medical evaluation of the hiv dental patient, 2005 (powerpoint)

Medical Evaluation of the HIV Dental Patient

Module 1

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

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

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.

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 -LipodystrophyHyperglycemiaLiver disease

Medical Concerns

• Patient’s susceptibility to infections

• Impaired hemostasis

• Drug actions and interactions

• Ability to withstand the stress and trauma due to dental care

Medical Problem List

• Patient’s susceptibility to infectionsHemodialysisBacterial endocarditisPoorly controlled diabetes mellitus

Medical Problem List

• Impaired hemostasisHemophiliaLiver disease due to:

• Hepatitis B infection and/or • Hepatitis C infections and/or• Alcohol, substance use/abuse

Idiopathic thrombocytopenia purpura

Medical Problem List

• Drug actions and interactionsAvoid acetaminophen in patients

with severe liver diseaseAvoid NSAIDs, including aspirin, in

patients with impaired hemostasisRecognize side-effects and

drug-interactions with antiretroviral medications• See Module 3, part 3

Medical Problem List

• Ability to withstand the stress and trauma due to dental careCardiovascular diseaseStrokePoorly controlled diabetes mellitus

Medical 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.

Medical History

• Medical history should include:Chief complaints and history of present illnessChief complaints and history of present illnessReview of past medical historyReview of past medical historyHospitalizations and surgeriesHospitalizations and surgeriesCurrent/recent illnessesCurrent/recent illnessesMedicationsMedicationsAllergiesAllergiesSubstance abuse historySubstance abuse historyReview of systemsReview of systems

Systems 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

Dental 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 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)

Medications• 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 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

Medical 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:

Hematological Blood

ValuesIndication of patient’s risk for infection and bleeding tendencies• Complete Blood Count (CBC)

Platelet countDifferential blood cell count

• Liver enzymes• Coagulation tests

HematologyCBC

• CBC includes: White blood cell count (WBC) Red blood cell count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelets (Plt)

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 bleedingShould 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

Hematology Differential White Blood Cell Count

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.

HematologyRed Blood Cells

• Red Blood CellsAnemia is common in HIV diseaseDecrease in RBCs or Hgb

often caused by antiretroviral therapy and other medications

Normal RBC: 4.5 - 5.5 x 106 cells/mm3

HematologyHemoglobin

• Hemoglobin: Carries oxygen in the RBC • Decreased hemoglobin means less ability for

oxygenationNormal 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 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

HematologyHematocrit

• HematocritMeasure of packed cell volume

(PCV) of RBCsNormal: 37% - 54%indication of anemia and

especially vitamin B12 deficiency

HematologyLiver Enzymes

• ALT, AST valuesNon-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

• Indicates patient’s clotting ability• Increase indicates:Coagulation abnormality due to liver diseaseOther systemic diseases Anticoagulant therapyMedications

• Significantly elevated coagulation test results may require modification of dental treatment

HematologyCoagulation Tests

• Coagulation tests:Prothrombin time (PT)

• Normal: 9-11 secondsActivated 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

• 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)• Absolute CD4 helper countTotal 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

• 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 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

Confidentiality

• 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

• 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

• 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

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

• 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 based on: Medical statusFinancesPatient acceptance

• Modify dental procedures according to ability of the patient to tolerate dental procedures

Antibiotic 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

Antibiotic 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.

Selected Bibliography• The American Academy of Oral Medicine. Clinicians Guide to HIV-Infected Patients, 2001,

3rd Edition, Editors: Patton L & Glick M, Baltimore, MD 21209. • Molinari JA, Glick M. Infectious Diseases. In Burket’s Oral Medicine. Greenberg MS, Glick

M. Eds. BC Decker Inc. Hamilton, Ontario, Canada. 2002 pp. 525-562• 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.

• 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.

• 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.

• 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.

• HIVDENT. Dental Treatment Considerations, August 2001; available for download at http://www.hivdent.org/dtc.htm.

• 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

• Infection Control Guidelines: September,1997; Organization for Safety & Asepsis Procedures (OSAP); available for download at http://www.osap.org/resources/IC/icguide97.htm.

• 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.