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HIV/AIDS

Risks to the dental patient

Management During Treatment

Questions to Ask 

Diagnostic Tests 

  • Medical consultation should be obtained in Stage 3 patients if invasive procedures are required (including periodontal treatment). 

Clinical Findings 

  • Oral lesions that may be present BEFORE diagnosis of HIV infection

    • Candidiasis (the most common oral manifestation of HIV infection) 

      • Psuedomembranous and erythematous candidiasis are strong indicators for progression to AIDS

    • Hairy leukoplakia

    • Kaposi's sarcoma

  • Other oral conditions associated with HIV infection

    • HSV

    • Herpes zoster

    • Recurrent aphthous ulcerations

    • Linear gingival erythema

    • Necrotizing ulcerative periodontitis

    • Necrotizing stomatitis

    • Oral warts (verruca vulgaris, squamous papilloma, HPV/condyloma acuminatum)

    • Salivary gland enlargement

    • Xerostomia

    • Linear gingival erythema

    • Lymphadenopathy at cervical and submandibular locations

Prevention 

  • Antibiotic prophylaxis prior to dental treatment IF severe neutropenia is present

  • Patients with severe thrombocytopenia may require platelet replacement

  • Routine periodic visits for Stage 1 patients

  • More frequent follow-up for patients in Stage 2 or 3

  • Stage 3 may require in-hospital treatment

  • Delay treatment in the case of pulmonary infections

  • Stage 1 and 2 patients

    • Routine and complex dental treatment may be provided as needed

    • Oral infections should be treated through local and systemic measures

    • Root canal therapy has good success in patients with HIV infection

  • Stage 3 patients

    • Routine dental treatment may be provided when risks of immunosuppression, neutropenia and thrombocytopenia have been addressed.

    • Severe oral infections may need to be treated in hospital setting

    • Complex treatment plans should not be undertaken without honest and open discussion of the patient's long term prognosis.  Routine or palliative treatment to control dental and oral disease should be provided.

  • Carefully evaluate the interactions of patient's drugs with medications that you may prescribe for your patient.

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • When were you diagnosed with HIV infection?

  • What is your current CD4+ count?

  • What is your current viral load?

  • What stage is your HIV infection?

  • Do you have any AIDS defining conditions?

  • What is your neutrophil count?

  • What is your platelet count?

  • What medications are you taking?

  • Are you taking your medications as directed?

  • How often do you see your physician?

Introduction

CDC Definition of AIDS

  • Laboratory-confirmed evidence of HIV infection in a person who has stage 3 HIV infection - CD4+ lymphocyte count less than 200 cells/microL

  • Patients who have a CD4+ lymphocyte count above 200 cells/microL, but have an AIDS-defining condition.

CDC Defined Stages of HIV Infection:  

  • Stage 1

    • Lab confirmation of HIV infection

    • no AIDS-defining conditions

    • CD4+ >= 500 cells/microL OR CD4+ percentage of total lymphocytes of >= 29

    • Asymptomatic

    • Begins immediately after HIV exposure and may last for years

  • Stage 2

    • Lab confirmation of HIV infection

    • no AIDS-defining condition

    • CD4+ = 200-499 cells/microL OR CD4+ percentage of total lymphocytes of 14-28

    • Progressive immunosuppression and symptomatic disease

  • Stage 3 - AIDS

    • Lab confirmation of HIV infection

    • CD4+ lymphocyte count  <200 cells/microL OR CD4+ T lymphocyte percentage of total lymphocytes is <14

    • AIDS -defining condition (supersedes CD4+ lymphocyte count  >200 cells/microL OR CD4+ T lymphocyte percentage of total lymphocytes is > 14)

Treatment Goals of Medical Management of the HIV-infected patient

  1. Reduce HIV-associated morbidity and prolong the duration and quality of survival

  2. Restore and preserve immunologic function

  3. Maximally and durably suppress plasma HIV viral load

  4. Prevent HIV transmission

Viral Load

  • Goal of HIV treatment is to move viral load to undetectable levels

  • Viral load is considered "undetectable" if it is <40-75 copies/mL

  • Virologic failure is >200 copies/mL in the presence of ART (antiretroviral treatment)

AIDS Defining Conditions

  • Infection

  • Bleeding

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