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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
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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.
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CDC- 2006
1. Cardiovascular disease
2. Cancer
3. Stroke
4. Pneumonia- influenza( #7 in 1996)
>>15. AIDS ( #7. in 1997)
Emerging
Infectious
Diseases
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Ebola virus > 50 deaths Oct. 2000
Hantavirus
Cryptosporidosis( Brewhouse tri)
E. coli and Enterococci
necrotizing Strep. A
Pneumococci
Staph. aureus
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Emerging &Re-emerging
Infectious Diseases
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antimicrobial resistance
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misuse of antibiotics
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mobility- travel
food, water and agriculture
child care
Behaviors
hospitals-health care
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Hepatitis C
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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
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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
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
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
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2006: 35 million, worldwide
6 million deaths !!
infected women ( world) ~40 %
>1 million infected children
( 90% = 3rd world)
HIV
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U.S.> 1.5 million
AIDS: U.S.>550,000 cases
AIDS: U.S.>350,000 deaths
changes in epidemiology
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homosexual-bisexual males
IVDUs
women
children
HIV-AIDS in the U.S.
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cases of AIDS-1996
deaths from AIDS-1996
cases of AIDS-2006
deaths from AIDS-2006
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=
=
=
=
~ 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*
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Pneumoncytis pneumonia
HIV wasting syndrome**
Candidal esophagitis
Kaposi’s sarcoma
TB
lymphoma
Viral: Herpesviridae, CMV, HPV, Pox family
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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
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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.
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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
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Nucleotide RT Inhibitor Adefovir
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$ 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
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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
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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
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Detection
Physical Evaluation
Medical treatment
Status
Management
Management Considerations
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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
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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
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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
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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
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Immunocompromised State
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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
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Condyloma acuminatum
Transmission
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HPV DNA detected in sperm 32% of
men detected in 24 of 45 men hx or
clinical evidence of HPV infection
HIV
Infection
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Angular cheilitis
Patient was HIV
infected
Later was diagnosed
with AIDS
Erythematous
candidiasis
Bacterial Infections
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Systemic Infections
Oral Infections
 Periodontal tissues
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Necrotizing ulcerative gingivitis (NUG)
Linear gingival erythema
Necrotizing ulcerative periodontitis
Tongue and other mucosal
structures
HIV Infection
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Linear gingival
erythemia
Necrotizing Ulcerative
Periodontitis
HIV Infection
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Recurrent herpes
simplex infection in a
patient with AIDS
HIV Infection
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Herpes zoster
Out break occurred in
patient with AIDS
Harrison’s Online, hppt://www.harrisonsonline.com, plate 11D-30, 2002
HIV Infection
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Aphthous ulceration
(major type)
Patient was diagnosed
with AIDS
HIV Infection
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Kaposi’s sarcoma
HIV transmission from HCW to
patients
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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.
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~ 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.
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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
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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
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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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