Patient Management and Case Presentation Cesar Augusto Migliorati DDS, MS, PhD.
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Transcript of Patient Management and Case Presentation Cesar Augusto Migliorati DDS, MS, PhD.
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Patient Management and Case Presentation
Patient Management and Case Presentation
Cesar Augusto Migliorati DDS, MS, PhD
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Cases of HIV+ patients who were referred for
dental care
Cases of HIV+ patients who were referred for
dental care
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Patient ManagementPatient Management
• HIV is a chronic disease
• Medical information is important for outlining a dental treatment plan
• Routine dental care should be provided to all HIV infected individuals
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Patient ManagementPatient Management
Case 1Patient presents to the dentist for routine dental examination
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Observe in this panoramic radiograph that the patient is missing some teeth on the lower right jaw and will need a bridge to replace the missing teeth. Note that this patient has had extensive dental care
Routine Dental EvaluationRoutine Dental Evaluation
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Observe in this set of full mouth radiagraphs that the patient had extensive dental work. He is missing a few teeth on the left side of the mouth. The lower front teeth have calculus and need to be cleaned.
Routine Dental CareRoutine Dental Care
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Medical HistoryMedical History
• HIV + for 20 years• Receiving HAART• TB status: PPD non-reactive (11/03)• Chest X-ray: moderate COPD• HIV-1 RNA load: undetectable• CD4 count: 598/mm3• WBCs: 8,500/mm3• Platelets: 353,000/mm3• Triglycerides: 337 mg/dl (<150 mg/dl)
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Lipid DystrophyLipid Dystrophy
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Medications - HealthMedications - Health
• Epivir, Viread, Ziagen (HIV)• Norvasc, Accupril (hypertension)• Oxycontin, Vicodin (arthritis/pain)• Wellbutrin (Depression)• Proscar, Oxandrin, Andro Gel ( prostate hyperplasia, HIV wasting, testosterone
replacement)
• Prevacid (GI antisecretory)• Ativan (sleep, anxiety)• Multivitamins, Vit C• Glucosamine/Condroitin
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Patient ManagementPatient Management
• Although the patient has been infected with HIV for 20 years and has a very complex medical history, there are no contraindications for dental treatment
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Patient ManagementPatient Management
Case 2Patient presents to the dentist with pain in the mouth
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34 y.o. male HIV + presents to the clinic for
evaluation
34 y.o. male HIV + presents to the clinic for
evaluation• “My lips hurt.”
• HPI: Patient has lip lesions for two weeks. Lesions are getting progressively worse. Cannot open mouth. Cannot shave. Mouth feels funny
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Important InformationImportant Information
• Viral Load: >45,000 copies/mL
• CD4 counts: < 200 / mm3
• TB status: 3 mos ago. negative
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Additional InformationAdditional Information
• Medical Hx• Pt has Hep C and is under
consideration for treatment. Liver enzymes are elevated. Feeling tired and running fever daily
• HIV test results and date of infection• Infected for about 10 years,
proved by ELISA and Western blot
• Risk behavior• Addicted to drugs of
injection (high risk for heart diseases and need for endocarditis prophylaxis)
• CBC and platelet count• Leukopenia, anemia,
thrombocytopenia (increased risk for bacterial infection and bleeding)
• Current medications• HAART, Methadone,
Multiple Vitamins
• Allergies and drug sensitivity• None
• Social history• TOB is negative now. Used
to smoke 2 PPD for 20 years• ETOH: beer drinker
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Clinical ExaminationClinical Examination
Note cracking of the corners of the lips and bleeding
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Differential DiagnosisDifferential Diagnosis
• Oral Candidiasis
• Angular Cheilitis : fungal + bacterial infection
• Advanced HIV disease
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Diagnostic TestsDiagnostic Tests
• Clinical impression + tests
• KOH smear
• Culture
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TherapyTherapy
• Fluconazole 100 mg/day for 10 to 14 days (Diflucan®)
• Topical• Nystatin (Micostatin®) cream• Clotrimazole (Mycelex® Lozenges)
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Two weeks follow-upTwo weeks follow-up
Healing of the corners of the lips has occurred
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Patient ManagementPatient Management
Case 3Patient HIV + for years presents to the dentist for routine dental examination
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Patient managementPatient management
Patient has severe periodontal disease. The gingiva is red and the teeth are covered with dental plaque and calculus. The front teeth have extensive decay (arrows)
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Patient managementPatient management
Upper teeth are missing due to severe periodontal disease. Palate (roof of the mouth) is red and inflamed.
The panoramic radiograph below shows extensive bone loss and several teeth that need extraction because of severe periodontitis
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Patient managementPatient management
Patient was treated for periodontal disease, had a few teeth extracted and after the oral disease was controlled she was given a partial denture. Patient is happy and can smile again
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Patient ManagementPatient Management
Case 4HIV + school teacher presents to the dentist complaining that she cannot work with children because of her bad teeth
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Patient managementPatient management
Decay and periodontal disease were treated. Gingival tissues look normal
Note extensive decay, missing teeth and periodontal disease
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Patient managementPatient management
Patient was given a partial bridge. She is back teaching and can smile again