HIV & AIDS part 2 Flashcards
- As a — pathogen it has important implications for dental practitioners.
bloodborne
The average dental practice is predicted to encounter at least — patients
infected with HIV per year.
two
In the United States, –% of individuals who have
acquired HIV are unaware of their status,
contributing to as high as –% of continuous HIV
spread.
15
40
The risk of HIV transmission from infected patients to
health care workers is very low, reportedly about – of
every 1000 cases (–%) through a – or other
sharp instrument contaminated with the virus
3, 0.3
needlestick
In comparison, the risk of infection from a needlestick is –% for hepatitis B and
is –% for hepatitis C
30
3
The CDC recommends — as soon as possible after
exposure to HIV-infected blood, regimen recommended is based on the severity
of the exposure and the HIV status of the source patient (two- vs three- drug
regimen of antiretroviral medication).
postexposure prophylaxis (PEP)
A less severe exposure (i.e., superficial), an
asymptomatic source patient or has a low viral load
(<1500 viral copies/mL) use a
two-drug PEP.
A more severe exposure (i.e., deep), or when the
patient is symptomatic, has AIDS, or a high viral load
use of at least a
three-drug PEP.
- Tests for seroconversion should be performed at
3, 6, and 12 months.
There have been six reports of occupational HIV
seroconversion despite combination postexposure
prophylaxis.
* Transmission from health care provider to patient has
occurred. The risk of transmission from healthcare
personnel to patients is also minimized by
adherence
to standard infection control procedures.
Standard precautions are a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with (4)
blood, body
fluids, non-intact skin (including rashes), and mucous membranes.
- — must be used for all patients.
Standard precautions
o Dentists are key stakeholders in facilitating the elimination of the stigma associated with the
infection.
o Several guidelines have emerged regarding the rights of dentists and patients with AIDS,
including the following:
- Dental treatment may not be withheld if the patient refuses to undergo testing for HIV exposure.
- A patient with AIDS who needs emergency dental treatment may not be refused care simply
because the dentist does not want to treat patients with AIDS. - No medical or scientific reason exists to justify why patients with AIDS who seek routine dental
care may be declined treatment by the dentist, regardless of the practitioner’s personal reason. - If the dentist and the patient agree, the dentist may refer the patient to another provider who is
more willing or better suited (in keeping with the patient’s oral health status) to provide
treatment. - A patient who has been under the care of a dentist and then develops AIDS or a related condition
must be treated by that dentist or receive a referral that is satisfactory for and agreed to by the
patient. - The CDC and the American Dental Association recommend that infected dentists inform their
patients of their HIV serostatus and should receive consent or refrain from performing invasive
procedures.
Two major consideration in dental treatment for patients living with HIV/AIDS
- Current CD4+ lymphocyte count.
- Level of viral load.
Other: neutrophils, platelets.
Dental treatment of HIV-infected patients without symptoms is no different from that
provided for any other patient in the practice. Generally, this is true for patients with a
CD4+ cell count of more than –/μL
350
Patients who are symptomatic for the early stages of AIDS (i.e., CD4+ cell count
<—/μL) have increased susceptibility to opportunistic infections and may be
medicated with prophylactic drugs.
200
Patients with AIDS can receive almost any dental care needed and desired after the
possibility of significant (3) has
been ruled out
immunosuppression, neutropenia, or thrombocytopeniz
For invasive dental procedures (including scaling and curettage)
*
* Patients with CD4+ cell counts below 200/μL or severe neutropenia (neutrophil count
<500/μL):
in patients with severe thrombocytopenia
Medical consultation (adverse reactions with ART and/or current blood dyscrasias)
use prophylactic antibiotics;
special measures my be indicated (platelet replacement)
Treatment Planning Considerations
o In patients with periodontal disease whose general health status is not clear,
periodontal scaling for several teeth can be provided to allow assessment of tissue
response and bleeding. If no problems are noted, the rest of the mouth can be treated.
— may be required if the patient’s CD4+ cell count is
below 200/μL or if tissues remain — to routine therapy.
o — has good success in patients with HIV infection, and no
modifications are required.
Adjunctive antibacterial measures
unresponsive
Root canal therapy
Since the late 1980s to date, oral manifestations have been acknowledged to
represent a major component of HIV infection that can correlate with
treatment
responses and disease progression.
—-can present as an early clinical sign of HIV disease soon after
seroconversion alerting clinicians for further investigation in the appropriate
clinical scenario.
Oral lesions
Although it is unlikely to encounter many of the oral lesions associated with HIV
in general dental practice, oral healthcare providers should be familiar with
HIVrelated oral manifestations and comfortable in managing and referring patients
with HIV/AIDS.
Persistent generalized lymphadenopathy (PGL)
* After seroconversion, HIV disease often
remains silent except for —.
* The prevalence of this early clinical sign
varies; however, in several studies it
approaches —%.
* PGL consists of lymphadenopathy that
has been present for – months and
involves two or more extrainguinal sites.
* The most frequently involved sites are the
(4)
* Nodal enlargement usually is larger than – cm, and varies from — cm.
* Because lymphoma is known to occur in this population, a lymph node biopsy may be indicated
for localized or bulky —, when — is present, or when
requested for patient reassurance.
* PGL does warn of progression to —; almost — of affected and untreated patients will
have diagnostic features of — within – years
PGL
70
> 3
posterior and anterior cervical,
submandibular, occipital, and axillary
nodes.
1, 0.5 to 5.0
adenopathy, cytopenia or an elevated ESR,
AIDS, one-third, AIDS, 5
— is the most common intraoral manifestation of HIV infection and often is the
presenting sign that leads to the initial diagnosis.
Candidiasis
- The most common organism identified in oral candidiasis is —
Candida albicans.
Approximately one— of HIV-infected individuals and more than —% of patients with AIDS
develop oral candidiasis at some time during their disease course
third
90
types of oral candidiasis
(4)
- Pseudomembranous candidiasis (appears when the CD4+ lymphocyte count <200 cells/mm3)
- Erythematous candidiasis (appears when the CD4+ lymphocyte count <400 cells/mm3)
- Hyperplastic candidiasis
- Angular cheilitis
- — multifocal oral involvement is common in HIV-infected patients.
Chronic
Some studies have shown that development of candidiasis correlates more closely with viral load
than CD4+ cell count.
Oral candidiasis can be — and associated with a reduction in taste and smell, which may
lead to decreased food intake and further wasting.
painful
Oral Candidiasis
Treatment
* — often is ineffective.
* Topical — is effective but has high rate of recurrence.
* Systemic (2) are effective but have a number of drug interactions and
may result in drug-resistant candidiasis.
* If azoles fail, then IV — B can be administered. (nephrotoxicity)
Nystatin
clotrimazole
fluconazole and itraconazole
amphotericin
The most common EBV-related lesion in patients with
AIDS. (EBV is associated with several forms of lymphoma
in HIV-infected patients)
Oral hairy leukoplakia
The presence of OHL in HIV-infected patients is a sign of
severe immunosuppression and advanced disease
OHL also has been reported in transplant recipients, but its
presence in the absence of a known cause of
— strongly suggests HIV infection.
immunosuppression
OHL clinically presents as a
white mucosal plaque that does
not rub off. Most cases occur on the lateral border of the
tongue and range in appearance from faint, white vertical
streaks to thickened, furrowed areas of leukoplakia with a
shaggy surface.
The lesions infrequently may extend to cover the (5)
entire
dorsal and lateral surfaces of the tongue. Rarely, the buccal
mucosa, soft palate, pharynx, or esophagus may be
involved.
Oral hairy leukoplakia
Histology
* Thickened — (corrugated or thin projections)
* Epithelium is acanthotic and exhibits a bandlike zone of
lightly stained cells with abundant cytoplasm (“—”) in the upper spinous layer.
* Characteristic pattern of peripheral margination of
chromatin termed — caused by extensive EBV
replication that displaces the chromatin to the nuclear
margin.
* — is not noted.
* In a patient with known HIV infection, the clinical features
of OHL typically are sufficient for a presumptive diagnosis.
* When definitive diagnosis is necessary, demonstration of
EBV can be achieved by (5)
parakeratin
balloon cells
nuclear beading
Dysplasia
in situ hybridization, PCR,
immunohistochemistry (IHC), Southern blotting, or electron
microscopy.
Hyperpigmentation
Mucosal, cutaneous, and/or nail(s) hyperpigmentation may be induced by:
(4)
- A variety of drugs taken by HIV/AIDS patients such as zidovudine and emtricitabine-based HIV
regimens. - Drugs used to control microbial infections in these patients such as ketoconazole (fungalinfections), clofazimine (leprosy and some TB), and pyrimethamine (toxoplasmosis/antiparasitic).
- Destruction of the adrenal cortex by disseminated infections (e.g. deep fungal infections) in this
immunocompromised population is another possible cause of the observed hyperpigmentation. - Pigmentation with no apparent cause has arisen in HIV-infected patients, and some investigators
have theorized that this may be a direct result of HIV infection.
Hyperpigmentation
Tx (3)
- Usually, no treatment is indicated.
- Single lesions may have to be biopsied so that melanoma
can be ruled out. - Patients with adrenal insufficiency may require
corticosteroids.
Linear gingivitis
Periodontal & gingival disease
* Linear gingivitis appears with a distinctive linear band of erythema that involves the — and
extends — mm apically.
* The alveolar mucosa and gingiva may demonstrate — in a significant percentage of
cases.
* This diagnosis should be reserved for gingivitis that does not respond to improved — and exhibits a
greater degree of — than would be expected for the amount of plaque present
* Results from an abnormal host immune response to subgingival bacteria or may represent an unusual pattern of —
free gingival margin
2 to 3
punctate or diffuse erythema
plaque control
erythema
candidiasis
- Necrotizing ulcerative gingivitis (NUG) appears as..
- Patients with NUG have (4)
ulceration and necrosis of one or more
interdental papillae with no periodontal attachment loss.
interproximal gingival necrosis, bleeding, pain, and halitosis.
