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Management of HIV patients


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Management of HIV patients

  2. 2. CONTENTS  Introduction  Definition  Epidemiology  Etiology and modes of transmission  Pathogenesis  Diagnosis  Prevention  Global AIDS strategy  AIDS vaccine  Drugs used for AIDS  Conclusion  Reference
  3. 3. INTRODUCTION  The human immunodeficiency virus infection (HIV) is of major interest and concern to dentists and other oral health care workers because of the pandemic nature of the disease.
  4. 4. DEFINITION  Acquired Immuno Deficiency Syndrome (AIDS) can be defined as presence of antibodies to HIV and opportunistic infections.
  5. 5. EPIDEMIOLOGY  WHO reported that one million children were infected with HIV by the end of 1992 and estimated that 10 million children will be born infected by the year 2000.
  6. 6. ETIOLOGY AND MODES OF TRANSMISSION  AIDS is caused by human immunodeficiency virus (HIV), a human retrovirus.  The most common cause of AIDS throughout the world is HIV I.
  8. 8. DIAGNOSIS  Clinical screening and serologic confirmation  WHO defined pediatric AIDS as an infant or child presenting with at least a major criterion along with at least 2 minor criteria in the absence of any immunosuppression.
  9. 9. Major signs  Chronic diarrhoea for more than one month  Prolonged fever for more than one month  Weight loss Minor signs  Oropharyngeal conditions  Repeated cough for more than one month  Generalised lymphadenopathy  Generalised dermatitis  Maternal HIV infection
  10. 10. Typical pediatric findings (Rubenstein, 1986)  Pulmonary lymphoid hyperplasia  Salivary gland enlargement  Pyogenic bacterial infection such as otitis media  Developmental craniofacial features  Chronic recurrent diarrhea  Hepatosplenomegaly  Chronic pneumonitis  Progressive encephalopathy
  11. 11. Oral and perioral findings of aids in children  Fungal infection like candidiasis of different types like:  Angular cheilitis  Hyperplastic  Bacterial infections either generalised, localized or pyogenic  Viral infections like:  Herpes zoster  Herpes simplex  Hairy leukoplakia  Herpetic stomatitis  Unknown etiology lesions  Parotid enlargement with xerostomia  Petechiae
  12. 12.  Aphthous stomatitis  Linear gingival erythema  Cervical lymphadenopathy  Gingival and periodontal lesions like ANUG and necrotising ulcerative periodontitis  Oral ulcerations  Dysmorphic craniofacial features
  13. 13. Other malignancies  Hepatic fibrosarcoma,  Hepatic leiomyosarcoma,  Hepatoblastoma,  Acute lymphoblastic leukemia,  Hodgkin’slymphoma  Ewing’s sarcoma
  14. 14. Group I Lesions strongly associated with HIV infection Candidiasis Erythematous Pseudomembranes Hairy leukoplakia Kaposi’s sarcoma Non-Hodgkin’s lymphoma Periodontal disease Linear gingival erythema Necrotising ulcerative gingivitis Necrotising ulcerative periodontitis Revised classification of HIV infection (1993)
  15. 15. Group II Lesions less commonly associated with HIV infection Bacterial infection Mycobacterium avium-intercellulare Mycobacterium tuberculosis Melanotic hyperpigmentation Necrotising ulcerative stomatitis
  16. 16. Group III Lesions seen in HIV infection Bacteial infections Actinomyces israelii Escherichia coli Klebsiella pneumoniae Cat-scratch disease Drug reactions(ulcerative,erythema multiforme, lichenoid reaction, toxic epidermolysis) Epithelioid(bacillary) angiomatosis
  17. 17. Group III Fungal infections other than candidiasis cryptococcus neoformans Geotrichum candidum Mucomycosis (zygomycosis) Aspergillus flavus Neurologic disturbances Facial palsy Trigeminal neuralgia Recurrent aphthous stomatitis(RAS) Viral infections CMV Molluscum contagiosum
  18. 18. CANDIDIASIS  Recurrent candidiasis which is persistent for long period and often resistant to conventional antifungal therapy, is a frequent oral manifestation in pediatric HIV infection/AIDS Oral manifestations  Pseudo membranous plaques  Erythematous patches  Angular cheilitis (appears as fissures or cracks at the commissures of the lips)  Hyperplastic plaques
  19. 19. Treatment  Lesion may subside or disappear with treatment, but relapse is common.  Treatment can be either topical or systemic
  20. 20. DRUGS DOSE Topical 1. Nystatin suspension (100000 v/ml) 1-2ml to be applied to the affected area tds or qds 2. Amphotericin suspension (100 mg/ml) qds for 14 days 1 ml to be held in the mouth or applied to the affected area after food Older children 1. Nystatin pastilles (100000b/ml) 1 pastille should be sucked qds for 7 days 2. Amphotericin lozenges (10 mg) 1 lozenge to be dissolved in the mouth for 10-15 days 3. Clotrimazole 10mg troches <5 /day orally
  21. 21. Systemic 1. Fluconazole By mouth or IV by infusion of 3-6 mg/kg on first day followed by 3mg/kg daily thereafter, every 72 hr in neonates up to 2 weeks old and every 48 hr in neonates 2-4 weeks old 2. Ketoconazole Orally with food, 3mg/kg daily with food for 2-3 weeks 3. Amphotericin B 0.25 mg/kg/day IV
  22. 22. VIRAL INFECTION  In HIV infection, several viruses are able to colonise or react, producing lesions in the mouth. These include herpes-group viruses and papilloma viruses. Includes  Herpes simplex (HSV I)  Herpes zoster (varicella zoster)  Oral hairy leukoplakia (EBV)  Oral warts (HPV)
  23. 23. TREATMENT OF VIRAL INFECTIONS  Herpetic lesions may be treated with systemic doses of Acyclovir ranging from 1 to 2 g daily taken orally or IV in individuals with more severe oropharyngeal lesions or in those unable to swallow
  24. 24. BACTERIAL INFECTION  Includes Mycobacterium avium intracellulare and Klebsiella pneumoniae
  25. 25. HIV ASSOCIATED GINGIVITIS (HIV-G) AND HIV ASSOCIATED PERIODONTITIS (HIV-P)  Gingival and periodontal diseases (NUG&NUP) - first sign of HIV infection.  Gingivitis in HIV infected children appears as an intensely erythematous band that extends 2 to 3 mm apically from the free marginal and attached gingiva.
  26. 26. FEATURES  Gingiva :  reddened,  edematous  spontaneous bleeding with punctate lesions  NUP -rapid loss of supporting periodontal structures and loose teeth with no pocket formation  Other features are  soft tissue and bone necrosis  pain and bleeding  The distinguishing feature of HIV G and HIV P is a lack of response to removal of plaque and good oral hygiene maintenance
  27. 27. TREATMENT  Aggressive curettage  Peridex (0.12 %chlorhexidine digluconate) rinses 3 times daily  Antibiotic treatment
  28. 28. PAROTID ENLARGEMENT WITH XEROSTOMIA INVOLVING SALIVARY GLANDS  The parotid glands are diffusely swollen and firm without evidence of inflammation or tenderness with unilateral or bilateral involvement TREATMENT  Chronic parotid enlargement does not require treatment  Drugs like Zidovudine can be given but usually there may recurrence of the lesion
  29. 29. ORAL ULCERATIONS  Recurrent aphthous ulcers  well circumscribed ulcers  erythematous margin  Three types- major, minor& herpetiform  Minor -0.5 to 1 cm  Herpetic form-clusters of small ulcers (1-2 mm) on the soft palate and oropharynx  Major ulcers -large necrotic ulcers of 2-4 cm which are painful and last for several weeks
  30. 30. TREATMENT  Fluconamide ointment (0.5%)  Orabase 3-6 times/day  Dexamethasone 0.5 mg/ml
  31. 31. PREVENTION The various approaches are:  If a pregnant lady on testing proves that the foetus is also HIV positive, she should be allowed to medically terminate pregnancy  Blood and blood products to be screened for any contamination  Needles should not be re-used  Educating & creating awareness among the population  Safe sex
  32. 32.  In dentistry there is a little scope of HIV transmission but precautions should be taken like: 1. Proper medical history of the patient 2. Proper sterilization 3. Barrier techniques like: i. Eye protection in terms of eye glasses ii. Mouth mask iii. Disposable needles iv. Gloves (double) v. Change of clothes
  33. 33. GLOBAL AIDS STRATEGY o Prevent sexual transmission by a) Information and education b) Health and social services c) A supportive environment to prevent sexual transmission of HIV o Prevent blood borne transmission of HIV o Prevent perinatal transmission of HIV
  34. 34. AIDS VACCINE  Since the genetic make up of HIV is constantly changing from one method of transmission to the other AIDS vaccine development is not successful  Still a lot of research on this aspect is coming up
  35. 35. DRUGS USED FOR AIDS  Mainly antiviral drugs like: 1. Acyclovir 1to 2 g daily orally or IV 2. Zidovudine (AZT) which attacks the virus through the enzyme reverse transcriptase 3. Three other inhibitors namely 1. Dideoxycytosine 2. Dideoxyinosis 3. stavudine 4. Use of protease inhibitors like Saquinavir, Indinavir and Ritonavir 5. Triple drug therapy combines Indinavir with Zidovudine and Lamivudine to reduce HIV copies in the plasma of infected patients.
  36. 36. POSTEXPOSURE PROPHYLAXIS (PEP)  Following exposure, postexposure prophylaxis may be required  Basic two drug regimen-Zidovudine 300 mg BD and Lamivudine 150 mg BD  Expanded three drug regimen contains Lopinavir 400 mg BD or 800 mg OD or Ritonavir 100mg BD or 200 mg OD as third drug.
  37. 37.  To be effective these drugs must be started within the first 72 hours and ideally within 2 hours.  PEP should be continued for a period of four weeks  Besides PEP, injured site on the wound should be thoroughly washed with soap and water  Antiseptics may also be used
  38. 38. CONCLUSION  All the professional should take detailed history before commencing the treatment  Universal precautions should be taken regardless of the patient condition  All health care professionals need to participate appropriately in the care of those in our population who are HIV-infected, including the children
  39. 39. REFERENCE  Text book of edodontics -2nd edition-Shobha Tandon  Principles and Practice of Pedodontics-3rd edition- Arathi Rao  Shafer’s textbook of oral pathology-7th edition  Textbook of Microbiology for Dental students-Prof. C P Baveja