hiv hcv coinfected patient
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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
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
0-50 250-750 >750
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
0-50 250-750 >750
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
0-50 250-750 >750
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
0-50 250-750 >750
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
0-50 250-750 >750
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
0-50 250-750 >750
Normal ModerateElevation
High
serumbilirubinmg/dl
0.5-1.2 4-10 10-50
alkalinephosphatase U/L
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.
What is the proper course of action?
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.
What is the proper course of action?
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.
What is the proper course of action?
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.
What is the proper course of action?
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