Download Complete medical history

EVALUATION AND
MANAGEMENT OF
DENTAL PATIENT WITH
VIRAL HEPATITIS
HEPATITIS
23
EVALUATION AND MANAGEMENT
OF DENTAL PATIENT WITH VIRAL
HEPATITIS
INTRODUCTION
Hepatitis is a worldwide health problem, with more than 5 million new cases occurring
annually and more than 300 million persons across the globe carrying the viruses. Regional
incidence rates are lowest in the Western hemisphere and northern regions and highest in the
Eastern hemisphere and tropical regions.[1]
Acute viral hepatitis is the most common form of infectious hepatitis. Five distinct viruses
(types A, B, C, D and E) are associated with this disease (Table 1). These viruses each
belong to a different family with distinct antigenic properties.
The patient with liver disease presents a significant management challenge for the dentist
because the liver plays a vital role in metabolic functions. Viral hepatitis and alcoholic liver
disease are two of the more common liver disorders. In
many cases, the liver dysfunction continues to progress
over time. Therefore, patients with liver disorders are of
significant interest to the dentist, as is their proper
management. [2]
Equally important, a number of patients become chronic
carriers of hepatitis antigen and are potentially
infectious. An understanding of the various types of viral
hepatitis and the common modes of transmission is
important in the prevention of infection. The dentist is
particularly at risk because exposure to the oral
secretions and blood of potentially infectious patients.
HEPATITIS
24
Table 1 Causes of viral hepatitis
Common causes
Less common
Rare
Hepatitis A
Cytomegalovirus Herpes simplex
Hepatitis B ± hepatitis D
Hepatitis C
Epstein-Barr
Yellow fever
Hepatitis E
virus
Hepatitis A: causes acute but not chronic hepatitis.
Hepatitis B: causes acute and chronic hepatitis.
Hepatitis C: causes chronic hepatitis but rarely manifests as
acute hepatitis.
Hepatitis D: rare and only occurs in patients infected with
hepatitis B.
Hepatitis E: clinically similar to hepatitis A but restricted to
endemic areas.
OTHERS: e.g., Epstein-Barr Virus (EBV, Mononucleosis)
and Cytomegalovirus (CMV) are not addressed within this
guideline.
HEPATITIS
25
MEDICAL EVALUATION OF PATIENTS
WITH HEPATITIS
CLINICAL FEATURES OF ACUTE INFECTION:
All these distinct viruses (types A, B, C, D, and E) cause illnesses with similar clinical and
pathological features and which are frequently an icteric or even asymptomatic. They differ
in their tendency to cause acute and chronic infections. The features of the major hepatitis
viruses are shown in table 2 [3]
A non specific prodromal illness characterized by headache, myalgia, arthralgia, nausea, and
anorexia usually precedes the development of jaundice by a
few days to 2weeks. Vomiting and diarrhoea may follow
and abdominal discomfort is common. Dark urine and pale
stools may precede jaundice. There are usually few physical
signs. The liver is often tender but only minimally enlarged.
Occasionally.
Mild
splenomegaly
and
cervical
lymphadenopathy are seen. These are more frequent in
children or those with Epstein-Barr virus infection.
Jaundice may be mild and the diagnosis may be suspected
only after finding abnormal liver blood tests in the setting
of non-specific symptoms. Symptoms rarely last longer
than 3-6 weeks. [2]
LABORATORY FINDINGS
Hepatitis A is diagnosed by the presence of elevated IgM anti-HAV for 2 to 4 weeks during
the acute phase of the infection, and later by a rise in IgG anti-HAV that indicates the
convalescent phase. [8]
The serologic relationships that occur during hepatitis B virus infection are summarized as
follows [1]:
 The first markers to appear in blood are HBsAg, HBeAg, and HBV DNA, followed by
antibodies against the core antigen (IgM anti-HBc and IgG anti-HBc). IgM antibodies
are markers of acute infection.
 IgG antibodies contribute to control of disease and indicate immunity.
 The presence of the virus surface antigen (HBsAg) indicates acute or chronic hepatitis
B; the patient is infectious.
 The antibody against the surface antigen (anti-HBs) indicates previous exposure to
HBV, HBV vaccination, or hepatitis B hyperimmunoglobulin (HBIG) prophylaxis. It
connotes recovery and immunity to HBV. If HBsAg is present with antibody response
(anti-HBs), the antibody is ineffective and the patient has chronic hepatitis.
 The hepatitis B virus core antigen (HBcAg) is present in liver and is not secreted
during acute or chronic disease but elicits an antibody response.
HEPATITIS
26
 HBeAg is a truncated form of HBcAg that is secreted into the blood. The presence f
HBeAg correlates with high infectivity. Antibody to HBeAg (anti-HBe) is an indicator
of decreased infectivity and recovery.
 The diagnostic markers that most accurately predict acute hepatitis B are HBsAg and
IgM anti-HBc.
Table 2 Features of the main hepatitis viruses
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Virus
Enterovirus Hepadna
Flavivirus
Incomplete Calicivirus
Group
virus
RNA
DNA
RNA
RNA
RNA
Nucleic
acid
27 nm
42 nm
30-38 nm
35 nm
27 nm
Size
(diameter)
4-20
2-26
6-9
3-8
Incubation 2-4
(weeks)
Spread
Yes
No
No
No
Yes
Faeces
Uncommon
Yes
Yes
Yes
No
Blood
Yes
Yes
Yes
?
?
Saliva
Uncommon Yes
Uncommon Yes
?
Sexual
No
Yes
Uncommon Yes
No
Vertical
No
Yes
Yes
Yes
No
Chronic
infection
Prevention
Vaccine
Vaccine
No
Prevented
No
Active
by
immune
HyperNo
Hepatitis B No
Passive
serum
immune
Vaccination
globulin
serum
globulin
Note: all body fluid are potentially infectious, although some (e.g. urine) are less
infectious than others.
HEPATITIS
27
SPECIFIC VIRAL HEPATITIS
Although the hepatitis viruses all cause similar hepatic illness they belong to distinct viral
HEPATITIS A
The hepatitis A virus (HAV) belongs to the picomvirus
group of enteroviruses, HAV is high infectious and is
spread by the fecal-oral route. Infected individuals,
who may be asymptomatic, excrete the virus in faeces
for about 2-3 weeks before the onset of symptoms and
then for a further 2 weeks or so. Its incubation period
ranges from 15 to 50 days and averages 25 days.
Serologic testing for IgM anti-HAV and IgG anti-HAV
may reveal a recent infection. No carrier state is known to
exist for it, and recovery usually conveys immunity
against re-infection. [2] [4]
Prognosis: Acute liver failure complicates acute hepatitis A in only 0.1 of cases and chronic
infection does not occur.
HEPATITIS B:
The intact HBV, or Dane particle, is composed of an outer shell and an inner core. The outer
shell is known as hepatitis B surface antigen (HBsAg) as in Figure 1. It circulates in the
blood for up to 6 months after infection, depending
on resolution of the infection. The inner core of the
particle is the hepatitis B core antigen (HBcAg),
with corresponding antibodies IgG anti-HBc and
IgM anti-HBc (indicating recent infection). A third
particle is the hepatitis B early antigen (HBeAg),
an antigenic component derived from cleavage of
the core antigen. It is related to hepatitis B
infectivity. Hepatitis B may be transmitted
efficiently by percutaneous, permucosal exposure
and sexual activity (Table 3). The incubation
period ranges from 45 to 180 days and averages 75
days. [2] [4] The virus is about ten times more infectious than hepatitis C, which in turn is
about ten times more infectious than HIV.[1]
Hepatitis B may cause an acute viral hepatitis; however, the acute infection is often
asymptomatic, particularly when acquired at birth. Many individuals with chronic hepatitis B
HEPATITIS
28
are also asymptomatic. Chronic hepatitis, associated with elevated serum transaminases,
may occur and can lead to cirrhosis, usually after decades of infection.[3] The lifetime risk of
hepatitis B occurrence among the general population is low; however, some groups have a
much higher risk (Table 3). Included among these are dental personnel and other health care
workers. .[1]
The risk of infection is directly related to exposure to blood, resulting in are ported
prevalence rate of past infection among general dentists in the 1980s ranging from 13% to
30%. Among oral surgeons, the prevalence rate was as high as 38%. More recent reports cite
the prevalence for general dentists at 7.8% to 8.9% and for oral surgeons at 21%. This
reduction presumably reflects the effectiveness of vaccination and infection control
measures. [5] [6] [7] Compared with hepatitis A, hepatitis B tends to cause greater morbidity
and mortality, especially in the very young and in older patients. [7]
Figure 1 schematic diagram of hepatitis B virus. Hepatitis B surface antigen (HBsAg) is a
protein which makes up part of the viral envelope. Hepatitis B core antigen (HBcAg) is a
protein which makes up the capsid or core part of the virus (found in the liver but not in
blood). Hepatitis B e antigen (HBeAg) is part of the HBcAg which can be found in the blood
and indicates infectivity. [3]
HEPATITIS
29
Table 3 Source of f hepatitis B infection and risk of chronic infection
Route of transmission
Horizontal transmission
Injection drug use
infected unscreened blood products
Tattoos/acupuncture needles
Sexual (homosexual and heterosexual)
Vertical transmission
HBsAg-positive mother
Risk of chronic infection
10%
90%
HEPATITIS D (DELTA VIRUS):
THE hepatitis D virus (HDV) is an RNA - defective
virus which has no independent existence; it requires
HBV for replication and has the same source and
modes of spread. It can infect individuals
simultaneously with HBV, or can super-infect those
who are already chronic carriers of HBV. HDV is
endemic in parts of the Mediterranean basin, Africa and
South America, where transmission is mainly by close
personal contact and occasionally by vertical
transmission from mothers who also carry HBV. [3]
HEPATITIS C:
This is caused by an RNA flavivirus. Acute symptomatic infection with hepatitis C is rare.
Most individuals will be unaware of when they became infected and are only identified when
they develop chronic liver disease. Hepatitis C is the cause
of what used to be known as 'non-A, non B hepatitis', a
syndrome of acute hepatitis often with jaundice seen after a
transfusion of blood or blood products. [3]
Hepatitis C infection is usually now identified in
asymptomatic individuals screened because they have risk
factors for infection such as previous injection drug use or
because they have incidentally been found to have abnormal
liver blood tests. Although most individuals remain
asymptomatic until progression to cirrhosis occurs, fatigue
can complicate chronic infection and appears to be unrelated
to the liver damage. [3]
HCV is similar to HBV in terms of behavior and characteristics. The incubation period of
HCV ranges from 2 weeks to 6 months, with a median of 50 days.
HEPATITIS
30
Approximately 60% to 90% of HCV cases are transmitted by blood and blood products.
Those at greatest risk for this disease are injection drug users and those with large or repeated
percutaneous exposures. Others at increased risk are patients on hemodialysis, persons who
have multiple sexual partners or who have sexual contacts with those who have chronic
HCV, health care workers exposed to blood, and recipients of whole blood, blood cellular
components, or plasma. The risk of vertical transmission of HCV from infected mother to
infant is low, accounting for 5% of cases. [1]
Hepatitis E:
Hepatitis E is caused by RNA virus which is endemic in India
and the Middle East. The clinical presentation of hepatitis E is
similar to hepatitis A. It is spread via the fecal-oral route; in
most cases it presents as a self-limiting acute hepatitis and does
not cause chronic liver disease. [3]
Investigations: In acute infection IgM antibodies to HEV are positive. [3]
Prevention: There is no active or passive immunity to hepatitis E. [3]
OTHER FORMS OF VIRAL HEPATITIS: Non-A, Non-B, non-C (NANBNC) or nonA-E hepatitis is the term used to describe hepatitis though to be due to a virus that is not
HAV, HBV, HCV, or HEV. Other viruses which affect the liver probably do exist, but the
hepatitis viruses described above now account for the majority of hepatitis virus infections.
Cytomegalovirus and Epstein-Barr virus infection causes abnormal liver function tests in
most common patients, and occasionally icteric hepatitis occurs. [3]
MEDICAL MANAGEMENT OF PATIENT WITH HEPATITIS
Prevention through Active Immunization:
Risk for viral hepatitis is reduced through active
immunization.
Hepatitis A virus vaccines are safe and highly
immunogenic and are recommended for persons 2
years of age and older. [9]
The two vaccines licensed for prevention of HBV
infection are produced by recombinant DNA
technology. These vaccines are administered in
three doses over a 6-month period and produce an
HEPATITIS
31
effective antibody response in more than 90% of adults and 95% of infants, children, and
adolescents. [3] Current guidelines of the CDC's Advisory Committee on Immunization
Practices recommend booster doses only for persons who did not respond to the primary
vaccine series. [10][11][12] Vaccination of target populatio ns who were at high risk for
contracting HBV was recommended. Health care workers, including dentists, are at the top
of the list; it is strongly recommended that they be inoculated with the vaccine. [1] Postvaccination serologic testing is recommended to determine whether the vaccine is effective.
Prevention through Passive Immunization
Treatment of viral hepatitis can be accomplished through administration of early postexposure immune globulins or post-exposure hepatitis B vaccine. Immune serum globulin
(IG) consists of a pool of antibodies collected from human plasma that is free of HBsAg,
HCV, and HIV. [11]
Currently, no treatment is available or recommended for occupational post-exposure to HCV,
hepatitis E virus (HEV), and non–A-E hepatitis viruses {Centers for Disease Control and
Prevention (CDC)}. Recommendations are for follow-up of health-care workers after
occupational exposure to hepatitis C virus. [1]
Unvaccinated individuals (>2 years of age) recently exposed to HAV are advised to receive a
single 0.02-mL/kg intramuscular injection of immune globulin according to the Advisory
Committee on Immunization Practices recommendations. [1]
SPECIFIC PREVENTIVE MEASURES
Hepatitis A Prevention: Infection in the community is best prevented by improving social
conditions, especially overcrowding and poor sanitation. Immediate protection can be
provided by immune serum globulin if this is given soon after exposure to the virus.
Immunization should be considered for those at particular risk such as close contacts, the
elderly, those with other major diseases and perhaps pregnant women. [3]
Hepatitis B Prevention: A recombinant hepatitis B vaccine containing HBsAg is available
(Engerix) and is capable of producing active immunization in 95% of normal individuals.
The vaccine gives a high degree of protection and should be offered to those at special risk of
infection who are not already immune, as evidenced by anti-HBs in the blood. [3]
Hepatitis D Prevention: Preventing hepatitis B effectively prevents hepatitis D. [3]
Hepatitis C Prevention and prognosis: There is no active or passive protection against
HCV. Risk factors for progression include male gender, immunosupression (such as coinfection with HIV) and heavy alcohol misuse. [1]
HEPATITIS
32
TREATMENT
Acute hepatitis:
As with many viral diseases, basic therapy is palliative and supportive. Bed rest and fluids
may be prescribed, especially during the acute phase. A nutritious, high-calorie diet is
advised. Alcohol and drugs metabolized by the liver are not to be ingested. Viral antigen and
alanine aminotransferase (ALT) levels should be monitored for 6 months so that it can be
determined whether the hepatitis is resolving. [3]
Chronic hepatitis:
Chronic hepatitis rarely resolves spontaneously. Treatments are still limited, with no drug
able to eradicate hepatitis B infection completely. [3] Standard therapy for patients with
chronic hepatitis is interferon (IFN) alfa-2b (3 to 10 million units) administered three times
weekly for 6 months to 1 year. [1] The addition of lamivudine (a nucleoside analog active
against HBV) or ribavirin (a guanosine analog active against HCV) results in a virologic
response in an additional 15% to 25%. [3]
Liver transplantation is a last resort for patients who develop cirrhosis.
Neonates born to hepatitis B infected mothers should be immunized at birth and given
immunoglobulin. Hepatitis B serology should then be checked at 12 months of age. [3]
PROGNOSIS OF VIRAL HEPATITIS INFECTIONS:
Hepatitis A: Acute liver failure complicates acute hepatitis A in only 0.1 of cases and
chronic infection does not occur. However, HAV infection in patients with chronic liver
disease may cause serious or life-threatening disease. [3]
Acute hepatitis B: Full recovery occurs in 90-95%
of adults following acute HB V infection. The
remaining 5-10% develops a chronic infection
which usually continues for life, although later
recovery occasionally occurs. [3]
Chronic hepatitis B: Most patients with chronic
hepatitis B are asymptomatic and develop
complications such as cirrhosis and hepatocellular
carcinoma only after many years. Cirrhosis
develops in 15-20% of patients with chronic HBV
over 5-20 years. [3]
Hepatitis C: Not everyone with hepatitis C infection will necessarily develop cirrhosis but
approximately 20% do so with 20 years.
DENTAL EVALUATION OF PATIENT WITH HEPATITIS
Based upon the history, examination, and laboratory profile, the relative risk of hepatitis
infectivity can be assessed:
HEPATITIS
33
A) PATIENT AT LOW RISK:
1. Little to no risk of transmission of HAV, HEV: Patients with histories compatible
with hepatitis A-E infection who have normal liver tests and negative hepatitis
antigen are at low risk. Transmission (hepatitis A) by contaminated blood products
is rare, occurring early during the course of the infection when titers in blood can be
high and the patient is most infectious. . [2] [4]
2. Patients with histories of hepatitis B infection who have normal liver function tests,
negative antigen tests, and positive antibody tests are also not infectious. It connotes
recovery and immunity to HBV
B) PATIENT AT HIGH RISK:
1. Patients with positive surface antigen for hepatitis B are at high risk.
2. Patients with abnormal liver function tests are at high risk.
3. Patients with jaundice and symptoms of viral hepatitis are at high risk.
C) PERSONS AT SUBSTANTIAL RISK FOR HBV OR HCV INFECTION:
Several groups are at unusually high risk for HBV and HCV infection (see Table 4).
Screening for HBsAg and anti-HCV is recommended for individuals who fit into one
or more of these categories unless they are already known to be seropositive. Even if a
patient is found to be a carrier, no modifications in treatment approach theoretically
would be necessary. If a patient is found to be a carrier, the information could be of
extreme importance for modification of lifestyle. In addition, the patient might have
undetected chronic active hepatitis, which could lead to bleeding complications or
drug metabolism problems.
Table 4 Persons at Substantial Risk for Hepatitis B
• Individuals with occupational risk
• Health care workers
• Public safety workers
• Hemodialysis patients
• Recipients of certain blood products
• Illicit drug users
• Inmates of long-term correctional facilities
• International travelers
• Clients and staff of institutions for the developmentally disabled
• Household contacts and sex partners of hepatitis B virus (HBV) carriers
• Adoptees from countries where HBV infection is endemic
• Sexually active homosexual and bisexual men
• Sexually active heterosexual men and women (who have multiple partners)
From Centers for Disease Control. MMWR 1991;40:14-16.
HEPATITIS
34
DENTAL
MANAGEMENT
GENERAL RECOMMENDATIONS:
Recommendations for infection control practices in dentistry published by the Centers for
Disease Control (CDC) have become the standard of care for preventing cross-infection in
dental practice. We strongly recommend that all dental health care workers who provide
patient care should receive vaccination against hepatitis B virus and should implement
universal precautions during the care of all dental patients. In addition, em ployers must offer
hepatitis B vaccine to employees who are occupationally exposed to blood or other
potentially infectious materials. No recommendations have been provided for immunization
against the other hepatitis viruses. [17]
SPECIFIC CONSIDERATION:
1. PATIENTS AT LOW RISK:
Patients have low risk can be managed utilizing normal protocols with the single
addition of masks and gloves for the dentists and assistants.
2. PATIENTS AT HIGH RISK:
Patients with Signs or Symptoms of Hepatitis (Active Hepatitis):
Any patient who has signs or symptoms suggestive of hepatitis should not be given
elective dental treatment but instead should be referred immediately to a physician.
The dentist should refer the patient who has acute hepatitis for medical diagnosis and
treatment. [2] [4]
No dental treatment other than urgent care (absolutely necessary work) should be
rendered for a patient with active hepatitis unless the patient is clinically and
biochemically recovered. Necessary emergency dental care should be provided with
the use of an isolated operatory and minimal aerosol production.
HEPATITIS
35
Urgent care should be provided only in:
 An isolated operatory with adherence to strict standard precautions.
 Aerosols should be minimized and
 Drugs metabolized in the liver should be avoided as much as possible (Table 6).
 If surgery is necessary, preoperative prothrombin time and bleeding time should
be obtained and abnormal results discussed with the physician.
3. PATIENTS WITH A HISTORY OF HEPATITIS (HEPATITIS CARRIERS):
Most carriers of HBV, HCV, and HDV are unaware that they have had hepatitis. One
explanation for this is that many cases of hepatitis B and hepatitis C apparently are
mild, subclinical, and non-icteric. These cases may be essentially asymptomatic or
may resemble a mild viral disease and therefore remain undetected.
Identification of potential or actual carriers of HBV, HCV, and HDV is problematic
because in most instances, carriers cannot be identified by history. Therefore, all
patients with a history of viral hepatitis must be managed as though they are
potentially infectious.
A) The only practical method of providing protection from these individuals and
from other patients with undetected infectious diseases is to adopt a strict
program of clinical asepsis for all patients.
B) If a patient is found to be a hepatitis B carrier (HBsAg positive) or to have a
history of hepatitis C, standard precautions are to be followed to prevent
transmission of infection.
C) Use of the hepatitis B vaccine further decreases the threat of hepatitis B
infection. Inoculation of all dental personnel with hepatitis B vaccine is strongly
urged. An additional/ consideration in patients with a history of hepatitis of
unknown type is the use of the clinical laboratory to screen for the presence of
HBsAg or anti-HCV. This may be indicated even in patients who specifically
indicate which type of hepatitis they had, because information of this type
derived from the patient's history is unreliable 50% of the time.
D) In addition, some hepatitis carriers may have chronic active hepatitis, leading to
compromised liver function and interference with hemostasis and drug
metabolism. Physician consultation and laboratory screening of liver function
are advised for determination of current status and future risks.
4. DENTISTS WHO ARE HEPATITIS VIRUS CARRIERS:
A question also arises concerning dentists who are carriers of HBsAg or HCV. Very
few cases of hepatitis B traceable to carrier dentists or oral surgeons have been
reported since 1974. After the discovery of a carrier state and the documented
transmission of disease, some HBsAg carrier dentists have been forced to quit practice
HEPATITIS
36
and others have faced lengthy periods of discontinuance until they have undergone
seroconversion.
The CDC suggests that health care professionals who perform invasive procedures
should know their infectivity status; if found positive for a blood-transmissible virus,
they should not perform exposure-prone procedures unless they have sought counsel
from an expert review panel in their state of practice. [18] If after discussion with this
panel, a carrier dentist elects to continue practice, professional ethics and practice
guidelines recommend aggressive efforts to prevent potential transmission through
adherence to strict aseptic technique, periodic retesting of HBsAg and HCV RNA, and
receipt of informed consent from patients.
5. CDC GUIDELINES FOR EXPOSURE TO BLOOD:
Risk exists for transmission of HBV, and a lesser risk is present for HCV after
occupational exposure to infected blood or bodily fluids that contain infected blood.
HCV is less infectious and less efficient in transmission when compared with HBV.
Moreover, HBV can survive for at least 1 week in dried blood on environmental
surfaces and on contaminated needles and instruments. [13] [14] [15] [16]
Finally, if an accidental needle stick or puncture wound occurs during treatment and
the dentist is not vaccinated (or antibody titer status is unknown), knowing whether the
patient was HBsAg or HCV positive would be of extreme importance in determining
the need for HBIG, vaccination, and follow-up medical care.
To reduce the risk of transmission of hepatitis viruses, the CDC has published post
exposure protocols for percutaneous or permucosal exposure to blood. Implementation
of these protocols is dependent on the virus present in the source person and the
vaccinated state of the exposed person (e.g., a dental health care worker) (see Table 5).
[18]
HEPATITIS
37
TABLE 5 Recommendations Following Accidental Exposure to Blood of a
Person Infected With Hepatitis Virus [*]
Source
Unvaccinated
Vaccinated Vaccinated
Vaccinated HCW
Person is HCW
HCW[†]
HCW
Known Response
Known
Non receptor
Unknown
Responder
HBsAg
1 dose of hepatitis No
Administer one Test exposed
Positive
B immune
treatment dose of HBIG + worker for antiglobulin (HBIG
hepatitis B
HBsAg; if
0.06 mL/kg IM) as
vaccine, or 2
inadequate (<10
soon as possible,
doses of HBIG
mU/mL), one
preferably within
with second
dose HBIG +
24 hours + initiate
dose 1 month
hepatitis B
hepatitis B vaccine
after the first
vaccine booster
dose
HBsAg
Initiate hepatitis
No
No treatment
No treatment
Negative
treatment
If
Initiate hepatitis
No
If known highTest exposed
unknown,
treatment risk source,
worker for antinot tested
consider treating HBsAg; if
as if source is
inadequate,
HBsAg positive initiate
revaccination
B vaccine series
HCW, Health care worker; HBsAg, hepatitis B surface antigen; IM, intramuscular.
Briefly, a vaccinated individual who sustains a needle stick or puncture wound
contaminated with blood from a patient known to be HBsAg positive should be tested for
an adequate titer of anti-HBs if those levels are unknown. If levels are inadequate, the
individual immediately should receive an injection of HBIG and a vaccine booster dose.
The risk that a health care worker will contract HBV from HBV carriers through a sharps
injury may approach 30%. If the antibody titer is adequate, nothing further is required. If
an unvaccinated individual sustains an inadvertent percutaneous or permucosal exposure
to hepatitis B, immediate administration of HBIG and initiation of the vaccine are
recommended. [19]
Although no post-exposure protocol or vaccine
is available at this time for HCV infection,
current CDC guidelines recommend that:
(1) The source person should receive baseline
testing for anti-HCV,
HEPATITIS
38
(2) Exposed persons should receive baseline and follow-up testing at 6 months for antiHCV and liver enzyme activity,
(3) Anti-HCV enzyme immunoassay positive results should be confirmed by recombinant
immunoblot assay (RIBA),
(4) Post exposure prophylaxis should be avoided with immunoglobulin or antiviral
agents,
(5) Health care workers should be educated regarding the risks and prevention of bloodborne infection. [19]
Drug Administration
No special drug considerations are required for a patient who has completely recovered
from viral hepatitis. However, if a patient has chronic active hepatitis or is a carrier of
HBsAg or HCV and has impaired liver function, the dosage of drugs metabolized by the
liver should be decreased, or these drugs should be avoided, if possible as advised by the
physician.
Many drugs commonly used in dentistry are metabolized principally by the liver; they
may be used in patients with hepatic disease that is not severe, although in limited
amounts (see Table 6). A quantity of three cartridges of 2% lidocaine (120 mg) is
considered a relatively limited amount of drug.
Table 6 Dental Drugs Metabolized Primarily by the Liver
• Local anesthetics (appear safe for use during liver disease when
used in appropriate amounts)
• Lidocaine (Xylocaine)
• Prilocaine (Citanest)
• Mepivacaine (Carbocaine)
• Bupivacaine (Marcaine)
• Analgesics
• Aspirin [*]
• Acetaminophen (Tylenol, Datril)
[†]
• Codeine [†]
• Meperidine (Demerol) [†]
• Ibuprofen (Motrin) [*]
• Sedatives
• Diazepam (Valium) [†]
• Barbiturates [†]
• Antibiotics
• Ampicillin
• Tetracycline
• Metronidazole [‡]
•Vancomycin [‡]
* Limit dose or avoid if severe liver disease (acute hepatitis and cirrhosis)
or hemostatic abnormalities are present.
† Limit dose or avoid if severe liver disease (acute hepatitis and cirrhosis)
or encephalopathy is present, or if taken with alcohol.
‡ Avoid if severe liver disease (acute hepatitis and cirrhosis) is present.
HEPATITIS
39
Oral Manifestations
and Complications
Abnormal bleeding is associated with hepatitis and significant liver damage. This may
result from abnormal synthesis of blood clotting factors, abnormal polymerization of
fibrin, inadequate fibrin stabilization, excessive fibrinolysis, or thrombocytopenia
associated with splenomegaly that accompanies chronic liver disease. Before any surgery
is performed, the platelet count should be obtained, and it should be confirmed that the
international normalized ratio (INR) is lower than 3.5. If the INR is 3.5 or greater, the
potential for severe postoperative bleeding exists. In this case, extensive surgical
procedures should be postponed. If surgery is necessary, an injection of vitamin K
usually corrects the problem and should be discussed with the physician. Platelet count
and platelet function analysis may indicate whether platelet replacement may be required
before surgery and should be discussed with the patient's physician.
Chronic viral hepatitis increases the risk for hepatocellular carcinoma. This malignancy
rarely metastasizes to the jaw (fewer than 30 cases in the jaw were reported as of this
writing). However, the incidence of hepatocellular carcinoma is on the rise in the United
States. Oral metastases primarily present as hemorrhagic expanding masses located in the
premolar and ramus regions of the mandible. [2] [4]
HEPATITIS
40
References
1. James W. Little, DMD, MS, Donald A. Falace, DMD, Craig S. Miller, DMD, MS,
Nelson L. Rhodus, DMD, MPH: Dental Management of the Medically Compromised
Patient, 7th ed. ISBN 13: 978-0-323-04535-3 Copyright © 2008 Elsevier Inc.
2. Friedman SL: In: Keefe FA, ed. Handbook of Liver Disease, New York, NY: Elsevier;
2005:496.
3. Dr. Sam, Davidson's Principles and Practice of Medicine. Copyright © 2007 Elsevier
Inc. pages 962-9634. Golla K, Epstein JB, Cabay RJ: Liver disease: Current perspectives on medical and
dental management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004; 98:516521.
5. Mosley JW, Edwards VM, Casey G, et al: Hepatitis B virus infection in dentists. N
Engl JMed 1975; 293:729-733.
6. Thomas DL, Gruninger SE, Siew C, et al: Occupational risks of hepatitis C infections
in North American dentists and oral surgeons. Am J Med 1996; 100:41-45.
7. Centers for Disease Control and Prevention: Update: Recommendations to prevent
hepatitis B transmission—United States. MMWR Morb Mortal Wkly Rep 1995;
44:574-577.
8. Pratt DS, Kaplan MM: Evaluation of abnormal liver-enzyme results in asymptomatic
patients. N Engl J Med 2000; 342:1266-1271.
9. Thoelen S, Van Damme P, Leentvaar-Kuypers A, et al: The first combined vaccine
against hepatitis A and B: An overview. Vaccine 1999; 17:1657-1662.
10.Hoofnagle JH, Doo E, Liang TJ, Fleischer R, Lok AS: Management of Hepatitis B:
Summary of a clinical research workshop. Hepatology 2007; 45(4):1056-1076.
11.Centers for Disease Control: Recommendations for prevention and control of hepatitis
C virus (HCV) infection and HCV-related chronic disease. MMWR Morb Mortal
Wkly Rep 1998; 47:1-38.
12.Mahoney FJ, Stewart K, Hu H, et al: Progress toward the elimination of hepatitis B
virus transmission among health care workers in the United States. Arch Intern Med
1997; 157:2601-2609.
13.Fiore AE, Wasley A, Bell BP: Prevention of hepatitis A through active or passive
immunization: Recommendations of the Advisory Committee on Immunization
Practices (ACIP). MMWR Recomm Rep 2006; 55:1-23.
14. Gerberding JL: Management of occupational exposures to blood-borne viruses. N
Engl JMed 1995; 332:444-451.
HEPATITIS
41
15.Lanphear BP. Management of occupational exposures to blood-borne viruses. Occup
Med 12(4):717- 730.
16. Cleveland JL, Gooch BF, Shearer BG, Lyerla RA: Risk and prevention of hepatitis C
virus infection: Implications for dentistry. J Am Dent Assoc 1999; 130:641-647.
17. ADA Council on Scientific Affairs and ADA Council on Dental Practice. Infection
control recommendations for the dental office and the dental laboratory. J Am Dent
Assoc 1996; 127:672-680.
18.Centers for Disease Control: Recommended infection-control practices for dentistry,
1993. MMWR Morb Mortal Wkly Rep 1993; 41:1-12.
19. Centers for Disease Control and Prevention: Immunization of health-care workers:
Recommendations of the Advisory Committee on Immunization Practices (ACIP) and
the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR
Morb Mortal Wkly Rep 1997; 46:1-42.
‫لجنة وضع البروتوكول‬
‫الدكتور نبيه عبد الرسول العلي‬
‫مدير قسم صحة الفم واألسنان‬
‫الدكتور ياسين عبد القادر ياسين‬
‫قسم اللجان االستشارية‬
‫الدكتور نبيل محمد حسن‬
‫قسم صحة الفم واألسنان‬
Pain
45
Dental Diagnostic Guidelines PART I
Introduction
An accurate diagnosis is imperative in all cases to reach an appropriate treatment in a timely
manner.
The importance of evaluation of both pulpal and per radicular status of the tooth or teeth
gathering with all the relevant information for making a correct diagnosis is very important .
TAKING HISTORY
Complete medical history:
There are several medical conditions which require special care in dental clinic. The most
relevant conditions are: Cardiovascular High-&moderate –risk categories of endocarditis ,pathologic heart
murmurs ,hypertension, unstable angina pectoris ,recent myocardial infarction ,cardiac
arrhythmias, poorly managed congestive heart failure .
 Pulmonary ; Chronic obstructive pulmonary disease , asthma , tuberculosis
 Gastrointestinal &renal : End stage renal disease ,hemodialysis ,viral hepatitis (types
B,C,D&E ) , alcoholic liver diseases , peptic ulcer disease , inflammatory bowl disease
, pseudomembranous colitis
 Hematologic : Sexually transmitted diseases , HIV&AIDS, diabetes mellitus ,adrenal
insufficiency , hyperthyroidism & hypothyroidism , pregnancy , bleeding disorders ,
cancer &leukemia , osteoarthritis & rheumatoid arthritis , systemic lupus
erythematosus
 Neurologic : Cerebrovascular accident , seizure disorders . anxiety , depression
&bipolar disorders , presence or history of drug or alcohol abuse ,Alzheimer's diseases
, schizophrenia , eating disorders ,neuralgias ,multiple sclerosis , Parkinson's diseases
 Dermatologic :herpes simplex ,herpes zoster .
DENTAL HISTORY
The dental clinician should listen carefully to the patient chief complaint which should be
write down by his own words.
Previous dental history should be recorded
Patients description of chief complaints
1.Do you
tooth it is?
Painknow which46
2.What initiates the pain? (The provoking factor)
3.Types of the pain:
* Sharp or dull
* Throbbing
* Mild or severe
* Localized or radiating.
4. Duration of the pain?
5. Does it hurt most during the day or night?( time of the pain )
6. Does anything relieve the pain?( relieving factor )
CLINICAL EXAMINATION
- Extra-oral examination
- Intra-oral examination:
Extra-oral examination:
The patient's face and neck are examined to see if
there is any cardinal signs ;( swelling, tender areas,
lymphadenopathy, extra-oral sinuses, redness, or
skin injury)should be noted
Intra-oral examination:
An assessment of the patient's general dental state is made, noting in particular the following
aspects:
 Standard of oral hygiene.
 Amount and quality of restorative work.
 Detection prevalence of caries by :1- conventional method:- (visual, gentleprobbing )
2- Advancer method :- ( diagnodentdevice ,dies)
 Missing and unopposed teeth.
 General periodontal condition.
 Presence of soft or hard swellings.
 Presence of any sinus tracts.
 Discolored teeth.
 Tooth wear and facets.
Pain
47
Diagnostic tests:
 There is a general rule that before treatment ?
 Most of the diagnostic tests used to assess the state of the pulp and periapical tissues
are relatively crude and unreliable ,however at least three diagnostic test is sufficient
to make a firm diagnosis of reversible or irreversible pulpits.
 Don’t depend on signal test alone use always multiple test for diagnosis
Palpation:
The tissues overlying the apices of any suspect teeth are palpated to locate tender areas. The
site and size of any soft or hard swellings are noted and examined for fluctuation and
crepitus.
Percussion:
Gentle tapping with a handle of the mirror both laterally( for periodontal problem) and
vertically on a tooth( for per apical problem) is sufficient to elicit any tenderness.
Mobility:
The mobility of a tooth is tested by placing a handle of tow instrument on either side of the
crown and pushing with one instrument while assessing any movement with the other.
Mobility may be graded as:
1.Slight (normal)
2.Moderate
3.Extensive movement.
Radiography for:
 Radiography is the most reliable of all the
diagnostic tests and provides the most
valuable information.
 A radiograph may be the first aid to diagnose
the presence of any dental or oral pathology.
 detection of caries ( hidden &proximal caries
using Bitewing film .
 Radiograph is important for detection any
dental abnormality in tooth structure, extend
caries, pulp stone, fractures both vertical &
horizontal .
 It's important to detect any abnormality of periodontal (both vertical &
Pain
horizontal bone resorption )
48
 Detection of any Pathological at the per apical area ,
 In all endodontic cases, a good intra-oral parallel radiograph of the root
and per apical .
 radiography in diagnosis its un reliable in cases of pulpal diseases.
 If a sinus is present and patent, a small-sized (about #40) gutta percha point should be
inserted and threaded, by rolling gently between the fingers, as far along the sinus tract
as possible. If a radiograph is taken with the gutta-percha point in place, it will lead to
an area of bone loss showing the cause of the problem
Pulp testing:
 Pulp testing 'vitality' testing. (these test used to check
the vitality of the teeth ( vital or non vital)
 Types of pulp testing :- Electrical
- Thermal
- Doppler
 Pulp testers should be used to assess vitality of the pulp& they don’t reflect the disease
status of the pulp .
 The teeth to be tested are dried and isolated with cotton rolls.
 Electric pulp tester may give a false-positive reading due to stimulation of nerve fibers
in the periodontium, Teeth with full crowns present problems with pulp testing.
 A conducting medium should be used; the most available one is toothpaste .
 Coated probe tip of pulp tester is placed in the incisalthird of labial or buccal surface
of the tooth to be tested.
 Multi rooted tooth may give misleading readings since a combination of vital and nonvital root canal pulps may be present.
 The use of gloves in the treatment of all dental patients has produced problems with
electric pulp testing.
 To complete the electrical circuit ,the patient should advised to hold the electrical tip (
if present ) by his hand
 Note :-Pulp testers should not be used on patients with pacemakers
Pain
because of49
the possibility of electrical interference.
Thermal pulp testing
A- Heat:
A light layer of lubricant should be placed onto the tooth surface before
applying the heated material to prevent the hot guttapercha from adhering
to the dry tooth surface
B- Cold:
1- An ethyl chloride spray may be used.
2- Ice sticks may be made by filling the plastic covers from a hypodermic needle with
water and placing in the freezing compartment of a refrigerator. When required for
use one cover is warmed and removed to provide the ice stick.
Note: False –positive reading due to presence of gases inside the canal
Local anesthetic test:
1- Inferior dental block as diagnostic technique
for referred pain .
2- Infiltration for upper jaw for diagnosis for
refried pain .
3- An intraligamental injection may be given to
anaesthetize the suspect tooth.
Wooden stick test:
If a patient complains of pain on chewing and there is no evidence of periapical
inflammation, an incomplete fracture of the tooth may be suspected. Biting on a wood
stick in these cases can elicit pain, usually on release of biting pressure.
Fiber-optic light test:
A powerful light can be used for Trans illuminating teeth to show interproximal caries,
fracture, opacity or discoloration. To carry out the test, the dental light should be
turned off and the fiber-optic light placed against the tooth at the gingival margin with
the beam directed through the tooth. If the crown of the tooth is fractured, the light will
pass through the tooth until it strikes the stain lying in the fracture line; the tooth
beyond the fracture will appear darker.
Drilling test:
Is one of the vitality test .When other tests have given an indeterminate result, a test
cavity may be cut in a tooth which is believed to be pulp less. In the author's opinion,
this test can be unreliable as the patient may give a positive response
although the pulp is necrotic. This is because nerve tissues can
Pain to conduct impulses for some time in the absence of a blood
continue
50
supply.
EXAMINATION AND DIAGNOSTIC PROCEDURES TO ASSESS
THE STATUS OF THE PULP AND ROOT CANALS:
The diagnostic process actually consists of four steps and is conducted in much the same
man
TABLE 1. COMMON CAUSES OF PULP DISEASE
ner as a detective might investigate a case in a mystery novel.
1- The first step is to assemble all available facts: These "clues" are
detected by considering the chief complaint, the medical and dental
histories, and the history of the present condition. Additional
information is gained from interviewing patients to determine what
symptoms they may have experienced.
2- The Second Step is to formulating a Provisional Diagnosis:
The provisional diagnosis should be based on the patient’s chief
complaint, their description of the symptoms and a thorough history
of an y relevant problems and any prior dental treatment.
Experienced investigators screen and interpret the assembled clues to
discover which are germane to the case.
3- Third step, Extra-oral, Intra-oral soft tissue and dentition examinations:
Extra-oral, Intra-oral soft tissue and dentition examinations should be performed to
establish the patient’s overall oral health. A complete examination, including
radiographic images, and laboratory tests, when
necessary, will disclose objective physical signs. The
subsequent clinical and radiographic examinations
together with the appropriate clinical tests are used to
confirm (or change) the provisional diagnosis.
4- final step, Operational or Working Diagnosis:
Once the information has been gathered and interpreted,
the investigator formulates a differential diagnosis, the
clinician carefully compares the patient's signs,
symptoms, and test results to known disease entities in
the differential diagnosis and selects the closest match.
This becomes the operational or working diagnosis.
Group
Microbial
Traumatic
Type
Coronal ingress
Examples or reasons
Caries, marginal breakdown of restorations,
fractures, cracks
Radicular ingress
Advanced periodontal disease, cracks,
fractures, breakdown of root canal fillings,
advanced external invasive resorption
External
invasive Advanced cases – pulp may be exposed, or
resorption
plaque enters through the defect
Accidental
Physiological
Cavity preparation
Iatrogenic
Chemical
Others
Restoration
procedures
Accumulative
Prosthetic
manipulation
Orthodontics
Periodontics
Radiation
General anaesthesia
Surgery
Fractures, concussion, luxation, avulsion,
traumatic occlusion
Attrition, abrasion, traumatic occlusion
Heat, deep cavity, dehydration, pulp
exposure
Insertion, fracture, cementing, polishing
Area of dentine cut
Fixed and removable prosthodontics
Electrical
Local analgesia
Tooth movement
Treatment of deep pockets
Radiotherapy for carcinoma
Trauma during intubation procedures
Rhinoplasty, Caldwell-Luc, dento-alveolar
surgery, oral surgery
Galvanic reaction
Reduced blood flow due to vasoconstrictors
Restorative materials
Erosion
Ageing
Systemic diseases
Material toxicity
Various acids, foods
Blood supply reduced
Hypophosphataemia
Australian Dental Journal Endodontic Supplement 2007;52:1.
Table 2. Summary of the examination and diagnostic processes for the
assessment of pulp, root canal and periapical conditions
Stage
Procedure
Outcome
Pain
Pain
History
Clinical
examination
Clinical tests
Radiographic
examination
Correlation of
all above
findings
Management
plan
Medical history
Dental history
Description of presenting
complaint
Details
of
previous ➜ Provisional diagnosis of
treatment of presenting
presenting condition
complaint
Extra-oral signs
Intra-oral signs
Individual tooth assessment ➜ Identify possible cause(s)
Restoration assessment
Provisional diagnosis of tooth
status
Pulp sensibility tests
➜ Provisional diagnosis of the
status of the pulp and/or root
canal system
Periradicular tests
➜ Provisional diagnosis of the
periapical status
Periapical radiograph(s)
➜ Provisional diagnosis of the
periapical status
Bitewings radiograph (if
➜ Assess/identify/confirm cause(s)
needed)
Combine the history,
➜ DEFINITIVE DIAGNOSIS
clinical examination,
tests and radiographic
clinical tests and
examination results Pulp, root
radiographic examination
canal and periapical status
results
+ Cause(s) of the condition(s)
Investigation of tooth (i.e.
➜ Confirm the definitive diagnosis
remove restoration, caries,
and cause(s)
cracks, etc)
Reassess amount of tooth
➜ Finalise the management plan
structure and overall
and continue treatment
prognosis
Pain
53
References:
1. Stephen Cohen, Frederick Liewehr Pathways of the pulp, part one, The Art of
Endodontics, Chapter 1,2011
2. Modaresi J, Dianat O, Mozayeni MA, Modaresi J, Dianat O, Mozayeni MA. The
efficacy comparison of ibuprofen, acetaminophen-codeine, and placebo premedication
therapy on the depth of anesthesia during treatment of inflamed teeth. Oral Surg Oral
Med Oral Pathol Oral RadiolEndod 2006;102:399- 403.
3. Abbott PV. Classification, diagnosis and clinical manifestations of apical periodontitis.
Endod Topics 2004;8:36-54.
4. Jhon I ,Endodontics ,6th edition ,2008
5. P Carrotte ,Endodontics ; part 2 Diagnosis &treatment planning .British dental journal
,2004
Pain
54
) ‫الخطوط العامة للخطوات التشخيصية لعمل أطباء األسنان (الجزء االول‬
‫مراحل التشخيص في مجال طب االسنان جزء مهم من الواقع العملي في مجال طب األسنان وهذا يشمل جمع المعلومات‬
‫لكثير من االختبارات التشخيصية التي تجرى في هذا المجال للوصول الى التشخيص المناسب (حيث ال يقتصر على‬
‫اختبار واحد )‪.‬‬
‫وتتلخص بإتباع المراحل الموجودة في الخطوط اإلرشادية في البروتوكول للوصول الى التشخيص النهائي من اجل تقديم‬
‫العالج المناسب للمريض ‪.‬‬
‫لجنة وضع الدالئل اإلرشادية لمعالجة األسنان‬
‫الدكتورة اسراء شكر ولي‬
‫قسم صحة الفم واألسنان‬
‫الدكتور نبيل محمد حسن‬
‫قسم صحة الفم واألسنان‬
‫الدكتور نبيه عبد الرسول‬
‫مدير قسم صحة الفم واألسنان‬
‫الدكتورة غادة زهير إبراهيم‬
‫قسم صحة الفم واألسنان‬
‫الدكتورة رقية عبد الوهاب‬
‫ماجستير معالجة أسنان‬
‫م‪.‬ص‪.‬ت لطب األسنان في المغرب‬
‫الدكتور فاضل سلمان‬
‫ماجستير معالجة أسنان‬
‫م‪.‬ص‪.‬ت لطب األسنان في الكرامة‬
‫الدكتورة شهد محمد علي‬
‫ماجستير معالجة أسنان‬
‫م‪.‬ص‪.‬ت لطب األسنان في العامرية‬
‫المقدمة‬
‫‪9‬‬
‫سالمة المريض‬
‫ان توجه المؤسسات الصحية ومنها المستشفيات نحو اتخاذ إجراءات فنية وتنظيمية وإدارية تشكل‬
‫وظائف معقدة تترجم على شكل خدمات صحية ذات جودة عالية تقدم للمرضى بهدف تحقيق صحة‬
‫ورفاهية المواطنين والمجتمع ‪0‬‬
‫ولكي تحقق هـذه الرعاية الصحية هدفهـا المنشود بتمامه يجب ان تكـون آمنـة وتتضمــن سالمة المرضى‬
‫من األخطاء الطبية واإلحداث السلبية الضارة التي قد تلحق بالمريض خالل تلقيه لتلك الرعاية‪.‬‬
‫وتستجيب المستشفيات عادة لذلك األمر عن طريق تحضير االستعدادات والمتطلبات التي تؤمن تحقيق‬
‫سالمة وأمان المرضى فيها ‪0‬‬
‫اال ان الواقع التي تشهده المستشفيات فــي كل انحاء العالم ومنها بلدنا العزيز يفصح عـن وقوع احداث‬
‫كبيره باستمرار يتعرض فيها المرضى والمراجعون للمستشفيات لخطر الحوادث السلبية واألخطاء الطبية‬
‫‪0‬‬
‫وقـد تنبهت دول العالم لذلك االمر وتبنت عـدة مبادرات وسياسات وبرامـج تحت مسمى سالمة المريض‬
‫منذ عام ‪ 1991‬م بعد ان تبين ان حجم المشكلة اكبر مما كان متوقعا ‪ 0‬ومنذ ذلك الحين ظهرت عدة‬
‫تطبيقات لبرامج خاصة بسالمة المريض واجريت الكثير من االبحاث واصدرت العديد من الدراسات‬
‫حول الموضوع اضافة الى المؤتمرات والندوات وورش العمل في جميع دول العالم ومنها دول اإلقليم‬
‫وتماشيا مع الحقاق العالمية حول فداحة االضرار التي تسببها االخطاء الطبية والحوادث في المستشفيات‬
‫وتماش يا" مع توجه دول العالم لوضع وتطبيق برامج لسالمة المريض ظهرت عدة محاوالت وطنية في‬
‫هذا الشأن‪.‬‬
‫ومن الواضح ان هناك حاجة الى مزيد من المساهمات مـن اجل بلورة الموضوع وتسليط الضوء عليه لـذا‬
‫نضع هذه المحاولة في التمهيد لبرنامج سالمة المريض والذي اصبح نظاما" قائما" بذاته عالميا " ‪000‬‬
‫وفي هذا التمهيد تـم التركيز على الجوانب العملية مــن هـذا الموضوع فقـد تمت اإلشارة فيه الى مفاهيم‬
‫ومبادئ سالمة المريض ومعطيات تطبيقة وإجراءات المستشفى المطلوبه لتنفيذ محاوره اضافة الى‬
‫التطرق الى أهم ماقامت به دائرة االمور الفنية في التمهيد والتحضير لوضع البرنامج موضع التطبيق في‬
‫المستشفيات ويهيأ هذا التمهيد لنا قاعدة يبنى عليها دليل سالمة المريض والذي سيتم اعداده قريبا" جدا" ‪0‬‬
‫وكذلك دليل تقييم سالمة المريض الذي سيتبعه ان شاء هللا ‪0‬‬
Patient Safety
10
Why is
patient safety
relevant to
health care?
Definition
Freedom from accidental or preventable injuries produced by medical care.
Patient safety protocol include: Patient safety culture
 Medical records
 Pharmacological issues
 Radiology
 Infection control
 Fire
 Disaster planning
 Disability
 Continuing education
 Falls
 Treatment
Patient safety culture
Create a culture of patient safety
 Drive out fear
 Everyone makes mistakes everyday
 Create a non-punitive environment
Characteristics of patient safety Culture:
- Non-punitive error reporting
- Error-proofing new products, programs, and services
- Training and organizing in teams
- Direct communication
WHO facts in Patients safety
WHO fact 1
 2002 Countries recognized the important patient safety
 2004 WHO: World Alliance for Patient Safety.
WHO fact 2
 1 in 10 patients is harmed receiving hospital care in developed countries.
 Harm can be caused by a range of errors or adverse events.
Patient Safety
11
WHO fact 3
 The probability is much higher in developing countries.
WHO fact 4
 At any given time, 1.4 million people worldwide suffer from infection acquired in
Hand hygiene is the most important measure in reducing health-care associated
infection and development of antimicrobial resistance.
WHO fact 5
 At least 50% of medical equipment in developing countries is unusable or only partly
useable.
 Equipment is not used duo to lack of skills.
 As a result, diagnostic procedure or treatment can't be performed.
 This leads to substandard or hazardous diagnosis or treatment that can pose a threat to
safety.
WHO fact 6
 In some countries, 70% is the proportion given with syringe or needles reused.
 Each year, unsafe injection cause 1.3 million deaths duo to Hep B,C,HIV












WHO fact 7
Surgery is one of the most complex health intervention to deliver
> 100 million people require surgical treatment annual.
Problems with surgical safety in developed country for half of the avoidable adverse
events that result in death or disability.
WHO fact 8
The economic benefits of improving PS are compelling.
Additional hospitalization, ligitation costs, infections acquired in hospitals, lost
income, disability and medical expenses costs between 6 and 29 billion dollars.
WHO fact 9
Industries with perceived higher risk such as aviation, nuclear energy have a much
better HS record than heath care.
1:1000,000 chance a traveler might be harmed.
1:300 chance of patient being harmed.
WHO fact 10
Patient experience and their health are at the heart of the patient safety movement.
The Alliance for patient safety is working with 40 bodies to make health care safer
worldwide.
How to improve safety?
Maintain a powerful and uniform culture of safety
Use optimal structure and procedures
Patient Safety
12
 Conduct through organizational learning and safety management
 Provide intensive and continuing training of individuals and teams
Risk factors in relation to Patients safety
 Mix of patients
 Staffing shortages
 Increased complexity of care
 Stressful work
 Fiscal restraints
 New technology
 Specialized equipment
 Aging physical structure
 Increased integration
Roles in Patient Safety
 Everyone
 Employees
 Students
 Volunteers
 Dentists
 Management
 Administrative and Medical staff leaders
Patients Safety Challenges
 Difficulty recognizing errors
 Lack of information systems to identify errors
 Relationship of trust with providers
 Shortages of clinical professionals
 Limited capacity on how to use quality improvement
 Culture of patient safety is lacking
Patient Safety
13
Patient
People
Environment
Health
Services
Facilities
Equipments
Dental Office
Employee
friendly
Patient
oriented
Doctor
centered
Patient safety
Accounting
Beautiful
decors
Billing
Patient Safety
14
Guidelines for patient safety
The followings guidelines are important to be followed:
1: Improve the accuracy of patient identification in dental settings
Safety Strategy:
Use at least two patient identifiers when providing care, treatment or services.
2: Improve the effectiveness of communication among all dental providers
Safety Strategy:
a: When receiving verbal or telephone information (referrals, prescriptions, test results, etc.)
verify the information by repeating back the information in its entirety
b: Standardize a list of abbreviations, acronyms, symbols, and dose designations to be used
throughout the office or clinic.
3: Improve the safety of using medications in dental setting
Safety Strategy:
a: Periodically check for look-alike/sound-alike drugs in the office/facility and take action to
prevent errors involving the mix-up of these drugs.
b: Periodically check for expired medications, emergency drugs and dental materials.
4: Eliminate opportunity for wrong-site, wrong-patient, wrong-procedure, treatment or
surgery
a: Conduct a pre-procedure verification of the service, treatment or surgery to be performed
b: When feasible mark the surgical site
c: Conduct a “time out” for final verification
5: Reduce the risk of health care-acquired infections in dentistry
a: Comply with current CDC hand hygiene and infection control guidelines
b: Manage breaks in infection control as serious events—analyze and report as required by
law
6: Improve the safety of using dental equipment
a: Ensure all equipment is in proper working order, regularly maintained and checked for
any hazards
b: Ensure the materials and workspace where equipment is utilized is hazard free
c: Provide training for staff responsible for utilizing and/or maintaining equipment
d: Notify the dentist or supervisor of unsafe or potential hazardous conditions
7: Accurately and completely reconcile medications with other dental and medical providers
as needed
Policy and procedure
Policy and procedure manuals that describe each facility’s established protocols serve as a
valuable training tool for new employees and reinforce a consistent approach for safe,
quality patient care. Identifying deviations from such protocols and studying patterns of
occurrence can help reduce the likelihood of adverse events. Reducing clinical errors
requires a careful examination of adverse events, including “near misses”, and root cause
analysis of how the event could be avoided in the future so that safety practices can be
implemented. Safety demands a culture in which communication does not depend on
hierarchy; a non-punitive or “no blame” culture encourages all personnel to report errors.
Patient Safety
15
Why human error
occurs ?
 Everyone commits errors
 Human error is generally the result of circumstances that are beyond the conscious
control of those committing the errors.
 Systems or processes that depend on perfect human performance are fatally flawed .
Error :An act of commission (doing something wrong ) or omission (failing to do the right
thing) that leads to an undesirable outcome or significant potential for such an
outcome
Error of omission much more difficult to recognized
ex : ordering penicillin for a patient allergic to it ( act of commission )
ex: failing to prescribe antibiotics for a patient with congenital heart disease before a
dental extraction ( error of omission )
Active Error :
Errors that occur at the point of contact between a human & a larger system
Called active failure , called "sharp end " errors
Between human & machine
Ex: Pushing incorrect button
Ex : Ignoring a warning light Involves a person at the front line Committed by the
person closest to the patient
Ex: Operating wrong tooth
Latent Error
Less apparent failures of organization or design that contributed to occurrence of
errors or allowed them to cause harm to patients.
 Called ''bland end'' errors.
 ''accidents waiting to happen''

Refers to the many layers of the healthcare systems that affect the person holding the
scalpel.
Error Chain
Series of events that led to a disastrous outcome typically uncovered by root cause
analysis.
 Failure to follow standard operating procedures
 Poor Leadership
 Breakdown in communication or team work
 Overlooking individual fallibility
 Losing track of objectives
 In order to break the chain, have checklists ready.
Patient Safety





16
Mistakes
Failure during attentional behavior
Incorrect choices
Insufficient Knowledge
Failure to correctly interpret available information
Application of the wrong cognitive ''heuristic'' or rule
Ex: ordering the wrong diagnostic test
Ex: ordering a suboptimal antibiotic dose.
Root Causes Analysis(RCA)
The point is to dig below the symptoms and find fundamental, underlying decisions and
contradictions that led to the undesired consequences
Definition:- It is a methodology for finding and correcting the most important reasons for
performance problems
General principles of RCA
- RCA is aiming at the root causes rather than merely treating the symptoms
- RCA must be performed systematically, with conclusions and causes backed
up by documented evidence
- There is usually more than one root cause for any given problems.
- The analysis must establish all known causal relationships between the root
causes and the defined problems
Goals of RCA
 Find out what happened? (brief description of the event. When did the event occur?
 Failure identification of what exactly went wrong
 Find out Why it Happened?
 People issues ?
 Computer / data issues?
 Environmental issues?
 Leadership issues?
 Communication?
 Uncontrollable factors?
 Failure analysis discover the root cause
 Find out what be done to prevent it?
 Failure resolution provide a solution that prevent recurrence.
Patient Safety
17
Conclusion
To promote patient health and protection the following should be encouraged:
1. Patient safety instruction in dental curricula to promote safe, patient-centered care.
2. Professional continuing education by all licensed dental professionals to maintain
familiarity with current regulations, technology, and clinical practices. Scientific knowledge
and technology continually advance, and patterns of care evolve due, in part, to
recommendations by organizations with recognized professional expertise and stature. Some
recommendations can be based only on suggestive evidence or theoretical rationale (eg,
infection control); other concerns of clinical practice remain in flux (eg, materials utilized in
restorative dentistry). Consequently, the dental patient would benefit from a practitioner who
follows current literature and participates in professional continuing education courses to
increase awareness and knowledge of best current practices
‫‪18‬‬
‫‪Patient Safety‬‬
‫الخـــالصة‬
‫تشير منظمة الصحة العالمية حول سالمة المريض الى حقائق عشر أهمها ان سالمة المريض حالياً هي قضية عالمية‬
‫ذات صلة عالية األهمية في الصحة العامة وبالمقارنة مع أنواع الصناعات والخدمات األخرى ‪ ,‬فان الصناعات ذات‬
‫المخاطر المتوقعة بشكل اعلى مثل الطيران والمحطات النووية لديها سجل سالمة أفضل بكثير من الرعاية الصحية‬
‫وتحديداً في المقارنة هناك احتمال تعرض مسافر واحد من كل مليون مسافر لألذى إثناء وجوده في الطائرة وفي المقابل‬
‫هنالك احتمال تعرض مريض واحد من بين ‪ 033‬مريض لألذى خالل توفير الرعاية الصحية ‪ .‬وتشير التقديرات الى ان‬
‫في البلدان المتقدمة يتضرر )واحد من كل ‪ 03‬مرضى( = ‪ %03‬اثناء تلقي الرعاية الصحية في المستشفيات ويكون سبب‬
‫الضرر مجموعة من األخطار او اإلحداث السلبية وفي البلدان النامية يكون احتمال تعرض المرضى في المستشفيات‬
‫اعلى منه قي الدول المتقدمة وتحديداً فأن خطر اإلصابة خالل تلقي رعاية صحية في بعض البلدان النامية يصل الى‬
‫‪ .%03‬ووجد انه ثمة ‪ 0,1‬مليون شخص يعانون من العدوى المكتسبة في المستشفيات وان مجرد الحرص على تحقيق‬
‫نظافة اليدين هو الخطوة االهم في سبيل الحد من حاالت العدوى الناشئة في مراكز تقديم الرعاية الصحية وحاالت تطور‬
‫الميكروبات للمضادات الحيوية وان تداخالت الجراحة من الحاالت االكثر تعقيداً وان اكثر من ‪033‬مليون شخص في كل‬
‫عام تتطلب معالجتهم بالمستشفيات جراحياً وهناك تقرير من منظمة الصحة العالمية مفادها على ان توفر بعض األجهزة‬
‫الطبية المتقدمة في الدول النامية فان ‪ %03‬اما التستخدم او تستخدم بطريقة غير صحيحة في تشخيص االمراض او‬
‫معالجتها او التوجد المهارات او الخبرات الستخدامها بطريقة امثل وبالنتيجة يتضرر المرضى نتيجة عدم التشخيص او‬
‫عدم االستفادة العالجية من تلك األجهزة الطبية المتوفرة وال يتوفر الفنيين الذين يمكنهم إصالحها فسالمة المريض هو علم‬
‫له أبحاثه التي تستهدف تحسين األداء الطبي وتجنب المضاعفات الناتجة من أخطاء تحدث نتيجة اإلجراءات الطبية‬
‫المختلفة ‪.‬‬
‫لجنة وضع البروتوكول‬
‫الدكتورة اسراء شكر ولي‬
‫قسم صحة الفم واألسنان‬
‫الدكتور سركون نوئيل ايليا‬
‫دائرة صحة كركوك‬
‫الدكتورة ابتسام عدنان عبود‬
‫قسم صحة الفم واألسنان‬
‫الدكتور نبيه عبد الرسول العلي‬
‫مدير قسم صحة الفم واألسنان‬
Patient Safety
19
‫المصادر‬
1-WHO P.S program
2- JCAHO ( joint commission on accreditation of health care organization )
‫مقــــــــــــــــــــــــــدمة‬
‫السرطان‬
‫‪57‬‬
‫سرطان االطفال‬
‫هو مرض غير شائع في األطفال وان أنواع مرض السرطان التي تظهر على األطفال‬
‫تختلف كثي ار عن تلك التي وجدت في البالغين‪ :‬سرطان الدم‪ ،‬سرطان الغدد الليمفاوية‪ ،‬وأورام الدماغ هي أكثر شيوعا نسبيا‬
‫في األطفال ‪.‬‬
‫سرطان الدم يشكل حوالي ‪ ٪03‬من جميع سرطانات األطفال وسرطان الدم الليمفاوي الحاد (‪ )ALL‬هو النوع األكثر‬
‫شيوعا من األورام الخبيثة‪ .‬يتم التعامل مع سرطان الدم الحاد بالعالج الكيماوي ‪ .‬وكذلك يستخدم زرع نخاع العظم‬
‫البشري الخيفي مع جرعة عالية من العالج الكيميائي وعالج اإلشعاع على كل الجسم ‪.‬‬
‫بعض االحتياطات الخاصة التي يجب ان تؤخذ بنظر االعتبار خالل تقديم خدمات عالجية للفم واألسنان‬
‫لتجنب أو‬
‫تقليل احتمال حدوث المضاعفات الغير مرغوب فيها والخطيرة في بعض األحيان ‪ ،‬وهناك اعتبار آخر هو تأثير المرض‬
‫والعالج على األسنان النامية والنمو ألوجهي‪-‬الفموي للطفل‪.‬‬
‫إجراءات العناية بالفم واالسنان لمرضى السرطان‬
‫يختلف عالج الفم واألسنان لمرضى السرطان تبعاً لمراحل المعالجة السرطانية وكما يلي ‪-:‬‬
‫أوالً‪ :‬العناية بالفم واألسنان قبل البدء بجرعة العالج‬
‫ثانياً‪ :‬العناية بالفم واألسنان خالل فترة العالج بجرعة السرطان (فترة انخفاض المناعة)‪.‬‬
‫ثالثاً‪ :‬العناية بالفم واألسنان بعد فترة الجرعة السرطانية‬
‫أوالً‪ :‬إجراءات العناية بالفم واألسنان قبل البدء بجرعة العالج‬
‫التحاليل المرضية التي يجب إجراءها قبل إجراء أي عالج ‪-:‬‬
‫‪ -0‬عدد كريات الدم النيوتروفيل ‪Neutrophil count‬‬
‫‪ -0‬عدد االصفيحات الدموية ‪Platelet count‬‬
‫‪ -0‬اختبار تخثر الدم ‪Coagulation tests‬‬
‫‪58‬‬
‫سرطان االطفال‬
‫إجراءات تقييم المريض‬
‫التحاليل المرضية التي يجب إجراءها قبل إجراء إي عالج ‪-:‬‬
‫‪ .0‬عدد كريات الدم النيوتروفيل‪:‬‬
‫أ‪ -‬اذا كان اكثر من ‪/ 0333‬ملم‪ 0‬يحتاج المريض لمضاد حيوي لإلغراض الوقائية وبعد استشارة طبيب األورام‬
‫ب‪ -‬واذا كان العدد اقل من ‪/0333‬ملم ‪ 0‬يؤجل أي عالج لحين ارتفاع العدد وفي الحاالت الطارئة يوصف مضاد حيوي‬
‫بعد االتفاق مع طبيب األورام قبل البدء باي عالج لألسنان مع وجوب إجراء العالج داخل المستشفى ‪( .‬هل‬
‫المقصود معالجة األسنان ؟)‬
‫‪ .0‬عدد الصفيحات الدموية ‪-:‬‬
‫أ‪ .‬اذا كان اكثر من ‪/00333‬ملم ‪ :0‬ال يوجد حاجة التخاذ إجراءات إضافية ولكن على طبيب األسنان أن يهيئ نفسه‬
‫التخاذ التدابير الالزمة عندما تزداد فترة النزف باستعمال الخيوط الطبية وعوامل وقف النزف والضمادات الضاغطة‬
‫ورغوة الجالتين‬
‫ب‪ .‬او من ‪ : 00333-13333‬قد يتم نقل صفيحات الدم قبل و ‪ 01‬ساعة ما بعد الجراحة اإلجراءات الموضعية للسيطرة‬
‫على طول فترة النزف قد تتضمن استعمال الخيوط الطبية وعوامل وقف النزف والضمادات الضاغطة ورغوة‬
‫الجالتين ‪.‬‬
‫ت‪ .‬اقل من ‪ : 13333‬تأجيل العالج وفي حالة طوارئ األسنان يتم االتصال بطبيب المريض لمناقشة اإلجراءات الساندة‬
‫مثل نقل صفيحات الدم أو السيطرة على النزف أو دخول المستشفى قبل البدء بالعمل ‪.‬‬
‫‪ .3‬اختبار تخثر الدم األخرى لبعض المرضى ‪.‬‬
‫االجراءات الوقائية للفم واالسنان قبل البدء بجرعة العالج‬
‫أ‪ .‬نظافة الفم‪:‬‬
‫‪ ‬ويشمل تفريش األسنان واللسان مرتين الى ثالثة يوميا بواسطة فرشاة ناعمة او كهربائية وان كان باإلمكان خيط‬
‫األسنان ‪.‬‬
‫‪ ‬األطفال ذوو نظافة الفم والذين يعانون من إمراض اللثة وما حول األسنان يجب ان يستعملون مضمضة الفم‬
‫كلورهكسدين يوميا حتى شفاء األنسجة وال يجوز استعمالها لألطفال دون سن السادسة لصعوبة السيطرة على البلع‬
‫لدى األطفال في هذا العمر ‪.‬‬
‫‪ ‬النسبة لألطفال مع قابلية تسوس عالية‪ ،‬استخدام غسول الفم الكلورهكسدين ‪ ٪3..0‬مرتين يوميا (ويمكن استخدام‬
‫أعداد ‪ ٪3.0‬بعد التخفيف إلى ‪ ٪3.00‬مع الماء الدافئ)‬
‫ب‪ .‬الطعام‪ :‬يشمل الغذاء الغير مسبب للتسوس وتثقيف المريض واألهل بهذا الخصوص (حسب مرفق رقم ‪)0‬‬
‫‪ -1‬الفلور‪:‬المس الفلوري من قبل طبيب األسنان‬
‫‪ -2‬الوقاية من التشنج العضلي‪ :‬يبدا المريض بتمارين العضالت ألوجهيه كـطب فيزياوي وذلك قبل إجراء اإلشعاع‬
‫وخالله (مرفق رقم ‪)0‬‬
‫ج‪ -‬التثقيف الصحي‪ :‬ويشمل تثقيف الشخص المعتني بالمريض حول ضرورة العناية القصوى بالفم لتقليل المشاكل‬
‫الفموية قبل وخالل وبعد العالج باإلشعاع‪.‬‬
‫‪59‬‬
‫سرطان االطفال‬
‫اإلجراءات العالجية للفم واالسنان قبل البدء بجرعة العالج‬
‫‪ ).‬إجراء فحص أسنان شامل مع الصور الشعاعية البانورامية واالطباقي ‪.‬‬
‫‪ )0‬قلع األسنان المتضررة و المشكوك بتشخيصها إذ ال يمكن الحد من مخاطر فشل العالج مع المريض و التي‬
‫تؤدي الحقا الى خراج السن المزمن والمخاطر المحتملة للمريض هي وجود تسمم الدم أثناء العالج الكيميائي لذلك‬
‫تكون المحافظة على األسنان أكثر أهمية‪ .‬وبناء عليه يجب قلع كل األسنان المصابة بالعصب قبل العالج‬
‫الكيميائي ويفضل قلع األسنان بفترة ال تقل عن ‪ .3‬إلى ‪ .1‬يوما قبل بدء العالج الكيميائي‪ ،‬ذلك إلعطاء فترة‬
‫كافية لكي ينتهي االندمال بتشكل النسيج الظهاري لموقع القلع قبل بدء العالج الكيميائي وكذلك نبتعد عن‬
‫احتمالية احتياج قلع السن خالل فترة هبوط المناعة وهي فترة حرجة ‪.‬‬
‫ويجب قلع األسنان الغير قابلة للمعالجة وكذلك الجذور واألسنان التي لها جيب لثوي أكثر من ‪ 6‬ملم واألسنان‬
‫المطمورة ذات اإلعراض األسنان ذات االلتهاب الميكروبي واألسنان المتحركة بسبب فقدان العظم ‪.‬‬
‫يجب إجراء تحليالت شاملة من الدم في اليوم نفسه‪ ،‬قبل قلع األسنان‪ .‬و نقل الصفائح الدموية قبل القلع إذا كانت‬
‫عددها غير طبيعي وتوصف المضادات الحيوية قبل قلع األسنان إذا كان عدد النيتروفيل ‪Neutrophils‬‬
‫منخفض وبعد استشارة طبيب األورام ‪.‬‬
‫‪ )0‬الحشوات المؤقتة لكل اآلفات المسوسة بالتسوس البسيط والمتوسط وبدون إعراض إذ تـعالج بالحشوات السادة‬
‫للشقوق كعالج مؤقت ويؤجل عالجها الى ان تستقر حالة المريض ‪.‬‬
‫‪ )4‬حشوات جذور األسنان‪-:‬‬
‫أ‪ .‬األسنان اللبنية‪:‬‬
‫‪ ‬اذا احتاجت يجب قلعها والتي سبق عالجها جذريا وصحيحة سريرياً وشعاعياً تترك‪.‬‬
‫ب‪ .‬األسنان الدائمية‪:‬‬
‫‪‬‬
‫يجب إنهاء حشوات الجذور أسبوع على األقل قبل اخذ اإلشعاع واال يفضل قلعه مع إعطاء المضاد الحيوي و‬
‫حسب توصيات طبيب األورام ‪.‬‬
‫‪‬‬
‫األسنان المعالجة سابقاً مع وجود التهاب فيجب قلعها ‪.‬‬
‫‪60‬‬
‫‪ )5‬تقويم األسنان ‪-:‬‬
‫سرطان االطفال‬
‫‪‬‬
‫يتم التنسيق مع اختصاص التقويم في حالة وجود جهاز تقويم أسنان عند المريض بإمكانية رفعه أو بقاؤه‬
‫وباستشارة طبيب األورام ‪.‬‬
‫‪ )6‬اللثة وما حول األسنان ‪:‬‬
‫‪ ‬يجب تقييمها وعالجها مهم قبل اخذ الجرعة‪.‬‬
‫‪ ‬يجب إجراء كل اإلجراءات الجراحية التي يحتاجها المريض وشرح كل ذلك لذوي المريض وطبيب األورام‬
‫قبل إجراء اإلشعاع أو العالج الكيماوي ‪.‬‬
‫ثانياً‪ :‬العناية بالفم واألسنان خالل فترة العالج بجرعة السرطان ( فترة انخفاض المناعة )‪:‬‬
‫‪ .1‬اإلجراءات الوقائية‪:‬‬
‫مضاعفات العالج الكيميائي التي تظهر في الفم هي ليست غير شائعة‪ .‬المظاهر الحادة التي غالبا ما تظهر تشمل‬
‫التهاب الغشاء المخاطي والنزيف اللثوي‪ ،‬جفاف الفم‪ ،‬داء المبيضات الثانوية‪ ،‬والهربس البسيط وااللتهابات البكتيرية علماً‬
‫بـأن تقرح األغشية المخاطية هي المشكلة األكثر شيوعا وتترافق مع معدل منخفض للنيتروفيل والهدف من العناية و‬
‫العالج الفموي هو للتخفيف من األعراض وكذلك لمنع وعالج أي عدوى ثانوية وخطر تسمم الدم لذا يفضل‪-:‬‬
‫‪ ‬استخدام غسول الفم الكلورهكسدين مرتين يومياً ووقف مؤقت لتنظيف األسنان بالفرشاة‬
‫اذا كانت آفات الدم مؤلمة جداً والحفاظ على نظافة الفم يصبح أكثر أهمية عند إعطاء‬
‫معلق النستاتين بسبب احتوائه على السكر ‪.‬‬
‫‪ ‬اعطاء النستاتين ( ‪ 033.333‬وحدة ‪/‬مل) كمعلق عن طريق الفم اربع مرات يومياً اذا‬
‫كان هناك عالمات داء المبضات الفموية ويجب ان يطلب من الطفل اإلبقاء على‬
‫الدواء في الفم ألطول فترة ممكنة قبل بلعه والينبغي استخدام النستاتين والكلورهكسدين‬
‫سوية في وقت واحد ألن احدهما يثبط عمل االخر ‪.‬‬
‫‪‬‬
‫سرطان األطفال‬
‫‪61‬هناك عالمات الهربس البسيط ‪.‬‬
‫إعطاء االسيكلوفير الموضعية اذا كانت‬
‫‪‬‬
‫استخدام ‪ %0‬من بيكاربونات الصوديوم كمحلول لتطهير الفم ويساعد‬
‫على معادلة األحماض‬
‫‪ ‬يمكن استخدام المسكنات في حالة القرح المؤلمة ( ال ينصح كثرة استخدام المخدر‬
‫الموضعي وذلك المتصاصه السريع في مجرى الدم من خالل التقرحات)‪.‬‬
‫‪ ‬يجب ان تعالج األسنان كلها قبل بدا اإلشعاع وذلك الن مكونات الدم تبدأ بالنزول لمدة ‪ 0 – 0‬أيام بعد جرعة عالج‬
‫السرطان وتبقى واطئة لمدة ‪ -01‬إلى ‪ 00‬يوم ثم ترجع الى المستوى الطبيعي ‪.‬‬
‫‪ ‬واذا كان العالج متأخ ار فبالمستطاع عالج األسنان التي تعاني التهاباً ليس حاداً بالحشوة المؤقتة لحين رجوع حالة الدم‬
‫إلى االستقرار وتكون األفضلية للمناطق ذات االلتهاب المايكروبي‪ ,‬القلع ‪ ,‬إزالة التكلسات القلحية ومسببات الجروح في‬
‫اللثة‪.‬‬
‫‪ ‬فحص الفم باستمرار وفي أوقات متقاربة لتشخيص أي التهاب بكتيري او فايروسي او فطري لغرض عالجه سريعا‪.‬‬
‫‪ .2‬العناية بالفم واألسنان ‪:‬‬
‫‪ ‬اللثة وما حول األسنان ‪:‬‬
‫النزف الفموي يحدث نتيجة قلة الصفيحات الدموية وعالجه يكون موضعيا باستعمال ضمادات الضغط كإسعاف‬
‫أولي وأحالته إلى اقرب مستشفى ‪.‬‬
‫‪ ‬تحسس األسنان (األلم) ‪-:‬‬
‫إرشاد المريض بأن التحسس حالة مؤقتة وينتهي بعد توقف العالج السرطاني بفترة قصيرة‪.‬‬
‫‪ ‬جفاف الفم ‪:‬‬
‫يعالج بوصف العلك الخالي من السكر (علك ماء) ومعاجين أسنان خاصة وتعدد شرب رشفات الماء‪.‬‬
‫‪ ‬التكزز العضلي ‪:‬‬
‫البدء بتمارين يومية لتمطية العضالت والتي تبدأ من قبل البدء بالعالج السرطاني وخالله وحسب جدول التمارين‬
‫مرفق رقم (‪ )0‬ويمكن استعمال المسكنات ومرخيات العضالت وباستشارة طبيب األورام ‪.‬‬
‫‪ ‬الغذاء‪:‬‬
‫عدم تناول الغذاء المسبب للتسوس مثل الكربوهيدرات وتـثقـيف األهل حول‬
‫طعام الطفل حسب مرفق رقم (‪.)0‬‬
‫‪ ‬االعتناء بالشفة‪ :‬استعمال النوليين كريم لترطيب الشفة‬
‫سرطان االطفال‬
‫‪62‬‬
‫‪ ‬العناية باألسنان ‪:‬‬
‫أي مشكلة طارئة لألسنان يجب ان تعالج باالتصال مع الطبيب العام للمريض‬
‫لنحصل على الجرعات الدوائية االسنادية مثل المضادات‬
‫الحيوية ونقل الصفائح الدموية و األدوية المهدئة‬
‫ثالثاً‪ :‬العناية بالفم واألسنان بعد جرعة العالج (ماعدا زراعة النخاع)‬
‫‪ .1‬اإلجراءات الوقائية‪:‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫نظافة الفم‪:‬‬
‫تفريش األسنان ‪ 0-0‬مرات يوميا باستعمال فرشاة ناعمة وتجفف الفرشاة بعد االستعمال‬
‫الغذاء‪:‬‬
‫عدم تناول الغذاء المسبب للتسوس مثل الكربوهيدرات وتثقيف األهل حول طعام الطفل‬
‫حسب مرفق رقم (‪)0‬‬
‫االعتناء بالشفة‪ :‬استعمال النولين كريم لترطيب الشفة‬
‫التثقيف الصحي‪ :‬حول ضرورة العناية بالفم واألسنان ومراجعة طبيب األسنان باستمرار للمتابعة وخاصة‬
‫لألطفال دون الست سنوات‬
‫‪ .2‬العناية باألسنان‬
‫‪ ‬الفحص الدوري‬
‫كل ‪6‬اشهر او اقل في حالة ظهور مشكلة مثل ظهور ورم في الفم حيث يجب مراقبته بزيارات متقاربة لطبيب‬
‫األسنان ‪.‬‬
‫‪ .3‬تقويم األسنان ‪:‬‬
‫تبدأ بعد سنتين من الشفاء مع تشخيص اإلضرار التي يمكن ان تظهر بعد استعمال عالج السرطان قبل إجراء‬
‫التقويم ويجب مراعاة ما يلي‪:‬‬
‫‪ ‬استشارة الطبيب العام قبل البدء بالتقويم‬
‫‪ ‬يجب عدم استخدام األجهزة التي تسبب انحالل الجذر‬
‫‪ ‬استخدام قوى طفيفة‬
‫‪ ‬إيقاف العالج بفترة اقل من الطفل االعتيادي‬
‫‪ ‬استخدام أسهل الطرق في التقويم‬
‫‪ ‬عدم إجراء التقويم للفك األسفل‬
‫‪ .4‬جراحة الفم‪:‬‬
‫سرطان االطفال‬
‫حيث يجب االبتعاد عن‬
‫استشارة الطبيب العام وخاصة للمرضى اللذين يتعاطون عالج البزفوسفونيتس ‪63‬‬
‫الجراحة المعقدة عند هؤالء‬
‫‪ .5‬جفاف الفم‪:‬‬
‫استخدام العلكة الخالية من السكر وارتشاف الماء بصورة متقطعة ومتكررة‬
‫‪ .6‬التكزز العضلي‪:‬‬
‫تمارين يومية لتمطيه العضالت التي تبدأ من قبل البدء بالعالج السرطاني وخالله وحسب جدول التمارين مرفق رقم‬
‫(‪ )0‬ويمكن استعمال المسكنات ومرخيات العضالت وباستشارة طبيب األورام ‪.‬‬
‫األطفال المعالجون بزراعة‬
‫نخاع العظم‬
‫الطور األول قبل الزراعةالمضاعفات الفمية ترجع الى الوضع البدني و الصحة الفموية والجرعة الدوائية للمريض‬
‫يتم أتحاذ نفس اإلجراءات المتخذة في السرطانات ماعدا اختالفين هما‬
‫‪ .0‬في زراعة النخاع يتعاطى المريض الدواء الكيميائي واإلشعاع لفترة أيام قليلة قبل الزراعة ‪:‬‬
‫‪ .0‬فترة انخفاض المناعة ستكون طويلة بعد الزراعة ‪.‬‬
‫‪ .0‬تأجيل عالج األسنان الى ‪ 00-9‬شهرا بعد الزراعة او أكثر اذا ظهرت آثار للمرض في الفم ولهذا يجب عالج أسنان‬
‫الطفل قبل خضوعه لهذا العالج‬
‫الطور الثاني فترة هبوط النيوتروفيلس‬
‫وهو اليوم الذي يدخل فيه المريض إلى المستشفى لبدء الزراعة الى ‪ 33‬يوم بعد الزراعة‬
‫‪ ‬يجب متابعة الفم واألسنان بصورة مستمرة وبفترات متقاربة لمالحظة وعالج التغيرات الفموية والتأكيد على‬
‫العناية الفموية القصوى ‪.‬‬
‫‪ ‬اي إجراءات عالجية غير مسموح بها في هذه الفترة وذلك لالنخفاض الشديد في المناعة ‪.‬‬
‫الطور الثالث إعادة تركيب النخاع‬
‫‪ ‬تبدأ المضاعفات تقل في هذه الفترة عادة ‪ 1-0‬أسابيع بعد الزراعة‬
‫‪ ‬احتمال إصابة الفم بالتهابات فطرية وحمى الحالئي والناية الفموية‬
‫‪ ‬ممكن إجراء عالج األسنان مثل تنظيف األسنان واللثة وذلك بعد موافقة الطبيب‬
‫للتأكد من المناعة‬
‫االطفال‬
‫سرطانالفم‬
‫‪ ‬ينصح المريض واألهل بضرورة‪64‬العناية القصوى بنظافة‬
‫‪ ‬االنتباه لعالج جفاف الفم ‪ 1-0‬أشهر بعد الزراعة‬
‫‪ ‬استخدام مضمضة الفلور و معجون األسنان المضاد لتحسس األسنان‬
‫العام‬
‫الطور الرابع إرجاع بناء المناعة‪ /‬الطور األخير بعد الزراعة‬
‫وهو اليوم ‪ 133‬بعد الزراعة‪ :‬المضاعفات الفموية لها عالقة بالتسمم المزمن المالزمة لنظام التأهيل وهبوط النيوتروفيل‬
‫(الطور الثاني) وله تأثيرات سلبية كبيرة وخاصة على األطفال تحت ‪ 6‬سنوات ويجب اتخاذ اإلجراءات التالية‪:‬‬
‫‪ ‬فحص دوري منتظم للفم واألسنان من ضمنها الفحوصات الشعاعية للفم من اجل الكشف المبكر ألي ورم الذي‬
‫يكون وارد في هذه الفترة ‪.‬‬
‫‪ ‬يجب تفادي اي عالج معقد في األسنان في األطفال الذين يعانون من هبوط في الجهاز المناعي‬
‫‪ ‬بالنسبة للتقويم يجب استشارة الطبيب العام‪.‬‬
‫‪65‬‬
‫مرفق رقم (‪)1‬‬
‫سرطان االطفال‬
‫استمارة الطفل قبل البدء بالعالج باإلشعاع والكيمياوي وزراعة نخاع العظم‬
‫اسم المستشفى ‪-:‬‬
‫االسم ‪-:‬‬
‫العمر ‪-:‬‬
‫العنوان ‪-:‬‬
‫التاريخ الطبي ‪-:‬‬
‫ نوع المرض‬‫ العالج المستعمل‬‫ تاريخ البدء بالعالج‬‫ الحساسية من األدوية‬‫ العمليات الجراحية‬‫التقارير الطبية‪-:‬‬
‫تاريخ طب األسنان للطفل ‪-:‬‬
‫ حوادث السقوط على الفم واألسنان‬‫ العالجات السابقة للفم واألسنان‬‫ اإلجراءات الوقائية المتخذة‬‫ تطبيق الفلورايد الموضعي‬‫‪ -‬تفريش األسنان‬
‫‪ -‬استعمال خيط األسنان‬
‫ الحشوات السادة للشقوق‬‫فحص الفم واألسنان ‪ :‬الراس‬
‫الفم‬
‫الرقبة‬
‫ التشخيص باألشعة‬‫أسم الطبيب‬
‫التوقيع‬
‫التاريخ‬
‫سرطان األطفال‬
66
)2( ‫نموذج رقم‬
 Moist heat is very helpful for the sore muscles of TMJ.


Jaw and neck exercises, which will help the muscles stretch.
Passive joint mobilization, re-education of the jaw movement, scar mobilization, and
strengthening exercises to the jaw muscles play vital part after the surgery or chemo
radiotherapy.
Some therapies may be preventative and may begin prior to and continue throughout
treatment. For example, the patient who receives radiotherapy and chemotherapy needs oral
Range Of Motion exercises to maintain movement of the lips, tongue, and jaw. Initiate these
exercises prior to radiation therapy and advise the patient to continue doing the exercises 4–6
times daily, if possible, for 5–10 min each time throughout the course of radiation and for at
least 3 months thereafter.
)1( ‫التمرين‬
‫فتح وغلق الفم‬
‫قبل وبعد العالج‬
)2( ‫التمرين‬
‫استعمال خافضات اللسان بعدد معين وزيادة العدد يومياً في تمارين فتح وغلق الفم‬
) ‫(بعد العالج‬
‫سرطان األطفال‬
)3( ‫التمرين‬
67
‫قبل وبعد العالج‬
‫لجنة أعداد بروتوكول برنامج طب األسنان الوقائي لألطفال المصابين بمرض السرطان‬
‫د‪ .‬بشرى رشيد نعمان‬
‫دائرة صحة بغداد الكرخ‬
‫د‪.‬زيد ناجي حسن‬
‫دائرة صحة بغداد الرصافة‬
‫د‪ .‬اسراء شكر ولي‬
‫دائرة األمور الفنية‬
‫د‪ .‬عماد جبار وهيب‬
‫دائرة صحة الديوانية‬
‫الدالئل اإلرشادية لقسم صحة الفم واألسنان لعام ‪3102‬‬
‫اشـــــــــــــــراف‬
‫الدكتور‬
‫حازم عبد الرزاق الجميلي‬
‫مدير عام دائرة األمور الفنية‬
‫اعــــــــــــــــــــــــداد‬
‫‪ -0‬طبيب األسنان ‪ /‬نبيه عبد الرسول العلي ‪ /‬مدير قسم صحة الفم واألسنان‬
‫‪ -3‬طبيبة األسنان ‪ /‬ابتسام عدنان عبود‬
‫‪ /‬قسم صحة الفم واألسنان‬
‫‪ -2‬طبيبة األسنان ‪ /‬إسراء شكر ولي‬
‫‪ /‬قسم صحة الفم واألسنان‬
‫‪ -4‬طبيبة األسنان ‪ /‬هناء سلمان مطر‬
‫‪ /‬قسم صحة الفم واألسنان‬
‫‪ -5‬تقني أسنان ‪/‬‬
‫فراس حميد راضي ‪ /‬قسم صحة الفم واألسنان‬
‫المحتويات‬
Patient safety protocol
........................................ 9
Evaluation and management of dental patient
with viral hepatitis
............................................. 21
Dental diagnostic guidelines part 1 ......... ............... 43
‫بروتوكول برنامج طب األطفال الوقائي للمصابين بمرض السرطان‬.................... 55
‫مقدمه‬
‫منننن ضنننمن خطنننة ق نننم صننننة ال نننم واألسننننان إعنننداد بروتوكنننوالت ودالئنننل إرشنننادية‬
‫( & ‪Guidelines‬‬
‫عالجيننننننة ووقائيننننننة لوضننننننع ليننننننات العمننننننل‬
‫‪ )Protocols‬خاصة بخدمات طب األسنان المقدمة في مؤس اتنا الصنية‪.‬‬
‫إن هننننذد النننندالئل والبروتوكننننوالت هنننني خطننننوة مننننن مجمننننوع خطننننوات تهنننند إلننننى‬
‫تن نننننين األداء الطبننننني وتخ ينننننا المعننننناع ات الناتجنننننة عنننننن خطننننناء تنننننندث فننننني‬
‫المؤس ننننات الصنننننية و تقليننننل احتمننننال حنننندوث المعنننناع ات غيننننر المرغننننوه فيهننننا‬
‫في بعض األحيان وهي ذات صلة عالية األهمية في سالمة المريض ‪.‬‬
‫الدكتور‬
‫نبيه عبد الرسول العلي‬
‫مدير قسم صحة الفم واألسنان‬