Causes of death in the world from infectious disease.

I. LAB EXERCISE : a. Select a dental patient requiring medical consultation b. Demonstrate completion of a medical consultation letter( form letter + actual letter to M.D.) c. List goals to minimize the potential for office emergencies in the HSS form + progress notes d. Turn-in copies of: med. consult form, actual letter, physician response and chart entry. Describe significance of specific patients medical condition as well as detailed dental management for this patient. e. Lab exercise is due to Dr. RHODUS by THE FINAL EXAMINATION

COMPETENCIES: Upon completion of this course the third year dental student will have demonstrated partial fulfillment of the following competencies:

1. Examine and evaluate the patient with medical problems.

2. Identify and record the medical problems presented by the patient. 3. Recognize and be able to prevent and provide immediate management for various medical emergencies in dental patients.

4. Recognize when it is necessary to refer the patient for further treatment, and coordinate care provided by others.

Causes of death in the world from infectious disease

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deaths

per

100,000

people

1980 1985 1990 2000

50

100

150

multiple cause of death

main cause of death

Deaths from infectious disease- US ( JAMA, 2000)

deaths

per

100,000

people

1980 1985 1990 2000

30

350

>65 y.o.

45- 64 y.o.

Deaths from infectious disease- US ( JAMA, 2000)

50

300

250____

10

25-44 y.o.

5-24 y.o.

0-4 y.o.

Causes of death in the U.S.Causes of death in the U.S. CDC- 2006 1. Cardiovascular disease 2. Cancer 3. Stroke 4. Pneumonia- influenza( #7 in 1996) >>15. AIDS ( #7. in 1997)

Emerging Infectious Diseases

Emerging Infectious Diseases

Ebola virus > 50 deaths Oct. 2000 Hantavirus Cryptosporidosis( Brewhouse tri) E. coli and Enterococci necrotizing Strep. A Pneumococci Staph. aureus





















Emerging &Re-emerging Infectious Diseases

Emerging &Re-emerging Infectious Diseases

antimicrobial resistance misuse of antibiotics mobility- travel food, water and agriculture child care Behaviors hospitals-health care









Hepatitis CHepatitis C formerly NANB transmission similar to Hep B + often

accompanies 40-50% = chronic active hepatitis acute liver disease; cirrhosis ~ 90 % develop chronic carrier state U.S. = 1992 ~ 150,000 infections > 1.5 million infections in 1998 >1000 HCW/yr. occupational! hep-Ca > 11 % !!

Antimicrobial resistanceAntimicrobial resistance

nosocomial infections >200,000/yr. Vancomycin resistant Staph. Aureus 1989<1% ; 1999 >15% methacillin res. 1999 >60%

inappropriate prescribing practices ! > 70 % !!



“Today’s discovery represents the triumph of modern science

over a dreadful disease.”

“Today’s discovery represents the triumph of modern science

over a dreadful disease.”

HEW Secretary

Margaret Heckler 1983

upon the discovery of HTLV-III

AIDS EPIDEMIC December 2006

35 million HIV infections35 million HIV infections worldwide, > 6 million worldwide, > 6 million cumulative deaths worldwide, including > 1.3 million cumulative deaths worldwide, including > 1.3 million dead children, 830,000 infected children worldwide dead children, 830,000 infected children worldwide (4.5 million AIDS cases).(4.5 million AIDS cases).

60% of worldwide cases of HIV are in Africa (18 60% of worldwide cases of HIV are in Africa (18 million, with 9 million cases of AIDS and million, with 9 million cases of AIDS and 1.8 million 1.8 million AIDs deaths in Africa in 1998) AIDs deaths in Africa in 1998) In S. Africa 50% of In S. Africa 50% of hospital beds are for AIDS; estimated by 2010 that 9 hospital beds are for AIDS; estimated by 2010 that 9 countires in Africa will have their life expectancy drop countires in Africa will have their life expectancy drop 16 yrs.16 yrs.

HIVHIV

2006: 35 million, worldwide 6 million deaths !! infected women ( world) ~40 % >1 million infected children

( 90% = 3rd world)

HIV HIV

U.S.> 1.5 million AIDS: U.S.>550,000 cases AIDS: U.S.>350,000 deaths changes in epidemiology

homosexual-bisexual males IVDUs women children

HIV-AIDS in the U.S.HIV-AIDS in the U.S. cases of AIDS-1996 = ~ 56,000 deaths from AIDS-1996 = ~ 45,000 cases of AIDS-2006 = ~ 25,000 deaths from AIDS-2006 = ~ 11,000



source: CDC- 2006

1990 1992 1994 2006

8000

1000

casesper wk

AIDSnew cases

DeathsDeaths

alive with AIDS

Incubation Period to AIDS

TransfusionRecipients

7 years

Hemophiliacs 10 years

Injecting drug users 10 years

Homosexual/bisexual men

8-12 years

Cumulative %0% 3% 12% 36% 53% 68% 85%1yr 3yr 5yr 8yr 10yr 14yr 20yr

CD4 cell/ mm3 CD4 % Clinical Presentation > 600 32-50 Normal

< 500 <29 Initial immune suppression. Initiation of retroviral therapy.

< 400 Manifestations of opportunistic infections.

200-400 14-28 More opportunistic infections and some major opportunistic infections.

< 200 <14 AIDS diagnosis; severe immune suppression, major opportunistic infections; prophylactic medications for PCP.

< 100 Appearance of fatal opportunistic infections and specific oral lesions. Prophylaxis for toxoplasmosis, MAC, cryptococcosis.

Viral Load

Stage B

AIDS defining diseases*AIDS defining diseases* Pneumoncytis pneumonia 38% HIV wasting syndrome** 18% Candidal esophagitis 14% Kaposi’s sarcoma 10% TB 10% lymphoma 10% Viral:

Herpesviridae, CMV, HPV, Pox family Neurologic < AIDS-related pain (neuropathy, myelopathy)

** loss of 10% body wt. < 30days

Clinical category C Bacterial infections, multiple or recurrent*Candidiasis, respiratoryCandidiasis, esophageal Cervical cancer**CoccidioidomycosisCryptococcosis

Cryptosporidiosis Cytomegalovirus disease

Cytomegalovirus retinitisEncephalopathy, HIV relatedHerpes simplex chronic; respiratory; esophagealHistoplasmosis HIV encephalopathyHIV wasting syndrome Immunosuppression, severe HIV-related

Isosporiasis Kaposi’s sarcoma

Lymphoid interstitial pneumonia* Lymphoma, Burkitt’s

Lymphoma, immunoblastic Lymphoma, primary; brainM. avium complex M. tuberculosis, disseminated; extrapulmonaryM. tuberculosis, pulmonary** Mycobacterial diseasePneumocystis carinii pneumonia Pneumonia, recurrent**Progressive multifocal leukoencephalopathySalmonella septicemiaToxoplasmosis* Not applicable as indicator of AIDS in adults/adolescents** Not applicable as indicator of AIDS in children Has oral manifestations

Dental patient management :AIDS

Dental patient management :AIDS

Opportunistic infectionsPneumoncystis carinii pneumonia (PCP)Toxoplasmic encephalitisTBMycobacterium avium complex(MAC)

Streptococcal pneumoniaCMVCandidiasis

Cancer

Preferred Antiretroviral RegimensPreferred Antiretroviral Regimens Optimal: 2 NRTIs + PI; Optimal: 2 NRTIs + PI; 2 NRTIs + NNRTI2 NRTIs + NNRTI

Less desirable: 3 NRTIsLess desirable: 3 NRTIs

Unacceptable: monotherapyUnacceptable: monotherapy Resistance Resistance

19901990 1%1%19941994 7%7%19991999 15%15%

Changing therapy: failure (rising viral load, Changing therapy: failure (rising viral load, falling CD4 count, symptoms, ADEs) never add falling CD4 count, symptoms, ADEs) never add a single drug to a failing regimen, begin with at a single drug to a failing regimen, begin with at least 2 drugs.least 2 drugs.

Highly Active Antiretrovial Therapy (HAART)

Nucleoside RT Inhibitors -Nucleoside RT Inhibitors - mg/daymg/day 30 day 30 day costcostAbacavir (ABC; Ziagen)Abacavir (ABC; Ziagen) 300 bid 300 bid $ 349 $ 349

Didanosine (ddI, Videx)Didanosine (ddI, Videx) 200 bid 200 bid 217217

Lamivudine (3TC, Epivir)Lamivudine (3TC, Epivir) 150 bid 150 bid 259259

Stavudine (d4T, Zerit)Stavudine (d4T, Zerit) 40 bid 40 bid 274274

Zalcitabine (ddC, Hivid)Zalcitabine (ddC, Hivid) 0.75 tid 0.75 tid 212212

Zidovudine (AZT, ZDV, Retrovir)Zidovudine (AZT, ZDV, Retrovir) 200 tid 200 tid 604604

Zidovudiine + Lamivudine (Combivir) 1 tab bid Zidovudiine + Lamivudine (Combivir) 1 tab bid 564564

Nucleotide RT Inhibitor -Nucleotide RT Inhibitor - AdefovirAdefovir 120 qd 120 qd only available thru EAPonly available thru EAP

Non-nucleoside RT inhibitors ( NNRTI)Non-nucleoside RT inhibitors ( NNRTI) Delavirdine (Rescriptor) 400 tid 239

Efavinrenz (EFV, Sustiva) 600 qd394

Nevirapine (Viramune) * 200 bid 279*Not drug of choice for HIV postexposure *Not drug of choice for HIV postexposure

prohpylaxisprohpylaxis

Anti-HIV Drugs

Protease Inhibitors: block an block an enzyme that cleaves Gag and Gag-enzyme that cleaves Gag and Gag-Pol polyproteins Pol polyproteins - 50 to 100X more potent than AZTAmprenavir (Agenerase) 50s, 150s 1200 bid

$ per month = 605Indinavir (Crixivan) 800 q8h

$ per month = 464Nelfinavir (Viracept) 750 tid

$ per month = 583Ritonavir (Norvir) 600 tid

$ per month = 668Saquinavir (Invirase) 600 tid

$ per month = 586

mg/daymg/day

Treatment of HIV Infection Most untreated patients have HIV-1 RNA levels stabilize

between 1000-10,000 copies/mL. In AIDS, levels > 1 million copies/mL

Combination therapy of NRTI + NNRTI + HIV Protease inhibitor

Up to 28% of newly infected individuals may contract HIV that is resistant to one or more anti-AIDS drugs

HIV Therapy Edge is software to search gene sequences for over 120 drug resistance mutations and to report which drugs to avoid.

AIDS treatmentAIDS treatment

complex Rx : 1-8 months> $12, 000.00poor complianceHIV +ve & infectiousviral genotyping to detect antiretroviral resistance

Opportuntistic infectionsCD-4 counts >500 ; esp. >200

Screening and rapid tests: Abbott/Murex Single Unit Diagnostic System [SUDS] HIV-1 test), oral mucosal transudate-based tests (e.g., OraSure HIV-1 western blot kit), home test systems (e.g., Home Access HIV-1 test kit).

Principles of medical management of dental patients

Detection Physical Evaluation Medical treatment Status Management

Management Considerations Viral load will determine level of viremia, efficacy of

antiretroviral therapy, disease progression, and prognosis, thus influencing appropriate treatment planning. There is no need for prophylactic medication prior to dental therapy based solely on viral load.

Management Considerations

Dental treatments, including extractions, can be safely performed in patients with platelet counts >50,000 platelets/mm3.

Prophylactic bactericidal antibiotics need to be considered when the neutrophil count drops below 500 cells/mm3 (normal 2,500-7,000 cells/mm3), but at this stage the patient is often already medicated with antibiotics due to frequent bacterial infections and as prophylaxis against opportunistic infections.

There are very few complications associated with dental care of HIV-infected patients and most infected patients can be safely treated by general dental practitioners.

Oral lesions found in HIV-infected persons are reliable markers for immune suppression, disease progression and AIDS.

GROUP 1 ORAL LESIONSStrongly Associated with HIV Infection

Candidiasis Oral hairy leukoplakia Kaposi’s sarcoma Non-Hodgkin’s lymphoma Periodontal disease - linear gingival

erythema, necrotizing (ulcerative) gingivitis, necrotizing (ulcerative) periodontitis

Oral candidiasis most common oral lesion among HIV+persons (39.6%), then hairy leukoplakia (26.3%), exfoliative cheilitis (18.3%), and linear gingival erythema (LGE) (11.5%). JOPM 2001 30(4):224-30 in Thailand

Oral candidiasis in HIVOral candidiasis in HIV

prevalent ( >45%) related to other oral diseases( i.e. caries

and periodontal disease, HSV, etc.) proportional to low CD-4 counts predictive of rapid progression to death

Oral Hairy Leukoplakia

Immunocompromised State HIV+ / AIDS Chemotherapy Organ transplant Autoimmune disease (SLE on prednisone

5-10mg/d X 1 yr + methotrexate) Often an indicator that AIDS will develop within a short time period

Human Papillomavirus Condyloma acuminatum Transmission

HPV DNA detected in sperm 32% of men detected in 24 of 45 men hx or clinical evidence of HPV infection

HIV Infection

Angular cheilitis Patient was HIV

infected Later was diagnosed

with AIDS Erythematous candidiasis

Bacterial Infections

Systemic Infections Oral Infections

Periodontal tissues Necrotizing ulcerative gingivitis (NUG) Linear gingival erythema Necrotizing ulcerative periodontitis

Tongue and other mucosal structures

HIV Infection

Linear gingival erythemia

Necrotizing Ulcerative Periodontitis

HIV Infection

Recurrent herpes simplex infection in a patient with AIDS

HIV Infection

Herpes zoster Out break occurred in

patient with AIDS

Harrison’s Online, hppt://www.harrisonsonline.com, plate 11D-30, 2002

HIV Infection

Aphthous ulceration (major type)

Patient was diagnosed with AIDS

HIV Infection

Kaposi’s sarcoma

HIV transmission from HCW to patients

HIV transmission from HCW to patients

still only one case (Dr. Acer) ! CDC : >70 infected HCW served over

100,000 patients tested = 0 HIV + risk per million from HCW = 0.0038 risk of death from PCN-ALLR =

20/million

HIV transmission from patients to HCW.


~ 10 per year dentistry : documented= 0 possible= 7 lab techs : documented= 18 possible= 30 nurses : documented= 15 possible= 40 MDs : documented= 0 possible= 12 others : documented= 10 possible= 47 Hep C > 1000 !!!



NEEDLE STICKS ! avg. follow-up >$600

wounds from HIV patients; CDC: >4000 incidents < 10 seroconversions

transmission rate= 0. 25% ( 1:400) >70% from blood draws; >25 % IVs >83% not high risk ( Rx goes in)...EPINet

1999 California law

Management of Occupational Blood

Exposures Evaluate exposure source. Assess the risk of infection

using available information. Test known sources for HBsAg, anti-HCV, and HIV antibody

(consider using rapid testing). For unknown sources, assess risk of exposure to HBV, HCV,

or HIV infection. Do not test discarded needles or syringes for virus

contamination. Evaluate exposed person.Assess immune status for HBV

infection (i.e., by history of HBV vaccination and vaccine response).

Management of Occupational Blood

Exposures Provide immediate care to the exposure site. Wash wounds and skin

with soap and water. Flush mucous membranes with water. Reporting of exposure. Access to medical provider for testing. Access to post-exposure protocol. Documentation for workers compensation or disability claims. Determine risk associated with exposure by: Type of fluid (e.g., blood,

visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus) and

Type of exposure (i.e., percutaneous injury, mucous membrane or nonintact skin exposure, and bites resulting in blood exposure.

Mucous membrane exposures are assessed for type as either small volume (i.e., a few drops) or large volume (i.e., major blood splash) and the guidelines differ from those for percutaneous injuries in that basic 2-drug PEP is considered for small volume injuries from HIV-positive Class 1 source patients and basic 2-drug PEP is recommended for small volume injuries from HIV-positive Class 2 patients and large volume injuries from HIV-positive Class 1 patients. For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g., dermatitis, abrasion, or open wound).

Can you refuse to treat and HIV infected person?

Federal law prohibits the dentist from refusing to treat patients with disabilities, including HIV infection. Under the Americans with Disabilities Act (AwDA), dental offices are considered places of public accommodation and are prohibited from refusing to treat patients with HIV solely because of their HIV status.





Causes of death in the world from infectious disease.

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