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DENTAL

FOURTH EDITION
EDITOR IN CHIEF
STEPHEN T. SONIS, DMD, DMSc
Clinical Professor of Oral Medicine
Harvard School of Dental Medicine;
Senior Surgeon and Chief
Divisions of Oral Medicine and Dentistry
Brigham and Women’s Hospital and the Dana-Farber Cancer Institute
Boston, Massachusetts;
Chief Scientific Officer
Biomodels, LLC
Watertown, Massachusetts
3251 Riverport Lane
St. Louis, Missouri 63043

DENTAL SECRETS, FOURTH EDITION ISBN: 978-0-323-26278-1

Copyright © 2015 by Elsevier Inc.
Copyright © 2003, 1998, 1994 by Hanley & Belfus, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval system,
without permission in writing from the publisher. Details on how to seek permission, further information about
the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other
than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient,
and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume
any liability for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.

Library of Congress Cataloging-in-Publication Data

Dental secrets / editor in chief, Stephen T. Sonis. -- Fourth edition.

p. ; cm. -- (Secrets)
Includes bibliographical references and index.
ISBN 978-0-323-26278-1 (pbk. : alk. paper)
I. Sonis, Stephen T., editor. II. Series: Secrets series.
[DNLM: 1. Dental Care--Examination Questions. WU 18.2]
RK57
617.60076--dc23
2014027439

Executive Content Strategist, Professional/Reference: Kathy Falk

Senior Content Development Specialist: Courtney Sprehe
Publishing Services Manager: Deborah L. Vogel
Project Manager: Bridget Healy
Design Direction: Amy Buxton

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

In memory of my father, H. Richard Sonis, DDS,
with admiration and gratitude
 PREFACE TO THE 4TH EDITION

It has been some time since the last edition of Dental Secrets. Despite the availability of many
terrific online resources, student enthusiasm for the Q & A short answer format found in this
book indicated that it was time for an update. Readers of older editions will note some changes
in contributors. We’ve been fortunate to recruit new authors and co-authors for a number of
chapters, which assures a fresh look at content. The science and practice of dentistry continues
to evolve. No matter how much we try, it’s almost impossible to be totally up-to-date. “Life-long
learning” is not just a catchy phrase. Hopefully, this book will help. Once again, Dental Secrets is
written for those who like to learn by those who love to teach.

iv
CONTRIBUTORS

Helene Bednarsh, RDH, BS, MPH Bernard Friedland, BChD, MSc, JD

Director of the HIV Dental Ombudsperson Assistant Professor of Oral Medicine, Infec-
Program tion, and Immunity;
Boston Public Health Commission Head, Division of Oral & Maxillofacial
Boston, Massachusetts Radiology
Harvard School of Dental Medicine
Isabelle I. Chase, DDS, FRCD(C) Boston, Massachusetts
Director of Postdoctoral Pediatric Dentistry
Boston Children’s Hospital; Jennifer L. Frustino, DDS, PhD
Instructor, Department of Growth and Director of Oral Cancer Screening and
Development Diagnostics
Harvard School of Dental Medicine Department of Dentistry
Boston, Massachusetts Division of Dental Oncology and Maxillofacial
Prosthetics
Joseph W. Costa Jr., DMD, MAGD Erie County Medical Center
Associate Surgeon Buffalo, New York
Brigham and Women’s Hospital;
Clinical Instructor David Kim, DDS, DMSc
Division of Oral Medicine, Infection, and Associate Professor of Oral Medicine, Infec-
Immunity tion, and Immunity;
Harvard School of Dental Medicine Director, Advanced Graduate Education
Boston, Massachusetts Program in Periodontology
Harvard School of Dental Medicine
Eve Cuny, BA, MS Boston, Massachusetts
Associate Professor
Department of Dental Practice; Kathy Kommit, MEd, LICSW
Director of Environmental Health and Safety Social Worker
Arthur A. Dugoni School of Dentistry The Stress Reduction Center
The University of the Pacific Acton, Massachusetts
San Francisco, California
Paul A. Levi Jr., DMD
Kathy Eklund, RDH, BS, MHP Associate Clinical Professor
Director of Occupational Health and Safety, Periodontology
and Patient and Research Participant Tufts University School of Dental Medicine
Advocate Boston, Massachusetts
Forsyth Institute
Steven Levine, DMD
Cambridge, Massachusetts;
Clinical Instructor
Adjunct Assistant Professor
Harvard School of Dental Medicine
Massachusetts College of Pharmacy and
Boston, Massachusetts;
Health Sciences
Endodontist
Forsyth School of Dental Hygiene
Limited to Endodontics: A Practice of
Boston, Massachusetts;
Endodontic Specialists
Adjunct Faculty
Brookline, Massachusetts
Mount Ida College
Newton, Massachusetts
Elliot V. Feldbau, DMD
Partner
General Dentist
Hammond Pond Dental Associates
Chestnut Hill, Massachusetts

v
 vi CONTRIBUTORS

Lin Li, DDS, MS, MPH Stephen T. Sonis, DMD, DMSc

Epidemiology Program Clinical Professor of Oral Medicine
School of Public Health Harvard School of Dental Medicine;
LSUHSC Senior Surgeon and Chief
New Orleans, Louisiana; Divisions of Oral Medicine and Dentistry
Department of Epidemiology and Health Brigham and Women’s Hospital and the
Promotion ­Dana-Farber Cancer Institute
College of Dentistry Boston, Massachusetts;
New York University Chief Scientific Officer
New York, New York Biomodels, LLC
Watertown, Massachusetts
Stephen A. Migliorini, DMD
Private Practice Ralph B. Sozio, DMD*
Stoneham, Massachusetts Former Associate Clinical Professor in Pros-
thetic Dentistry
Bonnie L. Padwa, DMD, MD Harvard University School of Dental
Oral Surgeon-in-Chief, Section of Oral and Medicine;
Maxillofacial Surgery Former Consultant
Department of Plastic and Oral Surgery Division of Oral Medicine and Dentistry
Boston Children’s Hospital; Brigham and Women’s Hospital
Associate Professor of Oral and Maxillofacial Boston, Massachusetts
Surgery
Harvard School of Dental Medicine Nathaniel Treister, DMD, DMSc
Boston, Massachusetts Assistant Professor
Department of Oral Medicine, Infection, and
Edward S. Peters, DMD, MS, ScD Immunity
Professor and Program Director Harvard School of Dental Medicine
Department of Epidemiology Brigham and Women’s Hospital
School of Public Heath Boston, Massachusetts
Louisiana State University
New Orleans, Louisiana Sook-Bin Woo, DMD, MMSc
Associate Professor
Andrew L. Sonis, DMD Department of Oral Medicine, Infection, and
Senior Associate Immunity
Pediatric Dentistry and Orthodontics Harvard School of Dental Medicine
Department of Dentistry Chief of Clinical Affairs
Boston Children’s Hospital; Division of Oral Medicine and Dentistry
Clinical Professor of Pediatric Dentistry Brigham and Women’s Hospital
Harvard School of Dental Medicine Boston, Massachusetts;
Boston, Massachusetts Co-Director, Center for Oral Disease
StrataDx Inc.
Lexington, Massachusetts

*Deceased
PATIENT MANAGEMENT:

CHAPTER 1
THE DENTIST-PATIENT
RELATIONSHIP
Elliot V. Feldbau and Kathy Kommit

CASE EXAMPLES
After you seat the patient, a 42-year-old woman, she turns to you and says glibly,
“I don’t like dentists.” How should you respond?
Tip: The patient presents with a gross negative generalization. Distortions and deletions of
information need to be explored. Not liking you, the dentist, whom she has never met before,
is not an accurate representation of what she is trying to say. Start the interview with curiosity
in your voice as you cause her to reflect by repeating her phrasing—“You don’t like dentists?”—
with the expectation that she will elaborate. Probably she has had a bad e­ xperience, and your
interest gives her an opportunity to elaborate on that and to understand what she needs from
you better. It is important to do active listening and allow the patient who comes to the office
with some negative expectations based on past situations to express her thoughts and feelings.
Therefore, you can show that perhaps you are different from a ­previous dentist with whom she
had a negative experience, and you can communicate that you want this to be a more positive
dental visit. The previous dentist might not have developed listening skills and left the patient
with a negative view of all dentists. The goals in a situation in which someone enters the office
with an already formed negative predisposition are to enhance communication, develop trust
and rapport, and start a new chapter in this patient’s dental experience.
As you prepare to do a root canal on tooth number 9, a 58-year-old man responds,
“The last time I had that dam on, I couldn’t catch my breath. It was horrible.” How
should you respond? What may be the significance of his statement?
Tip: The comment, “I couldn’t catch my breath,” requires clarification. Did the patient
have an impaired airway with past rubber dam experience, or has some long-ago experience
been generalized to the present? Does the patient have a gagging problem? A therapeutic
interview clarifies, validates, reassures, and allows the patient to be more compliant.
A 55-year-old man is referred for periodontal surgery. During the medical history,
he states that he had his tonsils out at age 10 years and, since then, any work on
his mouth frightens him. He feels like gagging. How do you respond?
Tip: A remembered traumatic event is generalized to the present situation. Although the
feelings of helplessness and fear of the unknown are still experienced, a reassured patient who
knows what is going to happen can be taught a new set of appropriate coping skills to enable
the required dental treatment to be carried out. The interview fully explores all phases of the
events surrounding the past trauma when the fears were first imprinted.
After performing a thorough examination for the chief complaint of recurrent swell-
ing and pain of a lower right first molar, you conclude that given the 80% bone loss
and advanced subosseous furcation decay, the tooth is hopeless. You recommend
extraction to prevent further infection and potential involvement of adjacent teeth.
Your patient replies, “I don’t want to lose any teeth. Save it!” How do you respond?
Tip: The command by the patient to save a hopeless tooth at all costs requires an understand-
ing of the denial process, or the clinician may be doomed to perform treatments with no hope of
success and face the likely consequence of a disgruntled patient. The interview should clarify the
patient’s feelings, fears, or interpretations regarding tooth loss. It may be a fear of not knowing
that a tooth may be replaced, fear of pain associated with extractions, fear of confronting disease
1
 2 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP

and its consequences, or even fear of guilt because of neglect of dental care. The interview
should clarify and inform while communicating a sense of concern and compassion.
With each of these patients, the dentist should be alerted that something is not routine.
Each patient expresses some concern and anxiety. This is clearly the time for the dentist
to remove the gloves, lower the mask, and begin a comprehensive interview. Although
responses to such situations may vary according to individual style, each clinician should pro-
ceed methodically and carefully to gather specific information based on the cues presented
by the patient. By understanding each patient’s comments and feelings related to earlier
experiences, the dentist can help the patient see that change is possible and that coping with
dental treatment is easily learned. The following questions and answers provide a framework
for conducting a therapeutic interview that increases patient compliance and reduces levels
of anxiety.

PATIENT INTERVIEW
1. What is the basic goal of the initial patient interview?
The basic goal is to establish a therapeutic dentist-patient relationship in which accurate
data are collected, presenting problems are assessed, and effective treatment is suggested.
The patient should feel heard and validated, which leads to a feeling of safety and trust.
2. What are the major sources of clinical data derived during the interview?
The clinician should be attentive to what the patient verbalizes (i.e., the chief complaint),
manner of speaking (how things are expressed), and nonverbal cues that may be related
through body language (e.g., posture, gait, facial expression, or movements). While listening
carefully to the patient, the dentist can observe associated gestures, fidgeting movements,
excessive perspiration, or patterns of irregular breathing that might indicate underlying
anxiety or emotional problems.
3. What are the common determinants of a patient’s presenting behavior?
1. The patient’s perception and interpretation of the present situation (the reality or view of
the present illness)
2. The patient’s past experiences or personal history
3. The patient’s personality and overall view of life
Patients generally present to the dentist for help and are relieved to share personal infor-
mation with a knowledgeable professional who can assist them. However, some patients also
may feel insecure or emotionally vulnerable because of such disclosures.
4. Discuss the insecurities that patients might encounter while relating their
­personal histories.
Patients may feel the fear of rejection, criticism, shame, or even humiliation from the dentist
because of their neglect of dental care. Confidential disclosures may threaten the patient’s
self-esteem. Thus, patients may react to the dentist with rational and irrational comments,
and their behavior may be inappropriate and even puzzling to the dentist. In a severely
­psychologically limited patient (e.g., one with psychosis or a personality disorder), their
behaviors may approach extremes. Furthermore, patients who perceive the dentist as judg-
mental or too evaluative are likely to become defensive, uncommunicative, or even hostile.
Anxious patients are more observant of any signs of displeasure or negative reactions by the
dentist. The role of effective communication is extremely important with such patients.
5. How can one effectively deal with the patient’s insecurities?
Communication founded on the basic concepts of empathy and respect gives the most sup-
port to patients. Understanding their point of view (empathy) and recognition of their right
to their own opinions and feelings (respect), even if different from the dentist’s personal
views, help deal with and avert potential conflicts.
6. Why is it important for dentists to be aware of their own feelings when dealing
with patients?
Although the dentist tries to maintain an attitude that is attentive, friendly, and even sym-
pathetic toward a patient, he or she needs an appropriate degree of objectivity in relation to
patients and their problems. Dentists who find that they are not listening with some degree
 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP 3

of emotional neutrality to the patient’s information should be aware of any personal feelings
of anxiety, sadness, indifference, resentment, or even hostility that may be aroused by the
patient. Recognition of any aspects of the patient’s behavior that arouse such emotions helps
dentists understand their own behavior and prevent possible conflicts in clinical judgment
and treatment plan suggestions. It is important to strive to be as neutral and nonjudgmental
as possible so that the patient can feel safe and trusting.
7. List two strategies for the initial patient interview.
1. During the verbal exchange with the patient, all the elements of the medical and dental
history relevant to treating the patient’s dental needs should be elicited.
2. In the nonverbal exchange between the patient and dentist, the dentist gathers cues from
the patient’s mannerisms while conveying an empathetic attitude.
8. What are the major elements of the empathetic attitude that a dentist tries to
relate to the patient during the interview?
• Attentiveness and concern for the patient
• Acceptance of the patient and his or her problems
• Support for the patient
• Involvement with the intent to help
9. How are empathetic feelings conveyed to the patient?
Giving full attention while listening demonstrates to the patient that you are physically
present and comprehend what the patient relates. Appropriate physical attending skills
enhance this process. Careful analysis of what a patient tells you allows you to respond
to each statement with clarification and interpretation of the issues presented. The
patient hopefully gains some insight into his or her problem, and rapport is further
enhanced.
10. What useful physical attending skills comprise the nonverbal component of
communication?
The adept use of face, voice, and body facilitates the classic “bedside manner,” including the
following:
Eye contact. Looking at the patient without overt staring establishes rapport.
Facial expression. A smile or nod of the head in affirmation shows warmth, concern, and
interest.
Vocal characteristics. The voice is modulated to create a calm tone, emphasize meaning,
and help the patient understand important issues.
Body orientation. Facing patients as you stand or sit signals attentiveness. Turning away
may seem like rejection.
Forward lean and proximity. Leaning forward tells a patient that you are interested and
want to hear more, thus making it easier for the patient to comment. Proximity infers inti-
macy, whereas distance signals less attentiveness. In general, 4 to 6 feet is considered to be a
social consultative zone.
A verbal message of low empathetic value may be altered favorably by maintaining eye
contact, leaning forward with the trunk, and having appropriate distance and body orienta-
tion. However, even a verbal message of high empathetic content may be reduced to a lower
value when the speaker does not have eye contact, turns away with a backward lean, or
maintains too far a distance. For example, do not tell the patient that you are concerned
while washing your hands with your back to the dental chair.
11. During the interview, what cues alert the dentist to search for more information
about a statement made by the patient?
Most people express information that they do not fully understand by using generalizations,
deletions, and distortions in their phrasing. For example, the comment, “I am a horrible
patient,” does not give much insight into the patient’s intent. By probing further, the dentist
may discover specific fears or behaviors that the patient has deleted from the opening
generalization. As a matter of routine, the dentist should be alert to such cues and use the
interview to clarify and work through the patient’s comments. As the interview proceeds,
trust and rapport are built as a mutual understanding develops and the patient’s level of fear
decreases.
 4 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP

12. Why is open-ended questioning useful as an interviewing format?

Questions that do not have specific yes or no answers give patients more latitude to express
themselves. More information allows the dentist to have a better understanding of patients
and their problems. The dentist is basically saying, “Tell me more about that.” Throughout
the interview, the clinician listens for any cues that indicate the need to pursue further ques-
tioning and obtain more information about expressed fears or concerns. Typical questions in
the open-ended format include the following:
• “What brings you here today?”
• “Are you having any problems?”
• “Please tell me more about it.”
13. How can the dentist help the patient relate more information or talk about a
­certain issue in greater depth?
A communication technique called facilitation by reflection is helpful. One simply repeats the last
word or phrase that was spoken in a questioning tone of voice. Thus, when a patient says, “I am
petrified of dentists,” the dentist responds, “Petrified of dentists?” The patient usually elaborates.
The goal is to go from a generalization to the specific fear to the origin of the fear. This process is
therapeutic and allows fears to be reduced or diminished as patients gain insight into their feelings.
14. How should one construct suggestions that help patients alter their behavior or
that influence the outcome of a command?
Negatives should be avoided in commands. Positive commands are more easily experienced,
and compliance is usually greater. To experience a negation, the patient first creates the
positive image and then somehow negates it. While experiencing something, only positive
situations can be realized; language forms negation. For example, to experience the command
“Do not run!,” one may visualize oneself sitting, standing, or walking slowly. A more direct
command is “Stop!” or “Walk!” Moreover, a negative command may create more resistance
to compliance, whether voluntary or not. If you ask someone not to see elephants, he or she
tends to see elephants first. Therefore, it may be best to ask patients to keep their mouth
open widely rather than say, “Don’t close,” or perhaps suggest, “Rest open widely, please.”
A permissive approach and indirect commands also create less resistance and enhance
compliance. One may say, “If you stay open widely, I can do my procedure faster and better,”
or “By flossing daily, you will experience a fresher breath and a healthier smile.” This style of
suggestion is usually better received than a direct command.
A linking phrase—for example, “as,” “while,” or “when”—to join a suggestion with some-
thing that is happening in the patient’s immediate experience provides an easier pathway for
a patient to follow and further enhances compliance. For example, “As you lie in the chair,
allow your mouth to rest open. While you take another deep breath, allow your body to
relax further.” In each of these, the patient easily identifies with the first experience and thus
complies with the additional suggestion more readily.
Providing pathways to achieve a desired end may help patients accomplish something that
they do not know how to do on their own. Patients may not know how to relax on command;
it may be more helpful to suggest that while they take in each breath slowly and see a drop of
rain rolling off a leaf, they can let their whole body become loose and at ease. Indirect sug-
gestions, positive images, linking pathways, and guided visualizations play a powerful role in
helping patients achieve desired goals.
15. How do the senses influence communication style?
Most people record experience in the auditory, visual, or kinesthetic mode. They hear, they
see, or they feel. Some people use a dominant mode to process information. Language can
be chosen to match the modality that best fits the patient. If patients relate their problem in
terms of feelings, responses related to how they feel may enhance communication. Simi-
larly, a patient may say, “Doctor, that sounds like a good treatment plan,” or “I see that this
disorder is relatively common. Things look less frightening now.” These comments suggest
an auditory mode and a visual mode, respectively. Matching your response to the patient’s
dominant mode can enhance communication.
16. When is reassurance most valuable in the clinical session?
Positive supportive statements to the patient that he or she is going to do well or be all right
are an important part of treatment. At some point, everyone may have doubts or fears about
 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP 5

the outcome. Reassurance given too early, such as before a thorough examination of the pre-
senting symptoms, may be interpreted by some patients as insincerity or as trivializing their
problem. The best time for reassurance is after the examination, when a tentative diagnosis is
reached. The support is best received by the patient at this point.
17. What type of language or phrasing is best avoided in patient communications?
Certain words or descriptions that are routine in the technical terminology of dentistry
may be offensive or frightening to patients. The words cutting, drilling, bleeding, injecting, or
clamping may be anxiety-provoking terms to some patients. Furthermore, being too technical
in conversations with patients may result in poor communication and provoke rather than
reduce anxiety. It is beneficial to choose terms that are neutral yet informative. One may
prepare a tooth rather than cut it or dry the area rather than suction all the blood. This
approach may be especially important during a teaching session when procedural and techni-
cal instructions are given as the patient lies helpless, listening to conversation that seems to
exclude his or her presence as a person.

DENTAL FEAR AND ANXIETY

18. How common is dental-related anxiety?
It is estimated that about 75% to 80% of individuals in the United States have some anxiety
about dental treatment. Approximately 5% to 10% of U.S. adults are considered to experi-
ence dental phobia to such a degree that complete avoidance of care ensues unless there is an
emergency toothache or abscess. Then it can be extremely stressful to the patient and pro-
vider. Women tend to be more phobic than men and younger individuals more than mature
adults. Unless this cycle of avoidance is treated by a knowledgeable and caring dentist, a
patient may never seek anything but beyond emergent care, with a resultant progression
toward edentulism.
19. What common dental-related fears do patients experience?
• Pain
• Drills (e.g., slipping, noise, smell)
• Needles (deep penetration, tissue injury, numbness)
• Loss of teeth
• Surgery
20. List four elements common to all fears.
1. Fear of the unknown 3. Fear of physical harm or bodily injury
2. Fear of loss of control 4. Fear of helplessness and dependency
Understanding these elements of fear allows effective planning for the treatment of fearful
and anxious patients.
21. During the clinical interview, how may one address such fears?
According to the maxim that “fear dissolves in a trusting relationship,” establishing good
rapport with patients is especially important. Second, preparatory explanations may deal
effectively with fear of the unknown and thus give the patient a sense of control. Allowing
patients to signal when they wish to pause or speak further alleviates their fear of loss of con-
trol. Finally, well-executed dental technique and clinical practices minimize unpleasantness.
22. How are dental fears learned?
Usually, dental-related fears are learned directly from a traumatic experience in a dental or
medical setting. The experience may be real or perceived by the patient as a threat, but a
single event may lead to a lifetime of fear when any element of the traumatic situation is
reexperienced. The situation may have occurred many years before, but the intensity of the
recalled fear may persist. Associated with the incident is the behavior of the doctor in the
past. Thus, for defusing learned fear, the behavior of the present doctor is paramount.
Fears also may be learned indirectly as a vicarious experience from family members,
friends, or even the media. Cartoons and movies often portray the pain and fear of the
dental setting. How many times have dentists seen the negative reaction of patients to the
term root canal, even though they may not have had one?
 6 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP

Past fearful experiences often occur during childhood, when perceptions are out of propor-
tion to events, but memories and feelings persist into adulthood, with the same distortions.
Feelings of helplessness, dependency, and fear of the unknown are coupled with pain and a
possible uncaring attitude on the part of the dentist creates a conditioned response of fear
when any element of the past event is reexperienced. Such events may not even be available
to conscious awareness.
23. How are the terms generalization and modeling related to the conditioning aspect
of dental fears?
Dental fears may be seen as similar to classic Pavlovian conditioning. Such conditioning may
result in generalization, in which the effects of the original episode spread to situations with
similar elements. For example, the trauma of an injury or details of an emergency setting,
such as sutures or injections, may be generalized to the dental setting. Many adults who had
tonsillectomies under ether anesthesia may generalize the childhood experience to the dental
setting, complaining of difficulty with breathing or airway maintenance, difficulty with gag-
ging, or inability to tolerate oral injections. Modeling is vicarious learning through indirect
exposure to traumatic events through parents, siblings, or any other source that affects the
patient.
24. Why is understanding the patient’s perception of the dentist so important in the
control of fear and stress?
According to studies, patients perceive the dentist as both the controller of what the patient
perceives as dangerous and as the protector from that danger. Thus, the dentist’s behavior
and communications assume increased significance. The patient’s ability to tolerate stress and
cope with fears depends on her or his ability to develop and maintain a high level of trust
and confidence in the dentist. To achieve this goal, patients must express all the issues that
they perceive as threatening, and the dentist must explain what he or she can do to address
patients’ concerns and protect them from the perceived dangers. This is the purpose of the
clinical interview. The result of this exchange should be increased trust and rapport and a
subsequent decline in fear and anxiety.
25. How do emotions evolve? What constructs are important to understanding
dental fears?
Psychological theorists have suggested that events and situations are evaluated by using inter-
pretations that are personality-dependent (i.e., based on individual history and experience).
Emotions evolve from this history. Positive or negative coping abilities mediate the interpreta-
tive process—people who believe that they are capable of dealing with a situation experience
a different emotion during the initial event than those with less coping ability. The resulting
emotional experience may be influenced by vicarious learning experiences (e.g., watching oth-
ers react to an event), direct learning experiences (e.g., having one’s own experience with the
event), or social persuasion (e.g., expressions by others of what the event means).
A person’s belief about his or her coping ability, or self-efficacy, in dealing with an appraisal
of an event for its threatening content is highly variable, based on the multiplicity of personal
life experiences. Belief that one has the ability to cope with a difficult situation reduces the
likelihood that an event will be appraised as threatening, and a lower level of anxiety will
result. A history of failure to cope with difficult events or the perception that coping is not
a personal accomplishment (e.g., reliance on external aids, drugs) often reduces self-efficacy
expectations, and interpretations of the event can result in higher anxiety.
26. How can learned fears be eliminated or unlearned?
Because fears of dental treatment are learned, relearning or unlearning is possible. A comfort-
able experience without the associated fearful and painful elements may eliminate the condi-
tioned fear response and replace it with an adaptive and more comfortable coping response.
Through the interview process, the secret is to uncover which elements have resulted in
the maladaptation and subsequent response of fear, eliminate them from the present dental
experience by reinterpreting them for the adult patient, and create a more caring and pro-
tected experience. During the interview, the exchange of information and insight gained by
the patient decrease levels of fear, increase rapport, and establish trust in the doctor-patient
relationship. The clinician only needs to apply an expert operative technique to treat the
vast majority of fearful patients.
 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP 7

27. What remarks may be given to a patient before beginning a procedure that the
patient perceives as threatening?
Opening comments by the dentist to inform the patient about what to expect during a
procedure—for example, pressure, noise, pain—may reduce the patient’s fear of the unknown
and sense of helplessness. Control through knowing is increased with these preparatory
communications.
28. How may the dentist further address the issue of loss of control?
A simple instruction that allows patients to signal by raising a hand if they wish to stop or
speak returns a sense of control. Also, patients can be given the choice of whether to lie back
or sit up.
29. What is denial? How may it affect a patient’s behavior and dental treatment
­planning decisions?
Denial is a psychological term for the defense mechanism that people use to block out the
experience of information with which they cannot emotionally cope. They may not be able
to accept the reality or consequences of the information or experience with which they
will have to cope; therefore, they distort that information or completely avoid the issue.
Often, the underlying experience of the information is a threat to self-esteem or liable to
provoke anxiety. These feelings are often unconsciously expressed by unreasonable requests
of treatment.
For the dentist, patients who refuse to accept the reality of their dental disease, such as the
hopeless condition of a tooth, may lead to a path of treatment that is doomed to fail. The
subsequent disappointment of the patient may result in litigation issues.
30. Define dental phobia.
A phobia is an irrational fear of a situation or object. The reaction to the stimulus is often
greatly exaggerated in relation to the reality of the threat. The fears are beyond voluntary
control, and avoidance is the primary coping mechanism. Phobias may be so intense that
severe physiologic reactions interfere with daily functioning. In the dental setting, acute
syncopal episodes may result.
Almost all phobias are learned. The process of dealing with true dental phobia may require
a long period of individual psychotherapy and adjunctive pharmacologic sedation. However,
relearning is possible, and establishing a good doctor-patient relationship is paramount.
31. What is PTSD and what are the symptoms?
Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops subsequent to a
traumatic event, such as sexual or physical abuse, serious accident, assault, war combat, or
natural disaster. Symptoms include intrusive memories, avoidance behaviors, mood disorders,
and high levels of physiologic arousal.
32. How do traumatic events create behaviors later in life?
Past traumatic events, whether remembered or suppressed in the subconscious, may
trigger behavioral responses that occur when similar or even vicarious events occur in
the present. These events may be through direct experience, such as an accident,
combat wound, or sexual abuse, or associated with observation of such events. The
triggered behavior in the patient may be generalized fear and anxiety, and even extreme
panic.
33. Why is it important for dental providers to be sensitive to this issue?
Patients with PTSD who come for dental treatment may feel very vulnerable and can some-
times find the experience retraumatizing. This is because the patient is often alone with the
dentist, is placed in a horizontal position, is being touched by the dentist, who is hierarchi-
cally more powerful (and often male), is having objects placed in the mouth, is unable to
swallow, and is anticipating or feeling pain. Many PTSD sufferers avoid going to the dentist,
often cancel or reschedule appointments, have stress-related dental issues, and experience
heightened distress while undergoing procedures.
34. How might a dentist know if a patient suffers from PTSD?
Often these patients are reluctant to admit this, so it is a good idea to ask during the diagnos-
tic interview, “Have you ever suffered from post-traumatic stress disorder?”
 8 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP

35. What are some special considerations when treating patients with PTSD?
Similar to treating other anxious patients, dentists want to practice active listening, show
compassion, and try to give the patient as much control in the situation as possible. You
might offer an initial appointment just to talk, place the chair in an upright position, keep
the door open, have an assistant present, check in frequently to see how the patient is doing,
offer reassurance, and explain the procedures as you proceed.
Also, you can offer soothing music, blanket, or body covering (e.g., an x-ray cover). Make
sure that the patient has been instructed to stop you whenever their anxiety level is getting
too high. Premedication may be helpful.
36. When should you refer a patient with PTSD for a psychological consultation?
If the patient is unable to tolerate being in the dental chair because her or his anxiety is
uncontrollably high, you might want to refer this patient to a professional who specializes in
the treatment of anxiety disorders. Counseling and antianxiety medications can be helpful
in the treatment of PTSD and, in some cases, may be a prerequisite to dental work being
carried out.
37. What strategies may be used with the patient who gags at the slightest
provocation?
The gag reflex is a basic physiologic protective mechanism that occurs when the posterior
oropharynx is stimulated by a foreign object; normal swallowing does not trigger the reflex.
When overlying anxiety is present, especially if anxiety is related to the fear of being unable
to breathe, the gag reflex may be exaggerated. A conceptual model is the analogy to being
tickled. Most people can stroke themselves on the sole of the foot or under their arm without
a reaction, but when the same stimulus is done by someone else, the usual results are laughter
and withdrawal. Hence, if patients can eat properly, put a spoon in their mouth, or suck on
their own finger, they are usually considered physiologically normal and may be taught to
accept dental treatment and even dentures with appropriate behavioral therapy.
In dealing with these patients, desensitization involves the process of relearning. A review
of the history to discover episodes of impaired or threatened breathing is important. Childhood
general anesthesia, near-drowning, choking, or asphyxiation may have been the initiating
event that created increased anxiety about being touched in the oral cavity. Patients may
fear the inability to breathe, and the gag becomes part of their protective coping mechanism.
Thus, reduction of anxiety is the first step; an initial strategy is to give information that allows
patients to understand their own response better.
Instruction in nasal breathing may offer confidence in the ability to maintain a constant
and uninterrupted air flow, even with oral manipulation. Also, diaphragmatic breathing,
which involves inflating the lower part of the abdomen, can be helpful. Eye fixation on a
single object may help dissociate and distract the patient’s attention away from the oral
cavity. This technique may be especially helpful for taking radiographs and for brief oral
examinations. For severe gaggers, hypnosis and nitrous oxide may be helpful; others may find
the use of a rubber dam reassuring. For some patients, longer term behavioral therapy may be
necessary.
38. What is meant by the term anxiety? How is it related to fear?
Anxiety is a subjective state commonly defined as an unpleasant feeling of apprehension or
impending danger in the presence of a real or perceived stimulus that the person has learned
to associate with a threat to well-being. The feelings may be out of proportion to the real
threat, and the response may be grossly exaggerated. Such feelings may be present before the
encounter with the feared situation and may linger long after the event. Associated somatic
feelings include sweating, tremors, palpitations, nausea, difficulty with swallowing, and
hyperventilation.
Fear is usually considered an appropriate defensive response to a real or active threat.
Unlike anxiety, the response is brief, the danger is external and readily definable, and
the unpleasant somatic feelings pass as the danger passes. Fear is the classic fight-or-flight
response and may serve as an overall protective mechanism by sharpening the senses and
ability to respond to the danger. The fear response does not usually rely on unhealthy actions
for resolution, but the state of anxiety often relies on noncoping and avoidance behaviors to
deal with the threat.
 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP 9

39. How is stress related to pain and anxiety? What are the major parameters of the
stress response?
When a person is stimulated by pain or anxiety, the result is a series of physiologic responses
dominated by the autonomic nervous system, skeletal muscles, and endocrine system. These
physiologic responses define stress. In what is termed an adaptive response, the sympathetic
responses dominate—increases in pulse rate, blood pressure, respiratory rate, peripheral vaso-
constriction, skeletal muscle tone, and blood sugar; decreases in sweating, gut motility, and
salivation. In an acute maladaptive response, the parasympathetic responses dominate,
and a syncopal episode may result—decreases in pulse rate, blood pressure, respiratory rate,
and muscle tone; increases in salivation, sweating, gut motility, and peripheral vasodilation,
with overall confusion and agitation. In chronic maladaptive situations, psychosomatic
disorders may evolve. Figure 1-1 illustrates the relationships of fear, pain, and stress. It is
important to control anxiety and stress during dental treatment. The medically compromised
patient requires appropriate control to avoid potentially life-threatening situations.
40. What is the relationship between pain and anxiety?
Many studies have shown the close relationship between pain and anxiety. The greater the
person’s anxiety, the more likely it is that he or she will interpret the response to a stimulus
as painful. In addition, the pain threshold is lowered with increasing anxiety. People who are
debilitated, fatigued, or depressed respond to threats with a higher degree of undifferentiated
anxiety and thus are more reactive to pain.
41. List four guidelines for the proper management of pain, anxiety, and stress.
1. Make a careful assessment of the patient’s anxiety and stress levels by a thoughtful
interview. Uncontrolled anxiety and stress may lead to maladaptive situations that could
become life-threatening in medically compromised patients. Prevention is the most
important strategy.

Perceived threat
or painful stimulus

Mind/Body

Mental/Psychological Physical/Somatic
response response

Anxiety Stress

Personality factors Medically compromising factors

Coping/Adaption Noncoping/ Chronic/Psychosomatic

Maladaptation disease

Physiologic arousal response Acute syncope

Figure 1-1. Relationships of pain, anxiety, stress, and reactions. (From Gregg JM: Psychosedation. Part 1. In
­McCarthy FM, editor: Emergencies in dental practice, ed 3, Philadelphia, WB Saunders, 1979, p 230.)
 10 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP

2. From all information gathered, medical and personal, determine the correct methods for
controlling the pain and anxiety. This assessment is critical to appropriate management.
Monitoring the patient’s responses to the chosen method is essential.
3. Use medications as adjuncts for positive reinforcement, not as methods of control. Drugs
circumvent fear; they do not resolve conflicts. The need for good rapport and communica-
tion is always essential.
4. Adapt control techniques to fit the patient’s needs. The use of a single modality for all
patients may lead to failure; for example, the use of nitrous oxide sedation to moderate
severe emotional problems may not be helpful for all patients.
42. Construct a model for the therapeutic interview of a self-identified fearful patient.
1. Recognize a patient’s anxiety by acknowledging what the patient says or observing the
patient’s demeanor. Recognition, which is verbal and nonverbal, may be as simple as say-
ing, “Are you nervous about being here?” This indicates the dentist’s concern, acceptance,
supportiveness, and intent to help.
2. Facilitate patients’ cues as they tell their story. Help them go from generalizations to
specifics, especially to past origins, if possible. Listen for generalizations, distortions, and
deletions of information or misinterpretation of events as the patient talks.
3. Allow patients to speak freely. Their anxiety decreases as they tell their story, describing
the nature of their fear and the attitude of previous doctors. Trust and rapport between
doctor and patient also increase as the patient is allowed to speak to someone who cares
and listens.
4. Give feedback to the patient. Interpretation of the information helps patients learn
new strategies for coping with their feelings and adopting new behaviors by confront-
ing past fears. Thus, a new set of feelings and behaviors may replace maladaptive coping
mechanisms.
5. Finally, the dentist makes a commitment to protect the patient—a commitment that the
patient may have perceived as absent in past dental experiences. Strategies include allow-
ing the patient to stop a procedure by raising a hand or simply assuring a patient that you
are ready to listen at any time.
43. Discuss behavioral methods that may help patients cope with dental fears and
related anxiety.
1. The first step for the dentist is to get to know the patient and his or her presenting needs.
Interviewing skills cannot be overemphasized. A trusting relationship is essential. As the
clinical interview proceeds, fears are usually reduced to coping levels.
2. Because a patient cannot be anxious and relaxed at the same moment, teaching methods
of relaxation may be helpful. Systematic relaxation allows the patient to cope with the
dental situation. Guided visualizations may be helpful to achieve relaxation. Paced
breathing also may be an aid to keeping patients relaxed. Guiding the rate of inspira-
tion and expiration allows a hyperventilating patient to resume normal breathing, thus
decreasing the anxiety level. A sample relaxation script is presented in Box 1-1.
3. Hypnosis, a useful tool with myriad benefits, induces an altered state of awareness, with
heightened suggestibility for changes in behavior and physiologic responses. It is easily
taught, and the benefits can be highly beneficial in the dental setting.
4. Informing patients of what they may experience during a procedure addresses the specific
fears of the unknown and loss of control. Sensory information—that is, what physical
sensations may be expected—as well as procedural information is appropriate. Knowledge
enhances a patient’s coping skills.
5. Modeling, or observing a peer undergo successful dental treatment, may be beneficial.
Videotapes are available for a variety of dental scenarios.
6. Methods of distraction may also improve coping responses. Audio or video programs have
been reported to be useful for some patients.
44. What are common avoidance behaviors associated with anxious patients?
Generally, putting off making appointments, followed by cancellations and failing to appear,
are routine events for anxious patients. The avoidance of care can be of such magnitude
that personal suffering is endured from tooth ailments, with emergency consequences. A
mutilated dentition often results.
 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP 11

BOX 1-1. Relaxation Script

The following example should be read in a slow, rhythmic, and paced manner while carefully observing the patient’s
responses. Backing up and repeating parts are beneficial if you find that the patient is not responding at any time.
Feel free to change and incorporate your own stylistic suggestions.
Allow yourself to become comfortable . . . and as you listen to the sound of my voice, I shall guide you along a
pathway of deepening relaxation. Often we start out at some high level of excitement, and as we slide, down lower,
we can become aware of our descent and enjoy the ride. Let us begin with some attention to your breathing . . .
taking some regular, slow. . . easy. . . breaths. Let the air flow in . . . and out . . . air in . . . air out . . . until you become
very aware of each inspiration . . . and . . . expiration . . . . [pause] Very good. Now as you feel your chest rise with
each intake and fall with each outflow, notice how different you now feel from a few moments ago as you comfort-
ably resettle yourself in the chair, adjusting your arms and legs just enough to make you feel more comfortable.
Now with regularly paced, slow, and easy breathing, I would like to ask that you become aware of your arms
and hands as they rest [describe where you see them—e.g., “on your lap”] … Move them slightly. [pause] Next
become aware of your legs and feel the chair’s support under them … they may also move slightly. We shall begin
our total body relaxation in just this way … becoming aware of a part and then allowing it to become at ease …
resting, floating, lying peacefully. Start at your eyelids and, if they are not already closed, allow them to become free
and rest them downward …your eyes may gaze and float upward. Now focus on your forehead … letting the subtle
folds become smoother and smoother with each breath. Now let this peacefulness of eyelids and forehead start a
gentle warm flow of relaxing energy down over your cheeks and face, around and under your chin, and slowly down
your neck. You may find that you have to swallow . . . allow this to happen, naturally. Now continue this as a stream
flowing over your shoulders and upper chest and over and across to each arm … [pause] … and when you feel this
warmth in your fingertips you may feel them move ever so slightly … [pause for any movement] Very good.
Next, allow the same continuous flow to start down to your lower body and over your waist and hips…reaching
each leg. You may notice that they are heavy or light, and that they move ever so slightly as you feel the chair supporting
them with each breath and each swallow that you take. You are resting easily, breathing comfortably and effortlessly.
You may now become aware of just how much at ease you are, in such a short time, from a moment ago,
when you entered the room. Very good, be at ease.

45. Whom do dentists often consider their most “difficult” patient?

Surveys have repeatedly shown that dentists often view the anxious patient as their most difficult
challenge. Almost 80% of dentists report that they themselves become anxious with an anxious
patient. The ability to assess a patient’s emotional needs carefully helps the clinician improve his
or her ability to deal effectively with an anxious patient. Furthermore, because anxious patients
require more chair time for procedures, are more reactive to stimuli, and associate more sensa-
tions with pain, effective anxiety management yields more effective practice management.
46. What are the major practical considerations in scheduling identified anxious den-
tal patients?
Autonomic arousal increases in proportion to the length of time before a stressful event. A
patient left to anticipate the event with negative self-statements and perhaps frightening
images for a whole day or for a long time in the waiting area is less likely to have an easy
experience. Thus, it is considered prudent to schedule patients earlier in the day and keep
the waiting period after the patient’s arrival as short as possible. In addition, the dentist’s
energy is usually optimal earlier in the day for dealing with more demanding situations.
47. What do patients describe as qualities and behaviors of a dentist who makes
them feel relaxed and lowers their anxiety?
• Explains procedures before starting
• Gives specific information during procedures
• Instructs the patient to be calm
• Verbally supports the patient: gives reassurance
• Helps the patient redefine the experience to minimize threat
• Gives the patient some control over procedures and pain
• Attempts to teach the patient to cope with distress
• Provides distraction and tension relief
• Attempts to build trust in the dentist
• Shows personal warmth to the patient
 12 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP

48. What qualities do patients describe as making them feel satisfied with their
­dentist and dental experience?
• Assured me that he or she would • Gave me moral support
prevent pain • Reassured me that she or he would
• Was friendly alleviate pain
• Worked quickly, but did not rush • Asked if I was concerned or nervous
• Had a calm manner • Made sure that I was numb before
starting

HEALTH INFORMATION AND IMPROVEMENT

49. What is the opportune time to teach new health information to patients?
Patients are most receptive to learning new health behaviors when there is an immediate
need for the new skill or behavior. A patient with gingival bleeding at a furcation site wants
to know how to resolve the problem and is most receptive to learning how to use a proxy
brush.
50. What is a strong motivational tool to use for communicating health improvement
issues?
Positive feedback while instructing often yields the greatest acceptance and minimizes
patient resistance to compliance. Fear of tooth loss, for example, may not weigh as much in
communicating the consequences of not brushing as creating a desire for a healthy smile and
teeth that last a lifetime.
51. In introducing new ideas about oral hygiene, what considerations help maximize
compliance?
People learn best when information is presented in the context of their own personal experi-
ence. In talking to an avid woodworker, for example, the dentist may speak about “planing
down” plaque and debris to create a smooth surface that will stay clean and healthy. Simi-
larly, a gardener may “keep plaque weeds suppressed” to allow healthy tissues to grow. In each
case, context-specific phrasing communicates ideas most effectively.
52. Does self-esteem play a role in adopting new behaviors such as flossing and
regular brushing?
It absolutely plays a role. Most adults want to learn concepts that enhance or maintain their
self-esteem. Enhancing their physical appearance is directly related to the acceptance of new
health behaviors.
53. List four important elements in maximizing the long-term retention of information
given by the dental team to patients.
1. 
Repetition of key ideas enhances patient learning and compliance. A patient may recall
only one third of a conversation after 24 hours and even less after 30 days. By artfully
repeating ideas and concepts at the initial presentation, recall is maximized.
2. 
Interest and direct relevance of information to the patient’s specific needs yield the great-
est learning experience. A patient with a loose tooth is concerned about why the problem
occurred and how to prevent tooth loss. This concern may outweigh issues related to the
general concepts of periodontal disease and the outcome of needing full dentures.
3. 
Context of the information presented should been within the personal experience of the
patient to maximize acceptance and understanding.
4. 
Emotion relates the patient’s feeling about dental issues. Understanding relevant emo-
tional history enhances doctor-patient rapport and the patient’s trust and acceptance of
the suggestions made by the dental team.

CLINICAL FINDINGS
54. What are four common styles that a dentist may use to communicate clinical
­findings and discuss treatment plans to the patient?
Because of the unique listening and learning styles of individuals, dentists should be adept at
varying their style of communication to suit the needs of their patients best.
 CHAPTER 1 PATIENT MANAGEMENT: THE DENTIST-PATIENT RELATIONSHIP 13

1. A classic style is the paternalistic model. This is a manner of communication in which

the dentist assumes the role of the parent and relates to the patient as an immature, in-
experienced individual. The patient becomes acquiescent to the directives of the dentist,
who has the clinical information and knows what is the best treatment. In this style, the
dentist uses his or her clinical knowledge and values in the decision process, giving the
patient little or no autonomy. In essence, the dentist becomes the patient’s guardian.
Although not considered appropriate in most situations, there are patients who do require
very careful guidance because they may be totally overwhelmed by making any decisions
for themselves. “Doctor, please do whatever you think is best for me” may be their request.
2. The informative model assumes that the patient is very inquisitive, perhaps even scien-
tific in their thoughtful analysis of presented information. The objective of the dentist
is to provide all the relevant clinical findings and treatment choices to the patient. The
patient then is able to make the decision about what dental treatment he or she wishes
to receive. This model gives the patient autonomy to choose based on her or his values.
The dentist only presents the factual objective information and does not include personal
values in the decision process. The patient relies on the dentist’s clinical knowledge and
technical expertise to execute the desired therapy.
3. The interpretive model creates a cooperative interaction between the dentist and patient
in which the patient’s values are elucidated and then the appropriate treatment choices
are developed that meet the patient’s desires. The dentist does not dictate the patient’s
values, but tries to help the patient articulate and understand them. The dentist becomes
a counselor, helping create patient autonomy through self-understanding by the patient.
4. The deliberative model creates a dentist’s role as teacher and partner by helping the
patient chose the best health-related values that can be realized for the patient’s health.
After presenting the clinical findings, the dentist explains the values related to the
treatment options, and expresses his or her opinions about why some choices are more
worthwhile to overall health. The dentist’s expression of these values is presented
here, but only to help patients in developing their own self-awareness of their choices
about health-related issues. It is a dialogue that becomes the goal, with mutual respect
preserved.
55. What are some of the factors that might contribute to bruxism?
Mental disorders, anxiety, stress, and adverse psychosocial factors can all be related to tooth
grinding during sleep. It has been found that almost 70% of bruxism occurs as a behavioral
symptom resulting from stress and anxiety. Job-related stress has been found to be the most
significant stressor associated with bruxism.
56. What are some treatment considerations for the dentist, in addition to dental ap-
pliance therapy?
As with other patients presenting with some variant of anxiety, the dentist wants to be sure
to conduct a thorough and sensitive interview. It is important to ask the bruxer, “Have you
been under any stress in your life lately?” and to explain how this could be a contributing
factor. There are some behavioral approaches that can be useful. Patients can be educated
about how postural habits such as chin thrusting and/or chewing on pencils can contribute to
straining the jaw muscles. Biofeedback is an effective treatment modality in which patients
can learn how to become aware of the tension in their jaw muscles and then practice alterna-
tive behaviors.

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TREATMENT PLANNING AND

CHAPTER 2
ORAL DIAGNOSIS
Stephen T. Sonis and Nathaniel Treister

TREATMENT PLANNING
1. What are the objectives of pretreatment evaluation of a patient?
1. Establishment of a diagnosis
2. Determination of underlying medical conditions that may modify the oral condition or
patient’s ability to tolerate treatment
3. Discovery of concomitant illnesses
4. Prevention of medical emergencies associated with dental treatment
5. Establishment of rapport with the patient
2. What are the essential elements of a patient history?
1. Chief complaint 5. Family history
2. History of the present illness (HPI) 6. Review of systems
3. Past medical history 7. Dental history
4. Social history

3. Define the chief complaint.

The chief complaint is the reason that the patient seeks care, as described in the patient’s
own words.
4. What is the history of the present illness?
The HPI is a chronologic description of the patient’s symptoms and should include informa-
tion about duration, location, character, and previous treatment.
5. What elements need to be included in the medical history?
• Current status of the patient’s general • Hospitalizations and surgeries
health • Allergies
• Medications

6. What areas are routinely investigated in the social history?

• Present and past occupations • Occupational hazards
• Smoking, alcohol or drug use • Marital status and relevant sexual history

7. Why is the family history of interest to the dentist?

The family history often provides information about diseases of genetic origin or diseases that
have a familial tendency. Examples include clotting disorders, atherosclerotic heart disease,
psychiatric diseases, and diabetes mellitus.
8. How is the medical history usually obtained?
The medical history is obtained with a written questionnaire supplemented by a verbal
history. The verbal history is imperative because patients may leave out or misinterpret
questions on the written form. For example, some patients may take daily aspirin and yet
not consider it a “true” medication. Surprisingly, patients who are treated with an annual
infusion of bisphosphonates for osteoporosis may not consider this a medication. The verbal
history also allows the clinician to pursue positive answers on the written form and, in doing
so, establish rapport with the patient.
9. What techniques are used for physical examination of the patient? How are they
used in dentistry?
Inspection, the most commonly used technique, is based on visual evaluation of the patient.
Palpation, which involves touching and feeling the patient, is used to determine the
15
 16 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS

consistency and shape of masses in the mouth or neck. Percussion, which involves differences
in sound transmission of structures, has little application to the head and neck. Auscultation,
the technique of listening to differences in the transmission of sound, is usually accomplished
with a stethoscope. In dentistry, it is generally used to listen to changes in sounds emanating
from the temporomandibular joint and to take a patient’s blood pressure.
10. What are the patient’s vital signs?
• Blood pressure • Pulse
• Respiratory rate • Temperature

11. What are the normal values for the vital signs?
• Blood pressure: 120 mm Hg/80 mm Hg • Pulse: 72 beats per minute
• Respiratory rate: 16 to 20 respirations per • Temperature: 98.6° F or 37° C
minute

12. What is a complete blood count (CBC)?

A CBC consists of a determination of the patient’s hemoglobin, hematocrit, white blood cell
count, differential white blood cell count, and platelet count.
13. What are the normal ranges of a CBC?

Hemoglobin: Men, 14-18 g/dL Differential white blood count:

Women, 12-16 g/dL Neutrophils, 50%-70%
Hematocrit: Men, 40%-54% Lymphocytes, 30%-40%
Women, 37%-47% Monocytes, 3%-7%
White blood count: 4,000-10,000 cells/mm3 Eosinophils, 0%-5%
Platelet count: 150,000-400,000 cells/ mm3 Basophils, 0%-1%

14. What is the most effective blood test to screen for diabetes mellitus?
The most effective screen for diabetes mellitus is fasting blood glucose. The glycosylated
hemoglobin test (HGbA1c, usually just called A1c) can be ordered without fasting and effec-
tively assesses glucose levels over a 90 day period. A1c is typically used to monitor patients,
rather than for diagnostic screening.

ORAL DIAGNOSIS
15. What is the technique of choice for the diagnosis of a soft tissue lesion in the
mouth?
With a few exceptions, a biopsy is the diagnostic technique of choice for almost all soft tissue
lesions of the mouth.
16. Is there any alternative diagnostic technique to biopsy for the evaluation of
suspected malignancies of the mouth?
Exfoliative cytology has been used in the past for the diagnosis of oral lesions. Because of its
high false-negative rate, it has never been particularly effective. Recently, the technique has
been modified to include the use of a brush to obtain a cell sample and then a specific pro-
cessing and evaluation procedure that increases the sensitivity of the assay. Biopsy remains
the most reliable way to make a diagnosis.
17. When is immunofluorescence of value in oral diagnosis?
Immunofluorescent techniques are of value in the diagnosis of autoimmune vesiculobullous
diseases that affect the mouth, including pemphigus vulgaris and mucous membrane pem-
phigoid. Immunofluorescence can also be used in the diagnosis and typing of herpes simplex
virus (HSV) infection.
18. What elements should be included in the dental history?
1. Past dental visits, including frequency, reasons, previous treatment, and complications
2. Oral hygiene practices
3. Oral symptoms other than those associated with the chief complaint, including tooth pain
or sensitivity, gingival bleeding or pain, tooth mobility, halitosis, and abscess formation
 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS 17

4. Past dental or maxillofacial trauma

5. Habits related to oral disease, such as bruxing, clenching, and nail biting
6. Dietary history
19. When is it appropriate to use microbiologic culturing in oral diagnosis?
1. 
Bacterial infection. Because the overwhelming majority of oral infections are sensitive
to treatment with penicillin, routine bacteriologic culture of primary dental infections is
not generally indicated. However, cultures are indicated for patients who are immu-
nocompromised or myelosuppressed for two reasons: (1) they are at significant risk for
sepsis; and (2) the oral flora often change in these patients. Cultures should be obtained
for infections that are refractory to the initial course of antibiotics before changing
antibiotics.
2. 
Viral infection. Immunocompromised patients who present with mucosal ulcerations may
be manifesting signs of a herpes simplex infection. A viral culture is warranted. Routine
culturing for typical secondary herpes infections (herpes labialis) is not warranted for
healthy patients. Once a specimen is obtained, it should be kept on ice and transported to
the laboratory as quickly as possible because viral cultures are temperature-sensitive.
3. 
Fungal infection. Candidiasis is the most common fungal infection affecting the oral mu-
cosa. Because its appearance is often varied, especially in immunocompromised patients,
fungal cultures may be of value. In addition, because a candidal infection is a frequent
cause of a burning mouth, culture is often indicated for immunocompromised patients,
even in the absence of visible lesions. Of note, however, a positive culture does not con-
firm infection, but only the presence of candida organisms.
20. How do you obtain access to a clinical laboratory?
It is easy to obtain laboratory tests for your patients, even if you do not practice in a hospital.
Community hospitals provide almost all laboratory services that your patients may require.
Usually, the laboratory provides order slips and culture tubes. Simply indicate the test
needed, and send the patient to the laboratory. Patients who need a test at night or on a
weekend can generally be accommodated through the hospital’s emergency department.
Commercial laboratories also may be used, and they also supply order forms. If you practice
in a medical building with other physicians, find out which laboratory they use. If they use a
commercial laboratory, a pick-up service for specimens may be provided. The most important
issue is to ensure the quality of the laboratory. Adherence to the standards of the American
College of Clinical Pathologists is a good indicator of laboratory quality.
21. What is the approximate cost of a complete blood count (CBC)?
The Medicare allowable rate is $10.95.
22. Which laboratory tests should be used to assess a patient who may be at risk for
a deficiency in hemostasis?
The basic laboratory tests for a possible coagulopathy should include assessments of platelet
number and clotting factors of the internal and external pathways. The three essential tests
are a CBC, which includes platelet number, prothrombin time (typically expressed as the
international normalized ratio, or INR), and partial thromboplastin time.
23. What positive responses in the medical history should suggest to you that a
patient may have a problem with hemostasis?
• Family history of a bleeding problem, such as hemophilia
• Taking medications that can cause thrombocytopenia, such as cancer chemotherapy
• History of a disease that may cause thrombocytopenia
• Taking medications known to cause prolonged bleeding, such as aspirin, warfarin, or vitamin E
• History of liver disease
24. What are the causes of halitosis?
Halitosis may be caused by local factors in the mouth and by extraoral or systemic factors.
Local factors include food retention, periodontal infection, caries, acute necrotizing gingivi-
tis, and mucosal infection. Extraoral and systemic causes of halitosis include smoking, alcohol
ingestion, pulmonary or bronchial disease, metabolic defects, diabetes mellitus, sinusitis, and
tonsillitis.
 18 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS

25. Which bacteria are associated with halitosis?

Gram-negative anaerobes are associated with halitosis.
26. Which gases are associated with halitosis?
Volatile sulfur compounds—in particular, hydrogen sulfide, methyl mercaptan, and dimethyl
sulfide—are associated with halitosis.
27. What are the most commonly abused drugs in the United States?
• Alcohol
• Marijuana
• Cocaine
• Phencyclidine (PCP)
• Heroin
• Methamphetamines
• Prescription medications
• Narcotic analgesics
• Tricyclic antidepressants
• Sedative-hypnotics
• Stimulants
• Anxiolytic agents
• Diet aids
28. What are the common causes of lymphadenopathy?
1. Infectious and inflammatory diseases of all types—oral conditions that can cause
lymphadenopathy include herpes infections, dental infection, pericoronitis, aphthous or
traumatic ulceration, and acute necrotizing ulcerative gingivitis
2. Immunologic diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and
drug reactions
3. Malignant disease, such as Hodgkin disease, non-Hodgkin lymphoma, leukemia, and
metastatic disease from solid tumors
4. Hyperthyroidism
5. Lipid storage diseases, such as Gaucher disease and Niemann-Pick disease
6. Other conditions, including sarcoidosis, amyloidosis, and granulomatosis
29. How can one differentiate between lymphadenopathy associated with an inflam-
matory process and lymphadenopathy associated with tumor?
1. Onset and duration. Inflammatory nodes tend to have a more acute onset and course than
nodes associated with malignancy.
2. Identification of an associated infected site. An identifiable site of infection associated
with an enlarged lymph node is probably the source of the lymphadenopathy. Effective
treatment of the site should result in resolution of the lymphadenopathy.
3. Symptoms. Enlarged lymph nodes associated with an inflammatory process are usually ten-
der to palpation. Nodes associated with cancer are not.
4. Progression. Continuous enlargement over time is associated with cancer.
5. Fixation. Inflammatory nodes are usually freely movable, whereas nodes associated with
tumor are hard and fixed.
6. Lack of response to antibiotic therapy. Continued nodal enlargement in the face of ap-
propriate antibiotic therapy should be viewed as suspicious.
7. Distribution. Unilateral nodal enlargement is a common presentation for malignant
disease. In contrast, bilateral enlargement is often associated with systemic processes.
30. What is the most appropriate technique for lymph node diagnosis?
The most appropriate technique for lymph node diagnosis is biopsy or needle aspiration.
Needle aspiration is preferred, but is technique-sensitive.
31. What are the most frequent causes of intraoral swelling?
The most frequent causes of intraoral swelling are infection and tumor (benign or
malignant).
32. Why does Polly get parotitis?
Polly gets it from too many crackers.
 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS 19

33. Why do humans get parotitis?

A viral or bacterial infection is the most common cause of parotitis in humans. Viruses
causing parotitis are mumps, coxsackie, and influenza. Staphylococcus aureus, the most
common bacterial cause of parotitis, results in the production of pus within the gland.
Other bacteria, such as Actinomyces, streptococci, and gram-negative bacilli, may also cause
suppurative parotitis.
34. What are common causes of xerostomia?
• Advanced age
• Certain medications
• Radiation therapy
• Sjögren syndrome
35. What is the presentation of a patient with a tumor of the parotid gland? How is
the diagnosis made?
The typical patient with a parotid gland tumor presents with a firm, fixed mass in the
region of the gland. Involvement of the facial nerve is common and results in facial palsy.
Fine-needle biopsy is a commonly used technique for diagnosis. However, the small sample
obtained by this technique may be limiting. Computed tomography (CT) and magnetic
resonance imaging (MRI) are also often helpful for evaluating suspected tumors.
36. What are the major risk factors for oral cancer?
Tobacco and alcohol use are the major risk factors for the development of oral cancer.
Human papilloma virus (HPV) subtypes 16 and 18 are associated with oropharyngeal can-
cers, with the primary risk factor being the number of lifetime sexual partners.
37. What is the most common location of cancers of the tongue?
The most common location is the lateral or ventral edge of the posterior tongue.
38. Summarize the impact of early detection of mouth cancers on survival.
Although the 5-year survival rate for advanced tongue cancers is only 20%, it is 65% for
more localized tumors. For tumors of the floor of the mouth, the difference in survival rates
between treatment of early tumors and treatment of advanced cancers is 60%. Patients with
early floor mouth tumors have a 5-year survival rate of 78%, but this rate plummets to only
18% for advanced cancers.
39. How is oral cancer staged?
Tumor staging is a system whereby cancers are clinically defined based on the parameters of
tumor size, involvement of local nodes, and metastases (TNM).
40. What is the possible role of toluidine blue stain in oral diagnosis?
Because toluidine blue is a metachromatic nuclear stain, it has been reported to be preferen-
tially absorbed by dysplastic and cancerous epithelium. Consequently, it has been used as a
technique to screen oral lesions. The technique has a reported false-positive rate of 9% and a
false-negative rate of 5%.
41. What are the two most common clinical presentations of oral cancers?
The two most common clinical presentations of oral cancer are a nonhealing ulcer or an
area of leukoplakia, often accompanied by erythema.
42. What percentage of keratotic white lesions in the mouth are dysplastic or
cancerous?
Keratotic white lesions are generally regarded as leukoplakia. The term has had inconsistent
interpretations, but is now considered simply to be a nonscrapable, keratotic plaque. The risk
of such lesions being dysplastic or cancerous is between 5% and 15%. The risk is higher in
smokers.
43. What is a simple way to differentiate clinically between necrotic and keratotic
white lesions of the oral mucosa?
Necrotic lesions of the mucosa, such as those caused by burns or candidal infections, scrape
off when gently rubbed with a moist tongue blade. Conversely, because keratotic lesions
result from epithelial changes, scraping fails to dislodge them.
 20 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS

44. How long should one wait before obtaining a biopsy of an oral ulcer?
Almost all ulcers caused by trauma or aphthous stomatitis heal within 14 days of presenta-
tion. Consequently, any ulcer that is present for 2 weeks or longer should be biopsied.
45. What is the differential diagnosis of ulcers of the oral mucosa?
• Traumatic ulcer • Chancre of syphilis
• Aphthous stomatitis • Noma
• Cancer • Necrotizing sialometaplasia
• Tuberculosis • Deep fungal infection
• Recrudescent HSV infection

46. Why is it a good idea to aspirate a pigmented lesion before obtaining a

biopsy?
Because pigmented lesions may be vascular in nature, prebiopsy aspiration is prudent to
prevent hemorrhage.
47. What are the major causes of pigmented oral and perioral lesions?
Pigmented lesions are caused by endogenous or exogenous sources. Endogenous sources
include melanoma, endocrine-related pigmentation (e.g., as in Addison disease), and perioral
pigmentation associated with intestinal polyposis or Peutz-Jeghers syndrome. Exogenous
sources of pigmentation include heavy metal poisoning (e.g., lead), amalgam tattoos, and
changes caused by chemicals or medications. A common example of medication-related
changes is black hairy tongue associated with antibiotics, particularly tetracycline, or
bismuth-containing compounds, such as Pepto-Bismol.
48. Do any diseases of the oral cavity also present with lesions of the skin?
Numerous diseases can cause simultaneous lesions of the mouth and skin. Among the most
common are lichen planus, erythema multiforme, lupus erythematosus, bullous pemphigoid,
and pemphigus vulgaris.
49. What is the appearance of the skin lesion associated with erythema multiforme?
The skin lesion of erythema multiforme looks like an archery target, with a central erythema-
tous bull’s eye and a circular peripheral area. Hence, the lesions are called bull’s-eye or target
lesions.
50. A 25-year-old woman presents with a chief complaint of spontaneously bleeding
gingiva. She also notes malaise. On oral examination, you find that her hygiene is
excellent. Would you suspect a local or systemic basis for her symptoms? What
tests might you order to make a diagnosis?
Spontaneous bleeding, especially in the presence of good oral hygiene, is most likely of
systemic origin. Gingival bleeding is among the most common presenting signs of acute
leukemia, which should be high on the differential diagnosis. A CBC and platelet count
should provide data to help establish a preliminary diagnosis. Definitive diagnosis most likely
requires a bone marrow biopsy.
51. A 45-year-old, overweight man presents with suppurative periodontitis. As you
review his history, he tells you that he is always hungry, drinks water almost every
hour, and awakens four times each night to urinate. Which systemic disease is
most likely a cofactor in his periodontal disease? What test(s) might you order to
help you with a diagnosis?
The combination of polyuria, polyphagia, polydipsia, and suppurative periodontal disease
should raise a strong suspicion of undiagnosed or poorly controlled diabetes mellitus.
A ­fasting blood glucose test is the most efficacious screen.
52. A 60-year-old woman presents with a complaint of numbness of the left side of
her mandible. Four years ago, she had a mastectomy for treatment of breast can-
cer. What is the likely diagnosis? What is the first step that you take to confirm it?
The mandible is not an infrequent site for metastatic breast cancer. As the metastatic lesion
grows, it puts pressure on the inferior alveolar nerve and causes paresthesia. Radiographic
evaluation of the jaw is a reasonable first step to make a diagnosis. Positron emission tomog-
raphy (PET)/CT imaging by the oncologist may also help demonstrate malignancy.
 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS 21

53. Which endocrine disease may present with pigmented lesions of the oral mucosa?
Pigmented lesions of the oral mucosa may suggest Addison disease.
54. What drugs cause gingival hyperplasia?
• Phenytoin
• Cyclosporine
• Nifedipine
55. What is the most typical presentation of the oral lesions of tuberculosis? How do
you make a diagnosis?
The oral lesions of tuberculosis are thought to result from organisms brought into
contact with the oral mucosa by sputum originating at the site of infection in the lung.
A nonhealing ulcer, which is impossible to differentiate clinically from carcinoma, is
the most common presentation in the mouth. Ulcers are typically located on the lateral
borders of the tongue and may have a purulent center. Lymphadenopathy also may be
present. Diagnosis is made by histologic examination and demonstration of organisms in
the tissue.
56. What are the typical oral manifestations of a patient with pernicious anemia?
Pernicious anemia is caused by a vitamin B12 deficiency caused by a lack of intestinal
absorption. The most common target site in the mouth is the tongue, which presents with a
smooth, dorsal surface denuded of papillae that may be associated with sensitivity and burn-
ing. Angular cheilitis is a frequent accompanying finding.
57. What is angular cheilitis? What is its cause?
Angular cheilitis, or cheilosis, is fissuring or cracking at the corners of the mouth. The
condition typically occurs because of a localized mixed infection of bacteria and fungi.
Cheilitis usually results from a change in the local environment caused by excessive saliva
because of loss of the vertical dimension between the maxilla and mandible. In addition, a
number of systemic conditions, such as deficiency anemias and long-term immunosuppres-
sion, predispose to the condition.
58. What is the classic oral manifestation of Crohn disease?
Mucosal lesions with a cobblestone appearance are associated with Crohn disease. Oral
manifestations of Crohn disease may also include aphthous-like lesions, orofacial granuloma-
tosis, and angular cheilitis.
59. List the oral changes that may occur in a patient receiving radiation therapy for
treatment of a tumor on the base of the tongue.
• Xerostomia • Osteoradionecrosis
• Cervical and incisal edge caries • Mucositis

60. A patient presents for extraction of a carious tooth. In taking the history, you learn
that the patient is undergoing chemotherapy for treatment of a breast carcinoma.
What information is critical before proceeding with the extraction?
Because cancer chemotherapy nonspecifically affects the bone marrow, the patient is likely to
be myelosuppressed after treatment. Therefore, you need to know the patient’s white blood
cell count and platelet count before initiating treatment. Because bisphosphonates may
constitute part of the treatment regimen (e.g., zoledronic acid), the patient might be at risk
for osteonecrosis of the jaw.
61. What oral findings have been associated with use of the diuretic
hydrochlorothiazide?
Lichen planus has been associated with hydrochlorothiazide.
62. Some patients believe that topical application of an aspirin to the mucosa next to
a tooth will help odontogenic pain. How may you detect this form of therapy by
looking in the patient’s mouth?
Because of its acidity, topical application of aspirin to the mucosa frequently causes a
chemical burn, which appears as a white necrotic lesion in the area corresponding to
aspirin placement.
 22 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS

63. What are the possible causes of burning mouth symptoms?

1. Dry mouth 8. Allergy
2. Nutritional deficiencies 9. Chronic infections (especially fungal)
3. Diabetes mellitus 10. Blood dyscrasias
4. Psychogenic factors 11. Anemia
5. Medications 12. Iatrogenic factors
6. Acid reflux from the stomach 13. Inflammatory conditions such as lichen planus
7. Hormonal imbalances

64. What is the most important goal in the evaluation of a taste disorder?
The most important goal in evaluating a taste disorder is the elimination of any underlying
neurologic, olfactory, or systemic disorder as a cause of the condition.
65. What drugs often prescribed by dentists may affect taste or smell?
1. Metronidazole 4. Tetracycline
2. Benzocaine 5. Sodium lauryl sulfate toothpaste
3. Ampicillin 6. Codeine

66. What systemic conditions may affect smell and/or taste?

1. Bell’s palsy 8. Adrenal insufficiency
2. Multiple sclerosis 9. Cushing syndrome
3. Head trauma 10. Diabetes mellitus
4. Cancer 11. Sjögren syndrome
5. Chronic renal failure 12. Radiation therapy to the head and neck
6. Cirrhosis 13. Viral infections
7. Niacin deficiency 14. Hypertension

67. What is burning mouth syndrome?

Burning mouth syndrome, also referred to as glossodynia or stomatodynia, is characterized by
unprovoked oral burning that typically affects the tongue, anterior aspects of the lips, and ante-
rior hard palate. It is a diagnosis of exclusion in which the mucosa appears normal and is not
associated with any underlying disease. Other frequently associated symptoms include xerosto-
mia and dysgeusia. Treatments vary; they often include topical or systemic clonazepam. Clini-
cal trials demonstrate a high placebo response among patients suffering with the condition.
68. What questions should a clinician consider before ordering a diagnostic test to
supplement a clinical examination?
1. What is the likelihood that the disease is present, given the history, clinical findings, and
known risk factors?
2. How serious is the condition? What are the consequences of a delay in diagnosis?
3. Is an appropriate diagnostic test available? How sensitive and accurate is it?
4. Are the costs, risks, and ease of administering the test worth the effort?
69. Distinguish among the accuracy, sensitivity, and specificity of a particular
diagnostic test.
The accuracy is a measure of the overall agreement between the test and a gold standard.
The more accurate the test, the fewer false-negative or false-positive results. In contrast,
the sensitivity of the test measures its ability to show a positive result when the disease is
present. The more sensitive the test, the fewer false-negatives. For example, one problem
with a cytologic evaluation of cancerous keratotic oral lesions is that 15 of 100 patients with
cancer will test as negative (unacceptable false-negative rate). Consequently, cytology for
this diagnosis is not highly sensitive. The specificity of the test measures the ability to show a
negative finding in people who do not have the condition (false-positives).
70. What is meant by FNA? When is it used?
No, FNA is not an abbreviation for the Finnish Naval Association. It refers to a diagnostic
technique termed fine-needle aspiration, in which a 22-gauge needle on a syringe is used to
aspirate cells from a suspicious lesion for pathologic analysis. Many otolaryngologists use
the technique to aid in the diagnosis of cancers of the head and neck. It can be particularly
 CHAPTER 2 TREATMENT PLANNING AND ORAL DIAGNOSIS 23

valuable for the diagnosis of submucosal tumors, such as lymphoma, salivary gland tumors,
and parapharyngeal masses that are not accessible to routine surgical biopsy. Like many
techniques, the efficacy of FNA depends on the skill of the operator and experience of the
cytopathologist reading the slide.
71. Which systemic diseases have been associated with alterations in salivary gland
function?
1. Cystic fibrosis 8. Thyroid disease
2. Human immunodeficiency virus (HIV) 9. Autoimmune disease (e.g.,
infection Sjögren syndrome, myasthenia
3. Diabetes mellitus gravis, graft-versus-host disease)
4. Affective disorder 10. Sarcoidosis
5. Metabolic disturbances (e.g., malnutrition, 11. Autonomic dysfunction
dehydration, vitamin deficiency) 12. Alzheimer’s disease
6. Renal disease 13. Cancer
7. Cirrhosis

72. What is PCR? Why may it become an important technique in oral diagnosis?
Polymerase chain reaction (PCR) is a technique developed by researchers in molecular
biology for the enzymatic amplification of selected DNA sequences. Because of its exquisite
sensitivity, PCR appears to have marked clinical potential for the diagnosis of viral diseases
of the head and neck. PCR tests for the diagnosis of HSV are available, but are are not
typically used for detection of oral disease.
73. What conditions and diseases may cause blistering (vesiculobullous lesions) in
the mouth?
1. Viral disease
2. Lichen planus
3. Pemphigoid
4. Pemphigus vulgaris
5. Erythema multiforme
74. What are the most common sites of intraoral cancer?
The posterior lateral and ventral surfaces of the tongue are the most common sites of
intraoral cancer.
75. What is staging for cancer? What are the criteria for staging cancers of the
mouth?
Staging is a method of defining the clinical status of a lesion; it is closely related to its future
clinical behavior. Thus, it is related to prognosis and is helpful for providing a basis for treat-
ment planning. The staging system used for oral cancers is called the TNM system. It is based
on three parameters: T = size of the tumor on a scale from 0 (no evidence of primary tumor)
to 3 (tumor > 4 cm in greatest diameter); N = involvement of regional lymph nodes on a
scale from 0 (no clinically palpable cervical nodes) to 3 (clinically palpable lymph nodes that
are fixed; metastases suspected); and M = presence of distant metastases on a scale from 0 (no
distant metastases) to 1 (clinical or radiographic evidence of metastases to nodes other than
those in the cervical chain).

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MANAGEMENT OF MEDICALLY

CHAPTER 3
COMPROMISED PATIENTS
Joseph W. Costa, Jr.

A SHORT HISTORY OF MEDICINE

2000 bc “Here, eat this root.”

1000 bc “That root is heathen. Say this prayer.”

1850 ad “That prayer is superstition. Drink this potion.”

1940 ad “That potion is snake oil. Swallow this pill.”

1985 ad “That pill is ineffective. Take this antibiotic.”

2000 ad “That antibiotic is artificial. Here, eat this root.”

—Authors Unknown

DISORDERS OF HEMOSTASIS
1. What questions should be asked to screen a patient for potential bleeding
problems?
The best screening procedure for a bleeding disorder is a good medical history. If the review
of the medical history indicates a bleeding problem, a more detailed history is needed. The
following questions are basic:
1. Is there a family history of bleeding problems?
2. Is there excessive bleeding after tooth extractions or other surgeries?
3. Has there been excessive bleeding after trauma, such as minor cuts and falls?
4. Is the patient taking any medications that affect bleeding, such as aspirin, commonly pre-
scribed anticoagulants (e.g., warfarin [Coumadin], enoxaparin [Lovenox], heparin), herbal
medications, or antibiotics?
5. Does the patient have any known illnesses that are associated with bleeding (e.g., hemo-
philia, leukemia, renal disease, liver diseases, cardiac diseases)?
6. Has the patient ever had spontaneous episodes of bleeding from anywhere in the body?
2. What laboratory tests should be ordered if a bleeding problem is suspected?
• Platelet count: normal values = 150,000-400,000/μL
• Prothrombin time (PT): normal value = 10-13.5 seconds
• International normalized ratio (INR): normal value = 1-2 (only useful for those patients on
known anticoagulant medications)
• Partial thromboplastin time (PTT): normal value = 25-36 seconds
• Thrombin time (TT): normal value = 9-13 seconds
• Bleeding time: normal value ≤ 9 minutes (bleeding time is a nonspecific predictor of plate-
let function)
Normal values may vary from one laboratory to another. It is important to check the normal
values for the laboratory that you use. If any of the tests are abnormal, the patient should be
referred to a hematologist for evaluation before treatment is performed.
3. What are the clinical indications for use of 1-deamino-8-d-arginine vasopressin
(DDAVP) in dental patients?
DDAVP (desmopressin) is a synthetic antidiuretic hormone that controls bleeding in
patients with type I von Willebrand’s disease, platelet defects secondary to uremia related to
25
 26 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

renal dialysis, and immunogenic thrombocytopenic purpura (ITP). The dosage is 0.3 μg/kg.
DDAVP should not be used in patients younger than 2 years; caution is necessary in older
patients and patients receiving intravenous fluids. In consultation with a patient’s hematolo-
gist, it can be used to reduce the risk of excessive bleeding after surgical procedures.
4. What is hemophilia A?
Hemophilia A is a congenital bleeding disorder characterized by a deficiency of clotting
­factor VIII.
5. What is hemophilia B?
Hemophilia B is a congenital bleeding disorder characterized by a deficiency of clotting
factor IX.
6. How are the hemophilias managed?
In general, hemophilia A and hemophilia B are managed with appropriate concentrates of
the deficient factor—factor VIII for hemophilia A and factor IX for hemophilia B. Adjunc-
tive treatment with ε-aminocaproic acid (Amicar) and tranexamic acid is also appropriate.
7. How does bleeding typically manifest in a patient with thrombocytopenia
­compared with a patient with hemophilia?
Patients with severe thrombocytopenia typically present with mucosal bleeds. Patients with
hemophilia typically present with deep hemorrhage in weight-bearing joints.
8. When do you use ε-aminocaproic acid or tranexamic acid?
ε-Aminocaproic acid (Amicar) and tranexamic acid are antifibrinolytic agents that inhibit
the activation of plasminogen. They are used to prevent clot lysis in patients with hereditary
clotting disorders. For epsilon aminocaproic acid, the dose is 75 to 100 mg/kg every 6 hours;
for tranexamic acid, it is 25 mg/kg every 6 hours. Tranexamic acid also comes in a mouth
rinse formulation (4.8%), which can be used as a local hemostatic agent. The mouth rinse
regimen is 10 mL, four times daily. The mouth rinse is not currently available for use in the
United States.
9. What is the minimal acceptable platelet count for an oral surgical procedure?
The normal platelet count is 150,000 to 450,000/μL. In general, the minimal count for an
oral surgical procedure is 50,000 platelets. However, emergency procedures may be done with
as few as 30,000 platelets if the dentist is working closely with the patient’s hematologist and
uses excellent techniques of tissue management.
10. For a patient taking warfarin (Coumadin), a dental surgical procedure can be done
without undue risk of bleeding if the PT is below what value?
Warfarin affects clotting factors II, VII, IX, and X by impairing the conversion of vitamin K
to its active form. The normal PT for a healthy patient is 10.0 to 13.5 seconds. The normal
INR is 1 to 2. Oral procedures with a risk of bleeding should not be attempted if the PT is
more than 1.5 times normal (>18 seconds). Caution must be taken when the INR is greater
than 2. Patients taking warfarin usually have a normal therapeutic INR in the 2 to 3 range,
and simple dental prophylaxis can usually be accomplished with an INR in this range. Simple
extractions or other minor surgical procedures can also usually be accomplished in the 2
to 3 range, using careful surgical technique. When the INR is 3 or above, surgery should
be deferred, and the patient’s physician should be consulted. Consider tapering the dose of
warfarin to bring the patient into the 2 to 3 range.
11. Is the bleeding time a good indicator of perisurgical and postsurgical bleeding?
The bleeding time is used to test for platelet function. However, studies have shown no cor-
relation between blood loss during cardiac or general surgery and prolonged bleeding time.
The best indicator of a bleeding problem in the dental patient is a thorough medical history.
The bleeding time should be used in patients with no known platelet disorder to help predict
the potential for bleeding.
12. Should oral surgical procedures be postponed in patients taking aspirin?
Non-elective oral surgical procedures in the absence of a positive medical history for bleed-
ing should not be postponed because of aspirin therapy, but the surgeon should be aware
that bleeding may be exacerbated in a patient with mild platelet defect. However, elective
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 27

procedures should be postponed in the patient taking aspirin, if possible. Aspirin irreversibly
acetylates cyclooxygenase, an enzyme that assists platelet aggregation. The effect is not dose-
dependent and lasts for the 7- to 10-day life span of the platelet.
13. Are patients taking nonsteroidal medications likely to bleed from oral surgical
procedures?
Nonsteroidal anti-inflammatory drugs (NSAIDs) produce a transient inhibition of platelet
aggregation that is reversed when the drug is cleared from the body. Patients with a preexist-
ing platelet defect may have increased bleeding.
14. If a patient presents with spontaneous gingival bleeding, which diagnostic tests
should be ordered?
A patient who presents with spontaneous gingival bleeding without a history of trauma,
tooth brushing, flossing, or eating should be assessed for a systemic cause. The causes of
gingival bleeding include inflammation secondary to localized periodontitis, platelet defect,
factor deficiency, hematologic malignancy, and metabolic disorder. A thorough medical his-
tory should be obtained, and the following laboratory tests should be ordered: (1) PT/INR,
(2) PTT, and (3) complete blood count (CBC).

INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS

15. For what cardiac conditions is prophylaxis for endocarditis recommended in
patients receiving dental care?
High-risk category
• Prosthetic cardiac valves, including bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Complex cyanotic congenital heart disease (e.g., single-ventricle states, transposition of
the great arteries, tetralogy of Fallot)
• Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category
• Most congenital cardiac malformations other than above and below (see next question)
• Acquired valvular dysfunction (e.g., rheumatic heart disease)
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with valvular regurgitation and/or thickened leaflets
16. What cardiac conditions do not require endocarditis prophylaxis?
Negligible-risk category (no higher than the general population)
• Isolated secundum atrial septal defect
• Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus
(without residua beyond 6 months)
• Previous coronary artery bypass graft surgery
• Mitral valve prolapse without valvular regurgitation
• Physiologic, functional, or innocent heart murmurs
• Previous Kawasaki disease without valvular regurgitation
• Previous rheumatic fever without valvular regurgitation
• Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
17. What are the antibiotics and dosages recommended by the American Heart As-
sociation (AHA) for the prevention of endocarditis from dental procedures?
The AHA updates its recommendations every few years to reflect new findings. The dentist
has an obligation to be aware of the latest recommendations. The patient’s well-being is the
dentist’s responsibility. Even if a physician recommends an alternative prophylactic regimen,
the dentist is liable if the patient develops endocarditis and the latest AHA recommenda-
tions were not followed.
Standard regimen:
Amoxicillin, 2.0 g orally 1 hour before procedure
For patients allergic to amoxicillin and penicillin:
Clindamycin, 600 mg orally 1 hour before procedure
or
 28 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

Cephalexin or cefadroxil,* 2.0 g orally 1 hour before procedure

or
Azithromycin or clarithromycin, 500 mg orally 1 hour before procedure
Patients unable to take oral medications:
Ampicillin, intravenous (IV) or intramuscular (IM) administration of 2 g 30 minutes
before procedure
For patients allergic to ampicillin, amoxicillin, and penicillin:
Clindamycin, IV administration of 600 mg 30 minutes before procedure
or
Cefazolin,* IV or IM administration of 1.0 g within 30 minutes before procedure
18. For which dental procedures is antibiotic premedication recommended in patients
identified as being at risk for endocarditis?
• Dental extractions
• Periodontal procedures including surgery, scaling and root planing, probing, and recall
maintenance
• Dental implant placement and reimplantation of avulsed teeth
• Endodontic (root canal) instrumentation or surgery only beyond the apex
• Subgingival placement of antibiotic fibers or strips
• Initial placement of orthodontic bands but not brackets
• Intraligamentary local anesthetic injections
• Prophylactic cleaning of teeth or implants if bleeding is anticipated
19. For what dental procedures is antibiotic premedication not recommended for
patients identified as being at risk for endocarditis?
• Restorative dentistry (including restoration of carious teeth and prosthodontic replace-
ment of teeth), with or without retraction cord (clinical judgment may indicate antibiotic
use in selected circumstances that may create significant bleeding)
• Local anesthetic injections (non-intraligamentary)
• Intracanal endodontic treatment (after placement and buildup)
• Placement of rubber dams
• Postoperative suture removal
• Placement of removable prosthodontic or orthodontic appliances
• Making of impressions
• Fluoride treatments
• Intraoral radiographs
• Orthodontic appliance adjustment
• Shedding of primary teeth
20. Should a patient who has had a coronary bypass operation be placed on
­prophylactic antibiotics before dental treatment?
No evidence indicates that coronary artery bypass graft surgery introduces a risk for
­endocarditis. Therefore, antibiotic prophylaxis is not needed.
21. What precautions should you take when treating a patient with a central line
devices such as a Hickman peripherally inserted central catheter (PICC) or
­Port-a-Cath (manufacturer: Smiths Medical, Dublin, OH)?
Current research recommends treating these patients as follows:
• Antibiotic prophylaxis is not routinely recommended after device placement for patients
who undergo dental, respiratory, gastrointestinal or genitourinary procedures.
• It is recommended for patients with these devices if they undergo incision and drainage of
infection at other sites (e.g., abscess) or replacement of an infected device.
22. Should a patient with a prosthetic joint be placed on prophylactic antibiotics
before dental treatment?
The newest guidelines concerning the use of prophylactic antibiotics before dental treatment
in patients with prosthetic joints are evidence-based. They were developed as a result of a

*Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (e.g., urticaria,
angioedema, anaphylaxis) to penicillins.
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 29

combined research effort by the American Academy of Orthopaedic Surgeons and American
Dental Association, the results of which were published in 2012.
The guidelines state that there is insufficient evidence to recommend routine antibiotic
prophylaxis for dental procedures in patients with joint replacements. The summary of
recommendations is as follows:
1. The practitioner might consider discontinuing the practice of routinely prescribing pro-
phylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing
dental procedures.
Strength of Recommendation: Limited
A Limited Recommendation means that the quality of the supporting evidence is uncon-
vincing, or that well-conducted studies show little clear advantage to one approach versus
another.
Practitioners should be cautious in deciding whether to follow a recommendation classified
as Limited and should exercise judgment and be alert to emerging publications that report
evidence. Patient preference should have a substantial influencing role.
2. We are unable to recommend for or against the use of topical oral antimicrobials in
patients with prosthetic joint implants or other orthopedic implants who are undergoing
dental procedures.
Strength of Recommendation: Inconclusive
An Inconclusive Recommendation means that there is a lack of compelling evidence,
resulting in an unclear balance between benefits and potential harm.
Practitioners should feel little constraint in deciding whether to follow a recommenda-
tion labeled as Inconclusive and should exercise judgment and be alert to future studies
that clarify existing evidence for determining the balance of benefits versus potential harm.
Patient preference should have a substantial influencing role.
3. In the absence of reliable evidence linking poor oral health to prosthetic joint infection,
it is the opinion of the work group that patients with prosthetic joint implants or other
orthopedic implants maintain appropriate oral hygiene.
Strength of Recommendation: Consensus
A Consensus Recommendation means that expert opinion supports the guideline recom-
mendation, even though there is no available empirical evidence that meets the inclusion
criteria.
Practitioners should be flexible in deciding whether to follow a recommendation classified
as Consensus, although they may set boundaries on alternatives. Patient preference should
have a substantial influencing role.
23. Is it necessary to prescribe prophylactic antibiotics for a patient on renal
dialysis?
Patients with arteriovenous (AV) shunts do not require antibiotic prophylaxis because the
shunt is derived from native vessels. Patients with synthetic grafts or indwelling catheters
should receive antibiotic prophylaxis, using the following regimens:
Standard regimen:
Amoxicillin, 2.0 g orally 1 hour before procedure
For patients allergic to amoxicillin and penicillin:
Clindamycin, 600 mg orally 1 hour before procedure
or
Cephalexin* or cefadroxil,* 2.0 g orally 1 hour before procedure
or
Azithromycin or clarithromycin, 500 mg orally 1 hour before procedure
Patients unable to take oral medications:
Ampicillin, IV or IM administration, 2.0 g within 30 minutes before procedure
For patients allergic to ampicillin, amoxicillin, and penicillin:
Clindamycin, IV administration of 600 mg within 30 minutes before procedure or
Cefazolin,* IV or IM administration of 1.0 g within 30 minutes before procedure

*Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria, angio-
edema, or anaphylaxis) to penicillins.
 30 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

TREATMENT OF HIV-POSITIVE PATIENTS

24. What do ART and HAART stand for as they relate to HIV (human immunodeficiency
virus) treatment?
ART stands for antiretroviral treatment. HAART stands for highly active antiretroviral
treatment and typically consists of a “cocktail” of at least three active antiretroviral medica-
tions. The primary goals of treatment are to reduce the HIV viral load to below the level of
assay detection for a prolonged period and reduce the virus mutation rates, which lead to
drug resistance.
25. What are the.common oral manifestations of HIV infection?
Over the years, there has been a significant drop in the incidence of oral lesions associated
with HIV, mostly because of the potent antiretroviral treatment regimens. However, the most
common HIV-associated conditions include the following:
• Xerostomia
• Candidiasis
• Oral hairy leukoplakia
• Linear gingival erythema
• Necrotizing ulcerative gingivitis
• Kaposi’s sarcoma
• Human papilloma virus (HPV)-associated warts
• Herpes (herpes simplex virus [HSV]) lesions
• Recurrent aphthous ulcers
• Neutropenic ulcers
26. What are the classifications of the most commonly used drugs to treat HIV
infection?
• Non-nucleoside reverse transcriptase inhibitors (NNRTIs). NNRTIs disable a protein
needed by HIV to make copies of itself. Examples include efavirenz (Sustiva), etravirine
(Intelence), and nevirapine (Viramune).
• Nucleoside reverse transcriptase inhibitors (NRTIs). NRTIs incorporate into the DNA
of the HIV virus and stop transcription. Examples include abacavir (Ziagen), and the
combination drugs emtricitabine plus tenofovir (Truvada), and lamivudine plus zidovudine
(Combivir).
• Protease inhibitors (PIs). PIs block the activity of the protease enzyme, which is a protein
that HIV needs to make copies of itself. Examples include atazanavir (Reyataz), darunavir
(Prezista), fosamprenavir (Lexiva), and ritonavir (Norvir).
• Entry or fusion inhibitors. Fusion inhibitors block the entry of HIV into CD4 cells. Ex-
amples include enfuvirtide (Fuzeon) and maraviroc (Selzentry).
• Integrase inhibitors. Integrase inhibitors disable the integrase protein that HIV uses to
insert its genetic material into CD4 cells. An example is raltegravir (Isentress).
27. What are the drugs that typically comprise the initial HAART regimen used to treat
HIV infection?
This question is very difficult to answer because the HAART drug regimens are continually
changing according to the latest research. Efavirenz is a NNRTI that has proven to be very suc-
cessful in reducing HIV viral loads. Currently, this drug is used to initiate many HAART regi-
mens. An example a currently preferred regimen for the initiation of treatment is: efavirenz plus
tenofovir (a nucleotide) plus emtricitabine (an NRTI). However, there are several possible drug
combinations that have proven to be effective at reducing viral load and virus mutation rates.
28. A patient with HIV infection requires an oral surgical procedure to remove teeth
after severe bone loss caused by HIV-related localized periodontitis. What
­precautions should be taken?
It is estimated that 10% to 15% of patients with HIV develop immunogenic thrombocytope-
nic purpura (ITP). The antiplatelet antibodies appear to be found more frequently in those
in an advanced stage of disease. Affected patients should have a CBC done before any oral
surgical procedure. If the platelets are low (<150,000/μL), the procedure should be done only
after consultation with the patient’s physician and with the knowledge that bleeding may be
increased. The patient may require platelet transfusions to control postoperative bleeding.
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 31

In the absence of any coagulopathy caused by thrombocytopenia or hemophilia, an other-

wise healthy HIV-positive patient who presents for an extraction typically may undergo an
extraction. However, the practitioner must proceed with caution. A careful medical history
must be taken, and consultation with the patient’s physician should be completed, as needed.
If no underlying blood dyscrasia is present, the patient may safely undergo extractions with-
out further precautions.
29. Are there any contraindications to restorative dentistry procedures in patients
with HIV infection?
If the patient is not neutropenic or thrombocytopenic, there are no contraindications to
preventive and restorative dental care. Patients should receive aggressive dental care to
reduce the oral cavity as a source of infection. They should be placed on a 3- to 6-month
recall to maintain optimal oral health and followed closely for opportunistic infections and
HIV-related oral conditions.
30. What is a normal CD4 count? At what level is a patient at risk for infections?
When should a patient begin antiretroviral treatment?
A normal CD4 count is from 500 to 1000 cells/mm3. When the CD4 count is less than 350
cells/mm3, the patient is considered to be at risk for acquiring an opportunistic infection. A
CD4 count of less than 200 cells/mm3 is one of the criteria for a diagnosis of acquired immu-
nodeficiency syndrome (AIDS).
The World Health Organization (WHO) issued a statement in 2013 regarding the
appropriate time to begin ART in HIV-positive patients. Here is an excerpt from of their
statement for the treatment of HIV-positive patients adults and adolescents:
• As a priority, ART should be initiated in all individuals with severe or advanced HIV clini-
cal disease (WHO clinical stage 3 or 4) and individuals with a CD4 count of 350 cells/mm3
or lower (strong recommendation, moderate-quality evidence).
• ART should be initiated in all individuals with HIV with a CD4 count of 350 to 500
cells/mm3, regardless of the WHO clinical stage (strong recommendation, moderate-quality
evidence).
• ART should be initiated in all individuals with HIV, regardless of WHO clinical stage or
CD4 cell count, in the following situations:
• Individuals with HIV and active tuberculosis (TB) (strong recommendation, low-quality
evidence)
• Individuals co-infected with HIV and HBV with evidence of severe chronic liver disease
(strong recommendation, low-quality evidence)
• Partners with HIV in serodiscordant couples should be offered ART to reduce HIV
transmission to uninfected partners (strong recommendation, high-quality evidence).

CARDIOVASCULAR DISEASE
31. What is the appropriate response if a patient with a history of cardiac disease
develops chest pain during a dental procedure?
1. Discontinue treatment immediately.
2. Take and record vital signs (blood pressure, pulse, respiration), and question the patient
about the pain. Chest pain from ischemia may be substernal or more diffused. Patients
often describe the pain as crushing, pressure, or heavy; it may radiate to the shoulders,
arms, neck, or back.
3. If the patient has a history of angina and takes nitroglycerin, give the patient his or her
own nitroglycerin or a tablet from your emergency cart. Continue to monitor the patient’s
vital signs. If the pain does not stop after 3 minutes, give the patient a second dose. If
after three doses in a 10-minute period the pain does not subside, contact the medical
emergency service and have the patient transported to an emergency department to rule
out a myocardial infarction.
4. If the patient does not have a history of heart disease but has persistent chest pain for lon-
ger than 2 minutes, the medical emergency service should be contacted and the patient
transported to a hospital emergency department for evaluation.
5. If the patient is not allergic to aspirin, administer one tablet of aspirin (325 mg) orally.
The aspirin acts as an antithrombotic agent.
 32 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

32. At what blood pressure should elective dental care be postponed?
Elective dental care should be postponed if the systolic blood pressure is ≥ 180 mm Hg or
higher and/or the diastolic pressure is 110 mm Hg or higher. Refer the patient to a physician for
follow-up. If the patient is also symptomatic, refer to the emergency room for immediate care.
33. Can or should emergency dental treatment be administered to a patient with
­uncontrolled hypertension?
Emergency dental treatment can be used to treat problems such as pain, infection, or bleed-
ing. The dentist must compare the benefit of such treatment with the risks. The patient must
be managed in consultation with a physician and be carefully monitored with intraoperative
blood pressure readings, at a minimum. Other measures such as electrocardiographic moni-
toring, IV lines, and nitrous oxide sedation can also be used. In addition to treatment of the
dental emergency, great care must be taken to reduce the patient’s stress and anxiety.
34. What are the dental treatment considerations for patients with unstable angina or
a history of myocardial infarction (MI) within the past 30 days?
Elective dental treatment should be avoided in a patient with unstable angina or who has
had an MI within the past 30 days. If care is absolutely necessary, the patient’s physician
should be consulted to help develop a plan. Care should be limited to management of pain,
infection, and/or bleeding. If possible, refer the patient to a hospital dental clinic.
35. Can a patient with stable (mild) angina and a past history of MI be treated safely
in the dental office?
This patient is at intermediate risk for having perioperative complications from dental proce-
dures. Dental treatment can be completed with some treatment modifications, such as short
morning appointments, comfortable chair position, recording of pretreatment vital signs,
having nitroglycerin readily available, use of oral sedation as needed, use of nitrous oxide–
oxygen sedation if needed, excellent local anesthesia (limiting the amount of epinephrine to
no more than two cartridges containing 1:100,000 epinephrine), and excellent postoperative
pain management.
36. Can nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen be admin-
istered safely to patients who have had a history of MI?
A recent study has shown that the use of NSAIDs in patients with a history of MI increases
the risk for another MI. This is true even if it is a relatively short course (e.g., 7 days) of
NSAID treatment. Therefore, NSAIDs should be used with caution in patients who have
had a previous MI, if at all, and perhaps limited to less than 7 days of use.
37. How do you differentiate between stable and unstable angina?
Unstable angina is characterized by a change in the pattern of pain. The pain occurs with
less exertion or at rest, lasts longer, and is less responsive to medication. Dental care for such
patients must be postponed and the patient referred to his or her physician immediately for
care. Patients are at increased risk for MI. If emergency dental care is necessary before the
patient is stable, it should be attempted only with cardiac monitoring and sedation.
38. Should a retraction cord that contains epinephrine be used in a patient with
cardiovascular disease?
The concentration of epinephrine in an impregnated cord is high, and systemic absorption
occurs. An impregnated cord should not be used in patients with cardiac disease, hyperten-
sion, or hyperthyroidism. It has been argued that an epinephrine-containing retraction cord
should not be used in dental practice.
39. Should vasoconstrictors be avoided in any patients with cardiovascular disease?
In a patient at major risk of developing perioperative cardiovascular complications, vasocon-
strictors should be used only in consultation with the patient’s physician. The result of this
consultation may dictate that vasoconstrictors be avoided. This high-risk category includes the
following conditions: acute or recent MI (between 7 to 30 days prior); decompensated heart
failure; and significant arrhythmias (e.g., AV block, ventricular-related arrhythmia). Some
studies have shown that very modest quantities of a vasoconstrictor are safe in these high-risk
patients when accompanied by oxygen, sedation, nitroglycerin, and adequate pain control.
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 33

40. Is it safe to treat a patient who has undergone heart transplantation in an out­
patient dental office?
During the first 3 months after heart transplantation, elective dental treatment should be
avoided. Various systemic complications and infections are common during this period because
the patient is receiving an intensive course of immunosuppressive medications. Emergency
dental treatment can be provided in consultation with the patient’s physician. If treatment is
required during these first 3 months, antibiotic prophylaxis should be administered. Emergency
dental treatment should be completed only after consultation with the patient’s cardiologist.
In the stable post-transplantation period (usually after 3 months, but the timing is deter-
mined in consultation with the physician), heart transplant patients can receive elective
dental treatment. The use of prophylactic antibiotics during this period is determined on an
individual basis based on the patient’s level of immunosuppression, whether he or she has
shown evidence of rejection, and other factors.

METABOLIC DISORDERS
41. What precautions do you need to take in treating a patient with insulin-dependent
diabetes mellitus (IDDM)?
The major concern for the dental practitioner treating the patient with IDDM is hypogly-
cemia. It is important to question the patient about changes in insulin dosage, diet, and
exercise routine before undertaking any outpatient dental treatment. A decrease in dietary
intake or increase in the normal insulin dosage or exercise may place the patient at risk for
hypoglycemia.
42. What are the symptoms of hypoglycemia?
1. Tachycardia 4. Tremulousness
2. Palpitations 5. Nausea
3. Sweating 6. Hunger
The symptoms may progress to coma and convulsions without intervention.
43. What should the dentist be prepared to do for the patient who has a
­hypoglycemic reaction?
The dental practitioner should have some form of sugar readily available, such as packets
of table sugar, candy, or orange juice. Also available are 4- to 5-gram tablets of glucose. It
is recommended that a hypoglycemic patient take 15 grams of fast-acting carbohydates
(glucose), which is approximately 3 to 4 tablets. If a patient develops symptoms of hypogly-
cemia, the dental procedure should be discontinued immediately; if conscious, the patient
should be given some form of oral glucose.
If the patient is unconscious, the emergency medical service should be contacted. Glucagon,
1 mg, can be injected IM, or 50 mL of 50% glucose solution can be given by rapid IV infusion.
The glucagon injection should restore the patient to a conscious state within 15 minutes, and
then some form of oral sugar can be given.
44. Is the diabetic patient at greater risk for infection after an oral surgical procedure?
It is important to minimize the risk of infection in diabetic patients. They should have
aggressive treatment of dental caries and periodontal disease and be placed on frequent recall
examinations and oral prophylaxis.
After oral surgical procedures, endodontic procedures, and treatment of suppurative peri-
odontitis, diabetic patients should be placed on antibiotics to prevent infection secondary to
delayed healing. Antibiotics of choice are amoxicillin, 500 mg 3 times daily, or clindamycin,
300 mg 3 times daily for 7 to 10 days.
45. When is it necessary to increase the dose of corticosteroids in dental patients
who have primary or secondary adrenal insufficiency?
Guidelines on the use of supplemental corticosteroids state that only those patients who have
primary adrenal insufficiency and who are undergoing surgical procedures require supple-
mentation with additional corticosteroids. They do not require supplementation for routine
dental procedures.
 34 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

Patients who have secondary adrenal insufficiency only require their usual dose of
corticosteroid on the morning of the procedure.
If supplementation is needed for those patients with primary adrenal insufficiency, the
following guidelines apply:
Procedure Target Dose
Routine dentistry None
Minor surgery 25 mg hydrocortisone preoperatively on day of surgery
Moderate surgical stress 50-75 mg hydrocortisone on day of surgery and up to 1 day after
Major surgical stress 100-150 mg/day of hydrocortisone, given for 2 to 3 days

46. What are the clinical symptoms of hypothyroidism? What dental care can be
safely provided?
The clinical symptoms of hypothyroidism are weakness, fatigue, intolerance to cold, changes
in weight, constipation, headache, menorrhagia, and dryness of the skin. Dental care should
be deferred until after a medical consultation in a patient with or without a history of
thyroid disease who experiences a combination of these signs and symptoms. If the patient is
myxedematous, he or she should be treated as a medical emergency and referred immediately
for medical care. It is important not to prescribe opiates for the palliative treatment of the
myxedematous patient, who may be unusually sensitive and die after being given a normal
dose of an opiate.

ALLERGIC REACTIONS
47. What would you prescribe for the patient who develops a mild soft tissue swelling
of the lips under the latex rubber dam?
The patient probably has had a contact allergic reaction from the latex. If the reaction is
mild (slight swelling, with no extension into the oral cavity) and self-limiting, the patient
should be given 50 mg of oral diphenhydramine and observed for at least 2 hours for a
possible delayed reaction. If the reaction is moderate to severe, the patient should be given
50 mg of diphenhydramine IM or IV and closely monitored. Emergency services should be
contacted to transport the patient to the emergency department for treatment and observa-
tion. Allergic patients should be instructed to inform their health care providers of their
latex allergy and referred to an allergist. Dentists are encouraged to use nonlatex rubber dams
and gloves whenever possible.
48. What should you do if a patient for whom you prescribed the prophylactic
­antibiotic amoxicillin approximately 1 hour previously reports urticaria, erythema,
and pruritus (itching)?
If the reaction is delayed (>1 hour) and limited to the skin, the patient should be given 50
mg of diphenhydramine IM or IV and then observed for 1 to 2 hours before being released.
If no further reaction occurs, the patient should be given a prescription for 25 to 50 mg of
diphenhydramine to be taken every 6 hours until symptoms are gone.
If the reaction is immediate (<1 hour) and limited to the skin, 50 mg of diphenhydramine
should be given immediately IM or IV. The patient should be monitored and emergency
services contacted to transport the patient to the emergency department. If other symptoms
of allergic reaction occur, such as conjunctivitis, rhinitis, bronchial constriction, or angio-
edema, 0.3 mL of aqueous 1:1000 epinephrine should be given by subcutaneous (SC) or IM
injection. The patient should be monitored until emergency services arrive. If the patient
becomes hypotensive, an IV line should be started with Ringer’s lactate or 5% dextrose in
water.
49. What are the signs and symptoms of anaphylaxis? How should it be managed in
the dental office?
Anaphylaxis is characterized by bronchospasm, hypotension or shock, and urticaria or
angioedema. It is a medical emergency in which death may result from respiratory obstruc-
tion, circulatory failure, or both. With the first indication of anaphylaxis, 0.3 to 0.5 mL of
1:1000 aqueous epinephrine should be injected SC or IM, and emergency services should be
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 35

contacted. The injection of epinephrine may be repeated every 20 to 30 minutes, if necessary,

for as many as three doses. Oxygen at a rate of 4 L/min must be delivered with a face mask.
The patient must be continuously monitored, and an IV line containing Ringer’s lactate or
normal saline should be infused at 100 mL/hr. If the patient becomes hypotensive, the IV
infusion should be increased. If airway obstruction occurs because of edema of the larynx or
hypopharynx, a cricothyrotomy must be performed. If the airway obstruction is caused by
bronchospasm, an albuterol or terbutaline nebulizer should be used or IV aminophylline, 6
mg/kg, infused over 20 to 30 minutes.

HEMATOLOGY AND ONCOLOGY

50. What are the normal values for a CBC?
White blood cell count Hemoglobin (Hgb)
≥18 years 4,000-10,000/mL ≥18 years
12-17 years 4,500-13,000/mL Male 13.5-18.0 g/dL
6 months-11 years 4,500-13,500/mL Female 11.5-16.4 g/dL
Red blood cell count 12-17 years 12.0-16.0 g/dL
≥18 years 6 months-11 years 10.5-14.0 g/dL
Male 4.5-6.4 M/mL
Female 3.9-6.0 M/mL
12-17 years 4.1-5.3 M/mL Platelet count (PLT)
6 months-11 years 3.7-5.3 M/mL 8 days and older 150,000-450,000/mL
Up to 7 days 150,000-350,000/mL
Hematocrit (Hct)
≥18 years
Male 40%-54%
Female 36%-48%
12-17 years 36%-39%
6 months-11 years 34%-45%

51. What precautions should be taken when providing dental care to a patient with
sickle cell anemia?
1. Patients with sickle cell disease should not receive dental treatment during a crisis, except
for the relief of dental pain and treatment of acute dental infections. Dental infections
should be treated aggressively; if facial cellulitis develops, the patient should be admitted
to the hospital for treatment.
2. The patient’s physician should be consulted about the patient’s cardiovascular status.
Myocardial damage secondary to infarctions and iron deposits is common.
3. Patients with sickle cell anemia are at increased risk for bacterial infections when surgical
procedures are performed. Although there is no evidence to support their use, prophylac-
tic antibiotics are often administered before any dental surgical procedure to prevent the
possibility of wound infection and/or osteomyelitis. It is not recommended for routine,
nonsurgical procedures. The same prophylactic antibiotic regimen used for the prevention
of endocarditis should be followed. After a surgical procedure, antibiotics (amoxicillin,
500 mg three times daily, or clindamycin, 300 mg three times daily) should be considered
for 7 to 10 days postoperatively.
52. What hematologic disorders are characterized by a so-called hair-on-end
­appearance of bone on radiographic surveys?
Thalassemia major and sickle cell anemia are characterized in this way.
53. Can local anesthetic with a vasoconstrictor be used for a patient with sickle cell
disease?
Because of the possibility of impairing local circulation, the use of vasoconstrictors in
patients with sickle cell disease is controversial. It is recommended that the planned dental
procedure dictate the choice of local anesthetic. If the planned procedure is a short routine
procedure that can be performed without discomfort by using an anesthetic without a
 36 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

vasoconstrictor, the vasoconstrictor should not be used. However, if the procedure requires
long profound anesthesia, 2% lidocaine with 1:100,000 epinephrine is the anesthetic of
choice.
54. Can nitrous oxide be used to help manage anxiety in patients with sickle cell
anemia?
Nitrous oxide can be safely used in patients with sickle cell anemia as long as the concen-
tration of oxygen is greater than 50%, the flow rate is high, and the patient can ventilate
adequately.
55. Can a dental infection cause a crisis in a patient with sickle cell anemia?
Preventive dental care—routine scaling and root planing, topical fluorides, sealants, and
treatment of dental caries—is important in patients with sickle cell anemia. Studies have
reported some cases of a sickle cell crisis precipitated by a periodontal infection.
56. What are the oral symptoms of acute leukemia?
More than 65% of patients with acute leukemia have oral symptoms. The symptoms result
from myelosuppression caused by the overwhelming numbers of malignant cells in the bone
marrow and/or large numbers of circulating immature cells (blasts).
1. Symptoms from thrombocytopenia—gingival oozing, petechiae, hematoma, and
ecchymosis
2. Symptoms from neutropenia—recurrent or unrelenting bacterial infections, lymphade-
nopathy, oral ulcerations, pharyngitis, and gingival infection
3. Symptoms from circulating immature cells (blasts)—gingival hyperplasia from blast
infiltration
Patients with these signs or symptoms should be evaluated to rule out a hematologic malig-
nancy. The dentist should consider carefully whether the symptoms can be explained by local
factors or are disproportionate to these factors. If a hematologic malignancy is suspected, a
CBC with a differential white cell count should be ordered.
57. Which leukemia is typically referred to as the leukemia of childhood?
Acute lymphocytic leukemia almost always occurs in children. The condition can be success-
fully treated, with a 50% to 70% 5-year survival.
58. Is it safe to extract a tooth in a patient who is receiving chemotherapy?
The major organ system affected by cytotoxic chemotherapy is the hematopoietic system.
When a patient receives chemotherapy, the white cell count and platelets may be expected to
decrease in about 7 to 10 days. If the patient’s absolute neutrophil count (calculated by multi-
plying the white cell count by the number of neutrophils in the differential count and dividing
by 100) drops below 500 neutrophils, the patient is considered neutropenic and at risk for infec-
tion. If the platelet count drops below 50,000/μL, the patient is at risk for bleeding.
If possible, dental procedures should be scheduled 2 weeks before planned chemotherapy
or after the counts begin to recover, usually 14 days for white cells and 21 days for platelets.
Dental treatment should be attempted only after consultation and in coordination with the
patient’s physician and after the patient has had a CBC.
59. Which precautions should be taken in treating a patient who has undergone bone
marrow transplantation for a hematologic malignancy?
Dental care should be done only in consultation with the patient’s physician. As a rule,
elective dental treatment should be postponed for 6 months after transplantation. However,
emergency dental treatment can be carried out. If dental care must be done before the recom-
mended postponement, a CBC should be checked, and if the results are acceptable (platelets
> 50,000/μL and neutrophils > 500), the patient should be premedicated using the same
regimen as for the prevention of endocarditis.
60. What should be done if a patient has enlarged lymph nodes?
Lymphadenopathy may be secondary to a sore throat, upper respiratory infection, or the
initial presentation of a malignancy. A thorough history and clinical examination help deter-
mine the cause of the lymphadenopathy.
Patients with lymphadenopathy and an identifiable inflammatory process should be reexam-
ined in 2 weeks to determine whether the lymphadenopathy has responded to treatment.
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 37

If no inflammatory process can be identified or the lymphadenopathy does not resolve after
treatment, the patient should be referred to a physician for further evaluation and possible
biopsy (Table 3-1).

KIDNEY DISEASE
61. Which precautions should be taken before beginning treatment of a patient on
dialysis?
Patients typically receive dialysis three times/week, usually on a Monday, Wednesday, Friday
schedule or Tuesday, Thursday, Saturday schedule. Dental treatment for a patient on dialysis
should be done on the day between dialysis appointments to avoid bleeding difficulties
(patients receive the anticoagulant, heparin, on dialysis days). Patients with grafts or indwell-
ing catheters should be premedicated to prevent infection of the graft or catheter. Patients
with an AV shunt do not need to be premedicated.
62. Which adjustments in the dosage of oral antibiotics should you make for a patient
on renal dialysis who has a dental infection?
Penicillin 500 mg orally every 6 hours; dose after hemodialysis
Amoxicillin 500 mg orally every 24 hours; dose after hemodialysis
Ampicillin 250 mg to 1 g orally every 12-24 hours; dose after hemodialysis
Erythromycin 250 mg orally every 6 hours; not necessary to dose after hemodialysis
Clindamycin 300 mg every 6 hours; not necessary to dose after hemodialysis
63. Which regional lymph nodes are most commonly involved in the presentation of
early Hodgkin’s disease?
Hodgkin’s disease typically presents with cervical, subclavicular, axillary, or mediastinal
lymph node involvement and, less commonly, with inguinal and abdominal lymph node
involvement.
64. Which pain medications can be safely prescribed for patients on dialysis?
Codeine is safe to use in dialysis but may produce more profound sedation. The dose should
be titrated, beginning with 50% of the normal dose for patients on dialysis and 50% to 75%
of the normal dose for patients with severely decreased renal function.
Acetaminophen is nephrotoxic in overdoses. However, it may be prescribed in patients
on dialysis at a dose of 650 mg every 8 hours. For patients with decreased renal function, the
regimen should be 650 mg every 6 hours.
Aspirin should be avoided in patients with severe renal failure and patients on renal dialysis
because of the possibility of potentiating hemorrhagic diathesis.
Meperidine (Demerol) should not be prescribed for patients on renal dialysis. The active
metabolite, normeperidine, accumulates and may cause seizures.

Table 3-1. Clinical Presentations of Lymphadenopathy

INFLAMMATORY GRANULOMATOUS DISEASE
PARAMETER PROCESS OR NEOPLASIA
Onset Acute Progressive enlargement
Pain on palpation Tender Neoplasia, asymptomatic
Granulomatous, painful
Symmetry Bilateral for systemic Usually unilateral
­infections
Unilateral for localized
­infections
Consistency Firm, movable Firm, non-movable
From Sonis ST, Fazio RC, Fang LS: Principles and practice of oral medicine, ed 2, Philadelphia, 1995, WB Saunders,
pp 269–271.
 38 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

65. Which changes do you expect to see in the dental radiographs of a patient on
renal dialysis?
The most common changes are decreased bone density with a ground glass appearance,
increased bone density in the mandibular molar area compatible with osteosclerosis, loss of
lamina aura, subperiosteal cortical bone resorption in the maxillary sinus and mandibular
canal, and brown tumor.
66. What is uremic stomatitis?
Uremic stomatitis is an ulcerative condition of the oral mucosa that develops in patients with
chronic renal failure. It is thought to be caused by ammonia metabolites.
67. What is a common oral complication of renal transplant patients who are on
chronic doses of cyclosporine?
Gingival hyperplasia is a common oral complication.
68. Which other medications are known to cause gingival hyperplasia?
Phenytoin (Dilantin), verapamil, nifedipine (Procardia), and amlodipine (Norvasc) are
known to cause gingival hyperplasia. Phenytoin is an anticonvulsant. Verapamil, nifedipine,
and amlodipine are calcium channel blockers.
69. What precautions should be taken when treating a patient after renal
transplantation?
After renal transplantation, patients receive immunosuppressive drugs and have an increased
susceptibility to infection. Dental infections should be treated aggressively. As with other
post-transplantation patients, elective dental treatment should be deferred during the first 3
months after renal transplantation. If emergency dental treatment is needed during the first 3
months, prophylactic antibiotics should be administered but should only be given thereafter
on an individual case basis in consultation with the patient’s physician. Erythromycin should
not be prescribed for any patient taking cyclosporine.
70. Which antibiotic should be avoided in a patient taking cyclosporine?
Cyclosporine is used to prevent organ rejection in renal, cardiac, and hepatic transplantation
and to prevent graft-versus-host disease in patients who have received a bone marrow trans-
plant. Erythromycin should not be prescribed for patients taking cyclosporine. Erythromycin
increases the levels of cyclosporine by decreasing its metabolism.

PULMONARY DISEASE
71. What precautions should be taken in treating a patient with chronic obstructive
pulmonary disease (COPD)?
Caution must be taken in prescribing drugs with antiplatelet activity (aspirin and NSAIDs)
to patients with COPD and a history of hemoptysis. Hemoptysis has been reported after the
use of aspirin in patients with COPD.
72. Which antibiotic should not be prescribed for patients with COPD who take
theophylline?
Erythromycin should not be prescribed for patients taking theophylline because it decreases
the metabolism of theophylline and may cause toxicity.
73. Which intervention is appropriate for a dental patient who has had an asthma at-
tack in the office?
The medical history should provide an indication of the severity of the asthma and the medica-
tions that the patient takes for an asthma attack. The symptoms of an acute asthma attack are
shortness of breath, wheezing, dyspnea, anxiety, and, with severe attacks, cyanosis. As with all
medical emergencies, the first two steps are to discontinue treatment and remain calm and not
increase the patient’s anxiety. Patients should be allowed to position themselves for optimal
comfort and then placed on oxygen, 2 to 4 L/min. If patients have their own nebulizer, they
should be allowed to use it. If the patient does not have a nebulizer, he or she should be given a
metaproterenol or albuterol nebulizer from the emergency cart or case and take two inhalations.
If the symptoms do not subside or increase in severity, emergency services should be con-
tacted. The patient must be closely monitored and given 0.3 to 0.5 mL of a 1:1000 solution
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 39

of epinephrine SC or IV aminophylline, 5.6 mg/kg, in 150 mL of 5% dextrose in half-

normal saline or normal saline infused over 30 minutes. (To calculate the patient’s weight
in kilograms, divide the patient’s weight in pounds by 2.2.) The dose of epinephrine may
be repeated every 30 minutes for as many as three doses. Epinephrine should not be used in
patients with severe hypertension, severe tachycardia, or cardiac arrhythmias. Aminophylline
should not be used in patients who have had theophylline in the past 24 hours.
74. Can nitrous oxide be used safely to sedate a patient with COPD?
Sedation with nitrous oxide should be avoided in patients with COPD. The high flow of
oxygen may depress the respiratory drive. Low-flow oxygen via a nasal cannula may be safely
used, without risk of respiratory depression.

LIVER DISEASE
75. Which laboratory blood tests should be ordered for a patient with alcoholic
hepatitis?
Alcoholic hepatitis is the most common cause of cirrhosis, which is one of the most common
causes of death in the United States. There are a number of concerns in treating the patient
with alcoholic hepatitis:
1. Increased risk of perioperative and postoperative bleeding, secondary to a decrease in
vitamin K-dependent coagulation factors
2. Qualitative and quantitative effects of alcohol on platelets
3. Anemia secondary to dietary deficiencies and/or hemorrhage
Before attempting a surgical procedure, the minimal laboratory tests that should be ordered
are PT/INR, PTT, CBC, and bleeding time.
76. What precautions should be taken with patients on anticonvulsant medications?
It is important to obtain a detailed history of the seizure disorder to determine whether the
patient is at risk for seizures during dental treatment. Important information includes the
type and frequency of seizures, date of the last seizure, prescribed medications, last blood test
to determine therapeutic ranges, and activities that tend to provoke seizures. For patients
taking valproic acid or carbamazepine, periodic tests for liver function should be performed.
Blood counts for patients taking carbamazepine and ethosuximide should be done by the
patient’s physician. Liver function test results and blood counts should be checked before any
oral surgical procedure is planned (Table 3-2).
77. Which emergency procedures should be taken for a patient having a seizure?
It is important to determine whether the patient has a history of seizure disorders. Any
patient who has a seizure in the dental office without a history of seizures must be treated
as a medical emergency. The emergency medical service should be contacted as the dentist
proceeds with management. There are two stages of a seizure, the ictal phase and postictal
phase. The management of each is described here.
1. Place the patient in a supine position, away from hard or sharp objects to prevent injury;
a carpeted floor is ideal. If the patient is in the dental chair, it is important to protect the
patient by moving equipment out of the way as far as possible.
2. The airway must be maintained and vital signs monitored during the tonic stage. If
suctioning equipment is available, it should be ready with a plastic tip for suctioning
secretions to maintain the airway. The patient may experience periods of apnea and develop
cyanosis. The head should be extended to establish a patent airway, and oxygen should
be administered. Vital signs, pulse, respiration, and blood pressure must be monitored
throughout the seizure.
3. If the ictal phase of the seizure lasts more than 5 minutes, emergency services should be
called. Tonic-clonic status epilepticus is a medical emergency. If the dentist is trained to
do so, an IV line should be initiated, and a dose of 25 g (50 mL) of 50% dextrose should
be given immediately in case the seizure is caused by hypoglycemia. If there is no response,
the patient should be given 10 mg of diazepam IV over a 2-minute period.
4. Once the seizure activity has stopped and the patient enters the postictal phase, it is
important to continue to monitor the vital signs and, if necessary, to provide basic life
support. If respiratory depression is significant, emergency services should be called, the
 40 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS

Table 3-2. Seizure Medications and Precautions for the Dental Practitioner

MEDICATION ADVERSE REACTIONS INTERACTIONS
Valproic acid (Depakote), Prolonged bleeding time, leu- Increased risk of bleeding with
Heparin kopenia, thrombocytopenia aspirin and NSAIDs or war-
farin; additive depression of
central nervous system (CNS)
with other depressants,
including narcotic analgesics
and sedative-hypnotics
Carbamazepine (Tegretol) Aplastic anemia, agranulocy- Erythromycin increases levels
tosis, thrombocytopenia, of carbamazepine, may cause
leukopenia, leukocytosis toxicity
Phenytoin (Dilantin) Aplastic anemia, agranu- Additive depression of CNS
locytosis, leukopenia, with other depressants,
thrombocytopenia sedative- including narcotics and
hypnotics sedative-hypnotics
Phenobarbital Additive depression of CNS
with other depressants,
including narcotics and
sedative-hypnotics; may in-
crease risk of hepatic toxicity
of acetaminophen
Primidone Blood dyscrasias, orthostatic Additive depression of CNS
hypotension with other depressants,
including narcotics and
sedative-hypnotics
Ethosuximide Aplastic anemia, granulocyto- Additive depression of CNS
sis, leukopenia with other depressants
Clonazepam Anemia, thrombocytosis, Additive depression of CNS
leukopenia with other depressants

airway maintained, and respiration supported. Blood pressure may be initially depressed
but should recover gradually.
5. If the patient recovers from the postictal phase without basic life support or other compli-
cations, the patient’s physician should be contacted and the patient, if stable, should be
discharged from the dental office, accompanied by a responsible adult.
78. Which dental considerations must be considered in treating patients with seizure
disorders?
Patients taking phenytoin are at risk for gingival hyperplasia. Tissue irritation from orthodontic
bands, defective restorations, fractured teeth, plaque, and calculus accelerate the hyperplasia.
The dental practitioner should consider the patient’s seizure status. A rubber dam with
dental floss tied to the clamp should be used for all restorative dental procedures to enable the
rapid removal of materials and instruments from the patient’s oral cavity. Fixed prosthetics, when
indicated, should be fabricated, rather than removable prosthetics. If removable prosthetics
are indicated, they should be fabricated with metal for all major connectors. Acrylic partial
dentures should be avoided because of the risk of breaking and aspiration during seizure activi-
ties. Unilateral partial dentures are contraindicated. Temporary crowns and bridges should be
laboratory-cured for strength.
79. Is general anesthesia contraindicated for patients with a seizure disorder?
No, it is not contraindicated. However, general anesthesia lowers the seizure threshold, and
precautions must be taken to ensure that serum levels of the antiseizure drug are within
therapeutic range.
 CHAPTER 3 MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS 41

80. What are the common causes of unconsciousness in dental patients?

The most common cause of loss of consciousness in the dental office is syncope. The signs
and symptoms are diaphoresis, pallor, and loss of consciousness. Place the patient in the
supine position with the feet elevated, monitor vital signs, and administer oxygen, 3 to 4 L/min
via a nasal cannula.

RADIATION THERAPY
81. What are the risk factors for the development of osteoradionecrosis?
Bone exposed to high radiation therapy is hypovascular, hypocellular, and hypoxic tissue.
Osteoradionecrosis develops because the radiated tissue is unable to repair itself. The risk for
osteoradionecrosis increases as the dose of radiation increases from 5000 rad to over 8000 rad.
Tissues receiving less than 5000 rad are at low risk for necrosis. In addition, the risk increases
with poor oral health. Oral surgical procedures after radiation therapy place the patient at
high risk for developing osteoradionecrosis. Soft tissue trauma from dentures and oral infec-
tions from periodontal disease and dental caries also put the patient at risk.
82. How should the dentist prepare the patient for radiation therapy of the head
and neck?
The dentist should consult with the radiotherapist to determine which oral structures will be
in the field of radiation, as well as the maximal radiation dose. If teeth are in the field and the
dose is greater than 5000 rad, periodontally involved teeth and teeth with periapical lucen-
cies should be extracted at least 2 weeks before radiation therapy begins. The patient should
receive antibiotic prophylaxis prior to the extractions and should continue with a 1-week
regimen of antibiotics four times daily after the extractions. The dentist should prepare the
patient for postradiation xerostomia—provide custom fluoride trays and prescribe 0.4% stan-
nous fluoride gel to be used for 3 to 5 minutes twice daily. The patient must be placed on a 2-
to 3-month recall schedule. On recall, the teeth must be carefully examined for root caries,
and instruction in oral hygiene should be reviewed.

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 CHAPTER 4
ORAL PATHOLOGY
Sook-Bin Woo

DEVELOPMENTAL CONDITIONS
Tooth-Related Problems
1. True or false: Dental fluorosis increases pitting and porosity of the enamel and
therefore increases the risk of dental caries.
It is true that fluorosis causes increased pitting and porosity because fluoride increases
retention of amelogenin, which results in hypomineralization of the enamel. This causes
an unesthetic chalky white or even brown discoloration of the enamel, which may be pit-
ted and fissured. However, because this enamel is more caries-resistant, the risk of dental
caries is lower.
2. Name the three main forms of amelogenesis imperfecta.
1. Hypoplastic form: inadequate deposition of enamel matrix. Whatever is deposited
calcifies normally. The teeth have thin enamel that may be pitted.
2. Hypomaturation form: adequate deposition of enamel, but the enamel crystal does not
mature normally. The result is soft pigmented enamel that chips easily.
3. Hypocalcified form: inadequate mineralization. The result is enamel that gets lost a few
years after eruption.
3. Describe the different types of dentinogenesis imperfecta.
Dentinogenesis imperfecta (DI) is a condition caused by abnormal dentin formation and
several types exist. The classic type lead to opalescent teeth in the primary and perma-
nent dentition. The teeth are bluish-brown and translucent. Enamel is lost early, and the
exposed dentine undergoes rapid attrition.

Osteogenesis imperfecta with opalescent teeth Dentin dysplasia Type I

Dentinogenesis imperfect Dentin dysplasia Type II

4. Describe the two main types of dentin dysplasia.

Type I, radicular type. The roots are poorly formed, short, and distorted or even absent,
with poorly formed crescent-shaped pulp chambers and absent pulp canals. Periapical
lucencies develop early and teeth exfoliate prematurely.
Type II, coronal type. The crowns contain large pulp chambers that are thistle- or flame-
shaped, that extend into the root. Pulp stones often develop. Primary teeth look like those
of dentinogenesis imperfect with early obliteration of the pulp.
5. What is the difference between fusion and concrescence? Between twinning
and gemination?
Fusion is a more complete process than concrescence and involves fusion of the entire
length of two teeth (enamel, dentin, and cementum) to form one large tooth, with one
less tooth in the arch, or fusion of the root only (dentin and cementum), with the mainte-
nance of two clinical crowns. Concrescence involves fusion of cementum only.
Twinning is more complete than gemination and results in the formation of two sepa-
rate teeth from one tooth bud (one extra tooth in the arch). In gemination, separation is
attempted, but the two teeth share the same root canal.
6. What is a Turner tooth?
A Turner tooth is a solitary, usually permanent tooth with signs of enamel hypoplasia or
hypocalcification. This phenomenon is caused by trauma or infection in the overlying
deciduous tooth that damages the ameloblasts of the underlying tooth bud and thus leads
to localized enamel hypoplasia or hypocalcification.
43
 44 CHAPTER 4 ORAL PATHOLOGY

7. What are “bull teeth”?

Bull teeth, also known as taurodonts, have long anatomic crowns, large pulp chambers,
and short roots, resembling teeth found in bulls. They are most dramatic in permanent
molars but may affect teeth in either dentition. They occur more frequently in certain
syndromes, such as Klinefelter syndrome.
8. What is the difference between dens evaginatus and dens invaginatus?
Dens evaginatus occurs primarily in the Chinese population (also named Leong premolar)
and affects the premolars. Evagination of the layers of the tooth germ results in the forma-
tion of a tubercle that arises from the occlusal surface and consists of enamel, dentin, and
pulp tissue. This tubercle tends to break when it occludes with the opposing dentition and
may result in pulp exposure and subsequent pulp necrosis. Dens invaginatus occurs mainly
in maxillary lateral incisors and ranges in severity from an accentuated lingual pit to what
is known as a dens in dente. This phenomenon is caused by invagination of the layers of the
tooth germ. Food becomes trapped in the pit, and caries begin early.
9. What are the causes of generalized intrinsic discoloration of teeth?
• Amelogenesis imperfecta • Fluorosis • Congenital porphyria
• Dentinogenesis imperfecta • Rh incompatibility • Biliary atresia
• Tetracycline staining
10. Why do teeth discolor from ingestion of tetracycline during odontogenesis?
Tetracycline binds with the calcium component of bones and teeth and is deposited at sites
of active mineralization, causing a yellow-brown endogenous pigmentation of the hard
tissues. Because teeth do not turn over the way bone does, this stain becomes a permanent
label that fluoresces under ultraviolet light.
11. Which teeth are most commonly missing congenitally?
Third molars, maxillary lateral incisors, and second premolars are the most common.
12. What conditions are associated with multiple supernumerary teeth?
Gardner’s syndrome and cleidocranial dysplasia are two important conditions.
13. What are the most common sites for supernumerary teeth?
Midline of the maxilla (mesiodens), posterior maxilla (fourth molar or paramolar), and
mandibular bicuspid areas.
Intrabony Lesions
14. 
A 40-year-old black woman presents with multiple periapical radiolucencies and
radiopacities. What is the diagnosis?
The U.S. black population is prone to developing benign fibro-osseous lesions of various
types. They range from localized lesions, such as focal cemento-osseous dysplasia, usually
involving the apex of a mandibular molar, to periapical cemento-osseous dysplasia, usually
involving the mandibular anterior teeth, to florid (multi-focal) cemento-osseous dysplasia,
involving all four quadrants. The term cemento-osseous is preferred to cemental because a
combination of cementum droplets and woven bone are usually present (Fig. 4-1).
15. Are fibrous dysplasias of bone premalignant lesions?
Fibrous dysplasia, a malformation of bone, is of unknown cause and is not premalignant,
although a gene (GNAS) has been identified for this condition. The monostotic form
often affects the maxilla unilaterally. The polyostotic form is associated with various other
abnormalities, such as skin pigmentations and endocrine dysfunction (Albright and Jaffe-
Lichtenstein syndromes). Cherubism, which used to be termed familial fibrous dysplasia, is
probably not a form of fibrous dysplasia and is associated with a different gene mutation
(SH3BP2). In the past, fibrous dysplasia was treated with radiation, which sometimes
caused the development of osteosarcoma. The best way to treat cherubism is by recontour-
ing the bone after the teenage growth spurt and when lesions become quiescent.
16. True or false: The globulomaxillary cyst is a fissural cyst.
False. Historically, the globulomaxillary cyst was classified as a nonodontogenic or fissural
cyst thought to result from the entrapment of epithelial rests along the line of fusion
between the lateral maxillary and nasomedial processes. Current thinking puts it into
Other documents randomly have
different content
animated, abandoned herself to her imagination; with discreet
reserve she spoke of princely “amours,” of royal favours, of romantic
adventures; she thus evoked all of those confused recollections of
novels read at other times, and trusted liberally to the credulity of
her listeners. Don Giovanni at these times turned his eyes upon her
full of inquietude, almost bewildered; moreover experiencing a
singular irritation that had an indistinct resemblance to jealousy.
Violetta at length ended with a stupid smile and the conversation
languished anew.
Then Violetta went to the piano and sang. All listened with profound
attention; at the end they applauded. Then Don Brattella arose with
the flute. An immeasurable melancholy took hold of his listeners at
that sound, a kind of swooning of body and soul. They rested with
heads lowered almost to their breasts in attitudes of sufferance. At
last all left, one after the other. As they took the hand of Violetta a
slight scent from the strong perfume of musk remained on their
fingers, and this excited them further. Then, once more in the street,
they reunited in groups, holding loose discourse. They grew
inflamed, lowered their voices and were silent if anyone drew near.
Softly they withdrew from beneath the Brina palace to another part
of the square. There they set themselves to watching Violetta’s
windows, still illuminated. Across the panes passed indistinct
shadows; at a certain time the light disappeared, traversed two or
three rooms and stopped in the last window. Shortly, a figure leaned
out to close the shutters. Those spying thought they recognised in it
the figure of Don Giovanni. They still continued to discuss beneath
the stars and from time to time laughed, while giving one another
little nudges, and gesticulating. Don Antonio Brattella, perhaps from
the reflection of the city-lamps, seemed a greenish colour. The
parasites, little by little in their discourse spit out a certain animosity
toward the opera-singer, who was plucking so gracefully their lord of
good times. They feared lest those generous feasts might be in peril;
already Don Giovanni was more sparing of his invitations.
“It will be necessary to open the eyes of the poor fellow. An
adventuress! Bah! She is capable of making him marry her. Why not?
And then what a scandal!”
Don Pompeo Nervi, shaking his large calf’s head, assented:
“You are right! You are right! We must bethink ourselves.”
Don Nereo Pica, “The Cat,” proposed a way, conjured up schemes;
this pious man, accustomed to the secret and laborious skirmishes of
the sacristy was crafty in the sowing of discord.
Thus these complainers treated together and their fat speeches only
returned again into their bitter mouths. As it was spring the foliage
of the public gardens smelt and trembled before them with white
blossoms and through the neighbouring paths they saw, about to
disappear, the figures of loosely-dressed prostitutes.

When, therefore, Don Giovanni Ussorio, after having heard from

Rosa Catana of the departure of Violetta Kutufa, re-entered his
widower’s house and heard his parrot humming the air of the
butterfly and the bee, he was seized by a new and more profound
discouragement.
In the entrance a girdle of sunlight penetrated boldly and through
the iron grating one saw the tranquil garden full of heliotropes. His
servant slept upon a bench with a straw hat pulled down over his
face.
Don Giovanni did not wake the servant. He mounted the stairs with
difficulty, his eyes fixed upon the steps, pausing every now and then
to mutter: “Oh, what a thing to happen! Oh, oh, what luck!”
Having reached his room he threw himself upon the bed and with
his mouth against the pillows, began again to weep. Later he arose;
the silence was deep and the trees of the garden as tall as the
window waved slightly in the stillness. There was nothing of the
unusual in the things about him; he almost wondered at this.
He fell to thinking and remained a long time calling to mind the
positions, the gestures, the words, the slightest motions of the
deserter. He saw her form as clearly as if she were present. At every
recollection his grief increased until at length a kind of dulness
benumbed his mind. He remained sitting on the bed, almost
motionless, his eyes red, his forehead blackened from the colouring
matter of his hair mixed with perspiration, his face furrowed with
wrinkles that had suddenly become more evident; he had aged ten
years in an hour, a change both amusing and pathetic.
Don Grisostomo Troilo, who had heard the news, arrived. He was a
man of advanced age, of short stature and with a round, swollen
face from which spread out sharp, thin whiskers, well waxed and
resembling the two wings of a bird. He said:
“Now, Giovà, what is the matter?”
Don Giovanni did not answer, but shook his shoulders as if to repel
all sympathy. Don Grisostomo then began to reprove him
benevolently, never speaking of Violetta Kutufa.
In came Don Cirillo d’Amelio with Don Nereo Pica. Both, on entering,
showed almost an air of triumph.
“Now you have seen for yourself, Don Giovà! We told you so! We
told you so!” they cried. Both had nasal voices and a cadence
acquired from the habit of singing with the organ, because they
belonged to the choir of the Holy Sacrament. They began to attack
the character of Violetta without mercy. She did this and that and
the other thing, they said.
Don Giovanni, outraged, made from time to time a motion as if he
would not hear such slanders, but the two continued. Now, also,
Don Pasquale Virgilio arrived, with Don Pompeo Nervi, Don Federico
Sicoli, Don Tito de Sieri; almost all of the parasites came in a group.
Supporting one another they became ferocious. Did he not know
that Violetta Kutufa had abandoned herself to Tom, Dick and
Harry...? Indeed she had! Indeed! They laid bare the exact
particulars, the exact places.
Now Don Giovanni heard with eyes afire, greedy to know, invaded
by a terrible curiosity. These revelations instead of disgusting him,
fed his desire. Violetta seemed to him more enticing, even more
beautiful; and he felt himself inwardly bitten by a raging jealousy
that blended with his grief. Presently the woman appeared in his
mind’s eye associated with a certain soft relaxation. That picture
made him giddy.
“Oh Dio! Oh Dio! Oh! Oh!” He commenced to weep again. Those
present looked at one another and restrained their laughter. In truth
the grief of that man; fleshy, bald, deformed, expressed itself so
ridiculously that it seemed unreal.
“Go away now!” Don Giovanni blubbered through his tears.
Don Grisostomo Troilo set the example; the others followed him and
chattered as they passed down the stairs.
Toward evening the prostrated man revived little by little. A woman’s
voice called at his door: “May I come in, Don Giovanni?”
He recognised Rosa Catana’s voice and experienced suddenly an
instinctive joy. He ran to let her in. Rosa Catana appeared in the
dusk of the room.
“Come in! Come in!” he cried. He made her sit down beside him, had
her talk to him, asked her a thousand questions. He seemed to
suffer less on hearing that familiar voice in which, under the spell of
an illusion, he found some quality of Violetta’s voice. He took her
hands and cried:
“You helped her to dress! Did you not?”
He caressed those rugged hands, closing his eyes and wandering
slightly in his mind on the subject of those abundant, unbound locks
that so many times he had touched with his hands. Rosa at first did
not understand. She believed this to be some sudden passion of Don
Giovanni, and withdrew her hands gently, while she spoke in an
ambiguous way and laughed. But Don Giovanni murmured:
“No, no!... Stay! You combed her, did you not? You bathed her, did
you not?”
He fell to kissing Rosa’s hands, those hands that had combed,
bathed and clothed Violetta. He stammered, while kissing them,
composed verses so strange that Rosa could scarcely refrain from
laughter. But at last she understood and with feminine perception
forced herself to remain serious, while she summed up the
advantages that might ensue from this foolish comedy. She grew
docile, let him caress her, let him call her Violetta, made use of all
that experience acquired from peeping through key-holes many
times at her mistress’s door; she even sought to make her voice
more sweet.
In the room one could scarcely see them. Through the open
windows a red reflection entered and the trees in the garden, almost
black, twisted and turned in the wind. From the sloughs around the
arsenal came the hoarse croak of the frogs. The noises of the city
street were indistinct.
Don Giovanni drew the woman to his knees, and, completely
confused as if he had swallowed some very’ strong liquor, murmured
a thousand childish nothings and babbled on without end, drawing
her face close to his.
“Ah, darling little Violetta!” he whispered. “Sweetheart! Don’t go
away, dear...! If you go away your Nini will die, Poor Nini...! Ban-
ban-ban-bannn!”
Thus he continued stupidly, as he had done before with the opera-
singer. Rosa Catana patiently offered him slight caresses, as if he
were a very sick, perverted child; she took his head and pressed it
against her shoulder, kissed his swollen, weeping eyes, stroked his
bald crown, rearranged his oiled locks.

VI
Thus, Rosa Catana, little by little, earned her inheritance from Don
Giovanni Ussorio, who, in the March of 1871, died of paralysis.
 III
THE RETURN OF TURLENDANA

The group was walking along the seashore. Down the hills and over
the country Spring was coming again. The humble strip of land
bordering the sea was already green; the various fields were quite
distinctly marked by the springing vegetation, and every mound was
crowned with budding trees. The north wind shook these trees, and
its breath caused many flowers to fall. At a short distance the
heights seemed to be covered with a colour between pink and violet;
for an instant the view seemed to tremble and grow pale like a ripple
veiling the clear surface of a pool, or like a faded painting.
The sea stretched out its broad expanse serenely along the coast,
bathed by the moonlight, and toward the north taking on the hue of
a turquois of Persia, broken here and there by the darker tint of the
currents winding over its surface.
Turlendana, who had lost the recollection of these places through a
long absence, and who in his long peregrinations had forgotten the
sentiments of his native land, was striding along with the tired,
regular step of haste, looking neither backward nor around him.
When the camel would stop at a tuft of wild grass, Turlendana would
utter a brief, hoarse cry of incitement. The huge reddish quadruped
would slowly raise his head, chewing the morsel heavily between his
jaws.
“Hu, Barbara!”
The she-ass, the little snowy white Susanna, protesting against the
tormenting of the monkey, from time to time would bray lamentingly,
asking to be freed of her rider.
But the restless Zavali gave her no peace; as though in a frenzy, with
quick, short gestures of wrath, she would run over the back of the
beast, jump playfully on her head, get hold of her large ears; then
would lift her tail and shake the hairs, hold it up and look through
the hairs, scratch poor Susanna viciously with her nails, then lift her
hands to her mouth and move her jaws as though chewing,
grimacing frightfully as she did so. Then suddenly, she would jump
back to her seat, holding in her hands her foot, twisted like the root
of a bush, and sit with her orange coloured eyes, filled with wonder
and stupor, fixed on the sea, while wrinkles would appear on her
head, and her thin pinkish ears would tremble nervously. Without
warning she would make a malicious gesture, and recommence her
play.
“Hu, Barbara!”
The camel heard and started to walk again.
When the group reached the willow tree woods, at the mouth of the
River Pescara, figures could be seen upon its right bank, above the
masts of the ships anchored in the docks of Bandiera. Turlendana
stopped to get a drink of water from the river.
The river of his native place carried to him the peaceful air of the
sea. Its banks, covered with fluvial plains, lay stretched out as
though resting from their recent work of fecundity. The silence was
profound. The cobwebs shone tranquilly in the sun like mirrors
framed by the crystal of the sea. The seaweed bent in the wind,
showing its green or white sides.
“Pescara!” said Turlendana, with an accent of curiosity and
recognition, stopping still to look at the view.
Then, going down to the shore where the gravel was clean, he
kneeled down to drink, carrying the water to his mouth in his curled
up palm. The camel, bending his long neck, drank with slow, regular
draughts. The she-ass, too, drank from the stream, while the
monkey, imitating the man, made a cup of her hands, which were
violet coloured like unripe India figs.
“Hu, Barbara!” The camel heard and ceased to drink. The water
dripped unheeded from his mouth onto his chest; his white gums
and yellowish teeth showed between his open lips.
Through the path marked across the wood by the people of the sea,
the little group proceeded on its way. The sun was setting when they
reached the Arsenale of Rampigna. Turlendana asked of a sailor who
was walking beside the brick parapet:
“Is that Pescara?”
The sailor, astonished at the sight of the strange beasts, answered
Turlendana’s question:
“It is that,” and left his work to follow the stranger.
The sailor was soon joined by others. Soon a crowd of curious
people had gathered and were following Turlendana, who went
calmly on his way, unmindful of the comments of the people. When
they reached the boat-bridge, the camel refused to pass over.
“Hu, Barbara! Hu, hu!” Turlendana cried impatiently, urging him on,
and shaking the rope of the halter by which he led the animal. But
Barbara obstinately lay down upon the ground, and stretched his
head out in the dust very comfortable, showing no intention of
moving.
The people jesting gathered about, having overcome their first
amazement, and cried in a chorus:
“Barbara! Barbara!”
As they were somewhat familiar with monkeys, having seen some
which the sailors had brought home, together with parrots, from
their long cruises, they were teasing Zavali in a thousand different
ways, handing her large greenish almonds, which the monkey would
open, gluttonously devouring the sweet fresh meat.
After much urging and persistent shouting, Turlendana succeeded in
conquering the stubbornness of the camel, and that enormous
architecture of bones and skin rose staggering to his feet in the
midst of the instigating crowd.
From all directions soldiers and sailors flocked over the boat bridge
to witness the spectacle. Far behind the mountain of Gran Sasso the
setting sun irradiated the spring sky with a vivid rosy light, and from
the damp earth, the water of the river, the seas, and the ponds, the
moisture had arisen. A rosy glow tinted the houses, the sails, the
masts, the plants, and the whole landscape, and the figures of the
people, acquiring a sort of transparency, grew obscure, the lines of
their contour wavering in the fading light.
Under the weight of the caravan the bridge creaked on its tar-
smeared boats like a very large floating lighter. Turlendana, halting
in the middle of the bridge, brought the camel also to a stop;
stretching high above the heads of the crowd, it stood breathing
against the wind, slowly moving its head like a fictitious serpent
covered with hair.
The name of the beast had spread among the curious people, and
all of them, from an innate love of sensation, and filled with the
exuberance of spirits inspired by the sweetness of the sunset and
the season of the year, cried out gleefully:
“Barbara! Barbara!” At the sound of this applauding cry and the well-
meant clamour of the crowd, Turlendana, who was leaning against
the chest of his camel, felt a kindly emotion of satisfaction spring up
in his heart.
The she-ass suddenly began to bray with such high and discordant
variety of notes, and with such sighing passion that a spontaneous
burst of merriment ran through the crowd.
The fresh, happy laughter spread from one end of the bridge to the
other like the roar of water falling over the stones of a cataract.
Then Turlendana, unknown to any of the crowd, began to make his
way through the throng. When he was outside the gates of the city,
where the women carrying reed baskets were selling fresh fish,
Binchi-Banche, a little man with a yellow face, drawn up like a
juiceless lemon, pushed to the front, and as was his custom with all
strangers who happened to come to the place, offered his services in
finding a lodging.
Pointing to Barbara, he asked first:
“Is he ferocious?”
Turlendana, smiling, answered, “No.”
“Well,” Binchi-Banche went on, reassured, “there is the house of
Rosa Schiavona.” Both turned towards the Pescaria, and then
towards Sant’ Agostino, followed by the crowd. From windows and
balconies women and children leaned over, gazing in astonishment
at the passing camel, admiring the grace of the white ass, and
laughing at the comic performances of Zavali.
At one place, Barbara, seeing a bit of green hanging from a low
loggia, stretched out his neck and, grasping it with his lips, tore it
down. A cry of terror broke forth from the women who were leaning
over the loggia, and the cry spread to other loggias. The people
from the river laughed loudly, crying out, as though it were the
carnival season and they were behind masks:
“Hurrah! Hurrah!”
They were intoxicated by the novelty of the spectacle, and by the
invigourating spring air. In front of the house of Rosa Schiavona, in
the neighbourhood of Portasale, Binchi-Banche made a sign to stop.
“This is the place,” he said.
It was a very humble one-story house with one row of windows, and
the lower walls were covered with inscriptions and ugly figures. A
row of bats pinned on the arch formed an ornament, and a lantern
covered with reddish paper hung under the window.
This place was the abode of a sort of adventurous, roving people.
They slept mixed together, the big and corpulent truckman, Letto
Manoppello, the gipsies of Sulmona, horse-traders, boiler-menders,
turners of Bucchianico, women of the city of Sant’ Angelo, women of
wicked lives, the bag-pipers of Atina, mountaineers, bear-tamers,
charlatans, pretended mendicants, thieves, and fortune-tellers.
Binchi-Banche acted as a go-between for all that rabble, and was a
great protégé of the house of Rosa Schiavona.
When the latter heard the noise of the newcomers, she came out
upon the threshold. She looked like a being generated by a dwarf
and a sow. Very diffidently she put the question:
“What is the matter?”
“There is a fellow here who wants lodging for his beasts, Donna
Rosa.”
“How many beasts?”
“Three, as you see, Donna Rosa—a monkey, an ass, and a camel.”
The crowd was paying no attention to the dialogue. Some of them
were exciting Zavali, others were feeling of Barbara’s legs,
commenting on the callous spots on his knees and chest. Two
guards of the salt store-houses, who had travelled to the sea-ports
of Asia Minor, were telling in a loud voice of the wonderful properties
of the camel, talking confusedly of having seen some of them
dancing, while carrying upon their necks a lot of half-naked
musicians and women of the Orient. The listeners, greedy to hear
these marvellous tales, cried:
“Tell us some more! Tell us some more!” They stood around the
story-tellers in attentive silence, listening with dilated eyes.
Then one of the guards, an old man whose eyelids were drawn up
by the wind of the sea, began to tell of the Asiatic countries, and as
he went on, his imagination became excited by the stories which he
told, and his tales grew more wonderful.
A sort of mysterious softness seemed to penetrate the sunset. In the
minds of the listeners, the lands which were described to them rose
vividly before their imaginations in all their strange splendour. Across
the arch of the Porta, which was already in shadow, could be seen
boats loaded with salt rocking upon the river, the salt seeming to
absorb all the light of the evening, giving the boats the appearance
of palaces of precious crystals. Through the greenish tinted heavens
rose the crescent of the moon.
“Tell us some more! Tell us some more!” the younger of those
assembled were crying.
In the meanwhile Turlendana had put his beasts under cover and
supplied them with food. This being done, he had again set forth
with Binchi-Banche, while the people remained gathered about the
door of the barn where the head of the camel appeared and
disappeared behind the rock gratings.
On the way Turlendana asked:
“Are there any drinking places here?”
Binchi-Banche answered promptly:
“Yes, sir, there are.” Then, lifting his big black hands he counted off
on his fingers:
“The Inn of Speranza, the Inn of Buono, the Inn of Assau, the Inn of
Zarricante, the Inn of the Blind Woman of Turlendana....”
“Ah!” exclaimed the other calmly.
Binchi-Banche raised his big, sharp, greenish eyes.
“You have been here before, sir?”
Then, with the native loquacity of the Pescarese he went on without
waiting for an answer:
“The Inn of the Blind Woman is large, and they sell there the best
wine. The so-called Blind Woman is a woman who has had four
husbands....”
He stopped to laugh, his yellowish face wrinkling into little folds as
he did so.
“The first husband was Turlendana, a sailor on board the ships of
the King of Naples, sailing from India to France, to Spain, and even
as far as America. He was lost at sea, no one knows where, for the
ship disappeared and nothing has ever been heard from it since.
That was about thirty years ago. Turlendana had the strength of
Samson; he could pull up an anchor with one finger ... poor fellow!
He who goes to sea is apt to have such an end.”
Turlendana was listening quietly.
“The second husband, whom she married after five years of
widowhood, was from Ortona, a son of Ferrante, a damned soul,
who was in conspiracy with smugglers in Napoleon’s time, during the
war with England. They smuggled goods from Francavilla up to Silvi
and Montesilvano—sugar and coffee from the English boats. In the
neighbourhood of Silvi was a tower called ‘The Tower of Saracini,’
from which the signals were given. As the patrol passed, ‘Plon, plon,
plon, plon!’ came out from behind the trees....” Binchi-Banche’s face
lighted up at the recollection of those times, and he quite lost
himself in the pleasure of describing minutely all those clandestine
operations, his expressive gestures and exclamations adding interest
to the tale.
His small body would draw up and stretch out to its full height as he
proceeded.
“At last the son of Ferrante was, while walking along the coast one
night, shot in the back by a soldier of Murat, and killed.
“The third husband was Titino Passacantando, who died in his bed of
a pernicious disease.
“The fourth still lives, and is called Verdura, a good fellow who does
not adulterate the wine of the inn. Now, you will have a chance to
try some.”
When they reached the much praised inn, they separated.
“Good night, sir!”
“Good night!”
Turlendana entered unconcernedly, unmindful of the curious
attention of the drinkers sitting beside the long tables. Having asked
for something to eat, he was conducted to an upper room where the
tables were set ready for supper.
None of the regular boarders of the place were yet in the room.
Turlendana sat down and began to eat, taking great mouthfuls
without pausing, his head bent over his plate, like a famished
person. He was almost wholly bald, a deep red scar furrowed his
face from forehead to cheek, his thick greyish beard extended to his
protruding cheek bones, his skin, dark, dried, rough, worn by water
and sun and wrinkled by pain, seemed not to preserve any human
semblance, his eyes stared into the distance as if petrified by
impassivity.
Verdura, inquisitive, sat opposite him, staring at the stranger. He was
somewhat flushed, his face was of a reddish colour veined with
vermilion like the gall of oxen. At last he cried:
“Where do you come from?”
Turlendana, without raising his head, replied simply:
“I come from far away.”
“And where do you go?” pursued Verdura.
“I remain here.”
Verdura, amazed, was silent.
Turlendana continued to lift the fishes from his plate, one after
another, taking off their heads and tails, and devouring them,
chewing them up, bones and all. After every two or three fishes he
drank a draught of wine.
“Do you know anybody here?” Verdura asked with eager curiosity.
“Perhaps,” replied the other laconically.
Baffled by the brevity of his interlocutor, the wine man grew silent
again. Above the uproar of the drinkers below, Turlendana’s slow
and laboured mastication could be heard. Presently Verdura again
Ventured to open his mouth.
“In what countries is the camel found? Are those two humps
natural? Can such a great, strong beast ever be tamed?”
Turlendana allowed him to go on without replying.
“Your name, Mister?”
The man to whom this question was put raised his head from his
plate, and answered simply, as before:
“I am called Turlendana.”
“What?”
“Turlendana.”
“Ah!”
The amazement of the inn keeper was unbounded. A sort of a vague
terror shook his innermost soul.
“What? Turlendana of this place?”
“Of this place.”
Verdura’s big azure eyes dilated as he stared at the man.
“Then you are not dead?”
“No, I am not dead.”
“Then you are the husband of Rosalba Catena?”
“I am the husband of Rosalba Catena.”
“And now,” exclaimed Verdura, with a gesture of perplexity, “we are
two husbands!”
“We are two!”
They remained silent for an instant. Turlendana was chewing the last
bit of bread tranquilly, and through the quiet room you could hear
his teeth crunching on it. Either from a natural benignant simplicity
or from a glorious fatuity, Verdura was struck only by the singularity
of the case. A sudden impulse of merriment overtook him, bubbling
out spontaneously:
“Let us go to Rosalba! Let us go! Let us go!”
Taking the newcomer by the arm, he conducted him through the
group of drinkers, waving his arms, and crying out:
“Here is Turlendana, Turlendana the sailor! The husband of my wife!
Turlendana, who is not dead! Here is Turlendana! Here is
Turlendana!”
 IV
TURLENDANA DRUNK

The last glass had been drunk, and two o’clock in the morning was
about to strike from the tower clock of the City Hall.
Said Biagio Quaglia, his voice thick with wine, as the strokes
sounded through the silence of the night filled with clear moonlight:
“Well! Isn’t it about time for us to go?”
Ciavola, stretched half under the bench, moved his long runner’s
legs from time to time, mumbling about clandestine hunts-in the
forbidden grounds of the Marquis of Pescara, as the taste of wild
hare came up in his throat, and the wind brought to his nostrils the
resinous odour of the pines of the sea grove.
Said Biagio Quaglia, giving the blond hunter a kick, and making a
motion to rise:
“Let us go.”
Ciavola with an effort rose, swaying uncertainly, thin and slender like
a hunting hound.
“Let us go, as they are pursuing us,” he answered, raising his hand
high in a motion of assent, thinking perhaps of the passage of birds
through the air.
Turlendana also moved, and seeing behind him the wine woman,
Zarricante, with her flushed raw cheeks and her protruding chest, he
tried to embrace her. But Zarricante fled from his embrace, hurling at
him words of abuse.
On the doorsill, Turlendana asked his friends for their company and
support through a part of the road. But Biagio Quaglia and Ciavola,
who were indeed a fine pair, turned their backs on him jestingly, and
went away in the luminous moonlight.
Then Turlendana stopped to look at the moon, which was round and
red as the face of a friar. Everything around was silent and the rows
of houses reflected the white light of the moon. A cat was mewing
this May night upon a door step. The man, in his intoxicated state,
feeling a peculiarly tender inclination, put out his hand slowly and
uncertainly to caress the animal, but the beast, being somewhat
wild, took a jump and disappeared.
Seeing a stray dog approaching, he attempted to pour out upon it
the wealth of his loving impulses; the dog, however, paid no
attention to his calls, and disappeared around the corner of a cross
street, gnawing a bone. The noise of his teeth could be heard plainly
through the silence of the night.
Soon after, the door of the inn was closed and Turlendana was left-
standing alone under the full moon, obscured by the shadows of
rolling clouds. His attention was struck by the rapid moving of all
surrounding objects. Everything fled away from him. What had he
done that they should fly away?
With unsteady steps, he moved towards the river. The thought of
that universal flight as he moved along, occupied profoundly his
brain, changed as it was by the fumes of the wine. He met two other
street dogs, and as an experiment, approached them, but they too
slunk away with their tails between their legs, keeping close to the
wall and when they had gone some little distance, they began to
bark. Suddenly, from every direction, from Bagno da Sant’ Agostino,
from Arsenale, from Pescheria, from all the lurid and obscure places
around, the roving dogs ran up, as though in answer to a trumpet
call to battle and the aggressive chorus of the famishing tribe
ascended to the moon.
Turlendana was stupefied, while a sort of vague uneasiness awoke in
his soul and he went on his way a little more quickly, stumbling over
the rough places in the ground. When he reached the corner of the
coopers, where the large barrels of Zazetta were piled in whitish
heaps like monuments, he heard the heavy, regular breathing of a
beast. As the impression of the hostility of all beasts had taken a
hold on him, with the obstinacy of a drunken man, he moved in the
direction of the sound, that he might make another experiment.
Within a low barn the three old horses of Michelangelo were
breathing with difficulty above their manger. They were decrepit
beasts who had worn out their lives dragging through the road of
Chieti, twice every day, a huge stage-coach filled with merchants
and merchandise. Under their brown hair, worn off in places by the
rubbing of the harness, their ribs protruded like so many dried
shingles through a ruined roof. Their front legs were so bent that
their knees were scarcely perceptible, their backs were ragged like
the teeth of a saw, and their skinny necks, upon which scarcely a
vestige of mane was left, drooped towards the ground.
A wooden railing inside barred the door.
Turlendana began encouragingly:
“Ush, ush, ush! Ush, ush, ush!”
The horses did not move, but breathed together in a human way.
The outlines of their bodies appeared dim and confused through the
bluish shadow within the barn, and the exhalations of their breath
blent with that of the manure.
“Ush, ush, ush!” pursued Turlendana in a lamenting tone, as when
he used to urge Barbara to drink. Again the horses did not stir, and
again:
“Ush, ush, ush! Ush, ush, ush!” One of the horses turned and placed
his big deformed head upon the railing, looking with eyes which
seemed in the moonlight as though filled with troubled water. The
lower skin of the jaw hung flaccid, disclosing the gums. At every
breath the nostrils palpitated, emitting moist breath, the nostrils
closing at times, and opening again to give forth a little cloud of air
bubbles like yeast in a state of fermentation.
At the sight of that senile head, the drunken man came to his
senses. Why had he filled himself with wine, he, usually so sober?
For a moment, in the midst of his forgetful drowsiness, the shape of
his dying camel reappeared before his eyes, lying on the ground
with his long inert neck stretched out on the straw, his whole body
shaken from time to time by coughing, while with every moan the
bloated stomach produced a sound such as issues from a barrel half
filled with water.
A wave of pity and compassion swept over the man, as before him
rose this vision of the agony of the camel, shaken by strange, hoarse
sobs which brought forth a moan from the enormous dying carcass,
the painful movements of the neck, rising for an instant to fall back
again heavily upon the straw with a deep, indistinct sound, the legs
moving as if trying to run, the tense tremor of the ears, and the
fixity of the eyeballs, from which the sight seemed to have departed
before the rest of the faculties. All this suffering came back clearly to
his memory, vivid in its almost human misery.
He leaned against the railing and opened his mouth mechanically to
again speak to Michelangelo’s horse:
“Ush, ush, ush! Ush, ush, ush!” Then Michelangelo, who from his
bed had heard the disturbance, jumped to the window above and
began to swear violently at the troublesome disturber of his night’s
rest.
“You damned rascal! Go and drown yourself in the Pescara River! Go
away from here. Go, or I will get a gun! You rascal, to come and
wake up sleeping people! You drunkard, go on; go away!”
Turlendana, staggering, started again towards the river. When at the
cross-roads by the fruit market, he saw a group of dogs in a loving
assembly. As the man approached, the group of canines dispersed,
running towards Bagno. From the alley of Gesidio came out another
horde of dogs, who set off in the direction of Bastioni.
All of the country of Pescara, bathed in the sweet light of the full
moon of the springtime, was the scene of the fights of amorous
canines. The mastiff of Madrigale, chained to watch over a
slaughtered ox, occasionally made his deep voice heard, and was
answered by a chorus of other voices. Occasionally a solitary dog
would pass on the run to the scene of a fight. From within the
houses, the howls of the imprisoned dogs could be heard.
Now a still stranger trouble took hold upon the brain of the drunken
man. In front of him, behind him, around him, the imaginary flight
of things began to take place again more rapidly than before. He
moved forward, and everything moved away from him, the clouds,
the trees, the stones, the river banks, the poles of the boats, the
very houses,—all retreated at his approach. This evident repulsion
and universal reprobation filled him with terror. He halted. His spirit
grew depressed. Through his disordered brain a sudden thought ran.
“The fox!” Even that fox of a Ciavola did not wish to remain with him
longer! His terror increased. His limbs trembled violently. However,
impelled by this thought, he descended among the tender willow
trees and the high grass of the shore.
The bright moon scattered over all things a snowy serenity. The
trees bent peacefully over the bank, as though contemplating the
running water. Almost it seemed as though a soft, melancholy breath
emanated from the somnolence of the river beneath the moon. The
croaking of frogs sounded clearly. Turlendana crouched among the
plants, almost hidden. His hands trembled on his knees. Suddenly he
felt something alive and moving under him; a frog! He uttered a cry.
He rose and began to run, staggering, amongst the willow trees
impeding his way. In his uneasiness of spirit, he felt terrified as
though by some supernatural occurrence.
Stumbling over a rough place in the ground, he fell on his stomach,
his face pressed into the grass. He got up with much difficulty, and
stood looking around him at the trees. The silvery silhouette of the
poplars rose motionless through the silent air, making their tops
seem unusually tall. The shores of the river would vanish endlessly,
as if they were something unreal, like shadows of things seen in
dreams. Upon the right side, the rocks shone resplendently, like
crystals of salt, shadowed at times by the moving clouds passing
softly overhead like azure veils. Further on the wood broke the
horizon line. The scent of the wood and the soft breath of the sea
were blended.
“Oh, Turlendana! Ooooh!” a clear voice cried out.
Turlendana turned in amazement.
“Oh, Turlendana, Turlendanaaaaa!”
It was Binchi-Banche, who came up, accompanied by a customs
officer, through the path used by the sailors through the willow-tree
thicket.
“Where are you going at this time of night? To weep over your
camel?” asked Binchi-Banche as he approached.
Turlendana did not answer at once. He was grasping his trousers
with one hand; his knees were bent forward and his face wore a
strange expression of stupidity, while he stammered so pitifully that
Binchi-Banche and the customs officer broke out into boisterous
laughter.
“Go on! Go on!” exclaimed the wrinkled little man, grasping the
drunken man by the shoulders and pushing him towards the
seashore. Turlendana moved forward. Binchi-Banche and the
customs officer followed him at a little distance, laughing and
speaking in low voices.
He reached the place where the verdure terminated and the sand
began. The grumbling of the sea at the mouth of the Pescara could
be heard. On a level stretch of sand, stretched out between the
dunes, Turlendana ran against the corpse of Barbara, which had not
yet been buried. The large body was skinned and bleeding, the
plump parts of the back, which were uncovered, appeared of a
yellowish colour; upon his legs the skin was still hanging with all the
hair; there were two enormous callous spots; within his mouth his
angular teeth were visible, curving over the upper jaw and the white
tongue; for some unknown reason the under lip was cut, while the
neck resembled the body of a serpent.
At the appearance of this ghastly sight, Turlendana burst into tears,
shaking his head, and moaning in a strange unhuman way:
“Oho! Oho! Oho!”
In the act of lying down upon the camel, he fell. He attempted to
rise, but the stupor caused by the wine overcame him, and he lost
consciousness.
Seeing Turlendana fall, Binchi-Banche and the customs officer came
over to him. Taking him, one by the head and the other by the feet,
they lifted him up and laid him full length upon the body of Barbara,
in the position of a loving embrace. Laughing at their deed, they
departed.
And thus Turlendana lay upon the camel until the sun rose.
 V
THE GOLD PIECES

Passacantando entered, rattling the hanging glass doors violently,

roughly shook the rain-drops from his shoulders, took his pipe from
his mouth, and with disdainful unconcern looked around the room.
In the tavern the smoke of the tobacco was like a bluish cloud,
through which one could discern the faces of those who were
drinking: women of bad repute; Pachio, the invalided soldier, whose
right eye, affected with some repulsive disease, was covered by a
greasy greenish band; Binchi-Banche, the domestic of the customs
officers, a small, sturdy man with a surly, yellow-hued face like a
lemon without juice, with a bent back and his thin legs thrust into
boots which reached to his knees; Magnasangue, the go-between of
the soldiers, the friend of comedians, of jugglers, of mountebanks,
of fortune-tellers, of tamers of bears,—of all that ravenous and
rapacious rabble which passes through the towns to snatch from the
idle and curious people a few pennies.
Then, too, there were the belles of the Fiorentino Hall, three or four
women faded from dissipation, their cheeks painted brick colour,
their eyes voluptuous, their mouths flaccid and almost bluish in
colour like over-ripe figs.
Passacantando crossed the room, and seated himself between the
women Pica and Peppuccia on a bench against the wall, which was
covered with indecent figures and writing. He was a slender young
fellow, rather effeminate, with a very pale face from which protruded
a nose thick, rapacious, bent greatly to one side; his ears sprang
from his head like two inflated paper bags, one larger than the
other; his curved, protruding lips were very red, and always had a
small ball of whitish saliva at the corners. Over his carefully combed
hair he wore a soft cap, flattened through long use. A tuft of his hair,
turned up like a hook, curled down over his forehead to the roots of
his nose, while another curled over his temple. A certain
licentiousness was expressed in every gesture, every move, and in
the tones of his voice and his glances.
“Ohe,” he cried, “Woman Africana, a goblet of wine!” beating the
table with his clay pipe, which broke from the force of the blow.
The woman Africana, the mistress of the inn, left the bar and came
forward towards the table, waddling because of her extreme
corpulence, and placed in front of Passacantando a glass filled to the
brim with wine. She looked at him as she did so with eyes full of
loving entreaty.
Passacantando suddenly flung his arm around the neck of
Peppuccia, forced her to drink from the goblet, and then thrust his
lips against hers. Peppuccia laughed, disentangling herself from the
arms of Passacantando, her laughter causing the unswallowed wine
to spurt from her mouth into his face.
The woman Africana grew livid. She withdrew behind the bar, where
the sharp words of Peppuccia and Pica reached her ears. The glass
door opened, and Fiorentino appeared on the threshold, all bundled
up in a cloak, like the villain of a cheap novel.
“Well, girls,” he cried out in a hoarse voice, “it is time for you to go.”
Peppuccia, Pica, and the others rose from their seats beside the men
and followed their master.
It was raining hard, and the Square of Bagno was transformed into a
muddy lake. Pachio, Magnasangue, and the others left one after
another until only Binche-Banche, stretched under the table in the
stupor of intoxication, remained. The smoke in the room gradually
grew less, while a half-plucked dove pecked from the floor the
scattered crumbs.
As Passacantando was about to rise, Africana moved slowly towards
him, her unshapely figure undulating as she walked, her full-moon
face wrinkled into a grotesque and affectionate grimace. Upon her
face were several moles with small bunches of hair growing out from
them, a thick shadow covered her upper lip and her cheeks. Her
short, coarse, and curling hair formed a sort of helmet on her head;
her thick eyebrows met at the top of her flat nose, so that she
looked like a creature affected with dropsy and elephantiasis.
When she reached Passacantando, she grasped his hands in order to
detain him.
“Oh, Giuva! What do you want? What have I done to you?”
“You? Nothing.”
“Why then do you cause me such suffering and torment?”
“I? I am surprised!... Good night! I have no time to lose just now,”
and with a brutal gesture, he started to go. But Africana threw
herself upon him, pressing his arms, and putting her face against
his, leaning upon him with her full weight, with a passion so
uncontrolled and terrible that Passacantando was frightened.
“What do you want? What do you want? Tell me! What do you want?
Why do I do this? I hold you! Stay here! Stay with me! Don’t make
me die of longing; don’t drive me mad! What for? Come,—take
everything you find ...”
She drew him towards the bar, opened the drawer, and with one
gesture offered him everything it contained. In the greasy till were
scattered some copper coins, and a few shining silver ones, the
whole amounting to perhaps five lire.
Passacantando, without saying a word, picked up the coins and
began to count them slowly upon the bar, his mouth showing an
expression of disgust. Africana looked at the coins and then at the
face of the man, breathing hard, like a tired beast. One heard the
tinkling of the coins as they fell upon the bar, the rough snoring of
Binchi-Banche, the soft pattering of the dove in the midst of the
continuous sound of the rain and the river down below the Bagno
and through the Bandiera.
“Those are not enough,” Passacantando said at last. “I must have
more than those; bring out some more, or I will go.”
He had crushed his cap down over his head, and from beneath his
forehead with its curling tuft of hair, his whitish eyes, greedy and
impudent, looked at Africana attentively, fascinating her.
“I have no more; you have seen all there is. Take all that you find ...”
stammered Africana in a caressing and supplicating voice, her
double chin quivering and her lips trembling, while the tears poured
from her piggish eyes.
“Well,” said Passacantando softly, bending over her, “well, do you
think I don’t know that your husband has some gold pieces?”
“Oh, Giovanni! ... how can I get them?”
“Go and take them, at once. I will wait for you here. Your husband is
asleep, now is the time. Go, or you’ll not see me any more, in the
name of Saint Antony!”
“Oh, Giovanni!... I am afraid!”
“What? Fear or no fear, I am going; let us go.”
Africana trembled; she pointed to Binchi-Banche still stretched under
the table in a heavy sleep.
“Close the door first,” she said submissively.
Passacantando roused Binchi-Banche with a kick, and dragged him,
howling and shaking with terror, out into the mud and slush. He
came back and closed the door. The red lantern that hung on one of
the shutters threw a rosy light into the tavern, leaving the heavy
arches in deep shadow, and giving the stairway in the angle a
mysterious look.
“Come! Let us go!” said Passacantando again to the still trembling
Africana.
They slowly ascended the dark stairway in the corner of the room,
the woman going first, the man following close behind. At the top of
the stairway they emerged into a low room, planked with beams. In
a small niche in the wall was a blue Majolica Madonna, in front of
which burned, for a vow, a light in a glass filled with water and oil.
The other walls were covered with a number of torn paper pictures,
of as many colours as leprosy. A distressing odour filled the room.
The two thieves advanced cautiously towards the marital bed, upon
which lay the old man, buried in slumber, breathing with a sort of
hoarse hiss through his toothless gums and his dilated nose, damp
from the use of tobacco, his head turned upon one cheek, resting on
a striped cotton pillow. Above his open mouth, which looked like a
cut made in a rotten pumpkin, rose his stiff moustache; one of his
eyes, half opened, resembled the turned over ear of a dog, filled
with hair, covered with blisters; the veins stood out boldly upon his
bare emaciated arm which lay outside the coverlet; his crooked
fingers, habitually grasping, clutched the counterpane.
Now, this old fellow had for a long time possessed two twenty-franc
pieces, which had been left him by some miserly relative; these he
guarded jealously, keeping them in the tobacco in his horn snuff-
box, as some people do musk incense. There lay the shining pieces
of gold, and the old man would take them out, look at them fondly,
feel of them lovingly between his fingers, as the passion of avarice
and the lust of possession grew within him.
Africana approached slowly, with bated breath, while Passacantando,
with commanding gestures, urged her to the theft. There was a
noise below; both stopped. The half-plucked dove, limping, fluttered
to its nest in an old slipper at the foot of the bed, but in settling
itself, it made some noise. The man, with a quick, brutal motion,
snatched up the bird and choked it in his fist.
“Is it there?” he asked of Africana.
“Yes, it is there, under the pillow,” she answered, sliding her hand
carefully under the pillow as she spoke. The old man moved in his
sleep, sighing involuntarily, while between his eyelids appeared a
little rim of the whites of his eyes. Then he fell back in the heavy
stupor of senile drowsiness.
Africana, in this crisis, suddenly became audacious, pushed her hand
quickly forward, grasped the tobacco box and rushed towards the
stairs, descending with Passacantando just behind her.
“Lord! Lord! See what I have done for you!” she exclaimed, throwing
herself upon him. With shaking hands, they started together to open
the snuff-box and look among the tobacco for the gold pieces. The
pungent odour of the tobacco arose to their nostrils, and both, as
they felt the desire to sneeze, were seized with a strong impulse to
laugh. In endeavouring to repress their sneezes, they staggered
against one another, pushing and wavering. But suddenly an
indistinct growling was heard, then hoarse shouts broke forth from
the room above, and the old man appeared at the top of the stairs.
His face was livid in the red light of the lantern, his form thin and
emaciated, his legs bare, his shirt in rags. He looked down at the
thieving couple, and, waving his arms like a damned soul, cried:
“The gold pieces! The gold pieces! The gold pieces!”
 VI
SORCERY

When seven consecutive sneezes of Mastro Peppe De Sieri, called La

Brevetta, resounded loudly in the square of the City Hall, all the
inhabitants of Pescara would seat themselves around their tables
and begin their meal. Soon after the bell would strike twelve, and
simultaneously, the people would become very hilarious.
For many years La Brevetta had given this joyful signal to the people
daily, and the fame of his marvellous sneezing spread through all the
country around, and also through the adjoining countries. His
memory still lives in the minds of the people, for he originated a
proverb which will endure for many years to come.

Mastro Peppe La Brevetta was a plebeian, somewhat corpulent,

thick-set, and clumsy; his face shining with a prosperous stupidity,
his eyes reminded one of the eyes of a sucking calf, while his hands
and feet were of extraordinary dimensions. His nose was long and
fleshy, his jaw-bones very strong and mobile, and when undergoing
a fit of sneezing, he looked like one of those sea-lions whose fat
bodies, as sailors relate, tremble all over like a jelly-pudding.
Like the sea-lions, too, he was possessed of a slow and lazy motion,
their ridiculously awkward attitudes, and their exceeding fondness
for sleep. He could not pass from the shade to the sun, nor from the
sun to the shade without an irrepressible impulse of air rushing
through his mouth and nostrils. The noise produced, especially in
quiet spots, could be heard at a great distance, and as it occurred at
regular intervals, it came to be a sort of time-piece for the citizens of
the town.
In his youth Mastro Peppe had kept a macaroni shop, and among
the strings of dough, the monotonous noise of the mills and wheels,
in the mildness of the flour-dusty air, he had grown to a placid
stupidity. Having reached maturity, he had married a certain Donna
Pelagia of the Commune of Castelli, and abandoning his early trade,
he had since that time dealt in terra cotta and Majolica ware,—
vases, plates, pitchers, and all the poor earthenware which the
craftsmen of Castelli manufactured for adorning the tables of the
land of Abruzzi. Among the simplicity and religiousness of those
shapes, unchanged for centuries, he lived in a very simple way,
sneezing all the time, and as his wife was a miserly creature, little by
little her avaricious spirit had communicated itself to him, until he
had grown into her penurious and miserly ways.
Now Mastro Peppe was the owner of a piece of land and a small
farm house, situated upon the right bank of the river, just at the spot
where the current of the river, turning, forms a sort of greenish
amphitheatre. The soil being well irrigated, produced very
abundantly, not only grapes and cereals, but especially large
quantities of vegetables. The harvests increased, and each year
Mastro Peppe’s pig grew fat, feasting under an oak tree which
dropped its wealth of acorns for his delectation. Each year, in the
month of January, La Brevetta, with his wife, would go over to his
farm, and invoke the favour of San Antonio to assist in the killing
and salting of the pig.
One year it happened that his wife was somewhat ill, and La
Brevetta went alone to the slaughtering of the beast. The pig was
placed upon a large board and held there by three sturdy farm-
hands, while his throat was cut with a sharp knife. The grunting and
squealing of the hog resounded through the solitude, usually broken
only by the murmuring of the stream, then suddenly the sounds
grew less, and were lost in the gurgling of warm vermilion blood
which was disgorged from the gaping wound, and while the body
was giving its last convulsive jerks, the new sun was absorbing from
the river the moisture in the form of a silvery mist. With a sort of
joyous ferocity La Brevetta watched Lepruccio burn with a hot iron
the deep eyes of the pig, and rejoiced to hear the boards creak
under the weight of the animal, thinking of the plentiful supply of
lard and the prospective hams.
The murdered beast was lifted up and suspended from a hook,
shaped like a rustic pitchfork, and left there, hanging head
downward. Burning bundles of reeds were used by the farm-hands
to singe off the bristles, and the flames rose almost invisible in the
greater light of the sun. At length, La Brevetta began to scrape with
a shining blade the blackened surface of the animal’s body, while
one of the assistants poured boiling water over it. Gradually the skin
became clean, and showed rosy-tinted as it hung steaming in the
sun. Lepruccio, whose face was the wrinkled and unctuous face of
an old man, and in whose ears hung rings, stood biting his lips
during the performance, working his body up and down, and
bending upon his knees. The work being completed, Mastro Peppe
ordered the farm-hands to put the pig under cover. Never in his life
had he seen so large a bulk of flesh from one pig, and he regretted
that his wife was not there to rejoice with him because of it.
Since it was late in the afternoon, Matteo Puriello and Biagio
Quaglia, two friends, were returning from the home of Don
Bergamino Camplone, a priest who had gone into business.
These two cronies were living a gay life, given to dissipation, fond of
any kind of fun, very free in giving advice, and as they had heard of
the killing of the pig, and of the absence of Pelagia, hoping to meet
with some pleasing adventure, they came over to tantalise La
Brevetta. Matteo Puriello, commonly called Ciavola, was a man of
about forty, a poacher, tall and slender, with blond hair and a yellow
tinted skin, with a stiff and bristling moustache. His head was like
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