- Email: [email protected]
Swine flu
cephalosporins, metronidazole, clindamycin, fluoroquinolones, and macrolides. Penicillin is the first-line choice for odontogenic infections. Amoxicillin has a broader spectrum of activity than penicillin V, but no better coverage. Patients tend to be more compliant with its use, however. The cephalosporins are not first-line treatment, but are used for sinus communications and antibiotic prophylaxis in patients with prosthetic joints. Metronidazole is effective against anaerobic bacteria and should be used along with penicillin. Concern over penicillin resistance has increased the use of clindamycin, which inhibits bacterial protein synthesis and is bactericidal in high dosages. Because of the high rate of penicillin resistance among hospital patients, clindamycin may be appropriate in this setting and for patients who are allergic to penicillin. It is effective against grampositive cocci and anaerobic bacteria. Fluoroquinolones have excellent bacterial coverage for odontogenic infections, but are broad-spectrum agents that are quite costly and should be reserved for second-line therapy. Erythromycin is the most commonly used macrolide. Its spectrum of activity is similar to that of penicillin V. Erythromycin resistance is becoming more common and its use may be considered historic with respect to odontogenic infections. Referral of a patient for a severe infection must be considered. If the patient has fever, stridor, odynophagia, rapid progression, and the involvement of multiple spaces and
secondary anatomic areas, he or she should be sent to an oral and maxillofacial surgeon. Discussion.—The prompt diagnosis and treatment of odontogenic infections are common situations for a dentist. The causative factor should be removed and antibiotics given as indicated. The current best treatment is penicillin plus metronidazole. Patients with severe infections should be referred to an oral and maxillofacial surgeon.
Clinical Significance.—The best way to address odontogenic infections is to remove the source of the infection, which is often a tooth. Then other management can be considered. The rising incidence of penicillin resistance or erythromycin resistance curtails the use of these agents somewhat. Dentists should be able to evaluate the situation and determine an appropriate course of action in most cases. Occasionally a more serious infection must be referred.
Gregoire C: Point of care. How are odontogenic infections best managed? J Can Dent Assoc 76:114-116, 2010 Reprints available from C Gregoire; e-mail: [email protected]
Oral Medicine Swine flu Background.—The swine-origin H1N1 influenza A virus (S-OIV) has spread faster than any previously identified virus worldwide. As of November 2009, there were more than 500,000 confirmed patients and at least 6200 deaths. The data specific to S-OIV and dental practice were reviewed to develop clinical practice guidelines for dental practices. Methods.—PubMed/Medline, Embase, and Google Scholar were searched for relevant material published up to November 2009. Virology and Historical Data.—The influenza A viruses are single-stranded, negative-sense RNA viruses, with eight genome segments encapsulated by a lipid bilayer containing hemagglutinin and neuraminidase glycoproteins. The surface proteins are both key antigens targeted by human
310
Dental Abstracts
humoral immunity to subtype the virus. All subtypes are found in aquatic wildfowl, with H1 and H3 also found in pigs. Six serotypes infect humans. The H1N1 influenza virus caused a highly contagious outbreak in 1918, which was called the Spanish flu. To date this virus remains endemic in pigs. Infected and asymptomatic carrier pigs transmit H1N1, H3N2, and H1N2 viruses to other hosts. The transmission of classical swine H1N1 virus can occur, causing flu-like illness and a mortality of 17%. In the United States, the vaccine against this virus developed previously carried a risk of Guillain– Barre syndrome and was discontinued. The new virus emerged at an unknown time and place, but evolutionary analysis reveals that multiple reassortment of the viral lineages may have taken place 9.2 to 17.2 years
Dental patients
A suspected or confirmed case of swine-origin H1N1 influenza Yes
No
Routine dental treatment
Urgent dental treatment needed No
Postpone dental treatment (at least 7 days after symptoms resolve)
Advise to seek appropriate medical care
Yes
- Patients: placed in a singlepatient room; a disposable surgical mask, towel paper and non-touch receptacle offered - Room: airborne infection isolation with negative air handling (in case of aerosolgenerated procedures), routine cleaning and disinfection - Dental staff: personal protection (a ‘fit-tested’ respirator, eye protection, gown, gloves), improved hand hygiene - Avoid prescribing NSAIDs
Fig 1.—Dental management of suspected or confirmed cases of swine-origin H1N1 influenza on the basis of the recommendations of the California Dental Association and the US Centers for Disease Control and Prevention. (Courtesy of Pitak-Arnnop P, Schubert S, Dhanuthai K, et al: Swine-origin H1N1 influenza A virus and dental practice: A critical review. Clin Oral Invest 14:11-17, 2010.)
before this outbreak. S-OIV differs genetically from previous swine and human influenza isolates, having been derived from four lineages. Sufficient data on the genetic interactions between viral and host factors have not yet been obtained. Because humans do not have a lifelong immunity to influenza A, the disease has a pandemic potential. The current S-OIV strain demonstrates significant alterations in surface antigens and amino acid sequences from the previous H1N1 isolates. Data correlating age and infection suggest that the H1N1 viruses circulating in humans before 1950 are more homologous to classic swine H1N1 viruses and S-OIV than to seasonal H1N1 viruses. Clinical Findings.—Droplet and contact spread are the main modes of transmission of S-OIV infection. The incubation period is 2 to 7 days. The median age of affected patients in the United States is 20 years. Diagnosis is
problematic because there are no disease-specific symptoms. Common symptoms are fever, cough, and sore throat, although patients also complain of headache, fatigue, rhinorrhea, chills, myalgia, nausea, abdominal pain, diarrhea, vomiting, shortness of breath and joint pain. Most symptoms are self-limiting. In the United States and Mexico, young age was associated with increased morbidity and mortality in the initial phase. Generally the disease is mild, resolves spontaneously, and lasts a short time. However, patients at high risk can develop significant complications, with many deaths related to severe pneumonia with multifocal infiltrates and rapid progression to severe sepsis with multi-organ system failure. Young to middle-aged persons who were previously healthy can develop severe illness and die, usually as a result of delayed hospitalization and delayed initiation of antiviral therapy. The virus cannot be differentiated from the seasonal influenza virus using antigen detection tests, with diagnosis of S-OIV depending on viral nucleic acid detection in specimens from nose
Volume 55
Issue 6
2010
311
or throat swabs or a combination of both. World Health Organization (WHO) recommendations indicate three confirmation methods: specific reverse-transcriptasepolymerase-chain-reaction testing to distinguish S-OIV from seasonal virus, isolation and identification of S-OIV, or detection of a fourfold increase in neutralization or hemagglutination inhibition test for antibodies to S-OIV. In areas where transmission has not been established, anyone with acute febrile respiratory illness should be tested for S-OIV. In endemic areas, only severely unwell persons, those at risk for complications, or those working with vulnerable populations need to undergo testing.
surgical mask, paper towels, and no-touch receptacles; postponing elective dental procedures; and advising patients to seek medical care. Viral transmission extends for 7 days after symptom resolution. If urgent dental care is needed, the patient should be treated in an airborne infection isolation room with negative-pressure air handling with 6 to 12 changes per hour. If the dental procedures are high risk and likely to generate aerosols, the attending dental staff should use personal protection equipment (PPE): a fit-tested disposable respirator, eye protection, impervious gown, and gloves. Self-inoculation should be avoided when removing the PPE.
Treatment and Prevention.—Early treatment is recommended. Both M2 proton channel blockers and neuraminidase inhibitors are effective against S-OIV. The decision to begin treatment depends on disease prevalence in the area, history of contact, characteristics of the illness, presence of complications, comorbidity and risk factors, onset of illness, availability of antiviral agents, and healthcare policy. WHO guidelines suggest that antivirals be given within 72 hours of symptom onset in patients who exhibit the following: shortness of breath, hypoxia, or fast or labored breathing in children; altered mental state, unconsciousness, drowsiness, and seizures; evidence of sustained virus replication or invasive secondary bacterial infection; or severe dehydration. The mass use of antiviral drugs could lead to the emergence of more antiviral-resistant variants. Agents that have proved useful include oseltamivir, zanamivir for patients infected with oseltamivir-resistant influenza viruses, appropriate antibiotics for secondary bacterial infections, and peramivir for hospitalized patients with antiviral-resistant S-OIV strains.
Other precautions include maintaining an arm’s length from other persons, hand washing with antimicrobial soap and water, use of an alcohol-based hand rub or antiseptic handwash after contact with respiratory secretions and contaminated objects or materials, and routine cleansing and disinfection. When transmission has been established in an area, chemoprophylaxis and early treatment of symptomatic dental staff are advisable. Nonsteroidal antiinflammatory drugs may enhance viral virulence, aggravate symptoms, and contribute to subsequent multi-organ failure, so these should be avoided until evidence proves them safe. Patients with a compromised immune response or prolonged illness may be further compromised by antipyretic agents.
All bodily fluids should be considered infective until evidence proves otherwise. Disease transmission among household contacts can be avoided by wearing surgical face masks and washing the hands frequently. S-OIV vaccines are available and recommended for high-risk groups, such as children age 5 years or younger, adults age 60 years or older, children and adolescents who take aspirin for a long term and are at risk for Reye’s syndrome after influenza, and those with underlying disease. People who are exposed occupationally, such as swine workers and healthcare providers, run a higher risk for infection and should also be immunized. Guidelines for Dental Practitioners.—As for any disease, strict adherence to infection control procedures is essential. The California Dental Association and Centers for Disease Control and Prevention have provided guidelines for dental practitioners (Fig 1). These suggest the following: early detection of known or suspected cases; placement in a private room with the door closed; offering a disposable
312
Dental Abstracts
Clinical Significance.—Humans do not have a natural immunity to S-OIV infection and the virus is readily spread through droplets and contact. Symptoms are nonspecific, so it is likely that some dental patients will come for treatment who are infected with this virus. Therefore, as with all infectious threats, the dental office must be vigilant about following infection control practices to protect not just patients but themselves from exposure. Prophylactic measures should be instituted, including vaccination against the virus. Should dental staff members become ill, early viral therapy is recommended.
Pitak-Arnnop P, Schubert S, Dhanuthai K, et al: Swine-origin H1N1 influenza A virus and dental practice: A critical review. Clin Oral Invest 14:11-17, 2010 Reprints available from P Pitak-Arnnop, Klinik und Poliklinik f€ ur Mund-, Kiefer- und Plastische Gesichtschirurgie, Universit€atsklini€R, N€ kum Leipzig Ao urnberger Str 57, 04103 Leipzig, Germany; e-mail: [email protected]
secondary anatomic areas, he or she should be sent to an oral and maxillofacial surgeon. Discussion.—The prompt diagnosis and treatment of odontogenic infections are common situations for a dentist. The causative factor should be removed and antibiotics given as indicated. The current best treatment is penicillin plus metronidazole. Patients with severe infections should be referred to an oral and maxillofacial surgeon.
Clinical Significance.—The best way to address odontogenic infections is to remove the source of the infection, which is often a tooth. Then other management can be considered. The rising incidence of penicillin resistance or erythromycin resistance curtails the use of these agents somewhat. Dentists should be able to evaluate the situation and determine an appropriate course of action in most cases. Occasionally a more serious infection must be referred.
Gregoire C: Point of care. How are odontogenic infections best managed? J Can Dent Assoc 76:114-116, 2010 Reprints available from C Gregoire; e-mail: [email protected]
Oral Medicine Swine flu Background.—The swine-origin H1N1 influenza A virus (S-OIV) has spread faster than any previously identified virus worldwide. As of November 2009, there were more than 500,000 confirmed patients and at least 6200 deaths. The data specific to S-OIV and dental practice were reviewed to develop clinical practice guidelines for dental practices. Methods.—PubMed/Medline, Embase, and Google Scholar were searched for relevant material published up to November 2009. Virology and Historical Data.—The influenza A viruses are single-stranded, negative-sense RNA viruses, with eight genome segments encapsulated by a lipid bilayer containing hemagglutinin and neuraminidase glycoproteins. The surface proteins are both key antigens targeted by human
310
Dental Abstracts
humoral immunity to subtype the virus. All subtypes are found in aquatic wildfowl, with H1 and H3 also found in pigs. Six serotypes infect humans. The H1N1 influenza virus caused a highly contagious outbreak in 1918, which was called the Spanish flu. To date this virus remains endemic in pigs. Infected and asymptomatic carrier pigs transmit H1N1, H3N2, and H1N2 viruses to other hosts. The transmission of classical swine H1N1 virus can occur, causing flu-like illness and a mortality of 17%. In the United States, the vaccine against this virus developed previously carried a risk of Guillain– Barre syndrome and was discontinued. The new virus emerged at an unknown time and place, but evolutionary analysis reveals that multiple reassortment of the viral lineages may have taken place 9.2 to 17.2 years
Dental patients
A suspected or confirmed case of swine-origin H1N1 influenza Yes
No
Routine dental treatment
Urgent dental treatment needed No
Postpone dental treatment (at least 7 days after symptoms resolve)
Advise to seek appropriate medical care
Yes
- Patients: placed in a singlepatient room; a disposable surgical mask, towel paper and non-touch receptacle offered - Room: airborne infection isolation with negative air handling (in case of aerosolgenerated procedures), routine cleaning and disinfection - Dental staff: personal protection (a ‘fit-tested’ respirator, eye protection, gown, gloves), improved hand hygiene - Avoid prescribing NSAIDs
Fig 1.—Dental management of suspected or confirmed cases of swine-origin H1N1 influenza on the basis of the recommendations of the California Dental Association and the US Centers for Disease Control and Prevention. (Courtesy of Pitak-Arnnop P, Schubert S, Dhanuthai K, et al: Swine-origin H1N1 influenza A virus and dental practice: A critical review. Clin Oral Invest 14:11-17, 2010.)
before this outbreak. S-OIV differs genetically from previous swine and human influenza isolates, having been derived from four lineages. Sufficient data on the genetic interactions between viral and host factors have not yet been obtained. Because humans do not have a lifelong immunity to influenza A, the disease has a pandemic potential. The current S-OIV strain demonstrates significant alterations in surface antigens and amino acid sequences from the previous H1N1 isolates. Data correlating age and infection suggest that the H1N1 viruses circulating in humans before 1950 are more homologous to classic swine H1N1 viruses and S-OIV than to seasonal H1N1 viruses. Clinical Findings.—Droplet and contact spread are the main modes of transmission of S-OIV infection. The incubation period is 2 to 7 days. The median age of affected patients in the United States is 20 years. Diagnosis is
problematic because there are no disease-specific symptoms. Common symptoms are fever, cough, and sore throat, although patients also complain of headache, fatigue, rhinorrhea, chills, myalgia, nausea, abdominal pain, diarrhea, vomiting, shortness of breath and joint pain. Most symptoms are self-limiting. In the United States and Mexico, young age was associated with increased morbidity and mortality in the initial phase. Generally the disease is mild, resolves spontaneously, and lasts a short time. However, patients at high risk can develop significant complications, with many deaths related to severe pneumonia with multifocal infiltrates and rapid progression to severe sepsis with multi-organ system failure. Young to middle-aged persons who were previously healthy can develop severe illness and die, usually as a result of delayed hospitalization and delayed initiation of antiviral therapy. The virus cannot be differentiated from the seasonal influenza virus using antigen detection tests, with diagnosis of S-OIV depending on viral nucleic acid detection in specimens from nose
Volume 55
Issue 6
2010
311
or throat swabs or a combination of both. World Health Organization (WHO) recommendations indicate three confirmation methods: specific reverse-transcriptasepolymerase-chain-reaction testing to distinguish S-OIV from seasonal virus, isolation and identification of S-OIV, or detection of a fourfold increase in neutralization or hemagglutination inhibition test for antibodies to S-OIV. In areas where transmission has not been established, anyone with acute febrile respiratory illness should be tested for S-OIV. In endemic areas, only severely unwell persons, those at risk for complications, or those working with vulnerable populations need to undergo testing.
surgical mask, paper towels, and no-touch receptacles; postponing elective dental procedures; and advising patients to seek medical care. Viral transmission extends for 7 days after symptom resolution. If urgent dental care is needed, the patient should be treated in an airborne infection isolation room with negative-pressure air handling with 6 to 12 changes per hour. If the dental procedures are high risk and likely to generate aerosols, the attending dental staff should use personal protection equipment (PPE): a fit-tested disposable respirator, eye protection, impervious gown, and gloves. Self-inoculation should be avoided when removing the PPE.
Treatment and Prevention.—Early treatment is recommended. Both M2 proton channel blockers and neuraminidase inhibitors are effective against S-OIV. The decision to begin treatment depends on disease prevalence in the area, history of contact, characteristics of the illness, presence of complications, comorbidity and risk factors, onset of illness, availability of antiviral agents, and healthcare policy. WHO guidelines suggest that antivirals be given within 72 hours of symptom onset in patients who exhibit the following: shortness of breath, hypoxia, or fast or labored breathing in children; altered mental state, unconsciousness, drowsiness, and seizures; evidence of sustained virus replication or invasive secondary bacterial infection; or severe dehydration. The mass use of antiviral drugs could lead to the emergence of more antiviral-resistant variants. Agents that have proved useful include oseltamivir, zanamivir for patients infected with oseltamivir-resistant influenza viruses, appropriate antibiotics for secondary bacterial infections, and peramivir for hospitalized patients with antiviral-resistant S-OIV strains.
Other precautions include maintaining an arm’s length from other persons, hand washing with antimicrobial soap and water, use of an alcohol-based hand rub or antiseptic handwash after contact with respiratory secretions and contaminated objects or materials, and routine cleansing and disinfection. When transmission has been established in an area, chemoprophylaxis and early treatment of symptomatic dental staff are advisable. Nonsteroidal antiinflammatory drugs may enhance viral virulence, aggravate symptoms, and contribute to subsequent multi-organ failure, so these should be avoided until evidence proves them safe. Patients with a compromised immune response or prolonged illness may be further compromised by antipyretic agents.
All bodily fluids should be considered infective until evidence proves otherwise. Disease transmission among household contacts can be avoided by wearing surgical face masks and washing the hands frequently. S-OIV vaccines are available and recommended for high-risk groups, such as children age 5 years or younger, adults age 60 years or older, children and adolescents who take aspirin for a long term and are at risk for Reye’s syndrome after influenza, and those with underlying disease. People who are exposed occupationally, such as swine workers and healthcare providers, run a higher risk for infection and should also be immunized. Guidelines for Dental Practitioners.—As for any disease, strict adherence to infection control procedures is essential. The California Dental Association and Centers for Disease Control and Prevention have provided guidelines for dental practitioners (Fig 1). These suggest the following: early detection of known or suspected cases; placement in a private room with the door closed; offering a disposable
312
Dental Abstracts
Clinical Significance.—Humans do not have a natural immunity to S-OIV infection and the virus is readily spread through droplets and contact. Symptoms are nonspecific, so it is likely that some dental patients will come for treatment who are infected with this virus. Therefore, as with all infectious threats, the dental office must be vigilant about following infection control practices to protect not just patients but themselves from exposure. Prophylactic measures should be instituted, including vaccination against the virus. Should dental staff members become ill, early viral therapy is recommended.
Pitak-Arnnop P, Schubert S, Dhanuthai K, et al: Swine-origin H1N1 influenza A virus and dental practice: A critical review. Clin Oral Invest 14:11-17, 2010 Reprints available from P Pitak-Arnnop, Klinik und Poliklinik f€ ur Mund-, Kiefer- und Plastische Gesichtschirurgie, Universit€atsklini€R, N€ kum Leipzig Ao urnberger Str 57, 04103 Leipzig, Germany; e-mail: [email protected]