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Dental Management of the Medically Complex Patient > HIV and AIDS > Flashcards

HIV and AIDS Flashcards

1
Q

HIV is a:

A

non transforming retrovirus of the lentivirus subfamily

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2
Q

what are the two main subtypes of HIV

A

HIV-1 and HIV-2

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3
Q

which type of HIV is more common and where are they both found

A
  • HIV-1: sub-saharan Africa - more common
  • HIV-2: West Africa
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4
Q

which type of HIV has a slower disease course

A

HIV-2

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5
Q

what percentage of eastern and southern africa are infected with HIV

A

54%

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6
Q

more than ______ people have been infected with HIV and ______ have died from AIDS

A

70,000,000; 35,000,000

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7
Q

an estimated ______ people across the globe are newly infected with HIV each year

A

2.7 million

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8
Q

the vast majority of people infected with HIV are in ______ countries

A

low and middle income

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9
Q

aprroximately ______ people in the US are living with HIV today

A

1.2 million

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10
Q

the CDC indicates there are ______ new HIV infections each year

A

38,000

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11
Q

the rate for males was ______ than the rate for females

A

5 times higher

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12
Q

new HIV diagnosis was highest among people aged:

A

25-44

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13
Q

what is the largest single risk factor for HIV

A

male to male sexual contact

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14
Q

what body fluids can HIV be transmitted through

A

blood, semen, breast milk and vaginal secretions are the main fluids that have shown to be associated with the transmission of the virus.
- can also be found in tears, saliva, CSF, amniotic fluid and urine

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15
Q

transmission of HIV is by:

A

exchange of infected bodily fluids predominantly through intimate sexual contact and by parenteral means

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16
Q

HIV infection can occur through:

A

oropharyngeal, cervical, vaginal and GI mucosal surfaces, even in the absence of mucosal disruption

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17
Q

infection with HIV is aided by the presence of other:

A

sexually transmitted diseases that can produce mucosal ulceration and inflammation

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18
Q

the most common method of sexual transmission in the US is:

A

anal intercourse in men who have sex with men in whom the risk of HIV infection is 40 times higher in other men and in women

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19
Q

_______ is the second most common form of transmission in the US

A

heterosexual transmission

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20
Q

transmission from _____ is the third largest group affected in the US

A

sharing needles

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21
Q

why is transmission by oral fluids rarely seen

A

saliva contains a number of HIV inhibitory factors which appear to reduce the ability of the virus to infect its target cells

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22
Q

what are the key antigenic components in HIV

A
  • gag
  • pol
  • env
  • p17
    -p24
    -p7
    -p66/51
    -p32
    -p11
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23
Q

what are the regulatory proteins for viral replication in HIV and accessory proteins in HIV

A
  • regulatory proteins: Tat and Rev
  • accessory: Nef, Vif, Vpu,Vpr
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24
Q

what is the cell cycle in the pathophysiology of HIV

A

entry -> replication -> release

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25
Q

describe the entry phase in the pathophysiology of the HIV virus

A
  • HIV mainly infects cells with CD4 cell-surface receptor molecules (CD4+ T helper lymphocytes mainly) at the site of HIV entry
  • infected is aided by langerhans cells in mucosal epithelial surfaces which can become infected delivering HIV to underlying T cells resulting in dissemination to lymphoid organs
  • the virus uses CD4+ cells to gain entry by fusion with a susceptible cell membrane or by endocytosis
  • the probability of infection depends on the number of infective HIV virions in the body fluid which contacts the host and the number of cells with appropriate CD4 receptors available at the site of contact
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26
Q

describe the replication phase of the pathophysiology of HIV

A
  • once in the cell the viral particle uncoats from its spherical envelope to release its RNA
  • the enzyme product of the pol gene, a reverse transcriptase that is bound to HIV RNA, synthesizes linear double stranded cDNA that is the template for HIV integrase
  • it is this HIV proviral DNA which is then inserted into the host cell genomic DNA by the integrase enzyme of the HIV
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27
Q

describe the release stage of the pathophysiology of HIV

A
  • just before the budding process, HIV protease cleaves Gag proteins into their functional form which gets assembled at the inner part of the host cell membrane and virions then begin to bud off
  • nucleocapsid (NC) protein interacts with the RNA within the capsid
  • Capsid (Ca) protein surrounds the RNA of HIV
  • Matrix (MA) protein surrounds the capsid and lies just beneath the viral envelope
  • the cells HIV selects for replication are soon “swell and burst” by caspase-3-mediated apoptosis (5%), the remaining greater than 95% of quiescent lymphoid CD4 T cells die by caspase-1 mediated pyroptosis triggered by abortive viral infection
  • the spectrum of HIV disease changes as CD4+ cell count declines
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28
Q

what is seroconversion

A

the transition from the point of viral infection to when antibodies of the virus become present in the blood (circulating antibodies)

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29
Q

what are the CDC stages of HIV infection in adults and adolescnts

A
  • stage 1: immediately after HIV exposure and may last for years
  • stage 2: progressive immunosuppresion and early symptomatic disease
  • stage 3: AIDS, variety of immunosuppression related diseases
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30
Q

describe stage 1 of HIV

A
  • lab confirmation of HIV infection
  • no AIDS defining conditions and CD4+ T lymphocytes count greater than 500 cells/microL
  • or CD4+ T lymphocyte percentage of total lymphocytes of greater than 29
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31
Q

describe stage 2 HIV infection

A
  • laboratory confirmation of HIV infection
  • no AIDS defining condition
  • laboratory confirmation of HIV infection and CD4+ lymphocyte count of 200-499 cells/microL
  • or CD4+ T lymphocyte percentage of total lymphocytes of 14-28
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32
Q

describe stage 3 HIV infection

A
  • lab confirmation of HIV infection and CD4+ T lymphocyte count is less than 200 cells/microL
  • or CD4+ T lymphocytes percentage of total lymphocytes is less than 14
  • or documentation of an AIDS defining condition
  • documentation of an AIDS defining condition supercedes a CD4+ T lymphocyte count of greater than 200 cells/microL and CD4+ T lymphocytes percentage of total lymphocytes of greater than 14
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33
Q

the average normal CD4 percentage for someone who is HIV negative is about: and the normal range is:

A

40%; 25-65%

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34
Q

during the first 2-6 weeks after initial infection with HIV:

A

70% of patients dvelop acute flulike sympotms marked by viremia

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35
Q

what are the symptoms of stage 1 HIV like

A
  • mononucleosis like
  • lymphadenopathy
  • fever
  • pharyngitis
  • weakness
    -diarrhea
  • nausea
    -vomitting
  • myalgia
  • headache
    -weight loss
  • skin rash
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36
Q

a _____ in CD4+ cells occurs with high levels of plasma HIV

A

drop

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37
Q

how long does it take for the body to make antibodies against HIV

A

between 6 and 12 weeks

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38
Q

how long can the latent asymptomatic period last

A

8-10 years

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39
Q

what is happening in the latent period

A

virus disseminates throughout lymphoid tissue, incubates, replicates and alters many physiologic processes, resulting in hyperimmune activation, persistent inflammation and impaired gut function and flora
- progressive decline in immune function evident as progressive depletion of CD4+ cell count and increase in viral load
- silent clinically except for persistent lymphadenopathy

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40
Q

what is happening in the early symptomatic period/stage 2 and how long does it last

A

1-3 years
- viral load continues to increase
- CD4+ count drops below 500
- viral load increases more
-platelet decreases in 10% of pts

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41
Q

what are the symptoms in the early symptomatic period for HIV

A
  • persistent generalized lymphadenopathy
  • fungal infections
  • vaginal yeast and trichomonal infections
  • oral hairy leukoplakia
  • HSV
  • herpes zoster
  • HIV related retinopathy
  • constitutional symptoms: fever, night swets, fatigue, diarrhea, weight loss, weakness
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42
Q

what happens in stage 3 AIDS

A
  • CD4+ count drops to below 200 cells or documentation of AIDS defining condition
  • platelet counts low
  • opportunistic infections
  • neutrophil count may be low
  • CD4+ cell count less than 50 and high risk for lymphoma and death
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43
Q

what are the malignancies associated with stage 3 HIV

A
  • kaposi sarcoma
  • burkitt lymphoma
  • non hodgkin lymphoma
  • primary CNS lymphoma
  • invasive cervical cancer
    -carcinoma of rectum
  • slim disease
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44
Q

what is a normal ratio of CD4 and CD8 cells

A

between 1 and 4

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45
Q

what are the 3 types of HIV tests available

A
  • nucleic acid tests
  • antigen/antibody tests
  • antibody tests
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46
Q

CD4+ and CD8+ cell counts should be performed when

A

at the time of HIV diagnosis and every 3-4months after

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47
Q

HIV tests are performed on:

A

blood or oral fluid and sometimes urine

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48
Q

what do nucleic acid tests test

A
  • viral load
  • detect HIV sooner than other tests
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49
Q

when is the greatest viral load found in HIV

A

during the first 3 months after initial infection and during the late stages of the disease

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50
Q

what do antigen/antibody tests detect

A

both HIV antibodies and antigens in the blood

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51
Q

in HIV infected individuals _____ is produced even before antibodies begin to develop

A

p24

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52
Q

antibody tests detect:

A

antibodies to HIV in blood or oral fluid

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53
Q

more rapid tests and the only approved HIV self tests are:

A

antibody tests

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54
Q

what are the lab tests ordered in medical setting for HIV diagnosis

A

first ELISA
- second ELISA
- all positive results are then confirmed with western blot analysis

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55
Q

the combination of ELISA tests and western blot are accurate more than _____ of the time and the aptients are considered_______

A

99%; potentially infectious

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56
Q

what is the drug therapy recommended for HIV

A

antiretroviral medications

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57
Q

what is the ARV medication

A

three drug regiment

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58
Q

what is virologic failure defined as

A

a confirmed viral load greater than 200 copies/mL in the presence of ART

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59
Q

what is pre exposure prophylaxis

A
  • a way for people who do not have HIV but who are at high risk of getting it to prevent it
  • the pill (Truvada) contains two medicines
  • when someone is exposed to HIV through sex or injection drug use, these medicines can work to keep the virus from establishing permanent infection
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60
Q

what is the management of infants born to women with HIV

A

all infants should receive postpartum ARVs to reduce the risk of perinatal transmission of HIV

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61
Q

the average dental practice is predicted to encounter _____ pts infected with HIV per year

A

at least 2

62
Q

in the US _____ of individuals who have acquired HIV are unaware of their status, contributing to as high as ____ of continuous HIV spread

63
Q

what is the incidence of HIV transmission from infected patients to health care workers? and how

A

0.3% - through a needlestick or sharp instrument contaminated with the virus

64
Q

the risk of infection from a needlestick is _____ for hep b and _____ for hep C

65
Q

the CDC recommends ___________ after exposure to HIV infected blood

A

postexposure prophylaxis (PEP) as soon as possible

66
Q

when should tests for seroconversion be done after HIV exposure

A

3,6 and 12 months

67
Q

what are standard precautions

A

a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non intact skin and mucous membranes

68
Q

the CDC and ADA recommend the infected dentist:

A

inform their patients of their HIV serostatus and should receive consent or refrain from performing invasive procedures

69
Q

what are the 2 major considerations in dental treatment for patients living with HIV/AIDS

A
  • current CD4+ lymphocyte count
  • level of viral load
70
Q

patients with greater than 350 CD4+ count:

A

dental treatment in no different than any other pt if the HIV pt has no symptoms

71
Q

patients who are symptomatic for the early stages of AIDS have increased suscpetibility to infection and may need:

A

AB prophylaxis

72
Q

patients with AIDS can receive almost any dental care needed after the possibility of _________ has been ruled out

A

significant immunosuppression, neutropenia, thrombocytopenia

73
Q

what is the prevalance of persistent generalzied lymphadenopathy

74
Q

PGL consists of:

A

lymphadenopathy that has been present for more than 3 months and involves two or more extralingual sites

75
Q

what are the most commonly involved extralingual sites in PGL

A

posterior and anterior cervical, submandibular, occipital, and axillary nodes

76
Q

nodal enlargement in PGL is:

A

usually larger than 1 cm and varies from 0.5-5cm

77
Q

what is indicated with PGL

A

lymph node bioppsy

78
Q

PGL _____ of progression to AIDS; _______ of untreated patients will have diangostic features of AIDS within 5 years

A

does warn; one third

79
Q

what is the histo of PGL

A

florid follicular hyperplasia

80
Q

what is the most common intraoral manifestation of HIV infection

A

candidiasis

81
Q

what is the most common organism in oral candidiasis

A

candida albicans

82
Q

about ______ of HIV infected individuals and more thaN _____ of patients with AIDS develope oral candidiasis at some point in their disease course

A

one third; 90%

83
Q

what candidiasis appears when the CD4 count is less than 200

A

pseudomembranous candidiasis

84
Q

what candidiasis appears when CD4+ is below 400

A

erythematous candidiasis

85
Q

what are the types of candidiasis seen with HIV and AIDS

A
  • pseudomembranous
  • erythematous
  • hyperplastic
  • angular chelitis
86
Q

oral candidiasis can cause:

A

pain, reduction in taste and smell which may lead to decreased food intake and further wasting

87
Q

what is the tx for oral candidiasis with HIV

A
  • nystatin is ineffective
  • topical clotrimazole is effective but has high rate of recurrence
  • systemic fluconazole and itraconazole are effective but have a lot of drug interactions and may result in drug resistant candidiasis
  • if azoles fail, then IV amphotericin B can be administered
88
Q

what is a SE of amphotericin B

A

nephrotoxicity

89
Q

what is the most common EBV related lesion in patients with AIDS

A

oral hairy leukoplakia

90
Q

EBV is associated with several forms of_____ in HIV infected patients

91
Q

OHL in HIV infected patients is a sign of:

A

severe immunosuppression and advanced disease

92
Q

OHL clinically presents as:

A

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

93
Q

what is the histology for oral hairy leukoplakia

A
  • thickened parakeratin
  • epithelium is acanthotic and exhibits a bandlike zone of lightly stained cells with abundant cytoplasm (ballon cells) in the upper spinous layer
  • characteristic pattern of peripheral margination of chromatin termed nuclear beading
  • dysplasia is not noted
94
Q

when definitive diagnosis is needed, demonstration of EBV can be achieved by:

A

in situ hybridization, PCR, immunohistochemistry, southern blotting or electron microscopy

95
Q

mucosal, cutaneous and or nail hyperpigmentation may be induced by:

A
  • a variety of drugs taken by HIV/AIDS patients such as zidovudine and emtricitabine based HIV regiments
  • drugs used to control microbial infections in these patients such as ketoconazole, clofazimine, and pyrimethamine
  • destruction of the adrenal cortex by disseminated infections in this immunocompromised population is another possible cause of the observed hyperpigmentation
  • pigmentation with no apparent cause has arisen in HIV infected patients
96
Q

what is the tx for hyperpigmentation

A
  • usually no tx
  • single lesions may have to be biopsied so that melanoma can be ruled out
  • patients with adrenal insufficiency may require corticosteroids
97
Q

where is linear gingivitis found

A

a distinctive linear band of erythema that involves the free gingival margin and extends 2-3mm apically

98
Q

linear gingivitis dx should be reserved for:

A

gingivitis that does not respond to improved plaque control and exhibits a greater degree of erythema than would be expected for the amount of plaque present

99
Q

linear gingivitis results from:

A

an abnormal host immune response to subgingival bacteria or may represent an unusual pattern of candidiasis

100
Q

necrotizing ulcerative gingivitis appears as:

A

ulceration and necrosis of one or more interdental papillae with no periodontal attachment loss

101
Q

patients with NUG have:

A

interproximal gingival necrosis, bleeding, pain and halitosis

102
Q

necrotizing ulcerative periodontitits is characterized by:

A

gingival ulceration and necrosis associated with rapidly progressing loss of periodontal attachment

103
Q

what is seen in NUP

A
  • multiple isolated defects
  • edema, severe pain, spontaneous hemorrhage
104
Q

necrotizing stomatitis may be seen as:

A

an extension of NUP or may involve oral mucosa separate from the gingiva

105
Q

necrotizing stomatitis involves mainly:

A

soft tissue or extends into the underlying bone resulting in extensive sequestration

106
Q

how is linear gingivitis treated

A

debridement, povidone iodide irrigation, chlorhexidine mouth rinse, and/or antifungal medication

107
Q

what is the tx for NUG and NUP

A

debridement, antimicrobial therapy, pain management, immediate follow up care, long term maintenance

108
Q

how is NUG and NUP maintained long term

A
  • chlorhexidine
  • after initial debridement, removal of additional diseased tissue should be performed within 24 hours and again every 7-10 days for two to three appointments, depending on the patients response
  • montly recalls are necessary until process stabilizes
  • evaluations then are performed every 3 months
109
Q

the prevalence of oral recurrent HSV infection among HIV individuals increases significantly once the CD4+ cell count is:

A

less than 50

110
Q

within the setting of HIV infection, recurrent herpetic lesions may be:

A

widespread, occur in an atypical pattern and persist for months

111
Q

herpes labialis may extend to:

A

the facial skin and exhibits extensive lateral spread

112
Q

what is one accepted definition of AIDS with HSV

A

persistence of active HSV infection for more than one month in a patient infected with HIV

113
Q

what is the tx for HSV

A
  • systemic acyclovir, valacyclovir, or famciclovir for at least 5 days
  • higher doses may be needed during immunosuppression
  • an elixir or syrup of diphenhydramine of 1.25mg/5mL can be used for pain control
114
Q

among patients with HIV infection, herpes zoster is often:

A

severe, with increased morbidity and mortality rates

115
Q

how old are varicells zoster virus patients

A

younger than 40 years

116
Q

in patients with well controlled HIV disease, herpes zoster usually is confined to:

A

a single dermatome but persists longer than usual

117
Q

in full blown AIDS ______ of varicella zoster is not unusual

A

dissemination to multiple dermatomes

118
Q

severe intraoral involvement of varicella zoster virus may lead to:

A

bone sequestration and loss of teeth, these sequelae may be delayed a month or more after the intitial onset of herpes zoster

119
Q

what is the treatment for varicella zoster virus lesions

A
  • valacyclovir 1g PO tid; famciclovir 500mg PO tid, acyclovir 800mg PO 5 times per day
  • IV acyclovir may be needed for severe herpes zoster in patients with immunosuppression
  • routine zoster vaccination for HIV infected patients is not recommended currently, however zoster vaccination may be considered for those with well controlled HIV disease with CD4+ counts greater than 200
120
Q

HIV associated salivary gland disease can arise anytime during HIV infection and is considered:

A

a localized manifestation of diffuse infiltrative lymphocytosis syndrome

121
Q

DILS is characterized by:

A

CD8+ lymphocytosis with diffuse lymphocytic infiltration of various sites such as the major or minor salivary glands, lacrimal glands, lungs, kidneys, muscles, nerve and liver

122
Q

what is the main clinical sign of DILS

A

salivary gland enlargement, particularly affecting the parotid. bilateral involvement is seen in about 60% of cases and often is associated with cervical lymphadenopathy

123
Q

what is a variable finding in DILS

A

xerostomia

124
Q

what is the tx for DILS

A

oral prednisone and antiretroviral therapy

125
Q

describe recurrent aphthous stomatitis

A
  • most lesions are major and herpetiform
  • with more severe reduction of CD4+ cells, major lesions are more common
  • lesions that are chronic or atypical or dont respond to tx should be biopsied
  • treatment invovles potent topical or intralesional corticosteroids. systemic steroids generally are avoided to prevent further immunosuppression
126
Q

describe HIV related oral ulceration

A

a distinct entity not corresponding to any pattern of recurrent aphthous stomatitis nor caused by fungal, bacterial , or viral organisms

127
Q

antiretroviral therapy can ____ oral ulceration

128
Q

most HPV lesions arise in:

A

the anogenital region

129
Q

what are the benign HPV lesions

A

oral squamous papilloma, verruca vulgaris, condyloma acuminatum, and multifocal epithelial hyperplasia

130
Q

what areas of the mouth are most commonly involved in HPV infections

A

labial mucosa, tongue, buccal mucosa, and gingiva

131
Q

what do the lesions in HPV look like

A

a cluster of white, spikelike projections, pink cauliflower like growths or slightly elevated sessile papules

132
Q

what is the histo for HPV infections

A
  • can be sessile or papillary and covered by acanthotic or hyperplastic stratified squamous epithelium
  • epithelium demonstrates vacuolization of numerous epithelial cells and occasionally may exhibit mild variation in size of nucleus
  • dysplasia has been noted within HPV related lesions in patients with AIDS and mandates close observation for development of squamous cell carcinoma
  • koilocytosis
133
Q

what is the tx for HPV infections

A
  • surgical excision is most common
  • surgical methods are associated with frequent recurrence
  • electrocautery and laser ablation may expose the surgical team and patient to a plume containing infectious HPV
134
Q

what is the associated with lymphoma and reduction in CD4+ lymphocytes

A

lack of an effective immune response in patients with AIDS contributes to the increase in malignant disease that has been associated with AIDS including kaposi sarcoma, lymphoma, and carcinoma

135
Q

what is the most common malignancy among the AIDS population in the US

A

non hodgkin lymphoma

136
Q

most cases of NHL represent

A

high grade, aggressive B cell neoplasms

137
Q

oral lesions in AIDS related NHL most frequently involve:

A

the gingiva, palate and tongue

138
Q

what is the radiographic presentation of NHL

A

widening of the periodontal ligement and loss of lamina dura

139
Q

Kaposi sarcoma most likely arises from:

A

endothelial cells which may express markers for both lymphatic and blood vessel differentiation and is caused by HHV-8

140
Q

what are the 4 clinical presentations of kaposi sarcoma

A
  • classic
  • endemic
  • iatrogenic
  • epidemic (AIDS related)
141
Q

what is the second most common malignancy with AIDS

A

kaposi sarcoma

142
Q

in western countries kaposi sarcoma is related to

A

the sexual transmission of HHV8

143
Q

in kaposi sarcoma high titer of _____ have been found in saliva

144
Q

what is required for dx of kaposi sarcoma

145
Q

relative to the general population HIV infected individuals have an estimated twofold increased risk of developing ______

A

oral cavity and pharyngeal cancer

146
Q

oral SCC tends to occur at a ______ among HIV infected individuals

A

a younger age

147
Q

what is the tx for oral SCC

A

surgical resection, radiation therapy, and/or chemotherapy

148
Q

most HIV patients with a dx of oral SCC have:

A

advanced disease and an unfavorable prognosis

149
Q

what is the clincial dx for oral SCC

A
  • SCC
  • deep fungal infection
  • TB
  • atypical lymphoproliferative disorder

Dental Management of the Medically Complex Patient (13 decks)

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