medical evaluation of the hiv dental patient module 1
TRANSCRIPT
Medical Evaluation of the HIV Dental Patient
Medical Evaluation of the HIV Dental Patient
Module 1Module 1
Medical Evaluation of the HIV Dental Patient
Medical Evaluation of the HIV Dental Patient
Louis G. DePaola, DDS, MSProfessor,
Department of Diagnostic Sciences and PathologyDental School
University of Maryland BaltimoreDirector, Dental Training
Pennsylvania-MidAtlantic AIDS ETC
Michael Glick, DMDProfessor and Chairman,
Department of Diagnostic SciencesUniversity of Medicine and Dentistry of New Jersey
Director, Dental TrainingNew Jersey, AIDS ETC
Dr. Valli I. Meeks, DDS, MS RDHDepartment of Diagnostic Sciences and Pathology
Dental SchoolUniversity of Maryland Baltimore
Louis G. DePaola, DDS, MSProfessor,
Department of Diagnostic Sciences and PathologyDental School
University of Maryland BaltimoreDirector, Dental Training
Pennsylvania-MidAtlantic AIDS ETC
Michael Glick, DMDProfessor and Chairman,
Department of Diagnostic SciencesUniversity of Medicine and Dentistry of New Jersey
Director, Dental TrainingNew Jersey, AIDS ETC
Dr. Valli I. Meeks, DDS, MS RDHDepartment of Diagnostic Sciences and Pathology
Dental SchoolUniversity of Maryland Baltimore
Medical Evaluation of the HIV Dental Patient
Medical Evaluation of the HIV Dental Patient
• Dental management of HIV infected patients does not differ from that of non-HIV infected patients. Most treatment can be performed by general practitioners. No special facility or equipment is required.
“Standard Precautions” are followed. • HIV infected patients who require specialist care
should be appropriately referred according to the same referral protocol as for the non-HIV infected patient. e.g. oral medicine, oral pathology, oral surgery,
endodontics, periodontal therapy, orthodontics, pedodontics, prosthodontics
• Dental management of HIV infected patients does not differ from that of non-HIV infected patients. Most treatment can be performed by general practitioners. No special facility or equipment is required.
“Standard Precautions” are followed. • HIV infected patients who require specialist care
should be appropriately referred according to the same referral protocol as for the non-HIV infected patient. e.g. oral medicine, oral pathology, oral surgery,
endodontics, periodontal therapy, orthodontics, pedodontics, prosthodontics
Medical Evaluation of the HIV Dental Patient
Medical Evaluation of the HIV Dental Patient
• A comprehensive medical and oral health assessment is an essential component for safe and appropriate oral health care. HIV infected persons often present with
medical problems resulting from HIV-related immune suppression and co-morbid conditions.
Early recognition and intervention for opportunistic infections (OIs) can significantly reduce morbidity and improve the quality of life for patients infected with HIV disease.
• A comprehensive medical and oral health assessment is an essential component for safe and appropriate oral health care. HIV infected persons often present with
medical problems resulting from HIV-related immune suppression and co-morbid conditions.
Early recognition and intervention for opportunistic infections (OIs) can significantly reduce morbidity and improve the quality of life for patients infected with HIV disease.
Medical Evaluation of the HIV Dental Patient
Medical Evaluation of the HIV Dental Patient
• HIV-infected patients are living longer and develop chronic diseases, many secondary to the toxicity of their medications, including - Lipodystrophy Hyperglycemia Liver disease
• HIV-infected patients are living longer and develop chronic diseases, many secondary to the toxicity of their medications, including - Lipodystrophy Hyperglycemia Liver disease
Medical ConcernsMedical Concerns
• Patient’s susceptibility to infections
• Impaired hemostasis
• Drug actions and interactions
• Ability to withstand the stress and trauma due to dental care
• Patient’s susceptibility to infections
• Impaired hemostasis
• Drug actions and interactions
• Ability to withstand the stress and trauma due to dental care
Medical Problem ListMedical Problem List
• Patient’s susceptibility to infections Hemodialysis Bacterial endocarditis Poorly controlled diabetes mellitus
• Patient’s susceptibility to infections Hemodialysis Bacterial endocarditis Poorly controlled diabetes mellitus
Medical Problem ListMedical Problem List
• Impaired hemostasis Hemophilia Liver disease due to:
• Hepatitis B infection and/or • Hepatitis C infections and/or• Alcohol, substance use/abuse
Idiopathic thrombocytopenia purpura
• Impaired hemostasis Hemophilia Liver disease due to:
• Hepatitis B infection and/or • Hepatitis C infections and/or• Alcohol, substance use/abuse
Idiopathic thrombocytopenia purpura
Medical Problem ListMedical Problem List
• Drug actions and interactions Avoid acetaminophen in patients
with severe liver disease Avoid NSAIDs, including aspirin, in
patients with impaired hemostasis Recognize side-effects and
drug-interactions with antiretroviral medications• See Module 3, part 3
• Drug actions and interactions Avoid acetaminophen in patients
with severe liver disease Avoid NSAIDs, including aspirin, in
patients with impaired hemostasis Recognize side-effects and
drug-interactions with antiretroviral medications• See Module 3, part 3
Medical Problem ListMedical Problem List
• Ability to withstand the stress and trauma due to dental care Cardiovascular disease Stroke Poorly controlled diabetes mellitus
• Ability to withstand the stress and trauma due to dental care Cardiovascular disease Stroke Poorly controlled diabetes mellitus
Medical HistoryMedical HistoryMedical HistoryMedical History• A medical history (MHx) should be
recorded for each patient.
• A thorough MHx should be recorded every 6 months.
• An abbreviated updated MHx should be recorded at every visit.
• A medical history (MHx) should be recorded for each patient.
• A thorough MHx should be recorded every 6 months.
• An abbreviated updated MHx should be recorded at every visit.
Medical HistoryMedical History
• Medical history should include: Chief complaints and history of present illnessChief complaints and history of present illness Review of past medical historyReview of past medical history Hospitalizations and surgeriesHospitalizations and surgeries Current/recent illnessesCurrent/recent illnesses MedicationsMedications AllergiesAllergies Substance abuse historySubstance abuse history Review of systemsReview of systems
• Medical history should include: Chief complaints and history of present illnessChief complaints and history of present illness Review of past medical historyReview of past medical history Hospitalizations and surgeriesHospitalizations and surgeries Current/recent illnessesCurrent/recent illnesses MedicationsMedications AllergiesAllergies Substance abuse historySubstance abuse history Review of systemsReview of systems
Systems ReviewSystems Review
Cardiovascular systemCardiovascular system Respiratory systemRespiratory system Central nervous systemCentral nervous system Gastrointestinal systemGastrointestinal system Genitourinary systemGenitourinary system Musculoskeletal systemMusculoskeletal system Endocrine systemEndocrine system SkinSkin Head and neckHead and neck
Cardiovascular systemCardiovascular system Respiratory systemRespiratory system Central nervous systemCentral nervous system Gastrointestinal systemGastrointestinal system Genitourinary systemGenitourinary system Musculoskeletal systemMusculoskeletal system Endocrine systemEndocrine system SkinSkin Head and neckHead and neck
Dental ExaminationDental Examination
• Document base line pulse and blood pressure
• Record pulse and blood pressure every visit for patients with hypertension or who are taking anti-hypertensive medications
• Intra and extra-oral examination
• Document base line pulse and blood pressure
• Record pulse and blood pressure every visit for patients with hypertension or who are taking anti-hypertensive medications
• Intra and extra-oral examination
HIV Disease HistoryHIV Disease HistoryHIV Disease HistoryHIV Disease History
• Date of HIV infection if knownDate of HIV infection if known• Current HIV disease progression Current HIV disease progression
CD4 count - trend (up, down, stable)CD4 count - trend (up, down, stable) Viral load - trend (up, down, stable)Viral load - trend (up, down, stable)
• History of opportunistic infection(s)History of opportunistic infection(s)• Medication(s)Medication(s)
• Date of HIV infection if knownDate of HIV infection if known• Current HIV disease progression Current HIV disease progression
CD4 count - trend (up, down, stable)CD4 count - trend (up, down, stable) Viral load - trend (up, down, stable)Viral load - trend (up, down, stable)
• History of opportunistic infection(s)History of opportunistic infection(s)• Medication(s)Medication(s)
MedicationsMedications• Current Medications including:
Prescription medications, OTC, herbal, naturopathic and homeopathic remedies and treatments, and nutritional supplements
• HIV patients are frequently on numerous antiretroviral medications with complex dosing regimens.
• Numerous drug-to-drug interactions have been well documented.
• A complete listing of all medications is essential to minimize potential adverse drug interaction to medications that may be prescribed by the dental provider.
• Current Medications including: Prescription medications, OTC, herbal,
naturopathic and homeopathic remedies and treatments, and nutritional supplements
• HIV patients are frequently on numerous antiretroviral medications with complex dosing regimens.
• Numerous drug-to-drug interactions have been well documented.
• A complete listing of all medications is essential to minimize potential adverse drug interaction to medications that may be prescribed by the dental provider.
Opportunistic InfectionsOpportunistic Infections
• History of opportunistic infections• Previous viral, fungal or bacterial
infections• Current or previous antibiotic prophylaxis
for opportunistic infections• Malignancies (including site)
Kaposi’s sarcoma (KS) Non-Hodkins Lymphoma (NHL) Other
• History of opportunistic infections• Previous viral, fungal or bacterial
infections• Current or previous antibiotic prophylaxis
for opportunistic infections• Malignancies (including site)
Kaposi’s sarcoma (KS) Non-Hodkins Lymphoma (NHL) Other
Medical Consultation Medical Consultation and Laboratory Testingand Laboratory TestingMedical Consultation Medical Consultation
and Laboratory Testingand Laboratory Testing
• Patients with HIV infection often have chronic/systemic disease(s) that is unrelated to HIV. When providing treatment for HIV infected
patients, as with any non-infected patient, a medical consultation may be indicated.
• The following additional information is indicated and can usually be obtained from the patients physician:
• Patients with HIV infection often have chronic/systemic disease(s) that is unrelated to HIV. When providing treatment for HIV infected
patients, as with any non-infected patient, a medical consultation may be indicated.
• The following additional information is indicated and can usually be obtained from the patients physician:
Hematological Blood
Values
Hematological Blood
ValuesIndication of patient’s risk for infection and bleeding tendencies• Complete Blood Count (CBC)
Platelet count Differential blood cell count
• Liver enzymes• Coagulation tests
Indication of patient’s risk for infection and bleeding tendencies• Complete Blood Count (CBC)
Platelet count Differential blood cell count
• Liver enzymes• Coagulation tests
HematologyCBC
HematologyCBC
• CBC includes: White blood cell count (WBC) Red blood cell count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelets (Plt)
• CBC includes: White blood cell count (WBC) Red blood cell count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelets (Plt)
HematologyCBC
HematologyCBC
• Total white and red blood cell count, hematocrit, and platelet counts are important in managing HIV patients: Many HIV+ patients are neutropenic,
thrombocytopenic, and anemic Values indicate susceptibility to infection
and bleeding Should be repeated at 3-6 month intervals
• Patients with advanced HIV disease may require more frequent evaluation
• Total white and red blood cell count, hematocrit, and platelet counts are important in managing HIV patients: Many HIV+ patients are neutropenic,
thrombocytopenic, and anemic Values indicate susceptibility to infection
and bleeding Should be repeated at 3-6 month intervals
• Patients with advanced HIV disease may require more frequent evaluation
Total WBC: 4,000 – 11,000 cells/mm3
Neutrophils: 3,000-6,000 cells/mm3
– 30% – 70% of total WBC
• Lymphocytes: 1,500 – 4,000 cells/mm3
– 20% - 50% of total WBC
• Monocytes: 200 - 900 cells/mm3
– 1% - 12% of total WBC
• Eosinophils: 100 - 700 cells/mm3
– 0% - 3% of total WBC
• Basophils: 20 - 50 cells/mm3
– 0% - 1% of total WBC
Total WBC: 4,000 – 11,000 cells/mm3
Neutrophils: 3,000-6,000 cells/mm3
– 30% – 70% of total WBC
• Lymphocytes: 1,500 – 4,000 cells/mm3
– 20% - 50% of total WBC
• Monocytes: 200 - 900 cells/mm3
– 1% - 12% of total WBC
• Eosinophils: 100 - 700 cells/mm3
– 0% - 3% of total WBC
• Basophils: 20 - 50 cells/mm3
– 0% - 1% of total WBC
Hematology Differential White Blood Cell Count
Hematology Differential White Blood Cell Count
Hematology WBC
Hematology WBC
• Neutropenia Normal neutrophil count:
• 4,500-10,000 cells/mm3
Mild neutropenia: • 2,500- 4,500 cells/mm3
Severe neutropenia:• Below 1,000 cells/mm3
Antibiotic prophylaxis is indicated with neutroplils < 500 cells/mm3 • Many clinicians use American Heart Association Regimen.
However, others feel that antibiotic therapy should continue for as long as open wounds are present in the oral cavity.
• Neutropenia Normal neutrophil count:
• 4,500-10,000 cells/mm3
Mild neutropenia: • 2,500- 4,500 cells/mm3
Severe neutropenia:• Below 1,000 cells/mm3
Antibiotic prophylaxis is indicated with neutroplils < 500 cells/mm3 • Many clinicians use American Heart Association Regimen.
However, others feel that antibiotic therapy should continue for as long as open wounds are present in the oral cavity.
HematologyRed Blood Cells
HematologyRed Blood Cells
• Red Blood Cells Anemia is common in HIV disease Decrease in RBCs or Hgb
often caused by antiretroviral therapy and other medications
Normal RBC: 4.5 - 5.5 x 106 cells/mm3
• Red Blood Cells Anemia is common in HIV disease Decrease in RBCs or Hgb
often caused by antiretroviral therapy and other medications
Normal RBC: 4.5 - 5.5 x 106 cells/mm3
HematologyHemoglobin HematologyHemoglobin
• Hemoglobin: Carries oxygen in the RBC • Decreased hemoglobin means less ability for
oxygenation Normal varies from men to women:
• Males: 12-16 g/dl • Females: 14-18 g/dl
Causes for hemoglobin decrease:• Decrease RBC production• Impaired production
• Hemoglobin: Carries oxygen in the RBC • Decreased hemoglobin means less ability for
oxygenation Normal varies from men to women:
• Males: 12-16 g/dl • Females: 14-18 g/dl
Causes for hemoglobin decrease:• Decrease RBC production• Impaired production
HematologyPlatelet CountHematology
Platelet Count Normal platelet count: 150,000 -
400,000 cells/mm3
Thrombocytopenia: Decreased platelet count
100,000 - 140,000 cells/mm3
> 50-60,000 cells/mm3, adequate for routine dental care including simple extractions
< 20,000 may see spontaneous bleeding
Thromboytopenia is associate with bruising, and petechiae of skin and mucosa
Normal platelet count: 150,000 - 400,000 cells/mm3
Thrombocytopenia: Decreased platelet count
100,000 - 140,000 cells/mm3
> 50-60,000 cells/mm3, adequate for routine dental care including simple extractions
< 20,000 may see spontaneous bleeding
Thromboytopenia is associate with bruising, and petechiae of skin and mucosa
HematologyHematocritHematologyHematocrit
• Hematocrit Measure of packed cell
volume (PCV) of RBCs Normal: 37% - 54% indication of anemia and
especially vitamin B12 deficiency
• Hematocrit Measure of packed cell
volume (PCV) of RBCs Normal: 37% - 54% indication of anemia and
especially vitamin B12 deficiency
HematologyLiver Enzymes
HematologyLiver Enzymes
• ALT, AST values Non-specific transaminases
• Often elevated with acute liver disease
• Marked elevation may indicate decreased liver function
• Patients may be prone to hemorrhage
• Drug metabolism may be impaired
• ALT, AST values Non-specific transaminases
• Often elevated with acute liver disease
• Marked elevation may indicate decreased liver function
• Patients may be prone to hemorrhage
• Drug metabolism may be impaired
HematologyCoagulation Tests
HematologyCoagulation Tests
Indicates patient’s clotting ability Increase indicates:
Coagulation abnormality due to liver disease Other systemic diseases Anticoagulant therapy Medications
Significantly elevated coagulation test results may require modification of dental treatment
Indicates patient’s clotting ability Increase indicates:
Coagulation abnormality due to liver disease Other systemic diseases Anticoagulant therapy Medications
Significantly elevated coagulation test results may require modification of dental treatment
HematologyCoagulation Tests
HematologyCoagulation Tests
Coagulation tests: Prothrombin time (PT)
• Normal: 9-11 seconds Activated partial thromboplastin time (aPTT)
• Normal: 28-38 seconds INR (international normalized ratio)
• Normal: 1.0• >2.0 indicative of possible use of
anticoagulation medications such as Coumadin®
Coagulation tests: Prothrombin time (PT)
• Normal: 9-11 seconds Activated partial thromboplastin time (aPTT)
• Normal: 28-38 seconds INR (international normalized ratio)
• Normal: 1.0• >2.0 indicative of possible use of
anticoagulation medications such as Coumadin®
Immunological Blood Values CD4 Count
Immunological Blood Values CD4 Count
• CD4 Count Indicates HIV progression and degree of
immune suppression Normal CD4 count 800-1000 cells/mm3
• Major opportunistic infections frequently seen with CD4 cell count <200 cells/mm3 • CD4 cell count < 200 cells/mm3 is an AIDS
diagnosis
• CD4 Count Indicates HIV progression and degree of
immune suppression Normal CD4 count 800-1000 cells/mm3
• Major opportunistic infections frequently seen with CD4 cell count <200 cells/mm3 • CD4 cell count < 200 cells/mm3 is an AIDS
diagnosis
CD4 Counts (T-4 Helper
Lymphocyte)
CD4 Counts (T-4 Helper
Lymphocyte) Absolute CD4 helper count
Total number of CD4 cells/mm3
CD4 % Percent of CD4 cells of the total lymphocytes
• “Healthy” and usually asymptomatic patients
–CD4 cell count >500 cells/mm3 (>29%)
• Symptomatic patient
–CD4 cell count of 200-499 cells/mm3 (14-28%) AIDS:
–CD4 cell count <200 cells/mm3 (<14%)
Absolute CD4 helper count Total number of CD4 cells/mm3
CD4 % Percent of CD4 cells of the total lymphocytes
• “Healthy” and usually asymptomatic patients
–CD4 cell count >500 cells/mm3 (>29%)
• Symptomatic patient
–CD4 cell count of 200-499 cells/mm3 (14-28%) AIDS:
–CD4 cell count <200 cells/mm3 (<14%)
Immunological Plasma Viral Load
Immunological Plasma Viral Load
• Plasma Viral Load: Indication of degree of viral replication and
suggestion of immune suppression • Destruction of CD4 lymphocytes
Measure of therapeutic (HAART) success or failure
Prognostic: • The higher the viral load, the faster the progression of
HIV disease and the poorer the long term prognosis
• Plasma Viral Load: Indication of degree of viral replication and
suggestion of immune suppression • Destruction of CD4 lymphocytes
Measure of therapeutic (HAART) success or failure
Prognostic: • The higher the viral load, the faster the progression of
HIV disease and the poorer the long term prognosis
Viral LoadViral Load Listed (usually) on lab results as:
HIV-1 RNA by PCR
< 10,000 copies/ml suggests a mean survival rate of >10 years
> 30,000 copies/ml suggest a mean survival rate of <5 years
Listed (usually) on lab results as: HIV-1 RNA by PCR
< 10,000 copies/ml suggests a mean survival rate of >10 years
> 30,000 copies/ml suggest a mean survival rate of <5 years
ConfidentialityConfidentiality
• At all times, confidentiality must be maintained for all patients, regardless of HIV serostatus.
• Proper consent should be obtained before any confidential medical or dental information is released to other medical or dental providers.
• At all times, confidentiality must be maintained for all patients, regardless of HIV serostatus.
• Proper consent should be obtained before any confidential medical or dental information is released to other medical or dental providers.
Dental Treatment Plan Dental Treatment Plan PrioritiesPriorities
Dental Treatment Plan Dental Treatment Plan PrioritiesPriorities
• Alleviate painAlleviate pain
• Prevent further oral diseasePrevent further oral disease
• Restore functionRestore function
• Restore estheticsRestore esthetics
• Improve quality of lifeImprove quality of life
• Alleviate painAlleviate pain
• Prevent further oral diseasePrevent further oral disease
• Restore functionRestore function
• Restore estheticsRestore esthetics
• Improve quality of lifeImprove quality of life
Restorative/Prosthodontic Restorative/Prosthodontic ConsiderationsConsiderations
Restorative/Prosthodontic Restorative/Prosthodontic ConsiderationsConsiderations
• Ability to perform oral hygiene Ability to perform oral hygiene
• Caries indexCaries index
• Reduced salivary flowReduced salivary flow
• Presence of oral lesionsPresence of oral lesions
• ““End of life” concerns/issuesEnd of life” concerns/issues
• Ability to perform oral hygiene Ability to perform oral hygiene
• Caries indexCaries index
• Reduced salivary flowReduced salivary flow
• Presence of oral lesionsPresence of oral lesions
• ““End of life” concerns/issuesEnd of life” concerns/issues
Management of Management of XerostomiaXerostomia
Management of Management of XerostomiaXerostomia
Replacement or stimulation of salivary Replacement or stimulation of salivary flowflow• Secretory stimulantsSecretory stimulants
1. Pilocarpine1. Pilocarpine
2. Salagen2. Salagen 3. Bethanecol3. Bethanecol
• Salivary substitutesSalivary substitutes 1. Xerolube1. Xerolube 2. Salivart2. Salivart 3. Unimist3. Unimist
Replacement or stimulation of salivary Replacement or stimulation of salivary flowflow• Secretory stimulantsSecretory stimulants
1. Pilocarpine1. Pilocarpine
2. Salagen2. Salagen 3. Bethanecol3. Bethanecol
• Salivary substitutesSalivary substitutes 1. Xerolube1. Xerolube 2. Salivart2. Salivart 3. Unimist3. Unimist
Treatment Plan Modifications For HIV Patients
Treatment Plan Modifications For HIV Patients
• No need for special facility• Treatment plan based on
medical status• Modify dental procedures
according to ability of the patient to withstand dental treatment
• No need for special facility• Treatment plan based on
medical status• Modify dental procedures
according to ability of the patient to withstand dental treatment
Treatment Plan Modifications For HIV Patients
Treatment Plan Modifications For HIV Patients
• Treatment plan based on: Medical status Finances Patient acceptance
• Modify dental procedures according to ability of the patient to tolerate dental procedures
• Treatment plan based on: Medical status Finances Patient acceptance
• Modify dental procedures according to ability of the patient to tolerate dental procedures
Antibiotic ProphylaxisAntibiotic Prophylaxis
Indicated when: Neutrophils: <500 cells/mm3
According to AHA guidelines if patient has heart/valvular problems
Need for antibiotic prophylaxis is not based on CD4 count
Indicated when: Neutrophils: <500 cells/mm3
According to AHA guidelines if patient has heart/valvular problems
Need for antibiotic prophylaxis is not based on CD4 count
Antibiotic ProphylaxisAntibiotic Prophylaxis
Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted.
Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.
Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted.
Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.
Selected BibliographySelected Bibliography1. The American Academy of Oral Medicine. Clinicians Guide to HIV-Infected Patients, 2001, 3rd Edition,
Editors: Patton L & Glick M, Baltimore, MD 21209. 2. Molinari JA, Glick M. Infectious Diseases. In Burket’s Oral Medicine. Greenberg MS, Glick M. Eds. BC
Decker Inc. Hamilton, Ontario, Canada. 2002 pp. 525-5623. Bartlett J and Gallant J. Medical Management of HIV Infection, 2001-2002 Edition, Publisher: Johns
Hopkins University School of Medicine, Department of Infectious Diseases, Baltimore, MD.4. Department of Health and Human Services (DHHS) and the Henry J. Kaiser Family Foundation.
Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents; May 2001. Available for download at: http://www.hivatis.org.
5. Department of Health and Human Services (DHHS). USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. July 2001. Available for download at: http://www.hivatis.org.
6. Infection Control Recommendations for the Dental Office and the Dental Laboratory ADA Council on Scientific Affairs and ADA Council on Dental Practice available for download at https://w3.ada.org/prof/prac/issues/topics/icontrol/ic-recs/index.html.
7. HIVDENT. Dental Treatment Considerations, August 2001; available for download at http://www.hivdent.org/dtc.htm.
8. The Dental Alliance for AIDS/HIV Care. Principles for the Oral Health Management of the HIV/AIDS Patient, 2001; available for download at http://www.critpath.org/daac/standards.html
9. Infection Control Guidelines: September,1997; Organization for Safety & Asepsis Procedures (OSAP); available for download at http://www.osap.org/resources/IC/icguide97.htm.
10. Centers for Disease Control and Prevention (CDC). Recommended Infection Control Practices for Dentistry, 1993. MMWR Morb Mortal Wkly Rep. 1993; 42(RR-8) 1-20.