AIDS & Dentistry

HARSH PARIKH

IV BDS

R.NO.36

Contents:

Introduction

HIV Virology

Transmission

Oral pathophysiology of HIV infection

Oral conditions associated with HIV infection

Infection Control

Ethical Considerations

AIDS & Dentistry

INTRODUCTION:

• AIDS is Acquired Immune Deficiency Syndrome.• It commonly occurs due to the infection of the Human Immune

Defficiency Virus.

HIV Virology– HIV belongs to retrovirus family. – It contains two copies of single

stranded rebonucleic acid(RNA).

• The viral RNA is surrounded by a capsid made

from viral proteins and this is enclosed in a viral

envelope formed from the cellular membrane

of the host cell.

• Following infection of a cell, viral RNA is converted to deoxyribonucleic acid (DNA).

• The main targets for HIV infection are cells in the immune system, particularly CD4 cells.

• CD4 cells are regulators and effectors of the normal• immune response. • Over time, CD4 cell counts decline, which results in a

poorly functioning immune system (immunodeficiency).

• This eventually leads to AIDS, which is indicated by the opportunistic infections.

Transmission

HIV can be transmitted through the following body fluids:• Blood• Semen• Vaginal fluid• Breast milk

HIV can’t be transmitted through the following :• Saliva• Tears• Urine• Mosquitoes• Toilet Seats• Kissing• Hugging

• HIV is present in saliva, however it is not considered a risk factor for transmission.

• It contains low levels of HIV that can be detected, and the endogenous antiviral factors present in saliva.

Oral pathophysiology of HIV infection

• Oral lesions may be present at all stages of HIV infection.

• As the immunodeficient state gradually impairs humoral and cell-mediated immunity it allows other diseases to affect the patient.

• Oral conditions associated with HIV infection are divided into

five major groups:

-Microbiological infections (fungal, bacterial, viral)

-Oral neoplasias

-Neurological conditions

-Lesions of uncertain aetiology

-Oral conditions associated with HIV treatment.

• Other co-infections and conditions associated with HIV infection,

which are significant to dentists are:

-Syphilis

-Tuberculosis

-Persistent generalised lymphadenopathy

-Gastro-oesophageal reflux disease (GORD).

Oral conditions associated with HIV treatment

Dry lips:• Associated with HIV-treatment. • The cracking and crusting of the lips

can be extremely uncomfortable and

unaesthetic. • Protective creams designed for use

on the dry lips.

Other conditions associated with HIV treatment include:• Xerostomia• Oral ulceration• Hyperpigmentation

HIV and tooth decay

• Dental caries is common in people with HIV infection,due to Xerostomia which occurs due to the HIV infection or its treatment.

• Treatment includes “scoop and fill”. • Decayed material is scooped out using

hand instruments and replaced with

temporary filling usually with

glass ionomer.

Microbiological infections

Fungal Infections

• Mycoses or fungal infections are often the first and most prevalent conditions affecting the oral mucosal surfaces of patients with HIV infection.

• The main fungal pathogen involved in oral disease is Candida albicans.

• Lesions occurring by candida albicans,

-Pseudomembranous candidiasis

-Erythematous candidiasis

-Chronic hyperplastic candidiasis

Pseudomembranous candidiasis

• Description: creamy white or yellow plaques which, when scraped, reveal an erythematous or bleeding mucosal surface.

• Location: may be found on any of the

intra-oral surfaces.

• Symptoms: none or mild-to-moderate

pain or burning.

• Duration: usually intermittent, however may be chronic.

• Diagnosis: clinical, with a swab for microscopy and culture

when the diagnosis is uncertain.

Erythematous candidiasis

• Description: patchy red or erythematous areas that may become diffuse and atrophic.

• Location: commonly found on the

hard palate and the dorsum of the

tongue and occasionally on the

buccal mucosa

• Symptoms: none or mild-to-moderate pain or burning

• Duration: usually intermittent, however may be chronic. The chronic form is often associated with dentures

• Diagnosis: clinical, with a swab for microscopy and culture when there is an uncertain diagnosis or poor response to treatment.

Chronic hyperplastic candidiasis

• This condition has an association with smoking.• It is generally considered premalignant and may demonstrate

dysplasia.• Description: Homogenous white patches that are rough and

irregular and cannot be wiped off.• Location: Buccal mucosa near the

labial commissures less frequently

palate or tongue• Symptoms: usually symptomless.• Duration: chronic• Diagnosis: clinical, with a swab for microscopy and culture.

Bacterial Infections

• There is a wide range of bacterial pathogens that cause oral disease in patients with HIV infection.

• Common bacterial infection occurs in HIV are,

-Necrotising ulcerative gingivitis

-Necrotising ulcerative periodontitis

-Necrotising ulcerative stomatitis

Necrotising ulcerative gingivitis• It presents with pain, ulceration and gingival bleeding. • The lesion does not involve the alveolar bone.

• Description: the characteristic lesion is a punched out, ulcerated and erythematous interdental papilla covered by a greyish necrotic slough.

• Location: gingival tissues particularly

the interdental papillae.

• Symptoms: moderate-to-severe pain,

bleeding.Systemic features such as

fever, malaise and lymphadenopathy.

• Duration: sudden onset and rapidly deteriorating

• Diagnosis: clinical.

Necrotising ulcerative periodontitis• The lesion involves the alveolar bone.

• Description: There may be exposed bone

gingival recession and tooth mobility.

• Location: the interdental papilla extending

into deeper periodontal tissues.

• Symptoms: moderate-to-severe pain, bleeding.Systemic features

such as fever, malaise and lymphadenopathy may be present.

• Duration: sudden onset and rapidly worsening

• Diagnosis: clinical

Syphilis and tuberculosis are also common opportunistic Bacterial infections in AIDS.

Viral Infections

Herpes simplex virus (HSV)

• Description:Small, round vesicles that rupture, leaving shallow ulcers which can coalesce.

• Location : Hard palate, gingiva and

dorsum of the tongue• symptoms: Mild-to-severe pain.

Fever, lymphadenopathy and

other symptoms may occur.• Duration: rapid onset with a duration of 7–14 days.• Diagnosis: swab for PCR analysis.

Epstein-Barr virus (EBV)

• EBV has been linked to oral ulceration in patients with advanced HIV infection.

• The chief manifestation of EBV in people with HIV infection is

Oral hairy leukoplakia.

Oral neoplasias

• Two common malignancies associated with HIV infection that are ----Kaposi’s sarcoma

-non-Hodgkin’s lymphoma (NHL).

Kaposi’s sarcoma(KS)• KS starts red macule which enlarges to form a red-blue plaque and

these plaques may grow into lobulated nodules that may ulcerate sometimes cause pain.

• Description: Pigmented lesions ranges from flat macules to ulcerated nodular masses. The lesions can be red, purple, blue or brown in colour.

• Location: Hard palate,gingiva and

buccal mucosa.• Symptoms: lesions are usually painless• Duration: chronic• Diagnosis: clinical followed by biopsy.

Non-Hodgkin’s lymphoma (NHL)

• HIV infection is association with EBV can induce NHL.

• Description: Diffuse, rapidly proliferating, slightly purplish mass

• Location: In the palatal-retromolar complex.

• Symptoms: Generalised symptoms fever, night sweats and weight loss.

• Duration: chronic.

• Diagnosis: clinical followed by biopsy.

Infection ControlHand Hygiene• The purpose of hand hygiene is to reduce the quantity of micro

organisms of hands.

Protective Equipment• Protective equipment would include gloves, masks, protective

eye-wear and protective clothing.• It protects from the splashing or spraying of blood, saliva or other

body fluids.

Gloves• Double-gloving may be utilized for some specific procedures and

in the infected patient’s treatment.

Masks ,Eye wear, Protective Clothing• They are weared to protect from splashes, sprays or spatter of

blood, saliva, other body fluids, or contaminated water.

Ethical Considerations

• A Common Form of Human Rights Violation is a Dentist refusing to take on a new patient due to their HIV status.

• Courts have recognized that privacy concerns are of paramount importance for people with HIV.

• HIV status of a patient should be protected and not revealed without the patient’s written informed consent.

• The form must be signed and dated and a witness signature may be prudent.

Title of the study with author and

journal information

Research design and Level Of

Evidence(According to CEBM criteria)

Problem/ population

Methods ( including

Intervention and comparison)

Outcome/Results

Conclusion

Is human immunodeficiency virus (HIV) stagean independent risk factor for altering theperiodontal status of HIV-positive patients?A South African study

A Cohort study. 120 HIV-infected patients attending an infectious diseases clinic in the Western Cape,South Africa were included in the study

The periodontal clinical indices such as plaque index, gingival index, pocketprobing depth and clinical attachment levels were measured on the mesial aspect of the six Ramfjord teeth. TheCD4 + T cell counts were taken from the patients’ medical records and patients’ HIV stage determined and groupedaccording to their CD4+ T cell counts into A (<200 cells /mm3), B (200–500 cells /mm3) and C (>500 cells /mm3).

The mean age of 120 HIV-positive patients was 33.25 years and the mean CD4 + T cell count was293.43 cells/mm3.-No correlation was found between age and HIV stage of thepatients.

HIV stage, ART and age are not independent risk factors forchanges in the periodontal status of HIV-positive subjects but rather that smoking and oral hygiene habitsdetermine their susceptibility to disease.