Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 186

 Stage 1: Initial infectionCan be asymptomaticWithin 2–4 weeks after infection, may also present as viral symptoms similar to influenza (fever, headache, lymphadenopathy, myalgia and exanthema)High viral load and infectivityTable 4.2.2 Main antiretroviral drugs with adverse orofacial effects.Drug class Generic nameAdverse orofacial effectsErythema multif.UlcersDry mouthDysgeusiaExfoliative cheilitisMucosal pigm.Cushingoid appear.Lipodys.Nucleoside/nucleotide reverse transcriptase inhibitors Zidovudine (AZT)Didanosine (DDI)Zalcitabine (ddC)Stavudine (d4T)Lamivudine (3TC)Abacavir (ABC)Adefovir (ADF)Tenofovir (TDF)Emtricitabine (FTC)+ + + + + + + + + + + + + + + + + Non‐nucleoside reverse transcriptase inhibitors Etravirine (ETR)Delavirdine (DLV)Efavirenz (EFV)Nevirapine (NVP)+ + + + + + + + + + + + Protease inhibitors Saquinavir (SQV)Ritonavir (RTV)Indinavir (IDV)Nelfinavir (NFV)Amprenavir (APV)Tipranavir (TPV)Fosamprenavir (FPV)Atazanavir (ATV)Darunavir (DRV)+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Fusion inhibitors Enfuvirtide (ENF)+++Entry inhibitors Maraviroc (MVC)++Integrase strand transfer inhibitors Raltegravir (RAL)++Erythema multif., Erythema multiforme; Mucosal pigm., Mucosal pigmentation; Cushingoid appear., Cushingoid appearance; Lipodys., LipodystrophyFigure 4.2.2 (a–c) Lesions closely associated with HIV infection: oral candidiasis, oral hairy leucoplakia and Kaposi sarcoma.Figure 4.2.3 Exfoliative cheilitis as an adverse oral effect of proteinase inhibitors.Figure 4.2.4 Infection control in the dental clinic.Table 4.2.3 Considerations for dental management.Risk assessmentThere are no absolute contraindications for performing dental treatment on patients with HIV infectionHowever, due to the HIV‐associated immunosuppression, it is important to consider any associated comorbidities (e.g. chronic hepatitis) and side‐effects of medication (e.g. thrombocytopenia related to ritonavir, neutropenia related to zidovudine)The transmission rate is estimated at 0.3% after exposure to contaminated blood by the percutaneous pathway and approximately 0.09% after contact with mucous membranesCriteria for referralMost patients can be treated in a conventional outpatient dental clinicReferral to a specialised clinic or hospital centre is determined mainly by the patient's general condition, presence of severe immunosuppression, presence of comorbidities and/or increased bleeding riskAccess/appointmentA number of barriers to treatment have been identified for these patients and include the anxiety caused by the dental setting, reluctance by the dentist to see them, concerns regarding confidentiality, cumbersome administrative processes, long waiting times and psychological problemsIf the viral load is high, schedule the patient for the last session of the day to minimise the risk of cross‐transmissionCommunicationA significant percentage of patients with HIV infection who receive dental treatment do not report their conditionAn HIV diagnostic test and/or the possibility of referring to the family doctor should be offered to patients with suspicious medical histories or oral findingsConsent/capacityPatients should be warned of the potential complications resulting from the HIV infection, side‐effects of medication and the additional risks associated with existing comorbiditiesNeurological involvement in HIV (HIV‐associated dementia) is commonly associated with cognitive impairment but is rare in those patients receiving antiretroviral drugs; comorbid conditions can also contribute to impairmentAnaesthesia/ sedationLocal anaesthesiaMinimise the risk of pricking with contaminated needles after infiltrative anaesthesia (e.g. single‐use devices)SedationMinimise the risk of pricking with contaminated needles after percutaneous injectionThe activity of benzodiazepines administered for sedation can increase in patients who take protease inhibitorsGeneral anaesthesiaA comprehensive assessment in conjunction with the anaesthetist is essentialThe patient's physician should be consulted and investigations undertaken to assess the risk of bleeding, infection and whether there are any concurrent infections which would compromise respirationDental treatmentBeforeUniversal cross‐infection control measures should be appliedThe treatment plan will be determined by the HIV disease prognosis and the previous oral health condition, among other factorsThe dental treatment needs of patients with HIV infection are significantly greater for those with a history of parenteral drug useRecent blood test results should be available including:CD4+ T‐lymphocyte countViral loadFull blood count (risk of anaemia, leucopenia, neutropenia, thrombocytopenia)Coagulation study (in case of liver disease)If invasive dental procedures are planned, it is advisable to administer antibiotic prophylaxis to patients with <200 CD4+ T‐cells/μL and/or those who with moderate neutropenia (500–1000 cells/μL)For cases of severe neutropenia (<500 cells/μL), antibiotic prophylaxis is mandatoryDuringApply conventional measures for infection controlIn the event of accidental exposure in the dental clinic, the contaminated area should be washed with soap and water, and the reference physician should be immediately informed so that they can evaluate the risk of exposure and the advisability of diagnostic tests and prophylactic administration of antiretroviral agentsAfterThe prevalence and severity of complications after an extraction are similar to those observed in healthy controlsThe success rates of osseointegrated implants, sinus lifts and bone regeneration surgery are similar for patients with well‐controlled HIV infection and the HIV‐negative populationBasic periodontal treatment procedures and periodontal surgery have been successfully performed in this contextThe rate of postoperative complications and the elimination of periapical lesions following a root canal are similar to those detected in the general populationDrug prescriptionThere is an increased risk of hypersensitivity to some drugs such as beta‐lactamsMetronidazole can cause a disulfiram‐like reaction in patients who take ritonavirThe risk of haematological toxicity and bleeding in patients who take zidovudine can increase if non‐steroidal anti‐inflammatory agents are administered concomitantlyEducation/preventionIf a patient is aware of their HIV‐positive condition and potential impact on the oral cavity, this can promote the need to maintain a healthy mouth and result in an improvement in their oral hygiene habitsPatients should be counselled regarding oral hygiene, xerostomia treatment, smoking cessation and reducing sugar in their dietMaintaining good oral health can prevent the onset of rapidly progressive periodontal diseaseEmphasis should be placed on cleaning the dental prosthesis and disinfecting toothbrushes (with antiseptic solutions such as chlorhexidine)Patients with peripheral neuropathy might have limited manual dexterity for performing proper oral hygiene

  Stage 2: Latency period/chronic infectionGenerally characterised by persistent generalised lymphadenopathyCan also be asymptomatic until the first opportunistic infections appear, such as oral candidiasisVery low viral load; if taking antiretroviral therapy, viral load may be undetectable with effectively no risk of viral transmission

 Stage 3: AIDSCharacterised by the onset of conditions that have been called ‘AIDS‐defining’These include oesophageal candidiasis, systemic mycosis (histoplasmosis, coccidioidomycosis, cryptococcosis), cerebral toxoplasmosis, pneumonia by Pneumocystis carinii (Figure 4.2.5), retinitis by Cytomegalovirus, encephalitis by HIV, tuberculosis and extrapulmonary infections by non‐tuberculosis Mycobacterium, cervical cancer, Kaposi sarcoma, lymphoma, progressive multifocal leucoencephalopathy and HIV wasting syndrome