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Library of Congress Cataloging-in-Publication Data
Names: Little, James W., 1934- author. | Miller, Craig S., author. | Rhodus, Nelson L., author.
Title: Little and Falace’s dental management of the medically compromised patient / James W. Little, Craig S. Miller, Nelson L. Rhodus.
Description: Ninth edition. | St. Louis, Missouri : Elsevier, Inc., [2018] | Preceded by Little and Falace’s dental management of the medically compromised patient / James W. Little … [et al.]. 8th ed., c2013. | Includes bibliographical references.
Identifiers: LCCN 2017025872 (print) | LCCN 2017027016 (ebook) | ISBN 9780323443951 (Ebook) | ISBN 9780323443555 (pbk. : alk. paper)
Subjects: | MESH: Dental Care | Dental Care for Chronically Ill | Oral Manifestations
LC record available at https://lccn.loc.gov/2017025872
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We dedicate this ninth edition to our role model and close friend: Dr. Selverio “Sol”/“Bud” Silverman, Jr., MA, DDS
In 2014, we lost our dearest colleague: Each of us in dentistry has been truly blessed by Dr. Silverman:
As a professor of oral medicine at University of California, San Francisco (UCSF) School of Dentistry, for many years, Silverman headed one of UCSF’s oral medicine clinics and was an advocate for prevention and early detection of oral cancer as well as AIDS. Silverman was a diplomat of the American Board of Oral Medicine, past president of the Board, and past President of the American Academy of Oral Medicine (AAOM). Dr. Silverman was a consultant to the American Dental Association Council on Scientific Affairs and a national spokesperson for the Association. He published more than 300 scientific articles, chapters in textbooks, and monographs. He received the prestigious Margaret Hay Edwards medal from the American Association for Cancer Education for outstanding contributions. UCSF Enumeration on October 16, 2006, yet practiced until his death. Deceased August 14, 2014, at 88 years of age.
Dr. Selverio Silverman, Jr., gave back so much to oral medicine profession worldwide and encouraged others around the world and as well as his fellow oral medicine colleges and students at UCSF’s oral medicine clinics yearly, stressing each to become an active member in AAOM. Filled with pride and love, Bud exchanged his family stories over the years with each of us. “Bud” was a very well-rounded doctor and family man who was filled with pride and love of both his family and his profession.
Oral medicine educators, doctors, students, and AAOM members should never tire of challenging each other academically because change makes for evolving changes, and teaming up with each other professionally makes for the very best for oral medicine worldwide. Giving is better than receiving always. Thanks, “Bud,” for giving each of us your very best. Dear friend, you shall always be missed.
Dr. “Bud” Silverman, Jr., has written the Foreword for this textbook for the prior last five editions. This book serves as a textbook as well as a must-have reference book for every dental office in the United States as well as throughout the world.
Dr. Sol Silverman, Jr., and Dr. James W. Little were best friends for the past 45+ years. Their world was carved with the same great values, yet they practiced and taught oral medicine more than 3250 miles apart. Jim and Bud were tethered via phone as they dedicated their lives to oral medicine through their teachings, research, and their own publications and textbooks. Each authored oral medicine textbooks as well as massive publications. Each had the total support and love of each of their own families, their own university workplace, and fellow members of the AAOM. Bud and Jim shared their love of sports by playing tennis, golf, and pick-up basketball into their 80s. They kept young by enjoying their daily playtime with their college kids and all their AAOM friends. “Bud” Silverman is missed daily by each of us involved with oral medicine.
Dr. James W. Little
It has been said that dental offices of the past were often located upstairs, on second floors, to screen out those who were too infirm to undergo dental treatment. Patients able to climb the flight of stairs to the office were considered fit enough to treat.
Largely because of modern medical care, people today are living and working with medical conditions that in the past might have been disabling or even unsurvivable. Statistics from 2012 show that roughly half of noninstitutionalized U.S. adults had one or more of 10 chronic medical conditions (hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, current asthma, or chronic obstructive pulmonary disease). Almost a quarter (24.3%) had one of these conditions, 13.87% had two, and 11.7% had three or more. Approximately one fourth of U.S. adults have more than one chronic illness.1
As one might expect, the incidence of chronic illness increases with age. A total of 69.5% of U.S. adults age 55 to 64 years had one or more of six chronic conditions (arthritis, current asthma, cancer, cardiovascular disease, chronic obstructive pulmonary disease, and diabetes), 37.1% had two or more, and 14.4% had three or more. For ages 65 years and older, the percentages increase to 85.6%, 56.0%, and 23.1%, respectively. Women were more affected than men in all age groups (2008 data).2
Prescription medication is a mainstay of modern health care, and all age groups use them. A total of 14.1% of children younger than age 12 years, 17.3% age 12 to 29 years, and almost 20% of adults age 20 to 59 years use a prescription medication. Of adults age 60 years and older, roughly a quarter take one or two prescription medications, and almost four of 10 people (36.7%) take five or more prescription medications.3 Almost one quarter of U.S. adults older than 65 years have three or more chronic illnesses, and more than one third take five or more medications.
Nowadays, many patients no longer have “a doctor.” Instead, a patient may see multiple doctors for his or her various conditions, such as a cardiologist for coronary artery disease, an endocrinologist for diabetes, a rheumatologist for arthritis, an oncologist for cancer, a psychiatrist for depression—the list can go on and on. This can make medical consultation challenging for the dentist because each specialist focuses on his or her own area and cannot be expected to be knowledgeable about the details of dental diseases and treatments. The dentist cannot expect simply to request a “clearance”
from one of the patient’s physicians, who may not have a thorough understanding of what the proposed treatment entails.
It is therefore essential that the dentist understand how patients’ dental diagnoses and planned treatment relate to their medical diagnoses and treatment. For example, some patients may take anticoagulants or have bleeding disorders that affect dental surgical options and require special considerations in treatment planning. Medical treatments such as head and neck radiation therapy or antiosteoclast medications may impair healing after dental infections or dental surgical procedures, and failure to appreciate and take into account such relationships may put patients at risk for serious complications. Some medical conditions, if unstable, may pose a risk of intraoperative medical emergency during dental treatment and may require modification of treatment planning and delivery. Organ and hematopoietic transplant recipients are an increasingly large group of patients, and among their considerations is the potential for opportunistic infections and malignancies, which can occur in the oral cavity as well as elsewhere. Certain medical problems may themselves adversely affect dental health, such as a patient with physical or cognitive impairment that precludes effective dental hygiene or a patient whose illness or medication produces such profound xerostomia that caries cannot be controlled.
Medications that a patient is taking may create the potential for interactions that must be considered when the dentist wishes to prescribe or administer a drug. In addition, therapeutic effects of medications, such as anticoagulation, or adverse effects, such as xerostomia or mucosal reactions, may bear on dental management. Advanced age, or renal, hepatic, or other diseases that alter drug uptake, metabolism, clearance, or response may require dosage adjustments. Furthermore, each new drug creates the potential for known or as yet unknown drug interactions and side effects, and adverse effects of older medications continue to be discovered with ongoing use.
These are just a few examples of common conditions that can impact dental management. Although the most complex and seriously ill patients may require specialists to provide their dental care, no dentist will be able to avoid treating patients with medical problems altogether, and all dentists must be prepared for them. This book, which has been thoroughly updated in the present edition, provides an excellent overview of pathophysiology and treatment of a broad range of common medical conditions
that will provide the dentist with understanding of the interrelationships between patients’ dental and medical care, as well as information on recommended modifications of treatment delivery. Competency in this critical and complex area of dentistry is essential to the safe and effective provision of dental care to an increasingly large part of our population. Its importance cannot be overstated.
John C. Robinson, MA, DDS, FAAOM Santa Rosa, California
REFERENCES
1. Ward BW, Schiller JS, Goodman RA. Multiple chronic conditions among US adults: a 2012 update. Prev Chronic Dis 2014;11:130389.
2. CDC/National Center for Health Statistics. National Health Interview Survey. https://www.cdc.gov/nchs/ health_policy/adult_chronic_conditions.htm
3. Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescription drug data for 2007-2008. NCHS data brief, no 42. Hyattsville, MD, 2010, National Center for Health Statistics.
PREFACE
The need for a ninth edition of Dental Management of the Medically Compromised Patient became apparent because of the continued, ever-increasing flow of new knowledge and changing concepts in medicine and dentistry.
The purpose of the book remains to give dental providers an up-to-date, concise, factual reference work describing the dental management of patients with medical problems. The more common medical disorders that may be encountered in a dental practice continue to be the focus. This book is not a comprehensive medical reference but rather a book containing enough core information about each of the medical conditions covered to enable readers to recognize the basis for various dental management recommendations. Medical problems are organized to provide a brief overview of the basic disease process, epidemiology, pathophysiology and complications, signs and symptoms, laboratory and diagnostic findings, and currently accepted medical therapy of each disorder. This is followed by a detailed explanation and recommendations for specific dental management and oral considerations.
The accumulation of evidence-based research over the years has allowed us to provide specific dental management guidelines that should benefit those who read this text. This includes practicing dentists, practicing dental hygienists, dental graduate students in specialty or general practice programs, and dental and dental hygiene students. In particular, the text is intended to give dental providers an understanding of how to identify a significant medical issue, ascertain the severity and stability of the disorder, and make dental management decisions that afford the patient the utmost health and safety.
An important feature of the book is access to the Evolve Resources for the ninth edition. These continue to be available at https://evolve.elsevier.com and include Evolve Student and Evolve Instructor Resources. Instructions for activating these resources are included. Working with our publisher, Elsevier, it is our goal to provide more information online via Evolve each year. This will allow dentists, dental hygienists, and students easy access to current information.
The “Dental Management: A Summary” at the front of the book is a very important resource because it is specific and to the point and serves as a current overview. This resource provides readers with a quick reference review with annotation of the corresponding chapter.
We are extremely pleased to welcome three experts who serve as contributing authors for this ninth edition:
Dr. Alexander Ross Kerr, clinical professor, Oral and Maxillofacial Pathology, Radiology, and Medicine, New York University, College of Dentistry; Dr. Eric T. Stoopler, associate professor and director of the Postdoctoral Oral Medicine Program, School of Dental Medicine, University of Pennsylvania, School of Dental Medicine; and Nathaniel Simon Treister, chief, Division or Oral Medicine and Dentistry, Brigham and Women’s Hospital and DanaFarber Cancer Institute and assistant professor of Oral Medicine, Harvard School of Dental Medicine. Each of these authors made important contributions to this edition and reinvigorated our knowledge base. We are pleased and proud to have these authors as a part of our team.
NEW TO THIS EDITION
A number of major changes have been made in this ninth edition. Near the front of most chapters, a clear statement has been made in red type regarding the complications that may occur. Chapter 1 presents the dental management and risk assessment process that is used as an important framework throughout the book. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure was added and explained in Chapter 3. Chapter 17 has been expanded and renamed “Women’s Health Issues.” It includes in-depth discussions of osteoporosis, osteonecrosis, and drugs used during pregnancy and breastfeeding. The 2012 report of the American Dental Association/American Academy of Orthopaedic Surgeons on dental management of invasive dental procedures for patients with knee and hip replacements was added to Chapter 20. Chapter 21 was completely rewritten with new tables and figures added. In Chapters 28 and 29, we made the decision not to use The American Psychiatric Association fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) that was published in 2013. The authors are aware of the implications of applying the new fifth edition of the DSM. We decided to postpone the application. This was based on the need to see how well accepted it becomes. Thus, in this ninth edition the fourth edition of the DSM is used.
All remaining chapters have been updated where necessary, and new dental considerations appear for steroid supplementation, antibiotic prophylaxis, and patients taking bisphosphonates. Some chapters have been provided with new color figures, boxes, and tables. Continued emphasis has been placed on the medications used to treat medical conditions. Dosages, side effects, and drug
interactions with agents used in dentistry—including those used during pregnancy and breastfeeding—are discussed in detail. Emphasis also has been placed on having contemporary equipment and diagnostic information to assess and monitor patients with moderate to severe medical disease.
Our sincere thanks and appreciation are extended to those many individuals who have contributed their time
and expertise to the writing and revision of this text. These include but are not limited to Brian Loehr, Jolynn Gower, Diane Chatman, and Kathy Falk as head of the Dental Division at Elsevier.
18 AIDS, HIV Infection, and Related Conditions, 309
19 Allergy, 330
20 Rheumatologic Disorders, 345
21 Organ Transplantation, 370
PART VIII Hematologic and Oncologic Disease, 389
22 Disorders of Red Blood Cells, 390
23 Disorders of White Blood Cells, 402
24 Acquired Bleeding and Hypercoagulable Disorders, 428
25 Congenital Bleeding and Hypercoagulable Disorders, 457
26 Cancer and Oral Care of Patients With Cancer, 480
PART IX Neurologic, Behavioral, and Psychiatric Disorders, 515
27 Neurologic Disorders, 516
28 Anxiety and Eating Disorders, 544
29 Psychiatric Disorders, 561
30 Drug and Alcohol Abuse, 581
Appendices, 596
A Guide to Management of Common Medical Emergencies in the Dental Office, 597
B Guidelines for Infection Control in Dental Health Care Settings, 606
C Therapeutic Management of Common Oral Lesions, 623
D Drug Interactions of Significance in Dentistry, 639
E Drugs Used in Complementary and Alternative Medicine of Potential Importance in Dentistry, 645
Index, 655
Dental Management: A Summary
This table presents several important factors to be considered in the dental management of medically compromised patients. Each medical condition is outlined according to potential problems related to dental treatment, oral manifestations, prevention of problems, and complications potentially impacting on dental treatment.
This table has been designed for use by dentists, dental students, graduate students, dental hygienists, and dental assistants as a convenient reference work for the dental management of patients who have medical diseases discussed in this book.
Infective Endocarditis (IE) Chapter 2
• Encourage the maintenance of optimal oral hygiene in all patients at increased risk for IE.
• Provide antibiotic prophylaxis only for patients with the highest risk for adverse outcomes of IE.
• Identify patients at greatest risk for adverse outcomes of IE, including patients with:
• Oral petechiae may be found in patients with IE.
• Provide antibiotic prophylaxis for all dental procedures, except:
• Routine anesthetic injections
• Taking of radiographs
• Placement of removable prosthodontic or orthodontic appliances
• Adjustment of orthodontic appliances
• Shedding of deciduous teeth or bleeding from trauma to the lips or oral mucosa
• For patients selected for prophylaxis, perform as much dental treatment as possible during each coverage period.
• A second antibiotic dose may be indicated if the appointment lasts longer than 6 hours or if multiple appointments occur on the same day.
• For multiple appointments (on different days), allow at least 10 days between treatment sessions so that penicillin-resistant organisms can “clear” from the oral flora. If treatment becomes necessary before 10 days have passed, select one of the alternative antibiotics for prophylaxis.
• For patients with prosthetic heart valves who are taking anticoagulants, the dosage may have to be reduced on the basis of international normalized ratio (INR) level and the degree of invasiveness of the planned procedure (see Chapter 24 ).
• Detection of patients with hypertension and referral to a physician if poorly controlled or uncontrolled. Defer elective dental treatment if blood pressure (BP) is ≥ 180/110 mm Hg.
• For patients who are being treated for hypertension, consider the following:
• Take measures to reduce stress and anxiety.
• Avoid the use of erythromycin or clarithromycin in patients taking a calcium channel blocker.
• Avoid the long-term use of nonsteroidal antiinflammatory drugs (NSAIDs).
• Provide oral sedative premedication or inhalation sedation (or both).
• Provide local anesthesia of excellent quality.
• For patients who are taking a nonselective beta blocker, limit epinephrine to ≤ 2 cartridges of 1 : 100,000 epinephrine.
• For patients with upper-level stage 2 hypertension, consider intraoperative monitoring of BP and terminate appointment if BP reaches 180/110 mm Hg.
• Make slow changes in chair position to avoid orthostatic hypotension.
• Prosthetic cardiac valves
• A history of previous IE
• Certain types of congenital heart disease (i.e., unrepaired cyanotic congenital heart disease, including patients with palliative shunts and conduits, completely repaired congenital heart disease for the first 6 months after a procedure, or repaired congenital heart disease with residual defect)
• Cardiac transplantation recipients who develop cardiac valvulopathy
1. Dental procedures that involve the manipulation of gingival tissues or the periapical region of teeth or perforation of the oral mucosa can produce bacteremia. Bacteremias can also be produced on a daily basis as the result of toothbrushing, flossing, chewing, or the use of toothpicks or irrigating devices. Although it is unlikely that a single dental procedure–induced bacteremia will result in IE, it is remotely possible that it can occur.
2. Patients with mechanical prosthetic heart valves may have excessive bleeding after invasive dental procedures as the result of anticoagulant therapy.
*
• Prescribe antibiotic prophylaxis only for at-risk patients, as listed, who undergo dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
• If prophylaxis is required for an adult, have the patient take a single dose 30 minutes to 1 hour before the procedure:
• Standard (oral amoxicillin 2 g)
• Allergic to penicillin (oral cephalexin 2 g, oral clindamycin † 600 mg, or azithromycin or clarithromycin 500 mg)
• Unable to take oral medications (intravenous [IV] or intramuscular [IM] ampicillin, cefazolin, or ceftriaxone)
• Allergic to penicillin and unable to take oral medications (IV or IM clindamycin phosphate, cefazolin, or ceftriaxone)
• See Chapter 24 for management of potential bleeding problems associated with anticoagulant therapy.
*It is of interest that in Great Britain, they had to return to antibiotic prophylaxis for patients considered not to be at risk.
† Cephalexin should not be used in patients with a history of anaphylaxis, angioedema, or urticaria with penicillins.
PREVENTION
• When under good medical management, the patient may receive any indicated dental treatment.
• Detection of patients with thyrotoxicosis by history and examination findings
• If acute infection occurs, the physician should be consulted regarding management.
• Referral for medical evaluation and treatment
• Avoidance of any dental treatment for patient with thyrotoxicosis until good medical control is attained; however, any acute oral infection will have to be dealt with by antibiotic therapy and other conservative measures to prevent development of thyrotoxic crisis; suggest consultation with patient’s physician during management of acute oral infection
• Avoidance of epinephrine and other pressor amines in untreated or incompletely treated patients
• Recognition of early stages of thyrotoxic crisis:
• Severe symptoms of thyrotoxicosis
• Fever
• Abdominal pain
• Delirious, obtunded, or psychotic
• Initiation of immediate emergency treatment procedures:
• Seek immediate medical aid.
• Cool with cold towels, ice packs.
• Hydrocortisone (100–300 mg)
• Monitor vital signs.
• Start cardiopulmonary resuscitation (CPR) if needed.
• Manage pain and xerostomia as described in Appendix C .
• Possible agranulocytosis; refer to physician for evaluation and stopping the antithyroid medication.
POTENTIAL
Hyperthyroidism (Thyrotoxicosis)
Chapter 16
• Osteoporosis may occur.
• Periodontal disease may be more progressive.
• Dental caries may be more extensive.
• Premature loss of deciduous teeth and early eruption of permanent teeth may occur.
1. Thyrotoxic crisis (thyroid storm) may be precipitated in patients with untreated or incompletely treated thyrotoxicosis by: a. Infection b. Trauma c. Surgical procedures d. Stress
• Early jaw development may be noted.
• Tumors found at the midline of the posterior dorsum of the tongue must not be surgically removed until the possibility of functional thyroid tissue has been ruled out by 131 I uptake tests.
• Acute—salivary gland swelling, pain, loss of taste
2. Patients with untreated or incompletely treated thyrotoxicosis may be very sensitive to actions of epinephrine and other pressor amines; thus, these agents must not be used. After the patient is well managed from a medical standpoint, these agents may be administered.
• Radioactive drug-induced: Chronic sialoadenitis— xerostomia, pain, and dental caries
• Sore throat, fever, mouth ulcers
3. Thyrotoxicosis increases the risk for hypertension, angina, myocardial infarction (MI), congestive heart failure, and severe arrhythmias.
• In hypothyroid patients under good medical management, indicated dental treatment may be performed.
• In patients with a congenital form of disease and severe mental retardation, assistance with hygienic procedures may be needed.
PREVENTION OF PROBLEMS
• Detection and referral of patients suspected of being hypothyroid for medical evaluation and treatment
• Avoidance of narcotics, barbiturates, and tranquilizers in untreated hypothyroid patients
• Recognition of initial stage of hypothyroid (myxedema) coma:
• Hypothermia
• Bradycardia
• Hypotension
• Epileptic seizures
• Initiation of immediate treatment for myxedema coma:
• Seek immediate medical aid.
• Administer hydrocortisone (100–300 mg).
• Provide CPR as indicated.
• Postpone elective dental care until infection has been treated.
• Avoid elective dental care if possible until symptoms of hyperthyroidism have cleared.
• Avoid elective dental care if possible until symptoms of hyperthyroidism have cleared.
• In hypothyroid patients under good medical management, any indicated dental treatment can be performed. See above for uncontrolled disease.
• None
• None
• Include in differential diagnosis for jaw pain; see earlier under Hyperthyroidism.
• See earlier under Hyperthyroidism.
• See earlier under Hypothyroidism.
• None
ORAL MANIFESTATIONS
POTENTIAL MEDICAL PROBLEM RELATED TO DENTAL CARE
Hypothyroidism Chapter 16
• Increased tongue size
• Delayed eruption of teeth
• Malocclusion
• Gingival edema
1. Untreated patients with severe hypothyroidism exposed to stressful situations such as trauma, surgical procedures, or infection may develop hypothyroid (myxedema) coma.
2. Untreated hypothyroid patients may be highly sensitive to actions of narcotics, barbiturates, and tranquilizers.
3. May have comorbidities: hypercholesterolemia, or bleeding issues
Thyroiditis Chapter 16
• Usually none
—patient has acute infection; antibiotics are required.
1. Acute suppurative
• Pain may be referred to mandible.
• None
2. Subacute painful —period of hyperthyroidism
3. Subacute painless —up to 6-month period of hyperthyroidism
• Tongue may be enlarged.
4. Hashimoto —leads to severe hypothyroidism
• None
5. Chronic fibrosing (Riedel)— usually euthyroid
PREVENTION OF PROBLEMS
• For most patients, the dental treatment plan is not affected unless the cancer treatment includes external irradiation or chemotherapy. See summaries for Chapter 26 .
• Patients with anaplastic carcinoma have a poor prognosis, and complex dental procedures usually are not indicated.
• Examine for signs and symptoms of thyroid cancer:
• Usually none; metastasis to the oral cavity is rare.
• Hard, painless lump in thyroid
• Dominant nodule in multinodular goiter
• Hoarseness, dysphagia, dyspnea
• Cervical lymphadenopathy
• Nodule that is affixed to underlying tissues
• Patient usually euthyroid
• Postradiation-induced chronic sialadenitis, xerostomia, risk for root caries.
Thyroid Cancer Chapter 16
1. Usually none
• Care with the use of epinephrine is indicated in patients made to be hyperthyroid as part of their cancer treatment regimen.
• Patients found to have thyroid nodule(s) should be referred for fine-needle aspiration biopsy.
• Consult with patient’s physician regarding permissible degree of hyperthyroidism in patients treated with thyroid hormone.
• Usually none
2. Levothyroxine suppression after surgery and radioiodine ablation is the usual treatment for follicular carcinomas. The patient may have mild hyperthyroidism and may be sensitive to actions of pressor amines.
Continued
• Prognosis is poor with anaplastic carcinoma.
• Manage complications of radiation therapy and chemotherapy as described in summaries for Chapter 26 .
• Patients with MEN2 can develop cystic lesions of the jaws related to hyperparathyroidism.
3. Patients with multiple endocrine neoplasia-2 (MEN2) may have symptoms of hypertension, hypercalcemia, or both.
• See oral complications listed in summaries for Chapter 26
4. Anaplastic carcinomas may be treated by external irradiation, chemotherapy, or both. See problems listed in summaries for Chapter 26
TREATMENT PLANNING MODIFICATION(S)
• Usually none indicated
PREVENTION OF PROBLEMS
• Detection and referral for diagnosis and treatment
• Recognition that in women, most cases are caused by physiologic process— menstruation or pregnancy
• Recognition that in men, most cases are the result of underlying disease—peptic ulcer, carcinoma of colon, other—requiring referral to the patient’s physician
• Usually none unless anemia is severe; then perform only procedures to meet urgent dental needs.
ORAL MANIFESTATIONS
POTENTIAL MEDICAL PROBLEM RELATED TO DENTAL CARE
• Paresthesias
• Loss of papillae on dorsum of tongue
• In rare cases, infection and bleeding complications
Iron Deficiency Anemia Chapter 22 1. Usually none 2. In rare cases, severe leukopenia and thrombocytopenia may result in problems with infection and excessive loss of blood.
• In patients with dysphagia, increased incidence of carcinoma of oral and pharyngeal areas (Plummer-Vinson syndrome)
• Control infection.
• Avoid drugs such as certain antibiotics or that contain aspirin or acetaminophen, which may increase risk for hemolytic anemia.
• Be aware that these patients also often have increased sensitivity to the actions of sulfa drugs and chloramphenicol.
• None indicated when the patient is under medical care
• Detection and medical treatment (early detection and treatment can prevent permanent neurologic damage)
• Usually none unless symptoms of severe anemia are present; then only urgent dental needs should be met.
• Consult with patient’s physician to ensure that condition is stable.
• Institute aggressive preventive dental care.
• Avoid any procedure that may produce acidosis or hypoxia (avoid long, complicated procedures).
• Drug modifications:
• Avoid excessive use of barbiturates and narcotics because suppression of the respiratory center may occur, leading to acidosis, which can precipitate acute crisis. Use benzodiazepine instead.
• Avoid excessive use of salicylates because “acidosis” may result, again leading to possible acute crisis; codeine and acetaminophen in moderate dosage can be used for pain control.
• Avoid the use of general anesthesia because hypoxia can lead to precipitation of acute crisis.
• Nitrous oxide may be used, provided that 50% oxygen is supplied at all times; it is critical to avoid diffusion hypoxia at the termination of nitrous oxide administration. For nonsurgical procedures, use local without vasoconstrictor; for surgical procedures, use 1 : 100,000 epinephrine in anesthetic solution.
1. Aspirate before injecting.
2. Inject slowly.
3. Use no more than two cartridges.
4. It is necessary to prevent infection. Use prophylactic antibiotics for major surgical procedures. 5. If infection occurs, manage aggressively , with the use of: a. Heat b. Incision and drainage c. Antibiotics
d. Corrective treatment (e.g., extraction, pulpectomy)
6. Avoid dehydration in patients with infection and in patients who are receiving surgical treatment.
• Medical consultation to determine current status of the patient under medical treatment
• Gingival bleeding
• Petechiae
• Ecchymosis
Aplastic Anemia Chapter 22 1. Bleeding
• Antimicrobial agents and supportive therapy are needed for oral infection (see Appendix C for specific treatment regimens).
• Some drugs (anticonvulsants, antithyroid drugs, select antidiabetic agents, diuretics, and sulfonamides) are associated with higher incidence of aplastic anemia.
• During periods of low white blood (WBC) counts, provide emergency care only. Treatment should include the use of antimicrobial agents and supportive therapy for oral lesions (see Appendix C for specific treatment regimens).
• Referral for medical diagnosis and treatment
• Drug considerations—some antibiotics (macrolides, penicillins, and cephalosporins) used for oral infections are associated with higher incidence of agranulocytosis. Avoid these antibiotics if possible.
• Modifications not required when the WBC count (neutrophils) is normal.
• Antibiotics should be given to prevent infection.
• If the WBC count (neutrophils) is depressed severely, antibiotics should be provided to prevent postoperative infection.
• Serial WBC counts should be performed to identify the safest period for dental treatment (i.e., when the WBC count is closest to normal level).
• Inspect head, neck, and radiographs for undiagnosed or latent disease (e.g., retained root tips, impacted teeth) and infections that require management before chemotherapy.
• Referral for medical diagnosis, treatment, and consultation
• Eliminate infections before chemotherapy.
• Complete blood count to determine risk for anemia, bleeding, and infection
• Extractions should be performed at least 10 days before initiation of chemotherapy.
• Implement plaque control measures and chlorhexidine during chemotherapy.
• Antibiotics, antivirals, and antifungals provided during chemotherapy to prevent opportunistic oral infection
• Use prophylactic antibiotics if WBC count is less than 2000/ µ L or neutrophil count is less than 500/ µ L (or 1000/ µ L at some institutions).
• Platelet replacement may be required (if platelet count is < 50,000/ µ L) when invasive dental procedures are performed.
• Chlorhexidine rinses or bland rinses to manage mucositis
• Oral infection
• During periods of low blood count (platelets, neutrophils, red blood cells), provide emergency care only. 2. Infection
• For patients in terminal stage, provide supportive dental care only.
• With the newer therapies, the long-term prognosis has been greatly improved, so complex dental procedures may be considered. If thrombocytopenia or leukopenia is present, special precautions (platelet replacement, antibiotic therapy) are needed to prevent bleeding and infection when invasive dental procedures are performed.
• Patients with oral soft tissue lesions or osseous lesions should have them biopsied by the dentist or should be referred for diagnosis and treatment as indicated.
• Patients may be bleeders because of the presence of abnormal immunoglobulin M macroglobulins, which form complexes with clotting factors, thereby inactivating the clotting factors. (See sections on chemotherapy and radiation therapy for treatment plan modifications.)
• Medical history should identify patients with diagnosed disease; medical consultation is needed to establish current status. (See sections on chemotherapy and radiation therapy on prevention and management of medical complications.)
• Be aware of and take precautions for medication-related osteonecrosis of the jaws.
• Patients in terminal phase should receive only supportive dental treatment.
• Patients under “control” may receive any indicated treatment; however, complex restorative treatment may not be indicated in cases with a poor prognosis.
• Patients with generalized lymphadenopathy, extranodal tumors, and osseous lesions must be identified and referred for medical evaluation and treatment.
• Platelet replacement may be needed for patients with thrombocytopenia. (See sections on radiation therapy and chemotherapy for treatment plan modifications.)
• Consider prophylactic antibiotics if the WBC count is less than 2000/ µ L or the neutrophil count is less than 500 (or 1000/ µ L at some institutions).
• The dentist can biopsy extranodal or osseous lesions to establish a diagnosis; patients with lesions involving the lymph nodes should be referred for excisional biopsy.
• Medical history should identify patients with diagnosed disease; medical consultation is needed to establish current status. (See sections on chemotherapy and radiation therapy on management and prevention of medical complications.)
• Before invasive procedures, a complete blood count should be obtained to determine risks for bleeding and infection.
• Patients who have been treated by irradiation to the chest area may develop acute and chronic cardiovascular complications such as arrhythmias or valvular heart disease. Medical consultation is needed to confirm their current status.
Multiple Myeloma
Chapter 23
• Soft tissue tumors
• Osteolytic jaw lesions
1. Excessive bleeding after invasive dental procedures
• Amyloid deposits in soft tissues
• Unexplained mobility of teeth
• Exposed bone
2. Risk of infection because of decrease in normal immunoglobulins
3. Risks of infection and bleeding in patients who are being treated by irradiation or chemotherapy
4. Risk of osteonecrosis of the jaws in patients who are taking bisphosphonates (especially intravenously) as well as other antiangiogenic medications
• Extranodal oral tumors in Waldeyer ring or osseous soft tissues
• Xerostomia in patients treated by radiation; some of these patients prone to osteonecrosis
• Burning mouth or tongue symptoms
• Petechiae or ecchymoses if thrombocytopenia present because of tumor invasion of bone marrow
• Cervical lymphadenopathy
• Mucositis in patients treated by radiation therapy or chemotherapy
1. Increased risk for infection
2. Risks of infection and excessive bleeding in patients receiving chemotherapy
3. Minor risk of osteonecrosis in patients treated by radiation to the head and neck region (usually does not occur because radiation dosage seldom exceeds 50 Gy)
4. Hyposalivation and xerostomia may occur in patients treated by irradiation ( > 25 Gy) to the head and neck region.
5. Non-Hodgkin lymphoma may be found in patients with AIDS; hence, transmission of infectious agents may be a problem.
TREATMENT PLANNING MODIFICATION(S)
• None unless test result(s) abnormal; then manage according to the nature of the underlying problem once diagnosis has been established by the physician.
PREVENTION OF PROBLEMS
ORAL MANIFESTATIONS
POTENTIAL MEDICAL PROBLEM RELATED TO DENTAL CARE
• In general, dental procedures can be performed if the platelet count is 30,000/ µ L or higher.
• Extractions and minor surgery can be performed if the platelet count is 50,000/ µ L or higher.
• Major oral surgery can be performed if the platelet count is 80,000/ µ L to 100,000/ µ L or higher.
• Platelet transfusion is needed for patients with platelet counts below the above values.
• Patients with severe neutropenia (500/ µ L or less) may require antibiotics for certain surgical procedures (1000/ µ L at some institutions).
• In children with primary thrombocytopenia, many will respond to steroids with increase in platelets to levels, allowing dental procedures to be performed.
Bleeding Problem Suggested by Examination and History Findings But Lack of Clues to Underlying Cause
• Screen patients with the following (if results of one or more tests are abnormal, refer for diagnosis and medical treatment):
• Excessive bleeding after dental procedures
Chapter 24 1. Excessive blood loss after surgical procedures, scaling, other manipulations
• Prothrombin time
• Activated partial thromboplastin time
• Thrombin time
• Platelet count
• Avoid use of aspirin and related drugs.
Thrombocytopenia (Primary or Secondary) Caused by Chemicals, Radiation, or Leukemia
• Identification of patients to include the following:
• History
• Examination findings
• Screening tests—platelet count
• Referral and consultation with a hematologist
• Correction of underlying problem or replacement therapy before surgery
• Local measures to control blood loss (e.g., splint, Gelfoam, thrombin)
• Prophylactic antibiotics may be considered in surgical cases to prevent postoperative infection if severe neutropenia is present.
• Additional steroids should be used for patients being treated with steroids, if indicated (see section on adrenal insufficiency).
• Aspirin, other NSAIDs, and aspirincontaining compounds are not to be used; acetaminophen (Tylenol) with or without codeine may be used if analgesia is required.
• Spontaneous bleeding
• Prolonged bleeding after certain dental procedures
• Petechiae
Chapter 24 1. Prolonged bleeding 2. Infection in patients with bone marrow replacement or destruction
• Ecchymoses
• Hematomas
3. A medical emergency can result from stress in patients being treated with steroids.
TREATMENT PLANNING MODIFICATION(S)
• Surgical procedures must be avoided in these patients unless the underlying problem has been corrected or the patient has been prepared for surgery by a hematologist and the dentist is prepared to control excessive loss of blood through local measures: splints, thrombin, microfibrillar collagen, Gelfoam, Oxycel, ε -aminocaproic acid (Amicar) (see Table 24.6 ).
PREVENTION OF PROBLEMS
ORAL MANIFESTATIONS
POTENTIAL MEDICAL PROBLEM RELATED TO DENTAL CARE
Vascular Wall Alterations (Scurvy, Infection, Chemical, Allergic, Autoimmune, Other Agents or Factors)
• Identification of patients should include the following:
• Excessive bleeding after scaling and surgical procedures
• History
• Clinical findings
• Screening tests—none reliable
• Consultation with a hematologist should be obtained.
• Local measures should be used to control blood loss: splints, Gelfoam, Oxycel, and surgical thrombin (see Table 24.6 ).
• Prevention of allergy if causative and if the antigen is identified
• Petechiae
Chapter 24 1. Prolonged bleeding after surgical procedures or any insult to integrity of oral mucosa
• Ecchymoses • Hematomas
Acquired Disorders of Coagulation (Liver Disease, Broad-Spectrum Antibiotics, Malabsorption Syndrome, Biliary Tract Obstruction , Heparin, Other Agents or Factors)
• No dental procedures should be performed unless the patient has been prepared on the basis of a consultation with a hematologist. Continued
• Identification of patients with such disorders should include:
• History
• Examination findings
• Screening laboratory tests— prothrombin time (prolonged) in liver disease, platelet count (low if hypersplenism present)
• Consultation and referral should be provided.
• Preparation before the dental procedure may include vitamin K injection by the physician and platelet replacement if indicated.
• Local measures are used to control blood loss (see Table 24.6 ).
• For patients with liver disease, avoid or reduce dosage of drugs metabolized by the liver.
• Do not use aspirin, other NSAIDs, or aspirin-containing compounds.
• Excessive bleeding
• Spontaneous bleeding
• Petechiae
Chapter 24 1. Excessive bleeding after dental procedures that result in soft tissue or osseous injury
• Hematomas
TREATMENT PLANNING MODIFICATION(S)
• Dental procedures should not be performed unless medical consult has been obtained and level of anticoagulation is at an acceptable range; the procedure may have to be delayed by 2 to 3 days if the dosage of anticoagulant has to be reduced.
• Avoid aspirin and aspirin-containing compounds. Use acetaminophen (Tylenol) for postoperative pain control.
PREVENTION OF PROBLEMS
• Identify patients who are taking anticoagulants or coumarin in the following ways:
• History
• Screening laboratory test—INR, prothrombin time
• Consultation should be obtained regarding level of anticoagulation:
• If INR is 3.5 or less, most surgical procedures can be performed.
• Dosage of anticoagulant should be reduced if INR is greater than 3.5. (It takes several days for INR to fall to desired level; confirmation should be obtained by new tests before surgery is completed.)
• Patients undergoing major oral surgery should be managed on an individual basis; in most cases, INR should be below 3.0 at the time of surgery.
• Low-molecular-weight heparin bridging can be considered for major surgery.
ε -Aminocaproic acid (Amicar) rinses, just before surgery and every hour for 6–8 hours, will aid in control of bleeding. Local measures should be instituted to control blood loss after surgery (see Table 24.6 ).
•
ORAL MANIFESTATIONS
POTENTIAL MEDICAL PROBLEM RELATED TO DENTAL CARE
Anticoagulation with Coumarin Drugs (Warfarin)
• Excessive bleeding
• Hematomas
• Petechiae
Chapter 24 1. Excessive bleeding after dental procedures that result in soft tissue or osseous injury
• In rare cases, spontaneous bleeding
POTENTIAL
• Depending on the cause of DIC, the treatment plan should be altered as follows:
• With acute DIC—No routine dental care until medical evaluation and correction of cause
• With chronic DIC—No routine dental care until medical evaluation and correction of cause when possible; if prognosis is poor on the basis of underlying cause (advanced cancer), limited dental care is indicated.
• Avoid aspirin, other NSAIDs, and aspirin-containing compounds.
• Do not use ε -aminocaproic acid (Amicar), tranexamic acid, or desmopressin because these agents may complicate the disorder and result in increased bleeding.
• Acetaminophen with or without codeine can be used for postoperative pain.
PREVENTION OF PROBLEMS
• Identification of patients includes the following:
• History—excessive bleeding after minor trauma; spontaneous bleeding from nose, gingiva, gastrointestinal tract, urinary tract; recent infection, burns, shock and acidosis, or autoimmune disease; history of cancer most often associated with chronic form of disseminated intravascular coagulation (DIC), in which thrombosis rather than bleeding usually is the major clinical problem
• Examination findings include the following: 1. Petechiae
2. Ecchymoses
3. Spontaneous gingival bleeding; bleeding from nose, ears, and so on.
• Screening laboratory findings include the following: 1. Acute DIC—prothrombin time (prolonged), partial thromboplastin time (prolonged), thrombin time (prolonged), platelet count (decreased)
2. Chronic DIC—most test results may be normal, but fibrin-split products are present (positive result on D-dimer test).
• Obtain referral and consultation with physician if invasive dental procedures must be performed, and include information on:
• Acute DIC—cryoprecipitate, fresh frozen plasma, and platelets
• Chronic DIC—anticoagulants such as heparin or vitamin K antagonists
• Aspirin or aspirin-containing products are prohibited.
• Local measures are used to control bleeding (see Table 24.6 ).
• Antibiotic therapy may be considered to prevent postoperative infection.
Disseminated Intravascular Coagulation (DIC)
• Spontaneous gingival bleeding
• Petechiae
• Ecchymoses
• Prolonged bleeding after invasive dental procedures
Chapter 24 1. Excessive bleeding after invasive dental procedures; in chronic form of disease, widespread thrombosis may occur.
Disorders of Platelet Release
• Usually, no modifications are indicated for patients who have no other platelet or coagulation disorders.
• Identification of patient should include the following:
• Excessive bleeding may occur after surgery.
Chapter 24 1. Excessive bleeding after invasive dental procedures
• History—recent use of aspirin, indomethacin, phenylbutazone, ibuprofen, or sulfinpyrazone; presence of other platelet or coagulation disorders
• Petechiae, ecchymoses, and hematomas may be found when other platelet or coagulation disorders are present.
• Examination—often negative unless signs related to other platelet or coagulation disorders are present
• Screening laboratory tests—partial thromboplastin time (prolonged)
• Most patients on drugs noted above without an additional platelet or coagulation problem will not bleed excessively after surgery.
• Patients with prolonged partial thromboplastin time should be referred for evaluation before performance of any surgical procedures.
• Elective surgery can be performed after withdrawal of drug for at least 3 days and management of other platelet or coagulation disorders by appropriate means.
• Patients with advanced cancer should have treatment limited to emergency dental procedures and preventive measures; complex dental restorations in general are not indicated; in other patients, after preparation to avoid excessive bleeding has occurred ( ε -aminocaproic acid), most dental treatment can be rendered.
• Identification of patients should include the following:
• Prolonged bleeding after invasive dental procedures
• History—liver disease, cancer of lung, cancer of prostate, and heat stroke may cause this condition.
• Delay procedure until patient is off the medication.
• Have physician stop medication and perform surgery the next day; when hemostasis is obtained, have the physician resume medication.
• Gingival bleeding • Petechiae • Ecchymoses
• In rare cases, excessive bleeding after dental procedures
1. Used in patients who have received prosthetic knee or hip replacement; patient takes medication for approximately 2 weeks after getting out of the hospital
• Usually none needed unless there are other medical problems, such as recent MI or stroke.
• Perform surgery and manage any excessive bleeding through local means (preferred if excessive bleeding is not anticipated).
2. Complications include the following: a. Excessive bleeding b. Anemia
c. Fever d. Thrombocytopenia e. Peripheral edema
Antiplatelet Drug Therapy: Aspirin, Aspirin Plus Dipyridamole (Aggrenox), Ibuprofen (Advil, Motrin)
Chapter 24
• If no other complications occur, dental procedures and surgery can usually be performed.
• Gingival bleeding
• Petechiae
• Ecchymoses
1. Used for prevention of initial or recurrent MI and stroke prevention
• In rare cases, excessive bleeding after dental procedures
2. Complications include: a. Excessive bleeding b. Gastrointestinal bleeding c. Tinnitus d. Bronchospasm
• Usually none needed, unless there are other medical problems such as recent MI or stroke.
• The American Diabetes Association and American Heart Association issued a statement that dual-antiplatelet treatment (clopidogrel and aspirin) should not be discontinued for patients with stents when receiving invasive dental treatment. Continued
Chapter 24
• Gingival bleeding
• Petechiae
1. Used for prevention of recurrent MI and stroke
• Ecchymoses
• In rare cases, excessive bleeding after dental procedures
• Adverse reactions increase risk for infection (neutropenia) and bleeding (thrombocytopenia).
2. Complications include: a. Excessive bleeding b. Gastrointestinal bleeding c. Neutropenia d. Thrombocytopenia
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27, or 36. And here, in this benign attention to the comfort of sick people, you will observe the usual effect of a fine art to soften and refine the feelings. The world in general, gentlemen, are very bloodyminded; and all they want in a murder is a copious effusion of blood; gaudy display in this point is enough for them. But the enlightened connoisseur is more refined in his taste; and from our art, as from all the other liberal arts when thoroughly mastered, the result is, to humanise the heart.
A philosophic friend, well known for his philanthropy and general benignity, suggests that the subject chosen ought also to have a family of young children wholly dependent upon his exertions, by way of deepening the pathos. And, undoubtedly, this is a judicious caution. Yet I would not insist too keenly on such a condition. Severe good taste unquestionably suggests it; but still, where the man was otherwise unobjectionable in point of morals and health, I would not look with too curious a jealousy to a restriction which might have the effect of narrowing the artist’s sphere.
So much for the person. As to the time, the place, and the tools, I have many things to say, which at present I have no room for The good sense of the practitioner has usually directed him to night and privacy. Yet there have not been wanting cases where this rule was departed from with excellent effect.
L B , whose works are variously adjudged by the critics, owes much to the fact that he was possessed of a distinct and definite sense of humor.
It is that which saves many of his long and dull stretches of verse from utter unreadability.
His facile rhymes, apparently tossed off with little of or no effort, embody in the best possible manner his graceful fun.
The ottava rima of Don Juan, though often careless, even slovenly as to technical details, is surely the meter best fitted for the
theme.
Juan embarked the ship got under way, The wind was fair, the water passing rough; A devil of a sea rolls in that bay, As I, who’ve crossed it oft, know well enough; And, standing upon deck, the dashing spray Flies in one’s face, and makes it weather-tough; And there he stood to take, and take again, His first—perhaps his last—farewell of Spain.
I can’t but say it is an awkward sight
To see one’s native land receding through The growing waters; it unmans one quite, Especially when life is rather new. I recollect Great Britain’s coast looks white, But almost every other country’s blue, When gazing on them, mystified by distance, We enter on our nautical existence.
So Juan stood, bewildered on the deck:
The wind sung, cordage strained, and sailors swore, And the ship creaked, the town became a speck, From which away so fair and fast they bore. The best of remedies is a beef-steak Against sea-sickness: try it, sir, before You sneer, and I assure you this is true, For I have found it answer so may you
“And oh! if e’er I should forget, I swear But that’s impossible, and cannot be Sooner shall this blue ocean melt to air, Sooner shall earth resolve itself to sea, Than I resign thine image, oh, my fair! Or think of anything excepting thee; A mind diseased no remedy can physic.”
(Here the ship gave a lurch and he grew sea-sick.)
“Sooner shall heaven kiss earth!” (Here he fell sicker.)
“Oh, Julia! what is every other woe?
(For God’s sake let me have a glass of liquor; Pedro, Battista, help me down below.)
Julia, my love! (you rascal, Pedro, quicker)
Oh, Julia! (this curst vessel pitches so) Beloved Julia, hear me still beseeching!” (Here he grew inarticulate with retching )
He felt that chilling heaviness of heart, Or rather stomach, which, alas! attends, Beyond the best apothecary’s art, The loss of love, the treachery of friends, Or death of those we dote on, when a part Of us dies with them as each fond hope ends No doubt he would have been much more pathetic, But the sea acted as a strong emetic
AFTER SWIMMING THE HELLESPONT
If, in the month of dark December, Leander, who was nightly wont (What maid will not the tale remember?)
To cross thy stream, broad Hellespont;
If, when the wint’ry tempest roar’d, He sped to Hero nothing loath, And thus of old thy current pour’d, Fair Venus! how I pity both!
For me, degenerate, modern wretch, Though in the genial month of May, My dripping limbs I faintly stretch, And think I’ve done a feat to-day
But since he crossed the rapid tide, According to the doubtful story, To woo—and—Lord knows what beside, And swam for Love, as I for Glory;
’Twere hard to say who fared the best: Sad mortals, thus the gods still plague you! He lost his labour, I my jest; For he was drowned, and I’ve the ague.
Thomas Hood, versatile alike in humorous or pathetic vein, was a prolific and successful punster. If the form could be forgiven anybody it must be condoned in his case. He also was apt at parody and often blended pathos and tragedy with his humorous work.
FAITHLESS NELLY GRAY
A PATHETIC BALLAD
Ben Battle was a soldier bold, And used to war’s alarms; But a cannon-ball took off his legs, So he laid down his arms!
Now, as they bore him off the field, Said he, “Let others shoot, For here I leave my second leg, And the Forty-Second Foot!”
The army-surgeons made him limbs; Said he, “they’re only pegs: But there’s as wooden Members quite As represent my legs!”
Now Ben he loved a pretty maid, Her name was Nelly Gray; So he went to pay her his devours, When he devoured his pay!
But when he called on Nelly Gray, She made him quite a scoff; And when she saw his wooden legs, Began to take them off!
“O, Nelly Gray! O, Nelly Gray! Is this your love so warm? The love that loves a scarlet coat Should be more uniform!”
Said she, “I loved a soldier once, For he was blithe and brave; But I will never have a man With both legs in the grave!
“Before you had those timber toes, Your love I did allow; But then, you know, you stand upon Another footing now!”
“O, Nelly Gray! O, Nelly Gray! For all your jeering speeches;
At duty’s call I left my legs, In Badajos’s breeches!”
“Why then,” said she, “you’ve lost the feet Of legs in war’s alarms, And now you cannot wear your shoes Upon your feats of arms!”
“O, false and fickle Nelly Gray! I know why you refuse: Though I’ve no feet some other man Is standing in my shoes!
“I wish I ne’er had seen your face; But now, a long farewell! For you will be my death; alas! You will not be my Nell!”
Now when he went from Nelly Gray His heart so heavy got, And life was such a burden grown, It made him take a knot!
So round his melancholy neck
A rope he did entwine, And, for his second time in life, Enlisted in the Line.
One end he tied around a beam, And then removed his pegs, And, as his legs were off of course He soon was off his legs!
And there he hung, till he was dead As any nail in town For though distress had cut him up, It could not cut him down!
A dozen men sat on his corpse, To find out why he died And they buried Ben in four cross-roads, With a stake in his inside!
NO!
No sun no moon!
No morn no noon
No dawn no dusk no proper time of day
No sky no earthly view
No distance looking blue
No road no street no “t’other side the way”
No end to any Row
No indications where the Crescents go—
No top to any steeple—
No recognitions of familiar people—
No courtesies for showing ’em
No knowing ’em!
To travelling at all no locomotion,
No inkling of the way no notion
No go by land or ocean
No mail no post
No news from any foreign coast
No park no ring no afternoon gentility
No company no nobility
No warmth, no cheerfulness, no healthful ease,
No comfortable feel in any member
No shade, no shine, no butterflies, no bees
No fruits, no flowers, no leaves, no birds November!
The brothers James and Horace Smith, wrote what was in their day considered lively and amusing humor, but which seems a trifle dry to us. Their greatest work was the Rejected Addresses, a series of parodies on the poets, such as Wordsworth, Southey, Coleridge, Scott, Moore and many others.
One of these, an imitation of Wordsworth’s most simple style, succeeds in parodying his mawkish affectations of childish simplicity and nursery stammering.
THE BABY’S DÉBUT
[Spoken in the character of Nancy Lake, a girl eight years of age, who is drawn upon the stage in a child’s chaise by Samuel Hughes, her uncle’s porter ]
My brother Jack was nine in May, And I was eight on New-Year’s day;
So in Kate Wilson’s shop
Papa (he’s my papa and Jack’s) Bought me, last week, a doll of wax, And brother Jack a top
Jack’s in the pouts, and this it is, He thinks mine came to more than his; So to my drawer he goes, Takes out the doll, and, oh, my stars! He pokes her head between the bars, And melts off half her nose!
Quite cross, a bit of string I beg, And tie it to his peg-top’s peg, And bang, with might and main, Its head against the parlour-door: Off flies the head, and hits the floor, And breaks a window-pane.
This made him cry with rage and spite: Well, let him cry, it serves him right. A pretty thing, forsooth!
If he’s to melt, all scalding hot, Half my doll’s nose, and I am not To draw his peg-top’s tooth!
Aunt Hannah heard the window break, And cried, “Oh naughty Nancy Lake, Thus to distress your aunt: No Drury-Lane for you to-day!”
And while papa said, “Pooh, she may!” Mamma said, “No, she sha’n’t!”
Well, after many a sad reproach, They get into a hackney coach, And trotted down the street
I saw them go: one horse was blind, The tails of both hung down behind, Their shoes were on their feet
The chaise in which poor brother Bill Used to be drawn to Pentonville, Stood in the lumber-room: I wiped the dust from off the top,
While Molly mopp’d it with a mop, And brush’d it with a broom.
My uncle’s porter, Samuel Hughes, Came in at six to black the shoes (I always talk to Sam): So what does he, but takes, and drags Me in the chaise along the flags, And leaves me where I am
My father’s walls are made of brick, But not so tall, and not so thick As these; and, goodness me! My father’s beams are made of wood, But never, never half so good As those that now I see.
What a large floor! ’tis like a town! The carpet, when they lay it down, Won’t hide it, I’ll be bound; And there’s a row of lamps! my eye! How they do blaze! I wonder why They keep them on the ground.
At first I caught hold of the wing, And kept away; but Mr. Thingum bob, the prompter man, Gave with his hand my chaise a shove, And said, “Go on, my pretty love; Speak to ’em, little Nan.
“You’ve only got to curtsey, whisper, hold your chin up, laugh, and lisp, And then you’re sure to take: I’ve known the day when brats, not quite Thirteen, got fifty pounds a night; Then why not Nancy Lake?”
But while I’m speaking, where’s papa? And where’s my aunt? and where’s mamma? Where’s Jack? Oh, there they sit! They smile, they nod; I’ll go my ways, And order round poor Billy’s chaise, To join them in the pit
And now, good gentlefolks, I go To join mamma, and see the show; So, bidding you adieu, I curtsey, like a pretty miss, And if you’ll blow to me a kiss, I’ll blow a kiss to you
THE MILKMAID AND THE BANKER
A Milkmaid, with a pretty face, Who lived at Acton,
Had a black cow, the ugliest in the place, A crooked-backed one, A beast as dangerous, too, as she was frightful, Vicious and spiteful; And so confirmed a truant that she bounded Over the hedges daily and got pounded:
’Twas in vain to tie her with a tether, For then both cow and cord eloped together Armed with an oaken bough—(what folly! It should have been of thorn, or prickly holly), Patty one day was driving home the beast, Which had as usual slipped its anchor, When on the road she met a certain Banker, Who stopped to give his eyes a feast, By gazing on her features crimsoned high By a long cow-chase in July.
“Are you from Acton, pretty lass?” he cried; “Yes” with a courtesy she replied.
“Why, then, you know the laundress, Sally Wrench?”
“Yes, she’s my cousin, sir, and next-door neighbor.”
“That’s lucky I’ve a message for the wench Which needs despatch, and you may save my labor. Give her this kiss, my dear, and say I sent it: But mind, you owe me one I’ve only lent it ”
[Blows a kiss, and exit
“She shall know,” cried the girl, as she brandished her bough, “Of the loving intentions you bore me; But since you’re in haste for the kiss, you’ll allow, That you’d better run forward and give it my cow, For she, at the rate she is scampering now, Will reach Acton some minutes before me.”
H S .
THE JESTER CONDEMNED TO DEATH
One of the Kings of Scanderoon, A royal jester, Had in his train a gross buffoon, Who used to pester The Court with tricks inopportune, Venting on the highest folks his Scurvy pleasantries and hoaxes. It needs some sense to play the fool, Which wholesome rule Occurred not to our jackanapes, Who consequently found his freaks Lead to innumerable scrapes, And quite as many kicks and tweaks, Which only seemed to make him faster Try the patience of his master
Some sin, at last, beyond all measure, Incurred the desperate displeasure Of his serene and raging highness: Whether he twitched his most revered And sacred beard, Or had intruded on the shyness Of the seraglio, or let fly An epigram at royalty, None knows: his sin was an occult one, But records tell us that the Sultan, Meaning to terrify the knave, Exclaimed, “’Tis time to stop that breath: Thy doom is sealed, presumptuous slave! Thou stand’st condemned to certain death: Silence, base rebel! no replying! But such is my indulgence still, That, of my own free grace and will, I leave to thee the mode of dying ”
“Thy royal will be done ’tis just,” Replied the wretch, and kissed the dust; “Since, my last moments to assuage, Your majesty’s humane decree Has deigned to leave the choice to me, I’ll die, so please you, of old age!”
H S
It is to be regretted that the feminine writers of this period showed practically no evidence of humorous scintillation, but we have searched in vain through the writings of Ann and Jane Taylor, Mary Russell Mitford, Felicia Hemans and Letitia Elizabeth Landon,— finding only some unconscious humor, not at all intentional on the part of the authoresses, as they were then called.
William Maginn was also adept at parody, but his work was ephemeral.
The rollicking rhyme of the Irishman is among the most interesting of his poems.
THE IRISHMAN
There was a lady lived at Leith, A lady very stylish, man, And yet, in spite of all her teeth, She fell in love with an Irishman, A nasty, ugly Irishman,
A wild, tremendous Irishman, A tearing, swearing, thumping, bumping, ranting, roaring Irishman.
His face was no ways beautiful, For with small-pox ’twas scarred across, And the shoulders of the ugly dog
Were almost double a yard across Oh, the lump of an Irishman,
The whisky-devouring Irishman, The great he-rogue, with his wonderful brogue, the fighting, rioting Irishman!
One of his eyes was bottle-green, And the other eye was out, my dear, And the calves of his wicked-looking legs Were more than two feet about, my dear.
Oh, the great big Irishman,
The rattling, battling Irishman, The stamping, ramping, swaggering, staggering, leathering swash of an Irishman!
He took so much of Lundy-foot
That he used to snort and snuffle, oh, And in shape and size the fellow’s neck Was as bad as the neck of a buffalo.
Oh, the horrible Irishman,
The thundering, blundering Irishman, The slashing, dashing, smashing, lashing, thrashing, hashing Irishman!
His name was a terrible name indeed, Being Timothy Thady Mulligan; And whenever he emptied his tumbler of punch, He’d not rest till he’d filled it full again
The boozing, bruising Irishman, The ’toxicated Irishman, The whisky, frisky, rummy, gummy, brandy, no-dandy Irishman
This was the lad the lady loved, Like all the girls of quality; And he broke the skulls of the men of Leith, Just by the way of jollity.
Oh, the leathering Irishman,
The barbarous, savage Irishman!
The hearts of the maids and the gentlemen’s heads were bothered, I’m sure, by this Irishman.
Thomas Haynes Bayly, though not especially a humorist, showed the influence of a witty muse in his songs, which were numerous and popular.
She Wore a Wreath of Roses, Oh, No, We Never Mention Her and Gaily the Troubadour Touched his Guitar are among the best remembered.
He was the author of many bright bits of Society Verse, and wrote some deep and very real satire.
WHY DON’T THE MEN PROPOSE?
Why don’t the men propose, mamma? Why don’t the men propose? Each seems just coming to the point, And then away he goes; It is no fault of yours, mamma, That everybody knows; You fête the finest men in town, Yet, oh! they won’t propose
I’m sure I’ve done my best, mamma,
To make a proper match; For coronets and eldest sons, I’m ever on the watch; I’ve hopes when some distingué beau A glance upon me throws; But though he’ll dance and smile and flirt, Alas! he won’t propose
I’ve tried to win by languishing, And dressing like a blue; I’ve bought big books and talked of them As if I’d read them through! With hair cropp’d like a man I’ve felt The heads of all the beaux; But Spurzheim could not touch their hearts, And oh! they won’t propose.
I threw aside the books, and thought That ignorance was bliss; I felt convinced that men preferred A simple sort of Miss; And so I lisped out nought beyond Plain “yesses” or plain “noes,” And wore a sweet unmeaning smile; Yet, oh! they won’t propose.
Last night at Lady Ramble’s rout I heard Sir Henry Gale Exclaim, “Now I propose again ” I started, turning pale; I really thought my time was come, I blushed like any rose; But oh! I found ’twas only at Ecarté he’d propose
And what is to be done, mamma? Oh, what is to be done? I really have no time to lose, For I am thirty-one; At balls I am too often left Where spinsters sit in rows; Why don’t the men propose, mamma? Why won’t the men propose?
Frederick Marryat, oftener spoken of as Captain Marryat was among the most renowned writers of sea stories, and easily the most humorous of the authors who chose the sea for their fictional setting.
His books are well known in all households, and after Dickens there is probably no English novelist who has caused more real chuckles.
NAUTICAL TERMS
All the sailors were busy at work, and the first lieutenant cried out to the gunner, “Now, Mr. Dispart, if you are ready, we’ll breech these guns.”
“Now, my lads,” said the first lieutenant, “we must slug (the part the breeches cover) more forward.” As I never had heard of a gun having breeches, I was very curious to see what was going on, and went up close to the first lieutenant, who said to me, “Youngster, hand me that monkey’s tail.” I saw nothing like a monkey’s tail, but I was so frightened that I snatched up the first thing that I saw, which was a short bar of iron, and it so happened that it was the very article which he wanted. When I gave it to him, the first lieutenant looked at me, and said, “So you know what a monkey’s tail is already, do you? Now don’t you ever sham stupid after that.”
Thought I to myself, I’m very lucky, but if that’s a monkey’s tail, it’s a very stiff one!
I resolved to learn the names of everything as fast as I could, that I might be prepared, so I listened attentively to what was said; but I soon became quite confused, and despaired of remembering anything.
“How is this to be finished off, sir?” inquired a sailor of the boatswain.
“Why, I beg leave to hint to you, sir, in the most delicate manner in the world,” replied the boatswain, “that it must be with a double-wall —and be damned to you—don’t you know that yet? Captain of the foretop,” said he, “up on your horses, and take your stirrups up three
inches.” “Aye, aye, sir.” I looked and looked, but I could see no horses.
“Mr Chucks,” said the first lieutenant to the boatswain, “what blocks have we below—not on charge?”
“Let me see, sir. I’ve one sister, t’other we split in half the other day, and I think I have a couple of monkeys down in the store-room. I say, you Smith, pass that brace through the bull’s eye, and take the sheep-shank out before you come down.”
And then he asked the first lieutenant whether something should not be fitted with a mouse or only a Turk’s-head—told him the gooseneck must be spread out by the armourer as soon as the forge was up. In short, what with dead-eyes and shrouds, cats and cat-blocks, dolphins and dolphin-strikers, whips and puddings, I was so puzzled with what I heard, that I was about to leave the deck in absolute despair.
“And, Mr. Chucks, recollect this afternoon that you bleed all the buoys.”
Bleed the boys, thought I; what can that be for? At all events, the surgeon appears to be the proper person to perform that operation.
Peter Simple.
Douglas Jerrold was an infant prodigy and later a noted playwright; beside being the author of the world famous Caudle lectures.
He was a celebrated wit and punster and though many epigrammatic sayings are wrongly attributed to him, yet he was the originator of as many more.
COLD MUTTON, PUDDING, PANCAKES
“What am I grumbling about, now? It’s very well for you to ask that! I’m sure I’d better be out of the world than—there now, Mr Caudle; there you are again! I shall speak, sir. It isn’t often I open my mouth, Heaven knows! But you like to hear nobody talk but yourself. You ought to have married a negro slave, and not any respectable woman.
“You’re to go about the house looking like thunder all the day, and I’m not to say a word. Where do you think pudding’s to come from every day? You show a nice example to your children, you do; complaining, and turning your nose up at a sweet piece of cold mutton, because there’s no pudding! You go a nice way to make ’em extravagant—teach ’em nice lessons to begin the world with. Do you know what puddings cost; or do you think they fly in at the window?
“You hate cold mutton. The more shame for you, Mr. Caudle. I’m sure you’ve the stomach of a lord, you have. No, sir; I didn’t choose to hash the mutton. It’s very easy for you to say hash it; but I know what a joint loses in hashing: it’s a day’s dinner the less, if it’s a bit. Yes, I dare say; other people may have puddings with cold mutton. No doubt of it; and other people become bankrupts. But if ever you get into the Gazette, it sha’n’t be my fault—no; I’ll do my duty as a wife to you, Mr. Caudle; you shall never have it to say that it was my housekeeping that brought you to beggary. No; you may sulk at the cold meat—ha! I hope you’ll never live to want such a piece of cold mutton as we had to-day! and you may threaten to go to a tavern to dine; but, with our present means, not a crumb of pudding do you get from me. You shall have nothing but the cold joint—nothing, as I’m a Christian sinner.
“Yes; there you are, throwing those fowls in my face again! I know you once brought home a pair of fowls; I know it; but you were mean enough to want to stop ’em out of my week’s money! Oh, the selfishness—the shabbiness of men! They can go out and throw away pounds upon pounds with a pack of people who laugh at ’em afterward; but if it’s anything wanted for their own homes, their poor wives may hunt for it. I wonder you don’t blush to name those fowls again! I wouldn’t be so little for the world, Mr. Caudle!
“What are you going to do? Going to get up? Don’t make yourself ridiculous, Mr. Caudle; I can’t say a word to you like any other wife, but you must threaten to get up. Do be ashamed of yourself.
“Puddings, indeed! Do you think I’m made of puddings? Didn’t you have some boiled rice three weeks ago? Besides, is this the time of the year for puddings? It’s all very well if I had money enough
allowed me like any other wife to keep the house with; then, indeed, I might have preserves like any other woman; now, it’s impossible; and it’s cruel—yes, Mr. Caudle, cruel—of you to expect it.
“Apples ar’n’t so dear, are they? I know what apples are, Mr. Caudle, without your telling me. But I suppose you want something more than apples for dumplings? I suppose sugar costs something, doesn’t it? And that’s how it is. That’s how one expense brings on another, and that’s how people go to ruin.
“Pancakes? What’s the use of your lying muttering there about pancakes? Don’t you always have ’em once a year—every Shrove Tuesday? And what would any moderate, decent man want more?
“Pancakes, indeed! Pray, Mr. Caudle—no, it’s no use your saying fine words to me to let you go to sleep; I sha’n’t. Pray, do you know the price of eggs just now? There’s not an egg you can trust to under seven and eight a shilling; well, you’ve only just to reckon up how many eggs—don’t lie swearing there at the eggs in that manner, Mr. Caudle; unless you expect the bed to let you fall through. You call yourself a respectable tradesman, I suppose? Ha! I only wish people knew you as well as I do! Swearing at eggs, indeed! But I’m tired of this usage, Mr. Caudle; quite tired of it; and I don’t care how soon it’s ended!
“I’m sure I do nothing but work and labour, and think how to make the most of everything; and this is how I’m rewarded.”
Mrs. Caudle’s Curtain Lectures.
“Call that a kind man,” said an actor of an absent acquaintance; “a man who is away from his family, and never sends them a farthing! Call that kindness!” “Yes, unremitting kindness,” Jerrold replied.
Some member of “Our Club,” hearing an air mentioned, exclaimed: “That always carries me away when I hear it.” “Can nobody whistle it?” exclaimed Jerrold.
A friend said to Jerrold: “Have you heard about poor R—— [a lawyer]? His business is going to the devil.” Jerrold answered: “That’s all right: then he is sure to get it back again.”
If an earthquake were to engulf England to-morrow, the English would meet and dine somewhere just to celebrate the event.
Of a man who had pirated one of his jests, and who was described in his hearing as an honest fellow, he said, “Oh yes, you can trust him with untold jokes.”
Jerrold met Alfred Bunn one day in Piccadilly. Bunn stopped Jerrold, and said, “I suppose you’re strolling about, picking up character.” “Well, not exactly,” said Jerrold, “but there’s plenty lost hereabouts.”
Jerrold was seriously disappointed with a certain book written by one of his friends. This friend heard that he had expressed his disappointment. Friend (to Jerrold): “I heard you said it was the worst book I ever wrote.” Jerrold: “No, I didn’t. I said it was the worst book anybody ever wrote.”
Some one was talking with him about a gentleman as celebrated for the intensity as for the shortness of his friendships. “Yes,” said Jerrold, “his friendships are so warm, that he no sooner takes them up than he puts them down again.”
Thomas Moore, called the most successful Irishman of letters of the nineteenth century, early developed a taste for music and a talent for versification. To this add his native wit, and we have a humorist of no mean order.
He wrote epistles, odes, satires and songs with equal facility, and to these he added books of travel and biography and history. His quick wit is shown in his lighter verse and epigrams.
NONSENSE
Good reader, if you e’er have seen, When Phœbus hastens to his pillow, The mermaids with their tresses green Dancing upon the western billow; If you have seen at twilight dim, When the lone spirit’s vesper hymn Floats wild along the winding shore, The fairy train their ringlets weave Glancing along the spangled green;— If you have seen all this, and more, God bless me! what a deal you’ve seen!
LYING
I do confess, in many a sigh, My lips have breath’d you many a lie, And who, with such delights in view, Would lose them for a lie or two?
Nay look not thus, with brow reproving: Lies are, my dear, the soul of loving! If half we tell the girls were true, If half we swear to think and do, Were aught but lying’s bright illusion, The world would be in strange confusion! If ladies’ eyes were, every one, As lovers swear, a radiant sun, Astronomy should leave the skies, To learn her lore in ladies’ eyes! Oh no! believe me, lovely girl, When nature turns your teeth to pearl, Your neck to snow, your eyes to fire,
Your yellow locks to golden wire, Then, only then, can heaven decree, That you should live for only me, Or I for you, as night and morn, We’ve swearing kiss’d, and kissing sworn And now, my gentle hints to clear, For once, I’ll tell you truth, my dear! Whenever you may chance to meet A loving youth, whose love is sweet, Long as you’re false and he believes you, Long as you trust and he deceives you, So long the blissful bond endures; And while he lies, his heart is yours: But, oh! you’ve wholly lost the youth
The instant that he tells you truth!
WHAT’S MY THOUGHT LIKE?
Quest Why is a Pump like Viscount Castlereagh?
Answ Because it is a slender thing of wood, That up and down its awkward arm doth sway, And coolly spout, and spout, and spout away, In one weak, washy, everlasting flood!
OF ALL THE MEN
Of all the men one meets about, There’s none like Jack he’s everywhere: At church park auction dinner rout
Go when and where you will, he’s there Try the West End, he’s at your back Meets you, like Eurus, in the East You’re call’d upon for “How do, Jack?”
One hundred times a day, at least A friend of his one evening said, As home he took his pensive way, “Upon my soul, I fear Jack’s dead I’ve seen him but three times to-day!”
ON TAKING A WIFE
“Come, come,” said Tom’s father, “at your time of life, There’s no longer excuse for thus playing the rake It is time you should think, boy, of taking a wife ” “Why, so it is, father,—whose wife shall I take?”
