Chapter 7

Managing Immunocompromised Patients

Aim

The aim of this chapter is to describe the oral health problems that immunocompromised patients may present with and how to effectively plan treatment for this group.

Outcome

After reading this chapter you should be able to recognise the conditions that may lead to immunosuppression and those patients that are at risk, i.e. immunocompromised in relation to oral healthcare. You should be able to assess the preventive and prophylactic regimes that may be necessary to carry out a range of dental treatments, and longer-term care, for immunocompromised patients.

Introduction

Immunodeficient, immunosuppressed and immunocompromised are the common terms used to refer to patients whose immune system is not functioning optimally. In the context of this chapter:

• Immunodeficient describes any state where the immune system is functioning below the optimum level.

• Immunosuppression refers to artificially depressed immune systems; for example, caused by drugs used to control disease processes or prevent rejection of transplanted organs.

• Immunocompromised describes patients with a medical condition where their immune function is inherently poor, suppressed artificially or depressed due to illness and where they may be at significant risk of concurrent illness due to the reduced immune function.

The term “immunocompromised” has the most clinical relevance, indicating that the risks of any complications may be increased as a result of dental treatment. As immunocompromised, patients may have significantly reduced ability to cope with dental treatment. It is important to be able to recognise this group of patients and to have strategies in place that take account of their medical condition during dental treatment.

Immunocompromised patients can present with oral signs of poor immune function and be at risk of other conditions, with or without oral manifestations. For example, Kaposi’s sarcoma and pneumocystis carinii pneumonia in patients with HIV disease.

Conditions Leading to Immunodeficiency

There are many medical texts that describe the underlying histological faults that lead to the different types of immunodeficiency. The reader is referred to such texts for information on the pathological processes involved. However, in order to understand the clinical relevance of immunodeficiency some explanation of taxonomy is required as this relates to cause and presentation.

The simplest classification is to divide the causes into:

• innate or primary (congenital, genetic, internal or inherent)

• acquired or secondary (environmental or external) conditions.

Innate (Primary) Immunodeficiency States

Genetic immunodeficiency states are relatively uncommon and can be sex-linked or autosomal in inheritance. Defects can occur in any or all of the white cell lines and/or the complement system producing very variable clinical effects. For example in 2 X-linked conditions presentation can be quite different, in Wiskott-Aldrich syndrome there is deficient production of IgM and in Bruton’s disease any or all of the immunoglobulins may be deficient.

In Common Variable Immunodeficiency (CVID) there can be deficiencies in both B and T cell production resulting in defects in both “arms” of the immune system. In some cases cell numbers are normal, but cell maturation or production defects exist. Finally, a number of these conditions have defects in other blood cell lines, such as platelets resulting in clotting defects as well as issues relating to infection and healing.

The terminology can be confusing. In the conditions cited in Table 7-1, the immune deficiency is the primary or innate disease. There are other innate diseases that have “secondary” immunodeficiencies. Insulin-dependent diabetes mellitus and Down’s syndrome are two examples where the subject has an innate condition, of which immunodeficiency may be a part, but the immunodeficiency is not generally the main presenting feature.

Immunodeficiency in these conditions can be variable, ranging from insignificant (rendering it clinically imperceptible) to severe enough to produce “primary” symptoms. An example of the latter is the tendency towards advanced periodontal disease in people with diabetes and Down’s syndrome. The immunodeficiency is not “secondary” to the primary condition per se, but is intrinsically part of the condition.

Acquired (Secondary) Immunodeficiency States

A number of conditions can cause immunodeficiency. The classes of conditions that may exhibit immunodeficiency are:

• infectious diseases, e.g. HIV disease

• malignancies, e.g. Hodgkin’s disease and the leukaemias

• autoimmune diseases, e.g. systemic lupus erythematosus, rheumatoid arthritis

• nutritional deficiencies, e.g. iron and vitamin deficiencies

• other miscellaneous conditions, e.g. sickle cell disease, can lead to splenic hypofunction which in turn can lead to immunodeficiency; idiopathic thrombocytopaenic purpura may require splenectomy leading to immunodeficiency

• iatrogenic suppression (e.g. antirejection drug therapy) for solid (e.g. heart, kidney and liver) and non-solid (e.g. bone marrow) organ transplantation; auto-immune diseases, such as systemic lupus erythematosus, requiring drug-induced immune suppression as part of their management; some tumours and the leukaemias respond to immunosuppressive drug regimes. Dru/>

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