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Oral Health Medical Dental Considerations for Patients with HIV on Antiretroviral Therapy

Table of Contents

  • Introduction
    • Important Facts
    • Important Medical Considerations
    • Important Dental Considerations
  • Treatment Recommendations for Common Oral Manifestations for Patient on ART
    • Xerostomia and Dental Caries
    • Periodontal Disease
    • Oral HPV
  • Changes in Oral Manifestations in the Era of ART
  • Significance of Oral Lesions
  • Important Lab Values
    • CD4 Count: T- 4 Lymphocytes
    • HIV RNA: Viral Load
    • Neutrophil Count
    • Platelet Count
  • Points to Remember for Patients Living with HIV in the Era of ART
  • Useful Resources
    • Evaluation of Drug Interactions
    • Comprehensive HIV Information
    • Mountain Plains AETC Oral Health
    • Comprehensive HIV Oral Health Information

Editors

Mark Schweizer, DDS MPH
Dental Director, Southeast AIDS Education Training Center

According to DHHS guidelines, antiretroviral therapy (ART) is recommended for all individuals with HIV regardless of CD4 T lymphocyte cell count, to reduce the mortality and morbidity associated with HIV infection and to prevent HIV transmission.1 Increased efficacy and tolerability of ART has led to a gradual increase in the number of patients on ART with an increase in the number of patients that are adherent to ART and virally suppressed. This guide aims to assist health professionals in evaluating medical and dental considerations for treating patients with HIV in the era of ART. Oral health professionals play a critical role in both evaluation of oral lesions, as well as monitoring health outcomes and ART adherence.

1. https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv/10/initiation-of-antiretroviral-therapy

Important Facts:

  • 90% of PLWHA (people living with HIV and AIDS) have at least one chronic oral condition
  • 32-46% of PLWHA will have at least one major HIV-related oral health problem
  • 58-68% PLWHA do not receive regular oral health care

https://hab.hrsa.gov/abouthab/files/oral_health_fact_sheet.pdf

Important Medical Considerations:

  • Take an accurate medical/dental history including all prescription and over the counter drugs and update at each visit. Carefully consider drug/drug interactions
  • Communicate regularly with all health providers including case managers and mental health providers and obtain regular lab test results.

Important Dental Considerations:

  • Complete a thorough intra/extra oral examination at each visit
  • Refer to oral medicine specialist for any suspicious oral lesions or oral lesions that do not resolve with or without treatment in two weeks
  • Follow UNIVERSAL PRECAUTIONS for all patients

Xerostomia and Dental Caries:

  • Increase water intake, OTC and/or prescription fluoride products
  • Nutritional/Tobacco counseling
  • Evaluation and referral for treatment of alcohol and illegal drug use
  • Salivary stimulants such a sugarless gum or candies
  • Oral cavity moisturizing products (Biotene)
  • Pilocarpine 5mg 4x daily (obtain clearance from medical provider)
  • Oral hygiene instructions and regular dental maintenance treatment intervals

Periodontal Disease

  • Regular periodontal evaluations (complete perio exam yearly) and appropriate treatment intervals
  • Acute periodontal infections should be treated with Amoxicillin 250mg 3 x/day with Metronidazole 250mg 3X/day x 5-7days
  • Antimicrobial rinses (0.12% Chlorhexidine) 15cc twice daily for 14 days and antifungal therapy if there is an overlying candidiasis infection

Oral HPV

  • Biopsy and surgical removal
  • HPV Positive Cancer- chemotherapy or radiation therapy or surgery followed by radiation therapy with or without the addition of chemotherapy

Decreasing

  • Candidiasis
  • Necrotizing Gingivitis
  • Kaposi’s Sarcoma
  • Oral Hairy Leukoplakia

 

Increasing

  • Xerostomia
  • Dental Decay
  • Periodontal Disease
  • Oral HPV
  • First sign of clinical disease*
  • Signify disease progression*
  • Signify possible ART failure*

* Should immediately be referred for dental/medical evaluation

CD4 Count: T- 4 Lymphocytes

Normal CD4 count: 500 – 2000 cells/mm3 (per lab standard) – Indicates progression of HIV infection and degree of immune suppression

  • Usually Asymptomatic: 500-600
  • May be Symptomatic: 200 – 499
  • AIDS: <200

HIV RNA: Viral Load

Indicates level / rate of viral replication and the effectiveness of ART

  • An increasing viral load indicates a faster progression of HIV disease and a decrease in the long term prognosis
  • An undetectable viral load (< 20-50 copies/mL; indicates success of ART and will decrease HIV transmission and disease progression

Neutrophil Count

Important indicator of oral infection risk

Normal neutrophil count: 1,800-7,000 cells/mm3
Severe neutropenia < 1000 cells/mm3

  • THIS REQUIRES MEDICAL CONSULTATIION AND PREMEDICATION WITH ANTIMICROBIAL PROPHYLAXIS

Amoxicillin at one dose of 2 g / 30 to 60 minutes before the procedure. If allergic may receive cephalexin, 2 g; clindamycin, 600 mg; azithromycin or clarithromycin, 500 mg, one dose 30 to 60 minutes before procedure

Platelet Count

Normal platelet count: 150 – 400 x 103 cells/mm3

>60,000: Routine dental care can be provided (e.g. simple extractions / scaling and root planning)

  • Dental treatment is the same for all patients including those living with HIV
  • The CD4 count and viral load are not indicators to withhold dental treatment
  • Universal precautions should be used for all patients
  • Routine antibiotic prophylaxis is only based on the neutrophil count (or medical provider recommendation)
  • The best treatment for oral manifestations of HIV is effective ART including viral suppression
  • Maintain open communication with the patient and medical providers
  • Listen

When in doubt get a medical/dental consult