Have you ever had letters written about your work

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Have you ever had letters written about your
work to your boss
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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
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Oral Health Managementfor the HIV/AIDS
Patient
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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

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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

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Awareness of Serostatus Among People With HIV and
Estimates of Transmission

• Of the 25 of that are unaware of their HIV
  infection, they account for 55 of new infections

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Medical Management of HIV

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

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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
• ZDV3TC dual NRTI Combivir
• ZDV3TCABC triple NRTI Trizivir

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Antiretroviral Agents

• 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

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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

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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

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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 patients 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 patients primary provider
• Assess risks associated with dental care

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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

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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 gt60,000/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

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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

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Laboratory Values (Reznik and Bednarsh, June 2006)
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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

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Cavity Prevention
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Cavity Prevention
toothpaste floss
rinses
proxabrush
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Xerostomia Aids
mouth spray
Rx fluoride paste
xylitol-based gum
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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

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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

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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 lt500 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

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Indications for Antibiotic Prophylaxis

• CD4 count is not in itself an indication for
  prophylaxis, but patients with CD4 lt100 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 lt500)
  antibiotics should be used before all invasive
  dental procedures
• Preferred prophylaxis AHA antibiotic prophylaxis
  regimen prior to invasive dental procedure

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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

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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 patients history to
  indicate a risk of HIV infection? If so, what?

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Case Study Suspicious Lesion
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Case Study Suspicious Lesion

• Rule out other reasons for candidiasis
• Ask patient about possible HIV exposure risks
• Be honest, compassionate, non-judgmental
• Dont 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

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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

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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

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Oral Candidiasis
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Oral Candidiasis
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Oral Candidiasis
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Oral Candidiasis
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Oral Candidiasis (erythematous)
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Oral Candidiasis / Angular Cheilitis
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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

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Bacterial Diseases

• Linear Gingival Erythema
• Necrotizing Ulcerative Gingivitis
• Necrotizing Ulcerative Periodontitis

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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

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Linear Gingival Erythema
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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.

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Necrotizing Ulcerative Gingivitis
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Necrotizing Ulcerative Gingivitis
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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 addl 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.

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Necrotizing Ulcerative Periodontitis
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Necrotizing Ulcerative Periodontitis
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Post Treatment
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Viral Diseases

• Hairy Leukoplakia
• Herpes Simplex
• Human Papilloma Virus (HPV)
• Kaposi Sarcoma
• Cytomegalovirus

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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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Oral Hairy Leukoplakia
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Oral Hairy Leukoplakia
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Herpes Simplex

• One or more 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 into large, erosive ulceration
• Treat with oral acyclovir for 10-14 days, follow
  up in 2 wks

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Oral Herpes Simplex
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Oral Herpes Simplex
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Oral HPV Infection

• Exophytic papillary lesions with cauliflower-like
  surface to raised, flat, or smooth lesions
  solitary or multiple
• Treatment
• Excision (for small lesions)
• Cryotherapy
• CO2 laser ablation (in-hospital)
• Interferon-alpha (intra-lesional)

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Oral Papilloma
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Oral Papilloma
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Aphthous Ulceration

• Unknown etiology (trauma, hormones, meds?)
• Non-keratinized mucosa, cheeks, lips, soft
  palate, floor of mouth, ventral tongue
• Minor lt 1cm, self-limiting, minor discomfort
• Tx topical steroid and/or anesthetic, f/u in
  10-14 days
• Major gt 1cm, deep into connective tissue,
  dysphagia
• Tx systemic steroids (prednisone, 80mg/day x 7
  days)
• Alternative tx thalidimide

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Aphthous Ulcer Minor
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Aphthous Ulcer Minor
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Aphthous Ulcer Major
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Aphthous Ulcer Major
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HIV Salivary Gland Disease

• Recurrent or persistent major salivary gland
  enlargement and xerostomia
• Treat associated xerostomia with pilocarpine (5mg
  TID) or other meds to increase secretion,
  sugarless chewing gum, sugarless lemon drops,
  topical fluoride and frequent dental cleanings

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Xerostomia

• Up to 30 of patients taking didanosine and 7
  of patients using protease inhibitors may
  experience xerostomia (HIV Clinician March 2005)
• Minimize use of alcohol and alcohol based
  mouthwashes
• Drink more water, sugarless chewing gums, xylitol
  based gums
• At home use of fluoridated pastes and gels

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Long Term Effects of Xerostomia

• Salivary Gland Enlargement
• Oral Mucosal Soreness
• Dry, sore, cracked lips
• Oral Candidiasis
• Increased frequency of cervical caries
• Gingival and periodontal disease
• Depapillation of tongue (burning tongue)
• Trouble eating, swallowing and speaking
• Dysgeusia (bad taste)
• HIV Clinician March 2005

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Rampant Caries with Root Decay
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Root Decay
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Root Decay Major Aphthous Ulcer
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Meth at the National Level

• An estimated 731,000 current Meth users in the
  US, age 12 or older (slight decline from 1.3M
  seen in 2005)
• 45 of the primary admissions to substance use
  treatment for Meth use were for women (vs 26
  women for alcohol abuse or marijuana use)

http//oas.samhsa.gov/
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Meth at the National Level
                                                  
                                                  
                                                  
                                                  
                                           
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Prevention Intervention

• Meth use has been linked with increased numbers
  of HIV infections in some populations
• Meth increases HIV and other STD risk
• Meth use suppresses immune response to HIV,
  forget to take HIV meds? development of drug
  resistance virus, accelerate HIV related dementia
  and other health problems

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Oral Health--Prevention Intervention

• Four fold effect of drug
• Xerostomic effect
• Cravings for sugarcarbonated beverages
• Tooth grinding, clenching
• Long duration of action leading to long periods
  of poor oral hygiene.

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Clinical Care

• Meth increases heart rate, blood pressure, body
  temperature and dehydrates the body
• Patient may be aggressive, irritable, violent,
  loss of short term memory, may have to give
  written post op-instructions

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Clinical Care

• Duration of Meth high is 8-12 hours, if patient
  reports use in the previous 24 hours, avoid using
  local anesthesia containing vasoconstrictor
• Avoid prescribing opioid analgesics due to their
  abuse potential and the risk of increased
  respiratory depression

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Clinical Care

• Initial treatment plan should include
  prophylaxis, fluoride treatment and caries
  control to determine tooth restorability
• In office and home use of fluorides, OHI,
  increase/stimulate salivary switch to water,
  sugarless gum, pilocarpine, review OHI.
• Damage to teeth is so extensive that the only
  option is extraction and fabrication of dentures

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Case Study Pre-treatment
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Case Study Post Extraction, Scaling, and Root
Planing
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Case Study Final Restorative
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Clinical HIV Resources

• AIDS Education and Training Centers Website
• www.aidsetc.org
• Has an extensive information onoral health
  topics
• Treatment planning guidelines
• Oral Manifestations
• Slide sets, video presentations, CE
• Patient information

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Clinical HIV Resources

• Clinical Manual for the Management of the HIV
  Infected Adult 2006 Edition
• Can print document from the AETC Natl
  Resource Center website
• www.aidsetc.org/aetc?pagecm-00-00

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Clinical HIV Resources

• www.ask.hrsa.gov
• Principles of Oral Health Management for the
  HIV/AIDS Patient- publication code HAB00230)
  call 1-888-275-4772 or Print copies (using Adobe
  Acrobat) directly from the HRSA website
  www.ask.hrsa.gov/ElectronicPublications.cfm?start
  29

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Clinical HIV Resources

• HIV Clinical Guidelines
• Developed by New York State Dept of Health AIDS
  Institute and The John Hopkins University School
  of Medicine, available at www.hivguidelines.org
• Online Database of Oral Health and HIV
• www.hivdent.org

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General HIV Resources

• National Prevention Information Network
• 800-458-5231
• National AIDS Clearinghouse
• 800-458-5231
• PO Box 6003, Rockville, MD 20849-6003

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PEP Resources

• National Clinicians PEPline 888-448-4911
• Needlestick! www.needlestick.mednet.ucla.edu
• HIV/AIDS Tx Info Service www.hivatis.org
• Hepatitis Hotline [phone] www.cdc.gov/hepati
  tis
• CDC 800-893-0485 www.cdc.gov
• FDA 800-332-1088 www.fda.gov/medwatch

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Sources

• Klasser, GD, Epstein J. Methamphetamine and Its
  Impact on Dental Care. JCDA 200571759-762.
• Goodchild JH, Donaldson M. Methamphetamine abuse
  in dentistry A review of the literature and
  presentation of a clinical case. Quintessence
  International 200738583-590.
• Health Bulletin Methamphetamine and HIV. Health
  Mental Hygiene News 200433

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Sources

• Department of Health and Human Services, Centers
  for Disease Control and Prevention.
  Methamphetamine Use and Risk for HIV/AIDS
  www.cdc.gov/hiv/resources/factsheets/meth.htm
• American Dental Association. Dental topics A-Z
  Methamphetamine use. www.ada.org/prof/resources/to
  pics/methmouth.asp
• American Dental Association. ADA warns of
  Methamphetamines effect on oral health. 2005
  www.ada.org/public/meida/releases/0508_release01.a
  sp

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Clinical Consultation Service
MATEC Dental Consultation services are provided
for the diagnosis, prevention, and oral health
management of HIV patients, as well as policy and
system development.
Please contact Mona Van Kanegan, DDS, MS Dental
Director Phone [phone] Fax (773)
275-3689 Email mvankanegan_at_heartlandalliance.org
Leave a voice message with your question, contact
info, and the best time to reach you. Or you can
fax or email the same information. You will be
contacted in 24-48 hrs.