Management of Common Dental Emergencies in HIV Patients

Emergency is an unforeseen serious situation that arises suddenly and threatens the wellbeing of a person; this is a health crisis requiring prompt action.

Dental Pain

In dental practice, pain is the most common cause of dental emergencies:

• Emergency treatment for dental or oral pain includes administration of analgesics and antibiotics if infection is present.
• Acute infections past the pain phase are still emergencies.
• Before institution of any emergency procedure body temperature and blood pressure of the patient should be checked.
• If a patient is running a fever, consultation with his/her physician is necessary. In this instance use of an appropriate antibiotic may be necessary. HIV patients have a tendency to develop painful dental conditions arising from infectious etiology. This is due to their increased susceptibility to infections.

Pulpitis is frequently responsible for dental pain.

• When a patient reports with pain a quick evaluation and diagnosis of the source of pain and its possible cause must be established.
• If the diagnosis of pulpitis is clear, vital signs and cardiovascular history are taken or verified followed by local anesthesia to control pain.
• With pain under control, x-rays and final clinical evaluation of restorability of the tooth is achieved.
• If the tooth is not restorable, extraction should be performed.
• If extraction is not advised due to lack of medical information or patient's physical condition, drainage is to be established by creating an access to the pulp.
• Exposed pulp can be left open temporarily to prevent formation of a potential abscess Irreversible pulpitis and necrotic pulp are treated by pulpectomy.
• Systemic antibiotic is not indicated when there are no local or systemic signs of an abscess.
• Biopulpectomy should be followed by irrigation, instrumentation and filling the canal or canals with calcium hydroxide paste or placing formocresol curative in the pulp chamber.
• Necropulpectomy should be followed by irrigation, instrumentation and placement of sedative curative with formocresol in the pulp chamber.
• In both cases all the carious dentin must be removed and the tooth sealed with temporary filling.
• Endodontic treatment in both cases should be completed as soon as symptoms subside.

Dental Abscess

If an abscess is suspected/detected, a differential diagnosis between periodontal and periapical abscess should be the first step.

• The first option for drainage is through the canal(s) or the periodontal pocket as the case may be.
• If the drainage is achieved, there is no need for an antibiotic.
• When the abscess is large, elicits fluctuation and do not drain by the conservative approaches, surgical drainage is advised.
• In this case pre medication is indicated, using a wide spectrum antibiotic and avoiding the ones recently prescribed for the patient.
• It is important to contact the physician before medicating to avoid conflicting therapies. Antibiotic is only used when patient has systemic signs and symptoms such as fever, headache, nausea, body aches and chills.
• The size and location of the abscesses or presence of cellulitis are also to be taken in to consideration. Occasionally these may pose serious threat to patient's life unless treated vigorously on time.

The protocol for premedication is to give antibiotic to the patient and wait for its blood levels and then intervene surgically.

• After the invasive procedure the patient should continue to take the same antibiotic, by prescription, for 10 days.
• Surgical drainage should be maintained for 24 hours.
• Once the acute phase is resolved extraction or endodontic treatment could start
• This should be carried out before the end of the course of the antibiotic to prevent reactivation of infection.
• It is important to establish a differential diagnosis between pulpitis and abscess: pulpitis is treatable by endodontic access with pulpectomy and there is no need for antibiotics. In presence of an abscess it is necessary to differentiate its origin between periapical or periodontal and decide how to drain it.
• Periapical abscess is treated according to its stages (firm or fluctuating), size, location and duration. Drainage through the root canal, drainage by incision and drain placement are important aspects of treatment of periapical abscesses.
• Periodontal abscess can be drained by three different ways depending on the size, location, duration and stage. Methods include :-
  • Drainage through the periodontal pocket.
  • Drainage by vertical incision.
  • Drainage by full flap.
  • All surgical drainages should be covered by systemic administration of antibiotics.

What the patient should do ?

• Rest.
• Drink water.
• Eat balanced meals.
• If eating solid food is not possible have soup or drink food supplements.
• Brush teeth.
• Use mouthwashes of warm water with salt take regular medications.
• Sleep with the head high.
• Take analgesics when needed.
• Follow recommendations of the doctor.
• Report any changes for the worse such as fever, increased pain, bleeding, dizziness, vomiting, reaction to the antibiotics and/or analgesics.

What the patient should not do is as follows:

• Do not smoke.
• Do not drink alcohol.
• Do not use recreational drugs.
• Do not forget to take antiretroviral or any other regular medications.
• Do not prematurely stop the use of antibiotics.
• Do not drink pop, do not eat spicy or hard food.
• Do not press or massage the inflamed area.
• Do not use heat over skin of the affected area.
• Do not exercise.
• Do not get exposed to extreme temperatures.
• Do not abuse analgesics.
• Do not take medication prescribed for another person.
• Do not use mouthwash containing alcohol.
• Do not use over the counter topical creams or waxes for pain.
• Do not keep aspirin or any other pain killer pill over the affected area.

Xerostomia

Dry mouth is without any doubt a major contributor to the development of secondary infections. This also increases severity of the primary diseases of the oral cavity.

• Xerostomia can have numerous causes; the most common being those induced by drugs, aging and radiation.
• The majority of patients with mild dry mouth do not know that they have a reduced flow of saliva.
• It is very easy to diagnose a very dry mouth, but it is not so in moderate cases.
• It is of extreme importance to have knowledge of evaluating the extent of dry mouth and the methods that are in use to evaluate salivary flow rate or volume.
• The examination of the major salivary gland duct openings should reveal abundant salivary flow.
• Reduction of salivary flow rate when caused by drugs is reversible, but caused by aging, infection and radiation is often irreversible.
• In HIV-positive patients, low volume of saliva is accompanied by chemical changes that affect its buffering qualities.
• This also creates an acidic environment in the oral cavity with devastating consequences for the dental and periodontal structures.
• The dry mouth with consequent bad taste and bad breath prompts the patient to use mouth washes, to increase frequency of smoking and drinking of alcohol and to use home remedies.
• "Over-the-counter" mouthwashes containing 2% alcohol as well as the use of hydrogen peroxide must be avoided. Short-term recall with frequent oral prophylaxis is necessary.