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Hiv Hcv Coinfected Patient


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Hiv Hcv Coinfected Patient

  1. 1. Dental Management of the HIV & HCV Infected Patient dr shabeel pn
  2. 2. <ul><li>Comprehensive Dental Management of the HIV/HCV Infected Patient </li></ul><ul><li>Diagnosis and Treatment of Oral Manifestations of HIV/HCV </li></ul>
  3. 3. Comprehensive Dental Management of the HIV/HCV Infected Patient
  4. 4. Human Immunodeficiency Virus <ul><li>First case discovered in retrospect in a British sailor that died in 1959 </li></ul><ul><li>Approximately 1 million infected individuals in the US </li></ul><ul><li>Greatest number of new infections is in minority males and women </li></ul>
  5. 5. HIV Pathogenesis <ul><li>Virus infects specific cells bearing CD4 membrane glycoprotein </li></ul><ul><li>HIV enters cell and its RNA is transcribed into DNA by reverse transcriptase enzyme </li></ul>
  6. 6. HIV Pathogenesis Cont. <ul><li>Viral DNA becomes integrated into host-cell genome until host cell is activated </li></ul><ul><li>Reverse transcriptase, protease, integrase (and other) enzymes are needed to make new viral particles that then infect other cells </li></ul>
  7. 7. HIV Disease Progression <ul><li>Good understanding of disease process, management of opportunistic infections and neoplastic conditions </li></ul><ul><li>Potential activators of HIV include concomitant infections of Cytomegalovirus, Hepatitis B virus, Herpes Simplex virus and Hepatitis C virus </li></ul><ul><li>Current treatments do not completely eliminate virus from body </li></ul>
  8. 8. Acute or Chronic Liver Disease <ul><li>Infection with hepatitis A, B or C </li></ul><ul><li>Drug induced - alcohol, IV drug, other toxic chemical </li></ul>
  9. 9. Hepatitis C Virus <ul><li>170 million infected people worldwide </li></ul><ul><li>4 million or 1.8% of US population is HCV+ </li></ul><ul><li>Up to 70% of intravenous drug abusers are HCV+ </li></ul><ul><li>40-70% HCV infected persons develop chronic liver disease which is the leading cause of liver transplantation in US </li></ul>
  10. 10. Hepatitis C Virus <ul><li>Dominant mode of transmission is blood-to blood contact </li></ul><ul><li>Risk groups: </li></ul><ul><li>Injection drug users </li></ul><ul><li>Body piercing, tattooing with contaminated equipment, blood products pre 1990 </li></ul>
  11. 11. HCV Disease Progression <ul><li>RNA virus, initial infection often asymptomatic, incubation period 2-26 weeks </li></ul><ul><li>Lots of mutations occur during viral replication thus the antibodies generated against HCV fail to neutralize mutant virus </li></ul><ul><li>Disease process not very well understood </li></ul>
  12. 12. HCV Disease Progression Cont. <ul><li>When HCV viral replication occurs, liver enzymes ALT and AST are elevated </li></ul><ul><li>Cirrhosis is indicated with the liver function tests shows AST levels exceed ALT levels </li></ul><ul><li>Liver dysfunction can be asymptomatic, a thorough medical history and consultation with patient’s physician should be done to determine degree of liver dysfunction </li></ul>
  13. 13. Hepatitis C Virus Treatment <ul><li>Limit alcohol consumption </li></ul><ul><li>Interferon alpha and ribavirin therapy </li></ul>
  14. 14. Hepatitis C Virus Therapy Side Effects: <ul><li>Lowers resistance to infection, invasive dental procedures should be postponed if possible until therapy has ceased </li></ul><ul><li>May induce the onset of clinical depression, in addition chronic HCV infection decreases salivary gland function resulting in xerostomia </li></ul><ul><li>Can cause bone marrow suppression, neutrophil, platelet count should be monitored, PT and PTT should be assessed before invasive procedures </li></ul>
  15. 15. Dental Management of the HCV Infected Patient <ul><li>Most significant problem for patients with cirrhosis is likelihood of prolonged bleeding due to lack of coagulation factors and thrombocytopenia </li></ul>
  16. 16. HIV/HCV Co-infection <ul><li>Because HIV and HCV have similar routes of infection, HIV infected patients are at a risk for co-infection with HCV </li></ul><ul><li>Estimated 300,000 people co-infected with HIV and HCV </li></ul><ul><li>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 </li></ul>
  17. 17. HIV/HCV Co-infection <ul><li>Early diagnosis, evaluation, and treatment of HCV should be considered for HIV+ patients because: </li></ul><ul><li>HCV: increases hepatotoxicity of HAART </li></ul><ul><li>increases risk of perinatal HIV transmission </li></ul><ul><li>may increase HIV progression, morbidity & mortality </li></ul><ul><ul><li>HIV: increases hepatitis C viremia </li></ul></ul><ul><ul><li>can hinder diagnosis of HCV </li></ul></ul><ul><li>increases HCV progression, morbidity & mortality </li></ul>
  18. 18. Patient Management <ul><li>Hemostatic function </li></ul><ul><li>Susceptibility to infection </li></ul><ul><li>Drug actions/interactions </li></ul><ul><li>Ability to withstand treatment </li></ul>
  19. 19. Patient Management Cont. <ul><li>Schedule appointments that cause minimal interruptions in eating or medication schedules, minimize stress </li></ul><ul><li>Be sympathetic, patients on a new regimen of medications may not feel well, may need to reschedule appointment, or may even forget an appt </li></ul>
  20. 20. Patient Management Cont. <ul><li>More frequent recalls, possibly every 3-4 months </li></ul><ul><li>Stress prevention and use topical fluorides and topical antimicrobials to maintain optimal oral health </li></ul>
  21. 21. Provider Management <ul><li>Take the time to do a thorough history and oral examination </li></ul><ul><li>Appropriate training to gain greater competence in identification, diagnosis and proper treatment of oral lesions </li></ul><ul><li>Access to a qualified oral pathology lab </li></ul><ul><li>Good follow-up system with patients </li></ul>
  22. 22. Treatment Planning - General <ul><li>Comprehensive oral exam and review of medical history/condition </li></ul><ul><li>Modifications to care are similar to other medically compromised patients </li></ul><ul><li>Communicate with primary care provider on HIV and/or HCV disease progression </li></ul><ul><li>Principles of good oral health are the same for people with HIV/HCV </li></ul>
  23. 23. Treatment Planning - General Cont. <ul><li>Consider more frequent recalls: every 3-4 months due to medication side effects, prevention and early detection of oral disease </li></ul><ul><li>Update medical history and markers of disease progression regularly: every 6 months </li></ul><ul><li>Aggressive in diagnosis and treatment of disease conditions </li></ul>
  24. 24. Treatment Planning - Restorative Considerations <ul><li>Most principles are similar to HIV/HCV negative patients </li></ul><ul><li>Poor candidates for extensive restoration: rampant caries, reduced salivary flow, oral acidity, poorly controlled oral manifestations </li></ul><ul><li>Use of topical fluorides to prevent recurrent or root caries </li></ul>
  25. 25. Treatment Planning - Oral Surgery Considerations <ul><li>Follow aseptic technique </li></ul><ul><li>Routine antibiotic use is contraindicated </li></ul><ul><li>Incidence of post-procedure complications is no greater that other populations, although patients with prolonged clotting time will experience delayed wound healing </li></ul>
  26. 26. Treatment Planning - OS Considerations Cont. <ul><li>Have results of recent labs to assess hemostatic function and susceptibility to infection </li></ul><ul><li>Antibiotic pre-medication for prevention of SBE (AHA guidelines) </li></ul><ul><li>Neutropenia </li></ul><ul><li>Indwelling catheters </li></ul>
  27. 27. Treatment Planning - Periodontal Considerations <ul><li>Frequent recalls </li></ul><ul><li>Adjunctive use of antimicrobials and chlorhexadine </li></ul>
  28. 28. Treatment Planning - Endodontic Considerations <ul><li>Assess ability to withstand treatment </li></ul><ul><li>Endodontic treatment offers same benefits and risks as with other groups </li></ul><ul><li>Consider one-step endodontic therapy where appropriate </li></ul>
  29. 29. Patient Management <ul><li>Hemostatic function </li></ul><ul><li>Susceptibility to infection </li></ul><ul><li>Drug actions/interactions </li></ul><ul><li>Ability to withstand treatment </li></ul>
  30. 30. Normal Lab Values <ul><li>Platelets/ml 150-300K </li></ul><ul><li>Neutrophil cells/ml 2500-7000 </li></ul><ul><li>Hemoglobin g/dl 14-18 male, 12-16 female </li></ul><ul><li>CD4 cells/ml 800-1500 </li></ul>
  31. 31. 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
  32. 32. Bleeding Problems <ul><li>Clotting factors are decreased in severe liver disease </li></ul><ul><li>Number and function of platelets may be decreased and factor replacement or transfusion may be required </li></ul><ul><li>Need PT/PTT for patient within 48 hrs of surgery </li></ul><ul><li>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 </li></ul>
  33. 33. Advanced Liver Disease <ul><li>Associated with altered drug metabolism </li></ul><ul><li>CNS dysfunction </li></ul><ul><li>Bleeding problems </li></ul><ul><li>Altered protein metabolism </li></ul>
  34. 34. Commonly Used Medications Metabolized in the Liver <ul><li>Analgesics - acetaminophen, narcotics, ASA, NSAIDS </li></ul><ul><li>Anesthetics - lidocaine, procaine, mepivicaine </li></ul><ul><li>Antibiotics - erythromycin, tetracycline, metronidazole, clindamycin </li></ul>
  35. 35. Commonly Used Medications Metabolized in the Liver Cont. <ul><li>Use extreme caution for patients with prolonged bleeding as ASA and NSAID can make it worse </li></ul><ul><li>Anesthetics - lidocaine has not been associated with any side effects when used appropriately </li></ul><ul><li>Antibiotics – metronidazole and tetracylcine metabolism may be severely impaired in patients with acute hepatitis or cirrhosis and should not be used </li></ul>
  36. 36. Diagnosis and Treatment of Oral Manifestations of HIV & HCV Infection
  37. 37. Fungal Disease Candidiasis- Candida albicans
  38. 38. Oral Candidiasis <ul><li>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 </li></ul><ul><li>Oral lesions may be erythematous, pseudomembranous, hyperplastic or angular cheilitis, DD-oral hairy leukoplakia </li></ul>
  39. 39. Candidiasis- Treatment <ul><li>Topical therapy with nystatin or clotrimazole is effective. Treatment length is usually 10-14 days, follow up in 2 weeks </li></ul><ul><li>Clotrimazole 10mg, 1 tab 5x/day, dissolve slowly and swallow, 10 day treatement </li></ul><ul><li>Systemic treatment with fluconazole 100 mg/day for 10 days for oropharyngeal/r esophageal disease, follow up in 2 weeks </li></ul>
  40. 40. Bacterial Diseases <ul><li>Linear Gingival Erythema </li></ul><ul><li>Necrotizing Ulcerative Gingivitis </li></ul><ul><li>Necrotizing Ulcerative Peridontitis </li></ul>
  41. 41. Periodontal Disease <ul><li>Linear Gingival Erythema - profound erythema of the free gingival margin, responds poorly to treatment, usually asymptomatic. </li></ul><ul><li>Treatment - plaque removal and reinforce good oral hygiene, follow up in 2 weeks, frequent recalls, chlorhexadine </li></ul>
  42. 42. Periodontal Disease <ul><li>HIV Necrotizing Gingivitis- erythema with ulceration and loss of interdental papillae. </li></ul><ul><li>Treatment - aggressive plaque removal, debridement, and reinforce good oral hygiene, follow up in 1 week, frequent recalls, chlorhexadine </li></ul>
  43. 43. Periodontal Disease Cont. <ul><li>HIV Necrotizing Periodontitis - erythema, necrotic tissue and bone, halitosis, severe pain and loose teeth. </li></ul><ul><li>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. </li></ul>
  44. 44. Viral Diseases <ul><li>Hairy Leukoplakia </li></ul><ul><li>Herpetic simplex ulceration </li></ul><ul><li>Human Papillomatous growth </li></ul><ul><li>Kaposi sarcoma </li></ul><ul><li>Cytomegalovirus ulceration </li></ul>
  45. 45. Hairy Leukoplakia <ul><li>Bilateral symmetrical white corrugated lesions on the lateral borders of the tongue as a result of reactivation of EBV </li></ul><ul><li>Usually asymptomatic, requires no treatment but podophyllum resin peels may be used </li></ul><ul><li>DD - tobacco associated leukoplakia, lichen planus, epithelial dysplasia, hyperplastic candidiasis </li></ul>
  46. 46. Herpes Simplex Ulceration <ul><li>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 </li></ul><ul><li>Begins as painful multiple lesions and may coalesce to large, erosive ulceration </li></ul><ul><li>Treat with oral acyclovir for 10-14 days, follow up in 2 weeks </li></ul>
  47. 47. Kaposi Sarcoma <ul><li>Reddish, purple flat or raised lesion usually on gingiva or hard palate. DD-hemangioma, hemorrhage. Biopsy shows neoplastic proliferation of endothelial cells </li></ul><ul><li>Inform patient’s medical provider to rule out KS in other locations </li></ul>
  48. 48. Kaposi Sarcoma Cont. <ul><li>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 </li></ul>
  49. 49. Cytomegalovirus Ulceration <ul><li>Usually in severely immunocompromised individuals, CD4<50 </li></ul><ul><li>Painful ulceration on any mucosal surface with nonindurated borders </li></ul>
  50. 50. Cytomegalovirus Ulceration Cont. <ul><li>Biopsy lesion to confirm diagnosis </li></ul><ul><li>Inform medical doctor, ophthalmologic consultation to rule out CMV retinitis </li></ul><ul><li>Treatment - oral or IV gangciclovir, foscarnet, follow up in 1 week </li></ul>
  51. 51. Other Diseases <ul><li>Lymphoma </li></ul><ul><li>Fibroma </li></ul><ul><li>Minor/ recurrent apthous ulceration </li></ul><ul><li>Major apthous ulceration </li></ul>
  52. 52. Lymphoma <ul><li>Non-Hodgkin's- soft tissue swelling that is red and inflamed, painful and progresses rapidly </li></ul><ul><li>Diagnosis - biopsy </li></ul><ul><li>Inform medical provider to coordinate treatment, follow up 1 week </li></ul><ul><li>Treatment - systemic combination of chemotherapy, radiation and excision </li></ul>
  53. 53. Fibroma <ul><li>Traumatically induced overgrowth of underlying connective tissue </li></ul><ul><li>May be calcified </li></ul><ul><li>Treatment - complete surgical removal, follow up 1-2 weeks for healing </li></ul>
  54. 54. Apthous Ulceration- Minor <ul><li>Hormonal and medication (hydroxyurea and ddC/HIVID) induced </li></ul><ul><li>Nonkeratinized mucosa, cheeks, lips, soft palate, floor of mouth, ventral tongue </li></ul><ul><li>Less than 1cm, self-limiting, minor discomfort </li></ul><ul><li>Treatment - application of topical steriod ointment and/or topical anesthetic, follow up 10-14 days </li></ul>
  55. 55. Apthous Ulceration- Major <ul><li>Hormonal and medication (hydroxyurea and ddC/HIVID) induced </li></ul><ul><li>Nonkeratinized mucosa, cheeks, lips, soft palate, floor of mouth, ventral tongue </li></ul><ul><li>Greater than 1cm, deep into connective tissue, dysphagia </li></ul><ul><li>Treatment - short course of systemic steroid (prednisone, 80mg/day for 7 days) or thalidomide, follow up 5-7 days </li></ul>
  56. 56. Salivary Gland Disease <ul><li>Enlarged parotid gland with xerostomia </li></ul><ul><li>Treat associated xerostomia with pilocarpine (5mg TID), sugarless chewing gum, sugarless lemon drops, topical fluoride and frequent dental cleanings </li></ul>
  57. 57. Discussion Questions
  58. 58. Case Studies
  59. 59. Patient I <ul><li>35 year old HIV+ male presents to clinic for extraction of #1. Tooth is severely decayed but is asymptomatic, patient feels healthy. </li></ul><ul><li>Medical history reveals: PCP January 1995, esophageal candidiasis 1998, hepatitis C +. </li></ul><ul><li>Current medications: combivir(AZT & 3TC), crixivan, bactrim, ibuprofen, salogen and vitamins. </li></ul><ul><li>Lab values: platelets: 210K, neutrophil 1000 cells/ml, hemoglobin 8g/dl, viral load 250 copies/ml, CD4 186 cells/ml, liver enzymes WNL. </li></ul><ul><li>What is the proper course of action? </li></ul>
  60. 60. Patient II <ul><li>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. </li></ul><ul><li>Medical history reveals: no history of any HIV-related illness, syphilis 1978 and gonorrhea 1980, artificial heart valve placed in June 1991. </li></ul><ul><li>Current medications: coumadin 5mg/day. </li></ul><ul><li>Lab values: platelets: 350K, neutrophils 600 cells/ml, hemoglobin 12g/dl, VL 8,000 copies/ml, CD4 380. </li></ul><ul><li>What is the proper course of action? </li></ul>
  61. 61. Patient III <ul><li>37 year old HIV+ female presents to clinic for extraction. Tooth is symptomatic, patient complains of lethargy and diarrhea. </li></ul><ul><li>Medical history reveals: PCP July 1995, IV drug use, “clean” since January 2000. </li></ul><ul><li>Current medications: tylenol and vitamins. </li></ul><ul><li>Lab values: platelets: 46K, neutrophils 700 cells, hemoglobin 14g/dl, viral load 40,000 copies/ml, CD4 45 cells/ml. </li></ul><ul><li>What is the proper course of action? </li></ul>
  62. 62. Patient IV <ul><li>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. </li></ul><ul><li>Medical history reveals: no opportunistic infections, recent diagnosis of HIV, HCV+. </li></ul><ul><li>Current medications: patient says he has chosen not to take any HIV medications, IFN, Ribavirin. </li></ul><ul><li>Lab values: platelets: 146K, neutrophils 1500 cells, hemoglobin 14g/dl, VL 800 copies/ml, CD4 455. </li></ul><ul><li>What is the proper course of action? </li></ul>
  63. 63. Patient V <ul><li>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.” </li></ul><ul><li>Medical history reveals: diabetes 1987, PCP July 1998, cervical cancer September 1999, esophageal candidiasis march 2000 and April 2000. </li></ul>
  64. 64. Patient V Cont. <ul><li>Current medications: Nelfinavir, HIVID, Ziagen, Bactrim, Insulin 2x/day </li></ul><ul><li>Lab Values: platelets: 85K, Neutrophils 700 cells/ml, hemoglobin 10g/dl, viral load 400,000 copies/ml, CD4 84 cells/ml, glucose 160mg/dl. </li></ul><ul><li>What is the proper course of action? </li></ul>
  65. 65. <ul><li>Log on to </li></ul><ul><li> </li></ul>