Ch 51&56 HIV & Oral Health / Substance Misuse Flashcards
Concepts of substance misuse
-substance misuse: pattern of self-administered drug use that may lead to drug addiction
-includes use of natural and synthetic substances as well as psychoactive drugs used by those with substance misuse issues
Drug use continuum
-Type 1: abstainers (about 1/3 of population)
-Type 2: social drinker or user (majority of the population)
-Type 3: drug misusers
-Type 4: physically dependant addicts
-Type 5: psychologically dependant addicts
Examples of misused substances
-alcohol
-illicit drugs (cocaine, heroin, hallucinogen, marijuana, synthetic drugs, tranquilizers, sedatives, pain killers)
-OTC drugs (cough and cold meds, inhalants )
Misuse vs abuse
-misuse is roughly equivalent to substance abuse
-substance abuse is older diagnostic term
-substance abuse is increasingly avoided by professionals because of its negative connotation
-substance misuse is now the preferred term
Addiction, dependence, withdrawal, and relapse
-drug addiction: prolonged, repeated misuse of any substance
-psychological dependence: rooted in belief that drug is needed to maintain state of wellbeing
-physiological dependence: results from biologic alteration in users brain from consistent drug use
-withdrawal: when drug use ceases
-tolerance; when an increasingly larger dose is required to produce same effect
-relapse: can occur after withdrawal cannot be tolerated
Concepts of alcohol misuse
-alcohol is most pervasive substance used in USA
-3 main types of alcohol; isopropyl alcohol, methanol and ethanol
-alcohol reduces anxiety and causes intoxication and sensory alterations
Medical emergency Trx for alcohol misuse
-overdose of abused substance requires immediate medical attention
-alcohol poisoning caused by binge drinking has become increasingly regular in college campuses
-alcohol enemas have become alternative means of consumption
Concepts of illicit and OTC drug misuse
-illicit drugs: variety of drugs that are used for nonmedical purposes and are illegal to manufacture, use or sell (cocaine, amphetamines, hallucinogens, heroin)
-OTC drugs: available for purchase without a prescription: commonly misused OTC drugs are dextromethorphan and ephedrine)
Drug schedules
-Schedule I: drugs with no currently accepted medical use; high potential for abuse
- Schedule II: drugs with high potential for abuse
-Schedule III: drugs with moderate to low potential for dependence
-Schedule IV: drugs with low potential for abuse and low risk of dependence
-Schedule V: drugs with lowest potential for abuse
Club drugs
-methylenedioxymethamphetamine (MDMA)
- gamma-hydroxybutyrate (GBH)
- ketamine
- rohypnol
- methamphetamine
- lysergic acid diethylamide (LSD)
Marijuana
-most commonly used illicit drug in the United States
-has become more socially acceptable
-as marijuana laws are changing so too is the drug itself
-marijuana use can impair driving; greater when combined with alcohol
-potential therapeutic use
Causes of substance abuse
-physiological factors
-genetic factors: addiction curve, fetal alcohol syndrome
Causes of substance abuse
-environmental factors: families play an important role in determining how children respond to the temptation to use alcohol, cigarettes and illegal drugs. Substance abuse by one family member affects all family members in some way
Medical Trx of substance abuse
-emergency treatment: acute alcohol poisoning
-behavioural treatment
-pharmacologic treatment
Extraoral signs of abuse
-needle marks, bruises, increased pigmentation of forearm veins
-skin abscesses
-burns and scars in the patients dominant thumb
-frequent nosebleeds
-tremors mod the hands, tongue and eyelids
-redness of the facial skin
-red or swollen eyes
-patients behaviour
Intraoral signs of abuse
Large buccal cervical caries
Oral candidiasis
Glossodynia
Poor OH
bruxism
Delayed healing
Red flags for suspicion of substance abuse
-missed appointments
-careless in appearance and hygiene
-lapses in memory or concentration
-speech insured
-needle marks in arm
-rapid mood swings
Frequently requests written excuses from work
-frequently request specific meds for pain
-high tolerance to sedatives and analgesics
-pupils are abnormally dilated or constricted
HIV and AIDS
-first documented cases of aids in the us in 1981
-hiv is identified and associated with aids in 1983
-HIV includes 2 closely related viruses:
1. HIV 1; more common, at least 9 subtypes known
2. HIV2; found mostly in West Africa
What do AIDS AND HIV stand for
Human immunodeficiency virus and acquired immunodeficiency syndrome
7 stages of HIV life cycle
-binding
-fusion
-reverse transcription
-integration
-replication
-assembly
-budding
What is a virion
The HIV virion or virus particle is composed of a core of ribonucleic acid [RNA] encapsulated within a lipid coating
HIV/AIDS causes gradual impairment of
Host immune system so that the disease is accompanied by other chronic health problems
CD4+T lymphocytes are a type of
White blood cell that is important for cell-mediated immunity
Natural course of HIV infection
-the virus infects by fusing with the cell membrane of the CD4+ T lymphocyte and entering the cell where it releases its RNA
-once inside the cell, it uses the reverse transcriptase enzyme to convert viral RNA into DNA. This process is the reverse of what typically occurs in animal cells
-serologic marker on coating of virion binds to receptor sites in CD4+ T lymphocytes
-Virus infects by fusing with cell membrane of CD4+ T Lymphocyte and entering the cell
-HIV is a retrovirus: once within the cell it uses the reverse transcriptase enzyme to convert viral RNA into DNA
-if left untreated HIV infection leads to gradually diminishing immune response
HIV Transmission is through contact with
Transmitted through contact with
-semen
-vaginal secretions
-breast milk
-infected blood or platelets
HIV transmission
-sexual contact is the primary source of infection among men who have sex with men
-intravenous drug users are at high risk owing to sharing blood contaminated needles
-HIV positive mothers may transmit the virus to their fetuses during pregnancy or to their babies at birth or when breastfeeding. However it must be noted that elimination of mother to child transmission is recognized benefit of medical advances
Acute HIV infection occurs 6-56 days after exposure. Signs and symptoms?
Fever
Enlarged lymph nodes
Headache
Rash
Pharyngitis (sore throat)
Myalgia (aching muscles)
Athralgia (aching joints)
Acute HIV infection oral manifestations
Erythematous round patches on hard and soft palate, angular cheilitis, tonsillitis, hairy leukoplakia, oral ulcers
Acute HIV infection
-is reported that most persons undergoing seroconversion (when antibodies are detected in the blood), the acquisition of the antibodies in the blood serum, are ill enough to seek medical attention
-the oral ulcers look similar to aphthous ulcers but may appear anywhere in the mouth or in the lips
-acute HIV infection is also characterized by viremia or the initial spike in the viral levels in the bloodstream
HIV latency and immune status
-depending on the health status of the host, hiv infection can remain latent for several years
-AIDS defining illness: clinical indicators the person has AIDS
-even though symptoms are not present during this latency period, the virus is present and replicating
-CDC classifies HIV infected persons according to their immune status (current system includes categories for asymptomatic infection, symptomatic infection and AIDS indicator conditions)
Medication therapy: highly active antiretroviral therapy (HAART) or HIV cocktails. Correct combination benefits?
-Control the infection
-Prevent the development of drug resistance
-prolong the lives of HIV infected individuals
Medication therapy for HIV serious adverse effects
Headache
Nausea
Lactic acidosis
Severe skin reactions
Lipid abnormalities
Organ failure
The highly active antiretroviral therapy or HIV cocktails is treatment with at least __ drugs and is the current standard of care
3
HIV medication therapy: Stribid, a commonly prescribed regimen to be taken once daily, is a combination of
Elvitegravir (integrase inhibitor), cobicistat (boosting agent), tenofovir (NRTI) and emtricitabine (NRTI)
HIV/AIDS related opportunistic infections
-people with weakened immune systems may be more vulnerable to an opportunistic infection (OI)
-oral mucosal and vaginal candidiasis are common OI
-CDC recommends PLWH receive immunization Ms for vaccine preventable diseases
Epidemiology of HIV infections and AIDS
-African American men are 6 times more likely than white men to contract HIV; African American women are 15 times more likely than white women to contract HIV
-is a chronic disease
-even people who do not suspect any reason to be infected with HIV should have at least one test in their lifetime
HIV and aging
-approx 50% of all PLWH are over 50
-comorbidities are associated with aging
-healthcare providers still do not routinely consider HIV when treating older patients
HIV care continuum
-first stage is testing and diagnosis (14-18% are unaware of infection)
-knowing one’s status is oath to linkage and retention in care
-oral healthcare team has many unique opportunities to collaborate with medical and support teams
Fungal infections
-no oral lesions have been identified as only being associated with HIV
-oral candidiasis is the most commonly seen manifestation and can be found not just in PLWH but also in its using steroid inhalers for asthma, undergoing chemo, presenting with uncontrolled diabetes, or using broad spectrum antibiotics
Oral candidiasis:
-pseudomembranous candidiasis: appears as soft, yellow-white, curd like plaque on oral tissues
-erythematous candidiasis: appears as smooth, red, denuded patches on tongue or red patches on buccal or palatal mucosa
-angular cheilitis: appears as redness, cracks, crusting or fissures at commissures of lips
Bacterial infections
Necrotizing ulcerative periodontitis (NUP)
-deep jaw pain
-fetid odor
-bleeding
-loose teeth
-rapid loss of bone and soft tissue
NUP
-this condition can be associated with severe immune suppression and is not isolated to PLWH
-postoperative care requires good mechanical biofilm control and twice daily 0.12% Chlorhexidine rinses for chemical oral biofilm control
-pts must be informed about the possible side effects of Chlorhexidine
-antibiotics such as metronidazole to control oral anaerobic pathogens often are prescribed
Viral infections
-HPV (many subtypes)
-herpes simplex virus (HSV)
-hairy leukoplakia (white corrugated lesion on lateral border of tongue): associated with Epstein Barr virus
- important to note that some subtypes of HPV are oncogenic and so identification of the subtype and medical referral are important
-squamous cell carcinoma is the most common type of oral cancer accounting for about 90% of all oral cancers
Neoplastic lesions
-kaposi sarcoma: malignant lesion that appears as flat, red, or purple macules or raised ulcerations that may be present in PLWH
-squamous cell carcinoma
- kaposi sarcoma has several associated causative factors, most notable, viral infection with human herpesvirus-8 and alterations in the immune system. It may also appear on the skin of the extremities as well as internal organs
Idiopathic lesions
-aphthous ulcers: characterized by halo appearance inflammation and a gray or yellow cover over ulcer
-occur in nonkeratinized tissue
-very painful
-treated not only to resolve ulcer but also to manage pain
Risk of HIV infection among healthcare workers
-risk is low
-proper use of PPE
-follow standard precautions
-management of exposure is an urgent medical concern; post exposure prophylaxis should be taken for 28 days
HIV pre exposure prophylaxis (PrEP)
Oral health professionals should be aware that individuals on PrEP:
-are HIV negative-usually engage in high risk behaviours
-greatly reduce their HIV risk if medication adherence is observed
-should receive periodic, thorough oral soft tissue examination
-oral healthcare professionals to explain PrEP for high risk individuals and implications for dentistry based on 2014 recommendations from the CDC
-only one med approved for PrEP, Truvada
