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COMPETENCIES: Upon completion of this course the third year dental student will have demonst rated partial fulfillment of the following competencies: 1. Examine and evaluate the patient with medical problems. 2. Identify and record the medical problems presented by the patient. 3. Recognize and be able to prevent and provide immediate management for various m edical emergencies in dental patients. 4. Recognize when it is necessary to refer the patient for further treatment, and coordinate care provided by others. I. LAB EXER CISE : a. Select a dental pa tient requiring medical consultation b. Demons trate completion of a medical consultation letter( form letter + actu al letter to M. D.) c. List goals to minimize the po tential for offi ce emergencies in the HSS form + prog ress notes d. Turn-in copies of: me d. consult form, actual letter, phy sician response and chart entr y. Describe significance of specific pati ents medi cal condition as well as det ailed denta l manag ement for this patient. e. Lab exercise is due to Dr. RHODUS by THE FIN AL EXAM INATION Causes of death in the world from infectious disease QuickTime™ and a decompressor are needed to see this picture. 150 multiple cause of death deaths per 100,000 100 people main cause of death 50 1980 1985 1990 2000 Deaths from infectious disease- US ( JAMA, 2000) 350 >65 y.o. 300 deaths 250 ____ per 50 100,000 people 45- 64 y.o. 30 10 1980 25-44 y.o. 0-4 y.o. 5-24 y.o. 1985 1990 2000 Deaths from infectious disease- US ( JAMA, 2000) Causes of death in the U.S. CDC- 2006 1. Cardiovascular disease 2. Cancer 3. Stroke 4. Pneumonia- influenza( #7 in 1996) >>15. AIDS ( #7. in 1997) Emerging Infectious Diseases QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Ebola virus > 50 deaths Oct. 2000 Hantavirus Cryptosporidosis( Brewhouse tri) E. coli and Enterococci necrotizing Strep. A Pneumococci Staph. aureus QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Emerging &Re-emerging Infectious Diseases antimicrobial resistance misuse of antibiotics mobility- travel food, water and agriculture child care Behaviors hospitals-health care QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Hepatitis C formerly NANB transmission similar to Hep B + often accompanies 40-50% = chronic active hepatitis acute liver disease; cirrhosis ~ 90 % develop chronic carrier state U.S. = 1992 ~ 150,000 infections > 1.5 million infections in 1998 >1000 HCW/yr. occupational! hep-Ca > 11 % !! Antimicrobial resistance QuickTime™ and a decompressor are needed to see this picture. nosocomial infections >200,000/yr. Vancomycin resistant Staph. Aureus 1989<1% ; 1999 >15% methacillin res. 1999 >60% inappropriate prescribing practices ! > 70 % !! “Today’s discovery represents the triumph of modern science over a dreadful disease.” HEW Secretary Margaret Heckler 1983 upon the discovery of HTLV-III AIDS EPIDEMIC December 2006 35 million HIV infections worldwide, > 6 million cumulative deaths worldwide, including > 1.3 million dead children, 830,000 infected children worldwide (4.5 million AIDS cases). 60% of worldwide cases of HIV are in Africa (18 million, with 9 million cases of AIDS and 1.8 million AIDs deaths in Africa in 1998) In S. Africa 50% of hospital beds are for AIDS; estimated by 2010 that 9 countires in Africa will have their life expectancy drop 16 yrs. HIV 2006: 35 million, worldwide 6 million deaths !! infected women ( world) ~40 % >1 million infected children ( 90% = 3rd world) HIV U.S.> 1.5 million AIDS: U.S.>550,000 cases AIDS: U.S.>350,000 deaths changes in epidemiology homosexual-bisexual males IVDUs women children HIV-AIDS in the U.S. cases of AIDS-1996 deaths from AIDS-1996 cases of AIDS-2006 deaths from AIDS-2006 QuickTime™ and a decompressor are needed to see this picture. = = = = ~ 56,000 ~ 45,000 ~ 25,000 ~ 11,000 source: CDC- 2006 8000 alive with AIDS AIDS new cases cases per wk Deaths 1000 1990 1992 1994 2006 Incubation Period to AIDS Transfusion Recipients 7 years Hemophiliacs 10 years Injecting drug users 10 years Homosexual/ bisexual men 0% 1yr 3% 3yr Cumulative % 12% 36% 53% 5yr 8yr 10yr 8-12 years 68% 14yr 85% 20yr 3 CD4 cell/ mm CD4 % Clinical Presentation Viral Load > 600 Stage < 500 B 32-50 <29 < 400 200-400 14-28 < 200 <14 < 100 Normal Initial immune suppression. Initiation of retroviral therapy. Manifestations of opportunistic infections. More opportunistic infections and some major opportunistic infections. AIDS diagnosis; severe immune suppression, major opportunistic infections; prophylactic medications for PCP. Appearance of fatal opportunistic infections and specific oral lesions. Prophylaxis for toxoplasmosis, MAC, cryptococcosis. AIDS defining diseases* Pneumoncytis pneumonia HIV wasting syndrome** Candidal esophagitis Kaposi’s sarcoma TB lymphoma Viral: Herpesviridae, CMV, HPV, Pox family 38% 18% 14% 10% 10% 10% Neurologic < AIDS-related pain (neuropathy, myelopathy) ** loss of 10% body wt. < 30days Clinical category C Bacterial infections, multiple or recurrent* Candidiasis, respiratory Candidiasis, esophageal Cervical cancer** Coccidioidomycosis Cryptococcosis= Cryptosporidiosis Cytomegalovirus disease= Cytomegalovirus retinitis Encephalopathy, HIV related Herpes simplex= chronic; respiratory; esophageal Histoplasmosis= HIV encephalopathy HIV wasting syndrome Immunosuppression, severe HIV-related= Isosporiasis Kaposi’s sarcoma= Lymphoid interstitial pneumonia* Lymphoma, Burkitt’s= Lymphoma, immunoblastic= Lymphoma, primary; brain M. avium complex= M. tuberculosis=, disseminated; Dental patient management :AIDS Opportunistic infections Pneumoncystis carinii pneumonia (PCP) Toxoplasmic encephalitis TB Mycobacterium avium complex(MAC) Streptococcal pneumonia CMV Candidiasis Cancer Highly Active Antiretrovial Therapy (HAART) Preferred Antiretroviral Regimens Optimal: 2 NRTIs + PI; 2 NRTIs + NNRTI Unacceptable: monotherapy Resistance 1990 1% 1994 7% 1999 15% Changing therapy: failure (rising viral load, falling CD4 count, symptoms, ADEs) never add a single drug to a failing regimen, begin with at least 2 drugs. Less desirable: 3 NRTIs Anti-HIV Drugs Nucleoside RT Inhibitors - mg/day 30 day cost Abacavir (ABC; Ziagen) 300 bid Didanosine (ddI, Videx) 200 bid Lamivudine (3TC, Epivir) 150 bid Stavudine (d4T, Zerit) 40 bid Zalcitabine (ddC, Hivid) 0.75 tid Zidovudine (AZT, ZDV, Retrovir) 200 tid Zidovudiine + Lamivudine (Combivir) 1 tab bid Nucleotide RT Inhibitor Adefovir $ 349 217 259 274 212 604 564 120 qd only available thru EAP Non-nucleoside RT inhibitors ( NNRTI) Delavirdine (Rescriptor) Efavinrenz (EFV, Sustiva) Nevirapine (Viramune) * 400 tid 600 qd 200 bid 239 394 279 *Not drug of choice for HIV postexposure prohpylaxis Protease Inhibitors: block an enzyme that cleaves Gag and Gag-Pol polyproteins - 50 to 100X more potent than AZT Amprenavir (Agenerase) 50s, 150s $ per month = 605 Indinavir (Crixivan) $ per month = 464 Nelfinavir (Viracept) $ per month = 583 Ritonavir (Norvir) $ per month = 668 Saquinavir (Invirase) $ per month = 586 mg/day 1200 bid 800 q8h 750 tid 600 tid 600 tid Treatment of HIV Infection Most untreated patients have HIV-1 RNA levels stabilize between 1000-10,000 copies/mL. In AIDS, levels > 1 million copies/mL Combination therapy of NRTI + NNRTI + HIV Protease inhibitor Up to 28% of newly infected individuals may contract HIV that is resistant to one or more anti-AIDS drugs HIV Therapy Edge is software to search gene sequences for over 120 drug resistance mutations and to report which drugs to avoid. AIDS treatment complex Rx : 1-8 months > $12, 000.00 poor compliance HIV +ve & infectious viral genotyping to detect antiretroviral resistance Opportuntistic infections CD-4 counts >500 ; esp. >200 Screening and rapid tests: Abbott/Murex Single Unit Diagnostic System [SUDS] HIV-1 test), oral mucosal transudate-based tests (e.g., OraSure HIV-1 western blot kit), home test systems (e.g., Home Access HIV-1 test kit). Principles of medical management of dental patients Detection Physical Evaluation Medical treatment Status Management Management Considerations Viral load will determine level of viremia, efficacy of antiretroviral therapy, disease progression, and prognosis, thus influencing appropriate treatment planning. There is no need for prophylactic medication prior to dental therapy based solely on viral load. Management Considerations Dental treatments, including extractions, can be safely performed in patients with platelet counts >50,000 platelets/mm3. Prophylactic bactericidal antibiotics need to be considered when the neutrophil count drops below 500 cells/mm3 (normal 2,500-7,000 cells/mm3), but at this stage the patient is often already medicated with antibiotics due to frequent bacterial infections and as prophylaxis against opportunistic infections. There are very few complications associated with dental care of HIV-infected patients and most infected patients can be safely treated by general dental practitioners. Oral lesions found in HIV-infected persons are reliable markers for immune suppression, disease progression and AIDS. GROUP 1 ORAL LESIONS Strongly Associated with HIV Infection Candidiasis Oral hairy leukoplakia Kaposi’s sarcoma Non-Hodgkin’s lymphoma Periodontal disease - linear gingival erythema, necrotizing (ulcerative) gingivitis, necrotizing (ulcerative) periodontitis Oral candidiasis most common oral lesion among HIV+persons (39.6%), then hairy leukoplakia (26.3%), exfoliative cheilitis (18.3%), and linear gingival erythema (LGE) (11.5%). JOPM 2001 30(4):224-30 in Thailand Oral candidiasis in HIV prevalent ( >45%) related to other oral diseases( i.e. caries and periodontal disease, HSV, etc.) proportional to low CD-4 counts predictive of rapid progression to death Oral Hairy Leukoplakia Immunocompromised State HIV+ / AIDS Chemotherapy Organ transplant Autoimmune disease (SLE on prednisone 5-10mg/d X 1 yr + methotrexate) Often an indicator that AIDS will develop within a short time period Human Papillomavirus Condyloma acuminatum Transmission HPV DNA detected in sperm 32% of men detected in 24 of 45 men hx or clinical evidence of HPV infection HIV Infection Angular cheilitis Patient was HIV infected Later was diagnosed with AIDS Erythematous candidiasis Bacterial Infections Systemic Infections Oral Infections Periodontal tissues Necrotizing ulcerative gingivitis (NUG) Linear gingival erythema Necrotizing ulcerative periodontitis Tongue and other mucosal structures HIV Infection Linear gingival erythemia Necrotizing Ulcerative Periodontitis HIV Infection Recurrent herpes simplex infection in a patient with AIDS HIV Infection Herpes zoster Out break occurred in patient with AIDS Harrison’s Online, hppt://www.harrisonsonline.com, plate 11D-30, 2002 HIV Infection Aphthous ulceration (major type) Patient was diagnosed with AIDS HIV Infection Kaposi’s sarcoma HIV transmission from HCW to patients still only one case (Dr. Acer) ! CDC : >70 infected HCW served over 100,000 patients tested = 0 HIV + risk per million from HCW = 0.0038 risk of death from PCN-ALLR = 20/million HIV transmission from patients to HCW. ~ 10 per year dentistry : documented= 0 lab techs : documented= 18 nurses : documented= 15 MDs : documented= 0 others : documented= 10 Hep C > 1000 !!! possible= 7 possible= 30 possible= 40 possible= 12 possible= 47 HIV transmission from patients to HCW. NEEDLE STICKS ! avg. follow-up >$600 wounds from HIV patients; CDC: >4000 incidents < 10 seroconversions transmission rate= 0. 25% ( 1:400) >70% from blood draws; >25 % IVs >83% not high risk ( Rx goes in)...EPINet 1999 California law Management of Occupational Blood Exposures Evaluate exposure source. Assess the risk of infection using available information. Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing). For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection. Do not test discarded needles or syringes for virus contamination. Evaluate exposed person. Assess immune status for HBV infection (i.e., by history of HBV vaccination and vaccine response). Management of Occupational Blood Exposures Provide immediate care to the exposure site. Wash wounds and skin with soap and water. Flush mucous membranes with water. Reporting of exposure. Access to medical provider for testing. Access to post-exposure protocol. Documentation for workers compensation or disability claims. Determine risk associated with exposure by: Type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus) and Type of exposure (i.e., percutaneous injury, mucous membrane or nonintact skin exposure, and bites resulting in blood exposure. Mucous membrane exposures are assessed for type as either small volume (i.e., a few drops) or large volume (i.e., major blood splash) and the guidelines differ from those for percutaneous injuries in that basic 2-drug PEP is considered for small volume injuries from HIV-positive Class 1 source patients and basic 2-drug PEP is recommended for small volume injuries from HIV-positive Class 2 patients and large volume injuries from HIVpositive Class 1 patients. For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g., dermatitis, abrasion, or open wound). Can you refuse to treat and HIV infected person? Federal law prohibits the dentist from refusing to treat patients with disabilities, including HIV infection. Under the Americans with Disabilities Act (AwDA), dental offices are considered places of public accommodation and are prohibited from refusing to treat patients with HIV solely because of their HIV status. 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