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 Textbook of Medical Dentistry
For Dental–Medical Students and Practitioners
Textbook of Medical Dentistry
for
Dental–Medical Students and Practitioners

Hari Vishnu Pophale

MBBS, DTM, DTM&H (Engl.), DCH (London)
FICA (USA), FAIMS, FICP, FICG, FMSPI
Hon Prof Emeritus in Clinical Medicine, Grand Medical College, Mumbai
Hon Prof Emeritus in Medicine, Govt. Dental College, Mumbai
Ex-Physician Supt GT & St Georges Govt. Hospitals, Mumbai
Fellow Emeritus, American College of Chest Physicians (ACCP)

JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
New Delhi
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
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Textbook of Medical Dentistry: For Dental–Medical Students and Practitioners

© 2007, Hari Vishnu Pophale

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by
any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and
the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure
accuracy of material, but the publisher, printer and authors will not be held responsible for any inadvertent error(s). In case of
any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition : 2007

ISBN 81-8061-979-6
Typeset at JPBMP typesetting unit
Printed and bound in India
 Dedicated to

My Beloved Son Sunil Pophale

and
My Inspiring Daughter Sunita Ramnathkar
We are a small insignificant part of the Universe and nothing we do more or less will ultimately matter.
Are we really capable of doing anything?
Whatever is done so far, Oh Almighty God, is due to Your kindness.
And whatever shall be done in future will only be through Your kindness and mercy.
 Preface
Teeth are the part of human body and are governed by all the biological processes and anatomical connections
existing in the body. Moreover, they are situated and well protected in the buccal cavity. They initiate the
digestive process by chewing the foodstuff and making it suitable for interaction with digestive enzymes in
the mouth, stomach and small intestine. Nature has provided all the facilities for teeth function to accomplish
perfectly without any problem. Every part of oral cavity assists them in chewing from either side with the
help of tongue and cheek before it is suitable to be swallowed. The salivary glands secrete saliva to moisten
the morsal during the process of chewing while lips and cheeks prevent the food from coming out. The arch
of the roof of the palate provides the required quantity of food to be accommodated for the processes of
chewing. The swallowing process is a super-phenomena which pushes the morsal in the esophagus by
temporarily closing the opening of the respiratory channel.
The teeth themselves are fixed in bone and get their blood supply and nerve supply through it. Thus
anatomically, physiologically, and pathologically all the structures around affect the teeth creating the problems
for practicing dentist. Moreover, systemic diseases do affect the teeth directly or indirectly along with
surrounding structures of buccal cavity and provide dependable evidence for diagnosis.
Thus the purpose of keeping general medicine in the curriculum of dentistry teaching is valid and essential
because without the background of general medicine, dentistry cannot be successfully practised. The practising
dentist has to face emergencies connected with systemic diseases and also be vigilant about legal obligatory
responsibilities answerable to Consumer Protection Court.
I remember a case of tooth extraction with continuous bleeding and diagnosed a bleeding disorder subsequently and
saved the patient after giving transfusions. Thus, it becomes relevant to exclude hemorrhagic diseases, leukemia,
hypertension, diabetics, etc. before submitting a patient for surgical treatment.
Again the latest and best dental material required is to be chosen having suitable mechanical and physical
properties and is safe locally, and systemically to the human body at large.
The latest ideology is to save the natural tooth than to extract and cure the pathology at the earliest and
mainly concentrate on prevention and by giving elaborate instructions in writing. Contact with patients
inbetween the appointments surmounts the respect and enhances the faith in treating dentist and prones
them more to follow the instructions given by the dentist.
An attempt is made in this book to present the essential knowledge in simple language and style, that is
easy to remember. Rarities are left for references and not to overload the reader and tax his memory.
Illustrations, figures, charts and photos are supplemented to facilitate the reader to clearly visualize and
remember the facts when needed.
Treatment, a part of important aspect, is dealt especially, to help prescribe the drugs specifically and properly. Only
mentioning the generic names does not help actually prescribe. The drugs are mentioned along with the doses and
names of the company to facilitate the chemist to dispense promptly. Awareness of contraindications and side effects
makes the prescriber more confident to continue or discontinue the drug. This aspect may be considered as an important
exclusive in this book which one should keep at hand to use it when needed with due confidence.
Hope the readers are satisfied to the extent expected by the author.
Hari Vishnu Phophale
 Contents
1. Introduction to the Systemic Medicine ................................................................................................... 1

2. Systematic Medicine: Modern Investigative Facilities ........................................................................ 3

3. Body Metabolism ......................................................................................................................................... 4

4. Nutritional Factors in Health and Diseases ........................................................................................... 6

5. Infection, Immunity and Epidemiology .............................................................................................. 16

6. Diseases of the Cardiovascular System and Essentials of Electrocardiogram .............................. 24

7. Diseases of the Respiratory System ....................................................................................................... 44

8. Gastrointestinal Diseases ......................................................................................................................... 61

9. Nephrology ................................................................................................................................................. 78

10. Neurology and Psychiatry ........................................................................................................................ 85

11. Hematology ............................................................................................................................................... 110

12. Endocrinology ........................................................................................................................................... 122

13. Skin Disorders Involving the Oral Cavity ......................................................................................... 137

14. Diseases of Connective Tissues, Bones and Joints (Rheumatology) ............................................ 145

15. Essentials of Oncology ........................................................................................................................... 156

16. Systemic Diseases Manifested in the Jaws and Orofacial Cavity ................................................ 157

17. Temporomandibular Joint Disorders .................................................................................................. 159

18. Tongue Disorders .................................................................................................................................... 167

19. Chronic Orofacial Pain ........................................................................................................................... 169

20. Congenital Anomalies in Clinical Practice ......................................................................................... 172

21. Oropharynx: Applied Anatomy ............................................................................................................ 183

22. Sketch of Applied Oropharyngeal Pathology .................................................................................... 189

23. Geriatric Dentistry ................................................................................................................................... 196

xii Textbook of Medical Dentistry
24. Sports Dentistry ....................................................................................................................................... 199

25. Emergencies in Dental Practice ........................................................................................................... 201

26. Use of Lasers in Dental Practice .......................................................................................................... 211

27. Computers in Clinical Dental Practice .............................................................................................. 213

28. Preventive Dentistry .............................................................................................................................. 215

29. Glimpses of Tropical Diseases ............................................................................................................. 220

30. Environmental Pollution ...................................................................................................................... 232

31. Future of Dentistry ................................................................................................................................. 237

32. Pediatric Procedures ............................................................................................................................... 239

33. Availability of Dental Equipment ..................................................................................................... 245

Appendices
Appendix 1: BDS Examination Papers and Sample Syllabus ................................................................... 247

Appendix 2: Probable Theory Exam Questions for MBBS, BDS, MDS and MD .................................... 251

Index ............................................................................................................................................................ 255

 Introduction
The planning of this book starts from embryonic development covering the congenital anomalies of teeth,
their applied anatomy, and physiology including the surrounding structures of buccal cavity. Then the
pathological possible lesions, their investigations, interpretations of results and also preventive and therapeutic
aspects. Association with systemic diseases is well illustrated.
It is essential to take required assistance of other specialists such as physician, hematologist, oncologist, surgeon,
ENT specialist, plastic and orthopedic surgeons in treating the complicated dental problems.
Every individual complicated case is a book in itself and should be considered separately, precisely,
thoroughly when the responsibility of active treatment is undertaken. The precision is an ideal and the top is
always vacant. Still everyone should honestly opt for it.
The dimensions of dentistry are rapidly increasing and expanding globally. The public at large have become
more and more conscious of the subspecialties and voluntarily approaching for their individual problems to
them directly.
Following are the subspecialities commonly known (They will be ever increasing with the advancement
of scientific research).
1. Prosthodontics
2. Endodontics
3. Orthodontics
4. Periodontics
5. Implants
6. Oral surgery
7. Oral radiology and medicine
8. Pedodontics.
These subspecialties are diagonally connected with systemic medicine and the reader will aptly appreciate
and use it for better services to the dental patients.
Over the last few decades, progressive dentists have been active agents in the revolution of transforming
the profession from being providers of “ Need Dentistry “ to “ Want Dentistry.” The main obstacles, for the
dentist is to provide “Want dentistry” to their patients, are the limits and types of services covered by
traditional dental plan, which may prove as barrier to the dentist to treat their patients which they really
need. Better understanding will prevail to find out the possible mid-way acceptable to both.
The minimal knowledge of systemic medicine will expand the outlook of the practising clinician and will
definitely help him in diagnosing and treating the patients promptly. When other specialists to whom the
patient is referred it is imperative that the referring clinician must be in a position to understand the line of
treatment suggested by the specialists. This will increase his own experience and knowledge.
Interpretations of investigation reports are also important factor on the basis of which the diagnosis is
arrived. Moreover, the modern investigations are needed for any particular case also depend upon the basic
knowledge, which is attempted to present in this textbook.
 Introduction to the
Systemic Medicine 1
PRINCIPLES OF MEDICINE DOCTOR
a. Medicine A doctor is a qualified practitioner who treats
b. Patient the patient after obtaining history, and after
c. Doctor physically examining him and he is suppo-
d. Medical ethics sed to be well-versed in the science and art
e. Physician’s approach to the patient of medicine. He is a compassionate, sympa-
f. Physical examination thetic as well as attentive listener and sober
g. Probable diagnosis enough not to loose patience or temper.
h. Treatment
i. Incurable diseases MEDICAL ETHICS
j. Preventive medicine and health for all.
The Hippocratic oath is taken with strict
MEDICINE adherence to the high standard behavior with
the patient and maintain secrecy as far as
The word medicine means drugs and reme-
possible about his ailment and observe
dies. It has got many branches developed such
benevolence and sympathy and try to give
as aviation medicine, and nuclear medicine,
relief and cure to the extent possible and
clinical, legal, forensic, ionic or nuclear,
avoid all avenues of malpractices and also
patent, preventive, proprietary medicine,
safeguard the public interest.
psychosomatic medicine, socialized medicine,
and medical public health, etc.
PHYSICIAN’S APPROACH
PATIENT TO THE PATIENT

A patient is one who suffers from diseases and It starts with history taking, attentive hearing,
desires to undergo treatment and who looks skillfully putting leading questions when
towards the doctor with faith, hopes and necessary and fully use the background of
expectations and likes to be heard and listened age, sex, education, geographic knowledge,
to sympathetically, attentively and always and existing epidemics and frequency of
wishes to know about diagnosis prognosis, disease, foreign travel, professional hazards,
and expenses. diet, habits and company he or she keeps
2 Textbook of Medical Dentistry
along with the required family history. Professor 3. General.
Dunlop used to say that 70 percent diagnosis 4. Preventive.
possibility can be reached if satisfactory history is 5. Isolation.
taken. 6. Quarantine.

PHYSICAL EXAMINATION
INCURABLE DISEASES
Inspection
If the patient is suffering from an incurable disease
From head to foot, purposeful, intelligent, having try to be tactful in communication with him in
insight and connection with his complaints. pieces with due intervals and impress aspects of
Patients to be seen sitting, bending, walking and positive variations and advise him about occupa-
lying down and for limb movements, coordination tion, games, marriage, driving, travel and also
and tremors, chest measurements during inspi- explain to him about the necessary precautions he/
ration and expiration and abdomen measurement she requires to take. Inform about the patients with
at the umbilicus. same diseases who have improved by advanced;
Palpation treatment and if possible; give their addresses so
that the patient can communicate with such
Height, weight, pulse, respiration, temperature,
relieved patients.
vital capacity, if necessary femoral and popliteal
When necessary refer to him various specialists
pulse palpation.
so that he/she feels more and more satisfied and
Percussion gets convinced about relief of ailment in due course
of time and does not get a shock or depression but
Required perfect silence and proper technique.
looks forward toward new therapeutic horizon
Auscultation with renewed hope and faith.
Over cardiac area, arteries, lungs, joints, eyeballs
and aneurysmal swellings, abdomen and skull. PREVENTIVE MEDICINE AND
HEALTH FOR ALL
PROBABLE DIAGNOSIS It is a Government public health ideal and will not
Note down probable diagnosis as No. 1, No. 2, and be achieved unless 100 percent literacy come up
No. 3 investigate one by one through latest and more than 30 percent of total budget of the
techniques of laboratory, X-rays, and other facilities country are spent carefully on public health
available such as sonography, scanning, skin test, requirements. The nationalization of health services
nuclear imaging, culture, biopsy, serological tests. in the UK is one of the constructive steps and is
required to be followed by all the nations and
TREATMENT strictly follow the international preventive rules for
Treatment depends on: the diseases like AIDS, etc. Not failure but low aim
1. Radical. is a crime and where there is a will, there is always
2. Symptomatic. a way out of all the odds.
 Systematic Medicine:
Modern Investigative
Facilities 2
VARIOUS INVESTIGATIVE 10. US (Ultrasonography).
FACILITIES FOR DIAGNOSIS 11. 2D Echocardiography.
12. 2DE Doppler echocardiography studies.
The modern clinician is really very fortunate
13. The latest is radionuclide imaging with
to have at his disposal a vast variety of clinical
computerized report.
imaging modalities, both conventional and
14. Radioactive tracer is given by mouth,
recent modern.
inhalation, or IV injection followed by
It may not be wise to take the dentist in
radiation detector, placed externally
this wilderness of technicalities; but at the over body.
same time, he should at least know their face These imaging modalities are required to
acquaintance and develop a habit to read the be used when absolutely indicated and cost-
reports written by the specialists and decide effective. Usually, simple and less expensive
about the safety in handling the difficult investigations are done first and then difficult
dental cases, having associated medical and expensive ones, if found necessary and
problems. helpful and affordable.
Following is the list of investigations:
1. Conventional radiography. ADVANCES IN DENTAL APPLIANCES
2. X-ray contrast studies (barium, IVP). 1. Laser.
3. CAT (Computerized axial tomograhy). 2. Air abrasion (for end cutting device)
4. MRI (Magnetic resonance imaging). 3. Radiovasography (RVG) (for diagnosis of
5. MRA (Magnetic resonance angio- caries).
graphy). 4. Pulse oximetry (for determining pulpal
6. MRS (Magnetic resonance spectroscopy). vascular health).
7. RI (Radionuclide imaging). 5. Laser Doppler flowmetry (LDF) (for
8. SPECT (Single photon emission compu- measuring the velocity of RBC in the
ted tomography). capillaries).
9. PET (Positron-emission tomography). 6. Apex locator.
 Body Metabolism 3
The sum total of physical and chemical pro- Hydrogen Ion Concentration or pH
cesses going on in living body by which cons- Blood pH is between 7.37 and 7.45. The blood
tructive activities are resulted, it is called is alkaline because of bicarbonates, phos-
anabolism; and when destructive processes phates and proteins. It becomes acidosis
are manifested, it is called catabolism. When because of carbonic acid which body meta-
it is measured in resting position, it is called bolism produces and it is eliminated by the
basal metabolic rate being determined by the body as CO2 pressure in alveoli of the lungs
oxygen utilized. and determine the component of carbonic
acid concentration which is eliminated as CO2
FLUIDS AND ELECTROLYTES by the lungs.
Body fluids constitute 60 percent of body Metabolic Acidosis
weight amounting to about 36 liters in a man
It occurs due to increase in the acid compo-
of 60 kg wt.
nents or depression of bicarbonates. Produc-
Electrolytes are sodium, potassium, chlo-
tion of large amounts of lactic acid in vigorous
rides, bicarbonates, magnesium, phosphates, exercises is one of the common causes of
sulphates, calcium. acidosis, but other important causes are
Regulatory Mechanism diabetic ketoacidosis and renal failure. The
depressant of the carbonates occurs in
Caloric intake and metabolic expenditure diarrhea. Acidosis stimulates the respiratory
require to be regulated to maintain the inter- center and the respiration becomes deep and
nal health and the balance between intake and rapid. The treatment is infusion of normal
losses requires to be kept properly up to the saline; and in severe cases, IV sodium bicar-
normal. bonate.
External losses may be due to vomiting,
diarrhea, blood loss, or due to succussion of Metabolic Alkalosis
gastrointestinal contents. It occurs due to loss of acids in vomiting of
Replacement should be quantitative pyloric stenosis, chloride deficiency stimula-
and qualitative without loss of time and tes renal tubules to reabsorb the bicarbonates
with efficient technique. Losses exceeding precipitating alkolosis. The diagnosis is only
15 percent of body weight are usually possible by estimating plasma bicarbonates.
incompatible with life. Clinically, apathy, personality changes,
 Body Metabolism 5
delirium and tetany appear. The treatment is IV b. Thyroid gland—excess produces thyrotoxicosis
isotonic sodium chloride; and in severe cases, IV (Graves’ disease).
ammonium chloride. Deficiency produces hypothyroidism, my-
xoedema, and goiter.
Inborn Errors of Carbohydrate Metabolism c. Parathyroid—excess produces hyperparathy-
roidism.
A group of rare disorders covering infancy to
Deficiency produces tetany.
adolescence maybe in the back of mind to be
d. Adrenal glands—excess produces Cushing’s
referred to the medical specialist for necessary
syndrome.
diagnosis, care and management.
Deficiency produces Addison’s disease.
ENDOCRINE METABOLIC DISORDERS e. Male sex hormone deficiency produces hypo-
gonadism, cryptorchidism, infertility, and
The components of internal system directly control impotence and also Klinefelter’s syndrome
the physical and mental development activities of where there is a testicular atrophy and absence
human body and are under endocrine influence of secondary sex character with bilateral
which requires to be kept in the mind while dealing gynecomastia, and often mental retardation
with the patients in practice. The whole spectrum f. Female sex disorders: They are as follows:
is due to either hypo- or hypersecretion of the Primary amenorrhea, Turner’s syndrome,
group of endocrine glands; and the following basic hermaphroditism, and menopause.
information and conditions can never be over- Tumors of ovary usually unilateral cause
looked by the clinician in practice: pseudosexual precocity in girls showing early
1. Pituitary gland is the king of endocrine and development of second sex character including
master of orchestra and secretes TRH/LH/FSH– the size of breast and start of early MC.
RH and GHR II. g. Diabetes mellitus—hyperglycemia is produced
2. Thyroid produces thyroxine (T 4 ) and tri- due to deficiency or diminished effectiveness of
iodothyronine (T3) hormones. insulin secreted by islets of Langerhans’ of
3. Parathyroid produces parathyroidal hormone. pancreas.
4. Adrenals produce ACTH. Its oropharyngeal manifestations require
5. Diabetes is produced by absolute or relative presumptive knowledge and attention on the
deficiency of insulin by islets of Langerhans of basis of which investigations are done and the
pancreas. diagnosis is reached.
6. Ovaries, the female sex hormone produces Hypoglycemia and hyperinsulinism require
estrogen. immediate attention because it can be fatal. It
7. Testis, a male sex hormone produces testerone. occurs due to overdose of insulin given in
The clinical conditions produced by excess or treatment. The blood sugar below 50 mg per
deficient quantities of hormones are as under: 100 cc generally is considered significant and
a. Pituitary—excess produces gigantism, acrome- calls for emergency treatment of glucose
galy, diabetes insipidus. replacement, corticoids, and ACTH therapy. In
Deficiency produces dwarfism, infantilism, case of tumor of pancreas, either benign or
pan-hypopituitarism, called Simmond’s disease malignant producing excess of insulin requires
produces pituitary cachexia. surgical extraction.
 Nutritional Factors in
Health and Diseases 4
Infancy (Both to 6 Month) Late Infancy Importance of Nutritional Problems
(6 Months to 1 Year)
It is unfortunate that medical students and
Breastfeeding is superior to the bottle feeding practising doctors do not appreciate the
due to economy, convenience, temperature, magnanimity of nutrition problems.
asepsis and automatic adjustments. It fulfills The overpopulation and shortage of food
the nutritional needs and also provides emo- with rising costs result into undernutrition,
tional and psychological benefits. It manages subnutrition, malnutrition leading to star-
the time intervals as well as use of breast to vation.
avoid overuse and to be regulated under the The clinical picture is underweight,
guidance of pediatrician. cachexia, chronic infections such of tuber-
culosis, malabsorption, kwashiorkor and
Early Childhood (1 to 5 Years) marasmus as well as nutritional dwarfism.
Late Childhood (6 to 12 Years) The art of treatment being the suitable food
Artificial feeding is to be introduced gradually in a way to meet the tolerability of the patient
by soft and nourishing feeds looking into the having prolonged alimentary tract dysfunc-
tolerability of the system and taste and variety tion, lower digestibility even sometimes
of foods including fruits, vegetables, soups, causing nutritional diarrhea. Some times
juices to be added conveniently. whole blood as plasma transfusions are
helpful.
Adolescence (12 to 18 Years)
Gradually increasing the quantity of nourish- Etiology of Nutritional Disorders
ing food as described above and quantity 1. Quantitative deficiency causing subnutri-
depends upon activity, intervals, appetites tion and starvation.
schooling and games. The components of the 2. Qualitative deficiency causing (wrong
food like carbohydrates, proteins and fats are food) malnutrition.
required to be provided. 3. Overfeeding causing overweight, obesity.
The dietic details are not appropriate to a 4. Quantitative overfeedings of vitamins/
clinical primer and may be sought in textbooks iron causing hypervitaminosis and
of nutrition, if needed. siderosis.
 Nutritional Factors in Health and Diseases 7
5. Excess of toxins in food depending on single apathy, mental retardation, avitaminosis,
foodstuff in that such as lathyrism (nutritional diarrhea and dehydration.
spastic paraplegia) due to neurotoxin BOAA. 3. Nutritional dwarfism: Usually apparent and
associated with a degree of mental retardation
Defective Intake of Food and presence of chronic infections such as TB.
1. Loss of appetite.
VITAMINS AND MINERALS
2. Persistent vomiting.
3. Food fads. The fat-soluble vitamins are A, D, E, and K.
4. Prolonged IV injections. The water-soluble vitamins are B complex, and
5. Nutritional dependence such as old age, infancy vitamin C.
and childhood. Minerals: Calcium, daily requirement is 500 to
700 mg.
CALORIC VALUE OF MAIN FOODSTUFF Iron, daily requirement about 100 mg.
1. Carbohydrates provide the main source of Iodine, present in sea food, vegetables, milk, and
requirement is in traces.
energy and is non-convertible from other
Fluorides prevent dental caries and the chief
nutrients with minimal daily requirement of
source is drinking water. When it is in excess in the
400 gm per day for an adult, but requirement is
water, we call it epidemic fluorosis (point to be
variable for hard physical work.
noted that it is deposited in the developing teeth
2. Fats have got high caloric value and requires 100
and not in developed).
gm, per day, per adult.
Sulphur, zinc, copper and chromium: Require-
3. The proteins provide 8 essential amino acids;
ment is in traces.
methionine, lysine, trytophane, phenylalanine,
leucine, isoleucine, thereonine, and valine. It is VITAMIN DEFICIENCY SYNDROMES
also proved that histidine and arginine are also
Vitamin A deficiency causes nightblindness,
needed for growth of infants. The daily
xerophthalmia, keratomalacia, and follicular
requirement of proteins is 100 gm per day for an
keratosis.
adult.
Vitamin D deficiency causes rickets in infants
KNOWN NUTRITIONAL DISORDERS and children and osteomalacia in adults and osteo-
porosis in elderly women.
1. Kwashiorkor: Due to prolonged breastfeeding Vitamin C deficiency causes scurvy.
practised in some African states, there is failure Vitamin B 1 deficiency causes beriberi and
of growth marked by edema due to hypo- amblyopia.
proteinemia. There are skin changes in the heir Nicotinic acid deficiency (B-complex) causes
growth and mental changes with GI pellagra which is common in maize eaters
disturbances, anemia, avitaminosis, complicated associated with dermatitis, diarrhea; and in late
with infections such as TB. stages, dementia.
2. Nutritional marasmus: It usually appears in Riboflavin deficiency causes angular stomatitis,
infants below one year, associated with poverty, chelosis, and nasolabial seborrhea and scrotal
inadequate nutritional feeds and presence of dermatitis, magenta-colored tongue.
chronic infection such as TB or GI tract dysfunc- Vitamin B12 (Cobalamins). Normal requirement
tion. There is retardation of growth and wasting is 2 mcg per day, deficiency affects bone marrow
of muscles. There are changes in skin, hair, and central nervous system causing neuropathy.
8 Textbook of Medical Dentistry
Folic acid deficiency causes megaloblastic be carefully adapted to take account of national,
anemia and atrophic changes in the GI tract. cultural and local eating habits and affordability.
The subcommittee on Metrication of the British
OBESITY National Committee for Nutritional Sciences of the
It is one of the most common nutritional disorders Royal Society recommended in 1972 that kilojoules
in infants, children and adults causing increased should be used in place of kilocalories. A kcal = 4.184
complications and mortality. There is abnormal kJ, so that the caloric conversion factors
storage of fat in depots. They are more prone to (heat of combustion; available energy) for carbo-
develop diabetes, gallstones, gout, cardiovascular hydrate, fat, protein and alcohol are 16, 37, 17 and
disorders and mechanical accidents. 29 kJ/g, respectively. Useful practical approxi-
The sheet anchor of treatment is continued by mations are:
strict dieting under the guidance of nutritional 950 kcal = 4,000 kJ
expert along with increased activities, outdoor 1,450 kcal= 6,000 kJ
games, swimming, exercises, yogic exercises, 2,850 kcal= 12,000 kJ
jogging and running.
DIET 1: LOW CALORIE (ENERGY) DIET
DIETS SUITABLE FOR ADULTS WITH
OBESITY (WITH OR WITHOUT DIABETES)
The diet sheets that follow have been constructed
to illustrate the quantitative and qualitative aspects Approximately protein 60 g, carbohydrate 100 g,
of diets required for the treatment of obesity and fat 40 g, energy 1,000 kcal (4,184 kJ).
diabetes mellitus. The quantities given in a stan- Early morning cup of tea, milk from allowance,*
dard diet sheet will obviously require some modifi- if desired.
cations in relation to the size, age, sex and occupa-
tion of the patient. In the dietetic treatment of most Breakfast
diseases it is unnecessary to weigh accurately the One egg or 1 oz (30 g) grilled lean bacon (2 rashers)
amounts of the different foods eaten. Under these or cold ham or breakfast fish. ~ oz (20 g) white or
circumstances, sufficient accuracy will be secured brown bread, or exchange, with butter from allow-
by the use of household measures as illustrated in ance. Tea, with milk from allowance.
Diet 1 and by the terms ‘small’, ‘medium’ or ‘large’ Mid-morning: Tea or coffee, with milk from
helping for meat, fish or chicken. A small helping allowance, or ‘free’ drink from Group A3.
weighs approximately 1 to 2 oz (30-60 g), a medium ½ oz (15 g) butter or margarine. (Cut a ½ lb
helping 2 to 3 oz (60-90 g) and a large helping 4 oz packet into 16 equal portions, each portion = ½ oz).
(120 g) or more. Exchanges for 2/3 oz (20 g) bread (1/2 slice from
The qualitative content of the diet, i.e. the actual a large cut loaf):
food consumed will vary widely. The examples 2 cream crackers. (1½ of any crisp bread)
detailed here are suitable for persons whose food 1 potato (the size of a hen’s egg).
habits are those of the Western world. If they are to 2 water biscuits: 1 portion of fruit (from list
be effective therapeutically, diet prescriptions must below), 1 triangular oatcake.

*Allowance for day, ½ pint milk (300 ml]) with the cream poured off the top (The use of whole milk will increase the
caloric content of this diet to approximately 1,100 kcal).
 Nutritional Factors in Health and Diseases 9
Exchanges for 1 1/3 oz (40 g) bread (1 slice from Group B
a large cut loaf): To be taken in strict moderation in consultation with
4 cream crackers. (3 of any crisp bread) the doctor.
2 potatoes (size of hen’s egg). Spirits, dry wines, dry sherries.
4 water biscuits: 2 portions of fruit (from list
below), 2 triangular oatcakes. Group C
Fruit to be taken as part of diet at lunch or
Foods not allowed.
evening meal:
Sugar, glucose, sweets, chocolate, honey, syrup,
1 piece of fresh fruit, i.e. apple, pear, orange,
treacle, jam, marmalade, cakes, biscuits (except
peach or medium-sized helping of fruit stewed
those specified), pies, fruit tinned in syrup, fruit
without sugar.
squash, lemonade or similar aerated drinks.
DIETARY EXCHANGES FOR DIABETICS Note—Most “diabetic’ foodstuffs on sale at
3 FAT EXCHANGES chemists and health food stores do contain some
carbohydrate and must, therefore, not be taken
Each exchange approximately 12 g fat and almost
without consulting your doctor or dietitian.
no carbohydrate or protein. Caloric value is
approximately 110. DIET 1: AN EXAMPLE OF THE DISTRIBUTION
Amount Remarks OF EXCHANGES FOR A DIET RESTRICTED IN
oz G CARBOHYDRATE
Butter, margarine, lard, 0.5 14
dripping, cooking Suitable for Adults with Diabetes Mellitus
Fat, olive oil, vegetable oil. Approximately protein 80 g, carbohydrate 210 g,
Cream (single) 2 60 fat 70 g, energy 1800 kcal (7560 kJ)
Cream (double) 1 30 Breakfast 1 protein exchange.
Salad cream or mayonnaise 1 30 4 carbohydrate exchanges.
Butter and milk from allowance.
Introductions for Diabetics—Continued Tea or coffee (no sugar)
Group A: Foods which May be Taken Mid-morning. 2 carbohydrate exchanges.
in any Quantity Butter and milk from allowance.
Tea, coffee (Milk from allowance, no sugar), Oxo, Tea or coffee (no sugar)
Bovril, Marmite, etc. Mid-day meal Clear soup if desired.
Tomato juice, lemon juice. 2 protein exchanges.
Diabetic fruit squashes. 4 carbohydrate exchanges.
Saccharine preparations. Vegetables if desired (group A.)
Clear soup. Butter and milk from allowance.
Herbs, seasonings and spices. Brussels, sprouts, Mid-afternoon 2 carbohydrate exchanges.
cabbage, carrots, cauliflower, celery, cucumber, Butter and milk from allowance.
French beans, leeks, lettuce, mushrooms, mustard Tea (with no sugar)
or cress, onions, spring onions, runner beans, Evening meal 2 protein exchanges.
Swedes spinach, tomatoes, turnips, watercress. 5 carbohydrate exchanges.
Cranberries, grapefruit, gooseberries, lemon, Vegetables if desired (group A)
melon, loganberries, redcurrants, rhubarb. Tea or coffee (with no sugar)
10 Textbook of Medical Dentistry
Before bed 2 carbohydrate exchanges 2 oz (60 g) bread with butter from
Reminder of butter and milk from allowance.
allowances. 3 oz (90 g) banana (weight with
A list of suitable exchanges is given as below skin)
under diet 2, 3, 4. 2 oz (60 g) ice cream.
Allowance for day ; ½ pint (400 ml) whole milk Tea or coffee with milk from
1 oz (30 g) butter or margarine. allowance.
Before bed Remainder of milk from allow-
DIET 2: AN EXAMPLE OF A MENU ance and ½ oz ovaltine. 2/3 (20 g)
RESTRICTED IN CARBOHYDRATES, bread, toasted with butter from
BASED ON DISTRIBUTION OF EXCHANGES allowance.
Allowance for day; 2/3 pint milk (400 ml),
Suitable for Adults with Diabetes Mellitus 1 oz (320 g) butter or margarine.
Approximately protein 80 g, carbohydrate 210 g,
fat 70 g, energy 1,800 kcal (7560 kJ) DIET 3: UNMEASURED DIET
Breakfast 4 oz (120 g) porridge with milk Suitable for Adults with Diabetes Mellitus
from allowance or
Patients who are unable to weigh their diet or for
1 egg + 2 oz (60 g) bread with
whom this is unnecessary, are given a list of foods
butter from allowance.
which are grouped into three categories.
Tea or coffee with milk from
a. Foods to be avoided altogether:
allowance.
1. Sugar, glucose, jam, marmalade, honey,
Mid-morning 1 oz (30 g) rich tea biscuits.
syrup, treacle, tinned fruits, sweets, chocolate,
Tea or coffee with milk from
lemonade, glucose drinks, proprietary milk
allowance.
preparations and similar foods which are
Mid-day meal Clear soup with shredded vege- sweetened with sugar.
tables. 2. Cakes, sweet biscuits, chocolate biscuits, pies,
2 oz (60 g) lean meat. puddings, thick sauces.
4 oz (120 g) boiled potatoes. 3. Alcoholic drinks unless permission has been
2 oz (60 g) tinned pies. given by the doctor.
Salad or other unrestricted vege- b. Foods to be eaten in moderation only:
tables from group A if desired. 1. Breads of all kinds (including so-called
4 oz (120 g) orange (peeled ‘sliming’ and ‘starch-reduced’ breads, brown
weight). or white, plain or toasted).
Tea or coffee with milk from 2. Rolls, scones, biscuits and crisp breads.
allowance. 3. Potatoes, peas and baked beans.
Mid-afternoon 1 oz (30 g) digestive biscuits. 4. Breakfast cereals and porridge.
Tea or coffee with milk from 5. All fresh or dried fruit.
allowance. 6. Macaroni, spaghetti, custard and foods with
Evening meal 3 oz (90 g) fish. much flour.
Tomato or other unrestricted 7. Thick soups.
vegetables from group A if 8. Diabetic foods.
desired. 9. Milk.
 Nutritional Factors in Health and Diseases 11
c. Foods to be eaten as desired: • Further reading about dietetics and additional
1. All meats, fish, eggs. diets:
2. Cheese. Davidson, Sir Stanley, Passmore, R, Brock JF,
3. Clear soups or meat extracts, tomato or lemon Trustwell AS. (19750 Human Nutrition and
juice. Dietetics (6 edn). Edinburgh: Churchill Livingstone
4. Tea or coffee, For additional diet sheets.
5. Cabbage, Brussels sprouts, broccoli, cauli- • Starch-reduced products, “diabetic” foodstuffs.
flower, spinach, turnip, runner or French • Sausages.
beans, onions, leeks or mushrooms. Lettuce, • All fried foods.
cucumber, tomatoes, spring onions, radishes, • All foods must be served without thickened
mustard and cress, asparagus, parsley, gravies and sauces. All foods may be baked,
rhubarb. grilled, boiled or steamed, but not fried.
6. Herbs, spices, salt, pepper and mustard.
7. Saccharine preparations for sweating. DIABETIC DIETS: METHODS OF
For overweight diabetics, butter, margarine, fatty CONSTRUCTING A DIET RESTRICTED
and dried foods must be restricted. IN CARBOHYDRATE CONTAINING
APPROXIMATELY 1800 KCAL (7560 kJ)
DIET 4 WITH 210 G CARBOHYDRATE, 80 G
Low in saturated fats and cholesterol with increa- PROTEIN AND 70 G FAT
sed amounts of polyunsaturated fat. Suitable for Adults with Diabetes Mellitus
Foods to be avoided: Butter and hydrogenated
margarines. Use polyunsaturated margarine, e.g. Each carbohydrate exchange contains approxi-
“flora.” mately 10 g carbohydrate, 1.5 g protein and 0.3 g
• Lard, suet, shortenings and cakes, biscuits and fat. Caloric value is about 50 (equivalent to 2/3 oz
pastries made with these. bread). Use is made of the at water caloric conver-
• Fatty meat and visible fat on meat. Meat pies, sion factors of 4, 4 and 9 kcal/g for carbohydrate,
sausages and luncheon meals. protein and fat, respectively.
• Whole milk and cream. Each protein exchange contains approximately
• Chocolate, icecream (except water ices). Cheese, 7 g protein and 5 g fat. Caloric value is about 70
except low fat cottage cheese. (equivalent to 1 oz meat)
• Coconut, coconut oil and coffee mate. Each fat exchange contains approximately
• Eggs—no more than 1 to 2 egg yolks per week, 12 g fat and almost no carbohydrate or protein.
including that used in cooking. Caloric value is about 110 (equivalent to ½ oz
• Organ meats—liver, kidneys and brain. butter). One pint of milk contains approximately
• Shelfish and fish roes, fried foods unless fried in 30 g carbohydrate, 18 g protein and 24 g fat. Caloric
polyunsaturated oil (like sunflower or corn oil). value is about 410.
• Potato crisp and most nuts. In practice, for quick calculation of a diabetic diet,
• Gravy unless made with polyunsaturated oil, it is usually only necessary to work in terms of
and tinned soups. grams of carbohydrate and total calories. For this
• Salad dressing unless made with polyunsatu- purpose, the caloric value of the exchanges can be
rated oil. rounded to the nearest 10, i.e.
12 Textbook of Medical Dentistry
Carbohydrate exchange = 50 kcal. Small helping 2 oz (60 g) lean meat,
Protein exchange = 70 kcal. ham, poultry, game or offal or 3 oz
Fat exchange = 110 kcal. (90 g) white fish (steamed, baked
One pint of milk = 410 kcal. or grilled) or 1 egg or 1 oz (30 g)
Thus, a diet prescription for 210 g carbohydrate, cheese.
1,800 kcal would be calculated as follows: Salad or vegetables from Group
1. The daily intake of carbohydrate (210 g) A1 as desired.
represents 21 carbohydrate exchanges. 1½ oz (40 g) bread (white or
2. The daily allowance of milk is decided either on brown) or exchange, with butter
from allowance if desired.
the basis of the patient’s food habits or on his
1 portion of fruit from list below.
special requirements; in this example, it is ½ pint
Tea or coffee, with milk from
(400 ml) which contains 2 carbohydrate
allowance.
exchanges, leaving 19 for distribution through-
Mid-afternoon ½ oz (20 g) white or brown bread,
out the day.
or exchange, with butter from
3. The daily allowance of protein is then decided.
allowance.
Five protein exchanges will provide 350 kcal.
Evening meal Clear soup, meat or yeast extracts,
4. The calories allocated so far amount to 1,580; a tomato juice or grapefruit, if
further 220 kcal are needed to bring the total up desired. Small helping 2 oz (60 g)
to 1,800 kcal. This must be provided by fat. As lean meat, ham, poultry, game or
one fat exchange provides 110 kcal, two are foul or 3 oz (90 g) white fish (stea-
needed. med, baked or grilled) or 1 egg or
1 oz cheese.
EXCHANGES
Salad or vegetables from Group
Grams of kcal A1 as desired.
carbohydrate
1 ½ oz (40 g) bread (white or
2/3 pint milk (400 ml) = 3 carbo- 20 280 brown) or exchange with butter
hydrate exchanges from allowance, if desired.
19 carbohydrate exchanges 190 950
5 protein exchanges — 350
One portion of the fruit from list
below.
Total 210 1,580 Tea or coffee, with milk from
2 fat exchanges — 220
allowance.
Grand Total 210 1,800 Before bed Tea or coffee, with milk from
allowance.
5. Finally, the exchange (21 carbohydrate, 5 protein
GROUP A: FOODS WHICH MAY BE
and 2 fat) are distributed throughout the day
TAKEN IF DESIRED BUT IN NOMINAL
according to the eating habits and daily routine
QUANTITY AND OCCASIONALLY
of the patient. Diet 2 shows a specimen menu
• Sugar (brown or white), glucose, sorbitol.
and a list of sample exchanges is shown on pages
• Sweets, toffees, chocolates, cornflour, custard
13 and 14).
powder.
Mid-day meal Clear soup, tomato juice or grape- • Jam, marmalade, lemon curd, syrup, honey,
fruit, if desired. treacle.
 Nutritional Factors in Health and Diseases 13
• Tinned, frozen or bottled fruits. • Evaporated or condensed milk.
• Dried fruits, e.g. dates, figs, prunes, apricots, • Peas, parsnips, beetroot, sweetcorns, Haricot
sultanas, currants, raisins, bananas, grapes. beans, butter beans, broad beans, lentils, nuts.
• Cakes, buns, pastries, pies, steamed or milk • Salad cream, salad dressing, mayonnaise.
puddings. • Tomato and brown sauce of any thickened sauce.
• Sweet or chocolate biscuits, scones. • Sweet pickles and chutney.
• Cereals, e.g. rice, sago, macaroni, barley, • Thickened soups, gravis Bisto.
spaghetti, etc. • Alcoholic drinks, e.g. beer, wine, sherry spirits.
• Breakfast cereal, porridge. • Sweetened fruit juices, fruit squash, cocoa, cola
• Cocoa, ovaltine, horlicks, etc. and other sweet fizzy, ‘soft drinks.’
• Icecream, fresh or synthetic cream, table jelly. • Lemonades, Lucozade, Ribena.

DIETARY EXCHANGES FOR DIABETICS CARBOHYDRATE EXCHANGES

Each item on this list = 1 carbohydrate exchange (10 g CHO)
Caloric value is approximately 50.
Amount Remarks
oz g
Bread, Biscuits and Scones:
Bread (white or btown) 2/3 20 ½ slice off a large, cut loaf
Bread (toasted) 2/3 15 ——
Scones, rolls and oatcakes 2/3 20 ——
Cream crackers, crisp breads
Digestive biscuits ½ 15 ——
Rich tea biscuits
Water biscuits
Pastry (unsweetened) 2/3 20 ——
Cereals
Porridge 4 120 Cooked
Breakfast cereals
Arrowroot, barley, cornflower,
Custard powder, oatmeal
Flour, macaroni, rice, sago, ½ 15 All in dry state
Semolina, spaghetti, tapioca
Rice, macaroni, spaghetti 1½ 45 Boiled
Spaghetti in tomato sauce 3 90 Tinned
Miscellaneous
Cocoa 1 30
Ovaltine, Horlicks, etc. ½ 15
Creamed (tinned or packet) soup 4 120 Small tear cup
Icecream (Lyons or Walls) 2 60 1 small plain
Packet Jelly 2 60 Made up
Milk fresh 7 210 ½ pint
Milk evaporated 3 90 ——
Milk condensed (sweetened) ½ 20 ——
Alelager and draught beer 1 pint 600 ——
Stout (Guinness) ½ pint 300 ——

Contd...
14 Textbook of Medical Dentistry
Contd...
Amount Remarks
oz g
Vegetables
Potatoes (raw or boiled) 2 60 ——
Potatoes (roasted or chipped) 1 30 ——
Potato crisps 2/3 20 ——
Baked beans
Butter beans
Haricot beans 2 60 ——
Sweet corn
Tinned peas
Fresh or frozen peas
Beetroot 4 120 ——
Parsnips 3 90 ——

CARBOHYDRATE EXCHANGES—CONTINUED
Each item = 1 carbohydrate exchange (10 g CHO)
Caloric value is approximately 50
Raw Stewed
(without sugar)
oz g oz g
Dried fruits:
Apricots 2/3 20 2 60
Figs 2/3 20 2 60
Prunes 1 30 2 60
Dates
Currants ½ 15 — —
Sultanas
Raisins
Fresh fruits
Apples (with skin) 4 120 5 150
Bananas (with skin) 3 90 — —
Black currants 5 150 7 210
Blackberries (brambles) 6 180 7 210
Cherries 3 90 4 120
Damsons 4 120 6 180
Grapes 2 60 — —
Oranges and tangerines:
With skin 6 180 — —
Without skin 4 120 — —
Orange juice 4 120 — —
Peaches 4 120 — —
Pears 5 150 5 150
Pineapple (fresh) 3 90 — —
Plums 4 120 7 210
Raspberries 6 180 7 210
Strawberries 6 180 7 210
 Nutritional Factors in Health and Diseases 15
PROTEIN EXCHANGES
Each item on this list = 1 protein exchange.
Calorie value is approximately 70
Amount Remarks
Oz g

Meat, poultry, game and offals 1 30 Cooked weight

Corned beef, corned mutton,
Tinned meat. 1 30 —-
Egg (1) 1½ 45 —-
Cheese 2 60 —-
Fish—white, smoked cured, oily
Shell or tinned and ripe 1½ 45 Cooked weight
Sausages (include 1 carbohydrate
exchange) 2 60 Cooked weight
Gravies should not contain cornflower or flour. Avoid frying as much as possible.

Note: The food fads vary from state to state in the subcontinent of India; and for practicing dentists, it is
advisable to refer the patient to Local Nutrition specialist giving the memo of total calories to be converted
into local agreeable food varieties desirable to patient’s habits after due discussion with the patient and
his affordability of cost.
It is necessary for the clinician to go through the prescribed diet chart by the diatician so that he can
omit or suggest alternate item if it contradicts his during treatment to the patients or stains the teeth
during consumption. Generaly avoid fried, spicy, hard or sticy foods, which are too cold or too hot or
sour. In due course of time the dental diatician speciality may develops.
 Infection, Immunity
and Epidemiology 5
NATURE OF THE MICROORGANISMS Other some animals: Cows, goats, birds, rats,
dogs, rodents,
Saprophytes are the living organisms on soil,
Environment: Soil, dust, water, airborne,
water, plants, etc. They generally do not
droplet, food which is contaminated.
produce diseases in man but exceptionally
Other sources: Mosquitoes, hospital infection,
may produce toxins and can spoil the food-
milk, fomites, insects, flies, sandfly, fleas,
stuff and cause food poisoning in patient with
ticks, lice, tics, or surgical instruments,
Clostridium botulinum. Saprophytes such as
wounds, injection needles, blood transfusion.
Pseudomonas may be opportunitist pathogens
invading the tissue when resistance of the host
INCUBATION PERIOD
is low. Similarly, commensal flora of the body
can become opportunist pathogen such as Microbes invade tissues and take some time
Candida leading to thrush infection. to produce symptoms and this period is called
Microbes and parasites remaining in close incubation period, e.g. diphtheria about three
association with host are highly adaptable to days, measles 10 days, viral hepatitis type A
local conditions as well. Such commensals can about 2 to 6 weeks and hepatitis type B about
turn into pathogens finishing their quasant 2 to 6 months, and leprosy about 3 to 33 years.
role on opportune moment. Microorganisms
grow very rapidly by binary fission and DEFENSE OF THE HOST
increase in millions and are also virulent that In the first stage of infection, the microbes
help them to overcome the host’s defense and invade the tissues. They have to confront
thus the pathogenesis starts. tissue’s mucus which mechanically limits
their progress, and other fluids and enzymes
SOURCE OF INFECTION
overcome and kill the infection by antibodies.
Autogenous: When the source is the patient But it is not the case always if the infection is
himself. massive, repeated and virulent, the similar
Exogenous: When the source is another person defenses come into dynamic action. If the
who is a patient or carrier. infection is carried through lymphatic to the
Carriers: Healthy persons are the source and glands, the reticuloendothelium tissue kills
they carry infection without suffering. those microorganisms. Some of the infections
 Infection, Immunity and Epidemiology 17
enter the bloodstream, which is supposed to be the biopsies. However, in some cases, when diagnosis
best medium for the organisms to grow and is still not clear, one has to follow the procedure as
multiply. The infection resistance is the below:
susceptibility and sensitivity that play an important 1. Re-take the history, such as trip abroad may
part in the end results. However, immunity can have been missed.
save from the infection. Immunity can be natural 2. New signs might have appeared requires careful
or even acquired from mother to child or by reassessment.
injection of vaccines like smallpox, measles, 3. Repeat laboratory test, especially urine, and
typhoid, cholera and triple vaccine. multiple types of tests.
When the infection reaches deeper tissues, the 4. Study temperature chart from beginning.
defense mechanisms, “humeral” and “mechanical” 5. Reassess all investigations and repeat the
are immediately called for. The defense mecha-
investigations such as X-rays, etc. and see
nisms kill the microorganisms by endothelial cells
whether the methods of investigations are
and macrophages. By humeral defense antibodies
correct.
are formed and by mechanical fibrin barriers try to
6. Lastly, therapeutic antibiotic trial may be taken
localize and round up the infection.
as a last resort.
GENERAL MANIFESTATIONS
ART OF TREATMENT INCLUDING
OF THE INFECTION
IMMUNIZATION
1. Fever.
The art of treatment as mentioned above depends
2. Rigors.
3. Local symptoms depending on the site of the upon symptomatic radical general treatment in
infection. which rest, diet and other facilities such as back rest,
All these accelerate the host-defense mechanism etc. and physiotherapeutic exercises on bed,
to counter-attack the bacterial infection. fomentation, electrotherapy, etc.
Immunization following charts of immunization
Pyrexia of Unknown Origin (PUO) schedule usually followed in all the institutions
It is called so when diagnosis is difficult even after supervised by the Local Municipal Corporations’
getting the routine laboratory tests, etc. health departments.
These are a group of diseases when the pro- The various subspecialties of systemic medicine
longed fever continues. Autoimmune disorders are developing by force of circumstances and that
such as disseminated lupus erythematosis, poly- are as follows, just for information:
arteritis nodosa, rheumatoid arthritis etc. 1. Critical care medicine.
Malignancy such as cancer or sarcoma of lungs, 2. High altitude medicine.
stomach, kidney, etc. with or without metastasis. 3. Submarine medicine.
Chronic infections such as TB, infective endo- 4. Anesthesia medicine.
carditis, brucellosis, pelvic/subdiaphragmatic 5. Pregnancy medicine.
infection. 6. Geriatric medicine.
Hypersensitivity to drugs such as barbiturates, 7. Pediatric medicine.
streptomycin. 8. Genetic engineering.
Most of the diseases are diagnosed through 9. Ophthalmic medicine.
various advanced investigative methods and 10. Yoga as medicine.
18 Textbook of Medical Dentistry
11. Sports medicine. usually arthropods such as lice and fleas, which
12. Life insurance medicine. remain on the surface of the body but may transmit
13. Clinical pharmacology—reactions and inter- a systemic infection. Protozoal infections such as
actions of the drugs. malaria, amebic dysentery, sleeping sickness and
14. Aviation medicine. leishmaniasis and helminthiasis (worms) are of
15. Nuclear medicine. great importance in the tropics. Fungi causing
16. Legal forensic medicine. ringworm and thrush occur all over the world; but
17. Psychosomatic medicine. systemic infections with other fungi, such as
18. Social medicine. coccidiosis, histoplasmosis and the blastomycoses,
19. Public health department. are rare except in certain geographical locations.
20. Dietitian’s role in medical treatment. The range of diseases caused by bacteria is large;
streptococci and staphylococci are widespread and
All these subdivisions appear as specialty
produce similar diseases throughout the world.
branches and are being separated for the practical
Others such as the cholera vibrio and plague
use of the patient. A point to be kept in the back of
bacillus are locally endemic but may produce
mind is that during the treatment, if the problem
epidemics from time-to-time. Some bacterial
comes within the range of these subspecialities,
infections may be acute such as diphtheria and
then there should be no hesitation to take their
tetanus, others chronic such as tuberculosis,
assistance and refer the patients to them specifically
syphilis and leprosy.
for their guidance. So that, the patient is also
Organisms smaller than true bacteria, the
mentally satisfied to get his doubt clarified through
rickettsiae which cause typhus fevers, the myco-
the subspecialist and also take the necessary
plasmas of a typical pneumonia and Chlamydia
guidance, which may not be within the limitations
(bedsoniae) of psittacosis, lymphogranuloma and
of this book. We have not included psychiatry in trachoma are now recognized to be widespread and
sub-specialty, because it is a fully-grown specialty are susceptible to chemotherapy. The most bacte-
and is discussed with neurology. rial, protozoal and fungal infections can be
successfully treated with antibiotics and chemo-
Diseases due to Infection
therapeutic agents provided that the appropriate
Diseases due to infection are the most common drug is prescribed early in the disease. This empha-
cause of ill health throughout the world. Organisms sizes the need for rapid and accurate diagnosis
involved include bacteria, mycoplasmas, rickett- supplemented wherever necessary by specific
siae, viruses, protozoa, metazoa and fungi. The sensitivity tests to indicate the most effective
term infestation is now limited to ectoparasites, therapeutic agent (Tables 5.1 to 5.7).
 Infection, Immunity and Epidemiology 19

Table 5.1: Antimicrobial spectra of chemotherapeutic agents

CAUTION See below*
Penicillin Strepto-and Tetracylines Chloram- Erythro- Neo- Poly- Baci- Sulfona- Nitro-
Dihydros- phenicol mycin mycin myxin tracin mides furantoin
treptomycin (Furad-
amtin®)
Actinomyces sp. +++C ++ ++ +++C +++ +C ++C ++
A.aerogenes
Anthrax abcillus ++C ++ ++ ++ +C
Brucella sp. ++C ++C +C + +C

Cholera vibrios + + + +
Clostridia group ++C, at ++C, at ++C, at +++ +c, at
C. diphtheriae +++C, at ++C, at ++C, at
Donovan body + ++ ++
Ery. rhusiopathiae +++ + +
Esch. coli ++ ++ +++ +++ + ++ ++U
Gonococci +++ + +++ +++ +++ ++
H. ducreyi + +++ ++ + ++
H. influenzae ++C ++C +++C +++ +++ ++C, at
H. pertussis + ++ ++ + +C, at
Klebsiella sp. +++ ++ +++ +++ +++ +
Leptospira + +++ + +
Lymphopathia ++ +++ +++ +
venereum virus
Meningococci ++ ++ ++ +++
Myco. tuberculosis +++C+
P. tularensis +++ +++ +++ ++
P. pestis +++C +++C +++C +C
Pneumococci +++ +++ +++ +++ +++ +
Prim. atypical
pneumonia virus ++ ++ ++
P. vulgaris +++ +U +U +++ +C, U +++U
Ps. aeruginosa + +U +U ++ ++ +++U
Psittacosis virus ++ +++ +++ +
Rickettsiaes +++ +++ +++ +++
S. typhosa + +++ ++ +
Shigella sp. ++ ++ ++ ++ +++
Spirochetes
B. recurrentis ++ +++ ++
Vincent’s bacillus ++
T. pallidum +++ ++ ++
Spirillum minus ++ +++ +++
Staphylococci ++ + ++ +++ +++ +++ +++ ++U
Streptobacillus ++
moniliformis
Str. pyogenes +++ + ++ ++ +++ +++ +++
(beta-hemolytic)
Str. viridans +++ + ++ ++ +++ +++ +++
(alpha-hemolytic)
Str. faecalis ++C ++C +C ++C ++C +++ +++

* These agents are nephrotoxic when used systemically and should be so used in hospitalized patients only.
† Combined therapy with streptomycin and dihydrostreptomycin and/or isoniazid (INH) and para-aminosalicylic acid (PAS).
Agents of typhus, Rocky Mountain spotted fever, Q fever, and scrub typhus.
+++ Very effective. ++ Moderately effective. + Slightly effective.
C Use only in combination with another drug at antitoxin or antiserum. U For urinary tract infection only
20 Textbook of Medical Dentistry

Table 5.2: Currently available antimicrobial drugs with mode of action and mechanism of resistance

Class of antimicrobial Mode of action Mechanism of resistance

1. Beta lactam antibiotics
A. Penicillins Bactericidal by in- Inactivation by betalactamase
(PCNs) hibition of cell
B. Cephalosporins wall synthesis by inhibition Mutation in penicillin
of cross linking reaction binding
C. Monobactam
D. Amdinocillin
(mecillinam)
E. Imipenem Impermeability
F. Beta lactam molecules ‘Suicide inhibitors’
Clavulanic acid of beta lactamase
Sulbactam
2. Macrolides
Erythromycin Bacteriostatic by reversibly Decreased ribosomal binding
Clindamycin inhibiting Impermeability
ribosomal protein synthesis
by binding to 50s fraction
3. Vancomycin Bactericidal by inhibition Unidentified mechanism
of cell wall synthesis
4. Tetracyclines Bacteriostatic by reversible Impermeability due to defective
inhibition of ribosomal transport
protein synthesis
5. Chloramphenicol Bacteriostatic by reversible Acetylation by R-factor
inhibition of ribosomal mediated enzyme
protein synthesis at peptidyl
transferase step
6. Aminoglycosides Bacteriostatic by inhibition of R-factor mediated enzymatic
Gentamicin protein synthesis at initiation modification by acetylation,
Kanamycin step adenylylation, phosphorylation
Streptomycin
7. Polymyxins Damage to cell membrane Impemeability
Colistin
Polymyxin B
8. Sulphonamides Bacteriostatic by interference Mutation in enzymes of folic
with folic acid acid synthesis
9. Trimethoprim Slow bactericidal effect by Mutation in dihydrofolate
inhibition of dihydrofolate reductase alternate pathway
reductase
10. Quinolones Inhibit DNA gyrase Unidentified mechanism; not
Nalidixic acid mechanism; not affected by
Fluoroquinolones plasmid-mediated resistance
Norfloxacin unlike beta lactam and
Ciprofloxacin aminoglycosides

Contd...
 Infection, Immunity and Epidemiology 21
Contd...
Class of antimicrobial Mode of action Mechanism of resistance
11. Metronidazole Unidentified mechanism Undelined resistance
of action
12. Pentamidine isethionate Unknown mechanism
13. Isoniazid Bactericidal for M. tuberculosis Mutation in mycolic acid
by inhibition of synthesis of synthesizing enzyme
mycolic acid
14. Rifampicin Bactericidal by inhibition of
DNA-dependent RNA
polymerase
15. Pyrazinamide Bactericidal for intracellular
mycobacteria
16. Ethambutol Undefined mechanism of Undefined resistance
action
17. Cycloserine Bactericidal by inhibition of Unidentified resistance
cell wall synthesis
18. Amphotericin B Interaction with ergosterol Unidentified resistance
to damage cell membrane
19. Flucytosine Inhibition of RNA synthesis Impermea
20. Imidazoles Inhibition of Unidentified resistance
Ketoconazole synthesis of ergosterol
Miconazole

Table 5.3: Antimicrobial selection based on organisms

Organism Drug of choice Alternative drug
Gram-positive cocci Penicillin V Erythromycin
Staphylococcus aureus Penicillin G Cephalosporin
Nonbeta lactamase producing Methicillin Vancomycin
Beta lactamase producing Diclozacillin Cephalosoprin
Methicillin-resistant Vancomycin
Streptococcus pyogenes
Group A, C, G Penicillin G or V Erythromycin
Group B Penicillin G or ampicillin Cephalosporin
Streptococcus viridans Penicillin G plus Cephalosporin plus aminoglycoside
Streptococcus, anaerobic Penicillin G Erythromycin
Enterococcus Ampicillin or amoxycillin
Pneumococcus Penicillin G or V Cephalosporin, erythromycin,
chloramphenicol (meningitis)
Gram-negative cocci
Neisseria menngitides Penicillin G Ampicillin or amoxycillin
chloramphenicol
Prophylaxis (meningitis) Rifampicin Micocycline
Neisseria gonorrhoeae Penicillin G Tetracycline spectinomycin
ampicillin or amoxycillin
Extragenital Penicillin G Tetracycline

Contd...
22 Textbook of Medical Dentistry
Contd...
Organism Drug of choice Alternative drug

Gram-positive bacilli
Bacillium anthracis Penicillin G Erythromycin, tetracycline
Listeria monocytogenes Ampicllin, penicillin G Penicillin G plus aminoglycoside
Clostridium tetani Penicillin G Tetracycline, erythromycin
Clostodium perfringens Penicillin G Chloramphenicol, tetracycline,
cephalosporin
Corynebacterium diphtheriae Penicillin G Erythromycin
Shigella Cotrimoxazole Cephalosporin, ampicillin
Haemophilus influenzae (meningitis) Chloramphenicol Ampicillin or amoxycillin
Acinelbactin Aminoglycoside Carbenicillin, ticarcillin
Bordetella pertussis Erythromycin Cotrimoxazole
Brucella Tetracycline Cotrimoxazole, chloramphenicol
Treponema pallida Penicillin G Tetracycline
Leptospira Penicillin G Tetracycline
Chlamydiae Erythromycin Tetracycline
Mycoplasma Erythromycin Tetracycline
Legionella pneumoniae Erythromycin Tetracycline, rifampicin
Gram-negative bacilli
Escherichia coli Aminoglycoside Ampicillin or amoxycillin,
carbenicillin or ticarcillin,
cephalosporin, cotrimoxazole
Klebsiella pneumoniae Aminoglycoside Cephalosporin, mezlocillin or
piperacillin, contrimoxazole
Pseudomonas aeruginosa Aminoglycoside (except Carbenicillin, ticarcillin, mezlocillin
streptomycin, kanamycin) piperacillin
Enterobacter Aminoglycoside Cephalosporin
Serratia Aminoglycoside Cephalosporin
Proteus mirabilis Aminoglycoside Carbenicillin, cefotaxime,
cotrimoxazole
Salmonella Fluoroquinolone Cephalosporin
chloramphenicol (if sensitive)

Table 5.4: Indications for prophylactic immunoglobulins

Human normal (pooled) immunoglobulins
Hepatitis A virus infection Travelers
Debilitated children
Measles Child with heart or lung disease

Human specific immunoglobulin

Rabies Postexposure protection

Tetanus Susceptible injured patient
Hepatitis B Needle stick injuries, sexual partner
Chickenpox Immunosuppressed children
 Infection, Immunity and Epidemiology 23

Table 5.5: Immunization schedule generally followed in Britain

Age Visits Vaccine Intervals
4-12 months 3 Three administrations of 6-8 weeks and
DTP + OPV 4-6 months
12-24 months 1 Measles vaccination
First year at school 1 Booster DT + OPV
10-13 years 1 BCG for the
Tuberculin negative
Girls: 11-13 years 1 Rubella vaccination
15-19 years or
on leaving school 1 TT + OPV

DTP = Diphtheria, tetanus, pertussis (“triple”) vaccine

OPV = Oral poliomyelitis vaccine
DT = Diphtheria, tetanus vaccine
TT = Tetanus toxiod

Table 5.6: National Immunization schedule

When Vaccine No Route
Women pregnancy 2* Intramuscular
15-36 weeks
Infants
5 weeks-9 months BCG** 1 Intradermal
5 weeks-9 months DPT*** 3 Intramuscular
5 weeks-9 months Polio*** 3 Oral
9-12 months Measles 1 Subcutaneous
15-24 months DPT booster 1 Intramuscular
16-24 months OPV booster 1 Oral
5-6 years DT 2 Intramuscular
10 years TT 1 Intramuscular
15 years TT 1 Intramuscular
* One booster if two doses received less than three years ago. The first dose is given at 16 weeks and the second at 20 weeks.
**BCG can be given at the earliest contact after bath. In case of institutional deliveries, it must be given after bath.
***Polio and triple should be started at the age of 6 weeks or after that at the earliest contact, and should be repeated at one
month interval

Table 5.7: Indications for chemoprophylaxis

Indication Drug of choice
Short term
1. Abdominal sepsis Colonic/gynaec surgery Gentamicin/cefuroxime plus metroindazole
2. Valvular heart disease Dental, urological, gynaec surgery Penicillin/lincomycin if allergic to penicillin
3. Tetanus Wound or injury Penicillin/metronidazole
4. Gas gangrene Wound or injury Penicillin/metronidazole
5. Diphtheria Susceptible contacts Erythromycin
6. Meningococcal Susceptible Rifampicin contacts
7. Whooping cough Susceptible contacts Erythromycin
Long term
1. Rheumatic fever Following rheumatic fever Penicillin
2. Malaria Travel to endemic area of residence Chloroquine/mefloquin if resistant to chloroquine
3. Tuberculosis Susceptible contact Isoniazid
4. Leprosy Childhood contact Rifampicin + Dapsone
5. Urethritis/cystitis in female Prior to intercourse Nitrofurantoin
 Diseases of
the Cardiovascular
System and Essentials of
Electrocardiogram 6
DISEASES OF THE CARDIOVASCULAR SYSTEM

At all ages and in all countries, cardiovascular CARDIAC SYMPTOMATOLOGY

system is a major cause of mortality and
1. Dyspnea.
morbidity. Congenital heart diseases accounts
2. Edema feet/dependent part.
for higher proportion of deaths in infancy. 3. Nocturia.
Whereas rheumatic disease in childhood and 4. Angina.
hypertension and ischemic disease of heart in 5. Syncope.
the adult life. 6. Undue fatigue.
The heart is an important vital living pump 7. Cyanosis.
continuously at work providing oxygen and 8. Palpation and chest pain with radiation.
nourishment to the body cells through the
network of outgoing channels called arteries EXAMINATION OF CARDIAC PATIENT
and incoming channels called veins, bringing
a. Inspection: See growth under or over-
back the deoxygenated blood and metabolites
weight, bulging or flattening of peri-
from the body cells for further disposal
cardium apex beat pulsation at the base of
through kidneys and lungs. the heart and root of the neck and epiga-
The heart lies in the thoracic cage 2/3rd on strium, dilated veins. Jugular venous pulse,
the left side of the midline below the left costal clubbing and cyanosis.
cartilage occupies lower level on diaphragm. b. Palpation: Check the movements of the
The right auricle lies mostly to the right of the chest, pulsations and feel for vibration
midline extending somewhat beyond the right (thrills). See pulse rate, rhythm normal or
margin of the sternum. gallop, volume, condition of the vessel
Series of vertical imaginary lines are drawn wall, and character of the pulse such as
on the chest for convenience of description and normal or collapsing, anacrotic, dicrotic,
they are midsternal, lateral sternal or para- bisferiens, alternans, bigeminus, parado-
sternal, anterior, mid and posterior axillary xus, or sinus arrhythmia which is normal
lines and scapular lines drawn through the phenomena. Press digitally for edema and
inferior angle of the scapula. see the blood pressure.
 Diseases of the CVS and Essentials of Electrocardiogram 25
c. Percussion: To find out dullness which has 4. It helps to know pericardial effusion.
crossed the normal boundaries such as in 5. It helps to know metabolic changes due to
pericardial effusion, thoracic aneurysm (requires disturbance in electrolyte or changes due to
confirmation by X-ray and other tests). potassium.
d. Auscultation: It is done by stethoscope; See Easy way to understand normal ECG waves:
whether change of posture affects the heart P wave = represents auricular systole
sound or murmur. Timing biphasic, note the QRS = represents ventricular systole
character of the heart sounds, intensity, quality, T = represents repolarization.
rhythm, murmurs, rub and also auscultate the
CARDIOVASCULAR
femoral and carotid arteries, over the thyroid,
DISORDERS (OUTLINE)
skull, eyeballs and to hear the third and fourth
heart sound on pericardial area. 1. Congenital heart disease.
2. Anatomical approach:
INVESTIGATION FOR CARDIAC DISORDERS A. Disorders of conduction system.
B. Disorders of myocardium.
1. X-ray of the chest AP and both lateral.
C. Disorders of pericardium.
2. Echocardiography (dimensional, color Doppler).
D. Disorders of valves.
3. ECG, Halter ambulatory ECG monitoring,
E. Cardiac failure acute and chronic CCF.
Treadmill exercise test, thallium exercise test.
F. Coronary (artery) heart disease.
4. Angiography.
G. Hypertension and diseases of arteries and
5. Cardiac catheterization and coronary angio-
veins.
graphy.
H. Cor pulmonale.
6. Cartographic coronary imaging (Non invasive).
I. Thyrotoxicosis and myxedema.
ECG Congenital Common Cardiac Disorders
It is a graphic record of electric activity of heart and Broad classification: Cyanotic cardiac disorders and
is a most important diagnostic test. Unlike other acyanotic cardiac disorders.
muscles of the body, the cardiac muscle has got a
unique quality of automatic rhythmic contraction The infant is acyanotic The infant is cyanotic

through its inherent conduction system. The 1. Patent ductus 1. Fallot’s tetralogy
Asteriosus PDA
impulse formation and conduction produces weak
2. Atrial septal defect 2. Transposition of great
electric currents, which spread through the entire (ASD) Vesseles
body. By applying electrodes to various positions 3. Ventricular septal defect
on the body, the ECG is recorded. (VSD)
4. Dextrocardia
5. Familial cardiomegaly
Diagnostic Value of the ECG
6. Coarctation of aorta
1. It helps to know cardiac muscular hypertrophy
of right or left ventricle. Names of disorders are pathognomonic and
2. It helps to know myocardial infarction, anterior, details to be referred from cardiac textbooks if so
posterior and inferior. required. Their incidence is 0.1 percent in survived
3. It helps to know arrhythmias. live births.
26 Textbook of Medical Dentistry
Anatomical Approach chronic rheumatic disease. Digitalis is useful
but treat thyrotoxicosis. The complications of
Disorders of Cardiac Rhythm and
embolism and cardiac failure to be kept in
Conduction System
mind and tried to prevent. The mitral valvu-
There is an autoexcitation center in the cardiac lotomy may be undertaken at the earliest in
muscle called SA node starting auto activity and is the case of mitral stenosis.
normally controlled by a vagus nerve which slows
the heart, and sympathetic nerves which accelerates Disorders of Myocardium
the heart rate. From SA node, impulse travels to
a. Acute myocarditis:
A-V node through bundle of HIS and through the
Etiology: It is manifested as complication of
right and left bundle branches to the respective
diphtheria, pneumonia, typhoid, typhus, and
ventricles.
meningitis and virus diseases such as influenza,
Rhythm variations: polio as well as rheumatic fever.
i. Sinus bradycardia: When heart rate is less than Clinical features: There is sinus tachycardia rather
60/min. found in athletes. out of proportion to the temperature there may
ii. Sinus tachycardia: When heart rate is more be third HS audible arrhythmias, and acute
than 100/min. found after exercise or anxiety. circulatory failure and shock management.
iii. Ectopic rhythm: When impulse arises else- Complete bed rest, antibiotics, anti-arrhythmic
where other than SA node. drugs, O 2, and treatment of shock in acute
iv. Atrial ectopic rhythm: Affects P wave in ECG. cardiac failure.
Atrial tachycardia may occur with rate of 140 b. Chronic cardiomyopathies:
to 220/min. as a result of rapidly firing ectopic They are a part of generalized disorders such as
focuses. It may last for few second or may if hemochromatosis, sarcoidosis, amyloidosis,
not treated for a day or two. Patient is aware muscular dystrophies, systematic lupus erythe-
of rapid heart rate. But sometimes may get matosis, polyarteritis, alcoholism.
fainting or may become breathless and Clinical features: It is of CCF and arrhythmias and
anxious. Coffee, alcohol, tobacco may be prognosis is fatal.
precipitating factors. Medical management is prolonged rest and
v. Paroxysmal atrial tachycardia (PAT): with symptomatic. Alcohol to be totally stopped.
A-V block where auricular rate is 140 to 220/ Surgery has got a restricted scope.
min. with varying degree of A-V block is
usually due to digitalis intoxication when Disease of Pericardium
digitalis administration requires to be com- Acute pericarditis: The commonest cause is myo-
pletely stopped. Practolob IV inj restores the cardial infarction, coxsackie, B virus infection,
sinus rhythm or betaloc tab (45 V) 20 to rheumatic, TB, bacterial, malignant, lupus erythe-
40 mg qid or inj 5 mg IV (Astra Zeneca). matosis, trauma, uremia.
vi. Atrial flutter rate is about 300/min many Fluid in pericardial cavity can be fibrinous,
impulses do not really reach the ventricles serous hemorrhagic or usually due to malignancy
which is usually regular otherwise. This is seen or purulent usually due to infection may ultimately
in chronic rheumatic disease. Digitalis gives cause adhesions and obstruction of pericardial
relief. cavity (constructive pericarditics).
vii. Atrial fibrillation: The atrial rates are rapid and Clinical features: Pericardial pain is variable; when
un-coordinated and ineffective it is found in present it is sharp and aching increases by
 Diseases of the CVS and Essentials of Electrocardiogram 27
movements, inspiration and lying flat. It could be Treatment: Consists of chronic congestive failure and
severe in viral infection. If fluid is large, the feeling hemoptysis management and radical is mitral
of compression at pericardial region is felt. Peri- valvotomy after due assessment. It is done with a
cardial localized friction rub is diagnostic best heard dilator into mitral valve. The outlook is encourag-
at left lower sternum and which is increased by ing although recurrence after 5 to 10 years is not
inspiration. Heart sounds low and muffled tachy- uncommon. Calcification in mitral valve is more or
cardia is present, pulses paradoxus may occur. As less contraindication, due to the complication of
a rule it disappears with increase of pericardial mitral regurgitation. No surgery permisable when
effusion. active rheumatic disease is present.
ECG shows ST elevation with upward concavity
over the affected area later on “T” inversion is seen. Mital Regurgitation
Investigations: X-ray, ECG fluid aspiration and lab Causes: Complications of mitral valve surgery,
tests. rheumatic heart disease, diphtheria, viral myo-
Management: The disease is serious, requires carditis, or cardiomyopathies, it may be even due
careful hospital treatment of causes as well as to damage to the papillary muscles and cords
symptomatic. tending to rupture after infarction. But, in such cases
onset is sudden and leads to acute pulmonary
Diseases of Heart Valve and edema. In older age group, myxedematous degene-
Ineffective Endocarditis ration of mitral valve causes mitral regurgitation.
There are four valves in the heart. Mitral, aortic, Clinical features: Apical systolic murmur will be
tricuspid and pulmonary. The defects are either heard into left axilla accompanied with Apical
stenosis or incompetence. systolic thrill is pathognomic. First heart sound is
Mitral stenosis The mitral stenosis which is 5 cm in low and third heart sound is loud and short mid
diastole becomes 1 cm short and deformed due to diastolic murmur.
rheumatic heart disease; resulting atrial fibrillation ECG shows left atrial and ventricular hyper-
and thrombus formation in the left atrium where trophy.
pressure increases retrograde into the pulmonary Treatment: The only effective treatment is mitral
veins and loss of lung compliance. The right valve replacement.
ventricle has to push the blood against pressure
becomes hypertrophied affecting the systemic Aortic Stenosis
venous return adversly. Causes: Congenital, rheumatic disease, in old age.
Clinically the patient is breathless even at rest Clinical features: Lowered cardiac output causes
more so when atrial fibrillation occurs, hemoptysis, diminished exercise tolerance, syncope, angina,
angina, episodes of embolism and hemiplegia more nocturnal dyspnea, sudden death may occur.
common in children; there may be malar flush. The
Physical signs: Systolic murmur at the base, thrill,
jet of blood through the mitral valve causes sound
transmitted to carotid arteries called “carotid
called “opening snap,” and presystolic murmur. The
shudder,” ECG and X-ray chests are confirmative
pulmonary valves closer causes loud second heart
and helpful.
sound loud. Due to restricted cardiac output the
pulse volume is small. Treatment: Apart from usual management the only
The ECG shows “P” wave bifid and atrial hyper- effective treatment is replacement of aortic valves
trophy and may shows even fibrillation. There is and in some cases valvotomy may be a treatment
right ventricular hypertrophy. of choice.
28 Textbook of Medical Dentistry
Aortic Regurgitation INFECTIVE ENDOCARDITIS
Causes: Congenital bicuspid valves damaged aortic Causes
valves due to rheumatic diseases, due to dilatation
Bacterial septicemia, coxiella virus and fungi. More
of root of aorta due to syphilis or atheroma. There common in rheumatic heart disease, in VSD, in
is left ventricular hypertrophy. PDA, concomitant with other valvular lesions are
Clinical features: Breathlessness, angina, paroxysmal also present.
nocturnal dyspnea, increase in pulse pressure, gross
pulsation in the large arteries called “Muscle knock.” Clinical Features

Treatment: Valve replacement with prosthesis is the Pyrexia persistent, excessive sweating at night,
treatment of choice. anemia, splenomegaly, embolic episodes and
stroke, CCF and death, purpura splinter hemor-
Tricuspid Valve Disease rhages under the nails, Osler’s nodes painful and
tender are helpful sign at the fingertips. Clubbing
A. Tricuspid stenosis: Is usually due to rheumatic in late, spleen and hepatomegaly embolism may
heart disease. Is almost always accompanied cause cerebral and coronary and splenic infarctions.
with mitral stenosis with similar clinical features Hematuria is present.
as mentioned under mitral stenosis. Acitis and
edema is more common. Investigations
Treatment: Surgery is less satisfactory as
CBC, ESR, blood culture and sensitivity test, ECG,
compared with mitral sinosis.
X-ray chest are helpful and give best guidance for
B. Tricuspid regurgitation: Shows more marked right management.
ventricular hypertrophy there is “C” wave in
jugular venous pulse. Treatment

Treatment: Replacement of valve with prosthesis. Antibiotics, removal of septic focuses or treats them
effectively. Hospitalization, complete bed rest and
Pulmonary Valve Disease treatment of the causes are essential.
In advanced cases, when the valve damage is
a. Pulmonary stenosis: Mostly congenital as in
considerable, the surgical replacement is preferred.
Fallout’s tetralogy. Ejection systolic murmur at
the base radiating to the left shoulder is reliable
Prevention
sign is usually accompanied with thrill. There is
marked right ventricular and right auricular Through antibiotic umbrella for long periods is
hypertrophy. indicated. The removal of septic foci should not be
neglected at any cost and while doing so, antibiotics
Treatment: Pulmonary valvotomy. before and after to be used without fail.
b. Pulmonary regurgitation: It is very rare, usually
CARDIAC FAILURE
features of pulmonary hypertension “Graham
steel” murmur best heard at left sternal edge to The pumping action of the heart is done by right
be distinguished from murmur of aortic regur- and left ventricles. When their function starts
gitation. gradually failing it is called cardiac failure.
 Diseases of the CVS and Essentials of Electrocardiogram 29
Right Ventricular Failure Venesection and paracentesis if required
Cause reduction of right ventricular output. Is for ascites and hydrothorax give considerable
Usually secondary to: symptomatic relief.
i. Left ventricular failure.
ii. Pulmonary pathology such as pulmonary Left Ventricular Failure
valvular diseases, acute massive pulmonary Causes
embolism or chronic pulmonary diseases such
as asthma, chronic bronchiactasis, TB, i. Hypertension.
pneumoconiosis, primary pulmonary hyper- ii. Aortic stenosis and regurgitation.
tension, recurrent pulmonary embolisms, iii. Coronary artery diseases.
harmophysis. iv. Mitral stenosis.
iii. Anatomical chest deformities such as kypho-
scoliosis add to the seriousness. Clinical Features
iv. Infections such as rheumatic disease, diph-
Dyspnea, distressing dry cough, Cheyne-Stokes
theria, causes toxic myocarditis.
respiration, sometimes hemoptysis when associa-
v. Nutritional deficiency such as anemia, wet
ted with embolism.
beriberi affects the myocardium also
vi. Endocrine such as thyrotoxicosis.
Physical Signs
vii. Circulatory causes such as arterio venous
fistula and shents, myxedema. BP may be raised, there may be pulses alternans
viii. Arterial fibrillation/paroxysmal tachycardia. and gallop rhythm, second pulmonary sound loud,
ix. Obstructive such as constructive pericarditis. pulmonary congestion, X-ray and ECG show
cardiac enlargement with hilar prominent shadows.
Clinical Features
Headaches, insomnia, confused mental state, Treatment
nausea, vomiting, flatulence, constipation or
It is a serious condition and requires hospitalization.
diarrhea, menstrual disturbances in ladies, cyanosis,
Best nursing care, oxygen inhalation, cardiac rest,
visible jugular pulsation, liver palpable and tender,
and injection of morphine with atropine. SC
ascities and pulmonary congestion.
Aminophylline injection IV slow, cardiazol or
Treatment nikethamide IM and if required venesection and
removal of 500 cc of blood at a time.
Hospitalization, bed rest, low salt, low caloric diet,
fluid restriction, diuretics and most importantly the
INFECTIVE ENDOCARDITIS
digitalis which can be given to start with 1.2 mg
and thereafter, 0.5 mg 6 hourly till the condition is Endocarditis is an affection of endocardium due to
controlled and thereafter, 0.25 mg daily 6 days a bacteria, viruses such as Coxiella or fungi. It may
week as maintenance dose. be fulminating in acute form and could be very
All other drugs such as analgesics, laxatives, anti- serious. In the insidious form, it goes on for months
coagulants and anti-thyroid drugs if thyrotoxicosis together with mild and general symptoms unless
is present. This part of treatment has got their own suspected and investigated the diagnosis cannot be
important place in dealing with the patients. established.
30 Textbook of Medical Dentistry
Clinical Features Pathogenesis
Unusual fatigue, pallor, anemia, anorexia, low grade 1. Atheroma: Lipid substances accumulate in
persistent fever, splenomegaly; the disease is fatal the intima of the aorta and larger arteries in
if not effectively treated. patchy irregular fashion causing various degree
of narrowing of the lumen specially when
Investigation encroaching on opening of the lumen of the
ESR increased, presence of anemia, thrombocyto- coronary vessel. They also cause pressure
penia, disturbed liver function, blood culture and atrophy on the underlying media affecting the
sensitivity test, complement fixation for Coxiella arterial elasticity, but the narrowing/obstruction
virus are helpful. is only caused by thrombosis. It is quite rare in
vegetarians.
Treatment 2. Blood lipids include natural fat, fatty acids, free
cholesterol and its easters as well as phos-
Treat the cause, bed rest hospitalization, nourishing
pholipids. The serum cholesterol 150 to 300 mg
but light diet, antibiotics, analgesics, antipyretics,
percent is definitely related to arteriosclerosis.
laxatives, vitamins, iron and folic acid, plenty of
The atheroma patches contain high proportion
fluids.
cholesterol.
Coronary Heart Disease The cholesterol and phospholipids are carried
(Ischemic Heart Disease) in combination with alpha or beta globulins and
are called alpha or beta lipoproteins and their
Definition
presence is demonstrated in atherosclerosis.
An occlusive disorder with or without thrombosis 3. Atherosclerosis is a most common cause of
of coronary arteries causing insufficiency of blood angina pectoris leading to myocardial infarction
supply to the heart muscle to meet the physiologi- and its complications are cardiac failure to
cal demands is called ischemic/coronary heart sudden death.
disease, which is manifested as angina pectoris,
coronary insufficiency or myocardial infarction. ANGINA PECTORIS

Incidence It is a clinical syndrome caused by reduced blood

flow to the heart less than required. These are the
Ever increasing due to fast life, increasing stress and two factors:
tension in modern urban life. A. Reduced blood flow as in aortic stenosis,
Sex obstructive cardiac myopathy, constructive
pericarditis, hypertension.
Four times more common in men. B. Increased requirement such as exercise of
Heredity exertion, anemia, hyperthyroidism.

Fifty percent cases give positive family history.

Clinical Features
Habits There is a sense of compression or tightness in the
Is more common in smokers of cigarettes. There is middle of the chest induced by exertion or anxiety.
no evidence that alcohol is responsible for high male It is worst while walking fast, uphill or climbing
incidence. stairs, particularly after meals on a cold day, and
 Diseases of the CVS and Essentials of Electrocardiogram 31
the feeling is reduced by rest. Similar conditions 6. Depin: 5 mg 10 mg cap (Cadila Health Care)
may occur due to coronary spasm with borderline and also Depin retard 20 mg cap and also depin
ECG changes but they are reversible. The pain and SR 30 mg cap start with lower dose and
discomfort radiate to left arm, wrist and hand with increase gradually.
feeling weakness. Rarely the radiation of pain goes Contraindication: Aortic stenosis, MI, preg-
to left scapular or intrascapular epigastric, to the nancy and lactation.
neck or jaw. 7. Dilzem (diltiazem) 30, 60 mg tab before food
(Torrent) 1 tab tds lts for long time use.
Investigations Contraindication: Pregnancy, lactation, hypo-
tension, hepatic and renal impairment and
ECG is normal on rest and abnormal after exercise
diabetes.
CBC for anemia, thyroid function tests, X-ray chest
8. Dynasprin (Aspirin 5 mg + Dipyridamole 75
for cardiomegaly.
mg (USV) 1 tab tds 1 hour before food.
Contraindication: Allergy to aspirin, peptic
Cartographic Imaging
ulcer, bleeding disorders.
Differential Diagnosis 9. Flavedon: 20 mg tabs and Flavedon MR 35 mg
Asthma, pericarditis, ostiochondritis, hiatus hernia. dose 1 bd
Contraindication: Pregnancy and lactation.
Treatment (glyceryl trinitrate) 10. Inderal: 10,40,80 mg tabs (Propranolol HCl)
(Nicholas Piramal) dose 1 tds can be increased
1. Angised (GSK) 0.5 mg tab one to be kept under
after one week.
tongue every 3 min till the chest pain is
Contraindication: Asthma, CCF, acute MI, heart
relieved. (Not to be chewed or swallowed)
block, hypotension, shock.
Contraindication: Hypertrophic cardiomegaly,
11. Chelation Therapy about 13 or more sittings
cerebral hemorrhage.
biveekly if recommended by treating cardio-
2. ATEN (Atenolol) 50, 100 mg tablets
logist.
(Cadila health care) only one tablet daily as
prophylaxis. Surgical Treatment
Contraindication: Bradycardia, heart block Surgical coronary bypass can give dramatic
CCF, hypotension. improvement in drug resistant cases when multiple
3. Betaloc (Metoprolol tart.) 50, 100 mg tab coronary arteries are affected.
(Astrane Zeneca) 1 tds and also inj 1 mg/cc im
if acute myocardial infarction is there. MYOCARDIAL INFARCTION (HEART ATTACK)
Contraindication: Bronchospasm, asthma, Definition
pulmonary hypertension.
Death and necrosis of portion of myocardium due
4. Ciplar (Propranolol HCl.) CIPLA 10, 40, mg
to coronary artery occlusion usually due to throm-
tab 1 tab tds.
bosis and when collateral circulation is inadequate
Contraindication: Asthama, CCF, MI, heart
which is followed by fibrosis.
block, hypertension and shock.
5. Clinium (Lidoflazine) 60 mg tab 1 od after Predisposing Factors
food. First week 1 bd after food second week. 1. Age between 40 to 70.
One tds after food third week and therafter. 2. Family history positive in about 50 percent of
Contraindication: Pregnancy. patients
32 Textbook of Medical Dentistry
3. Sex: 4 times more common in men. Complications
4. Underlying disorders: hypertension, diabetes, 1. Arrhythmias: Sinus tachycardia, sinus brady-
obesity, stress and tension, syphilis, Aids. cardia may result in syncope is also a special
5. Arteriosclerosis, hyperlipidemia, overweight. feature in inferior myocardiac infarction, atrial
6. Psychiatric: emotional shock, death of nearby tachycardia and fibrillation may occur leading
relation. to cardiac failure or hypertension requiring
Symptoms urgent treatment.
The ventricular arrhythmias are even more
H/o angina, pain onset is abrupt, dull aching and
dangerous. Ventricular tachycardia carries high
agonizing behind the upper sternum, radiating
mortality. Ventricular fibrillation appears in
usually to left arm but occasionally to right, neck,
about 10 percent of patients in warst proguo-
jaw interscapular region, epigastrium and usually
stiesign.
continuous. Restlessness, anxiety, dyspnea, vomi-
Various degree of atrioventricular blocks are
ting, syncope, profound sweating and shock.
also common which may lead to complete heart
Less than 5 percent of cardiac infarctions are
block common in anterior myocardial infarction
symptomless and half of them are completely
when both bundles are involved in the inter-
silent and diagnosed by routine ECG.
ventricular septal infarction when the infarction
is extensive and condition of shock is always
Signs
present.
Heart sounds low, muffled, first heart sound 2. Cardiogenic shock: It is a very serious condition
inaudible, tachycardia, tic-tac or gallop rhythm. demanding urgent proper treatment. If infarc-
Pericardial rub may be heard, BP low, systolic BP tion is extending an arrhythmias progress there
may go to 100 or 80 mm. is acute ventricular failure, pulmonary edema,
Fever appears after second day 100 or 102° F. renal failure and cardiac arrest leading to death.
3. Cardiac failure and pulmonary edema.
Investigations
4. Rare complication is rupture of mitral papillary
CBC shows leukocytes, ESR raised. Urine trace of muscle causing mitral regurgitation.
albumin, SGOT and SGPT raised. ECG may be 5. Rupture of interventricular septum followed by
normal or show ST elevation. The changes are as severe hypotension and venus pulmonary
below. hypertension.
A. Anterior infarction: The elevation of ST segment 6. Rupture of myocardium leading to cardiac
in lead I and II. Depression in lead III. Prominent temponade calls for emergency cardiac surgery
Q in chest lead IV “R” absent and ST shows (the cardiac temponade is compression of heart
coving. by large quantity of blood or fluid in pericardium
B. Posterior infarction: Elevation of ST segment in interferes with diastolic filling of the heart
lead III. Depression in lead I and inversion of T, ventricle) as a result of this, stroke output is
prominent Q III. reduced. There is compensatory tachycardia, fall
C. Inferior infarction: ECG is usually normal. ST of blood pressure and increase in the venous
segment, depression and later symetrical T pressure. There is shock and you may feel pulses
waves may be seen V2 to V6 as reciprocal paradoxus in exaggerated variation of volume
changes of inferior wall infarction. with breathing. Possibility of venous thrombosis
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Jack Down; t1Jan77; A882041. A882042. New Jersey uninsured
motorist coverage guide. By John J. Nooney. 33 p. Add. ti: New
Jersey uninsured gotorists coverage guide. © John J. Nooney;
15Jan77; A882042. A882043. Career education supplement for social
studies correlated to the curriculun guides for the secondary school
social studies program. By Joseph P. Hannon. 21 p- Appl. au: Board
of Education of the City of Chicago. © Board of Education of the City
of Chicago; 30Jun77; A882043. A882044. Career education
supplement for science correlated to the curriculum guides for the
secondary school science program. By Joseph P. Hannon. 14 p. Appl.
au: Board 2177 JUL. — DEC. 1977 of Education of the City of
Chicago. © Board of Education of the City of Chicago; 28Jun77;
A882044. A882045. The Sholtive method. John P. Muther (Jack)
22Jul77; A882045. 2 p- Appl. au: © Jack Muther; A882046.
Existentialism in literature and drama. Philosophy 107 A. By Hubert
L. Dreyfus. Sheets (104 p.) © Hubert L. Dreyfus; 15Jun77; A882046.
A882047. More bric-a-brac: a book of musings. By Alta Crowley. 81
p. 6 Alta Crowley; 14Jun77; A882047. A882048. Symbolic chess,
aftermath Jordan River. Sheets (8 p-) Appl. au: Edward Dorian
Brogden. © Edward Dorian Brogden; 21Apr77; A882048. A882049.
The Teacher and the child with spina bifida. By Betty Pieper
(Elizabeth Pieper) 25 p. © Betty Pieper; 24Apr77; A882049.
A882050. When something is wrong with your baby, looking in and
reaching out. By Betty Pieper (Elizabeth Pieper) 27 p. © Betty
Pieper; 24Apr77; A882050. A882051. Southport by the sea. Book 2.
By Thomas DeV. Fredericks, illustrated by Kim Dodge & Karen
Dodge. 35 p.- © Thomas DeV. Fredericks; 4Jul77; A882051.
A882052. Talisman, 1976-77. Editors: Adelbert Corey & Buni Bailey,
sketches: Judy Willard. 90 p. © Macomb County Community College;
9May77; A882052. A882053. American's coin book. By Charles
MayhewS 32 p. © Charles Mayhew; 13Jun77; A882053. A882054.
Indigo and the antiquity of dyeing. By Frederick H. Gerber, lay-out
artist: Juanita G. Gerber. 59 p. 6 Frederick H. Gerber; 8Jul77;
A882054. A882055. Parent resource directory. 82 p. au: Minnesota
Early Learning Design & Childbirth Education Association. ©
Minnesota Early Learning Design; (in notice: 1976); A882055. Appl.
1Jun77 A882056. A Day gone by in silence. Text by Eleanor B.
Rhodes. 1v. © Eleanor B. Rhodes; 31May77; A882056. A882057.
Come on int wine making. Opening the door to closet By Henry Ford,
illustrated by Mel Nedrud. 1v. © Henry Ford; 21May77; A882057.
A882058. Fair trial/free press; teacher's guide. By Rebecca J. Novelli
& E. Todd Clark. 50 p- Appl. au: Constitutional Rights Foundation. 6
Benziger Bruce and Glencoe, Inc.; 3Jan77; A882058. A882059.
Teacher*s guide for The Promise of equality; equal rights and equal
opportunity in American life. By Carlton S. Martz. 45 p. Appl. au:
Constitutional Rights Foundation. © Benziger Bruce and Glencoe,
Inc.; 31Jan77; A882059. These entries alone may not reflect the
complete Copyright Office record pertaining to a particular work.
Contact the U.S. Copyright Office for information about any
additional records that may exist.
 a882060 - A882101 A882060. Teacher's guide for Juvenile
justice; the leqal rights of young people. By Nancy Boyarsky. 40 p.
Appl. au; Constitutional Rights Foundation. © Benziger Bruce and
Glencoe, Inc.; 31Jan77; A882060. A882061. Don't talk to me about
death. By Charles R. Murrah. 75 p. © Charles R. Murrah; 15May77;
A882061. A882062. How to buy land cheap. Preston, pseud. of
Edward Guess. © Boggle Publications; 18Jun77; By Edward 43 p.
A882062. A882063. The First Epistle of John with special verses
underscored and specially prepared heips for new Christians. Arr.
Ernest W. Childs. 23 p. Add. ti: 1 John that ye may know. © Ernest
Childs; 1Jun75; A882063. A882064. Blueprint for articles. By Marie
O'Dea. 12 p. NM: editorial revision. © Marie O*Dea; 20Ju177;
A882064. A882065. TV Time. Folder. © United Publishing Company;
15Jan77; A882065. A882066. Response Center menstrual calendar.
© Response Center--Jewish Community Centers of Chicago;
20Jul77; A882066. A882067. Access North Suburban Chicago. 103 p.
© League of Women Voters of Illinois; 25Jun77; A882067. A882068.
1st savings baby's book. 1. Appl. au: Jo Trimm Jones. © Jo Trimm
Jones; 28Jun77; A882068. A882069. The New creation: an
anthology. By Marcia A. Bowie, Margaret Hunt & Sandra Louise
Reynolds. 33 p. © Sandra Louise Reynolds, Marcia A. Bowie &
Margaret Hunt; 220ct76 (in notice: 1975); A882069. A882070. Three
people chess. 7 p.- Appl. au: Joan Brandenburg & Eriwn Bachrach. 6
Joan Brandenburg; 1Apr77; A882070. A882071. We walk in their
footsteps; a Bicentennial booklet. Researched by the Bicentennial
Committee of the Somerville Branch of the A.A.U.8. 23 p- NU:
Compilation. © N.J.A.A.U.W., Somerville Branch a.a-d.o. American
Association of Gniversity Women, Somerville Branch; 24Apr77;
A882071. A882072. Lead line trolling depth calculator. Kit. Appl. au:
Clarence A. LaBonte. @ Clarence A. LaBonte; SMay77; A882072.
A882073. Teacher-developed infused curriculua modules: career
education in social studies, 7-12; teacher ideas. 125 p. NM: additions
& revisions. © Partners in Career Education; 1Jun77; A882073.
A882074. Your own poets; an anthology of Christian poems. Editor:
Phil Silva. 1 v. © Phil Silva d.b.a. Praise the Lord Press; 5May77;
A882074. A882075. Carter on the arts. Introduction by Joan
Mondale, editor: Nancy Bush, BOOKS & PAMPHLETS conclusion by
Michael Newton. 74 p. NM: introd., conclusion & material introducing
reprinted quotations. © Associated Councils of the Arts a.a.d.: ACA;
26May77; A882075. A882076. Principios de operaciones bancarias.
Por Rafael Rivera Emmanuelli. 256 p. © Rafael Rivera Emmanuelli;
30Mar76; A882076. A882077. Language of music for choirs and glee
clubs: the simple basic rudiments for vocalists. 1v. Appl. au: Udo W.
Klein. © Udo W. Klein; 27Jun77; A882077. A882078. Reality: an
essay concerning the stars and relative things considered. By Robert
LePage. 158 p2 © Dawn Eden; 1Jun77; A882078. A882079. The
Grizzly bear: the narrative of a hunter-naturalist. By William Henry
Wright, foreword by Frank C. Craighead, Jc. 274 p. Reprint of 1913
ed. Gon foreword; University of Nebraska Press; 15dJun77;
A882079. A882080. Poeas. By Roscoe Solley. 2nd ed. 40 p- I am the
great United States prev. pub. in The Progress, Clearfield, PA, July 3,
1976. © Roscoe Solley; 22Ju177; A882080. A882081. The Phoenix.
P- Appl. au: College. © The Phoenix; a882081. Vol. 1, spring 1977.
94 Delaware County Community 9May77; A882082. Guidelines and
leadership training. 74 p- Add. ti: Theos guidelines for chapter
leaders and chaplains. Appl. au: Beatrice Decker. © The Theos
Foundation, Inc.; 150ct76; A882082. A882083. Mon autre lyre. By
Janis L. Pallister. 2. ed., corrigee & augmentee. 48 p. French, English
& Spanish. Some poems prev. pub. 1974 & others. © Jan Pallister;
210ct74; A882083. A882084. PCI presents Cementing PVC pipe; or,
Installing PVC pressure pipe can be a sticky business! 1. © PCI
Industries, Inc.; 31May77; A882084. A882085. Absent healing
prayers. Alexander Worrall. 20 p. Add. ti: A Selection of healing
prayers. © Hrs. Ambrose A. Worrall a.k.a. Olga N- Worrall; 30Jun77;
A882085. By Ambrose A882086. : In Daddy"s arms By Jessie
Sherwin. 180 p. Appl. au: Carlyle Communications, Inc. © Carlyle
Communications, Inc.; 15Jul77; A882086. A882087. Drink mixing
guide. © Slide Chart Corporation; 28Mar77; A882087. A882088.
Official 1977 National Football League record manual, 58th season.
Compiled by the National’football League Public Relations
Department & Seymour Siwoff, edited by Jim Rooney, statistics by
Elias Sports Bureau, Inc. 399 p. Add. ti: National Football League
record manual, 1977. Appl. au: National Football League. © National
Football League; 15Jul77; A882088. 2178 JOL. — DEC. 1977
A882089. Resource manual for a living revolution. By Virginia Coover,
Ellen Deacon, Charles Esser & Christopher Moore. 343 p. © Virginia
Coover, Ellen Deacon, Charles Esser & Christopher Moore; 1Jul77;
A882089. A882090. N* cookbook of sporting tastes. Co-editors: Ann
Coppedge, Sandra Welsh & Rosemary Maersch, illus. by LeAnn
Bauer. 257 p- © Naval Academy Memorial Fund, Inc.; 3Jun77;
A882090. A882091. Notable women. By Marci Whitney. Appl. au:
Tribune Publishing Company. Prev. pub. in Tacoma news tribune,
Jan. 18-Aug. 29, 1976. NM: compilation & additional text & graphics.
© Tribune 59 p.Publishing Company; 1Mar77; A882091. A882092.
Circle Tennis: instructions. Folder. Appl. au: Robert W. Hankins &
Harry C. Pendleton, Jr. NM: additions & revisions. © H and P
Recreation Company, a par-— tnership of Robert W. Hankins, Harry
C. Pendleton, Jr. & Maynard L. Linngren; 23Mar76; A882092.
A882093. Blackjack: as played in gambling casinos throughout the
world. By Bert Vos. 51 p. Add. ti: Blackjack: how to play to win. NA:
new text & drawings & compilation of text. © Bert Vos; 11Jul77;
A882093. 4882094. The Double-check method of family planning. By
Paul Thyma, pseud. of Jan Mucharski. 44 p. NM: additions. © Paul
Thyma, pseud. of Jan Mucharski; 7Jun/77; A882094. A882095.
Review of research in social studies education, 1970-1975. Bulletin
49. By Francis P. Hunkins & others. 199 p. © National Council for the
Social Studies; 20May77; A882095. A882096. The New state of the
economy. By Fred C. Allvine & Fred A. Tarpley, Jr- 192 p. ©
Winthrop Publishers, Inc.; 15Feb77; A882096. A882097. The
Motivation process. By Susan Davidson Schaefer, photos. by Scott
Brickner. 189 p. © Winthrop Publishers, Inc.; 15May77; A882097.
A882098. Speak with confidence: a practical guide. Speak with
confidence: a practical guide, instructor's manual. By Albert J. Vasile
& Harold K. Mintz, cartoons by Steve Miles. 2 v. © Winthrop
Publishers, Inac.; 15May77; A882098. A882099. Understanding the
structure of English. By Joseph E. Littlejohn. 178 p. © Winthrop
Publishers, Inc.; 11Apr77; A882099. A882100. Cognitive psychology.
Reynolds & Paul W. Flagg. By Allan G. 457 p. NM: text. © Winthrop
Publishers, Inc.; 22Jun77; A882100. A882101. Principles of social
psychology. Principles of social psychology, teacher's manual. By
Kelly G. Shaver. 2 v. © Winthrop Publishers, Inc.; 24Feb77;
A882101. These entries alone may not reflect the complete
Copyright Office record pertaining to a particular work. Contact the
U.S. Copyright Office for information about any additional records
that may exist.
 A882102 - A882146 aA882102. Dear Amy Carter. Selected
by Biil Adler, illustrated by John Caldwell. 1 v. Accompanied by cover
illus., reg. K125159. © on all but the cover illus.; Bill Adler;
20May77; A882102. A882103. Stacey. By William Sherman. 223 p.
Accompanied by cover illus., reg. K125160. Appl. au: Bill Adler Books
a.k.a. Williaa Sherman. © on text only; William Sherman a.k.ea. Bill
Adler Books; 20May77; A882103. A882104. This ravaged heart. By
Alan Riefe a.k.a. Barbara Riefe. 413 p. Accompanied by cover illus.,
reg. K125161. © on text Barbara Riefe a.k.a. Alan Riefe; A882104.
only; 1Jun77; A882105. Family. No. 2: Transitions. Adapted by Leila
Andrews, 153 p. Based on the teleplay Coming apart, by Hindi
Brooks & others. Appl. au: Random House, Inc., employer for hire.
© on the adaptation of certain teleplays; Spelling-Goldberg
Productions; 15Dec76 (in notice: 1977); A862105. A882106. The
Cuban revolution. By Hugh Thomas. 755 p. Shortened version of
Cuba: the pursuit of freedom. © on revisions; Hugh Thomas;
18May77; A882106. A882107. Quarry 1. Editor: Scott Sanders &
other editors. 80 p. Appl. au: Department of English, Indiana
University. © Department of English, Indiana University; 1Mar72;
4882107. A882108. People as partners. Edited by Jacqueline P.
Wiseman. 2nd ed. 495 p. © Jacqueline P. Wiseman; 6Apr77;
A882108. A882109. A Life of Christ. Text by Williaa Barclay, scripted
by Iain Reid, cartoons by Eric Fraser. 94 p. © William Barclay & Iain
Reid; 23Mar77; A882109. A882110. Illegal but not criminal: business
crime in America. By John E. Conklin. 153 p. © Prentice-Hall, Inc.;
21Jul77; A882110. A882111. One child by choice. By Sharryl Hawke
& David Knox. 233 p. © Prentice-Hall, Inc.; 21Jul77; A882111.
A882112. How to reduce taxes by dividing income among the family.
By Arnold R. Cutler & John B. Martin. 35 p. WM: additional material.
© Prentice-Hall, Inc.; 2130177; A882112. A882113. What the Social
Security-Medicare law means to yous. 16 p. NM: additional material.
© Prentice-Hall, Inc.; 14Jul77; A882113. A882114. From Abacus to
Zeus: a handbook of art history. By James Smith Pierce. 2nd ed. 131
p. © Prentice-Hall, Inc.; 18Jul77; A882114. A882115. How to sleep
better: a drug-free program for overcoming insomnia. By Thomas J.
Coates & Carl E. Thoresen. 324 p. © Prentice-Hall, Inc.; 21Ju177;
A882115. These entries alone may not reflect the complete Copy
work. Contact the U.S. Copyright Office for information about an
BOOKS & PAMPHLETS A882116. The Expert consumer: a complete
handbook. By Kenneth Eisenberger, illus. by Joseph La Jeunesse.
396 p. © Kenneth Eisenberger; 21Jul77; A882116. A882117.
Instructor's manual for Applied finite mathematics. By Robert FP.
Brown & Brenda W. Brown. 198 p. © Wadsworth Publishing
Company, Inc.; 26May77; A882117. A882118. Solutions manual for
Norman L. Allinger, M. Jerome Bigelow and Harmon C. McAllister's
An Introduction to general, organic and biological chemistry. 21 p.
Appl. au: Norman L- Allinger, M. Jerome Bigelow & Harmon C.
McAllister. © Wadsworth Publishing Company, Inc.; 3Jun77;
A882118. A882119. Student's solutions for Applied finite
mathematics. By Robert FP. Brown & Brenda W. Brown. 114 p. NM:
abridgment & compilation. © wadsworth Publishing Company, Inc.;
26May77; A882119. 4882120. Move over fat bureaucrat. Kit. Appl.
au: Randolph Lore. © Randolph Lore; 8Aug77; A882120. A882121.
Western Athletic Conference Football Slide-Guide. NM: compilation.
© Sports Guides, Inc.; 10Jul77; A882121. A882122. Atlantic Coast
Conference Pootball Slide-Guide. NM: compilation. © Sports Guides,
Inc.; 10Jul77; A882122. A882123. Big-8 Conference Football Slide-
Guide. NM: compilation. © Sports Guides, Inc.; 10Jul77; A882123.
A882124. Big-10 Conference Football Slide-Guide. NM: compilation.
© Sports Guides, Inc.; 10Ju177; A882124. A882125. Ivy League
Football Slide-Guide. NA: compilation. © Sports Guides, Inc.;
10Jul77; a882125. A882126. Pacific 8 Conference Football
SlideGuide. NM: compilation. © Sports Guides, Inc.; 10Jul77;
A882126. A882127. Southeastern Conference Football Slide-Guide.
NM: compilation. © Sports Guides, Inc.; 10Jul77; A882127.
A882128. Southwest Conference Football SlideGuide. NM:
compilation. © Sports Guides, Inc.; 10Jul77; A882128. A882129.
National Football League--American Football Conference, Football
Slide-Guide. NM: compilation. © Sports Guides, Inc.; 10Jul77;
A882129. A882130. National Football League--National Football
Conference, Football Slide-Guide. NM: compilation. © Sports Guides,
Inc.; 10Jul77; A882130. A882131. The United States and the Latin
American revolution. By Martin C. Needler. 173 p.NM: revision & new
material. © The Regents of the University of California; 19Jul77;
A882131. 2179 JUL. — DEC. 1977 A882132. Quantitative Latin
American studies: methods and findings. Edited by James Wi. Wilkie
& Kenneth Ruddle. 91 p. © The Regents of the University of
California; 19Jul177; A882132. A882 133. Structured systems
analysis: tools and techniques. By Christopher Peter Gane & Patricia
Anne Sarson (Patricia Anne Sarson Gane) 373 p. © Improved
System Technologies, Inc.; S8Aug77; A882133. A882134. Tips for
teachers; a manual for the art of piano teaching. By Carolyn P.
Carson. 1 v. NM: additions & revisions. © Carolyn Carson; 3Aug77;
A882134. A882135. Perspectives in resources planning. Edited by
Alan Graham McQuillan. 132 p. © Hontana Forest and Conservation
Experiment Station, School of Forestry, University of Montana (in
notice: University of Montana); 4Aug77; A882135. A882 136. Career
education supplement for English, correlated to the curriculum
guides for the secondary school English program. 14 p. © Board of
Education of the City of Chicago; 28Jun77; A882136. A882 137.
Classic comic quiz. Book 2. Folder. © Guardian Photo Division,
Guardian Industries Corporation (in notice: Guardian Industries
Corporation); 1Aug77; A882 137. A882138. Ciassic comic quiz. Book
1. Folder. © Guardian Photo Division, Guardian Industries
Corporation (in notice: Guardian Industries Corporation) ; A882138.
1Aug77; A882139. The Wind from Tennessee. Elion. 1 p.- © Charles
Elion; A882139. By Charles 1Jul77; A882140. The Universal mantra.
By Thomas A. Horvai. 1p. © Thomas A. Horvai; 8Aug77; A882140.
A882141. Communication skills of the Bible for identity people. 45 p.-
Appl. au: Willian W. Strittmatter. © William WwW. Strittmatter;
17Jun77; A8&82141. A882142. Weaving ‘77. Author: Karol Smith,
photography: Andrew McKinney, illus. & mechanicals: Aleta Jenks.
31 p.- Applau: Taurus Publications. © Taurus Publications; 13Jul77;
A882142. A882143. The Happy fisherman chow list. Folder. Appl. au:
Michael B. Craig. © Relaxation, Inc.; 20May77; A882143. A882144.
Antepasados. Vol. 2, Bicentennial issue. Publications chairman:
Rudecinda Lo Buglio. 1v. English. © Los Californianos; 28Jul77;
A882144. A882145. A Proposal to develop compliance measures for
emergency medical services systems legislation. 1v. © Arthur Young
and Company; 5SAug77; A882145. A882 146. Daddy Long Legs. By
Diane Atwood. 7 p. © Diane Atwood; 8Mar77 (in notice: 1976);
A882146. right Office record pertaining toa particular y additional
records that may exist.
 A882147 — A882189 A882147. The Asteroid ephemeris,
1883-1999. Pref. by Eleanor Bach, introd. by Zipporah Pottenger
Dobyns, programming by Rique Pottenger, computations by Neil
Michelsen. 1v.- © TIA Publications; 23Ju177; A882147. A882148.
Negotiating for money. Sheets in folder. Appl. au: Somers H. &hite.
© Somers H. White; 3Aug77; A882148. A&82149. Time to, time for.
By Mary Bergan Blanchard. 1v. ‘% Mary Bergan Blanchard; 28Jun77;
A882149 A882150. The Suspension of the Earth and its motions. 1p.
Appl. au: James Roy Lowe. © James Roy Lowe; 8Aug77; A882150.
A882151. My own handwriting. By DeLores McMillian. 27 p. 6
DeLores McMillian; 3Auq77; A882151. A882152. The Seymour
manual of military cinematography (basic camera and lens) By Neal
Heathcote Seymour. 22 p. @© The Lancress Group; 29Jul77;
A882152. A882153. A Study guide for the North Carolina real estate
broker's and salesman's licensing examination. By Bruce H. Smith &
H. Lynn Moretz. 4th ed. 1 v. © Educational Systems, Inc.; 11Jul177;
A882153. A882154. Love me as I am, and not as you need me to
be. Verse & calligraphy by Leni, pseud. of Leni T. Lawatch. 37 p. @
Lawatch Design; 8Jul77; A882154. A882155. Florida's fantastic fauna
and flora. By Leslie Fletcher. 44 p. © Mary Preston Gross; 13Ju177;
A882155. A882156. Planning your engagement and wedding. 18 p.
Appl. au: Conklin, Labs and Bebee, Inc. © A. H- Pond Company,
Inc.; 3Aug77; A882156. A882157. Pastor and parish: a systems
approach. By E. Mansell Pattison. 88 p. Portions prev. pub. in Journal
of pastoral care, Mar. 1972 & winter 1965. NM: 98% new. ©
Fortress Press; 3Aug/7; A882157. A882158. Acadia National Park
motorists guide, Loop Road-Ocean Drive. 1v. Add. ti: Motorists
guide, Acadia National Park, Loop Road, Ocean Drive. Appl. au: John
A. Daley & Susan I- Daley. © John A. Daley & Susan I. Daley;
10Jun77; A882158. A882159. Woodrow Wilson: idealism and reality.
Edited by Raymond F. Pisney. 83 p. © Raymond F. Pisney; 9Aug77;
A882159. A882160. Talking tomfoolery. By Earl Groves with expert
commentary by Ben Rogers Lee. 101 p- © Earl Groves; 15Jun77;
Aa882160. A882161. Curriculum change toward the 21st century. By
Harold G. Shane. 184 p. © National Education Association of the
United States; 13Apr77; A882161. A882162. Physical education: the
behavior modification approach. By Robert J. BOOKS & PAMPHLETS
Presbie & Paul L. Brown. 122 p. © National Education Association of
the United States; 16Marcr77; A882162. A882163. Film in the
language arts class. By John Aquino. 56 p. © National Education
Association of the United States; 20Nov76 (in notice: 1977);
A882163. A882164. Minicalculators in the classroom. By Joseph R.
Caravella. 64 p. © National Education Association of the United
States; 6Dec76 (in notice: 1977); A882164. A882165. Oral history as
a teaching approach. By John A. Neuenschwander. 46 p. © National
Education Association of the United States; 22Sep75 (in notice:
1976); A882165. A882166. Futurism and future studies. By Draper L.
Kauffman, Jr- 59 p. © National Education Association of the United
States; 28Nov75 (in notice: 1976); A882166. A882167. Learning
centers in the classroom. Editor: Jimmy E. Nations. 64 p. © National
Education Association of the United States; 16Jan76; A882167.
A882168. Career education and vocational education: a comparison.
By Irene Clements. 32 p. © National Education Association of the
United States; 28Dec76 (in notice: 1977); A882168. A882169.
Grading. By James A. Bellanca. 96 p. © National Education
Association of the United States; 14Mar77; A882169. A882170.
Advising by faculty. By Howard C. Kramer & Robert Eugene Gardner.
55 p. © National Education Association of the United States;
4Feb77; A882170. A882171. Record keeping for individualized
instructional programs. By David G. Armstrong & Robert H. Pinney.
64 p. © National Education Association of the United States;
11Jan77; A882171. A882172. Bilingual/bicultural education and
teacher training. By Henry J- Casso. 96 p- © National Education
Association of the United States; 220ct76; A882172. A882173.
Dynamic Bible study; a manual of 12 Study methods. By Rick Warren
(Richard Duane Warren) 72 p. © Rick Warren; 1dun77; A882173.
A882174. The Philadelphia Trader Council shoulder patch check list,
1977. 28 p.- Appl. au: Roger T. Nazeley. © Roger T. Nazeley;
5Aug77; A882174. A882175. Leonard's Guide pocket directory for
Saint Louis motor freight carriers, summer-fall 1977. 25th ed. 51 p.
Appl. au: Albert E. Ercolani. © G. R. Leonard and Company; 8Aug77;
A882175. A882176. They*re rebuilding the temple. By Harvey A.
Smith. 101 p. © Harvey A. Smith; 23May77; A882176. 2180 JOL. —
DEC. 1977 A882177. Carmie and the other world. By Mohan
Koparkar, illus. & art format by Carmella DiMitri. 62 p. © Mohan
Koparkar/Mohan Enterprises; 1Aug77; A882177. A882178. Winter
reason--one woman's words. By Lois B. Henley. 58 p. © Lois B.
Henley; 20Ju177; A882178. A882179. Psychiatry: PreTest self-
assessment and review. Edited by J. Craig Nelson. 196 p- Appl. au:
PreTest Service, Inc. © PreTest Service, Inc.; 8Aug/7; A882179.
A882180. Physicians hotline: the national phone directory of all
organ retrieval teams. By Robert W. Boven. 26 p. © Robert W.
Boven; 8Aug77; A882180. A882181. The Edaville Railroad, South
Carver, Massachusetts: a history of narrow gauge steam railroading
in New England; a Historama booklet. By Carole J. Maconi, color
photos. by Keith W. Maconi. 25 p. © Yankee Colour Corporation;
24Jun77; A882181. 4882182. The Japanese Tea Garden, Golden
Gate Park, San Francisco, California. By Elizabeth McClintock,
drawings by Ruth Asawa. 43 ps. © Elizabeth McClintock; 30Jun77;
A882182. A882183. Papa Stahl"s Wild stuff cookbook. 40 p. Appl.
au: Carmine A. Stahl. NM: “this edition is illustrated, and slight
additions to textual material have been added." © Carmine A. Stahl;
8Aug77; A882 183. A882 184. Study guide for art, Sketching
landscape. Prepared by Wilma R. West. 17 p- Add. ti: Study guide
for Sketching landscape. Based on the textbook Sketching
landscape, by Victor Perard. Appl. au: American School. NM: “this
guide is a condensation & a revision of the old one, 20% is new
material." © American School; 28Jul77; A882184. A882185. A Peace
over troubled waters. 32 p. © Campus Crusade for Christ, Inc.;
15Apr77; A882185. A882 186. Discovery. By Chuck Klein, with Claire
Klein & Diana McGinty, art by Bob Cording. 1 v.- Appl. au: Campus
Crusade for Christ, Inc. © Campus Crusade for Christ, Inc.; iMar77;
A882186. A882187. Practice of medicine. Vol. 1-10. Editor: Paul G.
H. Wolber. 10 v. in 1. NM: additions. © Harper and Row Publishers,
Inc., Medical Department (in notice: Harper and Row Publishers,
Inc.) ; 27May77; A882187. A882188. Mercedes-Benz tune-up,
maintenance: gas and diesel, 1958-1976. By Mike Bishop, editor:
Eric Jorgensen. 2nd ed. revised by Ray Hoy. 207 p- Appl. au: Clymer
Publications, a.a.d.o. Andleer, Inc. © Clymer Publications, a.a.d.o.
Andleer, Inc.; 27Jul77; A882188. A882189. Opel service, repair
handbook: all models, 1966-1977. By Ray Hoy, editor: Eric
Jorgensen. 3rd ed. 222 p. Appl. au: Clymer Publications, a.a.d.o.
Andleer, These entries alone may not reflect the complete Copyright
Office record pertaining to a particular work. Contact the U.S.
Copyright Office for information about any additional records that
may exist.
 A882190 - A882230 A882189 (con.) Inc. © Clymer
Publications, a.a.d.o. Andleer, Inc.; 26Jul77; A882189. A882190.
Ford 4-wheel drive maintenance: Bronco, F-100, F-150, F-250, 1969-
1977. By Mike Bishop, editor: Jeff Robinson. 2nd ed. revised by Ray
Hoy. 127 p. Appl. au: Clymer Publications, a.a-d.o. Andleer, Inc. ©
Clymer Publications, a.a.d.o. Andleer, Inc.; 30Jun77; A882190.
A882191. Bultaco service, repair handbook: 125-370cc through
1977. 4th ed. updated by Brick Price. 191 p. Appl. au: Clymer
Publications, a-a.d.o. Andleer, Inc. © Clymer Publications, a.a.d.o.
Andleer, Inc.; 19Jul77; A882191. A882192. Suzuki service, repair
handbook: 50-120cc singles, 1964-1977. By David Sales, editor: Jeff
Robinson. 2nd ed. 146 p. Appl. au: Clymer Publications, a-a.d.o.
Andleer, Inc. © Clymer Publications, a-a.d-o. Andleer, Inc.; 27Jul77;
A882192. A882193. Subaru service, repair handbook: all models,
1972-1977. By Ray Hoy, editor: Eric Jorgensen. 141 p. Appl. au:
Clymer Publications, a.a.d.o. Andleer, Inc. WM: editorial revision,
additional text, illus., restatement of procedures & measurements &
updating. © Clymer Publications, a.a.d.o. Andleer, Inc.; 19Jul77;
A882193. A882194. Yamaha service, repair handbook: 80-175cc
Enduro and Motocross, 1968-1976. 2nd ed. 192 p. C€ Clymer
Publications, a-a.d.o. Andleer, Inc.; 11Jul77; A882194. 4882195. Salt
Lake City and adjoining towns telephone directory, July 1977. ©
Mountain States Telephone and Telegraph Company; tJun77;
A882195. A882196. Hembar, simplified edition. Game no. 2/1/S1/V1.
Sheets. Appl. au: Helen 4. Bartels (Hembar). NM: additions &
revisions. C€ Hembar; 6Aug77; A882196. A882197. Burpee's Fall
garden and gift ideas for 1977. 63 p. © W. Atlee Burpee Company;
19Jul77; A882197. A882198. Theory of endowment development.
Created, researched & developed by Leamon P. Grier, William M.
Floyd, Gunther H. Sahling & Ronald K. Bethea. 1 v© Endowment
Development Associates; 10Aug77; A882198. 4882199. Proclaiming
the goodness of God: suggested aids for teaching religion. By Sister
Mary Theresa Betz, S.N.D. 22 p. Appl. au: Sisters of Notre Dame. ©
Sisters of Notre Dame; S8Aug77; A882199. 4882200. The Speeches
of Carlton G. Ketchum: a selection from speeches delivered between
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