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Hiv Hcv Coinfected Patient
 

Hiv Hcv Coinfected Patient

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    Hiv Hcv Coinfected Patient Hiv Hcv Coinfected Patient Presentation Transcript

    • Dental Management of the HIV & HCV Infected Patient dr shabeel pn
      • Comprehensive Dental Management of the HIV/HCV Infected Patient
      • Diagnosis 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 worldwide
      • 4 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 users
      • Body 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 consumption
      • Interferon 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 HCV
      • Estimated 300,000 people co-infected with HIV and HCV
      • As 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 HAART
      • increases risk of perinatal HIV transmission
      • may increase HIV progression, morbidity & mortality
        • HIV: increases hepatitis C viremia
        • can hinder diagnosis of HCV
      • increases HCV progression, morbidity & mortality
    • Patient Management
      • Hemostatic function
      • Susceptibility to infection
      • Drug actions/interactions
      • Ability 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 lab
      • Good 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 technique
      • Routine antibiotic use is contraindicated
      • Incidence 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)
      • Neutropenia
      • Indwelling catheters
    • Treatment Planning - Periodontal Considerations
      • Frequent recalls
      • Adjunctive use of antimicrobials and chlorhexadine
    • Treatment Planning - Endodontic Considerations
      • Assess ability to withstand treatment
      • Endodontic treatment offers same benefits and risks as with other groups
      • Consider one-step endodontic therapy where appropriate
    • Patient Management
      • Hemostatic function
      • Susceptibility to infection
      • Drug actions/interactions
      • Ability to withstand treatment
    • Normal Lab Values
      • Platelets/ml 150-300K
      • Neutrophil cells/ml 2500-7000
      • Hemoglobin g/dl 14-18 male, 12-16 female
      • CD4 cells/ml 800-1500
    • Laboratory Markers of Liver Disease >750 250-750 0-250 U/L ALKALINE PHOSPHATASE 2000-30,000 400-2000 0-50U/L AST, SGOT 2000-30,000 400-2000 0-50 U/L ALT, SGPT 10-50 4-10 0.5-1.2 MG/DL SERUM BILIRUBIN HIGH ELEVATION MODERATE ELEVATION NORMAL
    • 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/mm 3 and PT/PTT of 0.8-1.5 INR
    • Advanced Liver Disease
      • Associated with altered drug metabolism
      • CNS dysfunction
      • Bleeding problems
      • Altered 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 Erythema
      • Necrotizing Ulcerative Gingivitis
      • Necrotizing 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 Leukoplakia
      • Herpetic simplex ulceration
      • Human Papillomatous growth
      • Kaposi sarcoma
      • Cytomegalovirus 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 diagnosis
      • Inform medical doctor, ophthalmologic consultation to rule out CMV retinitis
      • Treatment - oral or IV gangciclovir, foscarnet, follow up in 1 week
    • Other Diseases
      • Lymphoma
      • Fibroma
      • Minor/ recurrent apthous ulceration
      • Major apthous ulceration
    • Lymphoma
      • Non-Hodgkin's- soft tissue swelling that is red and inflamed, painful and progresses rapidly
      • Diagnosis - biopsy
      • Inform 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 calcified
      • Treatment - 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?
      • Log on to
      • www.hi-dentfinishingschool.blogspot.com