Quiz 2

• Red fiery line along the gingival margin is what

  linear gingival erythema
• HIV subtyes

  HIV includes subtypes and closely related viruses

  • HIV - 1
  • More common, in most of the world including the United States
  • HIV - 2
  • Found mostly in West Africa
• HIV

  • 90 % of HIV-infected patients will have AT LEAST one HIV-related oral manifestation in the course of their disease
  • To contain the spread, role of healthcare workers must include client education and early diagnosis
• HIV pathogenesis

  • HIV - Enveloped RNA virus / retrovirus
  • Has Enzyme: Reverse Transcriptase, no other group of organisms has this special enzyme
  • Viral DNA: Can remain latent or undetected for years in the host cell
• why is a retrovirus called a retrovirus

  Converts virus RNA to DNA (Rather than the conversion of dna to rna it converts virus rna to dna) = reverse transcriptase
• HIV / AIDS Pathogenesis

  • Virus attaches to host receptor: CD4+ T lymphocytes
  • Fuses with cell membrane of CD4+ T lymphocyte and enters, releases RNA
  • Reverse transcriptase
  • Viral RNA converts to DNA
  • Integrates into host cell’s genome and “ hijacks ” the host cell to produce more HIV virions -> kills immune cell
  • Less than 200/ml count of CD4+ (Thelper) lymphocyte = infected with HIV
  • Seroconversion
  • virus is present in the blood
  • -> Diminished immune response makes the host susceptible to opportunistic infections and malignancies
• Terminology

  Viral RNA converts to DNA

  Reverse transcriptase
• Terminology

  When a virus is present in the blood

  seroconversion
• Untreated HIV infection leads to:

  • Gradually diminishing immune response due to depletion of CD4+ T lymphocytes
  • Host susceptibility to opportunistic infections and malignancies
  • AIDS
• Is there a cure for HIV?

  No, but it can be controlled with medication (antiretroviral medication)
• HIV / AIDS

  • No cure
  • chronic and infectious
  • severe immunodeficiency, opportunistic infections
  • immunosuppression - suppression of the immune response, measured by a decrease in immune cells
  • multiple cases: Oral kaposi sarcoma (rare cancer of blood vessels)
  • pandemic infection
  • now considered treatable, chronic medical condition (treatable with medication, not curable)

  
• Terminology

  suppression of the bodys natural immune response, measured by a decrease in certain immune cells

  immunosuppression
• Terminology

  Infection caused by pathogens that usually do not cause disease in a host with a healthy immune system

  opportunistic infection
• HIV / AIDS symptoms of infection

  • acute infection 6 - 56 days after exposure
  • flu like symptoms (schede says roughly 2 weeks)
  • usually ill enough to seek medical attention
  • primary viremia = initial spike in viral levels in blood stream
  • fever
  • lymph node enlargement
  • headache
  • malaise (feeling of discomfort)
  • rash
  • pharyngitis
  • myalgia (aches and pain of muscles)
  • arthralgia (joint pain)
• HIV Latency and Immune Status

  • Depending on the health status of the host, HIV infection can remain latent for months to several years
  • No symptoms -> virus is present/replicating
  • Leads to loss of ~ 10 % of CD4+ T lymphocytes per year in infected individuals
• HIV exposure and infection

  Exposure

  • Exchange of bodily fluids* (blood/semen)
  • Sexual contact (most common in homosexual males)
  • Blood contaminated needles
  • infusion of contaminated blood
  • Mother’s pass to babies
  • Pregnancy or breast feeding
  • Medical advances now eliminates vertical transmission
• HIV / AIDS oral candidiasis

  • Pseudomembranous / Thrush
  • Soft, yellow-white, curd-like plaque
  • When wiped underlying tissue is red and tender
  • Atrophic / Erythematous
  • Smooth, red tongue, palate, mucosa
  • May complain of burning with salt, spice, acidic foods and beverages
  • Angular cheilitis
  • Redness, cracks, crusting, fissures at commissures of lips
  • Painful / eroded
• HIV / AIDs oral manifestations

  Hairy leukoplakia

  • White corrugated lesion on lateral border of tongue
  • Cannot be wiped off like candidiasis
  • Uni / Bilateral
  • Asymptomatic
  • Associated with Epstein - Barr virus
• HIV / AIDs oral manifestations

  Kaposi Sarcoma

  • Malignant lesion
  • Flat, red, or purple macules or raised ulceration
  • Anywhere intraorally
  • Depending on location can cause problems with phonation, swallowing, breathing
  • Related to newly discovered herpes virus

  Kaposi sarcoma on gingival tissue

  • enlarged by plaque / exaggerated response
  • treatment: excision depending on area, systemic therapy (laser excision, ART, low dose radiation, chemotherapy)
  • DH must not avoid this area as debridement can reduce the size of the tumor
• HIV / AIDs oral manifestations

  Recurrent Herpes Simplex Virus

  • Non-healing shallow ulcerations on vermilion border of lip / keratinized tissue
  • Can be Secondarily infected with bacteria or fungi
• Oral warts

  • Human papilloma virus
  • many sub types
  • common in HIV persons - tends to reoccur
  • treatment: excision

  
• Oral warts

  • cause aesthetic and functional problems
  • when taking antiretroviral therapy, will increase oral warts, but decrease hairy leukoplakia and oral candidiasis
• HIV and periodontal health

  • periodontal disease is not affected any more with an HIV client than a non HIV client
  • more studies still need to be performed
  • increased periodontal disease may be related to high candida albicans in oral cavity
  • bone loss
  • attachment loss
  • BOP
• Standard precautions vs Universal precautions

  Universal

  • infection control for blood and certain body fluids (treat everyone as if they are infectious)

  Standard

  • additional precautions on top of universal to reduce transmission of droplets, air, contaminations
• Tuberculosis

  • infectious: yes
  • TB in latency is not contagious, active TB is contagious
  • do not treat patient with active TB
  • hacking cough with blood
  • weight loss
  • sweating at night
  • Isolation ward for those with active TB
  • people at risk of TB: those in underdeveloped areas / countries
• Tuberculosis is also called

  wasting disease
• The target organ of TB is

  the lung
• People with active TB can cough blood, what is the other name for coughing up blood?

  hemoptysis
• Three forms of TB

  • primary
  • no clinical symptoms
  • positive TB test but not active
  • active
  • mild - low fever
  • low energy (listlessness)
  • loss of appetite
  • cough - occasional and chronic (most common)
  • disease progression
  • night sweats
  • weight loss
  • latent
  • no clinical symptoms
  • positive TB test but not active
• TB etiology

  • Airborne communicable disease
  • Primarily affects the lungs
  • Can also attack other organs
  • Mycobacterium tuberculosis
  • Close contact increases incidence of disease transmission
• TB High risk groups

  • Patients with HIV
  • IV drug users
  • Residence and workers of shared habitation
  • Prison workers
  • Nursing homes
  • Mental institutions
  • Shelters
  • Health care workers who care for high risk individuals
  • Immigrants from countries that have high incidence
  • Medically underserved (poverty, homeless)
  • High risk racial or ethnic minority populations
• TB testing

  • Mantoux tuberculin skin screening
  • (aka PPD purified protein derivative or tuberkulin) test
  • Chest x-ray
  • Sputum culture
• Treatment of TB

  • Active or LTBI
  • LTBI: Prevention with Isoniazid (INH) or Rifampin (4 - 9months)
  • Active: Short hospitalization, medications
  • Low compliance/inadequate tx -> Multidrug resistant TB
• TB DH care

  • Recognize signs and symptoms -> inform dentist -> refer for evaluation
  • Questions history of TB, positive skin test -> dates/results of tests or cultures, treatment regimens and compliance
  • Determine type of TB reported and current health status
  • Consult with physician to determine if safe to treat pt outside hospital setting *Active Tuberculosis should not be treated in the office
• TB vaccine

  • Developed in France (BCG = Bacille Calmette-Guerin)
  • Used in many parts of the world  - high risk populations
  • Rarely recommended in US due to low risk
  • Vaccinated = will always have positive PPD test
• Asthma

  • Chronic inflammatory respiratory disease
  • Increased responsiveness of the bronchial airways to stimuli
  • Intermittent or Persistent (Mild, moderate or severe)
  • Based on severity and occurrence of airflow obstruction symptoms
  • Tolerance to exercise, environmental factors
  • Night time sleep disturbances
• Asthma Etiology

  • Generalized narrowing of bronchi and bronchioles
  • Caused by mucosal inflammation, increased secretions and smooth muscle contraction -> Asthmatic symptoms
  • Various substances or environmental factors can precipitate an asthma attack

  Specific Antigen triggers

  • Pollen
  • Ragweed
  • Molds
  • Foods
  • Dyes
  • Flavorings
  • Latex
  • Dust mites

  Chemical triggers

  • smoke
  • scents
  • house sprays

  Environmental triggers

  • pollutants
  • exercise
  • cold air
  • emotional stress
• Asthma DH care

  • Prevention
  • Assess
  • Frequency
  • Conditions
  • Time of onset
  • Type (intermittent or persistent -> mild, moderate, severe)
  • Precipitating factors; Management
  • Medication used
  • Ever had an attack that sent you to ER?
• Asthma DH care

  • Medical consult
  • Poorly controlled asthma, persistent severe asthma
  • Document if using corticosteroid
  • Ensure compliance with dose
  • Bring inhalers to every appt
  • Air polisher contraindicated
  • Preprocedural Rinse; HVE
  • Reduce contaminated aerosols that can be inhaled with AGE
  • Local anesthetic
  • Consider using no epi -> may be sensitive to sulfite preservatives
  • Stress-free environment
• Childhood asthma

  dental considerations correlated with childrens asthma - more caries, malocclusion (open bite and cross bite)