Patient with shingles?

[I'mFillingFine]

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Getting some different opinions on this. Should an outbreak of shingles affect my care for a patient? This pt only needs SRP and a prophy, but it'd be good to know about more invasive treatment if the issue comes up again! Thanks for any and all information.

 

[SuperC]

This is a good question. I will give you my opinion, but it is by no means standard procedure.

How long has the pt had them? Short term out breaks in younger people are usually caused by stress and/or immunoco issues (as you know). However, if this were an older pt there could be some other issues here.

I would take a good Hx and consult w/ MD. If they have immuno problems prophlx may be required, or if they are old and the affect area is on the back it could be painful to lay on.

To the best of my knowledge, pt needs 200mg of anti virals 3x/day for 7days. Once you get the zoster under control you should be good to go.

Lastly, if you have not had chicken pox bail out!
-C

 

[I'mFillingFine]

This is a good question. I will give you my opinion, but it is by no means standard procedure.

How long has the pt had them? Short term out breaks in younger people are usually caused by stress and/or immunoco issues (as you know). However, if this were an older pt there could be some other issues here.

I would take a good Hx and consult w/ MD. If they have immuno problems prophlx may be required, or if they are old and the affect area is on the back it could be painful to lay on.

To the best of my knowledge, pt needs 200mg of anti virals 3x/day for 7days. Once you get the zoster under control you should be good to go.

Lastly, if you have not had chicken pox bail out!
-C

Thanks for the reply. I did have chicken pox as a little one, so I'm not as concerned about that. I know that shingles can manifest whether or not you've had them, but isn't it usually considered to be more immunocological than communicable? Regardless, it may make a difference with location so I'll ask her if it's on her head and neck. And I'll ask about her current tx. Thanks a bunch! As a sophomore, I only have 3 patients so I'd hate to lose one!! 😉

 

[aphistis]

Consulting with her physician is a good idea for two major reasons:
1) It lets you make sure there isn't anything else going on you need to know about, and lets the physician know about the problem.
2) We can handle shingles in the head & neck, but if she's having outbreaks elsewhere, it's technically outside our scope. I know it's the same skin above & below her collarbone, but that's just how it is.

Also, as I understand, shingles outbreaks are generally pretty painful (i.e. is she going to feel like having dental treatment if she's already feeling miserable?) and the benefit of giving antivirals gets pretty iffy if she's been symptomatic for more than 72 hours. You have to catch outbreaks in their prodromal phase for the acyclovir or whatever you're giving to have much impact.

 

[TucsonDDS]

Varicella is communicable and patients with active disease shouldn't be seen in the clinic where they could infect others. In the hospital, varicella patients (whether chicken pox or shingles) are actually put in airborn isolation and they are considered infective until all lesions are fully crusted over. In an area like a school dental clinic there are too many posibilities for contaminating other surfaces and infecting other patients. Give the patient a break and wait until they are feeling better. Also, just the stress of coming to the dentist is probably enough to give some patients an outbreak.

 

[I'mFillingFine]

I spoke with the patient again and she was immediately put on antivirals after speaking with her physician last Wednesday (the appointment with me wouldn't be for a few more weeks anyway.) She doesn't remember having chicken pox, though she did have measles and can't be sure that both didn't come together. The lesions are on her back and side. Though I realize the virus is communicable, some people have shingles outbreaks for months at a time, so should it always mean that no dental treatment can be attempted for so long? Especially if all lesions are covered by clothes and the patient is being treated?

 

[SuperC]

My question for you is why are you consulting with us when technically this is an issue that needs to be addressed with the dental staff. We can give you our opinons, but in the end the issue needs to be run by your dental faculty. You schools may have a policy that you are unaware of which addresses the issue.

Navy, I usually agree whit your statements, but this one I am going to have to get on you about!

SDN, IMO, is more about stupid things like "why do you like your school" and "I have a crush on my classmate, what should I do?" SDN SHOULD be a place for questions JUST LIKE THIS. I am sure that this student has consulted, or will consult with his/her professors, but he/she had a question and put it out to us to get a quick response. What is the problem with that?

Questions like this allow ALL OF US to learn something more than lame gossip and trivial BS.

To all of you, I encourage these questions and wish there were more.

-C

 

[SuperC]

Thanks for the reply. I did have chicken pox as a little one, so I'm not as concerned about that. I know that shingles can manifest whether or not you've had them, but isn't it usually considered to be more immunocological than communicable? Regardless, it may make a difference with location so I'll ask her if it's on her head and neck. And I'll ask about her current tx. Thanks a bunch! As a sophomore, I only have 3 patients so I'd hate to lose one!! 😉

In order to have shingles, you have to have had chicken pox first.
-C

 

[aphistis]

In order to have shingles, you have to have had chicken pox first.
-C

Subtle but important correction: you have to have had a primary varicella infection, which doesn't necessarily require a full-blown case of clinical chickenpox. The patient may have experienced a mild or even subclinical primary infection. It sounds like her current findings are good enough for her physician, and based on that I'd be pretty hesitant to countermand that diagnosis based solely on the patient's self-reported history.

 

[rdhdds1]

Getting some different opinions on this. Should an outbreak of shingles affect my care for a patient? This pt only needs SRP and a prophy, but it'd be good to know about more invasive treatment if the issue comes up again! Thanks for any and all information.

Not sure how your patient can only need SRPs and then a prophy. Standard protocal for anyone diagnosed with periodontal disease or gum disease (yes they are considered one in the same) severe enough to warrant SRP does not return to regular (buff and fluff) cleanings for oh let's say until they are...........uh, healthy and the disease is in remission (which is still in debate).

Some think that once SRPs are completed a patient will never return to regulaar 1110 and will be on 4910's for the rest of their natural born lives.

 

[Ebull]

Not sure how your patient can only need SRPs and then a prophy. Standard protocal for anyone diagnosed with periodontal disease or gum disease (yes they are considered one in the same) severe enough to warrant SRP does not return to regular (buff and fluff) cleanings for oh let's say until they are...........uh, healthy and the disease is in remission (which is still in debate).

Some think that once SRPs are completed a patient will never return to regulaar 1110 and will be on 4910's for the rest of their natural born lives.

You can do SRP, (which is scaling and root planing, for all the pre-dents reading this) where you sterilize the surfaces below the gingiva and then a prophy, which is essentially a polishing of the dentition above the gum line. Also the op didn't specify if it was full mouth SRP, it could be in as little as 1-3 teeth, so therefore it is quite possible to need only SRP and a prophy.

 

[I'mFillingFine]

Thanks for the discussion. So like I said in my last post, she is on antivirals and the lesions are on her back and side. Since she is indeed being treated by her physician, would you all continue to treat after getting permission from both her MD and your faculty?

Not sure how your patient can only need SRPs and then a prophy. Standard protocal for anyone diagnosed with periodontal disease or gum disease (yes they are considered one in the same) severe enough to warrant SRP does not return to regular (buff and fluff) cleanings for oh let's say until they are...........uh, healthy and the disease is in remission (which is still in debate).

Some think that once SRPs are completed a patient will never return to regulaar 1110 and will be on 4910's for the rest of their natural born lives.

No one is doubting that you know your stuff, but I would appreciate posts in this thread to remain on my topic inquiring about continuing treatment for a pt with shingles. This is a healthy recall patient who will only need polishing and supragingival scaling, but for the ease of typing I wrote SRP and prophy so that posters would know I will not be doing operative or anything more invasive than some minor scaling. But moving on...

My question for you is why are you consulting with us when technically this is an issue that needs to be addressed with the dental staff. We can give you our opinons, but in the end the issue needs to be run by your dental faculty. You schools may have a policy that you are unaware of which addresses the issue.

Thanks! Much agreed on this. I think it has slowly evolved to where dentaltown does a lot of the treatment discussion and SDN is mainly for life DURING dental school, but it would be wonderful if there were more medical-based advice thread where we all share our opinions on treatment (as long as it isn't for ourselves.) Alas!

 

[1992Corolla]

Lots has been said. I have nothing to add, but wanted to say great thread and agree with SuperC, we need more like it.

 

[rdhdds1]

You can do SRP, (which is scaling and root planing, for all the pre-dents reading this) where you sterilize the surfaces below the gingiva and then a prophy, which is essentially a polishing of the dentition above the gum line. Also the op didn't specify if it was full mouth SRP, it could be in as little as 1-3 teeth, so therefore it is quite possible to need only SRP and a prophy.

Understandable that a person can need only localized SRP's (4342), however, that was never mentioned and left to interpretation. I did not know that one sterilizes subgingival when doing SRP's whether localized or generalized. I thought that it is done to remove toxins, bacteria, biofilms, calculus (which isn't just a math) and necrotic and/or infected tissue. I guess in a sense it is sterilizing especially if one uses chlorhexidine gluconate as subgingival irrigation in the process.

And I differ in the perception that a prophy is "essentially" polishing of the dention above the gumline. A regular prophy (1110) is supragingival yes but also intales going 1-2 mm subgigival to ensure proper and thorough removal of calculus and plaque with hand instruments (scalers and currettes). The polishing aspects of the "prophy" only ensures a smoothing of the enamel surface.

 

[aphistis]

Understandable that a person can need only localized SRP's (4342), however, that was never mentioned and left to interpretation. I did not know that one sterilizes subgingival when doing SRP's whether localized or generalized. I thought that it is done to remove toxins, bacteria, biofilms, calculus (which isn't just a math) and necrotic and/or infected tissue. I guess in a sense it is sterilizing especially if one uses chlorhexidine gluconate as subgingival irrigation in the process.

And I differ in the perception that a prophy is "essentially" polishing of the dention above the gumline. A regular prophy (1110) is supragingival yes but also intales going 1-2 mm subgigival to ensure proper and thorough removal of calculus and plaque with hand instruments (scalers and currettes). The polishing aspects of the "prophy" only ensures a smoothing of the enamel surface.

No intraoral treatment comes anywhere near satisfying the criteria for sterilization. There's no "in a sense" about sterility--either something is sterile or it isn't, and no intraoral procedure comes anywhere close.

 

[Ebull]

Understandable that a person can need only localized SRP's (4342), however, that was never mentioned and left to interpretation. I did not know that one sterilizes subgingival when doing SRP's whether localized or generalized. I thought that it is done to remove toxins, bacteria, biofilms, calculus (which isn't just a math) and necrotic and/or infected tissue. I guess in a sense it is sterilizing especially if one uses chlorhexidine gluconate as subgingival irrigation in the process.

And I differ in the perception that a prophy is "essentially" polishing of the dention above the gumline. A regular prophy (1110) is supragingival yes but also intales going 1-2 mm subgigival to ensure proper and thorough removal of calculus and plaque with hand instruments (scalers and currettes). The polishing aspects of the "prophy" only ensures a smoothing of the enamel surface.

Your right, perhaps I need to learn to speak more precisely in these forums. Both you and Aphistis make an accurate point in that you cannot achieve sterility inside the mouth. I suppose I've gotten used to explaining it to patients in less scientific terms.

Also when I said a prophy is essentially a polishing it was in the context of the op's original statement. After SRP you have already removed all the calculus below the gum line, so your point is moot. You also made the statement yourself that a prophy = buff and fluff cleaning. And I didn't realize that the enamel had to be "smoothed" after a debridement, I think it is done more often to remove residual extrinsic stain from the surface.