periodontal management of hiv patients
DESCRIPTION
AIDS is a lethal viral infection caused by human immunodeficiency virus (HIV) and is characterized by severe depletion of T4 lymphocytes with associated opportunistic infections. Oral and perioral lesions are common in patients infected with human immune deficiency virus (HIV), are often the presenting feature, and may predict deterioration in general health and a poor prognosis. Due to multiple oral conditions and periodontal involvement, periodontists are in a unique position to recognize possible HIV infection in its early stage and to be involved in the oral care of these patients.TRANSCRIPT
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PERIODONTAL MANAGEMENT OF HIV
PATIENTS
ACHI JOSHI SAIMS, INDORE
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Contents 1. Introduction
2. Origin of aids
3. HIV- AIDS in India
4. Structure of HIV
5. Modes of transmission
6. Natural history of HIV
infection
7. Stages of HIV infection
8. CDC surveillance case classification
9. Classification of the most common
oral manifestations of aids
1. Lesions strongly associated
2. Lesions less commonly
associated
3. Lesion less seen in HIV.
10. PERIODONTAL TREATMENT
PROTOCOL
11. Treatment complications
12. Post exposure prophylaxis (PEP)
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INTRODUCTION
AIDS is a lethal viral infection caused by human immunodeficiency
virus (HIV) and is characterized by severe depletion of T4
lymphocytes with associated opportunistic infections.
Oral and perioral lesions are common in patients infected with
human immune deficiency virus (HIV), are often the presenting
feature, and may predict deterioration in general health and a
poor prognosis.
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• Most HIV-infected patients have head and neck
manifestations at some stage of disease and oral lesions are
often early signs.
(Schiodt & Pendborg 1989, Winkler & Robertson 1992)
• Due to multiple oral conditions and periodontal involvement,
periodontists are in a unique position to recognize possible HIV
infection in its early stage and to be involved in the oral care
of these patients.
ORIGIN OF AIDS
Studies comparing the genetics of HIV with various African monkey
viruses has provided some evidence.
HIV-1 & -2 are not closely related to each other as they are to simian
immunodeficiency virus (SIV).
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HIV 1
• HIV-1 is more common
worldwide
• HIV-1 is more pathogenic
• MTCT is relatively common
with HIV-1
HIV 2• HIV-2 is found in West
Africa, Mozambique, and
Angola.
• HIV-2 is less pathogenic
• Duration of HIV-2 infection
is shorter
• MTCT is relatively rare
with HIV-2
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History
• The first well-documented case of AIDS occurred in an
African man in 1959. Samples of his blood yielded
genetic material from an early version of HIV.
• It probably remained in small isolated villages, causing
sporadic cases and mutating into more virulent strains
that were readily transmitted from human to human.
• AIDS was first recognized in 1981 in USA.
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• The causative virus was isolated in 1983 from blood
lymphocytes and was called Lymphadenopathy Associated
Virus (LAV).
• 1984 - Human T-cell Lymphotropic Virus –III (HTLV-III).
• The International Committee on virus nomenclature in 1986,
decided on the generic name Human Immunodeficiency Virus
(HIV).
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HIV- AIDS in INDIA • India’s first cases of HIV were
diagnosed in Chennai in 1986.
• It is estimated that around 2.5
million people(61% male, 39%
female, 3.5% children) are currently
living with HIV.
• High Prevalence States: Tamil Nadu,
Maharashtra, Karnataka, Andhra
Pradesh, Manipur and Nagaland
STRUCTURE OF HIV
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VIRAL ENEVELOP
VIRAL PROTEIN
CAPSID
RNA
RNA virus.
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MODES OF TRANSMISSION
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STAGES OF HIV INFECTION
1. ACUTE HIV SYNDROME
First stage seroconversion
Virus rapidly spreads to organs, especially the lymphoid tissues
HIV virus not very aggressive in causing diseases or severe symptoms
2. ASYMPTOMATIC STATE
Infection is latent , No signs of HIV, immune system controls virus
production
Virus starts to grow and multiply in the lymph nodes
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3. SYMPTOMATIC DISEASE/AIDS
Viremia (spread of virus in the blood)
Physical signs of HIV infection
Loss of immune system, mainly due to infection of CD4 T- Lymphocytes
4. END STAGE DISEASE
Immune system collapses
Virus continues to slowly destroy the Immune System for up to 10 years
Usually an opportunistic infection is the cause of death
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CDC SURVEILLANCE CASE CLASSIFICATION
Category A : includes patients with acute symptoms or
asymptomatic diseases, along with individuals with persistent
generalised lymphadenopathy, with or without malaise , fatigue , or
low grade fever.
Category B : patients have symptomatic conditions such as : Oropharyngeal or vulvo-vaginal candidiasis Herpes zoster Oral hairy leukoplakia Idiopathic thrombocytopenia Constitutional symptoms of fever, diarrhoea and weight loss
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• Category C : patients are those with outright AIDS , as
manifested by life-threatening conditions or identified through
CD4+ T lymphocyte levels of less than 200 cells /mm3 (< 14%
of total lymphocytes)
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Classification of the Most Common Oral Manifestations of AIDS
Pindborg in 1989
• The first classification of the oral manifestations associated
with HIV-infection- based on etiological aspects and
distinguished between lesions caused by fungi, bacteria,
viruses, neo- plastic lesions.
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EEC-Clearinghouse on oral problems related to HIV-infection and WHO collaborating center on oral manifestations of the human immunodeficiency
virus.
In 1990, the classification was modified to establish three main groups:
1. Lesions strongly associated with HIV-infection
2. Lesions less commonly associated with HIV-infection, and
3. Lesions seen in HIV-infection
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Lesions strongly associated with HIV/ AIDS
• Oral candidiasis
• Oral hairy leukoplakia
• Kaposi’s sarcoma
• Non-Hodgkin’s lymphoma
• Periodontal diseases -
Linear Gingival Erythema
Necrotizing Ulcerative Gingivitis
Necrotizing Ulcerative Periodontitis
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Lesions less commonly associated
• Bacterial infections-
• Mycobacterium tuberculosis
• Mycobacterium
aviumintracellularae
• Melanotic hyperpigmentation
• Necrotizing ulcerative stomatitis
• Salivary gland diseases- xerostomia
• Thrombocytopenic purpura
• Ulceration (not otherwise
specified)
• Viral infections –
• Herpes simplex virus
• Human papilloma virus
• Condyloma accuminatum
• Multifocal epithelial
hyperplasia
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Lesions seen in HIV infectionBacterial infections:
• Actinomyces israelii
• Escherichia coli
• Klebsiella pneumonia
• Cat-scratch disease
Drug reactions,
• erythema multiforme,
• lichenoid,
• Toxic epidermolysis
Epitheliod (bacillary)angiomatosis
Fungal infection other than
candidiasis
• Cryptococcus neoformans
• Geotrichum candidum
• Histoplasma capsulatum
• Mucoraceae (mucomycosis
zygomycosis)
• Aspergilus flavus
Neurological disturbances
• Facial palsy
• Trigeminal neuralgia
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MOST COMMON ORAL MANIFESTATIONS OF
AIDS
ORAL CANDIDIASIS• Most oral candidal infections are associated with candida albicans
• Candidiasis is the most common oral lesion in HIV diseases and found in 90% AIDS
patients
It has 4 clinical presentations :
1. pseudomembraneous candidiasis
2. erythematous candidiasis
3. hyperplastic candiasis
4. angular cheilitis
Pseudomembraneous candidiasis
Oral Thrush
Multiple superficial, creamy white
plaques that can be easily wiped off
revealing erythematous base.
Yellow white curd-like lesion
Common on hard and soft palate, buccal
and labial mucosa and dorsal surface of
tongue
• Erythematous candidiasis
Appears as red patches
Seen on tongue or palatal mucosa
Associated with depapillation of the tongue
• Hyperplastic candidiasis
Least common form
Lesions appear white and cannot be removed by
scrapping.
Seen in buccal mucosa and tongue
More resistant to removal than other types
• Angular cheilitis
Seen on commissures of lips
Appear as erythematous with surface crusting and fissuring
1. Early oral lesions are usually responsive to topical antifungal therapy.
2. More advanced lesions, including hyperplastic candidiasis may require
systemic antifungal drugs.
3. Most oral topical antifungal agents contain large quantities of sucrose,
which may be cariogenic after long-term use.
MANAGEMENT
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Topical drugs
• CLOTRIMAZOLE (candid® ) 10mg tablets: dissolve in mouth 3-5tablets daily for 7-
14days
• NYSTATIN ( mycostatin® , nystec ® )
a) Oral suspension - (100,000 U/ml : Disp 240ml) Rinse with 1tsp qid.
b) Oral suspension- (extemporaneous) mix 1/8tsp with 4 oz water
c) Tablets(500,000U)- Dissolve 1tablet in mouth 4-5times daily.
d) Pastilles (200,000U)- dissolve 1-2 pastilles in mouth,4-5times daily.
e) Ointment 15g tube- Apply to affected area 3-4times daily
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CLOTRIMAZOLE ( candid) ointment 15g tube: apply to affected area
qid.
MICONAZOLE (oravig)2% ointment 15g tube: qid application.
ITRACONAZOLE ( icoz , sporonox) oral suspension 100-200mg once
daily for 7-28 days.
FLUCONAZOLE oral suspension 200mg of 1st day followed by 100mg
once daily for atleast 2weeks. (3mg/kg)
AMPHOTERICIN B oral suspension 100mg four times daily for 2 weeks.
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Systemic drugs
• Ketoconazole (hyphoral) 200mg tablets: 2 tablets immediately, then 1-2
tablets daily for 5-14days.
• Fluconazole (Diflucan) 100mg tablets: 2 tablets immediately, then 1 tablet
daily for 7-14 days. ( conflu)
• Itraconazole (Sporanox) 100mg capsules: 200mg once daily with meals for
4 weeks.
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ORAL HAIRY LEUKOPLAKIA
• Oral hairy leukoplakia most commonly presents as a
white ragged, corrugated or irregular lesion with a hair
like appearance involving the lateral and dorsolateral
tongue.
• Lesions may be unilateral or bilateral.
• Hairy leukoplakia is caused by infection of the lesion
epithelial cells with Epstein-Barr virus (EBV) and is
associated with immune deterioration.
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MANAGEMENT
• Oral hairy leukoplakia generally does not require treatment.
• Resolution has been reported after therapy with acyclovir, zidovudine,
podophyllin and interferon, but usually recurs when treatment is
discontinued.
• In cosmetically objectionable patients, lesions can be removed with laser or
conventional surgery.
• The incidence of OHL has been markedly reduced since the advent of
multidrug antiviral therapy for HIV infection.
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KAPOSI’S SARCOMA
• Kaposi’s sarcoma is a rare, multifocal vascular neoplasm which is the most
common malignant tumor associated with HIV infection.
• Herpes virus (HHV-8)
• This is an aggressive lesions and involves most frequently the palate 95% and
the gingiva 23%
• Kaposi’s sarcoma oral lesions may interfere with function, be cosmetically
objectionable, and proliferate uncontrollably.
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• Early lesions are painless, and appear as reddish purple macules of the
mucosa.
• As lesions progresses it becomes nodular, papular or non-elevated
macules, brown or purple in colour.
• May ulcerate and become painful with difficulty in eating and speech and
may cause cosmetic problems .
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Management • Treatment of oral KS may include use of
• Antiretroviral agents
• Laser excision
• Radiation therapy
• Nichols et al in 1993 described the successful use of intra-lesional injection
of vinblastine at a dosage of 0.1 mg/cm sq.
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• Intra-lesional injections with sodium tetradecyl sulfate (a sclerosing
solution) also have been effective.
• In case of destructive periodontitis in conjunction with gingival KS, scaling
and root planing and other periodontal therapy may be indicated along
with intra-lesional or systemic chemotherapy.
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NON-HODGKIN’S LYMPHOMA
• Second most common neoplasm
• Lesion are large, painful, ulcerated mass.
• Occurrence is more common in the gingiva.
• Has characteristic white verrucous surface or necrosis of the gingiva
resembling ANUG.
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MANAGEMENT
• Surgical excision
• Anti- cancer drugs
• Radiation therapy
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HIV RELATED PERIODONTAL DISEASES• The first report linking periodontal disease and HIV infection was published
in 1985 (Dennison et al)
• Classification on HIV related periodontal disease of the EC Clearing house
on oral problems related to HIV infection 1993.
• Linear gingival erythema.
• Necrotizing ulcerative gingivitis.
• Necrotizing ulcerative periodontitis
• Necrotizing ulcerative stomatitis
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Linear Gingival Erythema• Characterized by a marginal band of intense erythema with more apical
focal and/or diffuse areas of erythema that may extend beyond the
mucogingival line and is associated with earlier stages of HIV infection
and CD4+ suppression.
• No ulceration
• pocketing or attachment loss and strongly resistant to local treatment
The lesion may be- localised
generalized
• The microflora of LGE may closely mimic that of periodontitis rather than
gingivitis (Clark et al, 1991)
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MANAGEMENT
• LGE is often refractory to treatment but lesions may undergo spontaneous
remission.
• The success of treatment relies on identifying the important causative
factors like plaque, tobacco or substance usage, association with candidal
infection or presence of a number of periopathogenic bacteria consistent
with those seen in conventional periodontitis
• Scaling, CHX mouthwash and proper home care.
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• Step I: Instruct the patient in performance of meticulous oral hygiene
• Step II: Scale and polish affected areas, and perform subgingival irrigation
with chlorhexidine.
• Step III: Prescribe chlorhexidine gluconate mouthrinse for 2 weeks
• Step IV: Reevaluate in 2-3 weeks. If lesions persist evaluate for possible
candidiasis. Consider empiric administration of a systemic antifungal agent
such as fluconazole for 7-10 days
• Step V: Re-treat if necessary and place the patient on 2-3 month recall.
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NECROTIZING ULCERATIVE GINGIVITIS
• NUG has been associated with HIV infection.
• NUG is characteristic of red and swollen gingiva with
yellowish – grey marginal areas of necrosis leading to
destruction of inter-dental papillae usually takes a chronic or
sub acute course.
• Spontaneous hemorrhage and characteristic fetor
accompanied by severe pain.
• NUG rapidly progresses and becomes NUP.
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Management • Basis treatment consists of cleaning and debridement of
affected areas with a cotton pellet soaked in peroxide after
application of topical anesthetic
• The patient should be seen daily or every other day for the
first week; debridement of affected areas is repeated at each
visit and plaque control methods are gradually introduced.
• A meticulous plaque control program should be taught and
started as soon as the sensitivity of the area allows it.
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• Patient should refrain from tobacco, alcohol and condiments
• An antimicrobial mouthrinse such as chlorhexidine gluconate 0.12%
should be prescribed
• Systemic antibiotics such as metronidazole or amoxicillin may be
prescribed for patients with moderate to severe tissue destruction,
localized lymphadenopathy or systemic symptoms or both. The use of
prophylactic antifungal medication should be considered if antibiotics are
prescribed.
• The periodontium should be re-evaluated 1 month after resolution of
acute symptoms to assess the results of treatment and determine the
need for further therapy.
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NECROTIZING ULCERATIVE PERIODONTITIS
• NUP is necrotizing, ulcerative, rapidly progressive
form of periodontitis which occurs in HIV Positive
individuals
• NUP may represent an extension of NUG in which
bone loss and periodontal attachment loss occurs.
• NUP is characterized by soft tissue necrosis, rapid
periodontal destruction and interproximal bone loss.
Lesions may be localized or generalized and may be
present after marked CD4+ cell depletion.
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• Bone is often exposed resulting in necrosis and subsequent
sequestration.
• On treatment, patients undergo spontaneous resolution of the
necrotizing lesions, leaving painless, deep interproximal craters
that are difficult to clean and may lead to conventional
periodontitis (Glick et al, 2000).
• Data implicate a similar microbial component in both NUP and
chronic periodontitis (Glick et al 1994, Murray et al 1991).
• They found NUP in only 6.3% and concluded that NUP is a
predictive marker for severe immune deficiency because patients
with NUP were 20.8 times as likely to have CD4+ lymphocyte
counts <200/mm3
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MANAGEMENT
• Gradual, gentle, local debridement of affected area.
• Scaling and root planing with oral hygiene instruction
• In office irrigation with an effective antimicrobial agent such as chlorhexidine
gluconate or povidine iodine.
• Chlorhexidine gluconate 0.12% - 0. 2% mouth rinse twice daily.
• Metronidazole, 500 mg loading dose and 250 mg four times daily until ulcers
are healed, alternatively penicillin or tetracycline.
• Prophylactic topical or systemic antifungal agent and follow up visit within
next 3 days.
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NECROTISING ULCERATIVE STOMATITIS
• NUS maybe severely destructive and acutely painful.
• It is characterized by necrosis of significant areas of oral soft tissue and
underlying bone.
• It may occur separately or as an extension of NUP and is commonly
associated with severe depression of CD4+ immune cells and an increased
viral load (GRASSI et al 1988)
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Management
• Metronidazole
• Antimicrobial mouth rinse
• If osseous necrosis is present, its necessary to remove the affected bone to
promote wound healing
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ORAL HYPERPIGMENTATION• An increased incidence of oral hyperpigmentation has been described in
HIV-infected individuals.
• Pigmented areas often appear as spots or striations in the buccal mucosa,
soft palate and the gingiva or tongue.
• The pigmentation may relate to prolonged use of drugs such as zidovudine,
ketoconazole or clofazimine.
• Zidovudine is also associated with excessive pigmentation of the skin and
nails.
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Oral pigmentation may be caused by,
• Adrenocorticoid insufficiency caused by
prolonged use of ketoconazole
• Pneumocystitis carinii infection
• Cytomegalovirus infection
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ATYPICAL ULCERS
• HIV-infected patients have a higher incidence of recurrent herpetic lesion and
aphthous stomatitis
• Atypical large , persistent , non specific, painful ulcers
• Caused by-
• herpes simplex virus (HSV)
• varicella-zoster virus (VZV)
• epstein-barr virus (EBV)
• cytomegalovirus (CMV)
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Herpes labialis
• Seen as vesicles on lip and adjacent facial skin which break down to produce
shallow ulcers.
• HIV infected individuals responsive to topical antiviral therapy
• Acyclovir , pencyclovir , doconasol
• Reduces healing time of lesion
Recurrent aphthous stomatitis
• Sites : oropharynx, oesophagus, or other areas of GIT.
• Treatment:- Topical or intralesional corticosteroids, chlorhexidine,
antimicrobial mouth rinses, oral tetracycline rinses
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• Topical corticosteroid therapy (fluocinonide gel applied three to six times
daily) is safe and efficacious for treatment of recurrent aphthous ulcer or
other mucosal lesions in immunocompromised individuals.
• Prophylactic antifungal medications should be prescribed
• Large aphthae in HIV+ve individuals may be treated with systemic
corticosteriods - prednisone 40 to 60 mg daily
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Xerostomia
• Xerostomia may be associated with HIV disease and may be a complication of
prescribed medication that may be xerostomic.
• The disease is characterized by diffuse enlargement of the major salivary glands
and/ or xerostomia. CMV has been demonstrated in the salivary gland of xerostomic
patients (Greenspan et al. 1992).
• Identification of the dry mouth and reduced saliva production can also lead to further
investigation and diagnosis and requires management in order to control the
conditions associated with a dry mouth including increased risk of candidiasis and
caries risk. In addition, management of xerostomia will improve oral comfort, may
affect the quality of speech, and affect the use of any prosthesis.
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Treatment • Salivary stimulants – sugar free gums
• Systemic sialogouges pilocarpin 5 mg - 3 times daily
• Flouride rinses- decay
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BACILLARY (EPITHELIOD) ANGIOMATOSIS (BA)
• BA is an infectious vascular proliferative disease with clinical and histologic
features very similar to those of kaposi’s sarcoma.
• Caused by Rickettsia like organism - Bartonellaciae henselia, quintana, or
others.
• Gingival manifestations are red purple or blue edematous soft tissue
lesions that cause destruction of the periodontal ligament and bone.
• Histological picture
Epitheloid proliferation of angiogenic cells
Acute inflammatory cell infiltrate.
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TREATMENT
• Broad-spectrum antibiotics such as erythromycin or doxycycline in
conjunction with conservative periodontal therapy and possibly excision
of the lesion.
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PERIODONTAL TREATMENT PROTOCOL
• HEALTH STATUS
• INFECTION CONTROL MEASURES
• GOALS OF THERAPY
• SUPPORTIVE PERIODONTAL THERAPY
• PSYCHOLOGIC FACTORS
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HEALTH STATUS1. Should be determined from the health history, physical evaluation and
consultation with the patient’s physician.
2. Treatment decisions will vary depending on the patient’s state of health
3. Information should be obtained regarding-
• CD4+ T4 lymphocyte level
• current viral load
• difference from previous counts and load
• H/o of drug abuse, multiple infections
• present medications
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Viral load
Severity of illness is determined by amount of
virus in the body (increasing viral load) and
the degree of immune suppression
(decreasing CD4+ counts)
Higher the viral load, the sooner immune
suppression occurs
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INFECTION CONTROL MEASURES
1. Control measures should be based on American Dental
Association (ADA) and the Center for Disease Control and
Prevention (CDC) or the Organization for Safety and Asepsis
Procedure (OSAP).
2. A number of pathogenic microorganisms may be transmitted in
the dental setting and these include:
• Airborne pathogens - tuberculosis
• Blood borne pathogens -HIV, HBV, HCV
• Waterborne pathogens Legionella and Pseudomonas species
• Mucosal/ skin borne pathogens VZV or HSV
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GOALS OF THERAPY
• Primary goals should be restoration and maintenance of oral health,
comfort and function.
• Treatment should be directed toward control of HIV-associated mucosal
diseases such as chronic candidiasis and recurrent oral ulcerations
• Effective oral hygiene maintenance
• Conservative, nonsurgical periodontal therapy should be a treatment
option for virtually all HIV + patients
• NUP & NUS can be severely destructive to periodontal structures and
should be treated appropriately.
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SUPPORTIVE PERIODONTAL THERAPY
• Patient should be encouraged to maintain meticulous personal
oral hygiene.
• Recall visits should be conducted at short intervals (2 to 3
months)
• Systemic antibiotic therapy should be administered with caution
• Blood and other medical laboratory tests may be required to
monitor the patients overall health status and consultation and
co-ordination with the patient’s physician are necessary
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PSYCHOLOGIC FACTORS
• HIV infection of neuronal cells may affect brain function and lead to outright dementia.
• Coping with a life-threatening disease may elicit depression, anxiety and anger in such
patients and this anger may be directed toward the dentist and the staff (Asher et al
1993).
• Treatment should be provided a calm, relaxed atmosphere, and stress to the patient
must be minimized.
• Early diagnosis and treatment of HIV infection can have a profound effect on the
patient’s life expectancy & quality of life
• In case of suspected cases, testing for HIV antibody should be advised after patient
counseling and information.
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DENTAL TREATMENT COMPLICATIONS1. Adverse Drug Effects
• Foscarnet, Interferon - Oral ulcerations
• Didanosine - Erythema Multiforme
• Zidovudine & Ganciclovir - Leucopenia
• Dithiocarb - Xerostomia & Altered taste sensation
• HIV-positive patients more susceptible to drug-induced Mucositis &
Lichenoid drug reactions
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2. HAART drugs
• Insulin resistance, gynecomastia, blood dyscrasias, nausea, development of kidney
stones, oral warts
• Individuals with Hepatitis C + HIV co- infection are susceptible to liver cirrhosis
Lipodystrophy
• Redistribution of body fat
• Gaunt facial features yet display excessive abdominal fat or even a fat pad on the
rear of the shoulders (buffalo hump)
Severe systemic hyperlipidemia
Oral or perioral adverse effects oral lichenoid reactions, xerostomia, altered taste
sensation, perioral parasthesia, and exfoliative cheilitis
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TO ERR IS HUMAN
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Post exposure prophylaxis (PEP)• The term post-exposure prophylaxis mean the medical response
given to prevent the transmission of blood-borne pathogens
following a potential exposure to HIV.
• PEP should be provided following exposure of non-intact skin
(through percutaneous sharps injury or skin abrasion) or mucous
membranes (through sexual exposure or splashes to the eyes, nose
or oral cavity) to a potentially infected body fluid from a source
that is HIV-positive or has unknown HIV status.
•
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•When exposure occurs, Provide immediate care to the exposure
site.
•Wash needlestick injuries and cuts with soap and water.
• Flush mucous membranes with a sterile solution of water or
saline. If sterile solutions are not available, use clean potable
water.
• No data have demonstrated that using antiseptics or squeezing a
wound reduces the risk of transmission of a bloodborne pathogen.
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Evaluating eligibility for HIV post-exposure prophylaxis involves
assessing the following:
• The timing of the potential exposure
• The person’s HIV status
• The nature and risk of the exposure and
• The HIV status of the source of the potential exposure
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Conclusion
• HIV associated oro-facial lesions have been considered-
• Early clinical picture thus act as Clinical indicators of HIV in
otherwise healthy individual
• Also oral lesions are predictors of disease progression.
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THANK YOU