afterward.
• Poorly controlled—consultation with physician;
medication change may be required.
• Be awarene of adverse effects of anticonvulsants.
• Patients taking valproic acid should avoid aspirin/
other NSAIDs.
• Avoid propoxyphene and erythromycin in patients
taking carbamazepine.
• Use a ligated mouth prop at beginning of the
appointment.
Stroke
Chapter 27
1. Dental treatment could • An evolving stroke may • Identify stroke-prone patient from history (e.g., • Consider periodic panoramic films to

precipitate or coincide with a be associated with hypertension, congestive heart failure, diabetes, assess carotid patency.
stroke. unilateral loss of transient ischemic attacks, age >75 years). • Plan is dependent on physical
2. Bleeding is caused by drug function or sensation. • Reduce patient’s risk factors for stroke (smoking, impairment.
therapy used to prevent clots. • After a stroke, may have elevated cholesterol, hypertension). • All restorations should be made
3. Patient may be unable to unilateral atrophy and • For past history of stroke: easily cleansable—porcelain occlusals
understand, verbalize, or one-sided neglect. • For current transient ischemic attacks—No elective should be prevented.
transfer easily to the dental care • Modified oral hygiene aids may be
chair. • Delay elective care for 6 months. needed.
• Drug considerations include the following:
1. Aspirin and dipyridamole—be aware of
potential bleeding problems if another bleeding
problem is present.
2. Warfarin (Coumadin)—order INR; should be
3.5 or less before invasive procedures are
performed.
• Schedule short, morning appointments.
• Monitor blood pressure.
• Use minimal amount of vasoconstrictor in local
anesthetic.
• Avoid epinephrine-containing retraction cord.
• Provide frequent dental recall and specialized
toothbrushes (e.g., Collis curve toothbrush,
mechanical brushes) to maintain adequate oral
hygiene.
Parkinson’s Disease
Chapter 27
1. Patient may be unable to • Excess salivation and • Provide frequent dental recall and specialized • Sedation may be required to
perform oral hygiene drooling toothbrushes (e.g., Collis curve toothbrush, mechanical overcome muscle rigidity.
procedures. • Muscle rigidity and brushes) to maintain adequate oral hygiene.
2. Patient may have a tremor or repetitive muscle • Salivary substitutes and topical fluoride are beneficial.
may be unable to cooperate movements contribute to • Personal care providers should be educated about their
during dental treatment. poor oral hygiene role in assisting and maintaining the oral hygiene of
• Antiparkisonian drugs these patients (also applies to stroke victims).
may cause xerostomia,
nausea, and tardive
dyskinesia
Anxiety
Chapter 28
1. Extreme apprehension • Usually none • Behavioral aspects—the dentist should do the • Postpone complex dental procedures
2. Avoidance of dental care • Oral lesions associated following: until patient is more comfortable in
3. Elevation of blood pressure with adverse effects of • Provide effective communication (be open and the dental environment.

4. Precipitation of arrhythmia medications honest). • It is important to develop trust and
5. Adverse effects and drug • Explain what is going to happen. establish communication with
interactions with agents used • Make procedures as “pain-free” as possible. patients with posttraumatic stress
in dentistry • Encourage patient to ask questions at any time. disorder.
• Use relaxation techniques such as hypnosis, music, • May need to refer for diagnosis and
others. treatment patients with panic attack
• Pharmacologic aspects—the dentist should provide the or phobic symptoms related to
following as indicated: dentistry.
• Oral sedation—alprazolam, diazepam, triazolam
• Inhalation sedation—nitrous oxide
• Intramuscular sedation—midazolam, meperidine
• Intravenous sedation—diazepam, midazolam,

fentanyl
• Analgesics for pain control—salicylates/ NSAIDs,
acetaminophen, codeine, oxycodone, fentanyl
• Adjunctive medications—antidepressants, muscle
DM51
relaxants, steroids, anticonvulsants, antibiotics

Continued
DM52

Eating Disorder: Anorexia Nervosa and Bulimia Nervosa
Chapter 28
1. Patients with anorexia are in a • With bulimia, the • Patients with severe weight loss and no history of • Avoid elective dental procedures until
state of self-starvation (severe following may be noted: cancer or other illnesses, and who are hypotensive the patient is stable from a cardiac
weight loss) and may be subject • Dental erosion of the should be referred for medical evaluation and standpoint.
to hypotension, bradycardia, lingual surfaces of management. • In general, for both anorexic and
severe arrhythmia, and death. teeth (usually • Attempts should be made to ascertain the cause of bulimic patients, the emphasis should
2. Bulimic patients are at risk for maxillary teeth) dental erosion involving the lingual surfaces of teeth. be on oral hygiene maintenance and
serum electrolyte disturbances, • Patients with poor Consider referral for medical and psychosocial noncomplex repair, until significant
esophageal or gastric rupture, oral hygiene may be evaluation. improvement in medical health status
cardiac arrhythmia, and death. at increased risk for • Educate the patient as to the serious nature of the has been obtained.
3. Patients with bulimia may caries and periodontal complications of anorexia (hypotension, severe • Complex restorative procedures
induce vomiting through the disease. arrhythmia, and death) and of bulimia (gastric and should be avoided in bulimic patients
use of physical means (finger • Extensive dental esophageal tears, cardiac arrhythmia, and death). until the purging has been controlled.
in throat) or the use of ipecac caries (associated with However, crowns may have to be
(may cause myopathy or diet—lots of placed to stabilize a tooth or to
cardiomyopathy); laxatives carbohydrates) protect it from thermal symptoms in
and diuretics also are used by • Tooth sensitivity to patients who are still actively
bulimics to purge. thermal changes purging.
4. Some patients may show signs • With anorexia, the

and symptoms of both anorexia following may be noted:
and bulimia. • Intaroral findings are
infrequent without
concurrent bulimia.
• Sialodenosis
• If oral hygiene is
poor , there is
increased risk for
caries and periodontal
disease.
Anxiolytic Drugs (for Anxiety Control): Benzodiazepines—Chlordiazepoxide (Librium), Diazepam (Valium),
Lorazepam (Ativan), Oxazepam (Serax), Alprazolam (Xanax)
Chapter 28
1. Drug adverse effects include the • Usually no significant • Advise patient not to drive when using these • When using sedative agents, narcotics
following: oral findings medications. or antihistamines, reduce dosage or
a. Daytime sedation • Use reduced dosage in older adults. do not use these agents.
b. Aggressive behavior • Limit reduce dosage for patients on other CNS • All dental procedures can be
c. Amnesia (older adults) depressant drugs. provided to patients on these
2. Drug interactions (central • Use in reduced dosage in patients taking: medications.
nervous system [CNS] • Cimetidine • Use anxiolytic drugs in dentistry for
depression): • Ranitidine short durations to avoid tolerance
a. Antipsychotic agents • Erythromycin and dependency.
b. Antidepressants • Do not dispense to patients with narrow angle
c. Narcotics glaucoma.
d. Sedative agents
e. Antihistamines
f. Histamine H2 receptor
blockers
Depression and Bipolar Disorders
Chapter 29
1. Little or no interest in oral • Depression—poor oral • If patient appears very depressed: • Patients often have little interest in
health hygiene and xerostomia • Ask about thoughts of suicide: dental health or home care
2. Factors increasing risk of associated with agents 1. Does patient have a plan? procedures, and poor dental repair is
suicide: used to treat depression 2. Does patient have the means to carry out the common.
a. Age—adolescent and elderly increase risks for caries plan? • Emphasis should be on maintaining
at greatest risk and periodontal disease; • Immediately refer patient who is suicidal for the best possible oral health during

b. Chronic illness, alcoholism, facial pain syndromes medical intervention. depressive episodes.
drug abuse, and depression and glossodynia • If possible, involve family member or relative. • Dental treatment should be directed
c. Recent diagnosis of serious • Manic disorder—injury • Obtain good history, including medications toward immediate needs with elective
condition such as AIDS and to soft tissue and (prescription, herbal, over-the-counter), and avoid and complex procedures put off until
cancer abrasion of teeth from using agents that may have significant interactions effective medical management of
d. Previous suicide attempts overflossing and (see Table 29-7). depression and mania is obtained.
e. Recent psychiatric overbrushing • If history and examination findings suggest presence of
hospitalization • Oral lesions associated significant drug adverse effects, refer patients to their
f. Loss of a loved one with the adverse effects physician.
g. Living alone or little social of medications used to
contact treat depression and
3. Taking medications that have mania

significant adverse effects and
that may interact with agents
used by the dentist
Continued
DM53
DM54

Schizophrenia
Chapter 29
1. Patient may be difficult to • Usually none • Have family member or attendant accompany the • Emphasis is on maintaining oral
communicate with and • Oral lesions may be patient. health and comfort by preventing
uncooperative during dental self-inflicted or may • Schedule morning appointments. and controlling dental disease.
care. develop as adverse effects • Avoid confrontational and authoritative attitudes. • Family member or attendant may
2. Significant drug adverse effects of medications used to • Perform elective dental care only if patient is under have to assist patient with home care
are common, and agents used treat the patient (see good medical management. procedures.
by the dentist may interact later section on • Consider sedation with diazepam or oxazepam. • Complex dental procedures usually
with medications the patient antipsychotic drugs). are not indicated.
is taking (see later section on
antipsychotic [neuroleptic]
drugs).
Antidepressant Drugs
Chapter 29
1. Drug adverse effects include the • Usually, no significant • Identify by medical and drug history patients who are • Avoid elective dental procedures until
following: oral findings associated taking any of these medications. depression has been managed by
a. Xerostomia with medications, unless • Identify patients with significant drug adverse effects: medication or behavioral means.
b. Hypotension the following drug • History • Local anesthetic:
c. Orthostatic hypotension adverse effects are • Examination—blood pressure, pulse rate, bleeding, • Use without vasoconstrictor for
d. Arrhythmia present: soft tissue lesions, infection most dental procedures.
e. Nausea and vomiting • Xerostomia— • Refer patients with significant drug adverse effects. • For surgical or complex
f. Leukopenia, anemia, increases risk for • Consult with patient’s physician to confirm current restorative procedures:
thrombocytopenia, caries, periodontal status and medications. 1. Epinephrine is the
agranulocytosis disease, and mucositis • Minimize effects of orthostatic hypotension: vasoconstrictor of choice.

g. Mania, seizures • Leukopenia—infection • Change chair position slowly. 2. Use 1 : 100,000 concentration
h. Hypertension (venlafaxine) • Thrombocytopenia— • Support patients as they get out of the dental chair. of epinephrine.
i. Loss of libido bleeding • Avoid atropine in patients with glaucoma. 3. Aspirate before injecting.
• Use epinephrine with caution and only in small 4. In general, do not use more
concentrations. than 2 cartridges.
• Look up specific medication the patient is taking to • Do not use topical epinephrine to
explore significant adverse effects associated with the control bleeding or in retraction
drug and possible drug interactions with agents used cord.
in dentistry. • Provide treatment to deal with
xerostomia (see Appendix C).
2. Drug interactions include the • Do not mix the different classes of antidepressant
following: drugs
a. Epinephrine
• Hypertensive crisis
• Myocardial infarction
b. Sedative, hypnotics,
narcotics, and barbiturates
may cause respiratory
depression.
c. Atropine: Increase
intraocular pressure.
d. Warfarin metabolism may be
inhibited, thus causing
bleeding.
3. Patients taking monoamine

oxidase inhibitors (MOIs) must
avoid foods that contain
tyramine (may cause severe
hypertension).
Continued
DM55
DM56

Antimanic (Mood-Stabilizing) Drugs
Chapter 29
1. Lithium • Lithium (metallic taste) • Identify by medical and drug histories that patients are • No special modifications are needed
a. Adverse effects include the • Valproic acid and taking these medications. in the treatment plan of patients
following: carbamazepine • Refer to physician when significant drug adverse whose condition is well controlled
• Nausea, vomiting, • Oral ulcerations effects occur. with lithium or anticonvulsant drugs.
diarrhea • Bleeding • Avoid the use of NSAIDs and erythromycin, or use at • Patients with signs or symptoms of
• Metallic taste • Infection reduced dosage in patients on lithium. lithium toxicity should be referred to
• Xerostomia • Tremor of the tongue • Avoid the use of erythromycin, or use in reduced their physician for evaluation.
• Hypothyroidism dosage in patients who are taking valproic acid or • NSAIDs should be avoided or used at
• Diabetes insipidus carbamazepine. reduced dosage for pain control in
• Arrhythmia • Patients taking lamotrigine who complain of tingling patients who are taking lithium, to
• Sedation and itching of the skin should be referred to their prevent lithium toxicity.
• Seizures physician for possible change in medication, as such • It also should be avoided in patients
b. Drug interactions (toxicity) symptoms may be the first indication that Stevens- who are taking valproic acid or
include the following: Johnson syndrome may be developing. carbamazepine.
• NSAIDs • Patients on the anticonvulsant drugs
• Diuretics (valproic acid or carbamazepine) who

• Erythromycin develop oral ulcerations, infection, or
2. Valproic acid, carbamazepine, bleeding should be referred for
and lamotrigine medical evaluation.
a. Adverse effects include the
following:
• Nausea, ataxia, blurred
vision
• Tremor

• Xerostomia
• Agranulocytosis
(infection)
• Platelet dysfunction
(bleeding)
• Seizures, if abruptly
stopped
• Stevens-Johnson
syndrome
• Rare suicide ideation
b. Drug interactions (toxicity)
include the following:
• Erythromycin
• Isoniazid
• Cimetidine
Antipsychotic (Neuroleptic) Drugs
Chapter 29
1. Drug adverse effects include the • No significant oral • Identification of patients: • Local anesthetic guidelines include
following: findings are associated • Obtain history of mental disorder (patient may be the following:
a. Hypotension with these medications, taking antipsychotic medication). • Use without vasoconstrictor for
b. Acute dystonia, akathisia unless the following drug • Ask patients to list all drugs that they are taking. most dental procedures, if
c. Parkinsonism adverse effects are • Identify patients with recent onset of adverse possible.
d. Tardive dyskinesia present: effects. • For surgical or complex
e. Xerostomia, dry eyes • Agranulocytosis— • Refer patients with significant adverse effects. restorative procedures, epinephrine
f. Dizziness, postural ulceration, infection • Obtain consultation with patient’s physician to is the vasoconstrictor of choice:
hypotension • Xerostomia— confirm current status and medications. 1. Use 1 : 100,000 concentration.
g. Sexual dysfunction mucositis, caries, • Reduce dosage or avoid: 2. Aspirate before injecting.
h. Seizures periodontal disease • Epinephrine 3. In general, limit to two or
i. Neuroleptic malignant • Leukopenia—infection • Sedatives, hypnotics, opioids, antihistamines fewer cartridges.
syndrome • Thrombocytopenia— • Erythromycin • Do not use topical epinephrine to
j. Agranulocytosis bleeding control bleeding or in the retraction
2. Drug interactions include the • Tardive dyskinesia— cord.
following: uncontrolled • On the basis of patient needs and
a. Prolong or intensify the movement of the lips wants, any dental procedure can be
actions of the following: and tongue provided.
• Alcohol • Provide treatment to deal with
• Sedatives, hypnotics, xerostomia, if present (see
opioids, antihistamines Appendix C).
• Anesthetics (general) • Patients with tardive dyskinesia may
b. Antiarrhythmics—increase be difficult to manage; if this adverse
risk of arrhythmia effect has just started, refer patients
c. Anticonvulsants—reduce to their physician for evaluation and

effects of neuroleptic drugs possible change in medication.
d. Antihypertensives—increase
risk of hypotension
e. Erythromycin—increase
serum level of neuroleptic
drugs
f. Sympathomimetics
(epinephrine)—risk for
hypotension
Continued
DM57
DM58

Somatoform Disorders—Conversion Disorder, Pain Disorder, Factitious Disorder, Others
Chapter 29
1. Somatoform disorders: • Examples of oral • Refer patients found to have psychological disorders • Do not perform dental treatment on
a. Isolated symptoms with no symptoms that can be for diagnosis and management, but stay involved from the basis of the patient’s symptoms,
physical cause that do not related to somatoform a dental standpoint. unless a dental cause can be
conform to known anatomic disorders: • Discuss with patient the possible causes of symptoms, established.
pathways • Burning tongue and rule out underlying systemic conditions that could • A diagnosis of an oral
b. Psychological factors • Painful tongue account for the symptoms. somatoform disorder should not
involved in the origin • Numbness of soft • Continue to examine for signs and symptoms that may be made until after a thorough
c. May serve as a defense to tissues be related to an underlying systemic or local search over time has failed to
reduce anxiety (primary • Tingling sensations in condition. uncover pathologic findings that
gain) oral tissues could explain the symptoms.
d. Secondary gain reason for • Pain in the facial • Maintain good oral hygiene and
not working, attention from region dental repair for the patient, but
family • Oral examples of avoid complex dental procedures
e. When these patients are factitious injuries: until somatoform symptoms have
followed over time, in 10% • Self-extraction of been managed.
to 50%, a physical disease teeth • Patients may insist that the dentist
process will become • Picking gingiva with “do something” to relieve the

apparent. fingernails symptom, such as extraction or
2. Factitious disorders: • Nail file gingival endodontic therapy; the dentist must
a. Intentional production of injury avoid such nonindicated
physical or psychological • Chemical burning of interventions.
signs the lips and oral • Antidepressants and pain medication
b. Voluntary production of mucosa may be used to comfort the patient.
symptoms without external • Thermal burning of
incentive lips and oral mucosa
c. More often seen in men and
health care workers
Drug and Alcohol Abuse
Chapter 30
1. Drug abusers may try to obtain • Drug and/or alcohol 1. Be alert for signs or symptoms suggestive of substance • If patient has a history or clinical
controlled substances from the abusers may have abuse findings consistent with active drug
dentist by fraudulent claims or excessive caries and 2. Discuss concerns with the patient and refer to or alcohol abuse, elective dental care
behavior. periodontal disease from physician for further evaluation should be deferred and the person
2. Patients may be undiagnosed oral neglect; 3. If significant alcohol abuse is present, consider should be encouraged to seek medical
alcohol or drug abusers. amphetamine abuse often ordering liver function tests prior to surgical care.
3. Methamphetamine and cocaine leads to extensive caries procedures • If oral neglect is evident, patient
abusers are at risk for acute (“meth mouth”). 4. For suspected substance abusers, avoid prescribing should be required to demonstrate
hypertension if epinephrine is • Alcohol abuse and controlled medications or if needed, prescribe only a interest in and ability to care for
administered. associated altered drug limited amount with no refills dentition before any significant dental
4. Patients with alcohol abuse may metabolism by liver can 5. For recovering substance abusers, avoid prescribing treatment is undertaken.
have excessive bleeding and alter anesthesia controlled medications, if possible
unpredictable drug metabolism effectiveness. 6. For suspected methamphetamine or cocaine users,
due to liver disease. • Alcohol abuse is a risk avoid the use of epinephrine
5. Dilated pupils, elevated blood factor for oral cancer,
pressure, or cardiac arrhythmias especially when coupled
may indicate recent drug use with tobacco use.
and increases risk for stroke, • Drug and alcohol abuse
arrhythmias, and myocardial may lead to xerostomia.
infarction. • Alcohol abuse may lead
to petechiae, ecchymosis,
and parotid enlargement.

DM59

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Dental Management:

Potential Medical Problem

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Dental Management: A Summary—cont’d

Potential Medical Problem

© 2017, by Elsevier Inc. All rights reserved.

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• Antibiotic prophylaxis is not recommended for

Potential Medical Problem

from some dental equipment; vasoconstrictors.

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© 2017, by Elsevier Inc. All rights reserved.

Dental Management: A Summary—cont’d

© 2017, by Elsevier Inc. All rights reserved.

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• Recognize signs and symptoms of a severe or

Potential Medical Problem

• For patients producing consistently negative

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Potential Medical Problem

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

(diarrhea, GI distress) of pseudomembranous colitis.

Potential Medical Problem

(GFR) <60 mL/min. prognosis.

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

medical treatment provided.

Dental Management: A Summary—cont’d

to dermal sites and the oral cavity by the patient.

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

Potential Medical Problem

ketoconazole) at least 24 hours before surgery with

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

Potential Medical Problem

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

Potential Medical Problem

and affect time of delivery. prophylaxis, throughout pregnancy.

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

Dental Management: A Summary—cont’d

Potential Medical Problem

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

Potential Medical Problem

agent—administer diphenhydramine 50 mg up to alternate anesthetic, and wait 5

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© 2017, by Elsevier Inc. All rights reserved.

• Administer erythromycin or another macrolide

Potential Medical Problem

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

bacteremias that cause these invasive dental procedures.

Dental Management: A Summary—cont’d

Potential Medical Problem

© 2017, by Elsevier Inc. All rights reserved.

© 2017, by Elsevier Inc. All rights reserved.

Potential Medical Problem