4. HB Oral/Dental Considerations Flashcards
(42 cards)
Occupational Exposure
• Dentists use a lot of ____. Needles to inject patients with LA, trigger point injections into jaw muscles, inject lesions with corticosteroids to heal faster… Lots of uses for sharps.
• Don’t want to stick ourselves or put the patient at occupational exposure risk as well
• Deal with a lot of fluid from oral cavity: blood, saliva, things that can transport/harbor infectious
organisms that pose a risk to us and other patients. Have to be mindful of splashes to open sores and other mucous membranes
• Dentists use a lot of dental instruments that are ____
◦Student once dropped a perio scaler on her toe and got cut and infected.
◦D3s tend to lose awareness of clinical surroundings, accidentally stick themselves when
moving quickly and not paying attention. Can drop instruments or back up on a burr. ◦Have to maintain composure and maintain awareness to avoid unintentional occupational
exposures
sharps
sharps
Viral transmission in the dental setting
- Transmission of virus
- ____
- Most likely method of transmission
- DHCP to the patient
- Patient to patient
- Exposure to virus
- ____ injury
- Needle stick
- Cut with sharp instrument
• Contact of ____ tissues, blood, bodily fluids with mucous membranes or non-intact skin
patient to dental health care personnel
percutaneous
infectious
Risk of HBV occupational transmission
- Acute or chronic HBV infection
- Transmit virus if ____ (+)
- If ____ (+), risk of infx increases 10- fold than HBsAg (+) only
- Risk after a needlestick injury
- 3-6% if HBsAg (+) carrier
- 30% if HBeAg (+) carrier
- HBsAg detectable in ____
- Dentistry is considered one of the health care professions with the highest risk of ____ exposure
- Infection rates 3-10x higher than general population
- Prior to mandatory HBV vaccination for dentists
- Prevalence of HBV serologic markers ranged 16 -28%
HBsAg
HBeAg
saliva
HBV
Risk of HCV occupational transmission • Prevalence of infection to health care workers is \_\_\_\_% • Similar to that of general population • 1/10th of risk of \_\_\_\_ transmission • HCV is detectable in \_\_\_\_ • Case reports of transmission • 2 cases of \_\_\_\_ splash to conjuctiva • 1 case of HCV / HIV transmission after non – intact \_\_\_\_ exposure • 1 case of \_\_\_\_ HCV transmission
1-2 HBV saliva blood skin patient-to-patient
Dental occupational exposure
• Total elimination of risk is not ____
• Minimized with standard ____ and ____
achievable
precautions
vaccination
• Use ____, gloves, eye ____ (for provider and patient), hair coverings.
• Use needle caps and protectors to prevent sticks. Use cardboard protectors
• ____. Use of sterilization equipment is imperative to maintaining appropriate infection
control
gowns
protection
autoclaving
DHCP Vaccination
• DHCP who perform tasks involving contact with infectious materials must be vaccinated against ____
• Tested ____ months after 3-dose series
• Check for anti-HBsAg
• May receive 2nd 3-dose series if antibody titers are ____
• Vaccine-induced antibodies ____ over time
• 60% will lose detectable antibodies over 12 years
HBV
1-2
inadequate
decline
Exposure management
• Exposure management protocols
• SDM
• Private practice
- Basic principles
- Prompt ____
- Access to post-exposure ____ and care
- Ensure ____ for DHCP and source patient
• Specific protocol and policies in all schools and private practices. Need to have a record of exposure management bc if a health inspector comes and takes a look, need to have it ready
◦Lots of inspection in the school from ____ and other state officials. May get random state inspection in practices too. They always look for exposure management protocol!
◦Also good to have it just for normal office protocol policies
reporting
testing
confidentiality
• After exposure, obtain ____ to test source patient for HBsAg, anti-HCV and HIV
• Hepatitis B
• Treatment with Hep B ____ and / or ____ according to
protocols
- Hepatitis C
- No post-exposure medications ____
- Follow-up ____ evaluations
consent vaccine HBIG recommended laboratory
Detection of liver disease
____ and physical exam ____ signs / symptoms
____ signs / symptoms
history
general
oral
Oral manifestations of liver disease • \_\_\_\_ changes • Hemorrhagic changes • Petechiae • Hematoma • Gingival bleeding • \_\_\_\_ gland enlargement • Glossitis • \_\_\_\_ • Sjogren’s like syndrome • Lichen planus
mucosal
parotid
hepatitis C
Patient with yellow gingival tissue. End stage liver disease with jaundiced gingiva. Not common.
• Patient with hyperbilirubinemia and gingival tissues are affected. Hyperbilirubinemia can be be
seen ____!
intraorally
- Patient with hemorrhagic perioral lesion that can be seen in a patient with end stage liver disease.
- Larger varicosities that may ____ bleed. Can be hard to control this hemorrhage. They may need to be sclerosed or addressed in other ways
- Perioral region has a very vascular look to it
spontaneously
- Patient has gingival bleeding even though their gingival tissue looks good. No evidence of edema, mo visible plaque, nice stippling.
- Healthy gingiva, but ____ profusely. Cannot control gingival hemorrhage.
- This is not caused by local factors, caused by a ____ bleeding/clotting disorder related to liver disease.
- Good example of healthy gingiva with significant bleeding. Systemic disorder is the source of oral hemorrhage
bleeding
systemic
- Patient presents with parotid gland swelling (another manifestation of liver disease)
- Parotid gland is very enlarged. If you palpated it, it would be ____
- Looking intraorally, it would be difficult to milk the parotid gland and get ____ to come out of the parotid duct.
• This can be a recurrent issue. When patients have parotid gland swelling, it increases the risk of them developing ____ (parotid salivary gland infection.
- Dentists would have to manage this by putting them on ____, help them massage the gland to maintain the patency of the gland and the duct
- May be seen in emergency clinic or in hospital dental clinic.
tender
saliva
parotitis
antibiotics
- Glossitis: This does not look like benign migratory glossitis (alternating red/white patterns). This is a true ____ with areas of erythema.
- This may be attributed to an atrophic ____, a type of yeast infection that doesn’t have white cheesy plaque formation, more erythematous. This presentation could also be Fe or ____ deficiency or some type of anemia.
• Other possible causes, but this is also seen in liver disease!
• When patients present with things like this, rule out the local factors and then think about the
systemic causes for the oral sequelae.
de-papillation
candidiasis
B12
- Different presentations of ____. The most common mucosal disease you will encounter in the general patient population
- Left pic: typical ____ pattern. Wickhams striae, minimal erythema or ulceration. patients might not know they have it, might just not a textural change. Their cheek might feel rough, but there is no pain.
- Symptoms range from asymptomatic to severe pain (in erosive or ulcerative form)
- Right pic: ____ form. Extensive tongue ulcerations, pseudomembranes forming in different places. Significant pain and difficulty eating. This could have a huge impact on daily life
- Oral LP can run the spectrum in terms of clinical presentation and symptomolgy.
- Consider this when thinking of Hep C
lichen planus
reticular
ulcerative
Dental Management
• Impaired ____
• Impaired ____ metabolism
◦Patients may have impaired hemostasis ability. Difficulty clotting can cause excessive
bleeding
◦Impaired drug metabolism. Lots of drugs are metabolized in the liver, if it is not functioning
properly, may not be able to metabolize things appropriately which can cause big issues
hemostasis
drug
Pre-treatment evaluation • Medical \_\_\_\_ • Labs • \_\_\_\_ with differential • \_\_\_\_ function tests • \_\_\_\_ studies • Determine need for pre – op \_\_\_\_ products • Determine proper \_\_\_\_ for indicated dental treatment
Rarely in general out patient setting will a physician recommend a patient getting clotting factor or platelts as an infusion before dental treatment. Usually these types of patients are treated in a ____ dental clinic or an operating room dentistry setting. Physician will let you know if they need a platelet transfusion before major oral surgery (probs not routine dental treatment.
Most patients, if they are stable, can be treated in an out-patient setting (like the school or private practice). If patients have unstable liver disease, they might have to be treated in a dental hospital clinic or an OR dentistry setting.
consultation CBC liver coagulation blood venue
Drug Metabolism
• Acetaminophen
• Use with caution
• Avoid > ____gm / 24 hour
- ASA / NSAIDS
- Generally ____
- Aggravate ____
- Renal complications
• Avoid narcotics
• May precipitate hepatic
____
- Tramadol
- ____ mg q12h
- Antibiotics
- Avoid ____, tetracycline, ____ and metronidazole
2 contraindicated bleeding encephalopathy 50 clindamycin doxycycline
- ____ is acceptable in patients with severe liver disease
- Up to ____ carpules of 2% Xylocaine with 1:100K Epi
- IAN block may pose risk of ____ in patients with blood dyscrasias
- Consider diminished doses of hepatically-metabolized drugs when
- ALT / AST > ____X normal
- Bilirubin > ____ um/l
- Albumin < ____ g/l
- ____, encephalopathy, malnutrition are present
3 hematoma 4 35 35 ascites
Dental Management of the Liver Transplant Patient
• Pre-Transplant Dental Considerations
- Post-Transplant Dental Considerations
- ____ post-transplant period
- ____ post-transplant period
- ____ rejection period
immediate
stable
chronic
Dental Treatment Considerations Pre-transplantation considerations
- Significantly ill patient with ____-organ damage
- Medical ____ required
- Consider postponing ____ treatment
- Dental consultation prior to anticipated transplantation
- Evaluate for acute and chronic dental sources of ____
- Stabilize current ____ status
- Potentially remove sources of ____ that may lead to acute complications within the transplant process and immediate post-transplant period
end consultation elective infection oral infection
- Prior to administering treatment, consult with transplant ____ to determine medical risk vs. benefit of proposed dental treatment
- Obtain laboratory information/supplemental ____ as needed: CBC with differential, aPT, aPTT, INR, metabolic panel, liver function tests, other organ-specific panels
- Specific management issues as needed per individual case
physician
information
