Management of at-risk patients Immunocompromised patients (patients on long-term corticosteroid therapy for AIDS, liver failure, hepatitis)

Management of at-risk patients Immunocompromised patients (patients on long-term corticosteroid therapy for AIDS, liver failure, hepatitis)

Diseases that cause immunosuppression represent a very heterogeneous group of 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 treatment.

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.

1. General information
2. Definition :

Immunocompromised patients have dysfunction of one or more components of the immune system

• The role of the cells of the immune system is to ensure the integrity of the organism by protecting it against foreign substances or infectious agents to which it is exposed. We usually distinguish between primary deficiencies, which are hereditary immune deficiencies, and secondary, or acquired, deficiencies of immunity:

Primary immunodeficiencies: are rare; they are 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.

Secondary immune deficiencies : correspond to more diverse situations:

2. Etiology

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.

Secondary immunosuppression:

There are many secondary immunodeficiencies. They are due to environmental, behavioral, and medical factors that lead to a progressive weakening of immunity. They correspond to a wide variety of situations.

AIDS

Liver Diseases

Medication Intakes:

-Long-term corticosteroid therapy

-Immunosuppressive therapy Patients undergoing anticancer treatments:

• Chemotherapy
• Targeted therapy

Cancer patients: malignant blood diseases (leukemia, lymphoma) Certain autoimmune pathologies (systemic lupus erythematosus) Severe malnutrition,

CKD (chronic renal failure), uncontrolled diabetes,

Asplenism, or with a non-functioning spleen (sickle cell disease, malignant invasion, etc.).

The smoking patient also presents an alteration of the immune system secondary to a deficit in macrophage function.

C. Infectious risk:

The main risk for immunocompromised patients during their treatment by the dentist is the risk of infection.

The prescription of antibiotics is called preventive antibiotic therapy or antibiotic prophylaxis when it is prescribed before the invasive oral-dental procedure and it is called curative antibiotic therapy when it is prescribed after the procedure.

Preventive antibiotic therapy

The aim of prophylactic antibiotic therapy is to prevent the risk of infection, localized in the oral cavity or disseminated to the rest of the body, linked to an oral-dental procedure.

Antibiotic prophylaxis is recommended during all invasive procedures (with significant risk of bleeding) performed on immunocompromised patients: endodontic care, prosthetic care with risk of bleeding, all surgical procedures.

Recommendation of antibiotic prophylaxis in immunocompromised patients

Curative antibiotic therapy

Curative antibiotic therapy is indicated in all invasive treatments in an immunocompromised patient.

D- Management of the immunocompromised patient:

The management of immunocompromised patients by the dentist should 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 (apical granuloma, decay of carious teeth, scaling and root planing)
• the treatment of periodontal pathologies.
• Rigorous oral hygiene should also be established

2. Patient on long-term corticosteroid therapy

Corticosteroids are analogs of cortisone naturally secreted by the adrenal glands. These corticosteroids inhibit all phases of the inflammatory response (vascular and cellular). At very high doses, corticosteroids have a lymphocytolytic effect, allowing inhibition of cell-mediated immunity and a decrease in the synthesis of humoral antibodies. The side effects of short-term corticosteroid therapy are minimal and generally regress when treatment is stopped. However, prolonged use of corticosteroids can cause osteoporosis, adrenal insufficiency, ulcerative digestive pathologies, glaucoma, and hyperlipidemia.

Corticosteroid therapy is said to be long-term if the duration of treatment exceeds one month.

-1 Actions of corticosteroids:

• Anti-inflammatory action: Inhibition of all vascular and cellular phases of the inflammatory reaction.
• Action on the hypothalamic-pituitary-adrenal (HPA) axis: Causes adrenal insufficiency which persists throughout the entire phase of corticosteroid administration.
• Action on the immune system: Quantitatively and qualitatively affects the immune system (deficiency of cellular and humoral immunity.

 Metabolic actions: Reduces duodenal absorption of calcium ions (Ca2+) leading to hypocalcemia (osteoporosis in adults and rickets in children).

Support : Two scenarios are possible

• Patients on short-term corticosteroid therapy do not require any special precautions.
• Patients treated with prolonged corticosteroid therapy are at risk of infection and of developing an acute adrenal crisis.

Management of a patient on prolonged corticosteroid therapy:

 Medical consultation:

The dentist must seek the opinion of the attending physician: (the presence of adrenal insufficiency; the treatment followed is not satisfactory; the current state of health of the patient; the nature of the treatment according to the care envisaged).

 Precautions against stress

Stress has an impact on corticosteroid requirements and should be minimized in any endocrine condition. Dental care in patients with adrenal insufficiency should be short-term, preferably scheduled on

morning. Conscious sedation by inhalation of nitrous oxide and oxygen and sedative premedication with benzodiazepine is necessary.

 Precautions regarding the risk of infection :

Invasive procedures involving healing of the bone or mucosa (gingival manipulation, pulp manipulation, or manipulation of the periapical region of the tooth or breaking of the oral mucosa) must be carried out under antibiotic therapy, starting two days before the procedure and continuing until the mucosa has healed (7 to 10 days).

 Precautions in the context of the prescription:

Corticosteroids have drug interactions with aspirin and non-narcotic analgesics (decreased blood aspirin concentration, possible increased ulcerogenic effects), phenytoin, diuretics, oral contraceptives and barbiturates (decreased effectiveness).

 Complications: Acute adrenal crisis

Patients with low adrenal function who are scheduled for stressful surgery are at risk for adrenal crisis. Acute adrenal crisis is a life-threatening emergency that requires immediate treatment with 100 mg of hydrocortisone IV injection and fluid and electrolyte replacement. It should not be confused with hypoglycemic seizures.

3. liver failure:
   1. 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, long-term hepatocellular carcinoma.

2. General and oral repercussions:

General and oral repercussions:

• Cirrhosis causes immunosuppression
• Thrombocytopenia

– Disruption of coagulation by alteration of coagulation factors

• enlargement of the salivary glands, jaundice, gingival bleeding, purpura, petechiae, oral hematomas, alteration of taste,

3. Action to take:

• contact the treating hepatologist: stage of disease progression
• biological assessment: know the values ​​of the TP and the CBC (if TP is less than 50% hospital care), because of 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 agents, such as clindamycin, and to decrease or avoid the use of highly metabolized antibiotics with biliary elimination, such as macrolides and metronidazole.

4. Hepatitis:
   1. 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 the risk of cirrhosis and liver cancer.

2. Transmission:

-transfusion route_(hemophiliac) hemodialysis patients, drug addicts, healthcare personnel

-sexual transmission, feto-maternal, salivary

3. 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 liver failure. The latter is characterized by a drop in TP – therefore a risk of hemorrhage

4. 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 TP>50% Local hemostasis measurement assured

NP: 50,000/mm3 Transfusion of fresh frozen plasma may be indicated in consultation with the hematologist or hepatologist

• For invasive procedures but without risk of hemorrhage (scaling, procedures involving manipulation of the pulp): antibiotic prophylaxis should be discussed;
• For invasive procedures with moderate or high bleeding risk: antibiotic therapy and treatment setting will be determined with the hepatologist, depending on the type of procedure and the stage of the disease.

-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 the film is applied 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

1. Clean the injured skin area immediately with soap and then rinse.
2. Disinfection with 70° alcohol (3 min) or 12° bleach (lûmin) or povidone iodine in pure dermal solution (5 min).
3. Contact the referring physician quickly to assess the risk.

Benefits of hepatitis B vaccination for healthcare workers.

5- AIDS

Acquired Immunodeficiency Syndrome (AIDS):

HIV patients experience 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 sexually and through blood. 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 presents opportunistic germ infections (Kaposi’s sarcoma, pneumocystis pneumonia for example).

Oral manifestations frequently encountered in HIV patients are: oroesophageal candidiasis, Kaposi’s sarcoma, hairy leukoplakia, herpes simplex, thrombocytopenia probably of autoimmune origin, petechiae, ecchymoses and spontaneous or provoked gingival bleeding, and cervical lymphadenopathy.

Conduct and precautions to take in dental practice:

The care of HIV patients requires precautions designed to ensure that

• Eliminate the risk of cross-transmission
• Prevent postoperative infections (due to immunosuppression)
• Preventing the risk of bleeding in subjects with thrombocytopenia. Before treating an HIV patient, a discussion with their doctor is essential. The latter will specify the stage of the disease, the viral load, the associated complications and the treatments being followed.
• LT (T lymphocyte count) CD4+ > 200 /mm3, PNN < 500 /mm3, and platelets < 100,000 /mm3, without any other associated pathology: Non-invasive procedures are possible in the dental office, but for invasive procedures, a management protocol, including the prescription of antibiotic prophylaxis, must be decided with the doctor.

specialist depending on the patient’s condition, their treatments, and the procedure to be performed;

• CD4+ LT < 200/mm3, or AIDS stage: the patient can be treated at the dental office, after contact with the attending physician. These patients generally take long-term prophylactic antibiotic treatment to avoid opportunistic infections.

1. Regarding the risk of cross-transmission : All care will be carried out under strict clinical asepsis: wearing a mask, double gloves, goggles; 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 single-use instruments; appointments scheduled at the end of the day, to further reduce the risk of cross-contamination.
2. 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.

3. Precaution to take regarding the risk of hemorrhage:

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, surgical procedures will be performed according to the usual protocols.

If thrombocytopenia is moderate, local hemostasis measures are required.

If thrombocytopenia is severe, the appropriateness of a blood transfusion will be discussed with the attending physician.

Conclusion

There are several pathological situations involving immunodepression which will have an impact on the dental care of this type of patient.

The major risk encountered in immunocompromised patients is the risk of infection when performing invasive procedures. This risk will be prevented before proceeding with the procedure by adequate antibiotic coverage which will be continued until healing because, in addition to the risk

Infectious disease often adds a risk of delayed healing, hence the need for patient monitoring.

Collaboration with the attending physician is essential to ensure adequate care for these patients.

Management of at-risk patients Immunocompromised patients (patients on long-term corticosteroid therapy for AIDS, liver failure, hepatitis)

  Deep cavities may require root canal treatment to save the tooth.
Dental veneers can correct stained or malformed teeth.
Misaligned teeth can cause speech problems.
Dental implants prevent bone loss in the jaw.
Antiseptic mouthwashes reduce bacteria that cause infections.
Decayed baby teeth must be treated to avoid complications.
An electric toothbrush cleans more effectively than a manual one.
 

Management of at-risk patients Immunocompromised patients (patients on long-term corticosteroid therapy for AIDS, liver failure, hepatitis)