How do I protect my patient medically, while safely providing the required treatment?

This case was submitted by Dr. Ron Kellen 

Case Details

• Male patient, 55.  Diagnosed with AIDS in 2/2013 – at which time, CD4 count was 50. Now he says his CD4 count is 200.
• On Methadone (on-off for 10 years now). Ex heroin IV, and oxycontin, Percocet, etc. narcotics.
• On anti-convulsive for grand mal seizures. No more seizures since started medications.
• Smokes medical marijuana to increase his appetite. He is very underweight.
• On effective AIDS cocktail since Feb, 2013 
• Just finished thrush treatment of Nystatin swish & swallow (from G.P., not AIDS MD).  Still remnants clearly visible
• He has only 5 teeth.  Has “PLD”, CUD. Thrush sites still present in mouth, very poor lower ridge, very poor stability, retention.  
• I need to extract 46, Scaling, –> and keep 4 teeth. 34, 33, 43, 44 that are still vital despite natural crowns moth-eaten with fillings and caries. I will cut the crowns off 1 mm above the gingiva, do 4 vital RCT’s and place ERA post-attachments on the 4 teeth, to retain an overdenture CLD.  
• After treating 33, 34 RCT’s, he requested “something for pain” though I doubted there would be much if any. I offered Ketoprofen, he declined and wanted Percocet or oxycodone/Oxycocet. I refused to prescribe those and re-informed him about their interaction with methadone.  He said “no problem, not too bad a reaction” and “I’ll take care of it.”

My Concerns were: 

• CD4 count is below 500 so definite risk from depressed natural resistance.
• Thrush remnants were still present. Definite gingivitis, poor oral health.
• I wasn’t sure about any marijuana interactions?
• A number of common medications react with Methadone e.g.  Metronidazole, ketoconazole. 
• Nystatin (swish & swallow) is not very effective.   
• Getting good information was very difficult. There is much information about protecting the dentist and staff, but not much about protecting the patient. 

Through my search for pertinent information, there was consensus about the advisability of using antibiotic prophylaxis for invasive procedures, including a number of prophylactic regimens that I was able to find on the internet and through some of my colleagues. However, it was not clear when to use the antibiotics, why use them, which antibiotics to use, when to start, for what duration, what dose to use etc. 

I was able to find the name and phone number for my patient’s AIDS MD, who advised antibiotic prophylaxis for invasive procedures and indicated that it wasn’t needed for fillings. He indicated the use of Amoxicillin, following the American Heart Association’s (AHA) heart valve prophylaxis regimen, as least likely to create resistant bugs and to save other antibiotics in case the patient suffers from more complex infections. Amoxicillin would also be effective in the critical period. The MD also told me that the latest CD4 on my patient was even better at 270.

For the thrush, I prescribed fluconazole, 500 mg 1 x/day for 1 week. Interestingly enough, the pharmacy phoned my office to inform us that it was a restricted drug, used only with specific infections like Aids Thrush, so I informed them that it was in fact AIDS thrush and they filled the prescription.

I was fortunate to be able to get as much good information as I did. However, to get it, I wasted a LOT of time and went through frustration after frustration. Likely, there is much more and better data available, through other knowledgeable people and venues. This is also likely an area where many dentists are looking for good information and are aware of the need. Hence I bring it to OASIS.

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