COVID-19 creates new challenges for immunocompromised patients

A patient calls her dental practice and wants to schedule an appointment. The patient’s medical history is complex, and needs updated constantly. She takes about 16 medications daily, including immunosuppressants due to a solid organ transplantation; a kidney transplant in 1999. Her kidneys failed-end stage renal disease-secondary to a rare autoimmune disorder known as ANCA+ Vasculitis. After her kidneys had declined to 11 percent, she started the transplant process and has had a functioning renal transplant for the past 21 years.

This patient lives in an area of the country where dental practices are re-opening and once again offering preventive dental care. She is a long-standing dental patient who is overdue for periodontal maintenance and understands the importance of maintaining her periodontal disease and avoiding infection. The patient is eager to make her three-month re-care appointment. Are there any challenges facing the dental practice in accommodating this patient and welcoming her back for routine preventive care?

Patients with underlying health conditions who contract COVID-19 are more likely to suffer more adverse outcomes or be hospitalized, according to early survey data. In a study describing the demographics, baseline comorbidities of the first sequentially hospitalized patients with COVID-19 from an academic health care system in New York, patients with diabetes were more likely to have received invasive mechanical ventilation or care in the ICU compared to those who did not have diabetes.¹ Mortality rates for patients with hypertension who not taking an angiotensin-converting enzyme inhibitor or angiotension II receptor blocker were approximately 27-33 percent more likely.¹ In addition, the percentage of patients who developed acute kidney injury increased in patients with diabetes.¹ Although our hypothetical patient does not have diabetes as a comorbidity (which is the number one cause of kidney disease in the United States), she does have hypertension, which is very common in the renal transplant and Chronic Kidney Disease (CKD) population, according to the National Kidney Foundation (NKF).²

What does it mean to be immunocompromised?

An immunocompromised or immunosuppressed person’s immune system is weakened and not functioning normally. The body’s defenses against foreign invaders-such as COVID-19-are like an army of cells with potent superhero weapons. When these defenses are low or don’t work properly, an individual becomes highly susceptible to infection. An immunodeficiency is classified as primary or secondary (acquired).³

Many people with primary immunodeficiency are born missing some of the body’s immune defenses, leaving them more susceptible to microorganisms that can cause infection. The person with an immunodeficiency disorder will have frequent infections that are generally severe and last longer than usual. There are about 70 types of congenital immunodeficiency disorders, but they rarely occur in the general population.

Immunodeficiencies can be mild and unnoticed, or they can be severe enough to be discovered after birth. HIV is an example of an acquired immunodeficiency, which destroys CD4⁺ T lymphocytes (CD4⁺ cells), leaving the body vulnerable to life-threatening infections and cancers. Another example of acquired immunodeficiency is intentionally created by drugs used to suppress the immune system so the body will not reject a transplanted organ. Some chemotherapy drugs used to treat cancer may fight the cancer cells, but also adversely affect immune system cells. Patients with autoimmune and inflammatory conditions who often receive long-term immunosuppressive therapy (i.e., individuals who have received solid-organ transplants or who have rheumatoid diseases such as, arthritis or psoriasis, etc.) may have increased risk of a skin cancer or Post-Transplant Lymphoproliferative Disorder (PTLD) which can be a life threatening complication. This form of immunosuppression created by chemotherapeutic/anti-rejection medications is also referred to as iatrogenic immunosuppression.⁴

Furthermore, patients who are not on immunosuppressive medications but have CKD or are on dialysis due to end stage renal disease are also immunocompromised due to the disease process. Researchers know that most infections, like pneumococcal disease, are worse in people living with CKD.²

Immunocompromised and immunosuppressed populations are growing, and these individuals are vulnerable to opportunistic infections and certain cancers. These individuals have compromised immune systems that no longer scan the body’s cells; instead it kills neoplastic cells, known as immunosurveillance. Common opportunistic infections include candidiasis of bronchi, trachea, esophagus, or lungs; invasive cervical cancer; pneumonia; and fungal infections.

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With the growing epidemic of diabetes in this country, we are seeing new and more fulminant presentations of immunocompromise within those who are unable to control their glucose levels, diet, and exercise. These patients are considered to have “secondary” or “acquired” immunodeficiency, as opposed to those with “primary” immunodeficiency syndromes.⁴

Other chronic conditions that affect the immune system include heart disease, lung disease, lupus, and cancer. Immunosuppression from individual to individual is different. Some are more susceptible to infections, while others may have more severe or longer lasting infections. Some immunocompromised patients are at a continual high risk of infection and case exposure must be carefully and aggressively avoided.

Elderly individuals do not respond to immune challenge as robustly as the young. The effects of aging on the immune system are observed at multiple levels that include reduced production of B and T cells in bone marrow, and thymus and diminished function of mature lymphocytes in secondary lymphoid tissues. Serious complications of COVID-19 are likely to develop in the elderly, just as they do in the immunocompromised population groups.⁵

It’s still unclear if immunocompromised patients will schedule appointments for regular dental care in a post-coronavirus world if they’ll avoid treatment until they have a serious toothache. Regardless, dental practices should still be prepared to treat this patient population. Here are six guidelines to consider for dental care for immunocompromised patients:

• Call the patient’s primary care physician and/or specialist to determine if routine/preventive dental care can be scheduled. Request a written release that includes special precautions that may be appropriate.
  
  In the case of our hypothetical patient above, consulting with her nephrologist/transplant team and her primary care provider is advisable to determine whether routine care is appropriate at this time. Both the patient and staff involved in this appointment should be screened for temperature or COVID-19 symptoms before proceeding with treatment.
   

• Establish a protocol that allows you to screen the patients’ health when confirming their appointment. Patients should be aware of specific protocols the practice has put in place, such as a maximum number of patients allowed in the office at once, temperature screenings, and health questionnaires. Advise the patient to record their temperature the day before and the morning of their appointment. The patient should also be aware that the office may be cooler than recent visits and to dress accordingly. Ask open-ended questions in advance, which may help avoid overlooked issues and save time the day of the appointment. Be sure to give the patient the opportunity to ask questions as well.
  
  When discussing our hypothetical patient’s dental care with her healthcare team, be prepared to discuss the pros and cons of treatment versus infection. Because the patient has periodontal disease, it may be necessary to explain what periodontal disease is and the risks associated with it. Contributing factors pertaining to our patient’s periodontal health would include a history of xerostomia, personal dental care ability, and potential gingival overgrowth due to immunosuppressive therapy.
   

• Individuals who are immunocompromised have the most significant risk of contracting COVID-19. All staff members should understand that these patients should avoid public exposure and public gatherings, including staff interaction with multiple individuals present. Those in contact with the individual should be wearing proper PPE at all times and maintain appropriate hand hygiene standards. Prior room cleaning with aerosol reduction/elimination and antiseptic agents should be undertaken and performed before seating the patient. Avoid and/or reduce aerosol production whenever possible. Unless the patients’ healthcare team recommend it is safe to provide routine/preventative care, patient visits should be avoided unless emergency care is needed.⁵
   

• For immunocompromised individuals who have contracted COVID-19, the Centers for Disease Control (CDC) has published a possible strategy to discontinue home isolation for these individuals and it includes a test-based and non-test-based strategy.⁷ There is concern that immunocompromised individuals may continue to shed detectable viral material and be potentially infectious for an extended period of time after recovery.⁷ CDC testing guidance is based upon limited information and is subject to change as more information becomes available.
   

• Even though immunocompromised patients are within the high-risk group for severe outcomes for COVID-19, there is no clear evidence of an association between impaired immune host status and complications from COVID-19 infection.⁸
   

• Regularly check the CDC’s interim Infection Prevention and Control Guidance for Dental Settings During the COVID-19 Response.⁹ The “What’s New” section gives revisions for all patients entering a dental setting.

References:

1. Richardson S. Clinical Characteristics, Comorbidities, and Outcomes Among Patients With COVID-19 Hospitalized in the NYC Area. JAMA. https://jamanetwork.com/journals/jama/fullarticle/2765184. Published April 22, 2020.
    
2. High Blood Pressure and Chronic Kidney Disease. National Kidney Foundation. https://www.kidney.org/news/newsroom/factsheets/High-Blood-Pressure-and-CKD. Published January 27, 2016.
    
3. Fernandez J. Overview of Immunodeficiency Disorders - Immune Disorders. Merck Manuals Consumer Version. https://www.merckmanuals.com/home/immune-disorders/immunodeficiency-disorders/overview-of-immunodeficiency-disorders. Published December 2019.
4. Ending Isolation for Immunocompromised Persons. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ending-isolation.html. Published March 16, 2020.
   
5. Montecino-Rodriguez E, Berent-Maoz B, Dorshkind K. Causes, consequences, and reversal of immune system aging. The Journal of clinical investigation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3582124/. Published March 1, 2013.
    
6. UCSF Health. FAQ: Coronavirus Basics for Transplant and Other Immunosuppressed Patients. ucsfhealth.org. https://www.ucsfhealth.org/education/faq-coronavirus-basics-for-transplant-and-other-immunosuppressed-patients. Published April 22, 2020.
    
7. Ending Isolation for Immunocompromised Persons. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ending-isolation.html. Published March 16, 2020.
    
8. Sabino-Silva R, Jardim ACG, Siqueira WL. Coronavirus COVID-19 impacts to dentistry and potential salivary diagnosis. Clinical Oral Investigations. 2020;24(4):1619-1621. doi:10.1007/s00784-020-03248-x.
    
9. Dental Settings. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Published May 3, 2020.