Free Online CME: HIV and Oral Health Care

Updated December 2001 — Currently Under Revision

I. INTRODUCTION

General Recommendations:

Comprehensive primary care includes primary oral health care. Oral health should be an integral part of primary health care for all patients with HIV/AIDS.

Asymptomatic HIV-infected patients and clinically stable, fully functional AIDS patients should receive routine, comprehensive oral health care in the same manner as all other patients.

The provision of care should be coordinated between medical and oral health care providers.

Oral health care is an important component of the management of patients with HIV infection. A poorly functioning dentition can adversely affect the quality of life, complicate the management of medical conditions, and create or exacerbate nutritional and psychosocial problems.¹ Oral health status also affects antiretroviral (ARV) treatment adherence. When the oral cavity is compromised by the presence of pain or discomfort, maintaining adherence to complicated ARV regimens becomes more difficult.

Through June 2000, a cumulative total of 745,103 AIDS cases in adults and adolescents were reported to the Centers for Disease Control and Prevention (CDC); 8,804 cases were reported in children <13 years of age.² In New York State, 140,218 cumulative AIDS cases in adults and adolescents were reported through June 2000 (113,252 of the reported cases were from New York City); 2,158 cases were reported in children <13 years of age.

The HIV/AIDS epidemic poses enormous challenges for the United States. Increasing numbers of mostly impoverished people of color, including women and children, are becoming infected with HIV.^2-4 Although a cure is not in sight, highly active antiretroviral therapy (HAART) has made HIV/AIDS a chronic, manageable disease.⁵ Most of the new infections occur in populations among which oral health is the poorest in the nation.^6,7 Unmet oral health needs of people with HIV/AIDS have been consistently documented, and finding new strategies for meeting these needs is urgent.^6-9 Although great progress has been achieved in making oral health care services available for people with HIV/AIDS, much remains to be done in oral health professional education to ensure competent and non-judgmental care for all patients.

The principles of good oral health care are the same for patients infected with HIV as they are for all dental patients. Despite the medical and immunologic problems resulting from HIV infection, few complications resulting from dental treatment have been reported.¹⁰

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II. ACCESS TO ORAL HEALTH CARE

Recommendations:

To ensure adequate access to oral health care services, structural, financial, personal, and cultural barriers should be considered and addressed.^1,7,11-13

Due to the changing face of the HIV epidemic, which increasingly affects poor people of color who historically have experienced lack of proper access to oral health care,^1,13 health care providers should ensure that each patient receiving therapy for HIV infection has a regular, adequate oral health care source. The oral health care source should be located conveniently, open during times when patients can attend, and able to provide referral to culturally appropriate services.

For patients with HIV/AIDS who are clinically unstable, are seriously or terminally ill, or have complicating co-morbid conditions (e.g., homelessness, substance use, mental illness, extreme poverty), special efforts should be made to improve access to comprehensive primary oral health care. These efforts include outreach and culturally competent clinical services for the target population. Efforts to offer dental services should be ongoing through outreach and education.

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A. The Role of the Medical Provider

Recommendations:

The medical provider should forward any requested clinical information to the patient’s oral health care provider in a timely fashion.

B. The Role of the Dental Provider

Recommendations:

The oral health care provider should promptly communicate to the patient’s medical provider any clinical findings that may signify a change in the patient’s systemic health or any planned, extensive surgical procedures that may impact the patient’s systemic health.

III. ORAL HEALTH CARE TREATMENT FOR PATIENTS WITH HIV INFECTION

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A. Initial and Periodic Oral Examinations

Recommendations:

Patients with HIV infection may develop associated skin manifestations and cervical lymphadenopathy; therefore, extraoral head and neck examinations and oral soft-tissue examinations should be performed at each visit. Findings should be discussed with the patient and the patient’s primary care provider.

HIV infection results in a spectrum of sequelae, ranging from a clinically asymptomatic or mildly symptomatic phase to a stage of severe immunodeficiency in which life-threatening opportunistic infections and neoplasms occur. Medications used for treatment of HIV and associated diseases or prophylaxis of opportunistic infections may have significant adverse effects or may interact with other prescribed medications. To develop an appropriate treatment plan, the oral health care provider should obtain complete information about the patient’s health and medication status.

Many different oral mucosal lesions have been associated with HIV infection. Some, such as candidiasis and hairy leukoplakia, may have a prognostic value in HIV disease progression. A diagnosis should be made for all oral soft-tissue findings either on the basis of distinctive clinical features or by using appropriate laboratory tests (e.g., smear, culture, or biopsy) (see Figure 2-1). It is important to communicate information concerning oral findings to the patient and to the patient’s primary care provider. Treatment of these conditions may improve the quality of life for patients infected with HIV.

As part of a comprehensive medical-oral health work-up and treatment plan, the oral health care provider should obtain a past and present history of tobacco, alcohol, and other substance use because each of these histories may have a direct impact on the oral and HIV health of the individual. Dentists should be aware of experts and programs in their area that can assist in addressing the treatment of these issues. For in-office consumer and provider materials on tobacco cessation programs, dentists can access http://www.surgeongeneral.gov/tobacco/default.htm.

B. Treatment Planning

Recommendations:

Universal precautions (standard infection control procedures) should be followed for all patients (see Chapter 6: Infection Control).

There is no evidence to support modifications in oral health care based solely on the presence of HIV infection. However, such modifications may be indicated on the basis of certain medical problems that occur as a result of HIV infection. Severely or terminally ill patients, for example, will require alterations in care similar to those of patients suffering from other conditions that cause debilitating illness, such as cancer.^10,14

Complications associated with dental treatment of patients with HIV infection and AIDS are similar to those of uninfected patients. Increased efforts are needed in oral health promotion and disease prevention due to the high burden of oral disease in this special patient population.^1,15

Various treatment options should be discussed and developed in collaboration with the patient. As with all patients, a treatment plan appropriate for the patient’s health status, financial status, and individual preference should be chosen.

Medications may interfere with dental treatment and cause adverse effects, such as decreased salivary flow, altered liver function, and bone marrow suppression, resulting in anemia, thrombocytopenia, and neutropenia (see Appendix I). Drug-drug interactions also may occur.

C. Preventive Care

1. Dental Caries

Recommendations:

The clinician should practice evidence-based caries management in patients with HIV/AIDS.^16,17

The clinician should be aware that salivary gland disease, xerostomia, or HIV-related medications with high sugar content may be associated with increased risk for dental caries.

When there are non-cavitated lesions, remineralization should be performed with fluoride varnishes and home-care fluoride products. When there are cavitated lesions, proper restorative procedures and materials should be used according to the need of the patient.

A higher risk of dental caries in patients with HIV may be caused by decreased salivary flow, which may occur as a result of salivary gland disease or as a side effect of a number of medications. Also, some topical antifungal medications have high sugar content, possibly resulting in increased caries susceptibility.

As in all patients, prevention and management of carious lesions in individuals with HIV/AIDS should include diagnosis, caries risk assessment, and behavior modification to reduce caries activity.

Treatment should include remineralization of non-cavitated, smooth-surface lesions and restorative treatment of cavitated lesions. Establishment of recall intervals should be based on caries risk status, with high-risk patients being seen more frequently. Caries risk should be reassessed at each recall visit, and future care should be planned accordingly. In addition to fluoride varnishes, therapy in adults should include pit and fissure sealants and proper use of certain sugarless chewing gums that may provide protection.¹⁸

2. Gingival and Periodontal Disease

Recommendation:

The clinician should perform a comprehensive gingival and periodontal examination, which includes a periodontal probing depth record.

Conventional as well as atypical gingival and periodontal diseases have been reported in patients with HIV (see Chapter 3: Clinical Manifestations and Management of HIV-Related Periodontal Disease). Early recognition of these problems allows treatment that can prevent progression of these conditions, including severe attachment/bone loss.

IV. ORAL HEALTH CARE FOR HIV-INFECTED SUBSTANCE USERS

Recommendations:

Injection drug users (IDUs) have a high incidence of bacterial endocarditis. Oral health care providers should address this issue with respect to antibiotic prophylaxis before performing dental procedures.^19,20

Substance use is associated with behavioral, oral, and systemic changes that can create significant problems in dental treatment. Behavior changes may reflect a drug’s effect on the central nervous system, and underlying behavior problems may become more prominent with substance use. Narcotics, sedatives, hypnotics, and antihistamines should be prescribed appropriately as indicated and should not be withheld simply because the patient has a past or present history of substance use.

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V. HIV COUNSELING, TESTING, AND REPORTING

Recommendations:

When evaluating an oral lesion indicative of immune deficiency in a patient with unknown HIV status, the provider should consider HIV infection, particularly in the absence of other causes of immunodeficiency. HIV counseling and testing should be recommended in these cases.

Early identification of HIV infection in a patient can lead to earlier diagnosis and prophylaxis or treatment of opportunistic infections, as well as determination as to whether patients are candidates for ARV therapy. In addition, early diagnosis may help prevent HIV transmission to others.

Current medical standards encourage voluntary HIV testing for prevention of HIV transmission and early medical intervention. Physicians, dentists, physician assistants, and nurse practitioners have legal authority to obtain HIV tests and are accordingly responsible for 1) providing pre-test and post-test counseling, and 2) obtaining written, informed consent. For information about a one-day training course, “HIV Testing Procedures,” and other HIV-related courses offered by the AIDS Institute, call (518) 474-9866. Anonymous testing options are available (see Appendix IV for the New York State Department of Health anonymous testing sites).

As of June 1, 2000, medical providers in New York State are required to report all initial AIDS diagnoses and all initial HIV diagnoses to the New York State Department of Health. Providers are also required to report any known sexual or needle-sharing partners of the reported case (see Appendix III). In addition, all laboratories performing diagnostic tests in New York State are required to report to the New York State Department of Health all cases of confirmed (Western blot positive) HIV antibody positive test results, positive HIV nucleic acid (RNA or DNA) detection test results, and CD4 lymphocyte count <500 cells/mm³ or <29% of total lymphocytes (unless the test was known to be performed for reasons other than HIV infection or HIV-related illness) (10NYCRR 63.4A4).

New York State Public Health Law defines the required procedures for pretest and posttest counseling and for obtaining written, informed consent for HIV testing (see Appendix V).²¹ Confidentiality laws regarding testing extend to physicians, physician assistants, nurse practitioners, and to all members of the dental health care team. The provider should ensure that the patient understands the following:

• The nature and procedure of the HIV test
• Issues pertaining to the confidentiality of HIV test results
• Issues pertaining to HIV reporting and partner notification (see Appendix III)
• Disclosure and discrimination issues
• The meaning of the test results
• The benefits of testing
• The possible psychological consequences of testing

Any communication with the patient should be in language that is appropriate to the patient’s level of understanding. It is essential that counseling and testing be closely and effectively linked to medical treatment. The New York State Department of Health AIDS Institute’s Clinician’s Guide to HIV Pretest and Posttest Counseling provides further guidance.²²

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REFERENCES

1. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General – Executive Summary. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at: http://www.nidr.nih.gov/sgr/execsumm.htm

2. Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report. December 2000.

3. Bamberger JD, Unick J, Klein P, Fraser M, Chesney M, Katz MH. Helping the urban poor stay with antiretroviral HIV drug therapy. Am J Public Health 2000;90:699-701.

4. Levi J. The public health challenges of the HIV epidemic. Am J Public Health 2000;90:1023-1024.

5. Hogg RS, Rhone SA, Yip B, Sherlock C, Conway B, Schechter MT, et al. Antiviral effect of double and triple drug combinations amongst HIV-infected adults: Lessons from the implementation of viral load-driven antiretroviral therapy. AIDS 1998;12:279-284.

6. Marcus M, Freed JR, Coulter ID, Der-Martirosian C, Cunningham W, Andersen R, et al. Perceived unmet need for oral treatment among a national population of HIV-positive medical patients: Social and clinical correlates. Am J Public Health 2000;90:1059-1063.

7. Zabos GP. Meeting primary oral health care needs of HIV-infected women. Am J Public Health 1999;89:818-819.

8. Shiboski CH, Palacio H, Neuhaus JM, Greenblatt RM. Dental care access and use among HIV-infected women. Am J Public Health 1999;89:834-839.

9. Agency for Healthcare Research and Quality, Health Resources and Services Administration. Access to Quality Health Services. Healthy People 2010. August 22, 2000. Available at:
http://www.health.gov/healthypeople/document/HTML/Volume1/01Access.htm

10. Glick M, Abel SN, Muzyka BC, DeLorenzo M. Dental complications after treating patients with AIDS. J Am Dent Assoc 1994;125:296-301.

11. Cohen LA, Romberg E, Grace E. A revisitation of dental students’ attitudes toward individuals with AIDS. J Dent Educ 2000;64:289-301.

12. Brimlow DL, Ross MW, Rankin KV. The perception of surrogate teaching patients with HIV disease of dental providers’ fear and comfort. J Dent Educ 2000;64:597-602.

13. General Accounting Office. Oral Health: Factors Contributing to Low Use of Dental Services by Low-Income Populations. HEHS-00-149, September 11, 2000.

14. Dental management of the HIV-infected patient. J Am Dent Assoc 1995;(Suppl):1-40.

15. Greene VA, Chu SY, Diaz T, Schable B. Oral health problems and use of dental services among HIV-infected adults: Supplement to HIV/AIDS Surveillance Project Group. J Am Dental Assoc 1997;128:1417-1422.

16. Anusavice KJ. Management of dental caries as a chronic infectious disease. J Dent Educ 1998;62:791-802.

17. Frontiers in clinical dentistry: Caries and periodontal disease—Symposium proceedings. Seattle, Washington, USA. May 21-22, 1998. J Dent Educ 1998;62:749-889.

18. Fischman S (ed). Emerging issues and future directions in remineralization: Proceedings of the Remineralization Symposium of 22-24 June 1999 in the Forsyth Dental Center, Boston, USA. J Clin Dent 1999;10:55-93.

19. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. JAMA 1997;277:1794-1801. Available at: http://216.185.112.5/presenter.jhtml?identifier=1729

20. Glick M. Intravenous drug users: A consideration for infective endocarditis in dentistry? Oral Surg Oral Med Oral Pathol 1995;80:125.

21. New York State Public Health Law, Art 27-F.

22. Clinician’s Guide to HIV Pretest and Posttest Counseling. New York, NY: New York State Department of Health AIDS Institute; 2000.

FURTHER READING

American Dental Association and American Academy of Oral Medicine. Dental management of the HIV-infected patient. J Am Dent Assoc 1995;(Suppl):34-39.

Clinical Practice Guideline Number 7. Evaluation & Management of Early HIV Infection. Rockville, MD: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1994: AHCPR publication 94-0572.

Glick M. Dental Management of Patients with HIV. Chicago, IL: Quintessence Publishing Co Inc; 1994.