The Immunocompromised Patient

Question 1

what are the rare types of immune deficiency ?

Answer 1

congenital - cyclin neutropenia, wiskott aldrich syndrome

Question 2

what are the more common types of immune deficiency ?

Answer 2

corticosteroid therapy, malignancy leukaemia, chemotherapy, bone marrow or organ transplantation, HIV

Question 3

what are the side effects of steroids ?

Answer 3

predisposition to diabetes, 
cushingoid appearance,
increased risk of fungal infections,
hypertension,
osteoporosis, 
adrenal suppression,
gastric ulceration

Question 4

what oro dental problems are associated with steroid therapy ?

Answer 4

hypotensive crisis,
underlying disease process,
candidal infection,
delayed healing,
osteoporosis,
avoid aspirin and NSAIDs

Question 5

what are the recommendations for peri operative steroid supplementation in BDH?

Answer 5

patients currently taking steroids or who have had steroids in the last three months
under 10Mg prednisolone daily - no cover
greater than 10Mg prednisolone daily - elective treatment consider increasing steroid dose preoperatively
if immediate treatment required 100mg hydrocortisone hemisuccinate iv prior to procedure

Question 6

when is chemotherapy indicated ?

Answer 6

patients who have had previous surgical intervention to remove a malignancy
malignancy of haemopoietic tissue
in born errors of cell metabolism prior to bone marrow transplantation

Question 7

what are the effects of chemotherapy on the bone marrow ?

Answer 7

leukopenia and neutropenia
thrombocytopenia
anaemia

Question 8

what are the effects of chemotherapy on the oral cavity ?

Answer 8

mucositis,
ulceration with opportunistic infection,
pseudomonas, 
candida albicans,
herpes

Question 9

how does chemotherapy affect general treatment

Answer 9

prophylactic cover for viral and fungal infections
1st line antibiotics fluconazole/itraconazole if pyrexic and neutropenic
screening to eliminate causes of potential dental sepsis s

Question 10

when is prophylactic antibiotic cover recommended for patients on chemotherapy undergoing dental treatment ?

Answer 10

if they are neutropenic at time of treatment or if treatment likely to induce a bacteraemia

Question 11

what antibiotic prophylaxis is used for dental treatment ?

Answer 11

amoxycillin 3gms 1 hr before treatment

clindamycin 600mg 1 hr before if penicillin allergy

Question 12

when is it best to carry out treatment on patients having chemotherapy ?

Answer 12

just before or 2-3 days after

always check platelets and neutrophils for procedures likely to cause bacteraemia

Question 13

what are the most common immune suppressants taken by patients with transplants ?

Answer 13

cyclosporin, azathioprin, prednisilone

Question 14

what are the side effects of cyclosporin ?

Answer 14

gingival hyperplasia

Question 15

what happens to the immune system in HIV ?

Answer 15

decreased CD4 helper cells leading to impaired regulation and function

Question 16

how is HIV managed ?

Answer 16

antiretrovirals eg nucleoside analogues and protease inhibitors

Question 17

when is triple therapy offered for HIV patients ?

Answer 17

when CD4

Question 18

what are the extra oral manifestations of HIV ?

Answer 18

cervical lymph node enlargement, salivary gland enlargement, dermatitis, papillomas, molluscum contagiosum

Question 19

what are the intra oral manifestations of HIV?

Answer 19

candidosis, hairy leukoplakia, kaposi sarcoma, apthous type viral ulcers, ANUG, non hodgkins lymphoma

Question 20

what virus is hairy leukoplakia associated with ?

Answer 20

epstein barr virus

Question 21

what is cancrum oris ?

Answer 21

necrotising gingivitis caused by fusiform bacteria, poor OH, immunocompromised, malnutrition