special patient HIV, STDs, and substance abuse

HIV

• is an infection that attacks the body’s immune system, specifically the white blood cells called CD4 cells.

• infection destroys these CD4 cells, weakening a person’s immunity against opportunistic infections, such as tuberculosis and fungal infections, severe bacterial infections, and some cancers. 

AIDs

is the late stage of HIV infection that occurs when the body’s immune system is badly damaged because of the virus.

basic pathophysiology of HIV

◦HIV virus enters bloodstream and seeks out T lymphocytes (T4 or T helper)

◦Binds to CD4+ cell surface

◦Haploid, double-stranded DNA provirus is created and becomes incorporated into DNA of host cell

◦Provirus lays dormant until and event activates it

◦Activation leads to production of new virion

◦Virus takes hold and causes loss in the total number of T helper cells; changes ratio of CD4+ to CD8+ lymphocytes (normally 4:1- reversed in AIDS 1:4)

◦Reduction in T helper lymphocytes results in lack of an effective immune response

populations most susceptible to HIV

◦Homosexual and bisexual men of all races and ethnicities

◦African Americans

◦Latinos

◦Injection drug users

◦Transgender individuals

stage 1 HIV

• acute seroconversion syndrome

• 1-3 weeks after infection: 70% of infected patients experience fever, weakness, diarrhea, nausea, vomiting, myalgia, weightless, headache, pharyngitis, skin rashes, lymphadenopathy

• symptoms clear 1-2 weeks

recent HIV infection

• no signs or symptoms

stage 2 HIV infection latent period

• asymptomatic

• can last 8-10 years without treatment

stage 2 HIV infection early asymptomatic

• without treatment can last 1-3 years

• persistent generalized lymphadenopathy, fungal infections, vaginal yeast and trichomonal infections, oral hairy leukoplakia, herpes zoster, herpes simplex, HV retinopathy, fever, night sweats, fatigue, diarrhea, weight loss, weakness

stage 3 HIV infection

• AIDs

• opportunistic infections may include- pneumocystis jroveci pneumonia, cryptococcis tuberculosis, toxoplasmosis, and histoplasmosis

• malignancies may include kaposi sarcoma, burkitt lymphoma, non-Hodgkin lymphoma, primary CNS lymphoma, invasive cervical cancer, carcinoma of the rectum, slim (wasting) disease

four goals of HIV treatment

1.Prolong duration and quality of survival

2.Restore preserve immunologic function

3.Suppress plasma HIV load

4.Prevent transmission

three areas of treatment for HIV

1.Antiretroviral therapy (ART)

2.Prophylaxis for opportunistic infection

3.Treatment for HIV-related complications

ART

• Antiretroviral therapy

• Given in combination to inhibit HIV replication so viral load is below detection limit

• Restore immune dysfunction

• Recommended for all HIV+ patients

• Requires close physician monitoring for effectiveness,  drug reaction, resistance, and toxicity

chemoprophylaxis

• given when CD4+ levels drop to prevent opportunistic infection

dental management of patient with HIV

◦Thorough health history and all assessments included in the dental hygiene process of care; obtain personal information in a private area

◦Refer for physician consult if symptoms are present but there is no diagnosis

◦Use standard precautions for treatment as with all patients

◦HIV+ clinicians should inform patients of their status and receive consent to treat or do not provide care

follow-up questions prior to treatment

◦When were you diagnosed?

◦Are you under the care of a physician for this condition?

◦When was your last doctor appointment?

◦What is your current CD4+ lymphocyte count?

◦What is your viral load?

◦What medications are you taking for therapy or prophylaxis?

◦What are the symptoms that you are currently experiencing?

treatment planning considerations for patients with HIV

◦Consider CD4+ count and viral load levels- physician consult!!!

◦Ok to treat with CD4+ count > 350 cells/mm³

◦<200 cells/mm³ have increased susceptibility to infection and may require antibiotic prophylaxis and other antibacterial measures

◦Review medications and identify potential for/presence of opportunistic infections

◦No modifications are required for asymptomatic patients- use standard precautions

◦NSPT- complete several teeth and evaluate response and bleeding before treating the rest of the mouth

when to treat patients with HIV

◦HIV + no symptoms

◦Adjunctive antibacterial measures are required if CD4+ <200   L

◦Ok to treat if CD4+ >350   L

when to delay Tx for patient with HIV

◦Medical consult if symptoms are present

◦CD4+ <200   L have increased risk for opportunistic infections- may require prophylactic meds for treatment.

common head, neck, and oral manifestations of HIV

◦Persistent generalized lymphadenopathy

◦Oral candidiasis (pseudomembranous, erythematous, hyperplastic, angular cheilitis)

◦HIV-associated periodontal disease

◦Linear gingival erythema (LGE)

◦Necrotizing ulcerative gingivitis (NUG)

◦Necrotizing ulcerative periodontitis (NUP)

◦Necrotizing stomatitis (NS)

◦Herpes simplex virus (HSV)

◦Varicella zoster virus infection (VZV)

◦Oral hairy leukoplakia (OHL)

Kaposi sarcoma (KS)

less common head, neck, and oral manifestations of HIV

◦Aphthous stomatitis- minor, major, herpetiform

◦Human papilloma virus (HPV)- Verruca vulgaris; oral squamous papilloma

◦Histoplasmosis

◦Molluscum contagiosum

◦Thrombocytopenia

◦HIV-associated salivary gland disease

◦Hyperpigmentation

◦Lymphoma

◦Oral squamous cell carcinoma (SCC)

importance of studying STI’s in dentistry

•Oral manifestations are present

•Require referral for medical treatment

•May be transmitted by direct contact with lesions, blood, or saliva

•Responsibility to provide education regarding prevention

Gonorrhea

•Etiology- Neisseria gonorrhea; through sexual contact

•Medical management- Ceftriaxone IM and oral azithromycin or other antibiotics of unavailable or allergic

•May receive care soon after beginning antibiotic treatment- little threat of transmission once treatment has been administered

•Rare to see oral manifestations outside of the oropharynx

→ Oropharynx infection leads to sore throat, erythematous throat with small pustules; enlarged palatine tonsils with possible exudate; cervical lymphadenopathy

syphilis

•Etiology- Treponema pallidum through sexual contact and kissing or through bloodborne infection; can be transmitted to fetus

•Medical management- Parenteral injection of penicillin

•Dental considerations- May be infectious during treatment but dental treatment is ok with standard precautions

oral manifestations of syphilis

•Oral manifestations- oral chancres on the lips, tongue, oropharynx; possible lymphadenopathy

•Secondary- mucous lesions, erosions, ulcerations, plaques- may be asymptomatic

•Tertiary- oral gumma- on tongue and palate; exophytic, indurated, ulcerated; may erode bone and perforate into nasal cavity; also, may find glossitis

•Hutchinson’s incisor, mulberry molars, high narrow palate, skin fissures around the mouth common signs in congenital

genital herpes simplex virus

•Etiology- One virus in a family of 8; HSV-1 causes herpes infections above the waist; HSV-2 is transmitted through sexual contact

•Medical management- oral anti-viral meds: acyclovir, famciclovir, valacyclovir

•Lesions are infectious during papular, vesicular, and ulcerative stages- defer treatment until healed; once crusted it is safe to treat because patient can be considered non-infectious.

infectious mononucleosis

•Etiology- Epstein Barr virus through intimate contact

•Medical management- treat the symptoms (bedrest, fluids, pain management, gargling)

•No dental treatment while symptomatic- reschedule for ~4 weeks

•Oral manifestations include palatal petechiae, enlarged tonsils, pharyngitis with exudate, lymphadenopathy

genital warts and HPV

•Etiology- Human papilloma virus infection through sexual contact

•Medical management

•Genital warts- surgical ablation, immunomodulatory agents, electrosurgery, chemical destruction, topical agents

•Cancer- surgery + radiation or chemotherapy

•Dental considerations: Lesions present on tongue, gingiva, labial mucosa, and palate

•HIV may result in oral warts- solitary lesion or cluster

•Minimal risk to oral healthcare providers

Marijuana

• clinical presentation- altered sense of time and distance perception; anxiety, paranoia, delusions

• dental management- ID signs and symptoms of use; postpone treatment if used by a patient with ischemia or heart failure; refer to physician

opioids

• clinical presentation - euphoria, decreased pain perception, sedation, orthostatic hypotension

• overdose- slow, shallow respirations, bradycardia, lowered body temperature and unresponsiveness

• withdrawal- GI upset, muscle cramps, rhinorrhea, irritability

• medical management- administer Narcan to reverse effects

• dental management- identify drug-seeking behavior

cocaine

• clinical presentation- sense of well-being, heightened awareness, anorexia, needing less sleep, restlessness, elation, agitation, panic, paranoia, hallucinations and delusions, euphoria, heightened sexual desire, tachycardia, arrhythmias, HBP, chills, nausea, vomiting, visual needle tracks

• overdose- myocardial infarction, arrythmia, stroke, respiratory arrest, depression

cocaine medical and dental considerations

• increased risk for Hep B , Hep C, and HIV if injected

• no anesthesia with epinephrine for at least 6 hours after use

amphetamines

• clinical presentation- same as cocaine use; violent behavior, hyperactivity, increased physical endurance

• cessation symptoms- depression, sleepiness, or difficulty sleeping

• dental management- no dental treatment for patients who are high

sedative hypnotics

• Clinical Presentation During Withdrawal- nausea, vomiting, weakness, tachycardia, sweating, orthostatic hypotension, tremor, loss of appetite, weight loss, tinnitus, delirium, hallucinations

• Dental Management- do not treat if patient is not awake- unable to provide consent

alcohol

• Clinical Presentation- cognitive impairment, distress, psychiatric problems, inability to learn new material or inability to remember, blackouts, dementia, personality changes

• Treatment for Dependence- Identify condition, reduce consumption, administer benzodiazepine to manage CNS depression (also beta blockers or carbamazepine)

• Dental Management- screening, intervention, referral, treatment program

treatment planning considerations for patients abusing substances

• Requires aggressive approach to prevention and treatment of dental disease

• Diets include food that increase risk for dental disease

• Consider:

  • Ability of patient to provide informed consent

  • OHI- willingness to comply; motivation

  • Timing of procedures

  • Positive communication- do not berate patient; addiction is a disease

  • Appropriate pain control

  • Consult with physician regarding management of condition

oral complications

Presence of more deposits, stain, and disease due to neglect and dietary choice

• Cocaine- recession and erosion if rubbed on these surfaces

• Methamphetamines- xerostomia, rampant caries, bruxism, clenching, erosion, periodontal disease

• Alcoholism- glossitis, loss of tongue papillae, angular cheilitis due to malnutrition

• Alcohol + tobacco + increased risk for oral cancer