Oral Healthcare for the HIV-Infected Patient
Treatment considerations and infection control
Rama Kiran Chavali, BDS, MS; Ishita T. Johal, BDS; and Jeffery D. Hill, DMD
The human immunodeficiency virus (HIV) is a retrovirus transmitted horizontally via direct contact with infected bodily fluids, including blood, semen, and vaginal fluids, or transmitted vertically from infected mother to infant during childbirth. The acquisition of HIV results in the progressive destruction of CD4+ T lymphocytes and the deterioration of cell-mediated immunity. HIV is a chronic infection that, if left untreated, will eventually result in failure of the immune system, characterized by specific clinical symptoms such as rapid weight loss, recurring fever, diarrhea lasting more than a week, and persistent enlargement of lymph nodes; risk for opportunistic infections such as candidiasis, tuberculosis, pneumonia, herpes simplex, and Mycobacterium avium complex; and death. Acquired immunodeficiency syndrome (AIDS) is the term used to describe the last stage of HIV infection wherein the immune system is badly damaged and patients possess a CD4+ T lymphocyte count of less than 200 cells/mm3. The first published report of what would come to be known as HIV was released on June 5, 1981.1 On September 24, 1982, the U.S. Centers for Disease Control and Prevention (CDC) used the term "AIDS" for the first time.2 Prior to the introduction of antiretroviral therapy (ART), HIV was a terminal disease. However, with the advent of ART, HIV is now a chronic, manageable illness, and the life expectancy of individuals with well-controlled HIV approximates that of those without HIV.
According to CDC, at the end of 2013, 1.2 million people were living with HIV in the United States. The U.S. incidence of HIV in 2015 was 39,513 cases-an annual incidence that remained relatively unchanged for 5 years prior.3 This is despite concerted public health efforts and substantial resources focused on the prevention and management of HIV in the United States.4 In 2011, Edward Gardner and his team noted that despite the availability of ART and its ability to suppress HIV to undetectable levels in infected persons, obstacles to effectively treating individuals and controlling the epidemic still exist along the HIV care continuum.5 These obstacles include limited screening and late diagnosis of HIV, which occur in many cases in which patients present with opportunistic infections. When a diagnosis is made too late in the disease's progression, substantial damage may have already occurred to the immune system. Moreover, a patient's lack of knowledge of infection and lack of symptoms for years after infection can lead to continued transmission. After diagnosis, inadequate linkage to HIV care and non-adherence to ART can further hinder effective treatment of the individual and control of the epidemic. Developed by Gardner to describe the critical steps of HIV control (and potential points of breakdown in care), the HIV treatment cascade (ie, care continuum) includes the following stages: diagnosis, linkage to care, retention in care, prescription of ART, and finally, achievement of HIV suppression.6
The oral healthcare team can play an integral role in the HIV continuum of care by positively influencing screening in individuals who present with oral manifestations consistent with opportunistic infections and undiagnosed HIV. For HIV-infected persons, the oral healthcare team can play an important role in patient engagement, retention in care, and ART adherence by adopting a patient-centric approach built on trust that includes effective diagnosis and treatment as well as collaboration with the medical team for timely referrals. HIV-infected persons on ART who present with oral manifestations of HIV and AIDS may suggest a breakdown in care (eg, falling out of care, nonadherence to ART) and present an opportunity not only to treat the oral disease but also to reengage the patient in proper care. Finally, some oral conditions are more common in persons with HIV, even when it is well controlled. Oral healthcare providers should be aware of these conditions and their clinical presentation to ensure appropriate screening and intervention.
Oral Manifestations of HIV
Oral manifestations are common among HIV-infected individuals and have reported rates of prevalence ranging between 30% and 80%.7-9 When present, these oral manifestations may not only indicate HIV infection but also substantial immune compromise.10 The capacity of a dentist to correctly identify and differentiate between these lesions can play an integral role in instituting timely intervention and reducing patient morbidity and mortality. For a list of common conditions seen in HIV-infected persons, their typical clinical presentations, and first-line treatments, see "Table 1. Presentation and Treatment of Conditions Associated with HIV Infection." The conditions are classified as fungal, viral, bacterial, neoplastic, or miscellaneous.
HIV-positive patients present a unique set of challenges to dental clinicians. Although a patient's HIV-positive status alone is not a justifiable cause to alter treatment protocols, clinicians should realize that the oral health of compromised patients such as these directly affects their general health and that rapidly changing health statuses can call for modification of care. The following sections will discuss dental treatment considerations for HIV-infected individuals.
HIV-infected patients on ART with well-controlled HIV do not require any specific considerations or changes to dental treatment protocols. However, patients with poorly controlled HIV and/or the presence of opportunistic systemic or oral infections may require prioritization of medical therapy. The oral healthcare professional may need to be flexible and willing to alter the course or sequence of treatment until the medical issues are controlled. After control is established, a more traditional treatment plan can then be pursued. Persons with advanced HIV may have difficulty attending appointments or tolerating long, complex dental procedures. For these individuals, dental professionals may need to initially forgo some restorative and esthetic concerns to focus on treatments that improve functionality and nutrition. In addition, treating patients with advanced HIV requires close coordination with medical providers.
An effective treatment plan for the patient with HIV should incorporate any patient-reported oral health concerns as well as a thorough medical history, including all diagnoses, current medications, and a history of tobacco, alcohol, or other substance use. In addition, the patient's relevant laboratory test values (See "Table 2. Relevant Laboratory Information11") should be well-known because when they are abnormal, the sequence of care may need to be modified.
Antibiotic prophylaxis for HIV-positive patients is not indicated as a routine practice, and a low CD4+ cell count or the presence of a high viral load alone are not indications for prophylactic antibiotic coverage. As with any patient, the decision to use antibiotics should be based on a full analysis of the patient's medical history, oral examination, and current laboratory values to identify his or her propensity for infectious complications. The provider must also consider that prolonged usage of antibiotics can increase the likelihood of allergic reactions and contribute to drug resistance.
Because of their increased risk for bacteremia, HIV-infected persons with neutropenia (ie, neutrophil counts of less than 500 cells/mm3) should receive antibiotic prophylaxis prior to procedures likely to cause bleeding. Use of antimicrobial mouth rinses, such as 0.12% chlorhexidine gluconate, for 2 to 3 days pre- and postoperatively in cases where severe bleeding is expected or immediately prior to emergency and routine procedures can reduce the risk for bacteremia.
The physicians of HIV-infected patients with low CD4 counts may prescribe prophylactic antibiotics to prevent the development of pneumocystis pneumonia (CD4 count less than 200 cells/mm3) and Mycobacterium avium complex (CD4 count less than 50 cells/mm3). For HIV-infected patients who require antibiotic prophylaxis prior to dental procedures, the dental provider should first determine whether the patient is already taking prophylactic antibiotics and if so, prescribe an appropriate antibiotic for dental prophylaxis from an alternate drug class in accordance with the American Heart Association guidelines. Immunocompromised patients should always be considered to be in the "high risk" category.
Thrombocytopenia (ie, platelet count of less than 150,000/mcL) is a common occurrence among HIV-positive patients. Approximately 30% to 60% of infected individuals experience it at some point during the course of their infection. When such patients have platelet counts that are greater than 60,000/mcL and PT/PTT values that are no more than twice what is considered normal, routine procedures, including simple extractions, may be safely performed. Any reports of increased bleeding tendency in the past medical history or a platelet count below 60,000/mcL warrants a conservative tooth-by-tooth approach to treatment. When a patient's platelet count drops below 20,000/mcL, spontaneous bleeding can occur. Because platelet values can change rapidly, counts should be obtained no more than 1 to 2 days prior to a procedure with same-day values being most desirable.
As many as 10% to 20% of patients in the early stages of HIV infection and up to 85% of those with late-stage AIDS are affected by anemia, making it the most common hematologic abnormality seen in HIV-positive patients. When hemoglobin levels are below 7g/dL, a conservative tooth-by-tooth approach is preferred. In the event that extensive surgical intervention is required, an acceptable treatment plan can be formulated in conjunction with the patient's physician.
Pain and Anxiety Control
The presence of HIV infection does not rule out the use of chemical agents for the control of pain and anxiety in dental patients. Anxiety linked to dental procedures can be temporarily relieved with prudent use of nitrous oxide or other short-acting anxiolytics. Local anesthetics with or without epinephrine can be used topically or systemically to control procedural pain. If the patient has an increased bleeding tendency, deep block injections can be replaced by local infiltrations or intraligamentary or crestal injections. Analgesics that can be used postoperatively include nonsteroidal anti-inflammatory drugs (NSAIDs), non-narcotic drugs, and narcotic drugs. If the patient has a preexisting narcotic prescription for other symptoms, consultation with the patient's physician is advisable before prescribing additional drugs for pain relief. As with all patients, a thorough review of the past medical history and all current medications, both prescription and over-the-counter, should be conducted prior to the administration of any new medication to evaluate for potential interactions/contraindications.
Immediately following a diagnosis of HIV, oral healthcare should be emphasized to patients as an indispensable aspect of their disease management. Good oral health facilitates the patient's ability to take medications, sustain nutrition, and communicate effectively, while also ensuring that he or she is comfortable with his or her appearance and free of pain and infection. An effective preventive program is based on patient education and regular dental prophylaxis. Recall appointments should be used to reinforce proper self-care techniques as well as to conduct thorough soft-tissue examinations. Asymptomatic patients can be recalled for cleanings and evaluations every 6 months, whereas symptomatic patients or those unable to maintain good oral hygiene may need to be recalled more frequently.
Periodontal disease is common among HIV-infected individuals, and when it is present, it may be severe, aggressive, and difficult to manage. Necrotizing ulcerative periodontitis is associated with severe immune system deterioration. It requires time and aggressive dental therapy to treat and may also indicate poor adherence to ART or a failing regimen. Its presence should prompt communication with the patient's HIV treatment provider to optimize HIV-related care. Linear gingival erythema is also seen in HIV-infected patients. Although consequentially less severe than necrotizing ulcerative periodontitis, its presence in a person with unknown HIV status should prompt screening. The treatments for both necrotizing ulcerative periodontitis and linear gingival erythema are outlined in Table 1.
When endodontic therapy is indicated for an HIV-infected individual, it should not be deferred on the basis of HIV status alone. The overall health of the patient and the strategic importance of the tooth should also be considered when treatment planning. In severely immunocompromised patients with symptomatic lesions, subjective evidence suggests that extraction and curettage followed by an appropriate course of antibiotics may provide faster resolution of chronic infection when compared with endodontic therapy. However, the capacity to resolve chronic periapical lesions versus the outcome of extraction in the immunocompromised has not been adequately studied.
The use of standard protocols can help to ensure safety while performing oral surgical procedures in HIV-infected patients. A normal healing time and no increase in postoperative complications is typical for patients whose HIV is well-controlled and asymptomatic, thus routine antibiotic prophylaxis is not recommended. In patients with a severely weakened immune system, longer healing times may be seen; however, HIV-infected patients do not possess an increased risk of postoperative complications such as local infections or alveolar osteitis. Before conducting traumatic procedures, especially in patients with poor oral hygiene, use of a preprocedural antimicrobial mouth rinse can help decrease the bacterial load and lower the risk of systemic bacteremia. Similarly, treating any intraoral fungal infections before commencement of a procedure can decrease the risk of systemic fungemia. When emergency surgery is needed, the preoperative use of an antimicrobial mouth rinse and appropriate postoperative antifungal therapy is indicated. Clinical signs of postoperative infection such as inflammation and purulence may be reduced or absent, depending on the capacity of the patient's immune system. Any postoperative complications can be treated on an outpatient basis.
For patients with well-controlled HIV, restorative procedures may be routinely carried out per the standard of care. To reduce microbial reservoirs, non-restorable and periodontally hopeless teeth should be removed as soon as possible. When the restorability of a tooth is questionable, such as with large carious lesions, excavation and temporization along with periodontal therapy can be performed until stabilization is achieved. Immediate temporary or interim restorations are permissible until a definitive restoration can be fabricated. Because proper diet and nutrition are an important part of HIV management, procedures that restore correct function are indispensable.
Although the transmission of bloodborne pathogens, in particular viral pathogens, within the dental setting is rare, it can occur. To prevent the spread of infection, CDC's Standard Precautions must be followed. CDC defines Standard Precautions as "the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered."12 Therefore, the infection control protocols used in the oral healthcare setting should be the same when caring for HIV-infected patients as when caring for uninfected patients. As always, to optimize infection control, strict adherence to the use of personal protective equipment, proper hand hygiene, sterilization and disinfection protocols, safe injection practices, and sharps safety is of paramount importance.
1. U.S. Centers for Disease Control and Prevention. Pneumocystis pneumonia-Los Angeles. CDC Website. https://www.cdc.gov/mmwr/preview/mmwrhtml/june_5.htm. Updated May 16, 2001. Accessed January 23, 2018.
2. U.S. Centers for Disease Control and Prevention. Current Trends Update on Acquired Immune Deficiency Syndrome (AIDS)-United States. CDC Website. https://www.cdc.gov/mmwr/preview/mmwrhtml/00001163.htm. Updated August 5, 1998. Accessed January 23, 2018.
3. Hall HI, An Q, Tang T, et al. Prevalence of Diagnosed and Undiagnosed HIV Infection-United States, 2008-2012. CDC Website. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a2.htm?s_cid=mm6424a2_e. Updated June 26, 2015. Accessed January 23, 2018.
4. Kates J, Wexler A, Lief E. Financing the Response to HIV in Low- and Middle-Income Countries: International Assistance from Donor Governments in 2015. https://www.kff.org/global-health-policy/report/financing-the-response-to-hiv-in-low-and-middle-income-countries-international-assistance-from-donor-governments-in-2015/ Updated July 20, 2016. Accessed January 23, 2018.
5. Gardner EM, McLees MP, Steiner JF, et al. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793-800.
6. U.S. Centers for Disease Control and Prevention. HIV in the United States: The Stages of Care. CDC Website. https://www.cdc.gov/hiv/pdf/research_mmp_stagesofcare.pdf. Updated July 2012. Accessed January 23, 2018.
7. Arendorf TM, Bredekamp B, Cloete CA, et al. Oral manifestations of HIV infection in 600 South African patients. J Oral Pathol Med. 1998;27(4):176-179.
8. Dios PD, Ocampo A, Miralles C, et al. Changing prevalence of human immunodeficiency virus-associated oral lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;90(4):403-404.
9. Patton LL, McKaig R, Strauss R, et al. Changing prevalence of oral manifestations of human immune-deficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(3):299-304.
10. World Health Organization. Interim WHO Clinical Staging of HIV/AIDS and HIV/AIDS Case Definitions for Surveillance. World Health Organization Website. www.who.int/hiv/pub/guidelines/clinicalstaging.pdf?ua=1. Published June 16, 2005. Accessed January 23, 2018.
11. Reznik D, Bednarsh H. HIV and the dental team. Dimensions of Dental Hygiene. 2006;4(6):14-16.
12. U.S. Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. CDC Website. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf. Published October 2016. Accessed January 23, 2018.