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Dental Management of the HIV

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Comprehensive Dental Management of the HIV/HCV Infected Patient ... Follow aseptic technique. Routine antibiotic use is contraindicated ... – PowerPoint PPT presentation

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Title: Dental Management of the HIV


1
  • Dental Management of the HIV HCV Infected
    Patient
  • Mona Van Kanegan DDS, MS
  • 3.08.02

2
  • Comprehensive Dental Management of the HIV/HCV
    Infected Patient
  • Diagnosis and Treatment of Oral
    Manifestations of HIV/HCV

3
Comprehensive Dental Management of the HIV/HCV
Infected Patient
4
Human Immunodeficiency Virus
  • First case discovered in retrospect in a British
    sailor that died in 1959
  • Approximately 1 million infected individuals in
    the US
  • Greatest number of new infections is in minority
    males and women

5
HIV Pathogenesis
  • Virus infects specific cells bearing CD4 membrane
    glycoprotein
  • HIV enters cell and its RNA is transcribed into
    DNA by reverse transcriptase enzyme

6
HIV Pathogenesis Cont.
  • Viral DNA becomes integrated into host-cell
    genome until host cell is activated
  • Reverse transcriptase, protease, integrase (and
    other) enzymes are needed to make new viral
    particles that then infect other cells

7
HIV Disease Progression
  • Good understanding of disease process, management
    of opportunistic infections and neoplastic
    conditions
  • Potential activators of HIV include concomitant
    infections of Cytomegalovirus, Hepatitis B virus,
    Herpes Simplex virus and Hepatitis C virus
  • Current treatments do not completely eliminate
    virus from body

8
Acute or Chronic Liver Disease
  • Infection with hepatitis A, B or C
  • Drug induced - alcohol, IV drug, other toxic
    chemical

9
Hepatitis C Virus
  • 170 million infected people worldwide
  • 4 million or 1.8 of US population is HCV
  • Up to 70 of intravenous drug abusers are HCV
  • 40-70 HCV infected persons develop chronic liver
    disease which is the leading cause of liver
    transplantation in US

10
Hepatitis C Virus
  • Dominant mode of transmission is blood-to blood
    contact
  • Risk groups
  • Injection drug users
  • Body piercing, tattooing with contaminated
    equipment, blood products pre 1990

11
HCV Disease Progression
  • RNA virus, initial infection often asymptomatic,
    incubation period 2-26 weeks
  • Lots of mutations occur during viral replication
    thus the antibodies generated against HCV fail to
    neutralize mutant virus
  • Disease process not very well understood

12
HCV Disease Progression Cont.
  • When HCV viral replication occurs, liver enzymes
    ALT and AST are elevated
  • Cirrhosis is indicated with the liver function
    tests shows AST levels exceed ALT levels
  • Liver dysfunction can be asymptomatic, a thorough
    medical history and consultation with patients
    physician should be done to determine degree of
    liver dysfunction

13
Hepatitis C Virus Treatment
  • Limit alcohol consumption
  • Interferon alpha and ribavirin therapy

14
Hepatitis C Virus Therapy Side Effects
  • Lowers resistance to infection, invasive dental
    procedures should be postponed if possible until
    therapy has ceased
  • May induce the onset of clinical depression, in
    addition chronic HCV infection decreases salivary
    gland function resulting in xerostomia
  • Can cause bone marrow suppression, neutrophil,
    platelet count should be monitored, PT and PTT
    should be assessed before invasive procedures

15
Dental Management of the HCV Infected Patient
  • Most significant problem for patients with
    cirrhosis is likelihood of prolonged bleeding due
    to lack of coagulation factors and
    thrombocytopenia

16
HIV/HCV Co-infection
  • Because HIV and HCV have similar routes of
    infection, HIV infected patients are at a risk
    for co-infection with HCV
  • Estimated 300,000 people co-infected with HIV and
    HCV
  • As HIV disease becomes more controlled, in
    HIV/HCV co-infected patients the most common
    cause of death in co-infected patients is
    complications of end-stage liver disease

17
HIV/HCV Co-infection
  • Early diagnosis, evaluation, and treatment of HCV
    should be considered for HIV patients because
  • HCV increases hepatotoxicity of HAART
  • increases risk of perinatal HIV transmission
  • may increase HIV progression, morbidity
    mortality
  • HIV increases hepatitis C viremia
  • can hinder diagnosis of HCV
  • increases HCV progression, morbidity mortality

18
Patient Management
  • Hemostatic function
  • Susceptibility to infection
  • Drug actions/interactions
  • Ability to withstand treatment

19
Patient Management Cont.
  • Schedule appointments that cause minimal
    interruptions in eating or medication schedules,
    minimize stress
  • Be sympathetic, patients on a new regimen of
    medications may not feel well, may need to
    reschedule appointment, or may even forget an appt

20
Patient Management Cont.
  • More frequent recalls, possibly every 3-4 months
  • Stress prevention and use topical fluorides and
    topical antimicrobials to maintain optimal oral
    health

21
Provider Management
  • Take the time to do a thorough history and oral
    examination
  • Appropriate training to gain greater competence
    in identification, diagnosis and proper treatment
    of oral lesions
  • Access to a qualified oral pathology lab
  • Good follow-up system with patients

22
Treatment Planning - General
  • Comprehensive oral exam and review of medical
    history/condition
  • Modifications to care are similar to other
    medically compromised patients
  • Communicate with primary care provider on HIV
    and/or HCV disease progression
  • Principles of good oral health are the same for
    people with HIV/HCV

23
Treatment Planning - General Cont.
  • Consider more frequent recalls every 3-4 months
    due to medication side effects, prevention and
    early detection of oral disease
  • Update medical history and markers of disease
    progression regularly every 6 months
  • Aggressive in diagnosis and treatment of disease
    conditions

24
Treatment Planning - Restorative Considerations
  • Most principles are similar to HIV/HCV negative
    patients
  • Poor candidates for extensive restoration
    rampant caries, reduced salivary flow, oral
    acidity, poorly controlled oral manifestations
  • Use of topical fluorides to prevent recurrent or
    root caries

25
Treatment Planning - Oral Surgery Considerations
  • Follow aseptic technique
  • Routine antibiotic use is contraindicated
  • Incidence of post-procedure complications is no
    greater that other populations, although patients
    with prolonged clotting time will experience
    delayed wound healing

26
Treatment Planning - OS Considerations Cont.
  • Have results of recent labs to assess hemostatic
    function and susceptibility to infection
  • Antibiotic pre-medication for prevention of SBE
    (AHA guidelines)
  • Neutropenia
  • Indwelling catheters

27
Treatment Planning - Periodontal Considerations
  • Frequent recalls
  • Adjunctive use of antimicrobials and chlorhexadine

28
Treatment Planning - Endodontic Considerations
  • Assess ability to withstand treatment
  • Endodontic treatment offers same benefits and
    risks as with other groups
  • Consider one-step endodontic therapy where
    appropriate

29
Patient Management
  • Hemostatic function
  • Susceptibility to infection
  • Drug actions/interactions
  • Ability to withstand treatment

30
Normal Lab Values
  • Platelets/ml 150-300K
  • Neutrophil cells/ml 2500-7000
  • Hemoglobin g/dl 14-18 male, 12-16 female
  • CD4 cells/ml 800-1500

31
Laboratory Markers of Liver Disease
32
Bleeding Problems
  • Clotting factors are decreased in severe liver
    disease
  • Number and function of platelets may be decreased
    and factor replacement or transfusion may be
    required
  • Need PT/PTT for patient within 48 hrs of surgery
  • Elective surgery can be safely performed in
    patients with platelet counts greater than
    60,000/mm3 and PT/PTT of 0.8-1.5 INR

33
Advanced Liver Disease
  • Associated with altered drug metabolism
  • CNS dysfunction
  • Bleeding problems
  • Altered protein metabolism

34
Commonly Used Medications Metabolized in the Liver
  • Analgesics - acetaminophen, narcotics, ASA,
    NSAIDS
  • Anesthetics - lidocaine, procaine, mepivicaine
  • Antibiotics - erythromycin, tetracycline,
    metronidazole, clindamycin

35
Commonly Used Medications Metabolized in the
Liver Cont.
  • Use extreme caution for patients with prolonged
    bleeding as ASA and NSAID can make it worse
  • Anesthetics - lidocaine has not been associated
    with any side effects when used appropriately
  • Antibiotics metronidazole and tetracylcine
    metabolism may be severely impaired in patients
    with acute hepatitis or cirrhosis and should not
    be used

36
Diagnosis and Treatment of Oral Manifestations of
HIV HCV Infection
37
Fungal Disease
  • Candidiasis- Candida albicans

38
Oral Candidiasis
  • Occurs in persons with poorly controlled
    diabetes, pregnancy, hormone imbalance, those
    receiving broad spectrum antibiotics, long term
    steroid treatment, cancer therapy and other
    immunocompromised individuals
  • Oral lesions may be erythematous,
    pseudomembranous, hyperplastic or angular
    cheilitis, DD-oral hairy leukoplakia

39
Candidiasis- Treatment
  • Topical therapy with nystatin or clotrimazole is
    effective. Treatment length is usually 10-14
    days, follow up in 2 weeks
  • Clotrimazole 10mg, 1 tab 5x/day, dissolve slowly
    and swallow, 10 day treatement
  • Systemic treatment with fluconazole 100 mg/day
    for 10 days for oropharyngeal/r esophageal
    disease, follow up in 2 weeks

40
Bacterial Diseases
  • Linear Gingival Erythema
  • Necrotizing Ulcerative Gingivitis
  • Necrotizing Ulcerative Peridontitis

41
Periodontal Disease
  • Linear Gingival Erythema - profound erythema of
    the free gingival margin, responds poorly to
    treatment, usually asymptomatic.
  • Treatment - plaque removal and reinforce good
    oral hygiene, follow up in 2 weeks, frequent
    recalls, chlorhexadine

42
Periodontal Disease
  • HIV Necrotizing Gingivitis- erythema with
    ulceration and loss of interdental papillae.
  • Treatment - aggressive plaque removal,
    debridement, and reinforce good oral hygiene,
    follow up in 1 week, frequent recalls,
    chlorhexadine

43
Periodontal Disease Cont.
  • HIV Necrotizing Periodontitis - erythema,
    necrotic tissue and bone, halitosis, severe pain
    and loose teeth.
  • Treatment - removal of necrotic tissue,
    chlorhexadine rinsing with additional use of
    metronidazole, follow up in 3-4 days, frequent
    dental visits and reinforcement of good oral
    hygiene.

44
Viral Diseases
  • Hairy Leukoplakia
  • Herpetic simplex ulceration
  • Human Papillomatous growth
  • Kaposi sarcoma
  • Cytomegalovirus ulceration

45
Hairy Leukoplakia
  • Bilateral symmetrical white corrugated lesions
    on the lateral borders of the tongue as a result
    of reactivation of EBV
  • Usually asymptomatic, requires no treatment but
    podophyllum resin peels may be used
  • DD - tobacco associated leukoplakia, lichen
    planus, epithelial dysplasia, hyperplastic
    candidiasis

46
Herpes Simplex Ulceration
  • One or more small lesions usually on keratinized
    mucosa - hard palate, gingiva but may also be on
    vermilion border of lips and adjacent facial skin
  • Begins as painful multiple lesions and may
    coalesce to large, erosive ulceration
  • Treat with oral acyclovir for 10-14 days, follow
    up in 2 weeks

47
Kaposi Sarcoma
  • Reddish, purple flat or raised lesion usually on
    gingiva or hard palate. DD-hemangioma,
    hemorrhage. Biopsy shows neoplastic proliferation
    of endothelial cells
  • Inform patients medical provider to rule out KS
    in other locations

48
Kaposi Sarcoma Cont.
  • Treatment - intra-lesional injection with
    vinblastin (1x/week, 3-4 weeks), surgical
    excision, or radiation therapy, or both. Follow
    up every 4 weeks for 3 months

49
Cytomegalovirus Ulceration
  • Usually in severely immunocompromised
    individuals, CD4lt50
  • Painful ulceration on any mucosal surface with
    nonindurated borders

50
Cytomegalovirus Ulceration Cont.
  • Biopsy lesion to confirm diagnosis
  • Inform medical doctor, ophthalmologic
    consultation to rule out CMV retinitis
  • Treatment - oral or IV gangciclovir, foscarnet,
    follow up in 1 week

51
Other Diseases
  • Lymphoma
  • Fibroma
  • Minor/ recurrent apthous ulceration
  • Major apthous ulceration

52
Lymphoma
  • Non-Hodgkin's- soft tissue swelling that is red
    and inflamed, painful and progresses rapidly
  • Diagnosis - biopsy
  • Inform medical provider to coordinate treatment,
    follow up 1 week
  • Treatment - systemic combination of chemotherapy,
    radiation and excision

53
Fibroma
  • Traumatically induced overgrowth of underlying
    connective tissue
  • May be calcified
  • Treatment - complete surgical removal, follow up
    1-2 weeks for healing

54
Apthous Ulceration- Minor
  • Hormonal and medication (hydroxyurea and
    ddC/HIVID) induced
  • Nonkeratinized mucosa, cheeks, lips, soft palate,
    floor of mouth, ventral tongue
  • Less than 1cm, self-limiting, minor discomfort
  • Treatment - application of topical steriod
    ointment and/or topical anesthetic, follow up
    10-14 days

55
Apthous Ulceration- Major
  • Hormonal and medication (hydroxyurea and
    ddC/HIVID) induced
  • Nonkeratinized mucosa, cheeks, lips, soft palate,
    floor of mouth, ventral tongue
  • Greater than 1cm, deep into connective tissue,
    dysphagia
  • Treatment - short course of systemic steroid
    (prednisone, 80mg/day for 7 days) or thalidomide,
    follow up 5-7 days

56
Salivary Gland Disease
  • Enlarged parotid gland with xerostomia
  • Treat associated xerostomia with pilocarpine (5mg
    TID), sugarless chewing gum, sugarless lemon
    drops, topical fluoride and frequent dental
    cleanings

57
DiscussionQuestions
58
Case Studies
59
Patient I
  • 35 year old HIV male presents to clinic for
    extraction of 1. Tooth is severely decayed but
    is asymptomatic, patient feels healthy.
  • Medical history reveals PCP January 1995,
    esophageal candidiasis 1998, hepatitis C .
  • Current medications combivir(AZT 3TC),
    crixivan, bactrim, ibuprofen, salogen and
    vitamins.
  • Lab values platelets 210K, neutrophil 1000
    cells/ml, hemoglobin 8g/dl, viral load 250
    copies/ml, CD4 186 cells/ml, liver enzymes WNL.
  • What is the proper course of action?

60
Patient II
  • 45 year old HIV male recently diagnosed with HIV
    presents for scaling and root planning. Patient
    is a little apprehensive but states that he is in
    good physical condition.
  • Medical history reveals no history of any
    HIV-related illness, syphilis 1978 and gonorrhea
    1980, artificial heart valve placed in June
    1991.
  • Current medications coumadin 5mg/day.
  • Lab values platelets 350K, neutrophils 600
    cells/ml, hemoglobin 12g/dl, VL 8,000 copies/ml,
    CD4 380.
  • What is the proper course of action?

61
Patient III
  • 37 year old HIV female presents to clinic for
    extraction. Tooth is symptomatic, patient
    complains of lethargy and diarrhea.
  • Medical history reveals PCP July 1995, IV drug
    use, clean since January 2000.
  • Current medications tylenol and vitamins.
  • Lab values platelets 46K, neutrophils 700
    cells, hemoglobin 14g/dl, viral load 40,000
    copies/ml, CD4 45 cells/ml.
  • What is the proper course of action?

62
Patient IV
  • 17 year old HIV male presents for comprehensive
    dental care. After initial examination, you note
    that he needs 17 and 32 surgically extracted,
    prophylaxis of teeth, and several large
    restorations.
  • Medical history reveals no opportunistic
    infections, recent diagnosis of HIV, HCV.
  • Current medications patient says he has chosen
    not to take any HIV medications, IFN, Ribavirin.
  • Lab values platelets 146K, neutrophils 1500
    cells, hemoglobin 14g/dl, VL 800 copies/ml, CD4
    455.
  • What is the proper course of action?

63
Patient V
  • 67 year old HIV female presents to clinic for
    full mouth extractions and fabrication of full
    upper and lower dentures. Eight root tips are
    present in each arch and all are asymptomatic.
    Patient has a current complaint of burning tongue
    and trouble swallowing. She says that she has
    had this before and her doctor gave her some
    pink pills and it cleared it right up.
  • Medical history reveals diabetes 1987, PCP July
    1998, cervical cancer September 1999, esophageal
    candidiasis march 2000 and April 2000.

64
Patient V Cont.
  • Current medications Nelfinavir, HIVID, Ziagen,
    Bactrim, Insulin 2x/day
  • Lab Values platelets 85K, Neutrophils 700
    cells/ml, hemoglobin 10g/dl, viral load 400,000
    copies/ml, CD4 84 cells/ml, glucose 160mg/dl.
  • What is the proper course of action?
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