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❚Comprehensive Dental

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

❚ Virus infects specific cells bearing


CD4 membrane glycoprotein

❚ HIV enters cell and its RNA is


transcribed into DNA by reverse
transcriptase enzyme
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
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
Acute or Chronic Liver
Disease

❚ Infection with hepatitis A, B or C

❚ Drug induced - alcohol, IV drug,


other toxic chemical
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
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
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
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 patient’s physician should be done to
determine degree of liver dysfunction
Hepatitis C Virus
Treatment

❚ Limit alcohol consumption


❚ Interferon alpha and ribavirin
therapy
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
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
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
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
Patient Management

❚ Hemostatic function
❚ Susceptibility to infection
❚ Drug actions/interactions
❚ Ability to withstand treatment
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
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
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
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
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
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
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
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
Treatment Planning -
Periodontal Considerations

❚ Frequent recalls
❚ Adjunctive use of antimicrobials and
chlorhexadine
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
Patient Management

❚ Hemostatic function
❚ Susceptibility to infection
❚ Drug actions/interactions
❚ Ability to withstand treatment
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
Laboratory Markers of
Liver Disease
NORMAL MODERATE HIGH
Normal
Normal Moderate
Moderate High
Normal Moderate High
ELEVATION ELEVATION High
Elevation
Elevation
Elevation
SERUM 0.5-1.2 4-10 10-50
serum
serum
serum MG/DL
BILIRUBIN
bilirubin
bilirubin 0.5-1.2
0.5-1.2 4-10
4-10 10-50
10-50
bilirubin
ALT, 0.5-1.2
SGPT 0-50 U/L 400-2000 4-10
2000- 10-50
mg/dl
mg/dl 30,000
mg/dl
AST, SGOT 0-50U/L 400-2000 2000-
alkaline
alkaline
30,000
alkaline 0-250 U/L 250-750 >750
phosphatase
ALKALINE
phosphatase 0-50
0-50 250-750
250-750 >750
phosphatase 0-50
PHOSPHAT 250-750 >750
>750
U/L
U/L
ASE
U/L
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
Advanced Liver Disease

❚ Associated with altered drug


metabolism
❚ CNS dysfunction
❚ Bleeding problems
❚ Altered protein metabolism
Commonly Used Medications
Metabolized in the Liver

❚ Analgesics - acetaminophen,
narcotics, ASA, NSAIDS
❚ Anesthetics - lidocaine, procaine,
mepivicaine
❚ Antibiotics - erythromycin,
tetracycline, metronidazole,
clindamycin
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
Diagnosis and Treatment
of Oral Manifestations of
HIV & HCV Infection
Fungal Disease

Candidiasis- Candida
albicans
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
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
Bacterial Diseases

❚ Linear Gingival Erythema


❚ Necrotizing Ulcerative Gingivitis
❚ Necrotizing Ulcerative Peridontitis
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
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
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.
Viral Diseases

❚ Hairy Leukoplakia
❚ Herpetic simplex ulceration
❚ Human Papillomatous growth
❚ Kaposi sarcoma
❚ Cytomegalovirus ulceration
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
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
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 patient’s medical provider


to rule out KS in other locations
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
Cytomegalovirus
Ulceration

❚ Usually in severely
immunocompromised individuals,
CD4<50
❚ Painful ulceration on any mucosal
surface with nonindurated borders
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
Other Diseases

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

❚ Traumatically induced overgrowth of


underlying connective tissue
❚ May be calcified
❚ Treatment - complete surgical
removal, follow up 1-2 weeks for
healing
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
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
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
Discussion

Questions
Case Studies
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?
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?
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?
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?
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.
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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