9.6 - Immune Suppressed Patient Guidelines

The Health and Safety Committee develops guidelines that provide the criteria for the treatment of immune-suppressed patients.  These guidelines as well as clinic workflows can be found in axiUm Links in the Clinic Binder section. 

CRITICAL LAB TEST VALUES - Results are only valid for 6 months from the lab result date. The patient will need to have new labs completed once the results are > 6 months old.

Complete Blood Count W or W/O Differential:

• White Blood Cell: count <2000 consider premedication with an AHA regimen for invasive procedures or delay elective procedures
• Absolute Neutrophil: (ANC) ≥750 - <1,000/cc-consider premed for invasive procedures to prevent any infection with the regimen.
• Platelets:
  • ≥50,000: no contraindications
  • >20,000 - <50,000: minor treatment including endodontic and restorative treatment
  • ≤20,000: NO TREATMENT!
• Hemoglobin: ≥ 8 g/dL
• Blood Glucose: ≤ 200 mg/dL

CD4 Count – Considerations:

• A normal CD4 count ranges from 500–1,500 cells/mm³.
• Conventional wisdom says there is no level at which dental care cannot be done.

HIV-1 RNA Viral Load - Considerations:

• Does not have an impact on dental treatment planning, modifications would be based on the critical lab values.
• The viral load trends and is usually checked at 3- to 6-month intervals unless the patient is introduced to a new medication and then 2- to 8-weeks post-initial therapy.
• Viral load and CD4 count have a strong association, as one goes up the other goes down.

INR- International Normalized Ratio (prothrombin time):

• As with any patient taking blood thinners, an INR of 2.5-3.5 is ideal for most dental treatments. Full mouth extractions, periodontal surgery, etc. ~ 3.0 or physician consult.
• If planning an invasive procedure, INR should be checked within 24 hours prior to the procedure.

Dental Device Considerations:

• HIV/AIDS: ultrasonic scalers that generate aerosols are okay to use excluding no other respiratory complications i.e., COPD, TB, uncontrolled asthma. Evidence shows a reduced risk of potential exposure to the health care worker with an ultrasonic scaler VS traditional hand instruments that have blades. HIV/AIDS must have blood components for transmission.
• Lasers and electro surge: Contraindicated with patients who present with herpes simplex virus in vesicular stage (HSV) and human papillomavirus (HPV). No evidence exists of aerosolization or inhalation with HIV or HBV. Follow all recommended precautions with lasers. 

Follow Standard Precautions:

• Use standard precautions when working with any patient; everyone is treated the same.
• PPE: All required PPE used with blood and OPIMs for treatment, gown, mask, eyewear, and gloves

Good Clinical Judgment:

Use the above recommendations as general guidelines. This will ensure their safest and most efficient dental care.

References:

Maria Flores, DDS and Peter L. Jacobsen, Ph.D., DDS; Pacific Protocols for the Dental Management of Patients with HIV Disease, 2007

Little, James W, Falace, Donald A.; Dental Management of the Medically Compromised Patient 8^th edition

www.hivdent.org

www.cdc.org

Ryan White (RW) patients receive comprehensive dental care at OUCOD. This program is funded by Federal and State governments through grants. All the patient’s needs are taken care of except for the following:

1. Cosmetic Dentistry
2. Orthodontic Treatment
3. Implant Dentistry
4. Full Gold Crowns

New RW Patient Protocol:

OU Health Infectious Disease Institute (IDI) refers the potential RW patients to be screened to the OUCOD. The OUCOD will adhere to the following protocol:

1. IDI will send the patient’s information and initial bloodwork to the QA staff.
2. The QA staff will create a patient chart in axiUm and upload the initial lab results.
3. The Communications Center schedules the initial screening appointment.
4. If the patient is accepted into the predoctoral program, they will be assigned to a student.
5. The Communications Center will schedule the initial workup appointment.
6. Students (DS and DH) will work closely with faculty to complete comprehensive dental treatment.

Existing RW Patient Protocol:

All RW patients must have updated labs within their axiUm chart before receiving treatment. The lab results must be dated within six months of each treatment appointment. If labs are older than six months, they are considered expired. The patient should be contacted, by the student, to have new labs drawn.

1. For ongoing treatment, the Grant Coordinator will generate an axiUm report for all RW patients with appointments scheduled.
2. If the patient has current labs in the OUH chart, the labs will be uploaded into the patient's axiUm chart.
3. If the labs are expired, the assigned student should contact the patient at least five days before the appointment to instruct the patient to have new labs drawn.
4. It is the patient's responsibility to contact the IDI clinic, by calling 405-271-6434, to request that a lab script be sent to the OU Health lab so that necessary labs can be drawn. 
   • The COD does not submit lab scripts to the lab for RW patients.
   • The COD does not call the RW patient's physician to request lab scripts for our patients.
5. The COD requires the following lab results:
   1. Complete Blood Count With (or without) Differential
   2. HIV-1 RNA Viral Load
   3. CD4 Count
6. If all labs are not available, the student should discuss with the faculty to determine if treatment can continue or if all labs are required.

Labs Not in Chart:

If an RW patient is being seen for an emergency or placed on the schedule for treatment in less than five days, and the RW labs are expired in the patient's axiUm chart, the student should contact the Grant Coordinator to request a search for updated labs. From their OUHSC email account (to prevent a HIPAA violation), send an email to andrea-adams@ouhsc.edu or call extension 45444 (if calling from a COD phone) to request a search of the patient's OU Health EMR for current labs to upload into axiUm. The information needed is: 

• RW Patient’s Name
• Patient’s DOB
• Patient’s axiUm chart number
• Date of the scheduled appointment

If current labs are available within the patient’s EMR, they will be uploaded into the patient's axiUm chart. If labs are not present, the student will then need to contact the patient to have labs drawn. The appointment may need to be rescheduled.

• The COD faculty should assist students with interpreting lab results.