Special Care Client Report by Melody Ferzacca

My special care client has several conditions in which a dental clinician may need to
utilize treatment modifications. He is HIV positive, has hepatitis, has a history of angina attacks,
as well as a history of heart attacks and stroke, epilepsy, kidney disease, and sinus congestion.
He was diagnosed as being HIV positive in 1987. His last seizure was January 2, 2016, in which
he states he felt an aura and experienced dizziness prior to the seizure. My patient also has a
defibrillator, which was repositioned on March 8, 2016. The defibrillator was replaced in the
summer of 2015, and needed repositioned and secured in March because it had become loose.
Due to the above, as well as other conditions, my patient is taking several medications.
He is taking abacavir with lamivudine, and antiretroviral used in patients with HIV. There
are no dental treatment considerations for this medication. He also takes acyclovir for HIV,
which is another antiretroviral that does not have any dental treatment considerations. He
takes aspirin, an antiplatelet agent to prevent heart attack. Bleeding must be monitored during
dental treatment for patients who take aspirin. He takes carboxymethylcellulose sodium eye
drops, an ophthalmic agent to stimulate tear production. There are no dental treatment
considerations for this medication. He takes fenofibrate, an antilipemic agent, to lower
cholesterol levels. Fenofibrate can cause xerostomia in some patients. He takes ipratropium
nasal spray, an anticholinergic agent, to treat sinus congestion. There are no dental treatment
considerations for this medication. He takes lamotrigine, an anticonvulsant, to treat epilepsy.
This medication can cause dry mouth. He also takes levetiracetam, an anticonvulsant, to treat
epilepsy. There are no dental considerations for this medication. He takes lorazepam, a
benzodiazepine, to prevent status epilepticus caused by epilepsy. Xerostomia is a side effect of

lorazepam. He takes losartan, an angiotensin II receptor blocker, to reduce risk of another

stroke. Patients should be dismissed slowly, ensuring they will not experience syncope due to
orthostatic hypotension when taking losartan. He takes metoprolol, a beta-1 selective blocker,
for treatment of angina. There are no dental considerations for this medication. He takes
phenytoin, an anticonvulsant, also for epilepsy treatment. Gingival hyperplasia is a common
side effect of phenytoin. He takes Sudafed, an alpha-adrenergic agonist, for the treatment of
sinus congestion. Local anesthetics containing vasoconstrictors should be used with caution as
this medication can interact with epinephrine and cause a pressor response. He takes
raltegravir, an antiretroviral, also to treat HIV. There are no dental considerations with this
medication. He takes rosuvastatin, a HMG-CoA reductase inhibitor, to reduce cholesterol levels.
Muscle weakness can be a side effect and the patient should be monitored for weakness in
chewing and difficulty brushing their teeth. He takes testosterone cypionate, an androgen, for
hormone replacement therapy. The patient can experience bitter taste, gum edema, mouth
irritation, gingival tenderness, and taste perversion as potential side effects. He takes
tizanidine, an alpha-2 adrenergic agonist, for muscle spasms. Xerostomia is a side effect. He
takes warfarin, an anticoagulant, to prevent stroke. Mouth ulcers and taste disturbance are
potential side effects. He takes zolpidem, a hypnotic, used to treat insomnia. Xerostomia is a
potential side effect.
This patient would need medical clearance from either his cardiologist or primary care
provider in order to receive dental treatment, at least for his first treatment following the
repositioning of his defibrillator. Treatment modifications for this patient would be to use the
piezoelectric ultrasonic over the magnetostrictive ultrasonic. Having the patient in a less supine

position will aid in acid reflux incidents, as well as prevent the potential for an angina attack.
Using local anesthetics without a vasoconstrictor would be best for this patient in the event
anesthesia is needed. Ensuring the patients metoprolol is on hand in the event of an angina
attack is important. Short appointments and/or frequent breaks are also important for the
patient. Due to the complexity of this patients medical history, the biggest consideration is that
he as at a much higher risk for a medical emergency than the average patient. I would need to
make sure there is an oxygen tank next to my operatory so that it is readily accessible in the
event of a medical emergency with my patient.
According to a continuing education course on dentalcare.com, Management of
HIV/AIDS Patients in Dental Practice, when a person is initially infected with the HIV virus,
lymphoid tissue near the route of infection is where the virus is greatly produced, and then
spread to other lymphoid organs throughout the body. The immune system of an infected
individual does not decline immediately, but rather it progressively declines due to the
destruction of CD4 cells, which are important immune cells. Most oral lesions in HIV patients
are caused by their depleted immune system. Candidiasis, hairy leukoplakia, Kaposis sarcoma,
and periodontal disease are among the most common oral issues associated with HIV/AIDS.
An article published in The Journal of Contemporary Dental Practice in 2008 says that
elderly patients with epilepsy have an increased incidence of seizures as they age. The article
recommends that the reasoning for this is stroke, brain tumors, and Alzheimers disease, that
can cause brain trauma. Due to my patients medical history with him having had a stroke, he is
at a higher risk for having a seizure.

Reflection:
My patients treatment went very well. I kept him in a less supine position than what
most patients are treated in. His homecare is incredible and he had very little biofilm or calculus
deposit. I did not use the piezoelectric ultrasonic on him as I did not feel a need for it with such
little deposit. I felt like using it would add more time to his appointment, rather than keeping it
short. He kept his metoprolol in his jacket pocket, which was hung up directly behind me,
during treatment so I would have it ready in the incidence of an angina attack. I had the oxygen
tank chairside in case I needed that as well. Before dismissing my patient, I had him sit upright
for a few minutes while getting my papers signed, prior to releasing him. I ensured he was not
dizzy prior to walking him up front. Everything went very smoothly with this patient and his
appointment was only about an hour. In a regular clinic setting, this would have been even
shorter, which is very beneficial to this type of patient. Overall, I wouldnt have changed any
aspect of treatment.

References
Jacobsen, P. L., & Eden, O. (2008). Epilepsy and the Dental Management of the Epileptic Patient. The
Journal of Contemporary Dental Practice, 1-14.
Palenik, C. J., & Zunt, S. L. (2007, November 7). Crest and Oral-B. Retrieved from dentalcare.com:
http://www.dentalcare.com/media/en-us/education/ce70/ce70.pdf