Clinical Scenario

A 50‐year‐old male presents at the end of the day complaining of increasing mobility of his lower anterior incisors. The teeth were splinted as a temporary measure during a period of acute illness but have recently become increasingly loose.

Structured Learning

1. The patient requests that you resplint his mobile lower teeth as he does not want them extracted. What would you advise?
   • There is generalised advanced bone loss, most advanced in relation to the lower incisors, with evidence of periapical infection of the lower central incisor teeth
   • Retaining these teeth poses a local and focal infection risk
   • Splinting may compromise adjacent teeth and will make cleaning and maintenance more problematic
   • Discuss with the patient his oral health priorities and tolerance for dental treatment given his recent period of ill health
   • If the patient is relatively stable, it is a good opportunity to undertake invasive dental treatment
2. Why is dental infection a particular concern for this patient?
   • Castleman disease: involves multiple regions of enlarged lymph nodes, flu‐like symptoms, abnormal blood counts and dysfunction of vital organs due to uncontrolled infection with human herpes virus 8 (HHV‐8), leading to excessive production of inflammatory cytokines
   • HIV positive: immunocompromised, i.e. CD4 glycoprotein found on the surface of immune cells, such as T helper cells, monocytes, macrophages and dendritic cells, is lower than normal range (500–1200 cells/μL)
   • Recent chemotherapy
   • Diabetes: poor mobilisation and phagocytosis of granulocytes, leucocyte adherence and bactericidal activity
   • Coronary stent: risk of focal infection of oral origin
3. What is the connection between multicentric Castleman disease (MCD) and HIV?
   • Persons with HIV are at increased risk of developing HHV‐8‐associated MCD
   • In some cases, MCD diagnosis may have led to HIV testing and subsequent positive diagnosis
4. Why is surveillance for oral cancer of particular importance in this patient?
   • Patients with HHV‐8‐associated MCD are at increased risk of developing Kaposi sarcoma and non‐Hodgkin lymphoma which may present in the mouth
   • The risk is compounded by the associated HIV‐positive diagnosis and recent immunosuppression with chemotherapy
5. The patient agrees to dental extraction of #41, #42, #31 and #32 but is concerned about bleeding excessively after the procedure. He reports that he did not stop bleeding for two days after the upper right canine (#13) spontaneously exfoliated one year ago. What could be contributing to his increased bleeding risk?
   • Local infection/inflamed tissue: the patient has active periodontal disease
   • Dual antiplatelet therapy
     • Patients taking clopidogrel, dipyridamole, prasugrel or ticagrelor single or dual therapy (in combination with aspirin) may present with prolonged bleeding compared to aspirin monotherapy
     • However, this is not clinically significant and can be controlled by local measures
   • Medical comorbidities associated with increased bleeding risk
     • Arterial hypertension
     • HIV: immune‐mediated thrombocytopenia
     • MCD: multiorgan involvement; possible impaired liver function
     • Chemotherapy: thrombocytopenia due to chemotherapy‐induced pancytopenia

6. Would you discontinue the antiplatelet therapy to enable dental extractions?
   • No – do not interrupt antiplatelet therapy prior to dental treatment
   • The invasiveness of the proposed procedure, other medical conditions and the patient’s other prescribed or non‐prescribed medications should be assessed and the relevant physician consulted if there are additional concerns
   • There are no significant differences in the occurrence or degree of excessive blood loss between patients on single or dual antiplatelet therapy compared with control subjects
   • Discontinuation of antiplatelet therapy can increase the risk of a thromboembolic event if the drug is stopped prior to surgery
   • A thromboembolic event is significantly more consequential (e.g. a stent thrombosis is a catastrophic event) whereas bleeding from the mouth is usually manageable by local haemostatic measures
   • Given the relative ease with which the incidence and severity of oral bleeding can be reduced with local measures during surgery, and the unlikely occurrence of bleeding once an initial clot has formed, there is no indication to interrupt antiplatelet drugs for dental procedures
7. What additional factors do you need to consider in your risk assessment?
   • Social
     • Depression associated with multiple medical comorbidities
     • Impact of losing front teeth on social interaction and confidence
     • Limited social support to enable self‐ and oral care
     • Stigma and social discrimination experienced by many HIV‐positive patients may potentially result in concerns about privacy and access to dental services
   • Medical (see Chapters 4.2, 5.1 and 12.2)
     • Potentially increased bleeding risk due to dual platelet therapy, HIV, MCD, chemotherapy
     • History of myocardial infarction
     • Blood pressure control
     • Comorbidity associated with type 2 diabetes mellitus (e.g. blood glucose control)
     • MCD organ involvement
     • Recent chemotherapy
     • HIV (e.g. opportunistic infection risk, sharps injury, possible drug‐ and immune‐mediated thrombocytopenia)
   • Dental
     • Periodontal disease may be exacerbated in diabetes and HIV infection, and there is a possible association with cardiovascular disease
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