Download Medical Evaluation of the HIV Dental Patient

Module 1
Medical Evaluation of the HIV
Dental Patient
Medical Evaluation of the HIV
Dental Patient
Louis G. DePaola, DDS, MS
Professor,
Department of Diagnostic Sciences and Pathology
Dental School
University of Maryland Baltimore
Director, Dental Training
Pennsylvania-MidAtlantic AIDS ETC
Michael Glick, DMD
Professor and Chairman,
Department of Diagnostic Sciences
University of Medicine and Dentistry of New Jersey
Director, Dental Training
New Jersey, AIDS ETC
Dr. Valli I. Meeks, DDS, MS RDH
Department of Diagnostic Sciences and Pathology
Dental School
University 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 Lipodystrophy
Hyperglycemia
Liver 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 infections
Hemodialysis
Bacterial endocarditis
Poorly controlled diabetes mellitus
Medical 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
Medical 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
Medical Problem List
• Ability to withstand the stress and
trauma due to dental care
Cardiovascular disease
Stroke
Poorly controlled diabetes mellitus
Medical 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 illness
 Review of past medical history
 Hospitalizations and surgeries
 Current/recent illnesses
 Medications
 Allergies
 Substance
 Review
abuse history
of systems
Systems Review
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Cardiovascular system
Respiratory system
Central nervous system
Gastrointestinal system
Genitourinary system
Musculoskeletal system
Endocrine system
Skin
Head 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 History
• Date of HIV infection if known
• Current HIV disease progression
CD4 count - trend (up, down, stable)
Viral load - trend (up, down, stable)
• History of opportunistic infection(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
and 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 Values
Indication of patient’s risk for
infection and bleeding tendencies
• Complete Blood Count (CBC)
Platelet count
Differential blood cell count
• Liver enzymes
• Coagulation tests
Hematology
CBC
• CBC includes:
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White blood cell count (WBC)
Red blood cell count (RBC)
Hemoglobin (Hgb)
Hematocrit (Hct)
Platelets (Plt)
Hematology
CBC
• 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
Hematology
Differential White Blood Cell Count
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Total WBC: 4,000 – 11,000 cells/mm3
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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
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.
Hematology
Red 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
Hematology
Hemoglobin
• 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
Hematology
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
Hematology
Hematocrit
• Hematocrit
Measure of packed cell
volume (PCV) of RBCs
Normal: 37% - 54%
indication of anemia and
especially vitamin B12
deficiency
Hematology
Liver 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
Hematology
Coagulation Tests
 Indicates patient’s clotting ability
 Increase indicates:
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Coagulation abnormality due to liver disease
Other systemic diseases
Anticoagulant therapy
Medications
 Significantly elevated coagulation test
results may require modification of dental
treatment
Hematology
Coagulation 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®
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 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
• 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
Priorities
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Alleviate pain
Prevent further oral disease
Restore function
Restore esthetics
Improve quality of life
Restorative/Prosthodontic
Considerations
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Ability to perform oral hygiene
Caries index
Reduced salivary flow
Presence of oral lesions
“End of life” concerns/issues
Management of
Xerostomia
Replacement or stimulation of salivary
flow
• Secretory stimulants
1. Pilocarpine
2. Salagen
3. Bethanecol
• Salivary substitutes
1. Xerolube
2. Salivart
3. 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 status
Finances
Patient acceptance
• Modify dental procedures according
to ability of the patient to tolerate
dental procedures
Antibiotic Prophylaxis
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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
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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
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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.