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					                                                                                               HC 3395
                                                                                              2/14/2008
                                  Dent805 Take Home Final Exam

Question #1:
You (DH students) or your dental hygienist (Dental students) comes to you to inform you that she
has just injured herself (bleeding cut in palm of right hand) with a bloody scaler. The patient she was
treating is positive for chronic active hepatitis C. For the following questions, provide your
reference(s)
             a. What is the post-exposure prophylaxis protocol (if any) for exposure to hepatitis C?
             b. What is the responsibility of the employer in regards to provision of medical care as a
                 consequence of this exposure?


A) Post-exposure Prophylaxis (PEP) is a prophylactic treatment regimen that is begun immediately
(as soon as possible) after exposure to a disease in order to prevent its breakout in the exposed
individual. Current guidelines do not recommend any PEP treatment after exposure to Hepatitis C.
 After exposure, only the following testing is indicated:

       Immediately after exposure - perform anti-HCV and alanine aminotransferase (ALT) tests to
        set baseline levels.
       4–6 months after exposure - perform anti-HCV and alanine aminotransferase (ALT) tests.
       Positive anti-HCV tests should be confirmed with enzyme immunoassay using supplemental
        anti-HCV testing such as recombinant immunoblot assay (RIBATM).

       Instead of waiting 4-6 months, an HCV RNA test can be performed 4–6 weeks post-
        exposure.

B) The employer must during any working hours allow access for testing and PEP following such an
exposure. While in this case it is already known that the patient is Hep C positive, additional testing
for HIV and Hep B (unless the provider has had Hep B vaccination and is a known responder to that
vaccination) is still required. As the employer I would send the hygienist and patient to the local
testing clinic for testing (Hep B, Hep C, and HIV) and PEP (for HIV and/or HepB) as indicated.

Cost for treatment should be billed to worker’s compensation and not the individuals health
insurance.



References:

CDC. The Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Post-exposure prophylaxis. MMWR.
2001:50 (RR-11).
Foley, M and Leyden, A. American Nurses Association – Independent Study Module Needlestick Safety
and Prevention. World Health Organization. Online Availible
www.who.int/occupational_health/activities/1anaism.pdf. Accessed 2/12/2008.
Question #3:
The patient is a 54 year -old female with stage IV breast cancer, currently being treated with Avastin
and Zometa (monthly infusions). She has been treated for breast cancer for the past 12 months and
is stable. One year ago she had tooth #30 extracted because of severe periodontal disease. Today she
presents with pain and exposed bone on the lingual aspect of the mandible at tooth #30. She has pain
but no swelling. There is some erythema in the soft tissue surrounding the exposed bone.
     a. What is the most likely diagnosis?
     b. What are the current recommendations for preventing this condition?
     c. What are the current recommendations for treating this condition?
     d. What will you do for her? Be specific and provide your references

A) Osteonecrosis of the Jaw (ONJ) (associated with the use of IV bisphosphonates)

B) Prevention Recommendations
          For a patient about to begin IV bisphosphonate treatment:
           The dentist and oncologist should be in communication/working together.
           Do not start bisphosphonate treatment until oral surgical treatments have been
              completed
                     Dental treatment should be focused on eliminating infections and preventing
                      the need for invasive dental procedures in the future. This may include
                      extractions, periodontal surgery (eg. pocket reduction surgery), endodontic
                      treatment, caries control, dental restorations, and dentures
                     Complete bony impacted teeth should be left, those with some
                      communication to the oral cavity should be extracted.
                            Allow 1 month healing time post ext before beginning
                              bisphosphonate therapy.
                     Large mandibular tori with thin mucosal covering should be removed, small
                      tori can be left.
                            Allow 1 month healing time post ext before beginning
                              bisphosphonate therapy.
           If only non-surgical dental treatments are necessary, there is no need to delay the start
              of the bisphosphonate therapy.
                     Prophylaxis, restorations, fluoride treatment, denture fabrication, etc can be
                      performed without delaying the bisphosphonates.
                     Be sure that dentures are well fitting and not putting excessive stress on
                      individual areas.
           Put the patient on a more frequent recall interval (3-4mo) to watch for any developing
              problems (such as carious lesions developing).

           For a patient already on IV bisphosphonate treatment:
            The dentist and oncologist should be in communication/working together.
            Examine mouth for areas of exposed bone
            Take and assess radiographs for evidence of osteolysis, osteosclerosis, widened
              periodontal membrane spaces, and/or furcation involvements.
            Avoid extracting teeth whenever possible.
                      Endo and crown amputation is the preferred method for addressing non-
                       restorable teeth.
              Teeth with +1 or +2 mobility should be splinted, not extracted.
              Teeth with +3 mobility or associated with a periodontal abcess should be extracted
               and the patient should be placed on antibiotics
                    Penicillin is the antibiotic of choice, with erythromycin as the choice for
                       patients with a penicillin allergy
                    It is highly likely that osteonecrosis is already present and
                       the abscess and/or granulation tissue is merely covering exposed bone.
              Elective surgery (ex: third molar ext, tori removal, periodontal surgery, placement of
               dental implants) is strongly discouraged.
              Examine prosthesis for areas of excessive pressure or friction
                    Soft reline if needed.

C) Treatment Guidelines
           Treatment should be focused pain control and preventing progression of the exposed
              bone.
                  Patients reporting pain are thought to be related to possible secondary
                      infection of the area and should be placed on antibiotics.
                           Penicillin VeeK 500mg q.i.d. (or erythromycin if pen allergy)
                           Place on 0.12% chlorohexidine rinse (t.i.d. or q.i.d.)
                           In more symptomatic cases, metronidazole 500mg t.i.d is added to the
                              penicillin and chlorohexidine.
           Surgical treatment is not generally recommended.
                  Exception: sharp bony projections that are harmful to adjacent soft tissues
                      should be smoothed off.


D) For this patient, I would:

          Place her on PenVeeK 500mg q.i.d. for 2 weeks initially and prescribe chlorohexidine
           mouth rinse per above.
               i. I would contact her oncologist to let her know of the finding and use of
                   antibiotics and discuss desired duration for use of antibiotics; however, if I was
                   not able to speak with the oncologist right away I would start the patient onto the
                   penicillin and be willing to adapt after discussion with the oncologist.
          Smooth any sharp projections (with bone file) that are causing trauma to adjacent tissue.
          Have her back in 1 week to assess changes/improvement.
          Refer to an oral surgeon if I felt the situation was worse that I am equipped to handle.



References:

				
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