HIV infection

Question 1

HIV stats (3)

Answer 1

People living with HIV 36.7 million
 Fallen from 39.5 million 2006
Newly infected with HIV 2.1 million
 78 million infected since start of epidemic
AIDS deaths to date 35 million
 From 2005 to 2015, deaths per year due to AIDs fallen from 2 to 1.1 million people

Question 2

Retrovirus (5)

Answer 2

Single stranded RNA virus
With a reverse transcriptase gene
Spread is by body fluids
Mainly by unprotected sex or IV drug use
HIV damages the immune and nervous system

Question 3

HIV CD4 (6)

Answer 3

Cellular receptor for HIV is CD4 molecule
Found on T helper cells, monocytes and dendritic cells
Cells most affected are CD4 “helper” T cells
Damage causes severe immunodeficiency
Broad spectrum of illnesses related to level of immunodeficiency
AIDS occurs with CD4 cell counts <200/μL (normal >600/μL)

Question 4

Diagnosis of HIV (3)

Answer 4

History and clinical features
General lab investigations
 Lymphopenia
 CD4 count reduced
 CD4/CD8 ratio reduced
HIV testing (after counselling)
 HIV antibodies
 HIV antigens

Question 5

HIV Serology

Answer 5

See graph

Question 6

HIV - oral manifestations (3)

Answer 6

Group 1 lesions: (strongly associated with HIV infection)
Group 2 lesions: (Less commonly associated with HIV)
Group 3 lesions: (Possibly associated with HIV infection)

Question 7

HIV - group 1 lesions (5)

Answer 7

Candidosis
Hairy leukoplakia
HIV associated periodontal disease
Kaposi’
s sarcoma
Non-Hodgkin’s lymphoma

Question 8

Group 1 lesions - candidosis types (2)

Answer 8

Erythematous

Pseudomembranous

Question 9

Treatment for HIV candida (5)

Answer 9

Topical:
 Miconazole - oral gel
 Nystatin - suspension
Systemic:
 Fluconazole
 Itraconazole
 Voriconazole

Question 10

HIV - hairy leukoplakia (3)

Answer 10

Cause: Epstein-Barr virus
Lesions are bilateral and corrugated
Not premalignant

Question 11

Treatment for hairy leukoplakia (2)

Answer 11

Generally does not require treatment
May regress with acyclovir but usually
returns on stopping therapy

Question 12

Group 1 lesions - HIV associated periodontal disease (4)

Answer 12

 Linear Gingival Erythema
 Necrotising Ulcerative Gingivitis - NUG
 Necrotising Ulcerative Periodontitis – NUP
 Necrotising Ulcerative Stomatitis – NUS

Question 13

Aetiology of HIV periodontal disease (4)

Answer 13

 spirochaetes
 fusiform bacteria
 anaerobic rods
(Similar to ANUG, and cancrum oris)
 In linear gingival erythema Candida may also play a role

Question 14

Management of periodontal disease in HIV: immediate and long term (6)

Answer 14

IMMEDIATE
Removal of necrotic bone and severely
involved teeth
Debridement of necrotic tissue
6% Hydrogen peroxide irrigation of pockets /
mouthwash
Antibiotics – metronidazole
Oral hygiene instruction
LONG TERM
Periodontal management

Question 15

Management of Kaposi’s Sarcoma (4)

Answer 15

May include:
 Radiotherapy
 Systemic chemotherapy
 Intra-lesional chemotherapy
 Surgical excision

Question 16

Management of Non-Hodkin’s Lymphoma (2)

Answer 16

Radiotherapy

Chemotherapy

Question 17

Group 2 lesions (4)

Answer 17

Atypical oropharyngeal ulceration
Idiopathic thrombocytopenic purpura
Salivary gland disorder
Viral infections other than EBV

Question 18

Group 2 lesions: Atypical oropharyngeal ulceration (1)

Answer 18

Usually severe with atypical presentation

Question 19

Group 2 lesions: Idiopathic thrombocytopenic purpura (3)

Answer 19

 Low platelet count
 Can result in purpuric patches on the oral mucosa
 If platelet count very low (<60,000/ml) risk of post
extraction bleeding

Question 20

Group 2 lesions: Salivary gland disorder (3)

Answer 20

 Dry mouth, ↓ saliva flow rate
 Swelling of major salivary glands
 Treat with salivary stimulants and oral lubricants

Question 21

Group 2 lesions: Viral infections other than EBV (4)

Answer 21

 Cytomegalovirus – severe or atypical oral ulcers
 Herpes simplex – severe secondary Herpes
 Human papillomavirus – multiple warts
 Herpes (Varicella) zoster – severe shingles

Question 22

Group 3 lesions (4)

Answer 22

Oral bacterial infections other than periodontal
disease
Fungal infections other than candidosis
Melanotic hyperpigmentation
Neurological disturbances
-trigeminal neuralgia
-facial palsy

Question 23

Systemic treatment for HIV (3)

Answer 23

Modern combination anti-retroviral therapy
 Often called HAART (highly active anti-retroviral therapy)
 Very effective at preventing progression to AIDS
 Reduces immunosuppression and associated opportunistic
infections and tumours
Prophylactic treatment for opportunistic infections
Provided by HIV clinics, GUM clinics, GMP etc

Question 24

Management of HIV - dental care and oral manifestations (2)

Answer 24

Provided by GDP

Treat as per lesion requirements

Question 25

Needle stick/ occupational exposure

Answer 25

First aid
-encourage bleeding under running water
-apply or scrub with antiseptic then cover wound
-irrigate exposed eyes, nasal or oral mucosa
-record details in accident book
Management
-report to occy health, GUM clinic or GMP

Question 26

Occupational health will arrange (3)

Answer 26

Counselling re:
 Post-exposure prophylaxis with AZT
 confidential HBV and possible HIV testing
Risk assessment:
 Identification of source patient
 Clinical and serological evaluation of HIV/HBV status with
patients permission.
Follow-up:
 Hepatitis B status testing, vaccination and treatment
 HIV testing