Rabu, 28 Agustus 2013

Herpes Simplex Infections

Herpes simplex virus
A range of infections, mainly viral, can produce oral blistering, but most patients present with ulceration after the blisters break. Herpesviruses are frequently responsible (Figure 9.1). Affected patients are largely children and there is often fever, malaise and cervical lymphadenopathy.
More severe manifestations and recalcitrant lesions are seen in immunocompromised people.

Herpes simplex
Definition: Herpes simplex virus (HSV) infection is common and affects mainly the mouth (HSV-1 or human herpesvirus-1; HHV-1), or genitals or anus (HSV-2; HHV-2). Initial oral infection presents as primary herpetic stomatitis (gingivostomatitis). All herpesvirus infections are characterized by latency (Figure 9.2), and can be reactivated. Recurrent disease usually presents as herpes labialis (cold sore).
Prevalence (approximate): Common. Age mainly affected: Herpetic stomatitis is typically a childhood infection seen between the ages of 2–4 years, but cases are increasingly seen in the mouth and/or pharynx in older patients.

Gender mainly affected: M : F.

Etiopathogenesis: HSV, a DNA virus, is contracted from infected skin, saliva or other body fluids. Most childhood infections are with HSV-1, but HSV-2 is often implicated more often at later ages, often transmitted sexually. UNC-93B1 gene mutations predispose to herpesvirus infection.

Diagnostic features
History: The incubation period is 4–7 days. Some 50% of HSV infections are subclinical and may be thought to be “teething” because of oral soreness.

Clinical features: Primary stomatitis presents with a single episode of multiple oral vesicles which may be widespread, and break down to form ulcers that are initially pinpoint but later fuse to produce irregular painful ulcers (Figure 9.3). Gingival edema, erythema and ulceration are prominent (Figure 9.4). The tongue is often coated and there may be oral malodor.
Herpetic stomatitis probably explains many instances of “teething”.

Extraoral features: Commonly include malaise, drooling, fever and cervical lymph node enlargement.
Complications of HSV infection occasionally include erythema multiforme or Bell palsy. HSV-1 appears to increase the risk of developing Alzheimer disease. Rare complications include meningitis, encephalitis and mononeuropathies, particularly in people with impaired immunity, such as infants whose immune responses are still developing, or immunocompromised patients.

Differential diagnosis:Other oral infections and leukemic gingival infiltrates.
Investigations: The diagnosis is largely clinical but blood tests to exclude leukemia (full blood picture and white cell count) may be indicated, and a rising titer of serum antibodies is diagnostically confirmatory but only retrospectively. Cytology, viral DNA sequentiation, culture, immunodetection or electron microscopy are used occasionally (Figures 9.5a–c).

Treatment aims to limit the severity and duration of pain, shorten the duration of the episode, and reduce complications. Management includes a soft diet and adequate fluid intake. Antipyretics/analgesics such as paracetamol help relieve pain and fever. Products containing aspirin must not be given to children with any fever-causing illness suspected of being of viral origin, as this risks causing the serious and potentially fatal Reye syndrome (fatty liver plus encephalopathy).
Local antiseptics (0.2% aqueous chlorhexidine mouthwashes) may aid resolution. Aciclovir orally or parenterally is useful especially in immunocompromised patients. Valaciclovir or famciclovir may be needed for aciclovir-resistant infections.

Good, though HSV remains latent thereafter in the trigeminal ganglion and recurrences may occur.

Recurrent herpes labialis
Definition: Recurrent blistering of the lips caused by HSV reactivation. Prevalence (approximate): 5% of adults.
Age mainly affected: Adults.
Gender mainly affected: M = F.
Etiopathogenesis: HSV latent in the trigeminal ganglion travels to mucocutaneous junctions supplied by the trigeminal nerve, producing lesions on the upper or lower lip, occasionally the nares or the conjunctiva or, occasionally intraoral ulceration. Fever, sunlight, trauma, hormonal changes or immunosuppression can reactivate the virus which is shed into saliva, and there may be clinical recrudescence.

Diagnostic features
History: Oral premonitory symptoms may be tingling or itching sensation on the lip in the day or two days before, followed by appearance of macules, then papules, vesicles and pustules.
Clinical features: Oral lesions start at the mucocutaneous junction and heal usually without scarring in 7–10 days (Figure 9.6). Widespread recalcitrant lesions may appear in immunocompromised patients.
Extraoral: Occasionally lesions become superinfected with Staphylococcus or Streptococcus, resulting in impetigo. In immunocompromised persons, extensive and persistent lesions may involve the perioral skin. In atopic persons, the lesions of herpes labialis may spread widely to produce eczema herpeticum.

Differential diagnosis:Impetigo and other causes of blisters.
Investigations are rarely needed as the diagnosis is largely clinical.

Penciclovir 1% cream, aciclovir 5% cream or silica gel applied in the prodrome may help abort or control lesions in healthy patients. Systemic aciclovir or other antivirals may be needed for immunocompromised patients.

Usually good but immunocompromised patients can develop recalcitrant lesions.

Recurrent intraoral herpes
Recurrent intraoral herpes in healthy patients tends to affect the hard palate or gingiva, as a small crop of ulcers usually over the greater palatine foramen, following local trauma (e.g. palatal local anesthetic injection), and heals within 1–2 weeks.
Recurrent intraoral herpes in immunocompromised patients may appear as chronic, often dendritic, ulcers frequently on the tongue ( herpetic geometric glossitis). Clinical diagnosis tends to underestimate the frequency of these lesions.
Management: The aims are to limit the severity and duration of pain, shorten the duration of the episode, and reduce complications. Symptomatic treatment with a soft diet and adequate fluid intake, antipyretics/analgesics (paracetamol), local antiseptics (0.2% aqueous chlorhexidine mouthwashes) usually suffices. Systemic aciclovir or other antivirals may be needed for immunocompromised patients.

Senin, 26 Agustus 2013



Fortunately, medical emergencies in the dental office are a rare occurrence.  Unfortunately, this rarity prevents us from becoming comfortable with management of problems, and worse still, may lead to complacency.  In light of their uncommon occurrence, it is useful to revisit the subject, sometimes from a different perspective.  The perspective taken for today's discussion is a relatively broad one, allowing for a  "from first principles " approach to the prevention of preparation for, recognition of and action involved in the management of medical emergencies.


A medical emergency is a stress induced, relatively sudden, acute, uncontrolled failure of physiologic adaptation capability (or decompensation in the face of stress ).

A. Stress induced:  This implies that there is usually a more or less recognizable cause or identifiable stress that is driving the system toward failure.  This could be the presence of an allergen, anxiety, drugs or foreign object in the airway that stresses the system maximally and beyond in such a manner that the system is no longer able to cope.

B.Relatively  sudden:  While some emergencies occur rapidly, many take time to evolve.  An identifiable, gradual chain of events often conspire to lead a patient to the point where they are maximally stressed and failure occurs as the last link in the chain.  Prevention centres on breaking the chain of events prior to reaching failure.

C. Acute: The central theme of all emergencies is that they are acute occurrences happening right now.  From this perspective they require immediate recognition and attention.

D.Uncontrolled failure:Emergencies rarely display intrinsic control by the patient.  Clearly, the patient’s system has lost the ability to respond to the stress and extrinsic help must be brought in.  The key to management of emergencies is the resumption of control by the clinician.

E.Decompensation: Loss of compensation implies that compensation was happening in the first place.  In the normal healthy subject, this ability to compensate for stress or strategic reserve is maximal and much has to happen before the system is no longer able to adapt to rising levels of stress.  In the medically compromised patient, some of this reserve has been lost as a function of the underlying illness and decompensation or failure occurs earlier and in the face of lower levels of stress.

F. Examples:

                 An excellent model for medical emergency is the coronary stress test.  In this example, the stress is the treadmill, specifically related to its slope and its rate.  As the slope and rate of the treadmill increases, the stress to the heart and the demand for coronary perfusion of the myocardium increases.

                While the angina attack or the MI that the patient experiences while having the test is a relatively sudden event, the steps leading to the acute event took place over a well defined interval and occurred in a clearly laid out pattern.

Although the progression to the angina attack or the MI may have been drawn out, the event itself is acute and must be recognized and dealt with immediately by the stress lab technician.  If  the patient has gone on to having an MI during the stress test, the extent of the damage is essentially uncontrolled unless the technician intervenes, stops the test and begins supportive management immediately.

                The stress test is designed to assess the patient's coronary reserve. "Failing" a stress test means the patient's reserve was minimal in the first place and that decompensation or failure is likely to occur very early in the process of applying stress to the system.

What is a medical emergency?

A medical emergency can be described as any situation in which a patient becomes ill, may become unconscious and ultimately their life may be at risk due to a failure of an effective oxygenated circulation to the brain and vital organs. There are certain specific emergencies that are the most commonly encountered in General Dental Practice and all DCPs should be familiar with their presentation and management, these are shown in table 1.

Table 1 :Specific Medical Emergencies

·         Choking
·         Asthma
·         Anaphylaxis
·         Hyperventilation
·         Respiratory arrest
·         Angina
·         Myocardial infarction
·         Seizures
·         Faints/syncope
·         Cerebro-vascular accident (stroke)
·         Cardiac arrest


Viewed from this perspective, the management of emergencies can be thought of as occurring in four domains.  Each domain is interdependent with the other domains and requires support form the other three.

Prevention:   The most successful way to manage an emergency is to prevent it form happening in the first place.  This is based on:

                a) An assessment of relative risk: This is the ‘product’ of medical compromise multiplied by the complexity of the procedure.  The more ill the patient and the more invasive the procedure, the greater the likelihood of an emergency.  Careful medical assessment is the key to determining where the patient is sitting on the compensation curve, and therefore, their medical risk.

                b)  Risk reduction and hazard avoidance:  Having recognized increased risk (as a function of  illness and procedural complexity), prevention revolves around risk reduction (medical tune up in order to ensure optimal control of medical compromise) and hazard avoidance (reduce anxiety, avoid allergens, avoid drug interactions, reduced pain, shorter procedures, avoid aspiration, refer, etc.).

B.             Preparation:

                a) Medical assessment: Careful medical assessment not only allows for identification of risk and thus avoidance, it should also give the practitioner an indication of the type of medical emergency that the patient may have,  for example:  bronchospasm in the asthmatic.  Having this information readily at hand when dealing with an emerging problem will save on considerable guesswork and allow the practitioner to zero in on the most likely diagnosis.

                b) Emergency kit: An important aspect of preparation for emergencies is the purchase and careful maintenance of an emergency kit.  This should include key drugs and equipment needed to manage emergencies.  A key example of this is to ensure that there are syringes and needles for the delivery of emergency drugs when needed.  A further point to stress is the need to monitor expiration dates and the condition of equipment such as airways or          masks.  The following is a short list of recommend drugs and equipment:

1.   Oxygen                                                                                           6 1/min by mask
2.   Epinephrine (alpha and beta agonist)                               0.5 to 1 ml of 1:1,000 IM
3.   Nitroglycerine (vasodilator)                                                  0.3 mg sublingual to 3 doses (if no
  response…assume MI and call 911)
4.   salbutamol (Ventolin) (bronchodilator)                           2 puffs by inhalation                      
5.   diphenhydramine (Benedryl) (antihistamine)               50 mg IM or PO
6.   Sucrose                                                                                            soda PO
7.   Glucagon                                                                                         1 mg IM
8.   ASA                                                                                                    325 mg PO
9.   Lorazepam                                                                                      1 mg SL
10. Oxygen bottle with regulator and gas tubing
11. An assortment of adult and paediatric airways and face masks
12. Ball valve bag for ventilation (Ambubag)
13. Various syringes and needles for delivery of emergency drugs
14. Tape
15. Flashlight
16. Tonsil suction tip
17. File cards with emergency protocols and drug dosage information
                c) Clear guidelines: During the middle of a medical emergency is no time to be figuring out what to do next.  This has been recognized by the American Heart Association in their guidelines for CPR and ACLS (Advanced  Cardiac Life Support). These guidelines, once learned, allow the rescuer to follow standard protocols for the management of cardiac emergencies.  They are based on sound judgement and scientific study and most importantly, are detailed IN ADVANCE.  Similar thinking for the management of other emergencies is equally reasonable.  Taking the time, in advance, to think through an emergency situation, outlining it on a file card, familiarizing all staff, in advance, and then placing the card in the emergency kit will tremendously simplify problem management.

                d) Practice:  The AHA again recognizes the importance of rehearsal for the management              of emergencies. Annual mock emergencies not only keeps the staff sharp but it is also an excellent opportunity to recheck the emergency kit and restock stale dated medications.

                e) Vigilance:  Watching and listening for potentially emergent situations whether they be in the operatory, the other operatory or the waiting room will help to prevent problems before they occur and to act on emerging problems early in their progression.  This requires constant vigilance and observation for the patterns of  " problems waiting to happen".

Recognition:  Early recognition and intervention is essential to the successful management of emergencies once they have happened.  The comment,  " the right thing was done too late "  may be the epitaph for the unsuccessful emergency intervention.

                a) Monitoring: Monitoring of patients takes many forms. The most extreme is intensive ICU  or OR monitoring that involves EKG, pulse oximetry, blood pressure and so on.  In the normal dental office, these items are usually unnecessary and unfamiliar.  What is done is moment to moment monitoring through assessment of colour, respiratory rate and distress pattern, level of consciousness and observation of overt signs of  distress. Dentists are particularly good at this sort of monitoring because we are constantly watching for signs of discomfort or inadequate anaesthesia that may complicate our procedure.  The most useful practical technique is the comparison of patient's state of mind as we progress through treatment.  How often have you asked a patient  " are you OK", after observing some subtle  mood or postural change in the patient?  This type of monitoring is crucial for the detection of problems early in their progression.

                b) Context: The importance of an accurate and up-to-date medical history cannot be overstressed.  If a patient is decompensating, it is usually a function of a lack of strategic reserve in a given system and it is usually obvious from the medical history.  A patient with a history of six heart attacks in the past is likely having another one if he collapses in your waiting room.  This allows for early diagnosis and appropriate management.
                c) Assessment of severity: Determining the severity of a problem is a function of the interplay of a complex series of observations and then the performance of mental arithmetic in order to extrapolate ahead and try to predict just how bad things might get and how soon they might get there.  If a patient was fine two minutes ago and is now swelling visibly and wheezing audibly following the administration of a local anaesthetic, its a good bet that he going to continue getting worse in a hurry.  This determination of how severe things are (and how severe they are going to get) directs management in terms of the intensity of response.  The above noted patient needs epinephrine right now and an ambulance ride as soon as possible if he hopes to survive the day.  On the other hand a simple episode of syncope from which the patient recovers quickly may only require repositioning and reassurance before resuming the treatment.  Measurable parameters like heart rate, blood pressure and respiratory rate are much more objective guides to the ongoing status of the patient and as such will be very helpful in determining whether a patient is worsening or improving.

                d) Diagnosis and differential diagnosis: In some cases, the diagnosis will be obvious.  Examples of this are epileptic convulsions or airway obstruction following loss of a crown down the patients's throat.  In these cases, the obvious diagnosis leads to early appropriate management. In other situations, the diagnosis of the emergency situation may be obscure.  An unconscious patient lying on the floor of your waiting room may have fainted, overdosed on drugs, hypoglycaemic, dead, having a heart attack or simply be asleep.  Having a working differential diagnosis will direct the early steps in managing this situation to supporting the basic ABC's  and to determining the exact nature of the problem.  Quick review of the medical history is often helpful at this point.           In other circumstances, the results of early intervention may be diagnostic if  applied appropriately.  An excellent example of this is the patient with chest pain.  If the nitroglyercine does not clear up the problem after three dosages, then a call to the ambulance and a trip to the local emergency room is indicated to rule out an MI.

Action:   Action may be indicated even before an emergency situation is clearly diagnosed.  Supportive measures such as airway maintenance will buy valuable time for the clear determination of the problem and definitive intervention.
                1.  Stop the procedure and manage the emergency.

                2.  ABC's of emergency management:  airway, breathing and circulation

                3.  911....... Get help as soon as the situation appears serious

                4.  On the basis of diagnosis:
                                                a)  Maneuvers, eg. Trendellenberg position, Heimlich maneuver
                                                b)  Drugs......see emergency kit and protocol card
                                                c)  Follow up........911 (ambulance), emergency room or physician

How do you “manage” an emergency?

The ability to effectively manage a medical emergency is dependent on three things which are all inter-related:-

  • Theoretical knowledge.
  •  Practical skills
  •  Team work

Theoretical knowledge

This includes an understanding of the basic physiology of the vital organs and systems of the body, together with detailed knowledge of the causes, effects and treatment of the more common emergencies.  There are several textbooks available which are useful sources of reference and a list of useful websites is provided at the end of this article.

Practical skills

There are specific skills that are required to effectively assess and treat a patient who is feeling unwell, or who has collapsed.  It is not always immediately obvious what the cause of the problem is, but this does not preclude effective management.  A systematic assessment of the patient is essential, and the universally accepted method is the ABCDE approach.  The only way to acquire practical skills is simulation training which allows for constant repetition of the skill until the individual develops the appropriate level of competence.  The knowledge and skills are briefly described below:-


A person must have an open airway to allow oxygen to enter the lungs, so the first step in effective management is to assess the patency of the upper airway-the patency is obvious if the patient is talking ,however ,if the patient is unconscious. are there any obvious obstructions e.g. fluid, vomit, or the tongue?

A person must have an open airway to allow oxygen to enter the lungs, so the first step in effective management is to assess the patency of the upper airway-the patency is obvious if the patient is talking ,however ,if the patient is unconscious. are there any obvious obstructions e.g. fluid, vomit, or the tongue?

Airway skills
Know the location of the emergency suction and how to use it.
Deal effectively with choking-back blows; abdominal thrust.
Ability to place an unconscious patient into the “recovery position”
Jaw thrust             
Head tilt chin lift
Insertion of oro-pharyngeal airways
Insertion of naso-pharyngeal airways

If the airway is open then a person must be breathing effectively to draw inspired oxygen into the lungs.  Noisy breathing is indicative of an obstruction, and the type of noise produced will indicate the possible cause e.g. bronchospasm producing an expiratory wheeze in asthma and anaphylaxis. Administration of oxygen is essential, and if a person is not breathing then ventilations need to be supplied.

Breathing skills
Location of emergency oxygen and how to attach this to the relevant face mask.
Assembly and use of a pocket mask
Assembly and use of a bag-valve mask
Ability to deliver effective ventilations.
Ability to assess respiration for:-
  • Rate
  • Depth
  • Noise
  • Use of accessory muscles
  • Bilateral chest expansion 

  • An effective circulation is essential to ensure an adequate supply of oxygenated blood reaches all vital organs.  In a medical emergency this can become compromised and therefore needs to be monitored, and in a cardiac arrest external chest compressions need to be supplied.
Circulation skills

  • Ability to measure central and peripheral pulses for rate, regularity, volume.
  • Ability to measure blood pressure
  • Measure and understand the significance of capillary refill time
  • Ability to perform effective cardiac compressions at a rate of 100 per minute
  • Safe use of an automated external defibrillator if the practice has one.

  • This is an assessment of the effect the emergency is having on the patient’s brain and nervous system.  The two things that are essential for the brain to function effectively are an adequate supply of oxygen and glucose, if these are not supplied then the patient’s level of consciousness will be affected.  The method of assessment of conscious level is the AVPU scale, a further useful test is the response of the pupils of the eye to light.  Blood glucose level can be measured using a suitable monitor.
Disability skills

  • Use the AVPU response scale to assess consciousness ( Alert; responding to Voice; responding to Pain; Unresponsive)
  • Assess pupil reaction and understand the significance
  • Ability to use a blood glucose monitor. 

  • This assessment is a physical examination of the patient which will be limited in a dental surgery setting.  The main things to be considered are rashes/ flushing, any signs of swelling around the mouth and face, and prevention of heat loss. 
Exposure skills

  • Record any flushing or rashes
  • Know the location of blankets within the practice

The use of this systematic assessment will provide essential information about the nature of the emergency and which body systems are being affected, it is not always necessary to have a specific diagnosis to provide effective treatment to compensate for the problem.  This assessment is carried out each time something changes e.g. the patient becomes unconscious, and each time an intervention is done e.g. the respiration rate was 30 per minute but after oxygen was supplied it reduced to 20 per minute-this is reassuring that the intervention carried out was effective.  It is good practice to write down the assessment results each time it is carried out and this will provide valuable documentation for the paramedics on transfer.

Emergency Drugs
All dental practices carry an emergency drugs kit and all team members should know the location and content of this kit.  The presentation of emergency drugs varies quite considerably and therefore practice may be required to actually prepare the appropriate drug for administration e.g. how to assemble a syringe.  It is good practice for all team members to train to do this, using preparations that are out of date, to avoid confusion and delay if drug administration is required.  A summary of the emergency drugs and their use is given in table 2.

Emergency drug skills
Know the location of the emergency drug box
Know the type of drug and dose required for which emergency
Understand the different methods of drug delivery (inhalational ,oral; transmucosal; intra-muscular and intra-venous)
Practice assembling the drug ready for administration
Practice intra-muscular  administration using a simulator.

Paramedic Transfer

The last responsibility the dental team has is to transfer the patient safely into the care of the paramedics.  It is good practice to ensure that all the information required is provided as written documentation for ease of reference.  The acronym SAMPLE or MAPLES provides a useful “aide –memoir” to ensure all the appropriate details are included.

Paramedic Handover-essential information

Past Medical History
Last oral intake
Events prior to the incident

3. Team work

All members of the dental team should undertake regular scenario training within the dental practice.  This will help to increase the confidence and competence of each individual team member with their individual roles and responsibilities.  Each time a scenario is conducted the team members should alternate roles so all aspects of the management of the emergency are rehearsed.  All scenarios should end with a practised “paramedic handover” including provision of all documentation.  Attendance at lectures and external courses can be very beneficial but are no substitute for regular “in house” training.

Team roles and responsibilities

Who acts as the team leader and directs the team?
Who is responsible for locating and preparing the emergency equipment and drugs?
Who is keeping a note of the time and recording the results of the assessments?
Who contacts the paramedics and waits by the entrance to lead them to the emergency?
Who is responsible for collating and photocopying the necessary documentation?

For each of the following sample emergencies, consider the affected system, the pathophysiology of the emergency and add detail with respect to the mechanisms of action, dosages and routes of the emergency drugs.

E.            Sample Emergencies:

Medical Problems which may alter dental treatments
Medical Problems which may alter dental treatments