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www.pdflobby.com BDJ Clinician’s Guides Mark Greenwood John G Meechan General Medicine and Surgery for Dental Practitioners Third Edition www.pdflobby.com BDJ Clinician’s Guides www.pdflobby.com More information about this series at http://www.springer.com/series/15753 www.pdflobby.com Mark Greenwood • John G. Meechan General Medicine and Surgery for Dental Practitioners Third Edition www.pdflobby.com Mark Greenwood School of Dental Sciences Newcastle University School of Dental Sciences Newcastle upon Tyne North Humberside UK John G. Meechan The Coach House Stocksfield Northumberland UK Originally published by BDJ Books, London, 2010 ISSN 2523-3327     ISSN 2523-3335 (electronic) BDJ Clinician’s Guides ISBN 978-3-319-97736-2    ISBN 978-3-319-97737-9 (eBook) https://doi.org/10.1007/978-3-319-97737-9 Library of Congress Control Number: 2018957094 © Springer Nature Switzerland AG 2019 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland www.pdflobby.com Acknowledgements The authors are grateful to: • Dr M. Rudralingam, Consultant in Oral Medicine, University Dental Hospital of Manchester – Chapter 14 – Skin Disorders and Dental Practice • Dr I.  Macleod, Consultant in Dental Radiology, Newcastle Dental Hospital – Chapter 14 – Skin Disorders and Dental Practice • Dr S.  J Brown, Specialist Registrar in Psychiatry at Newcastle Upon Tyne – Chapter 15 – Psychiatry and Dental Practice • Professor J. V Soames, Professor R. R Welbury and Dr U. J Moore for providing some of the clinical photographs • Professor R.  R Welbury (University of Central Lancashire) and Dr F.  Hogg (University of Glasgow) – Chapter 11 – The Paediatric Patient and Dental Practice • Dr C.  Stroud, Consultant Immunologist at the Royal Victoria Infirmary in Newcastle – Chapter 20 – Immunology and the Dental Practitioner • Dr N. Jakubovics, Senior Lecturer, Newcastle University – Chapter 19 – Infections and Infection Control • Professor P. J Thomson, Oral and Maxillofacial Surgery, University of Hong Kong – Chapter 16 – Cancer, Radiotherapy and Chemotherapy and Dental Practice • Lt Col D. G Bryant, Consultant Oral and Maxillofacial Surgeon, James Cook University Hospital, Middlesbrough – Chapter – Renal Disorders and Dental Practice v www.pdflobby.com Contents 1 General Medicine and Surgery for Dental Practitioners: History Taking and Examination of the Clothed Patient ����������������������   1 1.1 Introduction����������������������������������������������������������������������������������������   1 1.2 Main Components of a Medical History��������������������������������������������   1 1.2.1 Presenting Complaint��������������������������������������������������������������   1 1.2.2 History of Presenting Complaint��������������������������������������������   2 1.2.3 Past Medical History��������������������������������������������������������������   2 1.2.4 Medications and Drugs ����������������������������������������������������������   2 1.2.5 Recreational Drugs�����������������������������������������������������������������   3 1.2.6 Past Dental History ����������������������������������������������������������������   4 1.2.7 Social History/Family History������������������������������������������������   4 1.2.8 Psychiatric History������������������������������������������������������������������   5 1.2.9 General Enquiry����������������������������������������������������������������������   5 1.2.10 Cardiovascular System������������������������������������������������������������   5 1.2.11 Respiratory System ����������������������������������������������������������������   6 1.2.12 Gastrointestinal System����������������������������������������������������������   6 1.2.13 Neurological System��������������������������������������������������������������   6 1.2.14 Musculoskeletal System����������������������������������������������������������   6 1.2.15 Genitourinary System ������������������������������������������������������������   7 1.3 Examination of the Clothed Patient����������������������������������������������������   7 1.4 Conclusions����������������������������������������������������������������������������������������  10 References����������������������������������������������������������������������������������������������������  11 2 The Cardiovascular System����������������������������������������������������������������������  13 2.1 Introduction����������������������������������������������������������������������������������������  13 2.2 Relevant Points in the History������������������������������������������������������������  14 2.2.1 Chest Pain ������������������������������������������������������������������������������  14 2.2.2 Angina Pectoris����������������������������������������������������������������������  15 2.2.3 Myocardial Infarction (MI)����������������������������������������������������  15 2.2.4 Hypertension ��������������������������������������������������������������������������  16 2.2.5 Syncope or Fainting����������������������������������������������������������������  16 2.2.6 Shortage of Breath (SOB)/Exercise Tolerance ����������������������  16 2.2.7 Rheumatic Fever ��������������������������������������������������������������������  17 vii www.pdflobby.com viii Contents 2.3 The Cardiovascular System����������������������������������������������������������������  17 2.3.1 Cardiac Rate/Rhythm��������������������������������������������������������������  18 2.4 Common Arrhythmias������������������������������������������������������������������������  18 2.4.1 Sinus Tachycardia (The Pulse Is More than 100 Beats/Min)�����������������������������������������������������������������������  18 2.4.2 Sinus Bradycardia (The Pulse Is Less than 60 Beats/Min)�������������������������������������������������������������������������  19 2.4.3 Atrial Fibrillation��������������������������������������������������������������������  19 2.4.4 Ventricular Extrasystole����������������������������������������������������������  19 2.5 Cardiomyopathy����������������������������������������������������������������������������������  19 2.6 Coronary Artery Bypass Graft������������������������������������������������������������  19 2.7 Valve Replacement������������������������������������������������������������������������������  19 2.8 Congenital Cardiac Defects����������������������������������������������������������������  20 2.9 Cardiac Transplants����������������������������������������������������������������������������  20 2.10 Venous/Lymphatic Disorders��������������������������������������������������������������  21 2.11 Examination����������������������������������������������������������������������������������������  21 2.12 Drugs Used in Cardiovascular Disease����������������������������������������������  22 2.12.1 Beta Blockers��������������������������������������������������������������������������  22 2.12.2 Diuretics����������������������������������������������������������������������������������  22 2.12.3 Digoxin ����������������������������������������������������������������������������������  22 2.12.4 ACE Inhibitors������������������������������������������������������������������������  23 2.12.5 Calcium Channel Blockers ����������������������������������������������������  23 2.12.6 Potassium Channel Activators������������������������������������������������  23 2.12.7 Warfarin����������������������������������������������������������������������������������  23 2.12.8 Heparin������������������������������������������������������������������������������������  24 2.12.9 Direct Oral Anticoagulants (DOACs) ������������������������������������  24 2.13 General and Local Anaesthesia, Sedation and Management Considerations in the Dental Patient with Cardiovascular Disease������  24 2.14 Summary ��������������������������������������������������������������������������������������������  26 References����������������������������������������������������������������������������������������������������  26 3 The Respiratory System and Dental Practice ����������������������������������������  27 3.1 Relevant Points in the History������������������������������������������������������������  28 3.2 Examination����������������������������������������������������������������������������������������  32 3.3 Relevance of Drugs in Respiratory Disorders������������������������������������  33 3.3.1 Corticosteroids������������������������������������������������������������������������  33 3.3.2 Beta Adrenergic Agonist Bronchodilators������������������������������  34 3.3.3 Antimuscarinic Bronchodilators ��������������������������������������������  34 3.3.4 Cromoglycate��������������������������������������������������������������������������  34 3.3.5 Antihistamines������������������������������������������������������������������������  34 3.3.6 Cough Suppressants and Decongestants��������������������������������  35 3.4 Relevance of Respiratory Disorders in the Provision of Local Anaesthesia Sedation, General Anaesthesia and Management in Dental Practice������������������������������������������������������������������������������������  35 3.5 Summary ��������������������������������������������������������������������������������������������  37 References����������������������������������������������������������������������������������������������������  37 www.pdflobby.com Contents ix 4 The Gastrointestinal System and Dental Practice����������������������������������  39 4.1 Relevant Points in History������������������������������������������������������������������  39 4.2 Examination����������������������������������������������������������������������������������������  44 4.3 Drugs Used in GI Disease������������������������������������������������������������������  45 4.3.1 Antacids����������������������������������������������������������������������������������  45 4.3.2 Ulcer-Healing Drug Proton Pump Inhibitors, e.g Omeprazole and Lansoprazole����������������������������������������  46 4.3.3 Drugs Used in Inflammatory Bowel Disease��������������������������  46 4.3.4 Pancreatic Supplements����������������������������������������������������������  46 4.4 Effects of Gastrointestinal Disease on Local Anaesthesia, Sedation, General Anaesthesia and Management in Dental Practice������������������������������������������������������������������������������������  46 4.5 Summary ��������������������������������������������������������������������������������������������  47 References����������������������������������������������������������������������������������������������������  48 5 Neurological Disorders and Dental Practice ������������������������������������������  49 5.1 Relevant Points in the History������������������������������������������������������������  50 5.2 Facial Pain������������������������������������������������������������������������������������������  52 5.3 Other Disorders����������������������������������������������������������������������������������  52 5.4 Neurological Disorders ����������������������������������������������������������������������  55 5.5 General Examination��������������������������������������������������������������������������  57 5.5.1 Consideration of the Cranial Nerves��������������������������������������  58 5.6 General and Local Anaesthesia, Sedation and Management Considerations in the Dental Patient with Neurological Disease��������������������������������������������������������������������������  59 5.7 Effects of Drugs Used in Neurological Disorders on Oro-­dental Structures��������������������������������������������������������������������������  60 5.8 Summary ��������������������������������������������������������������������������������������������  61 References����������������������������������������������������������������������������������������������������  61 6 Liver Disease and Dental Practice������������������������������������������������������������  63 6.1 Points in the History���������������������������������������������������������������������������  63 6.2 Examination����������������������������������������������������������������������������������������  66 6.3 Factors Affecting Dental Treatment Under GA/LA/Sedation������������  66 6.4 Prescribing for Patients with Liver Disease����������������������������������������  68 6.5 Summary ��������������������������������������������������������������������������������������������  68 References����������������������������������������������������������������������������������������������������  68 7 The Endocrine System and Dental Practice��������������������������������������������  69 7.1 Points in the History���������������������������������������������������������������������������  69 7.2 Examination of Patients with Endocrine Disorders����������������������������  73 7.3 Factors Relating to Dental Treatment and GA/LA/IV Sedation in Endocrine Disorders��������������������������������������������������������  76 7.4 Effects of Drugs Used in Endocrine Disorders on Orodental Structures ��������������������������������������������������������������������������  78 7.5 Summary ��������������������������������������������������������������������������������������������  78 References����������������������������������������������������������������������������������������������������  79 www.pdflobby.com x Contents 8 Renal Disorders and Dental Practice ������������������������������������������������������  81 8.1 Points in the History ������������������������������������������������������������������������  82 8.2 Examination of the Dental Patient with Renal Disease��������������������  84 8.3 Dental Management of Patients with Renal Disorders��������������������  86 8.4 Prescribing for Patients with Renal Disease ������������������������������������  87 8.5 Conclusion����������������������������������������������������������������������������������������  88 References����������������������������������������������������������������������������������������������������  88 9 The Musculoskeletal System and Dental Practice����������������������������������  89 9.1 Points in History ������������������������������������������������������������������������������  89 9.2 Disorders of the Bone ����������������������������������������������������������������������  90 9.3 Joint Disease ������������������������������������������������������������������������������������  92 9.4 Other Disorders��������������������������������������������������������������������������������  94 9.5 Examination��������������������������������������������������������������������������������������  96 9.6 General and Local Anaesthesia, Sedation and Management Considerations in the Dental Patient with Musculoskeletal Disease������������������������������������������������������������������  99 9.7 Syndromic Patients �������������������������������������������������������������������������� 100 9.8 Joint Disorders���������������������������������������������������������������������������������� 100 9.9 Other Disorders�������������������������������������������������������������������������������� 101 9.10 Effects of Drugs Used to Treat Musculoskeletal Disorders on Oro-­dental Structures������������������������������������������������������������������ 101 9.11 Summary������������������������������������������������������������������������������������������ 102 References���������������������������������������������������������������������������������������������������� 102 10 Haematology and Patients with Bleeding Problems and Dental Practice ������������������������������������������������������������������������������������������ 105 10.1 Points in the History������������������������������������������������������������������������� 106 10.2 Problems with Red Blood Cells�������������������������������������������������������� 107 10.2.1 Anaemia�������������������������������������������������������������������������������� 107 10.2.2 Polycythaemia���������������������������������������������������������������������� 108 10.3 Problems with White Cells �������������������������������������������������������������� 108 10.3.1 Leucopenia���������������������������������������������������������������������������� 108 10.3.2 Leucocytosis ������������������������������������������������������������������������ 108 10.3.3 Malignancy �������������������������������������������������������������������������� 109 10.4 Problems with Platelets�������������������������������������������������������������������� 110 10.5 Deficiencies in Clotting Factors�������������������������������������������������������� 111 10.6 Vascular Problems���������������������������������������������������������������������������� 112 10.7 Fibrinolytic Problems����������������������������������������������������������������������� 113 10.7.1 Direct Oral Anticoagulants (DOACs) ���������������������������������� 113 10.8 Examination�������������������������������������������������������������������������������������� 113 10.9 Influence of Haematological and Bleeding Disorders on Dental Management�������������������������������������������������������������������������� 114 10.9.1 Surgical Procedures�������������������������������������������������������������� 114 10.9.2 Choice of Anaesthesia���������������������������������������������������������� 116 www.pdflobby.com 238 20  Immunology and the Dental Practitioner Fig 20.2  Lip swelling in a patient with angioedema • Common variable immunodeficiency (CVID) is a form of antibody deficiency disorder of unknown cause It may be the result of multiple gene defects Treatment is with lifelong antibody replacement therapy • Chronic granulomatous disease (CGD) usually presents in childhood with recurrent deep-seated abscesses, which may be in unusual sites The underlying immunological defect is a failure of the neutrophil oxidative burst and subsequent killing of organisms • Wiskott-Aldrich syndrome (WAS) classically affects males and is associated with eczema, recurrent infections and low platelet counts • DiGeorge syndrome is a genetic disorder with variable features including congenital cardiac defects, cleft palate and abnormal facial features It is a disorder of T-cell function and leads to predisposition to infection • Severe combined immunodeficiency (SCID) is a genetic disorder leading to impaired function of B and T lymphocytes Patients may present with chronic diarrhoea, recurrent ear infections, candidosis and respiratory infections due to Pneumocystis jiroveci Haemopoietic stem cell transplants (bone marrow transplants) are the mainstay of management in these patients Antibiotic prophylaxis should be considered for procedures that have a high risk of leading to post-operative infection, and liaison with an immunologist is important 20.4 Allergy Patients may give a history of allergy, for example, to Elastoplast® (Fig.  20.3) Hypersensitivity reactions are immune-mediated antigen-specific reactions that are either inappropriate or excessive and result in harm to the host They have been classified by Gell and Coombs [2] (Table 20.3) www.pdflobby.com 239 20.4 Allergy Fig 20.3  An allergic reaction to Elastoplast® Table 20.3  An abbreviated version of Gell and Coombs’ classification of hypersensitivity reactions Type I Type II Type III Type IV IgE mediated—example allergic rhinitis, asthma, anaphylaxis IgG mediated—example transfusion reaction, autoimmune disease IgG mediated—example systemic lupus erythmatosus T cell mediated—contact dermatitis, chronic asthma, chronic allergic rhinitis The incidence of allergic disease in Western societies is increasing, and it is hypothesised that reasons for this may be as a result of a decrease in infections that are encountered and a consequence of immunisation regimens The proposed “hygiene hypothesis” suggests that the reduced exposure of the immune system to pathogens has led to a switch in the immune system leading to responses that allow the development of allergic conditions Changes in the environment, for example, changes to housing, have led to increased exposure to house dust mites, and dietary changes may also have a part to play There are many materials that are used in dental practice that may be considered as irritants or potential allergens A selection of these is listed in Table 20.4 Signs and symptoms can be variable in patients who have an adverse reaction to materials or media used in dentistry They can range from stomatitis, mouth ulceration, lichenoid reactions (Fig. 20.4), burning or tingling to lip swelling, oral swelling or facial rashes More systemic symptoms may arise such as urticaria, wheezing or anaphylaxis Type I hypersensitivity reactions to chlorhexidine have been seen in patients and healthcare workers [3] but are not common when the ubiquitous nature of this substance is taken into account Nevertheless fatal anaphylaxis to chlorhexidine has been attributed to dental use [3] www.pdflobby.com 240 20  Immunology and the Dental Practitioner Table 20.4  Potential irritants/allergens in dental practice • Latex • Mouthwashes • Adhesives • Acrylic • Amalgam • Cements • Impression materials • Antiseptics • Local anaesthetics • Ultra violet radiation Fig 20.4  An intraoral lichenoid reaction 20.5 Anaphylaxis Anaphylaxis is a Type I hypersensitivity reaction mediated by IgE to which free antigen binds leading to the release of vasoactive peptides and histamine The signs and symptoms of anaphylaxis are given in Table 20.5 The treatment of anaphylaxis is discussed in the chapter on medical emergencies in this series (Chap 18) 20.6 Potential Features on Clinical Examination Oral lichenoid lesions may cause patients to complain of oral soreness, and ulceration can occur Amalgam has been implicated in the production of oral lichenoid reactions in the tissues that contact restorations with this material [4] Figure 20.4 shows a lichenoid reaction Some patients with this condition have been found to have Type IV sensitivity to mercury and other metals, and patch testing may be useful in identifying this problem Removal of an amalgam restoration adjacent to a lesion may lead to improvement even when patch testing is negative as these materials can also act as irritants www.pdflobby.com 20.6  Potential Features on Clinical Examination Table 20.5  Signs and symptoms of an anaphylactic reaction 241 • Itchy rash with or without erythema • Pallor or facial flushing • Upper airway oedema and bronchospasm leading to stridor, wheezing and hoarseness • Vasodilatation leading to hypotension and circulatory collapse • If untreated or rapidly progressive, respiratory arrest and/ or cardiac arrest may occur Oral erythema can also occur secondary to Type IV hypersensitivity Implicated substances include acrylic Cheilitis is an inflammatory eruption of the lip and may be due to contact allergy or irritation from constant licking of lips, atopic dermatitis, infection, usually with Staphyloccocus aureus, or iron deficiency Candidosis may be seen in immunosuppressed patients Candidal organisms are highly opportunistic and are present in a dormant yeast phase in a significant proportion of the population Local and/or systemic factors may lead to the yeast developing into its pseudohyphal (pathogenic) form Management of these conditions usually involves eliminating local factors such as poor denture hygiene and antifungal medication In immunocompromised individuals antifungal treatment may need to be used for a prolonged period Systemic fluconazole is usually the drug of choice Immunosuppressed patients are susceptible to viral infections, in particular, those of the herpes group such as herpes simplex and varicella zoster virus [5] A significant proportion of the population carry these viruses in a latent form having acquired them during childhood Reactivation occurs if the host is unable to mount a significant immune response to the virus In immunocompetent individuals, these infections are usually self-limiting, but in the immunocompromised, both infections can be more serious and lead to life-threatening conditions such as herpes encephalitis Such patients need aggressive management with early antiviral medication Other viral infections include the papilloma virus group which leads to lesions anywhere on the skin or oral mucosa Other virus-related lesions may include hairy leukoplakia, which is related to Epstein-Barr virus and can be a feature of HIV There is a large number of conditions which results from autoimmunity These conditions can be organ-specific such as hyper or hypothyroidism or non-organ specific, for example, rheumatoid arthritis, systemic lupus erythematosus (SLE) and vasculitis Certain autoimmune conditions may present with oral signs Signs of Addison’s disease, or autoimmune adrenal insufficiency, include increased pigmentation of skin folds, buccal mucosa and scars In general terms it can present with symptoms of fatigue and depression In Type I diabetes mellitus, where there is immunologically mediated destruction of the islets of Langerhans in the pancreas, oral complications include candida infection, dry mouth, sialosis and glossitis Severe oral infection can upset glycaemic control, and patients are prone to increased superficial infections and poor wound healing www.pdflobby.com 242 20  Immunology and the Dental Practitioner Patients with coeliac disease may present with aphthous ulceration secondary to anaemia Some may describe a blistering skin rash known as dermatitis herpetiformis Other well-known but relatively rare autoimmune diseases that may be seen by dental practitioners include the vesiculobullous disorders pemphigoid and pemphigus Bullous pemphigoid is seen most commonly in the elderly with subepidermal blisters with the mucous membranes usually spared Treatment may be with immunosuppression Pemphigus vulgaris is often associated with non-healing erosion of mucous membranes, and treatment is with high-dose steroids Scleroderma is a multisystem disorder characterised by fibrosis of connective tissue Oral manifestations can include periarticular involvement of the temporomandibular joint, and skin involvement around the mouth leads to microstomia The tongue may become thickened and stiffened with oral telangiectasia and widening of the periodontal membrane space but without associated tooth mobility The hands may be affected which can lead to difficulties with compliance with oral hygiene measures Cutaneous manifestations of disorders such as systemic lupus erythematosus (SLE) may include oral ulceration A photosensitive facial skin rash (classically described as a “butterfly” rash), alopecia and Raynaud’s phenomenon may also be seen Clearly one of the best known immunological diseases recognised by dental practitioners is that of Sjögren’s syndrome comprising dry eyes, dry mouth and associated inflammatory arthritis Clearly the dry mouth may lead to other signs and symptoms from the mouth including impaired taste sensation, gingivitis, difficulty in swallowing, predisposition to candida infection, angular stomatitis and ascending parotitis The salivary glands may be enlarged Behcet’s disease, a systemic vasculitis, has significant oral manifestations Patients with the disease suffer from a clinical triad comprising aphthous-type oral ulceration, genital ulcers and iritis The ulceration can be severe, but oral symptoms may occur before the other features As a result, dental practitioners may be the first clinicians to see patients with this disease There may be associated skin lesions including a folliculitis Erythema multiforme is a disorder characterised by recurrent mucosal lesions with or without skin lesions The typical skin lesion is described as a “target lesion” due to its characteristic appearance Many different types of rash can be seen, hence the use of the word multiforme Severe cases are described as Stevens-Johnson syndrome Ocular and genital lesions may also be seen It is uncertain what causes erythema multiforme, but it is thought to be an immune complex disorder with a diverse range of possible antigens ranging from herpes simplex virus (thought to be responsible for most oral manifestations) to mycoplasma and drugs On examination, the characteristic clinical appearance is of oedematous, crusted and blood-stained lips Vesicles or bullae may be seen Treatment is usually via topical corticosteroids, chlorhexidine and possibly in severe cases systemic steroids If www.pdflobby.com 20.7  Drugs That May Be Taken by Patients With Immunological Disease 243 a viral aetiology is implicated or suspected, acyclovir may be prescribed If the oral signs and symptoms are significantly limiting nutrition or in particular hydration, the patient may need to be admitted to the hospital 20.7 D  rugs That May Be Taken by Patients With Immunological Disease The largest group of drugs that may be encountered are the immunosuppressants Clearly patients with other disorders may also take immunosuppressants as well as those with pure immune disease Some of the more common ones encountered are summarised in Table 20.6 Most immunosuppressants target the induction phase of the immune system by reducing lymphocyte proliferation Immunosuppressants can produce unwanted intra-oral effects Ciclosporin produces gingival hyperplasia and has been reported to cause this side-effect in up to 30% of patients taking this drug [6] Cyclophosphamide, methotrexate and mycophenylate cause bone marrow suppression, which can lead to oral ulceration [7] as well as a reduced resistance to periodontal disease As well as increasing the risk of infection, bone marrow suppression can increase post-operative bleeding as a result of thrombocytopaenia A platelet count below 50  ×  109/l is a contraindication to surgery until corrected or a platelet transfusion is administered Platelet counts of less than 100 × 109/l require the use of local haemostatic measures such as packing with haemostatic gauze and suturing after dental extractions Corticosteroids have a dual effect on the periodontium Their anti-inflammatory effects can offer protection against periodontal breakdown On the other hand, chronic use of steroids may produce osteoporosis, which increases the risk of periodontal disease [8] Dental practitioners should also remember that methotrexate has an hepatotoxic effect which varies between individuals but may be significant enough to adversely affect liver function, in particular its role in clotting factor metabolism Table 20.6  Immunosuppressants which may be encountered by dental practitioners Drug • Ciclosporin and tacrolimus • Corticosteroids • Azathioprine • Cyclophosphamide • Methotrexate • Mycophenylate mofetil • Monoclonal antibodies Target within the immune system Inhibits IL-2 production and action Specific effect on T-helper cells Inhibits cytokine gene expression Inhibits purine synthesis Binds and cross-links DNA preventing interfering with DNA replication and transcription (alkylating agent) Competitive inhibitor of dihydrofolate reductase Interferes with thymidine and therefore DNA synthesis Blocks synthesis of guanine Antibodies of a single specificity Available to multiple cytokine and receptor targets www.pdflobby.com 244 20  Immunology and the Dental Practitioner Patients on long-term immunosuppressant therapy, such as those who have had organ transplants, are at risk of developing malignancies on the lip [1] as well as other cutaneous cancers As mentioned above dentists treating these patients should have a high level of suspicion and be vigilant in monitoring the lips, oral mucosa and skin Any suspicious lesions should be referred for urgent biopsy Concurrent therapy with immunosuppressant medication impacts on the drugs the dentist may prescribe The main groups to note are the nonsteroidal anti-­ inflammatories (NSAIDs) and antibacterials NSAIDs should be avoided in those taking corticosteroids as this combination can lead to peptic ulceration Similarly NSAIDs interact with methotrexate leading to an increase in methotrexate toxicity The toxicity of the latter drug may also be increased by the penicillins If an alternative antibacterial drug is not feasible, then current advice is that patients receiving a penicillin and methotrexate should be carefully monitored during treatment Monitoring involves measuring platelet levels and blood counts twice weekly for 2 weeks, with methotrexate levels being taken if the patient becomes symptomatic [9] NSAIDs also increase the nephrotoxic effects of ciclosporin In addition to immunosuppressants, patients may be receiving other medications to treat conditions secondary to their underlying disease, for example, antimicrobial drugs 20.8 Summary The study of immunology is a specialist area There are some fundamental concepts and conditions with which it is essential for a dental practitioner to be familiar for safe clinical practice References Nolan A, Girdler NM, Seymour RA, Thomason JT. The prevalence of dysplasia and malignant lip lesions in transplant patients J Oral Pathol Med 2012;41:113–8 Gell PGH, Coombs RRA.  The classification of allergic reactions underlying disease In: Coombs RRA, Gell PGH, editors Clinical aspects of immunology Hoboken: Blackwell Science; 1963 Pemberton MN, Gibson J. Chlorhexidine and hypersensitivity reactions in dentistry Br Dent J 2012;213:547–50 McParland H, Warnakulasuriya S. Oral lichenoid contact lesions to mercury and dental amalgam—a review J Biomed Biotechnol 2012 doi: https://doi.org/10.1155/2012/589569 Westley S, Seymour R, Staines K.  Recurrent intra-oral herpes simplex infection Dent Update 2011;38:368–70 372–4 Seymour RA, Smith DG, Rogers SR.  The comparative effects of azathioprine and cyclosporine on some gingival health parameters of renal transplant patients J Clin Periodontol 1987;14:610–3 Weng RR, Foster CE, Hsieh LL, Patel PR. Oral ulcers associated with mycophenolate mofetil use in a renal transplant recipient Am J Health Syst Pharm 2011;68:585–8 www.pdflobby.com References 245 Wactawski-Wende J, Grossi SG, Trevisan M, Genco RJ, Tezal M, Dunford RG, Ho AW, Hausmann E, Hreshchyshyn MM.  The role of osteopenia in oral bone loss and periodontal diseases J Periodontal 1996;67:1076–84 NHS National electronic library for medicines What is the clinical significance of the interaction between methotrexate and penicillins? http://www.nelm.nhs.uk/en/NeLM-Area/Evidence/ Medicines-Q%2D%2DA/What-is-the-clinical-significance-of-the-interaction-betweenmethotrexate-and-penicillins/ Accessed 08 May 2018 www.pdflobby.com Index A Acne rosacea, 155 Acne vulgaris, 155, 165 Acromegaly, 72–75 Addison’s disease, 72, 75, 162, 164, 217, 236, 241 Adrenal crisis signs and symptoms, 217 treatment, 217 Adult respiratory distress syndrome (ARDS), 31 Allergy hygiene hypothesis, 239 signs and symptoms, 239 Alopecia areata, 162 American Society of Anaesthesiologists (ASA), 189 Anaphylaxis signs and symptoms, 214 treatment, 214 Angioedema, 156 signs and symptoms, 215, 216 treatment, 215 Angiotensin-converting enzyme (ACE), 23, 135 Angular cheilitis, 161, 232 Anorexia nervosa/bulimia nervosa, 168, 171 Aspiration signs and symptoms, 215 treatment, 216 Asthma inhaler, 207 signs and symptoms, 207 spacer device, 207 spacer procedure, 207 treatment, 208 Atrial fibrillation, 10, 19, 22, 23, 70, 75, 113, 130, 131, 218 Automatic external defibrillators (AEDs), 200 B Basal cell carcinoma, 149, 151, 152, 163, 236 Basal cell papilloma, 149, 150 Behcet’s disease, 242 Bipolar affective disorder, 170 Blood-borne viruses, 221, 229, 230 Brain abscess, 56 Bronchial asthma, 29 Bronchiectasis, 8, 27, 28, 30, 31, 35, 121 C Carbuncle, 159 Cardiac arrest, 16, 192, 195, 197, 199, 200, 206, 214, 241 Cardiomyopathy, 15, 19, 31, 73, 94, 101, 108, 140, 144 Cardiovascular system clinical examination ACE inhibitors, 23 beta blockers, 22 calcium channel blockers, 23 digoxin, 22 direct oral anticoagulants, 24 diuretics, 22 heparin, 24 warfarin, 23, 24 common arrhythmias atrial fibrillation, 19 cardiac transplants, 20 cardiomyopathy, 19 congenital cardiac defects, 20 coronary artery bypass graft, 19 sinus bradycardia, 19 sinus tachycardia, 18 valve replacement, 19 ventricular extrasystole, 19 medical history angina pectoris, 15 © Springer Nature Switzerland AG 2019 M Greenwood, J G Meechan, General Medicine and Surgery for Dental Practitioners, BDJ Clinician’s Guides, https://doi.org/10.1007/978-3-319-97737-9 247 www.pdflobby.com Index 248 Cardiovascular system (cont.) cardiac rate/rhythm, 18 chest pain, 14, 15 exercise tolerance, 16 high risk, 18 hypertension, 16 moderate risk, 18 myocardial infarction, 15, 16 rheumatic fever, 17, 18 shortage of breath, 16 syncope/fainting, 16 treatment drug therapy, 25 general anaesthesia, 24–25 local anaesthesia, 24, 25 Cellulitis, 21, 159, 237 Cerebral palsy, 56, 57, 60, 122, 124 C1 esterase inhibitor deficiency, 237 Choking signs and symptoms, 215 treatment, 216 Chronic granulomatous disease (CGD), 238 Chronic mucocutaneous candidosis (CMC), 237 Chronic obstructive pulmonary disease (COPD), 28, 126, 130, 193, 195, 208 Clothed patient clinical examination, 7–10 medical history cardiovascular system, family history, gastrointestinal system, general questions, genitourinary system, medications /drugs, 2, musculoskeletal system, neurological system, past dental history, past medical history, presenting complaint, psychiatric history, recreational drugs, respiratory system, social history, Common variable immunodeficiency (CVID), 238 Congenital disorders, 15, 43, 44, 121 Conn’s syndrome, 72, 74 Cough, 6, 23, 27, 28, 30, 31, 35, 51, 125, 215, 216 Coxsackie group, 160 Cushing’s disease, 70, 72, 74 Cushing’s syndrome, 72, 73, 75, 76 Cystic fibrosis, 28, 30, 46, 121, 124–126 D Defibrillation, 200, 201 Dental unit waterlines (DUWLs), 221, 227, 228, 232 Dermatitis herpetiformis, 43, 159, 242 Dermatomyositis, 94, 96, 97, 99, 157 DiGeorge syndrome, 238 Direct oral anticoagulants (DOACs), 24, 113 Discoid LE, 157 Distal interphalangeal joints (DIP), 7, 96 Dyspnoea, 5, 16, 27, 28, 33, 39, 77, 214 E Ectodermal dysplasia, 120, 125, 163 Eczema, 148, 154, 164, 238 Endocrine disorders clinical examination acromegalic patient, 75 cushingoid patient, 75 facial flushing, 75 goitre, 75 hirsutism, 75 medical history acromegaly, 73 addison’s disease, 72 conn’s syndrome, 72 cushing’s disease, 72 cushing’s syndrome, 72 diabetes mellitus, 69–70 hyperparathyroidism, 73 nelson’s syndrome, 73 phaeochromocytoma, 73 pregnant patient, 71 thyroid gland, 70 orodental structures, 78 treatment general anaesthesia, 77, 78 local anaesthesia, 77 IV sedation, 78 Epidermoid cyst, 149 Epidermolysis bullosa, 163 Epilepsy, 2, 7, 50, 51, 56, 57, 59, 60, 122, 124, 151, 163, 211, 212 Epileptic seizure signs and symptoms, 211 treatment, 211, 212 Erythema multiforme, 23, 46, 61, 78, 102, 158, 242 Exercise tolerance, 15, 16, 19 F Facial pain, 6, 50, 52, 168, 171, 182 Furuncle, 159 www.pdflobby.com Index G Gastrointestinal (GI) system clinical examination jaundiced, 44 oral lesions, 44 pallor, 44 drug effects antispasmodics, 45 inflammatory bowel disease, 46 lansoprazole, 46 omeprazole, 46 pancreatic supplements, 46 medical history anaemia, 39 clostridium difficile, 44 congenital disorders, 43 dysphagia, 40 erythema nodosum, 43 heartburn, 40 indigestion, 40 inflammatory bowel disease, 41 jaundice, 43 pancreatic disease, 43 peptic ulcer, 40 pseudomembranous colitis, 44 pyoderma gangrenosum, 43 vomiting, 40 treatment general anaesthesia, 46, 47 local anaesthesia, 46, 47 sedation, 46, 47 Gilbert’s syndrome, 65 H Haematological and bleeding disorders clinical examination, 113 clotting factor deficiency, 111, 112 direct oral anticoagulants, 113 fibrinolysis, 113 measurements in, 106 medical history, 106 platelets, 110, 111 red blood cells anaemia, 107–108 polycythaemia, 108 treatment cross-infection control, 117 general anaesthesia, 116 medical prescription, 116, 117 IV sedation, 116 surgical procedures, 114–116 vascular problems, 112, 113 white cells leucocytosis, 108 249 leucopenia, 108 leukaemias, 109 lymphomas, 109 myeloma, 110 Heparin, 24, 71, 83, 84, 112, 116 Hepatorenal syndrome, 47, 67 Hereditary haemorrhagic telangiectasia (HHT), 112, 149 Herpes simplex, 64, 84, 86, 158–160, 241, 242 Herpes zoster infection, 160 Hirsutism, 75, 76, 161 Huntington’s chorea, 57 Hygiene hypothesis, 239 Hyperglycaemia, 69, 73, 77, 213, 214 Hyperpigmentation, 32, 33, 75, 82, 98, 162, 164, 236 Hyperthyroidism causes, 70 signs, 70 symptoms, 70 treatment, 70 Hyperventilation signs and symptoms, 208 treatment, 208, 209 Hypoglycaemia, 70, 73 signs and symptoms, 77, 213 treatment, 77, 213, 214 Hypopigmentation, 162 Hypothyroidism causes, 70 signs, 70 symptoms, 70 treatment, 70 I Immune system allergy, 238, 239 anaphylaxis, 240 clinical examination, 240–243 drugs effects, 243, 244 immunodeficiency classification, 235–236 medical history, 236 chronic granulomatous disease, 238 chronic mucocutaneous candidosis, 237 common variable immunodeficiency, 238 DiGeorge syndrome, 238 hereditary angioedema, 237 severe combined immunodeficiency, 238 Wiskott-Aldrich syndrome, 238 Infections and infection controls dental unit waterlines, 227, 228 hand hygiene policy, 222–223 www.pdflobby.com 250 Infections and infection controls (cont.) immunisations, 228 infectious agents blood-borne viruses, 229, 230 legionella, 232 Methicillin-Resistant Staphylococcus aureus (MRSA), 231, 232 prions, 232, 233 pseudomonas, 232 respiratory viruses, 230, 231 medical history, 222 personal protective equipment, 223–225 safe working, 225 screening, 228, 229 sterilisation and disinfection, 226, 227 surgery design, 227 waste management, 228 Inflammatory bowel disease, 8, 41–46 K Keratoacanthoma, 149, 150 L Legionella, 28, 227, 230, 232 Lichen planus, 65, 102, 155, 156 Liver disease clinical examination, 66 medical history bleeding tendency, 65 cirrhosis, 65 jaundice, 64 medications, 65 viral hepatitis, 64 prescribing, 68 treatment general anaesthesia, 66, 67 local anaesthesia, 67 sedation, 67 Lower respiratory tract infections, 28 Lupus erythematosus (LE), 157 M Malignant melanoma, 152, 153, 162 Malignant tumours clinical examination, 182–184 general complications, 180 medical history, 180–182 orofacial manifestations, 180 treatment chemotherapy, 181, 185 drug effects, 186–187 oral complications, 182 Index osteonecrosis, 185 radiotherapy, 184, 185 Medical emergencies ABCDE approach airway (A), 192–195 breathing (B), 195–197 circulation (C), 197, 198 disability (D), 198 exposure (E), 198–200 ASA classification, 189 defibrillation, 200–202 drug box, 190 equipment, 191 local anaesthetic, 218 minimum equipment, 192 staff training, 191 training, 191 Melanocytic naevus, 152 Melanotic lesions, 152 Metabolic disorders clinical examination, 141, 142 medical history amyloidosis, 140, 141 carbohydrate metabolism, 141 glucose-6-phosphate dehydrogenase deficiency, 139 haemochromatosis, 140 hereditary coproporphyria, 138 hypercholesterolaemia, 138 malignant hyperpyrexia, 139 neuroleptic malignant syndrome, 139 porphyrias, 138 suxamethonium apnoea, 139, 140 variegate porphyria, 138 treatment drug effects, 144 drug interactions, 144, 145 general anaesthesia, 142, 143 hypercholesterolaemia, 142, 143 local anaesthesia, 143, 144 malignant hyperpyrexia, 142 methaemoglobinaemia, 144 sedation, 143 Methicillin-Resistant Staphylococcus aureus (MRSA), 231, 232 Multiple sclerosis, 50, 51, 60 Musculoskeletal system clinical examination cleidocranial dysplasia, 98 cranial arteritis, 99 dermatomyositis, 99 fibrous dysplasia, 98 Marfan’s patient, 98 oral complications, 98 penetrating injury, 98 www.pdflobby.com Index polymyositis, 99 Reiter’s syndrome, 99 rheumatoid arthritis, 96 medical history achondroplasia, 92 ankylosing spondylitis, 94 cleidocranial dysplasia, 90 cranial arteritis, 94 duchenne muscular dystrophy, 94 Ehlers-Danlos syndrome, 94 fibrous dysplasia, 90 gout, 93 joint replacements, 93 juvenile chronic arthritis, 92, 93 Marfan’s syndrome, 94 muscular disorders, 94 osteoarthritis, 92 osteogenesis imperfecta, 91 osteomalacia, 91 osteopetrosis, 90 osteoporosis, 90 Paget’s disease, 90 polymyalgia rheumatica, 94 rheumatoid arthritis, 92 rickets, 91 oro-dental structures, 101, 102 treatment general anaesthesia, 99–101 local anaesthesia, 99–101 sedation, 99–101 Myasthenia gravis, 31, 41, 53, 60, 94, 101, 126 Mycobacterium tuberculosis, 30, 98, 231 Myocardial infarction (MI) signs and symptoms, 210 treatment, 210, 211 N The National Early Warning Score (NEWS), 202 Nelson’s syndrome, 73 Neurological disorders clinical examination Horner’s syndrome, 57 Sturge-Weber syndrome, 57 cranial nerves, 58, 59 drugs effects, 60, 61 medical history brain abscess, 56 cerebral palsy, 56 cerebrovascular accident, 51 epilepsy, 50 facial pain, 52 Huntington’s chorea, 57 impairment of vision, 53 251 infections, 55 Motor neurone disease, 52 multiple sclerosis, 51 myasthenia gravis, 53 parkinson’s disease, 52 Ramsay-Hunt syndrome, 55 spina bifida, 56 stokes-Adams attacks, 51 syncope, 50 transient ischaemic attack, 51 tumours, 52 treatment general anaesthesia, 59–60 local anaesthesia, 59, 60 sedation, 59, 60 O Occupational lung disease, 31 Odontophobia, 169 Older patient clinical examination, 132–133 medical history, 130–132 elements, 131 national service framework, 133 prescribing, 134–135 treatment, 133–134 P Paediatric patient clinical examination cleidocranial dysplasia, 124, 125 cystic fibrosis, 125 down syndrome, 125 medical history cardiovascular conditions, 120 craniofacial disorders, 124 drug therapy, 123 endocrine conditions, 123 haematological conditions, 121 hepatic conditions, 122 neurological conditions, 122 renal disease, 122 respiratory conditions, 120, 121 treatment general anaesthesia, 125, 126 local anaesthesia, 125–127 sedation, 126, 127 Pancreatic disease, 15, 43, 44, 47, 69, 210 Paranasal air sinuses, 28 Parkinson’s disease, 50, 52, 60, 130, 133 Pemphigoid, 43, 158, 242 Peptic ulcer, 40, 44, 47, 82, 130, 244 Personal protective equipment (PPE), 223 www.pdflobby.com 252 Peutz Jeghers syndrome, 43, 44, 162 Polyarteritis nodosa, 157 Prions, 221, 230, 232, 233 Proximal interphalangeal (PIP), Pseudomembranous colitis, 44 Pseudomonas, 230, 232 Psoriasis, 7, 93, 148, 152, 155 Psychiatric disorders alcohol abuse, 174 anxiety, 168, 169 capacity, 175, 176 complications, 173 consent, 175, 176 dementia, 174 depression, 169, 170 disinhibition, 170 eating disorders, 171 hallucinations, 172, 173 hard and fast rules, 176 hyperactivity, 170, 171 hypochondriasis, 172 learning disability, 174 pain syndromes, 171, 172 paranoia, 169 presenting complaint, 176, 177 risk assessment, 177 substance misuse, 172 Pyogenic granuloma, 149 R Ramsay-Hunt syndrome, 55 Recurrent herpes infections, 159 Renal disorders clinical examination arteriovenous fistula, 86 gingival hyperplasia, 86 periorbital oedema, 84 clinical features, 82 medical history chronic kidney disease, 82 diabetic nephropathy, 82 haemostasis, 83 nephrotic syndrome, 82, 84 renal osteodystrophy, 83 prescribing, 87 treatment, 86, 87 Respiratory disorders clinical examination COPD, 32 relevant factors, 33 TB, 32 drugs effects antihistamines, 34 Index antimuscarinic bronchodilators, 34 Beta2 adrenergic agonists, 34 corticosteroids, 33 cough suppressants, 35 cromoglycate, 34 decongestants, 35 medical history adult respiratory distress syndrome, 31 bronchial asthma, 29 bronchiectasis, 30 cough, 27 cystic fibrosis, 30 infections, 28 lower respiratory tract infections, 28 occupational lung disease, 31 paranasal air sinuses, 28 sarcoidosis, 31 tuberculosis, 30 treatment general anaesthesia, 35–37 local anaesthesia sedation, 35–37 Respiratory viruses, 230, 231 Reye’s syndrome, 64, 65 Rheumatic fever, 5, 15, 17, 18 S Sarcoidosis, 28, 31, 53, 55 Scleroderma, 41, 242 Seborrhoeic dermatitis, 154 Severe combined immunodeficiency (SCID), 238 Shingles, 14, 160, 161, 229 Shortage of breath (SOB), 15, 16, 28, 83, 85 Sinus bradycardia, 19 Sinus tachycardia, 18–19 Skin disorders bacterial infections, 159 fungal infections, 160–161 hair disorders, 161–162 medical history acne rosacea, 155 acne vulgaris, 155 angioedema, 156 basal cell carcinoma, 152 basal cell papilloma, 149 dermatitis herpetiformis, 159 dermatomyositis, 157 discoid LE, 157 eczema, 154 epidermoid cyst, 149 erythema multiforme, 158 hereditary haemorrhagic telangiectasia, 149 www.pdflobby.com Index keratoacanthoma, 149 lichen planus, 155 lupus erythematosus, 157 malignant melanoma, 152 melanocytic naevus, 152 melanotic lesions, 152 pemphigoid, 158 polyarteritis nodosa, 157 psoriasis, 155 pyogenic granuloma, 149 seborrhoeic dermatitis, 154 squamous cell carcinoma, 152 strawberry naevus, 151 systemic LE, 157 systemic sclerosis, 157 urticaria, 156 varicose eczema, 154 miscellaneous conditions, 163 pigmentation disorders, 162 treatment addison’s disease, 164 antimicrobial drugs, 165 asymptomatic conditions, 163 corticosteroids, 165 dapsone, 165 dermatological conditions, 163 immunosuppressant drugs, 165 retinoids, 165 thrombocytopaenia, 164 viral infections, 159–160 Squamous cell carcinoma, 149, 151, 152, 180, 236 Staphylococcus aureus, 29, 98, 159, 161, 223, 231, 241 Stevens-Johnson syndrome, 34, 61, 159, 165, 242 Stokes-Adams attacks, 51 Strawberry naevus, 151 Stroke risk factors, 218 signs and symptoms, 218 treatment, 218 Syncope, 15, 16, 50, 51, 59, 197, 205, 206 253 Systemic LE, 157 Systemic sclerosis, 157, 163, 164 T Tuberculosis (TB), 231, 27, 30, 98, 224, 228, 229 Tuberous sclerosis, 163 Tumours, 43, 52, 56, 57, 65, 73, 75, 163, 179, 181, 182 U Urticaria, 154, 156, 237, 239 V Varicose eczema, 154 Vasodilators, 23 Vasovagal syncope signs and symptoms, 206 treatment, 206 Venous/lymphatic disorders, 15, 21 Ventricular extrasystole, 19 Ventricular fibrillation (VF), 199, 200 Verrucae (common warts), 159 Visual acuity, 58 W Warfarin, 4, 15, 19, 23, 24, 46, 106, 112, 113, 115–117, 135 Wiskott-Aldrich syndrome (WAS), 238 X Xanthelasma, 9, 141, 142 Xerostomia, 41, 61, 98, 102, 123, 172, 182, 186 Z Zollinger-Ellison syndrome, 73 ... Meechan, General Medicine and Surgery for Dental Practitioners, BDJ Clinician’s Guides, https://doi.org/10.1007/978-3-319-97737-9_1 www.pdflobby.com 1  General Medicine and? ?Surgery for Dental Practitioners: ... www.pdflobby.com General Medicine and? ?Surgery for Dental Practitioners: History Taking and? ?Examination of the Clothed Patient In Brief • All dental practitioners must be proficient at taking a medical... www.pdflobby.com 1  General Medicine and? ?Surgery for Dental Practitioners: History Taking… Table 1.2  Complementary medicines and their interactions with conventional medicines with potential

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