Burket's Oral Medicine 12th Edition PDF

 Burket’s ORAL MEDICINE 12th edition FM.indd 1 11/10/14 1:18 AM FM.indd 2 11/10/14 1:18 AM  Burket’s ORAL MEDICINE 12th edition Michael Glick...

 Burket’s ORAL MEDICINE 12th edition FM.indd 1 11/10/14 1:18 AM FM.indd 2 11/10/14 1:18 AM  Burket’s ORAL MEDICINE 12th edition Michael Glick, DMD, FDS RCSEd William M. Feagans Chair Dean and Professor of Oral Medicine School of Dental Medicine State University of New York University at Buffalo Buffalo, New York 2015 People’s Medical Publishing House—USA Shelton, Connecticut FM.indd 3 11/10/14 1:18 AM  People’s Medical Publishing House-USA 2 Enterprise Drive, Suite 509 Shelton, CT 06484 Tel: 203-402-0646 Fax: 203-402-0854 E-mail: [email protected] © 2015 PMPH-USA, LTD All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into 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 publisher. 14 15 16 17/JPBros/9 8 7 6 5 4 3 2 1 ISBN-13 978-1-60795-188-9 ISBN-10 1-60795-188-6 eISBN-13 978-1-60795-280-0 Printed in India by Jaypee Brothers Medical Publishers, Ltd. Editor: Linda H. Mehta; Copyeditor/Typesetter: diacriTech; Cover designer: Mary McKeon Library of Congress Cataloging-in-Publication Data Burket’s oral medicine / [edited by] Michael Glick. -- 12th edition. p. ; cm. Proudly sourced and uploaded by [StormRG] Oral medicine Kickass Torrents | TPB | ET | h33t Includes bibliographical references and index. ISBN 978-1-60795-188-9—ISBN 1-60795-188-6—ISBN 978-1-60795-280-0 (eISBN) I. Glick, Michael, editor. II. Title: Oral medicine. [DNLM: 1. Mouth Diseases. 2. Diagnosis, Oral—methods. WU 140] RK308 617.5'22—dc23 2014032898 Sales and Distribution Canada Singapore, Thailand, Philippines, India, Bangladesh, Pakistan, Sri Lanka, Malaysia Login Canada Indonesia,Vietnam, Pacific Rim, Korea Jaypee Brothers Medical Publishers (P) Ltd. 300 Saulteaux Cr., Winnipeg, MB McGraw-Hill Education 4838, 24 Ansari Road, Darya Ganj R3J 3T2 60 Tuas Basin Link New Delhi- 110002, India Phone: 1.800.665.1148 Singapore 638775 Phone: +91 11 23272143 Fax: 1.800.665.0103 Tel: 65-6863-1580 Fax: +91 11 23276490 www.lb.ca Fax: 65-6862-3354 www.jaypeebrothers.com www.mheducation.com.sg Foreign Rights People’s Republic of China John Scott & Company Australia, New Zealand, Papua People’s Medical Publishing House International Publisher’s Agency New Guinea, Fiji, Tonga, Solomon International Trade Department P.O. Box 878 Islands, Cook Islands No. 19, Pan Jia Yuan Nan Li Kimberton, PA 19442, USA Woodslane Pty Limited Chaoyang District Tel: 610-827-1640 10 Apollo Street Beijing 100021, P.R. China Fax: 610-827-1671 Warriewood NSW 2102 Tel: 8610-67653342 [email protected] Australia Fax: 8610-67691034 Tel: 612-8445-2300 www.pmph.com/en/ United Kingdom, Europe, Middle East, Africa Fax: 612-9997-5850 Eurospan Limited www.woodsland.com.au 3, Henrietta Street, Covent Garden, London WC2E 8LU, UK Within the UK: 0800 526830 Outside the UK: +44 (0)20 7845 0868 http://www.eurospanbookstore.com Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment. FM.indd 4 11/10/14 1:18 AM  DEDICATION In memory of my mother, Siv Glück, who encouraged me to be the best person I could be; and my friend and colleague Jonathan Ship, whose life sadly ended much too early. For my father, Dan Glück, with love and appreciation. FM.indd 5 11/10/14 1:18 AM FM.indd 6 11/10/14 1:18 AM  Contents Contributors ix Preface xv Chapter 1 Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient................... 1 by Michael Glick, DMD, FDS RCSEd; Martin S. Greenberg, DDS, FDS RCSEd; Mats Jontell, DDS, PhD, FDS RCSEd and Jonathan A. Ship, DMD, FDS RCSEd Chapter 2 Overview of Clinical Research............................................................. 17 by Jane C. Atkinson, DDS; Dena Fischer, DDS, MSD, MS; Holli A. Hamilton, MD, MPH and Mary A. Cutting, MS, RAC Chapter 3 Pharmacotherapy....................................................................... 29 by Mark Donaldson, BSP, PharmD; Jason H. Goodchild, DMD and Mark J. Wrobel, PharmD Chapter 4 Ulcerative, Vesicular, and Bullous Lesions.................................................... 57 by Sook Bin Woo, DMD, MMSc, FDS RCSEd and Martin S. Greenberg, DDS, FDS RCSEd Chapter 5 Red and White Lesions of the Oral Mucosa.................................................. 91 by Mats Jontell, DDS, PhD, FDS RCSEd and Palle Holmstrup, DDS, PhD, DrOdont Chapter 6 Pigmented Lesions of the Oral Mucosa.................................................... 123 by Alfredo Aguirre, DDS, MS; Faizan Alawi, DDS and Jose Luis Tapia, DDS, MS Chapter 7 Benign Lesions of the Oral Cavity and the Jaws.............................................. 147 by A. Ross Kerr, DDS, MSD; K. C. Chan, DMD, MS, FRCD(C) and Joan A. Phelan, DDS Chapter 8 Oral and Oropharyngeal Cancer.......................................................... 173 by Joel Epstein DMD, MSD, FRCD(C), FDS RCSEd and Sharon Elad, DMD, MSc Chapter 9 Oral Complications of Nonsurgical Cancer Therapies: Diagnosis and Treatment..................... 201 by Douglas E. Peterson, DMD, PhD, FDS RCSEd and Siri Beier Jensen, DDS, PhD Chapter 10 Salivary Gland Diseases................................................................. 219 by Leah M. Bowers, DMD; Philip C. Fox, DDS, FDS RCSEd and Michael T. Brennan, DDS, MHS, FDS RCSEd Chapter 11 Temporomandibular Disorders........................................................... 263 by Richard Ohrbach, DDS, PhD; Bruce Blasberg, DMD, FRCD(C), FDS RCSEd and Martin S. Greenberg, DDS, FDS RCSEd Chapter 12 Orofacial Pain........................................................................ 309 by Rafael Benoliel, BDS, LDS, RCS Eng; Sowmya Ananthan, BDS, DMD, MSD; Julyana Gomes Zagury, DMD, MSD; Junad Khan, BDS, MPH, PhD and Eli Eliav, DMD, MSc, PhD Chapter 13 Common Headache Disorders........................................................... 323 by Scott S. De Rossi, DMD and J. Ned Pruitt II, MD vii FM.indd 7 11/10/14 1:18 AM  viii Contents Chapter 14 Diseases of the Respiratory Tract.......................................................... 335 by Patrick Vannelli, MD; Frank A. Scannapieco, DMD, PhD; Sandhya Desai, MD; Mark Lepore, MD; Robert Anolik, MD and Michael Glick, DMD, FDS RCSEd Chapter 15 Diseases of the Cardiovascular System..................................................... 363 by Peter B. Lockhart, DDS and Laszlo Littmann, MD Chapter 16 Diseases of the Gastrointestinal Tract...................................................... 389 by Michael A. Siegel, DDS, MS, FDS RCSEd; Lynn W. Solomon, DDS, MS and Lina M. Mejia, DDS Chapter 17 Renal Disease......................................................................... 411 by Scott S. De Rossi, DMD and Matthew J. Diamond, DO, MS, FACP Chapter 18 Hematologic Diseases.................................................................. 435 by Michaell A. Huber, DDS and Vidya Sankar, DMD, MHS, FDS RCSEd Chapter 19 Bleeding and Clotting Disorders.......................................................... 463 by Joel J. Napeñas, DDS, FDS RCSEd and Lauren L. Patton, DDS, FDS RCSEd Chapter 20 Immunologic Diseases.................................................................. 489 by Jane C. Atkinson, DDS; Niki Moutsopoulos, DDS, PhD; Stanley R. Pillemer, MD; Matin M. Imanguli, MD, DDS and Stephen Challacombe, BDS, PhD, FDS RCSEd, FRCPath Chapter 21 Transplantation Medicine............................................................... 521 by Thomas P. Sollecito, DMD, FDS RCSEd; Andres Pinto, DMD, MPH; Ali Naji, MD, PhD and David L. Porter, MD Chapter 22 Infectious Diseases..................................................................... 543 by Michaell A. Huber, DDS; Spencer W. Redding, DDS, MEd; Vidya Sankar, DMD, MHS, FDS RCSEd and Sook-Bin Woo, DMD, FDS RCSEd Chapter 23 Disorders of the Endocrine System and Metabolism.......................................... 563 by Mark Schifter, BDS, MDSc, (Oral Med), M SND, M Oral Med; RCSEd, FFD RCSI (Oral Med), FRACDS (Oral Med); Mark McLean, BMed, PhD, FRACP and Sunday O. Akintoye, BDS, DDS, MS Chapter 24 Neuromuscular Diseases................................................................ 611 by Eric T. Stoopler, DMD, FDS RCSEd, FDS RCSEng and David A. Sirois, DMD, PhD Chapter 25 Basic Principles of Human Genetics: A Primer for Oral Medicine................................ 625 by Harold C. Slavkin, DDS; Mahvash Navazesh, DMD and Pragna Patel, PhD Chapter 26 Geriatric Oral Medicine................................................................ 653 by Katharine Ciarrocca, DMD, MSEd and Nidhi Gulati, MD Chapter 27 Pediatric Oral Medicine................................................................ 669 by Juan F. Yepes, DDS, MD, MPH, MS, DrPH, FDS RCSEd Chapter 28 Panoramic Image Interpretation.......................................................... 683 by Ernest W. N. Lam, DMD, MSc, PhD, FRCD(C) Index 695 FM.indd 8 11/10/14 1:18 AM  Contributors Alfredo Aguirre, DDS, MS Bruce Blasberg, DMD, FRCD(C) School of Dental Medicine Professor Emeritus, Dentistry State University of New York Faculty of Dentistry University at Buffalo University of British Columbia Buffalo, New York Vancouver, British Columbia, Canada Sunday O. Akintoye, BDS, DDS, MS Leah M. Bowers, DMD Associate Professor Resident, Department of Oral Medicine Department of Oral Medicine Carolinas Medical Center Director, Oral Medicine Research Program Charlotte, North Carolina University of Pennsylvania School of Dental Medicine Philadelphia, Pennsylvania Michael T. Brennan, DDS, MHS, FDS RCSEd Professor and Director, Carolinas Medical Center Faizan Alawi, DDS Charlotte, North Carolina Associate Professor of Pathology Director, Penn Oral Pathology Services Stephen Challacombe, BDS, PhD, FDS RCSEd, University of Pennsylvania School of FRCPath Dental Medicine Professor of Mucosal Immunology, Oral Microbiology and Philadelphia, Pennsylvania Oral Medicine Kings College London Sowmya Ananthan, BDS, DMD, MSD London, England Clinical Assistant Professor Divisions of Temporomandibular Disorders and Orofacial K. C. Chan, DMD, MS, FRCD(C) Pain & Oral Medicine Clinical Assistant Professor of Oral and Maxillofacial Rutgers School of Dental Medicine Pathology, Radiology and Medicine Newark, New Jersey New York University College of Dentistry New York, New York Robert Anolik, MD President and Director of Clinical Research Katharine Ciarrocca, DMD, MSEd Allergy and Asthma Specialists Assistant Professor of Oral Medicine Blue Bell, Pennsylvania Georgia Regents University Augusta, Georgia Jane C. Atkinson, DDS [2, 20] Center for Clinical Research Mary A. Cutting, MS, RAC Division of Extramural Research Center for Clinical Research National Institute of Dental and Craniofacial Research Division of Extramural Research National Institutes of Health National Institute of Dental and Craniofacial Research Bethesda, Maryland National Institutes of Health Bethesda, Maryland Rafael Benoliel, BDS, LDS RCSEng Professor and Associate Dean for Research Scott S. De Rossi, DMD [13, 17] Department of Diagnostic Sciences Chairman, Diagnostic Sciences Rutgers School of Dental School Department of Oral Health and Diagnostic Sciences Rutgers State University of New Jersey Georgia Regents University Newark, New Jersey Augusta, Georgia ix FM.indd 9 11/10/14 1:18 AM  x Contributors Sandhya Desai, MD Philip C. Fox, DDS, FDS RCSEd Family Medicine Specialist President, PC Fox Consulting LLC Scripps Coastal Medical Center Cabin John, Maryland Carlsbad, California Michael Glick, DMD, FDS RCSEd [Ed, 1, 14] Matthew J. Diamond, DO, MS, FACP William M. Feagans Chair Assistant Professor of Nephrology, Hypertension, and Dean and Professor of Oral Medicine Transplant Medicine School of Dental Medicine Georgia Health Sciences University State University of New York Augusta, Georgia University at Buffalo Buffalo, New York Mark Donaldson, BSc (Pharm), RPh, PharmD, FASHP, FACHE Jason Goodchild, DMD Director of Pharmacy Services Clinical Associate Professor, Department of Oral Medicine Northwest Healthcare University of Pennsylvania School of Dental Medicine Kalispell, Montana Philadelphia, Pennsylvania Clinical Professor Clinical Assistant Professor, Division of Oral Diagnosis Skaggs School of Pharmacy Department of Diagnostic Sciences University of Montana New Jersey Dental School Missoula, Montana Newark, New Jersey Clinical Assistant Professor Oregon Health and Sciences University Martin S. Greenberg, DDS, FDS RCSEd [1, 4, 11] School of Dentistry Professor Emeritus Department of Oral Medicine Portland, Oregon University of Pennsylvania School of Dental Medicine Philadelphia, Pennsylvania Sharon Elad, DMD, MSc Professor and Chair, Division of Oral Medicine Nidhi Gulati, MD Eastman Institute for Oral Health Medical Director, Georgia War Veterans Nursing Home Professor of Oncology Assistant Professor, Department of Family Medicine Wilmot Cancer Center Medical College of Georgia University of Rochester Medical Center Assistant Professor, Department of Biobehavioral Nursing Rochester, New York Georgia Regents University College of Nursing Augusta, Georgia Eli Eliav, DMD, MSc, PhD Holli A. Hamilton, MD, MPH Director, Eastman Institute for Oral Health Senior Medical Officer University of Rochester Medical Center Division of Extramural Research Vice Dean for Oral Health National Institute of Dental and Craniofacial Research School of Dentistry and Medicine National Institutes of Health Rochester, New York Bethesda, Maryland Joel Epstein, DMD, MSD, FRCD(C), Palle Holmstrup, DDS, PhD, DrOdont FDS RCSEd Professor and Chairman, Section of Periodontology, Diplomat, American Board of Oral Medicine Microbiology and Community Dentistry Consulting Staff, Division of Otolaryngology and Department of Odontology Head and Neck Surgery School of Dentistry, Faculty of Health Sciences City of Hope University of Copenhagen Duarte, California Copenhagen, Denmark Dena Fischer, DDS, MSD, MS Michaell A. Huber, DDS [18, 22] Center for Clinical Research Associate Professor, Department of Comprehensive Division of Extramural Research Dentistry National Institute of Dental and Craniofacial Research University of Texas Health Science Center National Institutes of Health Dental School Bethesda, Maryland San Antonio, Texas FM.indd 10 11/10/14 1:18 AM  Contributors xi Matin M. Imanguli, MD, DDS Peter B. Lockhart, DDS, FDS RCPS, RCSEd Center for Clinical Research Professor and Chair Emeritus of Oral Medicine Division of Extramural Research Carolinas Medical Center National Institute of Dental and Craniofacial Research Charlotte, North Carolina National Institutes of Health Bethesda, Maryland Lina M. Mejia, DDS Siri Beier Jensen, DDS, PhD Associate Professor, Oral Medicine and Diagnostic Associate Professor Sciences Section of Oral Medicine, Clinical Oral Physiology, College of Dental Medicine Oral Pathology & Anatomy Nova Southeastern University School of Dentistry, Faculty of Health Sciences Fort Lauderdale, Florida University of Copenhagen Copenhagen, Denmark Mark McLean, BMed, PhD, FRACP Professor and Chair, Department of Medicine Mats Jontell, DDS, PhD, FDS RCSEd [1, 5] University of Western Sydney Professor of Oral Medicine and Pathology Penrith, New South Wales, Australia Chairman of the Department of Continuing Education Institute of Odontology at Sahlgrenska Academy University of Gothenburg Niki Moutsopoulos, DDS, PhD Gothenburg, Sweden Assistant Clinical Investigator Oral Immunity and Infection Unit Junad Khan BDS, MPH, PhD National Institute of Dental and Craniofacial Research Assistant Professor, Department of Diagnostic Sciences National Institutes of Health Rutgers School of Dental Medicine Bethesda, Maryland Newark, New Jersey Ali Naji, MD, PhD A. Ross Kerr, DDS, MSD J. William White Professor of Surgery Department of Surgical Sciences (Oral and Maxillofacial Director, Kidney/Pancreas Transplant Programs Surgery) Associate Director, Institute for Diabetes, Obesity, and NYU Langone Medical Center Metabolism New York, New York University of Pennsylvania School of Medicine Philidelphia, Pennsylvania Ernest W.N. Lam, DMD, MSc, PhD, FRCD(C) Professor and the Dr. Lloyd & Mrs. Kay Chapman Chair in Clinical Sciences Joel J. Napeñas, DDS, FDS RCSEd Graduate Program Director and Head Assistant Professor, Division of Oral Medicine and Discipline of Oral and Maxillofacial Radiology Radiology Faculty of Dentistry Schulich School of Medicine and Dentistry The University of Toronto Western University Toronto, Ontario, Canada London, Ontario, Canada Department of Oral Medicine Carolinas Medical Center Mark Lepore, MD Charlotte, North Carolina Vice President, Clinical Development, Inhalation Lupin Pharmaceuticals Philadelphia, Pennsylvania Mahvash Navazesh, DMD Associate Dean, Academic Affairs and Laszlo Littmann, MD, PhD Student Life Department of Internal Medicine Herman Ostrow School of Dentistry Carolinas Medical Center University of Southern California Charlotte, North Carolina Los Angeles, California FM.indd 11 11/10/14 1:18 AM  xii Contributors Richard Ohrbach, DDS, PhD J. Ned Pruitt II, MD Associate Professor, Department of Oral Diagnostic Director, MCG Neurology Residency Program Sciences Associate Professor, Department of Neurology School of Dental Medicine Georgia Regents Medical Center State University of New York Augusta, Georgia University at Buffalo Buffalo, New York Spencer W. Redding, DDS, MEd Department of Comprehensive Dentistry Pragna Patel, PhD University of Texas Health Science Center Professor of Biochemistry & Molecular Biology and San Antonio Dental School Dentistry San Antonio, Texas Institute of Genetic Medicine Vidya Sankar, DMD, MHS, FDS RCSEd [18, 22] Keck School of Medicine Department of Comprehensive Dentistry University of Southern California University of Texas Health Science Center Los Angeles, California San Antonio Dental School San Antonio, Texas Lauren L. Patton, DDS FDS RCSEd Professor and Chair, Department of Frank A. Scannapieco, PhD, DMD Dental Ecology Professor and Chair, Department of Oral Biology UNC School of Dentistry School of Dental Medicine The University of North Carolina State University of New York Chapel Hill, North Carolina University at Buffalo Buffalo, New York Douglas E. Peterson, DMD, PhD, FDS RCSEd Professor of Oral Medicine Mark Schifter, BDS, MDSc (Oral Med), M SND, School of Dental Medicine RCSEd, FFD RCSI (Oral Med), FRACDS Co-Chair, Head & Neck Cancer and Oral Oncology (Oral Med) Program Staff Specialist and Head, Department of Oral Medicine, Neag Comprehensive Cancer Center Oral Pathology, and Special Needs Dentistry University of Connecticut Westmead Centre for Oral Health Farmington, Connecticut Westmead Hospital Westmead, NSW, Australia Joan A. Phelan, DDS Professor, Oral and Maxillofacial Pathology, Jonathan A. Ship, DMD, FDS RCSEd * Radiology and Medicine Director, Bluestone Center for Clinical Research New York University College of Dentistry Professor of Oral and Maxillofacial Pathology, Radiology New York, New York and Medicine New York University College of Dentistry New York, New York Stanley R. Pillemer, MD *Deceased Senior Consultant American Biopharma Corporation Michael A. Siegel, DDS, MS, FDS RCSEd Gaithersburg, Maryland Professor and Chair, Department of Diagnostic Sciences College of Dental Medicine Andres Pinto, DMD, MPH Professor, Internal Medicine (Dermatology) Associate Professor and Chair, Oral and College of Osteopathic Medicine Maxillofacial Medicine and Nova Southeastern University Diagnostic Sciences Fort Lauderdale, Florida Case Western Reserve University School of Dental Medicine David A. Sirois, DMD, PhD Cleveland, Ohio Associate Professor, Oral & Maxillofacial Pathology, Radiology and Medicine David L. Porter, MD New York University College of Dentistry Director, Blood and Marrow Transplantation Associate Professor of Neurology Hospital of the University of Pennsylvania New York University School of Medicine Philadelphia, Pennsylvania New York, New York FM.indd 12 11/10/14 1:18 AM  Contributors xiii Harold C. Slavkin, DDS Patrick Vannelli, MD Founding Director, USC Center for Craniofacial Molecular Physician, Private Practice Biology Allergy & Asthma Specialists Professor, Ostrow School of Dentistry Blue Bell, Pennsylvania University of Southern California Los Angeles, California Sook Bin Woo, DMD, MMSc, FDS RCSEd [4, 22] Associate Professor, Oral Medicine, Infection, and Thomas P. Sollecito, DMD Immunity Professor and Chairman, Department of Oral Medicine Director, Advanced Graduate Education Program in Oral University of Pennsylvania School of Dental Medicine and Maxillofacial Pathology Philadelphia, Pennsylvania Division of Oral Medicine and Dentistry Brigham and Women’s Hospital Boston, Massachusetts Lynn W. Solomon, DDS, MS Associate Professor, Department of Oral Medicine and Mark J. Wrobel, PharmD Diagnostic Sciences Clinical Assistant Professor College of Dental Medicine Director, PharmD Advisement Nova Southeastern University SUNY at Buffalo School of Pharmacy and Pharmaceutical Fort Lauderdale, Florida Sciences SUNY at Buffalo School of Dental Medicine Eric T. Stoopler, DMD, FDS RCSEd, Buffalo, New York FDS RCSEng Associate Professor of Oral Medicine Juan F. Yepes, DDS, MD, MPH, MS, DrPH, FDS Director, Postdoctoral Oral Medicine Program RCSEd University of Pennsylvania School of Dental Medicine Associate Professor of Pediatric Dentistry Attending Physician, Department of Oral & Maxillofacial Department of Pediatric Dentistry Surgery Riley Hospital for Children University of Pennsylvania Health System Indiana University School of Dentistry Philadelphia, Pennsylvania Indianapolis, Indiana Jose Luis Tapia, DDS, MS Julyana Gomes Zagury, DMD, MSD Assistant Professor, Oral Diagnostic Sciences Clinical Assistant Professor School of Dental Medicine Division of Temporomandibular Disorders and State University of New York Orofacial Pain Department of Diagnostic Sciences University at Buffalo Rutgers School of Dental Medicine Buffalo, New York Newark, New Jersey FM.indd 13 11/10/14 1:18 AM FM.indd 14 11/10/14 1:18 AM  Preface In the introduction to the first edition of Burket’s Oral Pediatric Oral Medicine, and Radiologic Interpretations, and ­ edicine published in 1946, Dr. Appleton, Dean of the M 28 new contributors. Together, the more than 70 ­contributors School of Dentistry at the University of Pennsylvania, wrote of the chapters included in the 12th edition represent seven “The practitioner of medicine, physician and internist, would countries and present a text truly international in scope. do well to read at least the Table of Contents. If he does that, Due to the complexity of the “art and science” of the I believe he’ll delve deeper. It should convince him that the field of oral medicine, there will be inconsistencies among mouth contains much more than the doubly unruly tongue. the chapters in cases in which lack of evidence for specific There are many situations and ways in which he can help the protocols results in reliance on clinical judgment. Such dis- neighboring dentist, and the dentist can in turn help him. crepancies add rather than detract from our knowledge base Both physician and dentist will benefit, but the patient would and, when found, were left as is. benefit most.” Although our knowledge of oral medicine has The 12th edition of this definitive text on oral medicine dramatically increased in the past 70 years, this new 12th delivers indispensable content to students, residents, and clini- edition could have been introduced in a similar fashion. Oral cians from many different health disciplines seeking to advance medicine is at the forefront of interprofessional education their knowledge in this exciting field of healthcare delivery. and practice, and the 12th edition of Burket’s Oral Medicine The text offers support with necessary diagnostic skills, basic will be a resource to all health professionals. research, and clinical advice needed to treat medically complex In order to reflect changes in the reach of the discipline of dental patients, as well as a myriad of oral complications. oral medicine, the 12th edition of this seminal text includes five new chapters: Research Design and Evaluation, Oral —Michael Glick, DMD Complications of Cancer Therapy, Geriatric Oral Medicine, Buffalo, New York xv FM.indd 15 11/10/14 1:18 AM FM.indd 16 11/10/14 1:18 AM  Chapter 1 Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient Michael Glick, DMD, FDS RCSEd Martin S. Greenberg, DDS, FDS RCSEd Mats Jontell, DDS, PhD, FDS RCSEd Jonathan A. Ship, DMD, FDS RCSEd * ❒❒ INFORMATION GATHERING ❒❒ ORAL MEDICINE CONSULTATIONS Medical History ❒❒ THE DENTAL AND MEDICAL RECORD: Patient Examination Consultations ORGANIZATION, CONFIDENTIALITY, AND INFORMED CONSENT ❒❒ ESTABLISHING A DIFFERENTIAL AND FINAL Organization DIAGNOSIS Problem-Oriented Record ❒❒ FORMULATING A PLAN OF ACTION Condition Diagram Medical Risk Assessment The SOAP Note Modification of Dental Care for Medically Complex Confidentiality Patients Informed Consent Monitoring and Evaluating Underlying Medical ❒❒ ELECTRONIC HEALTH RECORDS Conditions Oral medicine is a specialized discipline within dentistry that and multiple comorbidities, and having endured complex focuses on provision of dental care for medically complex surgical procedures while taking multiple medications. This patients, and the diagnosis and management of medical population of patients requires oral health professionals with disorders involving the mouth, jaws, and salivary glands. an increased knowledge of medical diseases and their effect Offering care to a patient seeking diagnosis and treatment is a on oral diseases and provision of oral health care. What responsibility that entails both broad and detailed knowledge and should only be provided by a health-care professional previously was considered the purview of hospital-based with appropriate training and experience. dentists has become a common occurrence in general and Clinicians are presently caring for an aging population specialty dental practice. Oral health is an integral part of who are living longer with complications of chronic illnesses total health, and oral health professionals must adapt to * Deceased 1 CH01.indd 1 10/10/14 10:46 AM  2 Burket’s Oral Medicine these demographic changes by increasing their knowledge of 4. providing a basis for determining whether dental medicine related to oral and dental health care.1 treatment might affect the systemic health of the Technological advances are influencing all aspects of patient patient interactions, from our initial contact with a patient, 5. providing a basis for determining necessary modifica- through medical history taking, diagnosis, and treatment tions to routine dental care options. Electronic health records (EHRs) afford a means 6. monitoring known medical conditions for sharing health information among multiple clinicians caring for the same patient and can provide point-of-care Medical History algorithms for eliciting and using health information.2 Mod- Obtaining an appropriate and accurate medical history is the ern imaging techniques such as computed tomography and sine qua non of all patient care. A patient’s medical history magnetic resonance imaging provide more detailed inform- is elicited through a systematic review of the patient’s chief ation but require increased interpretation skills. Technology or primary complaint, a detailed history related to this com- is a means to acquire more sophisticated data but requires plaint, information about past and present medical condi- increased training for accurate interpretation; and yet, the tions, pertinent social and family histories, and a review of most important skills for accurate diagnosis remain an exper- symptoms by organ system. A medical history also includes ienced clinician who has developed the skills to listen and biographic and demographic data used to identify the patient. examine. There is no universally agreed upon method for obtain- The initial encounter with a patient will influence all ing a medical history, but a systematic approach will help subsequent care. The skilled, experienced practitioner has the practitioner to gather all necessary information without learned to elicit the clinical, laboratory, and other necessary overlooking important facts. The nature of the patient’s oral information required for an accurate diagnosis. Performing health visit (i.e., initial dental visit, complex diagnostic prob- a diagnostic evaluation, including a patient interview and a lem, emergency, elective continuous care, or recall) often dic- physical examination, is an art as well as a skill. Although tates how the history is obtained. The two most common mastering a patient evaluation can be assisted by specific means of obtaining initial patient information are a patient- clinical protocols, the experienced practitioner will add his self- administered preprinted health questionnaire or by or her own skills to the diagnostic methodology. recording information during a systematic health ­interview A variety of accessible sources of health-care informa- without the benefit of having the patient fill out a ques- tion are now readily available to patients, and many will use tionnaire. The use of self-administered screening question- this information to self-diagnose, as well as demand spe- naires is the most commonly used method in dental settings cific treatments.3 Although, a patient-centered approach is (­Figure 1-1). This technique can be useful in gathering back- encouraged, in which a patient’s preferences and values will ground medical information, but the accurate diagnosis of a influence care, the practitioner has the responsibility for specific oral complaint requires a history of the present illness treatment decisions and needs to educate the patient to make and other information that is necessary to obtain verbally. informed, scientific- and evidence-based choices. The challenge in any health-care setting is to use a question- Obtaining, evaluating, and assessing a patient’s oral naire that has enough items to obtain the essential medical and overall health status is the obligation of the treating information but is not too long to deter a patient’s willing- oral health-care professional. This process can arbitrarily be ness and ability to fill it out. These questionnaires should be divided into four major overlapping parts: constructed in a manner that allows the clinician to query 1. Information gathering the patient about the most essential and relevant required 2. Establishing a differential and final diagnosis information yet provides a starting point for a dialogue with 3. Formulating a plan of action the patient about other pertinent information not included 4. Initiating treatment and follow-up on the health form. Preprinted self-administered health questionnaires are readily available, standardized, and easy to administer and do not require significant “chair time.” They INFORMATION GATHERING give the clinician a starting point for a dialogue to conduct more in-depth medical queries but are restricted to the ques- An appropriate interpretation of the information collected tions chosen on the form and are therefore limited in scope. through a medical history and patient examination achieves The questions on the form can be misunderstood by the several important objectives; it affords an opportunity for patient, resulting in inaccurate information, and they require 1. gathering the information necessary for establishing a specific level of reading comprehension. Preprinted forms the diagnosis of the patient’s chief complaint (CC) cover broad areas without necessarily focusing on particular 2. assessing the influence of the patient’s systemic health problems pertinent to an individual patient’s specific medical on patient’s oral health condition. Therefore, the use of these forms requires that the 3. detecting underlying systemic conditions that the provider has sufficient background knowledge to understand patient may or may not be aware of reason for the questions on the forms. Furthermore, the CH01.indd 2 10/10/14 10:46 AM  Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient 3 provider needs to realize that a given standard history form information of a primary care physician, and referral necessitates timely and appropriate follow-up questions, source. especially when positive responses have been elicited. An 2. CC: The main reason for the patient seeking care or established routine for performing and recording the history consultation—recorded in the patient’s own words. and examination should be followed conscientiously. 3. History of present illness: A chronologic account of The oral health-care professional has a responsibility events; state of health before the presentation of the to obtain relevant medical and dental health information, present problem; description of the first signs and yet the patient cannot always be relied upon to know this symptoms and how they may have changed; descrip- information or provide an accurate and comprehensive tion of occurrences of amelioration or exacerbation; assessment of his or her medical or dental status. previous clinicians consulted and prior treatment. All medical information obtained and recorded in an oral For those who favor mnemonics, nine dimensions health-care setting is considered confidential and constitutes of a medical problem can be easily recalled using a legal document. Although it is appropriate for the patient OLD CHARTS (Onset, Location/radiation, Dura- to fill out a history form in the waiting room, any discussion tion, Character, Habits, Aggravating factors, Reliving of the patient’s responses must take place in a private setting. factors, Timing, and Severity). (Modification of Ref- Furthermore, access to the written or electronic (if applic- erence 5). able) record must be limited to office personnel who are dir- 4. Medical history: General health; childhood illnesses; ectly responsible for the patient’s care. Any other release of major adult illnesses; immunizations; surgeries (date, private information should be approved, in writing, by the reason, and outcome); pregnancies (gravid); births patient and retained by the dentist as part of the patient’s (para); medications (prescribed medications, over- medical record. the-counter medications, supplements, and home Changes in a patient’s health status or medication regi- remedies); and allergies. men should be reviewed at each office visit prior to initiating 5. Family history: Blood relatives with illnesses similar to dental care. This is important as medical status and med- the patient’s concern; specific genetic disorders, car- ication regimens often change. The monitoring of patients’ diovascular diseases, diabetes mellitus, different types compliance with suggested medical treatment guidelines and of cancers. prescribed medications is part of the oral health-care pro- 6. Personal and social history: Birthplace; marital status; fessional’s responsibilities.4 The following strategies are com- children; habits (tobacco use, alcohol use, recreational mon to all methods of history taking drug use); sexual history; occupation; religious prefer- ences that may have an impact on types of care. review available patient information prior to meeting 7. Review of systems (ROS): Identifies symptoms in dif- the patient; ferent body systems (Table 1-1). make the patient feel comfortable and pay attention to the patient’s concerns; do not rush the interview The ROS is a comprehensive and systematic review of process; subjective symptoms affecting different bodily systems. It pay attention to the patient; greet the patient; use the is an essential component for identifying patients with an patient’s name; ensure privacy; sit rather than stand; undiagnosed disease that will affect dental treatment or maintain eye contact as often as possible; do not con- associated symptoms that will help determine the primary centrate chiefly on entering the information into an diagnosis; for example, identifying a patient with skin, gen- EHR as this may distract the clinician from listening ital, or conjunctival lesions who also has oral mucosal dis- to pertinent information; ease or a patient with anesthesia, parasthesia, or weakness use the patient’s own words to describe her primary who also complaints of orofacial pain. The clinician records reason(s) (“CC”) to seek care/consultation; both negative and positive responses. Direct questioning of use open-ended questions that allow the patient to the patient should be aimed at collecting additional data to express herself; assess the severity of a patient’s medical conditions, mon- although all information should be collected in a sys- itor changes in medical conditions, and assist in confirming tematic fashion, the order is not as important as is ini- or ruling out those disease processes that may be associated tiating a dialogue with the patient about her health; with a patient’s symptoms. create a timeline of the reported patient-related events; an accurate chronology is an extremely important Patient Examination ­element to establish a causative relationship. The examination of the patient represents the second stage of the evaluation and assessment process. An established routine The medical history traditionally consists of the follow- for examination decreases the possibility of overlooking undis- ing subcategories: covered pathologic conditions. The examination is most con- 1. Identification: Name, date and time of the visit, veniently carried out with the patient seated in a dental chair, date of birth, gender, ethnicity, occupation, contact with the head supported. When dental charting is involved, CH01.indd 3 10/10/14 10:46 AM  4 Burket’s Oral Medicine Figure 1-1 Health history questionnaire. Health History Form Email: Today’s Date: As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. Name: Home Phone: Include area code Business/Cell Phone: Include area code Last First Middle ( ) ( ) Address: City: State: Zip: Mailing address Occupation: Height: Weight: Date of Birth: Sex: M F SS# or Patient ID: Emergency Contact: Relationship: Home Phone: Include area code Cell Phone: Include area code ( ) ( ) If you are completing this form for another person, what is your relationship to that person? Your Name Relationship Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the the question) Yes No DK Active Tuberculosis...................................................................................................................................................................................................................................................... Persistent cough greater than a 3 week duration...................................................................................................................................................................................................... Cough that produces blood......................................................................................................................................................................................................................................... Been exposed to anyone with tuberculosis................................................................................................................................................................................................................ If you answer yes to any of the 4 items above, please stop and return this form to the receptionist. Dental Information For the following questions, please mark (X) your responses to the following questions. Yes No DK Yes No DK Do your gums bleed when you brush or floss?..................................................... Do you have earaches or neck pains?................................................................... Are your teeth sensitive to cold, hot, sweets or pressure?.................................. Do you have any clicking, popping or discomfort in the jaw?.............................. Is your mouth dry?................................................................................................. Do you brux or grind your teeth?.......................................................................... Have you had any periodontal (gum) treatments?............................................... Do you have sores or ulcers in your mouth?......................................................... Have you ever had orthodontic (braces) treatment?........................................... Do you wear dentures or partials?........................................................................ Have you had any problems associated with previous dental treatment?........... Do you participate in active recreational activities?............................................. Is your home water supply fluoridated?................................................................ Have you ever had a serious injury to your head or mouth?................................ Do you drink bottled or filtered water?................................................................. Date of your last dental exam: If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY What was done at that time? Are you currently experiencing dental pain or discomfort?...................... Date of last dental x-rays: What is the reason for your dental visit today? How do you feel about your smile? Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Yes No DK Yes No DK Are you now under the care of a physician?......................................................... Have you had a serious illness, operation or been hospitalized Physician Name: Phone: Include area code in the past 5 years?................................................................................................ ( ) If yes, what was the illness or problem? Address/City/State/Zip: Are you taking or have you recently taken any prescription or over the counter medicine(s)?.......................................................................... Are you in good health?......................................................................................... If so, please list all, including vitamins, natural or herbal preparations Has there been any change in your general health within the past year?............ and/or dietary supplements: If yes, what condition is being treated? Date of last physical exam: © 2012 American Dental Association Form S500 CH01.indd 4 10/10/14 10:46 AM  Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient 5 Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the question) Yes No DK Yes No DK Do you wear contact lenses?................................................................................. Do you use controlled substances (drugs)?.......................................................... Joint Replacement. Have you had an orthopedic total joint Do you use tobacco (smoking, snuff, chew, bidis)?.............................................. (hip, knee, elbow, finger) replacement?................................................................ If so, how interested are you in stopping? Circle one: VERY / SOMEWHAT / NOT INTERESTED Date: __________________ If yes, have you had any complications? __________________________ Do you drink alcoholic beverages?........................................................................ Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for If yes, how much alcohol did you drink in the last 24 hours? _______________________________ osteoporosis or Paget’s disease?........................................................................... If yes, how much do you typically drink i n a week? _________________________________________ Since 2001, were you treated or are you presently scheduled to begin WOMEN ONLY Are you: treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) Pregnant?...............................................................................................................n n n for bone pain, hypercalcemia or skeletal complications resulting from Number of weeks: ______________________ Paget’s disease, multiple myeloma or metastatic cancer?.................................... Taking birth control pills or hormonal replacement?.............................................n n n Date Treatment began: _____________________________________________________________________ Nursing?.................................................................................................................n n n Allergies. Are you allergic to or have you had a reaction to: Yes No DK To all yes responses, specify type of reaction. Yes No DK Metals._______________________________________________________________________________. Local anesthetics.___________________________________________________________________. Latex (rubber).______________________________________________________________________. Aspirin._______________________________________________________________________________. Iodine.________________________________________________________________________________. Penicillin or other antibiotics _______________________________________________________. Hay fever/seasonal._________________________________________________________________. Barbiturates, sedatives, or sleeping pills.__________________________________________. Animals.______________________________________________________________________________. Sulfa drugs.__________________________________________________________________________. Food._________________________________________________________________________________. Codeine or other narcotics.________________________________________________________. Other.________________________________________________________________________________. Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Yes No DK Yes No DK Yes No DK Artificial (prosthetic) heart valve........................................................................... Autoimmune disease................. Glaucoma.................................. Previous infective endocarditis.............................................................................. Rheumatoid arthritis................. Hepatitis, jaundice or Systemic lupus liver disease............................... Damaged valves in transplanted heart.................................................................. erythematosus.......................... Epilepsy..................................... Congenital heart disease (CHD) Asthma...................................... Fainting spells or seizures.......... Unrepaired, cyanotic CHD.............................................................................. Bronchitis.................................. Neurological disorders.............. Repaired (completely) in last 6 months......................................................... If yes, specify:____________________________. Repaired CHD with residual defects.............................................................. Emphysema............................... Sleep disorder........................... Sinus trouble............................. Except for the conditions listed above, antibiotic prophylaxis is no longer recommended Do you snore?........................... Tuberculosis............................... for any other form of CHD. Mental health disorders............ Cancer/Chemotherapy/ Specify: __________________________________ Yes No DK Yes No DK Radiation Treatment................. Recurrent Infections................. Cardiovascular disease............ Mitral valve prolapse................. Chest pain upon exertion.......... Type of infection: _________________________ Angina...................................... Pacemaker................................. Chronic pain.............................. Kidney problems....................... Arteriosclerosis........................ Rheumatic fever........................ Diabetes Type I or II................. Night sweats............................. Congestive heart failure......... Rheumatic heart disease.......... Eating disorder.......................... Osteoporosis............................. Damaged heart valves............ Abnormal bleeding.................... Malnutrition.............................. Persistent swollen glands Heart attack............................ Anemia...................................... Gastrointestinal disease............ in neck....................................... Severe headaches/ Heart murmur.......................... Blood transfusion...................... G.E. Reflux/persistent migraines................................... If yes, date:_______________________________ heartburn.................................. Low blood pressure................. Severe or rapid weight loss...... Hemophilia................................ Ulcers........................................ High blood pressure................. Sexually transmitted disease.... AIDS or HIV infection................ Thyroid problems...................... Other congenital Excessive urination................... heart defects........................... Arthritis..................................... Stroke........................................ Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?....................................................................................................... Name of physician or dentist making recommendation: Phone: Include area code ( ) Do you have any disease, condition, or problem not listed above that you think I should know about?................................................................................................................. Please explain: NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Signature of Patient/Legal Guardian: Date: Signature of Dentist: Date: FOR COMPLETION BY DENTIST Comments: CH01.indd 5 10/10/14 10:46 AM  6 Burket’s Oral Medicine Table 1-1 Review of Systems Is a Systematic Approach to Ascertain Mostly Subjective Symptoms Associated With the Different Body Systems General: Weight changes, malaise fatigue, night sweats Head: Headaches, tenderness, sinus problems Eyes: Changes in vision, photophobia, blurring, diplopia, spots, discharge Ears: Hearing changes, tinnitus, pain, discharge, vertigo Nose: Epistaxis, obstructions Throat: Hoarseness, soreness Respiratory: Chest pain, wheezing, dyspnea, cough, hemoptysis Cardiovascular: Chest pain, dyspnea, orthopnea (number of pillows needed to sleep comfortably), edema, claudication Dermatologic: Rashes, pruritus, lesions, skin cancer (epidermoid carcinoma, melanoma) Gastrointestinal: Changes in appetite, dysphagia, nausea, vomiting, hematemesis, indigestion, pain, diarrhea, constipation, melena, hematochezia, bloating, hemorrhoids, jaundice Genitourinary: Changes in urinary frequency or urgency, dysuria, hematuria, nocturia, incontinence, discharge, impotence Gynecologic: Menstrual changes (frequency, duration, flow, last menstrual period), dysmenorrhea, menopause Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, pigmentations Musculoskeletal: Muscle and joint pain, deformities, joint swellings, spasms, changes in range of motion Hematologic: Easy bruising, epistaxis, spontaneous gingival bleeding, increased bleeding after trauma Lymphatic: Swollen or enlarged lymph nodes Neuropsychiatric: Syncope, seizures, weakness (unilateral and bilateral), changes in coordination, sensations, memory, mood, or sleep pattern, emotional disturbances, history of psychiatric therapy having an assistant record the findings saves time and limits skin surfaces provided that the examination is carried out cross-contamination. Before seating the patient, the clinician competently and there is adequate privacy for the patient. A should observe the patient’s general appearance and gait and male oral health professional should have a female assistant should note any physical deformities or impediments. present in the case of a female patient; a female oral health The routine oral examination should be carried out at least professional should have a male assistant present in the case once annually or at each recall visit. This includes a thorough of a male patient. Similar precautions should be followed inspection and, when appropriate, palpation, auscultation, and when it is necessary for a patient to remove tight clothing for percussion of the exposed surface structures of the head, neck, accurate measurement of blood pressure. A complete phys- and face and a detailed examination of the oral cavity, denti- ical examination should not be attempted when facilities are tion, oropharynx, and adnexal structures. Laboratory studies lacking or when religious or other customs prohibit it. and additional special examination of other organ systems The degree of responsibility accorded to the oral health may be required for the evaluation of patients with orofacial professional in carrying out a complete physical examination pain, oral mucosal disease, or signs and symptoms suggestive varies from institution to institution, hospital to hospital, of otorhinologic or salivary gland disorders or pathologies sug- state to state, and country to country. gestive of a systemic etiology. A less comprehensive but equally The examination procedure in a dental office setting thorough inspection of the face and oral and oropharyngeal includes five areas: mucosae should be carried out at each dental visit. The tend- 1. Registration of vital signs (respiratory rate, temperat- ency for the oral health professional to focus on only the tooth ure, pain level, pulse, and blood pressure) or jaw quadrant in question should be strongly resisted. 2. Examination of the head, neck, and oral cavity, Each visit should be initiated by a deliberate inspection including salivary glands, temporomandibular joints, of the entire face and oral cavity prior to the scheduled or and head and neck lymph nodes emergency procedure. The importance of this approach in 3. Examination of cranial nerve function the early detection of head and neck cancer and in promot- 4. Special examination of other organ systems ing the image of the dentist as the responsible clinician of 5. Requisition of appropriate laboratory studies the oral cavity cannot be overstated (see Chapter 8, “Oral and Oropharyngeal Cancer”). Examination carried out in the dental office is tradition- Consultations ally restricted to that of the superficial tissues of the oral cav- Consultations with other health-care professionals are ini- ity, head, and neck and the exposed parts of the extremities. tiated when additional information is necessary to assess a On occasion, evaluation of an oral lesion logically leads to patient’s health status. Consent from the patient is needed an inquiry about similar lesions on other skin or mucosal before a consultation is initiated.6 All verbal and written surfaces or about the enlargement of other regional groups consultation should be documented in the patient’s record. of lymph nodes. Although these inquiries can usually be A consultation letter should identify the patient and con- satisfied directly by questioning the patient, the oral health tain a brief overview of the patient’s pertinent medical his- professional may also quite appropriately request permis- tory and a request for specific medical information (Figure sion from the patient to examine axillary nodes or other 1-2). A physician cannot “clear” a patient for treatment.7 CH01.indd 6 10/10/14 10:46 AM  Introduction to Oral Medicine and Oral Diagnosis: Evaluation of the Dental Patient 7 A physician’s advice and recommendation may be helpful in period of posttreatment disability; and details of the partic- managing a dental patient, but the responsibility to provide ular symptom, sign, or laboratory abnormality that gave rise safe and appropriate care lies ultimately with the oral health- to the consultation should be provided to the consultant. The care provider. written request should be brief and should specify the partic- Patients for whom a dentist may need to obtain med- ular concern and items of information needed from the con- ical consultation include (1) the patient with known medical sultant. Importantly, requests for “medical clearance” should problems who is scheduled for either inpatient or outpatient be avoided.7 dental treatment and cannot adequately describe all of his or her medical problems; (2) the patient in whom abnormalities are d