Oral manifestations and management of patients with immunodeficiency

Question 1

What are the side effects from steroids? i.e from corticosteroid therapy

Answer 1

• Predisposition to diabetes mellitus
• Cushingoid appearance
• Increased risk of fungal infections
• Hypertension
• Osteoporosis
• Adrenal suppression
• Gastric ulceration

Question 2

What are the orodental problems associated with steroids?

Answer 2

• Hypotensive crisis
• Underlying disease process
• Oportunistic infections / Candidal infection
• Delayed healing
• Osteoporosis
• Avoid aspirin and NSAID’s

• Following a case report in 1953 it became common practice that patients currently or recently taking exogenous
steroids require large doses of steroids when subjected to surgery
• This practice has now been challenged

Question 3

What is a steroid/adrenal crisis?

Answer 3

Crisis occurs when the physiological demand for these hormones exceeds the ability of adrenal glands to produce them, ie in patients with chronic adrenal insufficiency when subject to an intercurrent illness or stress.

Question 4

What is the hypothalamic, pituitary, adrenal (HPA) axis?

Answer 4

The hypothalamic, pituitary, adrenal (HPA) axis is our central stress response system. The HPA axis is an eloquent and every-dynamic intertwining of the central nervous system and endocrine system.

It can be suppressed by oral corticosteroids and lead to an adrenal crisis in times of stress.

Question 5

What are the BDH recommendations to prevent an adrenal crisis?

Answer 5

Patients currently taking steroids or who have had steroids in the last three months:
• Under 10mgs Prednisolone daily no cover
• Greater than 10mgs Prednisolone daily:
-For elective treatment, liase with medical practitioner to consider increasing steroid dose preoperatively
• If immediate treatment required 100mg hydrocortisone hemisuccinate iv
prior to procedure

Question 6

What is Addison’s disease?

Answer 6

Primary adrenal insufficiency
• 78,000 patients in the UK
• Require Steroid Cover for invasive/stressful procedures

Question 7

What should you do for a dental patient that is going to undergo chemotherapy?

Answer 7

• Screening to eliminate any likely causes of potential dental sepsis prior to commencement of treatment
• Intervention needs to be timed in a window of count recovery
• High dose regime requires extra vigilance, slightest opportunistic infection can prove fatal

Best to treat:
• Just before chemotherapy given
• Just after within 2-3 days)
Always check platelets and neutrophils for procedures likely to cause a bacteraemia

Question 8

What should you do if the patient is neutropenic at the time of treatment or if the treatment is likely to induce a bacteraemia?

Answer 8

Prophylactic antibiotic cover is recommended

Question 9

Prior to cancer therapy it is recommended that:

Answer 9

Oro/dental care:
– Comprehensive oral assessment undertaken
– Detailed oral hygiene instruction
supplementation with chlorhexidine M/W gel
– Carious teeth stabilised with appropriate
restorations
– Smooth any sharp teeth restorations
– Teeth with doubtful prognosis removed (any teeth likely to be pulpally involved or with chronic apical pathology, advanced periodontal disease)

Special consideration in children: The dentition is still developing and cytotoxic
agents and RTX may affect the developing
dentition

Question 10

What is this?

Answer 10

Mucositis

Question 11

What is this?

Answer 11

Neutropenic ulceration

Question 12

What are some examples of opportunistic infections?

Answer 12

• Thrush
• Systemic Aspergillosis
• Zoster
• Recurrent herpes

Question 13

What is this?

Answer 13

Systemic Aspergillosis

Question 14

What is this?

Answer 14

Herpes Zoster (unilateral)

Question 15

What is this?

Answer 15

Recurrent herpes

Question 16

What is this?

Answer 16

Atypical herpes simplex aciclovir resistant

Question 17

What are some different types of anti-rejection drugs?

Answer 17

• Cyclosporin (known to cause gingival hyperplasia but surgical removal provides resolution once cyclosporin stopped)
• Azathioprin
• Tacrolimus
• Prednisilone

Question 18

What is this?

Answer 18

Gingival hyperplasia. Can only be removed by surgery.

Question 19

What are the guidelines for the different types of transplants?

Answer 19

• Patients who have had a kidney transplant may also be medicated to reduce their hypertension
• Heart transplant patients will usually have a pacemaker fitted and may be further medicated to compensate for the previous damage to the cardiovascular system
• The guidelines for treatment in heart transplant patients suggest antibiotic prophylaxis is desirable for any invasive procedure

-In Lung transplant patients aerosols
should be avoided (air rotor/ultrasonics)

-In respect of all solid organ transplant patients it must be remembered that these patients are immunocompromised (must avoid bacteraemia!)

Question 20

What are stem cell and bone marrow transplants used for?

Answer 20

Bone marrow: Used for treatment of haemopoeitic malignancy and some genetic disorders

Stem cell: Used for high dose chemotherapy

Question 21

What can Bone Marrow Transplant lead to?

Answer 21

Graft versus Host disease which may be
severe and cause persistent oral complications (mucosal lesions). Due to GVHD the immunosuppression may be increased to combat this effect causing more likelihood of opportunistic oral infections

Question 22

What are the HIV stats in the UK?

Answer 22

HIV is the fastest growing serious health condition
in the UK.
There were estimated to be 100,000 people living with HIV in 2012
22% undiagnosed and so unaware of their infection.
6,390 people were newly diagnosed with HIV in 2012, 490 died

Question 23

What is HIV?

Answer 23

HIV causes a progressive disease in which
regulation and function of the immune
system are impaired. There’s a decrease in CD4 helper cells.

• The CD4 count is used as a marker of
disease progression
• In normal health >600
• Initial immune suppression 40

Often diagnosed with pneumonia in late stages.

Question 24

What is this an image of?

Answer 24

A man with AIDS.

Question 25

What’s the risk group for AIDS?

Answer 25

Any sexually active male or female.

Question 26

What’s the management of HIV?

Answer 26

– Nucleoside analogues
– Protease inhibitors

Antiretroviral drug therapy has proved very effective, HIV cannot be cured but it can be treated and you can still live a long life, often men with HIV will live longer than men without as they are receiving ongoing medical attention.

• An HIV+ve patient on treatment with a fully suppressed viral load is of
minimal risk to health care professionals.
• Good universal cross infection practice will eliminate the majority of the
risk factors.

Question 27

What are the extra oro-facial manifestations of HIV?

Answer 27

Extra-oral:
• Cervical lymph node enlargement
• Salivary gland enlargement
• Skin disorders:
-Molluscum contagiosum
-Dermatitis
-Papillomas

Question 28

What is this?

Answer 28

Seborrhoeic Dermatitis

Question 30

What are the intra-oral manifestations of HIV?

Answer 30

• Candidosis
• Hairy leukoplakia
• Kaposi sarcoma
• Apthous type and viral ulcers
• Periodontal disease (ANUG)
• Papillomavirus infections
• Non Hodgkin’s Lymphoma

Question 31

What is this?

Answer 31

Erythematous Candidiasis

Question 32

What is this?

Answer 32

Acute Pseudomembranous Candidiasis

Question 33

What is this?

Answer 33

Hairy Leukoplakia

Question 34

What is this?

Answer 34

Kaposi’s Sarcoma

Question 35

What is this?

Answer 35

Oral Ulceration

Question 36

What is this?

Answer 36

Herpes Zoster

Question 37

What is this?

Answer 37

Lymphomas

Question 38

What is this?

Answer 38

Acute necrotising ulcerative gingivitis

Question 39

What is this?

Answer 39

Periodontal disease