Immunocompromised patients
Diseases that cause immunosuppression represent a very
Heterogeneous pathologies, ranging from the rarest (congenital immune deficiencies) to much more frequent pathologies (cancer, corticosteroid therapy, acquired immunodeficiency syndrome, etc.)
Immunocompromised patients have a high susceptibility to infections which must be taken into account by the dentist during their care.
Its role, in close consultation with the doctor in charge of the patient, is to control intra-oral infectious foci and prevent their systemic dissemination.
- Definition:
Immunocompromised patients have dysfunction of one or more components of the immune system
- The immune system is composed of a set of cells (lymphocytes, polymorphonuclear cells, monocytes and macrophages); this is cellular immunity and molecules (cytokine and complement) this is humoral immunity,
- Whose role is to ensure the integrity of the organism by protecting it against foreign substances or infectious agents to which it is exposed
- Immune deficiencies can affect cellular immunity or humoral immunity.
- Etiology:
2.1- primary immunodepression:
These are rare hereditary diseases caused by a genetic anomaly that can alter lymphocyte maturation, lead to a quantitative or qualitative deficit of phagocytic cells or, finally, lead to a complement deficiency.
2.2. Secondary immunosuppression:
There are many secondary immunodeficiencies. They are caused by environmental, behavioral, and medical factors that lead to a progressive weakening of immunity.
- HIV (the human immunodeficiency virus that causes AIDS: Acquired Immunodeficiency Syndrome) is a known and recognized factor in immunosuppression. The virus causes a decrease in the number of lymphocytes, essential cells of the immune system.
- Malnutrition (and more specifically undernutrition) leads to the dysfunction of certain cells due to an insufficient supply of the components necessary for their proper functioning.
- Type 2 diabetes causes a marked decrease in the number of immune cells.
- Certain autoimmune pathologies (systemic lupus erythematosus) lead to a state of immunodepression.
- Drugs and therapies (including cancer chemotherapies and immunosuppressants) weaken the immune system by damaging certain cells and putting excessive strain on the body.
- Leukemia is a disease characterized by an overproduction of abnormal white blood cells that disrupt the functioning of the immune system.
- Infectious risk:
The main risk for immunocompromised patients following their treatment by a dentist is the risk of infection.
In 2001, the French Agency for the Safety of Health Products (Afssaps) defined two categories of patients at risk of infection:
- risk A corresponds to patients at risk of locally identified infection and/or general infection (septicemia);
- risk B corresponds to patients at risk of infection linked to a secondary location of the bacteria, i.e. a new infectious focus located at a distance from the primary focus (infectious endocarditis and infection on joint prosthesis).
Immunocompromised patients correspond to risk A.
Recommendations on the indication of antibiotic prophylaxis or curative antibiotic therapy depending on the procedure performed are also proposed.
- Management of the immunocompromised patient:
-The management of immunocompromised patients by the dentist must first be early (ideally before the start of the immunosuppression period)
-Close consultation with the physician in charge of immunosuppression is essential.
-The patient must benefit from a thorough examination of the oral cavity, supplemented by a dental panoramic (search for and eradication of all suspected infectious foci (apicodental granuloma, decay of carious teeth, scaling and root planing)
-treatment of periodontal pathologies.
- Rigorous oral hygiene should also be established.
- Care continues during the period of immunosuppression with regular examinations.
- Patients on long-term corticosteroid therapy
- Definition :
Corticosteroid therapy is used in a wide variety of diseases (systemic inflammatory diseases such as rheumatoid arthritis, etc.), severe vasculitis, adrenal insufficiency, Crohn’s disease, etc.).
It has important anti-inflammatory and immunoallergic properties and immunomodulatory properties.
Said to be long term when it exceeds one month of treatment.
- Corticosteroids have side effects:
- Predisposition to infections (viral, bacterial, fungal)
- Digestive disorders
- Adrenal insufficiency
- High blood pressure
- Steroid diabetes
- Osteoporosis
- Infectious complications: reactivation of a latent infectious focus (shingles, herpes)
- Action to take :
- Contact the attending physician: specify the duration of corticosteroid therapy; identify the patient with adrenal insufficiency
- Limit patient stress (imperative in patients with adrenal insufficiency)
Invasive procedures involving mucosal and/or bone healing: manipulation of the gingival, pulp, or periapical region of the tooth, or breach of the oral mucosa:
- I Coverage antibiotic therapy to start the day before or the morning before the procedure and continue until the mucosa has healed (7a 10d)
- No precautions regarding anesthetic.
NB: no special precautions for non-invasive procedures – namely conservative care; non-bloody prosthetic care, ODF device adjustment, etc.
4. 2-AIDS:
Patients with HIV have a decrease in immune defenses caused by a progressive and irreversible decrease, as well as qualitative abnormalities, of CD4+ T lymphocytes in the blood.
The virus is transmitted through sexual, blood, and maternal-fetal routes. The natural evolution takes place in three phases.
- Primary infection, which occurs two to eight weeks after transmission and is asymptomatic in almost 50% of cases;
- The asymptomatic phase, which can last 10 years and sometimes more
- The AIDS phase when the patient has opportunistic germ infections (Kaposi’s sarcoma, pneumocystis pneumonia for example)
Oral manifestations frequently encountered in HIV patients are:
-oral and esophageal candidiasis
-Kaposi’s sarcoma,
-hairy leukoplakia,
- Herpes, thrombopenia probably of autoimmune origin, can result in petechiae, ecchymoses and spontaneous or provoked gingival bleeding, and cervical adenopathy.
Conduct and precautions to take in dental practice:
- The management of HIV patients requires precautions designed to eliminate the risk of cross-transmission.
- Prevent postoperative infections (due to immunosuppression)
- Prevent the risk of bleeding in subjects with thrombocytopenia.
-Regarding the risk of cross-transmission: All care will be carried out under strict clinical asepsis: wearing a mask, double gloves, glasses and a gown for both the practitioner and the staff; protection by fields of all exposed surfaces
-minimization of contact with blood and saliva as well as the use of Aerosols
- use of powerful suction, preference given to the use of instruments for use
unique
-appointments set at the end of the day, to further reduce the risk of cross-contamination.
Precaution to take regarding the risk of infection:
It is based on the administration of anti-infectious prophylaxis to reduce the risk of post-operative infection. The choice of antibiotic is not subject to consensus. It follows the general principles of antibiotic cover therapy.
c ) Precaution to be taken with regard to the risk of hemorrhagic stroke
-Due to the risks of thrombocytopenia and/or thrombopathia as well as the liver disorders that may be associated, a CBC and a prothrombin level will be requested before any procedure involving a risk of bleeding.
-If the values are normal, the surgical procedures will be performed according to the usual protocols.
-If thrombocytopenia is moderate, local hemostasis measures are required.
-If severe thrombocytopenia (AIDS disease), the opportunity for a blood transfusion will be discussed with the attending physician
4.4. Liver failure:
- Definition : Liver failure is essentially defined by the impairment of the liver’s synthesis functions and comes in two forms:
- Acute: when it is of drug origin (such as paracetamol poisoning), or viral (hepatitis B, C)
- chronic : follows the development of cirrhosis (cirrhosis is an irreversible and diffuse disease of the liver, characterized by a disorganization of the hepatic lobular architecture, the main etiologies of which are excessive alcohol consumption, viral hepatitis B, C, autoimmune hepatitis.)
Cirrhosis can be complicated by: hepatic encephalopathy, hepatorenal syndrome, digestive hemorrhage, and in the long term, hepatocellular carcinoma.
General and oral repercussions :
General repercussions:
- Cirrhosis causes immunosuppression
- Thrombocytopenia due to hypersplenism
- Disruption of coagulation by alteration of coagulation factors
Oral repercussions:
- Jaundice, gingival bleeding, purpura, petechiae,
- oral hematomas, altered taste,
- enlarged salivary glands
- Action to take:
- contact the attending physician: stage of development of the disease
- biological assessment: know the values of the TP and the NFS (if TP
less than 50% hospital care), due to the risk of hemorrhage.
- precautions during care to avoid a blood exposure accident
- avoid lidocaine (increased elimination half-life in liver failure)
- It is important to avoid hepatotoxic products, such as clindamycin, and to
reduce or avoid the use of highly metabolized antibiotics with biliary elimination such as macrolides and metronidazole.
4.5. Hepatitis:
- Definition :
Viral hepatitis is a liver disease characterized by inflammation of the liver tissue secondary to a viral infection (HAV, HBV, HCV, HDV, HEV), only hepatitis B and C can become chronic with a risk of cirrhosis and liver cancer.
- Transmission:
-transfusion route_ (hemophiliac) hemodialysis patients, drug addicts, healthcare personnel
-sexual transmission, feto-maternal, salivary
- diagnosis : in the acute stage, laboratory tests are carried out in the presence of jaundice, based on:
*increased transaminases
*serology which highlights the antigens and antibodies characteristic of the virus responsible.
*Viral hepatitis (B or C) can cause cirrhosis and therefore insufficiency
hepatic. The latter is characterized by a decrease in TP and therefore a risk of hemorrhage
- Action to take:
- In the presence of acute viral hepatitis, dental care should be avoided, except in urgent cases, due to the high contagiousness of the disease and the immune deficiency that characterizes this period.
- Given the risk of hemorrhage, request a hemostasis assessment (TP, TCK, FNS)
| Platelet count (PC) between 80,000 and 150,000/mm3 PT>50% | Local hemostasis measurement ensured (Risk of hemorrhage in the event of avulsion) |
| NP <50 OOO/mm3 | Blood transfusion may be indicated in consultation with the hematologist or hepatologist |
- use low doses of amine-based anesthetics (lidocaine, mepivacaine, articaine) in patients with severe liver disease
- Strict and rigorous clinical asepsis: wearing goggles, mask, gloves, disposable equipment, avoiding aerosols (turbine, air pump), rigorous asepsis chain.
- X-ray films must be placed in protective bags before film application and the X-ray cone must also be covered with protection.
- Exclude drugs metabolized by the liver (erythromycin, paracetamol, aspirin)
- In the event of an accident involving blood exposure (AES) by puncture or injury:
-Immediate cleaning of the injured skin area with soap then rinse.
-Disinfection with 70° alcohol (3 min) or 12° bleach (10 min) or povidone iodine in pure dermal solution (5 min).
- Contact the referring physician quickly to assess the risk.
- Benefits of hepatitis B vaccination for healthcare workers.
Conclusion
The management of immunocompromised patients is part of our daily practice, it is imperative to know how to recognize them through a good anamnesis and especially not to ignore the new molecules for the treatment of cancers and other autoimmune pathologies, and in order to successfully carry out our therapeutic approach, close consultation with the treating physician remains essential.
Bibliography
1-French National Agency for the Safety of Medicines and Health Products. Recommendations on the prescription of antibiotics in oral and dental practice [Internet]. ANSM; 2011 Sept. Available at: http://www.mbcb-journal.org/articles/mbcb/pdf/2011/04/mbcb110038.pdf
- French Society of Oral Surgery. Management of oral infectious foci. Med Buccale Chir Buccale. August 2012;18(3):251-314.
- French Dental Association. Medical Risks: A Guide to Management by the Dental Surgeon. ADF Notebooks. ADF. Paris, France; 2013. 135 p.
- Directorate General of Health. Guide to the prevention of infections associated with dental surgery and stomatology [Internet]. DGS; July 2006. Available at: http://socialsante.gouv.fr/IMG/pdf/Guide_de_prevention_des_infections_liees_aux_soins_e n_chirurgie_ dentaire_et_en_stomatologie.pdf
- Najm SA, Lesclous P, Lombardi T, Bouzouita I, Carrel JP, Samson J. Osteonecrosis of the
maxillary injuries due to bisphosphonates: update. Oral Medicine Oral Surgery. 2008;14(1):5-18.
- French National Agency for the Safety of Medicines and Health Products. Recommendations on the oral care of patients treated with bisphosphonates [Internet]. ANSM; 2007. Available at: http://ansm.sante.fr/content/download/11694/140950/version/2/file/lp071203.pdf
- French-speaking Association for Supportive Cancer Care. Radiotherapy and Oral Care [Internet]. AFSOS; December 2010. Available at: http://www.afsos.org/IMG/pdf/Radiothrapie_et_soins_bucco-dentaires.pdf
- Commission on Prevention and Public Health. Smoking and Periodontal Disease. Bull Acad Natle Chir Dent. 2004;(47).
- French Society of Oral Surgery. Management of patients on vitamin K antagonist therapy in oral surgery. Med Buccale Chir Buccale. Oct 2006;12(4):188-212.
- French Society of Oral Surgery. Recommendations for the perioperative management of patients treated with antithrombotics in oral surgery [Internet]. SFCO; 2015. Available at: http://www.mbcbjournal.org/images/stories/recommendations/recommandations_festion_peri_operatoire_2015_co urt.pdf
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