Have you ever had letters written about your work– to your boss…

1. Have you ever had letters written about your work– to your boss…

2. From people that are so thankful that you provided them with much needed dental care, when everyone else they turned to-- turned them away?

3. This still happens in this country, in our cities and towns…

4. Oral Health Managementfor the HIV/AIDS Patient

5. Objectives & Disclosures • Review of common medications in the medical management of HIV • Discuss the role of oral health professional in HIV care • Discuss pertinent factors in the medical and laboratory assessment • Diagnosis & treatment of oral conditions in an HIV patient Mona Van Kanegan has no financial interest/relationship with any manufacturers of commercial products

6. Awareness of Serostatus Among Persons With HIV, United States 800,000 diagnosed HIV/AIDS cases 250,000 undiagnosed HIV infections (25%) 40,000 new infections annually

7. Of the 25% of that are unaware of their HIV infection, they account for 55% of new infections Awareness of Serostatus Among People With HIV and Estimates of Transmission

8. Medical Management of HIV • Opportunistic Infection Prophylaxis • recurrent Candida = fluconazole, clotrimazole • recurrent HSV = acyclovir • TB (if PPD+) = INH + B6, RIF + PZA • PCP (CD4 < 200) = TMP-SMX, dapsone • Toxo (CD4 < 100) = TMP-SMX, dapsone • MAC (CD4 < 75) = azithromycin, clarithromycin • Antiretroviral Therapy (HAART) • 3 – 4 anti-HIV meds used in a combination regimen

9. Antiretroviral Agents • Nucleoside Analog RT Inhibitors (NRTIs) • Thymidine: AZT / ZDV = zidovudine = Retrovir • d4T = stavudine = Zerit • Adenosine: ddI = didanosine = Videx • TFV = tenofovir = Viread • Cytidine: 3TC = lamivudine = Epivir • ddC = zalcitabine = Hivid • Guanosine: ABC = abacavir = Ziagen • ZDV+3TC = dual NRTI = Combivir • ZDV+3TC+ABC =triple NRTI = Trizivir

10. Non-nucleoside RTIs Nevirapine = Viramune Delavirdine = Rescriptor Efavirenz = Sustiva Fusion Inhibitor Enfuvirtide (T-20) Protease Inhibitors Indinavir = Crixivan Nelfinavir = Viracept Ritonavir = Norvir Saquinavir = Fortovase = Invirase Amprenavir = Agenerase Lopinavir/Ritonavir = Kaletra Antiretroviral Agents

11. Role of Oral Health Professionals in HIV Care • Provide preventive and theraputic dental care to improve health and reduce complications from dental infections • Help maintain overall physical well-being of patients and improve health outcomes • Recognize, treat, and understand the significance of oral lesions

12. Routine Oral Care of HIV Patients • Is part of a multidisciplinary approach by improving oral health and maintaining overall health • Recognize oral manifestation of systemic disease– diabetes, HIV, eating disorders… • Is usually straight forward and requires no special facility or equipment • Clinicians should comply with the current infection control recommendations

13. Assessment of HIV Patients • The medical complexities of patients with HIV often involve non-HIV associated conditions • diabetes, heart, liver & kidney diseases, etc • Develop an appropriate dental treatment plan: • Assess patient’s overall health (not just HIV issues) and screen for underlying medical conditions that may require modification of dental care • Obtain a medical history and labs in consultation with the patient’s primary provider • Assess risks associated with dental care

14. Medical History & Labs • CBC with differential • PT, PTT, INR, hemoglobin and neutrophils • CD4 cells and Viral load • first count; lowest count; latest count • Recent HIV-related symptoms or illnesses • HAV/HBV/HCV and TB status • Current medications

15. Assessment of the Risks Associated with the Provision of Dental Care • Hemostasis • Clotting factors are decreased in severe liver disease • Number & function of platelets may be reduced 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 pts with platelets >60,000/mm3 and PT/PTT of 0.8-2.5 INR • For multiple extractions / extensive cleaning, remove 1 tooth or clean 1 area at a time and then proceed

16. Assessment of the Risks Associated with the Provision of Dental Care • Susceptibility to infections • low CD4 count, leukopenia, neutropenia • hyperglycemia and diabetes • other immuno-compromised conditions • Drug actions and interactions • polypharmacopiea: HIV-related and other meds • antibiotics (prophylaxis, etc): avoid “doubling up” • hepatic and/or renal disease

17. Laboratory Values (Reznik and Bednarsh, June 2006)

18. Aggressive Prevention Efforts • Recall visits every 3 – 4 months • BWX every 6 – 8 months • Topical fluoride foam or varnish • Assess need for oral hygiene instruction and dispense toothbrush, other aids, antimicrobials • Nutritional counseling

19. Cavity Prevention

20. Cavity Prevention toothpaste & floss rinses proxabrush

21. Xerostomia Aids mouth spray Rx fluoride paste xylitol-based gum

22. Routine Oral Care of HIV Patients Treat as indicated: • Restorative • same • Oral Surgical Procedures • Take care to minimize bleeding and trauma, postoperative complications no higher than in the HIV-negative group • Removable Prosthodontics • same

23. Invasive Dental Procedures • Follow aseptic technique • Have results of recent labs to assess hemostatic function and susceptibility to infection • Incidence of post-procedure complications is no greater than other populations (w/o diabetes), although patients with prolonged clotting time will experience delayed wound healing

24. Indications for Antibiotic Prophylaxis • Literature does not support routine antibiotic prophylaxis, decision to use antibiotic should be made on an individual basis • If Neutrophil count is <500 cells/mm3, antibiotic use in indicated. • Ask specifically about hospitalizations due to bacterimia (esp. in the IDU population) and consult with PCP • Follow the updated AHA guidelines on antibiotic prophylaxis to prevent bacterial endocarditis

25. Indications for Antibiotic Prophylaxis • CD4 count is not in itself an indication for prophylaxis, but patients with CD4 <100 or on long-term chemotherapy should be checked for neutropenia • For moderate neutropenia (absolute count 500-1000), determine antibiotic use based on procedure performed (if extensive prophylax), anticipated risk of secondary infection, and consultation with physician • For severe neutropenia (absolute count <500) antibiotics should be used before all invasive dental procedures • Preferred prophylaxis: AHA antibiotic prophylaxis regimen prior to invasive dental procedure

26. Support Overall Physical Well-being of HIV Patients • Help pts be free of pain and able to eat/chew • Support patient compliance with medical care • Reinforce adherence to medications • Screen for medication side effects / toxicities • Tobacco cessation; referral for drug / alcohol abuse • STD prevention / risk reduction • Help identify undiagnosed patients and refer them for testing and/or medical care

27. Case Study: New Patient • 48 yo female, immigrated from Eastern Europe ~ 8 yrs ago schedules dental appointment for an exam and treatment plan; patient states that her mouth “burns.” • Med Hx: no reported meds or diseases • Drug Hx: tobacco (12/pk yr history) and cocaine use. • Dental Hx: teeth extracted 2 yrs ago and complete immediate dentures made • Is there anything in the patient’s history to indicate a risk of HIV infection? If so, what?

28. Case Study: Suspicious Lesion

29. Case Study: Suspicious Lesion • Rule out other reasons for candidiasis • Ask patient about possible HIV exposure risks • Be honest, compassionate, non-judgmental • Don’t be afraid of silence • HIV diagnosis is no longer a death sentence; the sooner the diagnosis is confirmed, the sooner effective treatment can be initiated • Offer referrals for HIV/AIDS testing and other support systems/ service agencies

30. Diagnosis of Oral Lesions • Oral exam procedures are the same for HIV patients as for all dental patients • Most lesions are not caused directly by HIV but result from secondary infections stemming from underlying immune deficiency or derangement. • Similar lesions occur in association with other immune deficiency disorders • Diagnosis should be re-evaluated if treatment is not effective

31. Fungal Disease • Oral candidiasis (Candida albicans) • Occurs with poorly controlled diabetes, hormone imbalance, pregnancy, long term antibiotic and steroid treatments, cancer therapy, and other immuno-compromised conditions • Oral lesions may be pseudomembranous, hyperplastic, erythematous, or angular cheilitis, DD = oral hairy leukoplakia

32. Oral Candidiasis

33. Oral Candidiasis

34. Oral Candidiasis

35. Oral Candidiasis

36. Oral Candidiasis (erythematous)

37. Oral Candidiasis / Angular Cheilitis

38. Candidiasis Treatment • Topical therapy with nystatin or clotrimazole; tx length is usually 10-14 days, follow-up in 2 wks • Clotrimazole 10mg, 1 tab 5x/day, dissolve slowly and swallow, 10 day treatment • For oropharyngeal/esophageal disease, apply systemic treatment with fluconazole 100 mg/day for 10 days, follow-up in 2 wks

39. Bacterial Diseases • Linear Gingival Erythema • Necrotizing Ulcerative Gingivitis • Necrotizing Ulcerative Periodontitis

40. 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 wks, frequent recalls, chlorhexadine

41. Linear Gingival Erythema

42. Necrotizing Ulcerative Gingivitis • Erythema with mild ulceration of gingival tissue • Treatment is usually very successful • aggressive plaque removal • Thought to be a precursor of the more extensive ulcerative peridontitis • follow-up in 3-4 days; dental visits every 3-4 mos for cleaning • stress good oral hygiene and return for any recurrence of sxs.

43. Necrotizing Ulcerative Gingivitis

44. Necrotizing Ulcerative Gingivitis

45. Necrotizing Ulcerative Periodontitis • Erythema with ulceration and loss of interdental papillae, necrotic tissue and bone, halitosis, severe pain and loose teeth • Treatment is usually very successful • aggressive plaque removal (may need to numb up first) • debridement of necrotic tissue and chlorhexadine rinsing (with add’l use of metronidazole if large areas are affected) • follow-up in 3-4 days; dental visits every 3-4 mos for cleaning • stress good oral hygiene and return for any recurrence of sxs.

46. Necrotizing Ulcerative Periodontitis

47. Necrotizing Ulcerative Periodontitis

48. Post Treatment

49. Viral Diseases • Hairy Leukoplakia • Herpes Simplex • Human Papilloma Virus (HPV) • Kaposi Sarcoma • Cytomegalovirus

50. 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