Clinical Aspects of Oral Health Care for PLWHA


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The goal of Integrating HIV Innovative Practices (IHIP) is to enable health care providers to implement proven innovations in HIV care and services within their own practices. This Webinar is the third in a three-part series exploring innovative approaches to delivering oral health care and services to people living with HIV/AIDS, featuring grantees of the Health Resources and Services Administration’s Special Projects of National Significance (SPNS) Innovations in Oral Health Care Initiative (Oral Health Initiative).

This Webinar explores the clinical aspects of oral health care for people living with HIV/AIDS (PLWHA). The presenters include Dr. David Reznik of Grady Health System in Atlanta, GA and HIVdent and Ms. Helene Bednarsh, MPH of Boston Public Health Commission in Boston, MA and HIVdent. Dr. Reznik and Ms. Bednarsh detail common oral health diseases among HIV-infected people, as well as the prevention, detection, and treatment of these diseases.

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  • This special supplement describes the importance of oral healthcare for PLWHA, new approaches to care, innovations and results from SPNS sites on their initiatives. The viewpoint article on Financing Oral Health Care for Low Income Adults Living with HIV/AIDS provides background on the two key sources of coverage for oral healthcare, Medicaid and the RW HIV/AIDS program and underscores the importance of sustaining RW if we are to ensure access to care and promote and provide oral health for PLWHA
  • This is the first update since guidelines published in 2001 and then updated in 2005 only to discuss new treatments available. This is a comprehensive guide to PEM
  • Clinical Aspects of Oral Health Care for PLWHA

    1. 1. SPNS IHIP Oral Health Webinar Series: Clinical Aspects of Oral Health Care for PLWHA ………………. Presented by Dr David Reznikof Grady Health System &HIVdent and Helene Bednarsh, RDH, MPH of the Boston Public Health Commission &HIVdent January 22, 2014
    2. 2. Agenda ■ Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project ■ ■ Presenters ■ ■ ■ Sarah Cook-Raymond, Managing Director of Impact Marketing + Communications Dr. David Reznik ■ Chief of Dental Service and Director of Oral Health Center – Infectious Disease Program, Grady Health System ■ President of HIVdent Ms. Helene Bednarsh, RDH, MPH ■ Director of the HIV Dental Program at the Boston Public Health Commission ■ Vice President of HIVdent Q&A
    3. 3. IHIP Resources on TARGET Center
    4. 4. IHIP Oral Health Resources ■Training Manual ■Curriculum ■Pocket Guide ■Webinar ■ ■ ■ Series Healthy Mouth, Healthy Body (Held Dec. 13) Dental Case Management (Held Jan. 9) Clinical Aspects of Oral Health Care for PLWHA Recording and slides for all Webinars will be uploaded to TARGET Center Web site following the live event:
    5. 5. Other IHIP Resources ■ Buprenorphine Therapy ■ ■ Engaging Hard-to-Reach Populations ■ ■ Training Manual, Curriculum, and Webinars on engaging hard-toreach populations Jail Linkages ■ ■ Training Manual, Curriculum, Monograph, and Webinars on implementing buprenorphine in primary care settings Training Manual, Curriculum, Pocket Guide, and Webinars on enhancing linkages to HIV care in jails settings UPCOMING: Hepatitis C Treatment Expansion ■ In Spring/Summer 2014, look for training materials on increasing access to and completion of Hepatitis C treatment for PLWHA on the TARGET Center Web site.
    6. 6. David Reznik DDS Chief of Dental Service Director, Oral Health Center – Infectious Disease Program Grady Health System President, HIVdent Helene Bednarsh BS, RDH, MPH Director HIV Dental Program-Boston Public Health Commission Vice President, HIVdent
    7. 7. HRSA SPNS Innovations in Oral Health Care Initiative The overarching clinical goal of the SPNS Project is to improve access and adherence to high quality oral health care for people living with HIV/AIDS.
    8. 8. Urgent Need for Dental Care  Most people with HIV experience oral manifestations of the disease  Preventive care can stall progression of periodontal disease  Preventive care/prompt treatment can reduce discomfort and ensure better nutrition and ability to take medications  Detection of oral symptoms may serve as trigger for medical care
    9. 9. Unmet Need is High  Surgeon General’s report – significant oral health disparities  Unmet oral health needs among HIV+ people are higher than for the general population (Marcus et al, 2000)  Unmet needs for oral health care are higher than unmet needs for medical care (Helsin et al, 2001).  40-50% of HIV+ do not receive oral health care.
    10. 10. Innovations in Oral Health Care for People Living With HIV/AIDS  Public Health Reports (Vol127 Supplement 2 May /June 2012) 
    11. 11. Surgeon General Regina M. Benjamin “While good oral health is important to the well-being of all population groups, it is especially critical for PLWHA. Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.”
    12. 12. Oral Manifestations of HIV Disease: The Basics  Oral manifestations of HIV infection are a fundamental component of disease progression.  There has been a significant decrease in the overall prevalence of oral lesions from 47 – 85% pre-cART to 3246% post cART.  (Patton et al. 2000; Schmidt-Westhausenet al. 2000; GaitanCepedaet al. 2008, Tamí-Maury IM et al. 2011)  Factors, which predispose expression of oral lesions, include:      CD4 counts less than 200 cells/mm3 Viral load greater than 3,000 copies/mL xerostomia (dry mouth) poor oral hygiene smoking
    13. 13. Smoking-Related Health Risks Among Persons with HIV in the Strategies for Management of Antiretroviral Therapy Clinical Trial  Among participants, 40.5 percent were current smokers and 24.8 percent were former smokers.  Compared to never smokers, adjusted Health Risks for current smokers were higher for overall mortality (2.4; P<.001), major cardiovascular disease (2.0; P=.002), nonAIDS cancer (1.8; P=.008) and bacterial pneumonia (2.3; P<.001).  “Providers should routinely integrate smoking cessation programs into HIV health care."  Smoking-Related Health Risks Among Persons with HIV in the Strategies for Management of Antiretroviral Therapy Clinical Trial" American Journal of Public Health Vol. 100; No. 10: P. 1896-1903 (10.10): Alan R. Lifson, MD, MPH; Jacqueline Neuhaus, MS; Jose Ramon Arribas, MD; Mary van den Berg-Wolf, MD; Ann M. Labriola, MD; Timothy R.H. Read, MBBS; and the INSIGHT SMART Study Group
    14. 14. Trends in Oral Manifestations Advances in Dental Research 04/06 - Hodgson TA, Greenspan D, Greenspan JS  Studies from both the Americas and Europe report a decreased frequency of HIV-related oral manifestations of 10-50% following the introduction of ART.  Evidence suggests that cART plays an important role in controlling the occurrence of oral candidiasis.  The effect of cART on reducing the incidence oforal lesions, other than oral candidiasis, does not appear as significant.
    15. 15. Trends in Oral Manifestations Advances in Dental Research 04/06 - Hodgson TA, Greenspan D, Greenspan JS  Increased prevalence of oral warts in patients on cART has been reported from the USA and the UK.  HIV-related salivary gland disease may show a trend of rising prevalence in the USA and Europe.  A possible association between an increased risk of oral squamous cell carcinoma and HIV infection has been suggested by at least three epidemiological studies.
    16. 16. Prevalence, Incidence, and Recurrence of Oral Lesions Among HIV-Infected Patients on HAART in Alabama: A Two-Year Longitudinal Study  A retrospective study based on chart review was conducted among patients (n = 744) who were ≥19 years of age and initiated cART between 01/2000 and 06/06 at the University of Alabama at Birmingham (UAB) 1917 Clinic.  Patients' laboratory data and oral conditions were recorded for 2 years after enrollment into the study.  During 2 years of follow-up 35.6% (266/744) experienced at least one oral lesion.
    17. 17. Prevalence, Incidence, and Recurrence of Oral Lesions Among HIV-Infected Patients on HAART in Alabama: A Two-Year Longitudinal Study  Oropharyngeal candidiasis (OPC) was the most frequent manifestation.  Patients undergoing cART continue to be affected by HIV-related oral conditions, especially OPC.  These results clearly indicate that oral lesions during HIV infection are still highly prevalent in spite of the improvements in medical care and the availability of cART.  Tamí-Maury IM, Willig JH, Jolly PE, Vermund S, Aban I, Hill JD, Wilson CM, Kempf MC. South Med J. 2011 Aug;104(8):561-566.
    18. 18. Candidiasis  There are three common presentations of candidiasis seen among people living with HIV/AIDS  Angular cheilitis  Erythematouscandidiasis  Pseudomembranouscandidiasis
    19. 19. Treatment of Mild to Moderate Erythematous &PseudomembranousCandidiasis  Topical agents for mild to moderate oral candidiasis  Clotrimazole troches 10 mg: Dispense 70, dissolve one troche in mouth 5 times a day for 14 days  Nystatin oral suspension 500,000 units: Swish 5 mL in mouth as long as possible then swallow (optional), 4 times a day for 14 days
    20. 20. Available Systemic Medications Used in the Management of Moderate to Severe Oral/Esophageal Candidiasis  Systemic agents  Fluconazole 100mg: dispense 15 tablets, take 2 tablets on day 1 followed by 1 tablet a day for the remainder of the 14 day treatment period  Voriconazole200mg: dispense 14 tabs, take 1 tab BID for two weeks or at least 7 days following resolution of symptoms.  Drug interactions – Contraindications: Rifampin, Rifabutin, Ritonavir and Efavirenz (all potent CYP450 inducers)
    21. 21. Dental Treatment Considerations  Evidence-based research has proven that providing dental care for the vast majority of people living with HIV/AIDS is no different than providing care for the general patient population.  Evidence Report/Technology Assessment No. 37, Management of Dental Patients Who Are HIV Positive (AHRQ Publication No. 01-E042)
    22. 22. Dental Complications After Treating Patients With AIDS. Glick M., Abel S., et al JADA 125:1994  331 patients (average CD4 count of 71 cells/mm3) 1,800 invasive dental procedures (defined as the breaking of the mucosal membrane) were performed.  RESULTS: The number of post-procedural complications was only 17, representing an overall complication rate of 0.9%  CONCLUSIONS: Incidence of post-procedural complications is no greater than in other populations
    23. 23. Important Lab Values  CD4 count1  No need to premedicate prior to invasive dental care no matter how low.  HIV Viral Load1  No need to premedicate prior to invasive dental care no matter how low.  Platelet count1  Normal – male/female: 150,000 – 450,000 per microliter (mcl) of blood  Dental procedures can safely be performed with a platelet count of 60,000 mcl or greater 1Dental Management of the HIV-Infected Patient, copyright © 1995 American Dental Association, published by the ADA and the American Academy of Oral Medicine.
    24. 24. Important Lab Values  INR for patients on warfarin  No alteration of anticoagulation is necessary for INR that is in therapeutic range (INR 2-3), given that local hemostatic measures are used.2  Absolute Neutrophil Count1  An Absolute Neutrophil Count <500 cells/mcl requires premeditation prior to invasive dental procedures.  Follow the American Health Association/ADA guidelines  Glucose/ A1c  A1c > 8% is poorly controlled; <7% is well controlled. 2J Am Dent Assoc, Vol 134, No 11, 1492-1497. © 2003 American Dental Association.
    25. 25. Guideline Summary  Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis  Published August 2013
    26. 26. What the Guidelines Emphasize  Prompt management of occupational exposures       within 2 hours and first dose during evaluation Occupational exposure require urgent medical evaluation Selection of effective and tolerable PEP regimens Tenofovir/Emtricitabine + Raltegravir is now the preferred regimen for all exposures of significant risk AZT is no longer recommended in the preferred PEP regimen Potential toxicities and interactions of PEP drugs Consultation with experts for post-exposure management strategies Counseling and follow-up of exposed personnel 34
    27. 27. Postexposure Management  Wound management  Exposure reporting  Assessment of infection risk
    28. 28. Wound Care – Dos and Don’ts
    29. 29. DO Wash Wound with Soap and Water
    30. 30. BLEACH DON’T Wash wound with bleach or other caustic agents
    31. 31. DON’T Squeeze or “milk” wound
    32. 32. DO Flush Mucous Membranes
    33. 33. Wound Care • Clean wounds with soap and water • Flush mucous membranes with water • No evidence of benefit for: • Application of antiseptics or disinfectants • Squeezing (“milking”) puncture site • Avoid use of bleach, surface disinfectants, and other agents caustic to skin • Do not delay physician assessment/reporting
    34. 34. Oral Warts due to HPV  Published reports show a markedly increased incidence of oral warts in the cART era1,2  1Greenspan D, Canchola AJ, MacPhail LA, Cheikh B, Greenspan JS. Effect of highly active antiretroviral therapy on frequency of oral warts.Lancet 2001 May 5;357(9266):1411-2)  2King MD, Reznik DA, O’Daniels CM, Larsen NM, Osterholt DM, Blumberg HM. Human Papillomavirus-Associated Oral Warts among HIV-Seropositive Patients in the Era of Highly Active Antiretroviral Therapy: An Emerging Infection. Clinical Infectious Diseases, March, 2002.
    35. 35. Oral Human Papillomavirus Infection in HIV-negative and HIV-infected MSM  In 2010-2011, 794 MSM were included, of whom 767 participants had sufficient data for analysis.  Median age was 40.1 years [interquartile range (IQR) 34.847.5] and 314 men were HIV-infected (40.9%).  Oncogenic HPV types were detected in 24.8 and 8.8% of oral samples from HIV-infected and HIV-negative MSM, respectively (P < 0.001). Of these high-risk types, HPV-16 was the most common (overall 3.4%).  Oral infection with high-risk HPV was associated with HIV infection in multivariable analysis (P < 0.001).  Mooij SH, Boot HJ, Speksnijder AG, et al AIDS. 2013 Aug 24;27(13):2117-28
    36. 36. HPV and Cancer  High-risk HPV infection accounts for approximately 5 percent of all cancers worldwide.  Most high-risk HPV infections occur without any symptoms, go away within 1 to 2 years, and do not cause cancer. These transient infections may cause cytologic abnormalities that go away on their own.  National Cancer Institute Fact Sheet: HPV and Cancer V#r4
    37. 37. HPV and Cancer  HPV infections have been found to cause cancer of the posterior oropharynx, (soft palate, the base of the tongue, and the tonsils).  In the United States, more than half of the cancers diagnosed in the oropharynx are linked to HPV-16  Jayaprakash V, Reid M, Hatton E, et al. Human papillomavirus types 16 and 18 in epithelial dysplasia of oral cavity and oropharynx: a meta-analysis, 1985–2010. Oral Oncology 2011; 47(11):1048–1054.
    38. 38. Squamous Cell Carcinoma Due to HPV
    39. 39. Do the HPV Vaccines Protect Against Oropharyngeal Cancers caused by HPV?  The vaccines protect against HPV-16 and HPV-18, which have been identified in approximately 90 to 95 percent of HPV-positive oropharyngeal cancers.  However, it will likely be decades before their effectiveness in preventing oropharyngeal cancers is known.  ADA Science and Technology - Essential Updates for Your Practice – March 2012
    40. 40. Q&A To be informed about Webinars and other upcoming IHIP resources, sign up for the IHIP listservby emailing IHIP Web site: Connect with Us Sarah Cook-Raymond, Managing Director |Impact Marketing + Communications Twitter: @impactmc1| Facebook: ImpactMarCom | | 202-588-0300