Isabel Rambob, DDS Assistant Professor University of Maryland School of Dentistry

Transcription

1 Isabel Rambob, DDS Assistant Professor University of Maryland School of Dentistry

2 Sponsor Accreditation: Howard University College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credits for Physicians: Howard University College of Medicine, Office of Continuing Medical Education, designates this live activity for a maximum of 0.5 AMA PRA Category I Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Funded by Health Resources Services Administration (HRSA) Grant #H4AHA24081 Goulda A. Downer, PhD, RD, LN, CNS Principal Investigator/Project Director

3 AETC-Capitol Region Telehealth Project Planning Committee : The following committee members have nothing to disclose in relation to this activity: Keith W. Crawford, RPH, PhD I. Jean Davis, PhD, PA, AAHIVS Goulda A. Downer, PhD, RD, LN, CNS John I. McNeil, MD Denise Bailey, M.Ed Marjorie Doulas-Johnson, BA Speaker: The following speaker has nothing to disclose in relation to this activity: Isabel Rambob, DDS

4 Intended Audience: Low volume clinicians (i.e. those with fewer than 25 patients in their case load who are HIV positive): Physicians, Physician Assistants, Nurse Practitioners, Pharmacists, Dentists, Nurses, Social Workers, Case Managers and other Clinical Personnel. Webinar Requirements: A computer, phone, etc. with Internet accessibility and a telephone line. Your presence on the call must be acknowledged at the start of each session. Please log in for the session announce your name loud and clear at the beginning of the session. You will not be able to receive CME credits if you leave the session early. At the end of the Webinar our Training Coordinator will a CME Evaluation Survey. All participants are required to complete and return the CME Evaluation Survey at the end of each session. It may be scanned and ed back to mdouglas@howard.edu, or faxed to: AETC-Capitol Region Telehealth Project (FAX#: ) ATTN: Training Coordinator. Please indicate in your or FAX if you would like to receive a certificate of credit.

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6 A person with latent TB is infectious and therefore should not be treated in the dental office: A. True B. False

7 According to guidelines from CDC all individuals newly diagnosed with HIV infection should be promptly tested for TB: A. True B. False

8 What is the most common oral condition associated to TB infection: A. Dry mouth B. Periodontal disease C. Tooth sensitivity D. Ulcer on the lateral border of the tongue

9 People who have both HIV infection and latent TB infection are 20 to 30 times as likely to develop active TB disease as those who do not have HIV infection: A. True B. False

10 Isabel Rambob, DDS Assistant Professor University of Maryland School of Dentistry

11 At the end of Part 1 of this webinar the participating providers will have an enhanced ability to: Describe the impact of HIV, TB and Tobacco use on the oral health of people living with HIV/AIDS. Discuss the importance of multidisciplinary health teams in the oral care for people living with HIV/AIDS. Discuss concrete steps that clinicians can take to promote positive behavioral health changes in patients living with HIV/AIDS.

12 HIV, TB and smoking has a direct impact in the oral health. The proportion of individuals living with HIV/AIDS who are current cigarette smokers is between 47%-65%. Tobacco use in persons who are HIV+ is responsible for increased periodontal disease and tooth loss. Multidisciplinary approach is necessary to reduce the impact of these conditions.

13 Christina, a 32 year-old Caucasian woman who is an IV drug user, has recently been diagnosed as HIV+. Her medical history also includes: pneumonia, mild COPD, hepatitis C and depression. She is currently taking dapsone, norvir, epsicom, combivir and Cymbalta. Baseline January 2014 laboratory data included HIV VL of 3, 450 copies/ml and CD4 count of 450 cells/mm 3. She has been coughing up blood, and has been loosing weight. She was diagnosed with periodontitis 3 weeks ago during her routine dental appointment.

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15 Should the diagnosis of TB (either latent infection or active disease) be on the radar screens of health practitioners?

16 Diagnosis delay and non-completion of treatment are two central behavioral challenges for TB control. Patients are expected to seek care and complete treatment. Health care providers are expected to perform successfully a number of actions, including offering sputum smear examination to patients, conducting tests adequately, and monitoring medicine intake. Success in TB detection and treatment requires specific behaviors from patients and health care providers within contexts that facilitate those practices.

17 HIV has added a new face to respiratory disease with increased rates of TB and pneumonia.

18 Currently, more than 1.1 million people in the United States are living with HIV infection, and almost 1 in 6 (15.8%) are unaware of their infection. In 2011, 82% of patients with TB disease knew their HIV status.

19 Among 8,683 people with TB disease who had a documented HIV test result in 2011, 6% were coinfected with HIV. In 2011, the rate of incident TB cases was 12 times as greater for foreign-born that United States-born individuals. Among US-born racial and ethnic groups, non- Hispanic blacks had a rate six times that of non- Hispanic whites.

20 People who have both HIV infection and latent TB infection (LTBI) are 20 to 30 times as likely to develop active TB disease as those who do not have HIV infection.

21 All individuals newly diagnosed with HIV infection should be immediately tested for TB.

22 PWID are at significant risk for both HIV & TB, and active IDU negatively impacts treatment access, adherence and retention. Combined ART and OST have improved ART access, adherence and treatment outcomes among HIV and HIV HCV co-infected PWID. Given the high prevalence of HCV among PWID and the risk of hepatotoxicity associated with TB prevention and treatment, incorporation of HCV care is also vital to improving the quality of integrated healthcare for PWID. Grenfell et al Drug and Alcohol Dependence 2013,129:

23 Regional tracking of changes in behavioral risk will be necessary to identify settings, subpopulations, and geographical regions with special risk for seroconversion to HIV+ status. The HIV epidemic in US is currently shifting to young people. It is important to establish interventions for youth at an earlier age before the onset of risk behavior (sexual activity and drug use).

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25 Christina, a 32 year-old Caucasian woman who is an IV drug user, has recently been diagnosed as HIV+. Her medical history also includes: pneumonia, mild COPD, hepatitis C and depression. She is currently taking dapsone, norvir, epsicom, combivir and Cymbalta. Baseline January 2014 laboratory data included HIV VL of 3, 450 copies/ml and CD4 count of 450 cells/mm 3. She has been coughing up blood, and has been loosing weight. She had a dental appointment 3 weeks ago and was informed she has periodontitis.

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28 All individuals newly diagnosed with HIV infection should be tested for TB ASAP. PWID are at increased risk of TB. TB is particularly dangerous for people with HIV infection. People who have both HIV infection and latent TB infection (LTBI) are 20 to 30 times as likely to develop active TB disease as those who do not have HIV infection. Christina is presenting with some of TB symptoms: She has been coughing up blood, and has been loosing weight. Integrated HIV and TB services are critical to timely diagnosis and treatment of LTBI and TB-related health outcomes in PLHIV.

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30 If urgent dental care must be provided for a patient who has suspected or confirmed infectious TB disease, dental care should be provided in a setting that meets the requirements for an Airborne Infection Isolation (AII) room. Respiratory protection (at least N95 disposable respirator) should be used while performing procedures on such patients. Non-urgent dental treatment should be postponed, and these patients should be promptly referred to an appropriate medical setting for evaluation of possible infectiousness. In addition, these patients should be kept in the dental health-care setting no longer than required to arrange a referral. Because a person with latent TB is not infectious, he or she can be treated in the dental office under standard infection control precautions.

31 HIV & Dental Treatment: PLHIV are more at risk to gingivitis and periodontal disease and may also face more rapid and severe forms of these conditions. Dry mouth, a common side effect of HIV/AIDS, increases the risk of caries and may make chewing, swallowing and talking difficult. More than 1/3 of PLHIV have oral conditions related to their weakened immune systems.

32 HCV & Dental Treatment: Approximately 3.2 million Americans are infected with HCV. Chronic HCV increases the risk of developing serious liver disease such as cirrhosis and cancer. Poor dental health is a rising problem among people living with hepatitis C. Hepatitis C is associated with a wide range of dental problems ranging from dry mouth, caries, periodontal disease and tooth sensitivity which can dramatically affect one s quality of life. Patients with liver disorders are of significant interest to the dentist because liver plays a vital role in metabolic function.

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34 Any patient with symptoms suggestive of active TB disease should be assessed for the urgency of their dental care and promptly referred for medical care. Elective dental treatment should be deferred until the patient has been declared non-infectious by her physician. Chlorhexidine rinse should be prescribed. Once patient has been declared non-infectious by her physician periodontal treatment should be initiated as soon as possible. Ideally patient should be placed in a 3-4 month recall regimen.

35 Successful TB control requires specific behaviors from patients and health providers as well as a conducive environment that facilitates those behaviors. Behavioral assessments of factors that cause diagnosis delay and poor treatment adherence in TB management are needed to plan behavior change. Behavioral interventions to reduce risk for HIV/AIDS are effective and should be disseminated widely.

36 Altice,. F.L., Kamarulzaman, A., Soriano, V.V., Schechter, M., Friedland, G.H.Treatment of medical, psychiatric, and substance-use comorbidities in people infected with HIV who use drugs. Lancet 2010, 376: CDC. HIV and Tuberculosis. March CDC. HIV/AIDS Surveillance Report vol CDC. The Tuberculosis Behavioral and Social Science Research Forum Proceedings. September Grenfell P, Leite R, Garfein R, Lussigny S, Platt L, Rhodes T. Tuberculosis, injecting drug use and integrated HIV-TB care: A review of the Literature. Drug and Alcohol Dependence 2013,129: Van Zyl-Smit RN, Pai M, Yew WW, Leung CC, Zumla A, Bateman ED, Dheda K: Global lung health: the colliding epidemics of tuberculosis, tobacco smoking, HIV, and COPD. Eur Respir J 2010, 35: Van Zyl-Smit RN, Brunet L, Pai M, Yew WW. The convergence of the global smoking, COPD, Tuberculosis, HIV, and respiratory infection epidemics. Infect Dis Clin North Am September ; 24(3):

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38 A person with latent TB is infectious and therefore should not be treated in the dental office: A. True B. False

39 According to guidelines from CDC all individuals newly diagnosed with HIV infection should be promptly tested for TB: A. True B. False

40 What is the most common oral condition associated to TB infection: A. Dry mouth B. Periodontal disease C. Tooth sensitivity D. Ulcer on the lateral border of the tongue

41 People who have both HIV infection and latent TB infection are 20 to 30 times as likely to develop active TB disease as those who do not have HIV infection: A. True B. False

42 Howard University HURB th Street NW, 2 nd Floor Washington, DC (Office) (Fax) As a Reminder: At the end of the Webinar, All participants are required to complete and return the CME Evaluation Survey. It may be scanned and ed back to mdouglas@howard.edu, or faxed to: AETC-Capitol Region Telehealth Project (FAX#: ) ATTN: Training Coordinator. Please indicate in your or FAX if you would like to receive CMEs.