Dental Management of the HIV

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

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

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Comprehensive Dental Management of the HIV/HCV
Infected Patient
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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

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HIV Pathogenesis

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

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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

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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

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Acute or Chronic Liver Disease

• Infection with hepatitis A, B or C
• Drug induced - alcohol, IV drug, other toxic
  chemical

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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

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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

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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

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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

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Hepatitis C Virus Treatment

• Limit alcohol consumption
• Interferon alpha and ribavirin therapy

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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

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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

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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

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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

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Patient Management

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

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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

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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

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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

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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

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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

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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

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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

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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

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Treatment Planning - Periodontal Considerations

• Frequent recalls
• Adjunctive use of antimicrobials and chlorhexadine

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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

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Patient Management

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

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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

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Laboratory Markers of Liver Disease
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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

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Advanced Liver Disease

• Associated with altered drug metabolism
• CNS dysfunction
• Bleeding problems
• Altered protein metabolism

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Commonly Used Medications Metabolized in the Liver

• Analgesics - acetaminophen, narcotics, ASA,
  NSAIDS
• Anesthetics - lidocaine, procaine, mepivicaine
• Antibiotics - erythromycin, tetracycline,
  metronidazole, clindamycin

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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

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Diagnosis and Treatment of Oral Manifestations of
HIV HCV Infection
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Fungal Disease

• Candidiasis- Candida albicans

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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

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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

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Bacterial Diseases

• Linear Gingival Erythema
• Necrotizing Ulcerative Gingivitis
• Necrotizing Ulcerative Peridontitis

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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

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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

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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.

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Viral Diseases

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

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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

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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

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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

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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

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Cytomegalovirus Ulceration

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

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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

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Other Diseases

• Lymphoma
• Fibroma
• Minor/ recurrent apthous ulceration
• Major apthous ulceration

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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

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Fibroma

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

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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

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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

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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

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DiscussionQuestions
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Case Studies
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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?

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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?

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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?

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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?

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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.

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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?