Hiv Hcv Coinfected Patient

Comprehensive Dental Management of the HIV/HCV Infected PatientDiagnosis 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 worldwide4 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 usersBody 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 consumptionInterferon 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 HCVEstimated 300,000 people co-infected with HIV and HCVAs 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 HAARTincreases risk of perinatal HIV transmissionmay increase HIV progression, morbidity & mortality

HIV: increases hepatitis C viremiacan hinder diagnosis of HCV

increases HCV progression, morbidity & mortality

Patient Management

Hemostatic functionSusceptibility to infectionDrug actions/interactionsAbility 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 labGood 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 techniqueRoutine antibiotic use is

contraindicatedIncidence 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)

NeutropeniaIndwelling catheters

Treatment Planning - Periodontal Considerations

Frequent recallsAdjunctive use of antimicrobials and

chlorhexadine

Treatment Planning - Endodontic Considerations

Assess ability to withstand treatmentEndodontic treatment offers same

benefits and risks as with other groups

Consider one-step endodontic therapy where appropriate

Patient Management

Hemostatic functionSusceptibility to infectionDrug actions/interactionsAbility to withstand treatment

Normal Lab Values

Platelets/ml 150-300KNeutrophil cells/ml 2500-7000Hemoglobin g/dl 14-18 male,

12-16 female

CD4 cells/ml 800-1500

Laboratory Markers of Liver Disease

Normal ModerateElevation

High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50

alkalinephosphatase U/L

0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750


High

serumbilirubinmg/dl

0.5-1.2 4-10 10-50


0-50 250-750 >750

NORMAL MODERATEELEVATION

HIGHELEVATION

SERUMBILIRUBIN

0.5-1.2 MG/DL

4-10 10-50

ALT, SGPT 0-50 U/L 400-2000 2000-30,000

AST, SGOT

0-50U/L 400-2000 2000-30,000

ALKALINE PHOSPHATASE

0-250 U/L 250-750 >750

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 dysfunctionBleeding problemsAltered 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 ErythemaNecrotizing Ulcerative GingivitisNecrotizing 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 LeukoplakiaHerpetic simplex ulceration Human Papillomatous growthKaposi sarcomaCytomegalovirus 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 diagnosisInform medical doctor,

ophthalmologic consultation to rule out CMV retinitis

Treatment - oral or IV gangciclovir, foscarnet, follow up in 1 week

Other Diseases

LymphomaFibromaMinor/ recurrent apthous ulcerationMajor apthous ulceration

Lymphoma

Non-Hodgkin's- soft tissue swelling that is red and inflamed, painful and progresses rapidly

Diagnosis - biopsyInform 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 calcifiedTreatment - 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.


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.


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.


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.


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