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1 Oral Health Fact Sheet for Dental Professionals Adults with Human Immunodeficiency Virus (HIV) Human immunodeficiency virus (HIV) disease is a syndrome resulting from the acquired deficiency of cellular immunity caused by a complex family of lentiviruses. ese are composed of 2 sub types HIV-1 and HIV-2. HIV infection is characterized by the reduction of the Helper T-lymphocytes in the peripheral blood and the lymph nodes. (ICD 9 code 042) United States Prevalence • >1,000,000 persons in US living with HIV infection; 21% are undiagnosed Manifestations Clinical – among untreated or treatment resistant adults • Generalized lymphadenopathy, fever, weight loss, and chronic diarrhea • Marked suppression of immune function resulting in opportunistic infections such as: pneumocystis carinii pneumonia, cytomegalovirus (CMV) infections, tuberculosis, HSV infections, and cryptococcosis • HIV-associated Neoplasms (usually non-Hodgkin’s lymphoma and Kaposi’s Sarcoma) Oral – oral lesions may be among the first manifestations of disease • Candidiasis of the oral mucosa (most common oral manifestation) * Pseudomembranous type is most common, followed by atrophic/erythematous type and angular cheilitis • Aphthous lesions • HIV-associated periodontal diseases * Linear gingival erythema * Necrotizing ulcerative gingivitis (NUG) and Necrotizing Ulcerative Periodontitis (NUP) • Viral Infection: Herpes Virus Family – HSV, CMV, EBV, VZV, and Human Papilloma Virus lesions • Aphthous ulcerations • Hairy leukoplakia (primarily on the lateral border of the tongue but can involve other areas) • Salivary gland enlargement and decreased salivary gland function • Kaposi’s sarcoma • Intraoral, head and neck lymphomas • Increased caries risk with xerostomia that can be heightened by the use of sugar containing medicines Other Potential Disorders/Concerns • Progressive wasting disease if not well managed • Nausea, vomiting, and diarrhea Behavioral • Apathy • Depression • Anorexia • Fatigue Medication Management and Side Effects • Highly Active Antiretroviral erapy (HAART) are multidrug protocols that allow for suppression of HIV replication (thus lowering viral load) and will allow for recovery to CD4 cell counts and ultimately can lead to improved immune function. Several classes of antiretroviral drugs are available and HAART protocols can include one or several drugs from the drug classes listed below: * Protease inhibitors (PI) * Nucleoside reverse transcriptase inhibitors (NRTIs) * Non Nucleoside reverse transcriptase inhibitors (NNRTIs) * Integrase inhibitors * Fusion inhibitors

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  • 1Oral Health Fact Sheet for Dental ProfessionalsAdults with Human Immunodeficiency Virus (HIV)

    Human immunodeficiency virus (HIV) disease is a syndrome resulting from the acquired deficiency of cellular immunity caused by a complex family of lentiviruses. These are composed of 2 sub types HIV-1 and HIV-2.

    HIV infection is characterized by the reduction of the Helper T-lymphocytes in the peripheral blood and the lymph nodes. (ICD 9 code 042)

    United States Prevalence >1,000,000personsinUSlivingwithHIVinfection;21%areundiagnosed

    ManifestationsClinical among untreated or treatment resistant adults

    Generalizedlymphadenopathy,fever,weightloss,andchronicdiarrhea Markedsuppressionofimmunefunctionresultinginopportunisticinfectionssuchas:pneumocystiscariniipneumonia,cytomegalovirus(CMV)infections,tuberculosis,HSVinfections,andcryptococcosis

    HIV-associatedNeoplasms(usuallynon-HodgkinslymphomaandKaposisSarcoma)

    Oral oral lesions may be among the first manifestations of disease Candidiasisoftheoralmucosa(mostcommonoralmanifestation)* Pseudomembranoustypeismostcommon,followedbyatrophic/erythematoustypeandangularcheilitis

    Aphthouslesions HIV-associatedperiodontaldiseases* Lineargingivalerythema* Necrotizingulcerativegingivitis(NUG)andNecrotizingUlcerativePeriodontitis(NUP)

    ViralInfection:HerpesVirusFamilyHSV,CMV,EBV,VZV,andHumanPapillomaViruslesions Aphthousulcerations Hairyleukoplakia(primarilyonthelateralborderofthetonguebutcaninvolveotherareas) Salivaryglandenlargementanddecreasedsalivaryglandfunction Kaposissarcoma Intraoral,headandnecklymphomas Increasedcariesriskwithxerostomiathatcanbeheightenedbytheuseofsugarcontainingmedicines

    Other Potential Disorders/Concerns Progressivewastingdiseaseifnotwellmanaged Nausea,vomiting,anddiarrhea

    Behavioral Apathy Depression Anorexia Fatigue

    Medication Management and Side Effects HighlyActiveAntiretroviralTherapy(HAART)aremultidrugprotocolsthatallowforsuppressionofHIVreplication(thusloweringviralload)andwillallowforrecoverytoCD4cellcountsandultimatelycanleadtoimprovedimmunefunction.SeveralclassesofantiretroviraldrugsareavailableandHAARTprotocolscanincludeoneorseveraldrugsfromthedrugclasseslistedbelow:* Proteaseinhibitors(PI)* Nucleosidereversetranscriptaseinhibitors(NRTIs)* NonNucleosidereversetranscriptaseinhibitors(NNRTIs)* Integraseinhibitors* Fusioninhibitors

  • 2Adults with Human Immunodeficiency Virus (HIV) continued

    Side Effects Peripheralneuropathy Dysgeusia(tastealteration) Lacticacidosis Lypodystrophy(disturbancesinfatdistribution,oneofwhichresultsinsunkencheeks) Skinrash Melanoticpigmentationandskinrashes Hepatotoxicity,Hyperglycemia,Hyperlipidemia,LacticAcidosis,Lipodystrophy Alteredbonemetabolism:Avascularnecrosisofthehipandshoulder,Osteoporosis,Osteopenia Neutropenia,Thrombocytopenia,whichcancauseanincreaseinthepotentialforinfectionandbleeding Stevens-JohnsonSyndrome/ErythemaMultiforme

    HAARTtherapycansignificantlyaffectthemetabolismandeliminationofdrugsbytheliver.SomeHAARTdrugswillcausemedicationstobebrokendownandeliminatedfromthebodymoreslowlythanusualresultinginhigherthanusualbloodlevelswithstandarddoses.OtherHAARTdrugscanhavetheoppositeeffectleadingtomorerapidbreakdownandeliminationofdrugsfromthebloodstreamresultinginsuboptimalbloodlevelswithstandarddosing.WhenprescribingmedicationstoHIV+patientsonHAARTtherapy,besuretohaveconsideredthesepossibilitiesandcheckwiththepatientsphysicianorpharmacistaboutneedstoadjustthedosesofdrugsyouwillbeprescribing.

    Generally,themostcommonlyprescribedantibioticsfordentalinfections(e.g.,amoxicillinandclindamycin)arenotaffectedbyHAARTtherapy.Additionally,dosingofnystatinrinsesandclotrimazoletrochesarenotaffectedbyHAARTtherapy.However,asnotedabove,itisalwayswisetocheckwiththepatientsmedicalteambeforeprescribingforpatientsonHAARTtherapy.

    Dental Treatment and PreventionConsult with patients physician to establish current level of immunocompromise and acceptable procedures specific to treatment plan

    RuleoutsignificantriskforinfectionduetoimmunosuppressionassociatedwithneutropeniabyobtainingbloodvaluesfromacurrentCBCwithDifferential.LookspecificallyforANC(absoluteneutrophilcount)priortotreatment.ANC

  • 3Adults with Human Immunodeficiency Virus (HIV) continued

    DOH160-168March2012

    Forpersonswithdisabilities,thisdocumentisavailableonrequestinotherformats.

    Tosubmitarequest,pleasecall1-800-525-0127(TTY/TDD1-800-833-6388).

    FactsheetsdevelopedbytheUniversityofWashingtonDECOD(DentalEducationintheCareofPersonswithDisabilities)ProgramthroughfundingprovidedtotheWashingtonStateDepartmentofHealthOralHealthProgrambyHRSAgrant#H47MC08598).

    Permissionisgiventoreproducethisfactsheet.Oral Health Fact Sheets for Patients with Special Needs 2011byUniversityofWashingtonandWashingtonStateOralHealthProgram

    Providedentalproceduresinaccordancewithpatientsdesiresandneeds.ForpatientswithadvancedAIDS,renderonlymoreurgentlyneededtreatmenttocontrolpainandinfection,consistentwiththepatientsdesiresandneeds.

    Consideraggressivecariespreventionprogramsforpatientswithxerostomiaand/orpoororalhygieneincludingincreasedfrequencyofrecall,fluoridevarnishapplication,1.1%neutralsodiumtoothpaste/gelorconcentratedcalcium/fluorideproducts.

    Asneededforpatientswithxerostomia:* Educateonproperoralhygiene(brushing,flossing)andnutrition.* Recommendbrushingteethwithafluoridecontainingdentifricebeforebedtime.Afterbrushing,applyneutral1.1%fluoridegel(e.g.,Prevident5000gel)intraysorbybrushfor2minutes.InstructpatienttospitoutexcessgelandNOTtorinsewithwater,eatordrinkbeforegoingtobed.

    * Recommendxylitolmints,lozenges,and/orgumtostimulatesalivaproductionandcariesresistance.

    Additional information:SpecialNeedsFactSheetsforProvidersandCaregivers

    References Little,J.W.,Falace,D.A.,Miller,C.S.,Rhodus,N.L.AIDS,HIVInfection,andRelatedConditions.Chapter19inDentalManagementoftheMedicallyCompromisedPatient.7thedition.MosbyElsevier,St.Louis,MO,2008,pp.280301.

    Nittayananta,W.,Talungchit,S.,Jaruratanasirikul,S.,Silpapojakul,K.,Chayakul,P.,Nilmanat,A.,Pruphetkaew,N.(2010)Effectsoflong-termuseofHAARTonoralhealthstatusofHIV-infectedsubjects.JOralPatholMed.39(5):397406.

    Vernon,L.T.,Demko,C.A.,Whalen,C.C.,Lederman,M.M.,Toossi,Z.,Wu,M.,Han,Y.W.,Weinberg,A.(2009)CharacterizingtraditionallydefinedperiodontaldiseaseinHIV+adults.CommunityDentOralEpidemiol.37(5):42737.

    dosSantosPinheiro,R.,Frana,T.T.,Ribeiro,C.M.,Leo,J.C.,deSouza,I.P.,Castro,G.F.,(2009)Oralmanifestationsinhumanimmunodeficiencyvirusinfectedchildreninhighlyactiveantiretroviraltherapyera.JOralPatholMed.38(8):61322.

    Holderbaum,R.M.,Veeck,E.B.,Oliveira,H.W.,Silva,C.L.,Fernandes,A.(2005)Comparisonamongdental,skeletalandchronologicaldevelopmentinHIV-positivechildren:aradiographicstudy.BrazOralRes.19(3):20915.

    Church,J.A.HIVdiseaseinchildren.Themanywaysitdiffersfromthediseaseinadults.(2000)PostgradMed.107(4):1636,16971,1757passim.

    5minuteclinicalconsult NIHInstituteforHIV

    Additional Resources NIHInstituteforHIV HIV/AIDSOralHealthCareResource(HIVdent.org) FreeofchargeCDEcourse:NIDCRCDE(2CDEhours)


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