Periodontal+Case+3

= Case #3 - HIV =

** __I. Overview of HIV:__ **
HIV is characterized by deterioration of the immune system, as noted by decreases in CD4+ cells (cluster of differentiation 4 lymphocyte count of less than 200 in a patient who is infected with HIV). CD4+ cells have an important role in immune response. HIV can replace only within cells using the reserve transcriptase enzyme to convert these RNA into DNA, thus becoming part of the host cell. HIV is composed of a viral envelope, an RNA genome, and structural proteins. Proteins in the envelope facilitate HIV's entry and exit from CD4+ cells, and enzymes within the cell core control replication.

The virus' affinity to the CD4 cells, greatly affects the T-lymphocytes function in the immune response. The B-lymphocytes are not infected, but affected indirectly by the abnormal function of the T-lymphocytes. There is dysregulation of the B-lymphocytes, altering the neutrophil function, increasing the patient's risk for malignancies, and infections.

Although, AIDS patients are classified by the CD4 count of less than 200/mm3, the viral count may fluctuate depending on the patient's response to the drug therapy, highly active antiretroviral therapy (HAART). This therapy consists of a combination of antiretrovial drugs, protease inhibitors, and fusion inhibitors. The medication lower the viral load by causing a dormant effect, but the virus is always present. The medications have increased the life expectancy of HIV patient, but have adverse side-effects.

Individuals have HIV often suffer from complications due to a compromised immune system. Some of these complications include:

 With continuing improvements in the pharmacologic management of patients with AIDS, opportunistic infections are less frequent.
 * pulmonary tuberculosis
 * Oral Candidiasis
 * Leukoplakia
 * recurrent episodes of pneumonia
 * invasive cervical carcinoma
 * Kaposi's sarcoma
 * lymphoma
 * wasting syndrome
 * central nervous system syndromes
 * HIV infection of neuronal cells may lead to dementia

__**II. Medical history**__
A 35 year old male arrives as a new patient to your office. He does not have any dental insurance and is paying cash. He came in as an emergency patient and stated "I am having severe pain in my gums and I have sores I need the Doctor to check!". He also stated that some of his teeth were "getting loose" and that he had "really bad breath." It was noted that he had palpable bilateral cervical and submandibular lymph nodes. While reviewing the medical history, he complains of fatigue, muscle aches, night sweats and loss of appetite. He reports on the medical history that he has HIV and is under his physician's care. The patient is currently taking the following medic //ation: Combivir which is a combination of lamivudine + ziduvudine (AZT). // 

Once HIV/ AIDS is noted on the health history, the status of the patient will need to be thoroughly evaluated. According to Carranza, the following questions should be addressed through the **<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">health history **<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">, **<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">physical evaluation **<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">, and **<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">medical consultation **<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">,

<span style="font-family: 'Comic Sans MS',cursive;">
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">What is the CD4+T4 lymphocyte level?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">What is the current viral load?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">How do current Cd4+ T4 cell and viral load counts differ from, previous evaluations? How often are such tests performed?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">How long ago was the HIV infection identified?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">Is it possible to identify the approximate date of original exposure?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">Is there a history of drug abuse, sexually transmitted diseases. multiple infections or other factors that might alter immune response? For example, does the patient have a history of Chronic Hepatitis B, Hepatitis C neutropenia, thrombocytopenia, nutritional deficiency, or adrenocorticoid insufficiency?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">What medications is the patient taking?
 * <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">Does the patient describe or present with possible adverse side effects from the medications?

__**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">III. Gingival description (refer to photo above) **__
<span style="color: #000000; font-family: 'Comic Sans MS',cursive;"> Mandibular right buccal aspect: <span style="font-family: 'Comic Sans MS',cursive;">

<span style="font-family: 'Comic Sans MS',cursive;">
 * <span style="font-family: 'Comic Sans MS',cursive;">Free gingiva is erythematous, ulcerative necrotic, edematous, with loss of architecture and supperation
 * <span style="font-family: 'Comic Sans MS',cursive;">Attached gingiva is erythematous, firmly bound to bone, shiny and smooth with loss of stippling

<span style="font-family: 'Comic Sans MS',cursive;">
 * <span style="font-family: 'Comic Sans MS',cursive;">Based on the clinical findings, the patient presents with ANUP
 * <span style="font-family: 'Comic Sans MS',cursive;">Necrosis and ulceration of the coronal portion of the interdental papillae and gingival margin
 * <span style="font-family: 'Comic Sans MS',cursive;">Painful
 * <span style="font-family: 'Comic Sans MS',cursive;">Tissue bleeds easily
 * <span style="font-family: 'Comic Sans MS',cursive;">Deep interdental osseous craters
 * <span style="font-family: 'Comic Sans MS',cursive;">The patient does not present with deep pocket probing depths
 * <span style="font-family: 'Comic Sans MS',cursive;">Patient has white-red patches on the hard palate. Which was not noted previously by the patient
 * <span style="font-family: 'Comic Sans MS',cursive;">Oral candidiasis is present on the entire dorsal surface of the tongue
 * <span style="font-family: 'Comic Sans MS',cursive;">Enlarged and swollen bilateral submandibular and cervical lymph nodes
 * <span style="font-family: 'Comic Sans MS',cursive;">Fever
 * <span style="font-family: 'Comic Sans MS',cursive;">Localized mobility on LRQ in teeth #28 thru 30

**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">__V. OHI:__ <span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-weight: normal;"> **
====**<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-weight: normal;">It is imperative that the patient maintain meticulous personal oral hygiene. When initial OHI is given to discuss the difficulties of brushing, considering the severe pain associated with ANUP. An ultra soft toothbrush should be introduced to the patient. The clinician must show and discuss with the patient how to only remove the supra gingival surface debri with the toothbrush in a gentle manner. The use of a mild, ungrainy toothpaste should also be advised. Patient should be advised that dental floss and interdental aids will be painful and avoided until condition is under control. **====

<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-weight: normal;">
====<span style="font-family: 'Comic Sans MS',cursive; font-weight: normal;"> <span style="color: #000000; font-family: 'Comic Sans MS',cursive;">Discussion of the importance of the multiple visits to help get the ANUP condition under control. ==== ====**<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-weight: normal;">Depending on the medications the dentist, in coordination with the patients physician, will be prescribing: the use of antibiotics, oral mouth rinses, and pain relief must also be discussed before discharge of the patient. **==== ====**<span style="color: #000000; font-family: 'Comic Sans MS',cursive; font-weight: normal;">By using CHX in the morning for the duration that the patient experiences pain from the tissue being inflamed as well as warm salt water rinses or hydrogen peroxide (50/50 solution). Consult with the dentist to prescribe an antifungal to control oral candidiasis. **====

<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">__**VI. Treatment Plan Appointments**__

 * ====<span style="color: #000000; font-family: 'Comic Sans MS',cursive;">**Treatment planning will vary depending on health status** ====

<span style="font-family: 'Comic Sans MS',cursive;"> Appt #1: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #2: <span style="font-family: 'Comic Sans MS',cursive;">Appt #3: <span style="font-family: 'Comic Sans MS',cursive;">Appt #4: <span style="font-family: 'Comic Sans MS',cursive;">Appt #5: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #6: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #7: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #8: <span style="font-family: 'Comic Sans MS',cursive;"> Appt #9:
 * <span style="font-family: 'Comic Sans MS',cursive;">The primary goal for HIV patients is maintain oral health, comfort, and function. Any areas in need of restoration due to decay <span style="color: #ff7200; font-family: 'Comic Sans MS',cursive;"> <span style="font-family: 'Comic Sans MS',cursive;">must be addressed as soon as possible to avoid any source of infection. <span style="color: #ff7200; font-family: 'Comic Sans MS',cursive;">
 * <span style="font-family: 'Comic Sans MS',cursive;">Medical consult with questions from medical history above. No treatment would be done until clearance is received and patients current symptoms of malaise and fever have been alleviated.
 * =====Coordination with patients physician for poss. Rx Metronidozole 250mg 2 tabs taken immediately and then 1 tablet 4 x a day for 5-7 days, and topical or systemic antifungal agent. Systemic agent would be recommended, since topical would not be effective on candida infections subgingivally. The recommended antifungal agent of choice is fluconazole for 7 to 10 days. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">This is recommended because according to Carranza this therapeutic approach is based on reports involving patients that have NUP. In severe NUP, antibiotic therapy may be necessary but should be used with caution in HIV-infected patients to avoid a opportunistic and potentially serious, localized candidiasis or even candidal septicemia. **Can someone explain why this is being recommended?** =====
 * <span style="font-family: 'Comic Sans MS',cursive;">Debridement and in office CHX irrigation (every other day). For this patient, <span style="color: #800080; font-family: 'Comic Sans MS',cursive; font-size: 12px; line-height: normal;">Debridement would initially consist of the removal of excessive amounts of plaque and tarter supragingivally from the patients teeth. This is done in part since a patient with NUP can be in a lot of pain. After this, according to Ca <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">rranza, treatment for NUP includes local debridement of lesions with scaling and root planning, lavage and instructions for good oral hygiene. At this point anesthesia maybe needed in the debridement because lesions are frequently painful. The use of the debridement and an irrigant is used for flushing of the deep lesions. <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;">**What is the rationale for this and how are you defining debridement?**
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current healt status with physician prior to continuing treatment. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;">**Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">Localized debridement and in office CHX irrigation. For this patient, **<span style="color: #000000; font-family: arial,helvetica,sans-serif; font-weight: normal;"><span style="color: #800080; font-family: 'Comic Sans MS',cursive; font-size: 12px; line-height: normal;">Debridement would initiallly consist of the removal of excessive amounts of plaque and tarter from the patients teeth. This is done in parts since a patient with NUP can be in a lot of pain. After this, <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">According to Carranza, treatment for NUP includes local debridement of lesions with scaling and root planning, lavage and instructions for good oral hygiene. At this point anesthesia maybe needed in the debridement because lesions are frequently painful. The use of the debridement and an irrigant is used for flushing of the deep lesions. What is the rationale for this and how are you defining debridement?**
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current healt status with physician prior to continuing treatment. ** Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">Localized debridement and in office CHX irrigation. For this patient, **<span style="color: #000000; font-family: arial,helvetica,sans-serif; font-weight: normal;"><span style="color: #800080; font-family: 'Comic Sans MS',cursive; font-size: 12px; line-height: normal;">Debridement would initially consist of the removal of excessive amounts of plaque and tarter from the patients teeth. This is done in parts since a patient with NUP can be in a lot of pain. After this, <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">According to Carranza, treatment for NUP includes local debridement of lesions with scaling and root planning, lavage and instructions for good oral hygiene. At this point anesthesia maybe needed in the debridement because lesions are frequently painful. The use of the debridement and an irrigant is used for flushing of the deep lesions. What is the rationale for this and how are you defining debridement?**
 * <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;">** Evaluate patient's current healt status with physician prior to continuing treatment. Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">Localized debridement and in office CHX irrigation. For this patient, **<span style="color: #000000; font-family: arial,helvetica,sans-serif; font-weight: normal;"><span style="color: #800080; font-family: 'Comic Sans MS',cursive; font-size: 12px; line-height: normal;">Debridement would inititially consist ofthe removal of excessive amounts of plaque and tarter from the patients teeth. This is done in parts since a patient with NUP can be in a lot of pain. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">According to Carranza, treatment for NUP includes local debridement of lesions with scaling and root planning, lavage and instructions for good oral hygiene. At this point anesthesia maybe needed in the debridement because lesions are frequently painful. The use of the debridement and an irrigant is used for flushing of the deep lesions. What is the rationale for this and how are you defining debridement?**
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current healt status with physician prior to continuing treatment. ** Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">OHI. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">Here we would like to evaluate the patient's technique in brushing, focusing the use of a ultra soft toothbrush, just in-case the patient still has areas that are sore from the prior appointments, if there are no signs of pain patient can begin to use either floss or an interproximal aid. If the inter proximal aid is of desire. We can recommend a rubber tip stimulator. We need to inform the patient the importance of removing bacteria, because patients that have had NUP often harbor bacteria, fungi, viruses and other nonoral microorganisms that complicate the preventive treatment. <span style="font-family: 'Comic Sans MS',cursive;"> <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;">**We discussed in class that we need to specify what would be addressed and then build on this at each appointment. I don't see that here.**
 * <span style="font-family: 'Comic Sans MS',cursive;">Scale LRQ with anesthesia and CHX irrigation and fluoride varnish. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">Post-treatment patient needs to be informed that warm salt water rinse maybe used and if any discomfort to use Ibuprofen. Also patient needs to be made aware that if there was a lot of vascularity when scaling that he might have some blood on the pillow in the morning and that is common and not to worry.
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current health status with physician prior to continuing treatment. ** Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">OHI. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">During this visit we will evaluate the techniques reviewed the appointment prior and introduce the use of the tongue scraper as an aide to decrease the amount of bacteria in the oral cavity. <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;"> **We discussed in class that we need to specify what would be addressed and then build on this at each appointment. I don't see that here.**
 * <span style="font-family: 'Comic Sans MS',cursive;">Scale URQ with anesthesia and CHX irrigation and fluoride varnish. Post-treatment patient needs to be reiterated so the patient is informed with the following information that a warm salt water rinse should be used and if any discomfort to use Ibuprofen. Also patient needs to be made aware that if there was a lot of vascularity when scaling that he might have some blood on the pillow in the morning and that is common and not to worry.
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current health status with physician prior to continuing treatment. Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. **Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">OHI. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">As a review from the weeks prior we can see how the brushing and the interproximal aids have worked for the patient and offer the use of fluoride mouth rinse. <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;"> **We discussed in class that we need to specify what would be addressed and then build on this at each appointment. I don't see that here.**
 * <span style="font-family: 'Comic Sans MS',cursive;">Scale ULQ with anesthesia and CHX irrigation and fluoride varnish. Post-treatment patient needs to be reiterated so the patient is informed with the following information that a warm salt water rinse should be used and if any discomfort to use Ibuprofen. Also patient needs to be made aware that if there was a lot of vascularity when scaling that he might have some blood on the pillow in the morning and that is common and not to worry.
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current health status with physician prior to continuing treatment. ** Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">OHI. <span style="color: #800080; font-family: 'Comic Sans MS',cursive;">Ask patient how products have worked, if there are any likes or dislikes and offer patient information about techniques of using certain above stated products. Evaluate the use of the toothbrush and at this time you offer the patient an electrical toothbrush if it is beneficial. Also the patient can be given an Endtuft brush or Tepe brush as alternatives for interproximal aids or gum stimulation therapy. But we do not want to overload the patient with products either. <span style="color: #f51919; font-family: 'Comic Sans MS',cursive;"> **We discussed in class that we need to specify what would be addressed and then build on this at each appointment. I don't see that here.**
 * <span style="font-family: 'Comic Sans MS',cursive;">Scale LLQ with anesthesia and CHX and fluoride varnish. Post-treatment patient needs to be reiterated so the patient is informed with the following information that a warm salt water rinse should be used and if any discomfort to use Ibuprofen. Also patient needs to be made aware that if there was a lot of vascularity when scaling that he might have some blood on the pillow in the morning and that is common and not to worry.
 * <span style="font-family: 'Comic Sans MS',cursive;">Evaluate patient's current health status with physician prior to continuing treatment. ** Yes, this was done prior to this appointment, but since this patient is considered medically compromised a consultation with a physician is necessary because this patient is immune compromised and we want to check on the WBC count in order to make sure that patient is stabilized to be treated. We would need the CD4 count and viral load especially. Wasn't this done prior to this appointment?**
 * <span style="font-family: 'Comic Sans MS',cursive;">4-6 week re-evaluation and maintain patient on a 2 month recall

**<span style="color: #800080; font-family: 'Comic Sans MS',cursive;">__VII. Additional treatment__ <span style="font-family: 'Comic Sans MS',cursive;"> **

 * ====<span style="font-family: 'Comic Sans MS',cursive;">Nutritional counseling- due to the wasting syndrome of HIV and pain associated to the ANUP to ensure proper nutrient intake is balanced. ====

<span style="color: #800080; font-family: 'Comic Sans MS',cursive; font-size: 130%;">__**Multiple choice questions**__
<span style="font-family: 'Comic Sans MS',cursive;"> 1. Dental treatment conditions should be based on the following:

A. Overall health status of the patient B. The degree of periodontal involvement C. Motivation and ability of the patient to perform effective oral hygiene. D. All the above E. A and B only

2. Antibiotics should always be given to patients with HIV experiencing ANUP. Metronidazole is the antibiotic of choice for this treatment.

A. The first sentence is true. The second sentence is false B. The first sentence is false. The second sentence is true. C. Both sentences are true. D. Both sentences are false.

3. An AID patients is classified by a CD4 cell count of

A. 400/mm3 B. Less than 200/mm3 C. Less than 100/mm3 D. 500/mm3

4. <span style="font-family: 'Comic Sans MS',cursive;">HIV is characterized by deterioration of the immune system and B lymphocytes are directly affected

A. The first sentence is true. The second sentence is false B. The first sentence is false. The second sentence is true. C. Both sentences are true. D. Both sentences are false.

5. The patient's condition is not affected by his CD4 count and viral load, therefore his symptoms are not related to HIV

A. The first sentence is true. The second sentence is false B. The first sentence is false. The second sentence is true. C. Both sentences are true. D. Both sentences are false.

6. Which of the following are symptoms of ANUP A. Rapid bone loss B. Mobility C. Acute inflammation D. all of the above

7. Prescribing antibiotics for this patient may be contraindicated due to: A. His current oral candidiasis condition B. Because he has HIV C. Because it may increase inflammation

8. Both a topical and systemic antifungal agents would be affective for any type of fungal infection in the oral cavity. One drug of choice is the flucanozole.

A. The first sentence is true. The second sentence is false B. The first sentence is false. The second sentence is true. C. Both sentences are true. D. Both sentences are false.

9. Fungal infections can be diagnosed by: A. Clinical evaluation B. Culture analysis C. Microscopic sample D. all of the above

10. The goal of therapy is: A. Restoration and maintenance of oral health B. Comfort C. Function D. All of the above