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Principles of Oral Health Management for the HIV/AIDS Patient

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1 Principles of Oral Health Management for the HIV/AIDS Patient
A Course of Training for the Oral Health Professional Made possible from a grant to the New York State Department of Health AIDS Institute from the HIV/AIDS Bureau, Division of Community Based Programs, Health Resources and Services Administration, DHHS

2 Module 2 Basic Principles Of Management
Stephen N. Abel, DDS, MS Francisco Ramos-Gomez, DDS, MS, MPH June 2000

3 Basic Principles Of Management
The principles of good oral health care are the same for people with HIV as they are for all dental patients. There is no evidence to support alterations in oral health care solely based on HIV status. By focusing on routine and preventive care, dentists can maintain and improve the quality of life for patients with HIV. Basic Principles of Management HIV positive patients need routine dental care just as other patients. Poor patient prognosis is not a reason to deny care. A preventive approach to care can obviate and emergent situation which can place an immune-compromised patient at risk for infection. June 2000

4 General Treatment Planning
Oral health can impact upon systemic health; systemic health can impact upon oral health. Modifications of care are similar to other medically compromised patients. Individual needs assessments (fiscal, physical and psychosocial, etc) will ensure more successful treatment outcomes. General Treatment Planning The literature supports an interaction between oral health and systemic health. Patients with periodontal disease, for instance, may be more prone to coronary heart disease and/or low birth-weight babies. Similarly, diabetic patients or smokers are more prone to periodontal disease. Patients who are HIV+ are more likely to exhibit certain types of periodontal diseases and other oral pathologies. Each patient must undergo an individual needs assessment through which multiple issues can be factored into the treatment plan. June 2000

5 General Treatment Planning
The initial visit should include a completely documented overview of the patient’s overall oral condition along with medical status review. Initial Visit This is the visit where communication and documentation of the other members of the primary care team should take place including: 1) definitive record of all soft and hard tissues 2) documentation of the members of the primary care team 3) medical status review June 2000

6 Restorative Considerations
Most principles are similar to those of the general population Poor candidates for extensive restoration include those with: rampant caries reduced salivary flow oral acidity dysgusia compromised motor skills upper airway obstruction poorly controlled oral manifestations Restorative Considerations In the presence of those conditions which would put the patient at risk for recurrent decay, the practitioner may wish to place temporary restorations. Once conditions associated with conditions such as oral acidity or xerostomia are corrected, permanent restorations can be placed. Overall, a patient’s ability to undergo restorative treatment will depend on his or her ability to emotionally and physically tolerate dental visits. June 2000

7 Xerostomia Impacts on hard and soft tissue Impacts on quality of life
Treatments are available (prescription and OTC) Xerostomia Xerostomia enhances caries development, periodontal disease and soft tissue infection. Most patients who experience this disorder report a significant negative impact on eating, taste and usually exhibit fissures at the commisures. Appropriate management of xerostomia includes secretory stimulants (oral pilocarpine), OTC saliva substitutes or lozenges (sugarless) June 2000

8 Oral Surgery: Treatment Planning Guidelines
Follow same principles as other medically complex patients. Communicate Immune-compromised patients may at some points be more susceptible to infection, bleeding and delayed healing Update the medical history Oral Surgery: Treatment Planning Guidelines When developing treatment planning guidelines for patients with HIV disease, the same principles should be followed as you would for treating other medically complex patients with careful attention to issues of bleeding, infection and healing. The best information about the patients present medical history can be elicited from both the patient (self-reporting) and from other members of the patient’s primary care team. It should be emphasized that HIV disease may be an evolving and progressive disease. Because not all patients are stable, a careful medical review and update is appropriate at every dental visit. Also, a definitive review is appropriate before any surgical procedure. June 2000

9 Oral Surgery Antibiotic Therapy
The appropriate administration of antibiotic therapy to patients with HIV disease will be presented in the following categories: Antibiotic premedication in the absence of infection Antibiotic administration pre and post treatment n the presence of infection June 2000

10 Antibiotic Pre-medication In The Absence Of Infection
To prevent complications associated with post-procedural bleeding, delayed healing or infections. According to AHA guidelines to prevent SBE Neutropenia Indwelling catheters? Antibiotic Premedication in the Absence of Infection As with any patients with conditions requiring antibiotic premedication, according to AHA guidelines to prevent SBE, HIV+ patients with similar conditions should be premedicated similarly. For patients who are neutropenic with absolute neutrophil counts less than 500 cells/mm3, premedication is appropriate. For patient with indwelling catheters, many physicians will request premedication to prevent post-procedural infection. This recommendation may not be scientifically evidenced-based and a discussion with the primary care team is advisable. June 2000

11 Antibiotic Administration During And After Treatment In The Presence Of Oral Infection
Antibiotic Premedication in the Presence of Infection Most head and neck infections that originate in the mouth are the result of mixed anaerobic infections. Metronidazole, unless contraindicated, is the drug of choice because bacteria exhibit no resistance and because metronidazole does not alter the normal bacterial flora of the mouth. For there reasona, overgrowth of opportunistic pathogens, such as Candida species, is less likely to occur with metronidazole use than with a broad-spectrum antibiotic. Clindamycin may also be used to treat infections of dental origin. June 2000

12 Oral Surgery: Extractions
Post-Operative Complications Dry socket Other Oral Surgery: Extractions A conclusion one can draw from the literature is: 1) incidence of dry socket in persons with HIV disease is no greater than the general population 2) the incidence rate of dry socket is approximately 3-4%. Most complications associated with extractions (prolonged bleedings, delayed healing, dry socket, infections, unusual pain) are associated with age of patient, smoking habits of patient, experience of dentist, tooth type extracted and number of teeth extracted at the visit. Complications are NOT NECESSARILY associated with the HIV status. June 2000

13 Oral Surgery Incidence of post-procedural complications is no greater than in other populations Oral Surgery Most studies support the conclusion that the incidence of post-procedural complications is no greater among HIV+ patients is no greater than the general population. In a study of 331 patients (with an average CD4 count of 71 cells/mm3) 1800 invasive dental procedures (defined as the breaking of the mucosal membrane) were performed. The number of post-procedural complications was only 17, representing an overall complication rate of 0.9% June 2000

14 Summary Of Oral Surgery Considerations
Collaborate with other members of primary care team. Routine antibiotic use is contraindicated Hemostatic function assessment is indicated before extensive surgery Aseptic technique reduces post-procedural complications Incidence of complications no higher in HIV+ population Summary of Oral Surgery Considerations 1. Communicate and integrate with other members of the primary care team in order to better understand patients present medical history. 2. Antibiotics should be used selectively an appropriately. 3. Like any other patient and especially among patients with complex medical histories, hemostatic functions (platelets, PT/PTT) should be assessed prior to extensive oral surgery. 4. Technique impacts on post-op complications. 5. Post-procedural complications are no different in this population (in terms of bleeding, pain and infection and delayed healing). June 2000

15 Dental Caries Cariogenic potential of drugs HIV-associated xerostomia
Drug associated xerostomia Acid reflux If recurrent caries cannot be controlled, extensive crown and bridge should be avoided Dental Caries Patients with HIV disease may be more prone to dental decay for a number of factors. 1. Certain drugs have a cariogenic potential. One such category would be the topical antifungals which have a high sucrose or dextrose content. 2. A small proportion of HIV patients have HIV-associated salivary gland disease which can also result in xerostomia leading to enhanced decay. 3. Certain HIV drugs such as ddi(Videx) have a xerostomic side-effect. Additionally other drugs that are prescribed for associated conditions (anti- depressants) have xerostomic side-effects. 4. Patient with gastric acidity and reflux may experience rampant decay. 5. Dietary assessment may need to be performed (carbohydrate-rich foods). 6. Extensive crown and bridge should be delayed until caries control can be achieved. June 2000

16 Periodontal Considerations And The HIV+ Patient
Periodontal diseases is found among patients with HIV disease as they are among the general population. The literature is still evolving with recent reports suggesting that the degree of disease is more strongly related to smoking than it is to CD4 count or viral load. Thus, the relationship of periodontal diseases and HIV disease, especially as it relates to gingival inflammation and rate of attachment loss, is still not definitively understood. What we do know is there are some periodontal disease manifestations which are more common among those with compromised immune systems. Those diseases are lineaer gingival erythema, necrotizing ulcerative gingivitis and necrotizing ulcerative periodontitis. June 2000

17 Periodontal Considerations
Linear Gingival ERYTHEMA (LGE) Periodontal Considerations: Linear Gingival Erythema (LGE) Clinical Features: Distinct erythematous band which can extend into the alveolar mucosa. Localized or generalized. Bleeds on probing; often edemaous. No attachment loss. Unrelated to plaque. Differential Diagnosis: Distinct from gingivitis in that it does not necessarily respond to scaling or plaque control. Treatment and Management: Scaling, root planing, chlorhexidine and treatment with an antifungal for the non-responders. This lesion may, but not necessarily, progress on to necrotizing ulcerative periodontitis. Prevalence among the HIV population is unclear although clearly less than 10% and may be much lower than this. June 2000

18 Linear Gingival ERYTHEMA (LGE) Frontal
Periodontal Considerations: Linear Gingival Erythema (LGE) Clinical Features: Distinct erythematous band which can extend into the alveolar mucosa. Localized or generalized. Bleeds on probing; often edemaous. No attachment loss. Unrelated to plaque. Differential Diagnosis: Distinct from gingivitis in that it does not necessarily respond to scaling or plaque control. Treatment and Management: Scaling, root planing, chlorhexidine and treatment with an antifungal for the non-responders. This lesion may, but not necessarily, progress on to necrotizing ulcerative periodontitis. Prevalence among the HIV population is unclear although clearly less than 10% and may be much lower than this. June 2000

19 Linear Gingival ERYTHEMA (LGE) Side
Periodontal Considerations: Linear Gingival Erythema (LGE) Clinical Features: Distinct erythematous band which can extend into the alveolar mucosa. Localized or generalized. Bleeds on probing; often edemaous. No attachment loss. Unrelated to plaque. Differential Diagnosis: Distinct from gingivitis in that it does not necessarily respond to scaling or plaque control. Treatment and Management: Scaling, root planing, chlorhexidine and treatment with an antifungal for the non-responders. This lesion may, but not necessarily, progress on to necrotizing ulcerative periodontitis. Prevalence among the HIV population is unclear although clearly less than 10% and may be much lower than this. June 2000

20 Periodontal Considerations
Necrotizing Ulcerative Gingivitis (NUG) Periodontal Considerations: Necrotizing Ulcerative Gingivitis (NUG) Clinical Features: Destruction of one or more interdental papillae, gingival pain and fetor oris. In the acute stage of the process, ulceration, papillary necrosis and sloughing may be seen. No involvement of the hard tissues. Differential Diagnosis: Necrotizing Ulcerative Periodontitis Treatment and Management: Systemic antibiotics such as ___, tetracycline, and tissue debridement, oral hygiene and anti-microbial rinses. June 2000

21 Periodontal Considerations
Necrotizing Ulcerative Periodontitis (NUP) Periodontal Considerations: Necrotizing Ulcerative Periodontitis (NUP) Clinical Features: Severe soft-tissue necrosis and destruction of the periodontal attachment and osseous supporting structure. Significant loss over a very short period of time. Often accompanied by spontaneous gingival bleeding with patients reporting a deep-seated bone pain. Differential Diagnosis: Necrotizing Stomatitits Lymphoma NUG Treatment and Management: Treatment consists of antibiotic therapy (metonidazole/augmentin) along with careful debridement, chemotherapeutics (chlohexidine/betadine) and oral hygiene instruction. Relief for patients is generally achieved with hours once antibiotic therapy is instituted. June 2000

22 Necrotizing Ulcerative Periodontitis (NUP)
Periodontal Considerations: Necrotizing Ulcerative Periodontitis (NUP) Clinical Features: Severe soft-tissue necrosis and destruction of the periodontal attachment and osseous supporting structure. Significant loss over a very short period of time. Often accompanied by spontaneous gingival bleeding with patients reporting a deep-seated bone pain. Differential Diagnosis: Necrotizing Stomatitits Lymphoma NUG Treatment and Management: Treatment consists of antibiotic therapy (metonidazole/augmentin) along with careful debridement, chemotherapeutics (chlohexidine/betadine) and oral hygiene instruction. Relief for patients is generally achieved with hours once antibiotic therapy is instituted. June 2000

23 Necrotizing Ulcerative Periodontitis (NUP)
Periodontal Considerations: Necrotizing Ulcerative Periodontitis (NUP) Clinical Features: Severe soft-tissue necrosis and destruction of the periodontal attachment and osseous supporting structure. Significant loss over a very short period of time. Often accompanied by spontaneous gingival bleeding with patients reporting a deep-seated bone pain. Differential Diagnosis: Necrotizing Stomatitits Lymphoma NUG Treatment and Management: Treatment consists of antibiotic therapy (metonidazole/augmentin) along with careful debridement, chemotherapeutics (chlohexidine/betadine) and oral hygiene instruction. Relief for patients is generally achieved with hours once antibiotic therapy is instituted. June 2000

24 Necrotizing Ulcerative Periodontitis (NUP)
Periodontal Considerations: Necrotizing Ulcerative Periodontitis (NUP) Clinical Features: Severe soft-tissue necrosis and destruction of the periodontal attachment and osseous supporting structure. Significant loss over a very short period of time. Often accompanied by spontaneous gingival bleeding with patients reporting a deep-seated bone pain. Differential Diagnosis: Necrotizing Stomatitits Lymphoma NUG Treatment and Management: Treatment consists of antibiotic therapy (metonidazole/augmentin) along with careful debridement, chemotherapeutics (chlohexidine/betadine) and oral hygiene instruction. Relief for patients is generally achieved with hours once antibiotic therapy is instituted. June 2000

25 Implants Studies to date have demonstrated no differences in the success rate of implants between HIV+ and HIV- patients Implants At this time, the literature is scarce on this topic. Case reports to date tend to indicate little or no adverse reactions or unusual post-surgical responses. Anecdotal reports suggest that patients with HIV disease have been successful candidates for implants. Thus, there are a number of parameters which must be weighed before a determination to place an implant is made. An HIV diagnosis alone should not be a determining factor. June 2000

26 Endodontic Considerations
Endodontic treatment appears to offer many benefits and few drawbacks for HIV patients Reduced infection risk Reduced need for extraction Improved ability to chew Improved self-esteem Endodontic Considerations Endodontic therapy ultimately eliminates the source of infection thus reducing the possibility of spread through fascial spaces and a septicemia. Through endodontic therapy more of the dentition is retained. This can lead to an improved ability to chew and improved self esteem, especially among adolescents. Through endodontic therapy the patient may be able to avoid a removable prothodontic appliance. Finally, the cost/risk benefit ratio of performing an endodontic procedure versus placing the patient in a surgical risk situation (undergoing an extraction) must be considered. June 2000

27 Endodontic Considerations
Endodontic treatment and post-procedural complications. Consider one-step endodontic therapy when appropriate. Endodontic Considerations Most literature supports that patients with HIV disease respond no differently to endodontic therapy than seronegative patients. Situations where one-step endodontic therapy has been recommended are: cases of acute pulpititis when the patient is not able to return to the dental setting when premedication is indicated acute or chronic infections requiring antibiotic treatments when a history of oral fungal infections is present. June 2000

28 Orthodontic Considerations
Factors to consider before instituting therapy Factors to consider due to non-treatment Orthodontic Considerations Key issues to factor before instituting therapy, which is likely to continue for 2-3 years, include: patient’s overall health patient’s overall oral health ability to withstand multiple appointments ability to comply with oral hygiene level of speech impairment due to malocclusion occlusal malfunction psychosocial impact associated with appearance before, during, and after therapy which important to individuals, especially adolescents. June 2000

29 Prosthodontic Considerations
Most principles are similar to the general population. Special considerations should be given to those with: candidiasis xerostomia wasting syndrome slower bone remodeling resulting in more frequent relines Prosthodontic Considerations The principles for prosthodontic therapy are no different for th is population. Some special considerations should be given to individuals with uncontrolled/recurrent candidiasis and care of the prosthondontic appliance. Patients with xerostomia are at increased risk for decay and periodontal disease. Fixed appliances should not be placed until this condition is controlled. Patients with wasting syndrome are likely to require frequent denture relines. June 2000

30 Guidelines To Prevention Of Oral Disease
A focus on prevention in HIV+ patients may eliminate or reduce oral complications and improve or preserve overall quality of life. Patients with HIV infection may develop alterations in the mucosal barrier, alterations in saliva flow and composition and changes in the microbial flora. These changes can lead to: xerostomia, dysgeusia (distortion of taste), ageusia (loss of taste), dysphagia (difficulty in swallowing) and loss of appetite. A preventive approach to the care of patients with HIV disease should include: a complete hard and soft tissue examination appropriate management of the oral disease(s) with referral as necessary. primary caries detection with restorations secondary caries prevention to identify risk factors, patient education in oral hygiene. Also the appropriate in-office application of fluoride, the prescription and/or OTC fluoride and salivary lubricants. periodontal maintenance program including antimicrobial rinses and gels smoking cessation/reduction program June 2000

31 Additional HIV Oral Health Guidelines
Review any issues surrounding HIV drug adherence Work to teach other members of the primary care team to understand the importance of oral health as a component of comprehensive HIV care. Additional HIV Oral Health Guidelines One issue that we may not think about is the role of the HIV dentist as a counselor on drug adherence. The importance of appropriate drug regimens cannot be overemphasized as it relates to the development of viral resistance. Every visit to a health professional should/can be viewed as an opportunity to review patient compliance with his drug regimen. If barriers to compliance are recognized by the dentist, a prompt referral to the appropriate member of the primary care team should be made in order to address the issues and if necessary change the drug regimen. Finally, it is important to act as a teacher to other members of the primary care team reinforcing the potential complications/interplay between compromised oral health and its impact on general health (systemic infections, coronary heart disease and periodontal disease). June 2000


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