Patient

What the Dentist Should Know About a Patient with HIV/AIDS

Ann M. Lyles, DDS

Copyright 2001 Journal of the California Dental Association.

Chances are good that oral health care providers will treat someone with diagnosed or undiagnosed HIV during their careers. The Centers for Disease Control and Prevention estimate that 650,000 to 900,000 U.S. residents are living with HIV infection, more than 200,000 of whom are unaware of their infection.1,2 As with any medical condition, it is possible for a dentist to do great harm by ignoring systemic manifestations of HIV. On the other hand, dentists who are ignorant of modern HIV disease management often request unnecessary medical consultations resulting in dental treatment delays. Since 1996, the growing use of highly active anti-retroviral therapy and ultrasensitive viral load testing has changed the picture of the dental patient with HIV. The goal of this article is to update and summarize information the oral health care provider needs to safely treat a person with HIV/AIDS. It is not intended to replace previous comprehensive publications on HIV and dentistry,3-5 as they are still excellent resources for information. Here, simple instructions for physical evaluation of a patient with HIV/AIDS will be presented and steps for determining safe procedures explained.

Many recent articles on HIV and dentistry have focused on infection control and prevention of HIV transmission from the patient to the practitioner.^6-13 But, for health care providers, the primary objective is to do no harm, so it is important to remember that the person with HIV needs protection from the practitioner as well. One golden rule can be applied in every situation: Treat a person with HIV/AIDS as one would treat anyone else. In other words, HIV itself is not a valid reason to deny, delay, or alter treatment. However, medications and manifestations of HIV may affect dental treatment, and these factors should be considered carefully.

Why dentists need to understand treatment of patients with HIV

At a time when humans are living longer than ever and people with multiple systemic diseases are common in dental practices, it would be inconsistent to refuse oral health care to those with well-controlled HIV disease. When Congress considered the Americans with Disabilities Act, it noted, "Some 43,000,000 Americans have one or more physical or mental disabilities, and this number is increasing as the population as a whole is growing older."¹⁴ It also added, "The nation’s proper goals regarding individuals with disabilities are to assure equality of opportunity, full participation, independent living, and economic self-sufficiency for such individuals."

In 1995, the American Dental Association took a position on treatment of people with HIV: "The American Dental Association believes that HIV-infected individuals should be treated with compassion and dignity."¹⁵

In 1998, that position was expanded in a brief to the Supreme Court supporting Sidney Abbott, a dental patient with HIV who was denied treatment solely because of her HIV status: "Patients with HIV infection may be safely treated in private dental offices when appropriate infection control procedures are employed. In addition, a decision not to provide treatment to an individual based solely on their AIDS or HIV seropositive status is unethical.¹⁶

If someone with HIV/AIDS requests dental care, it is unfair, unethical, and possibly illegal to deny treatment based solely on the person’s HIV status. In Bragdon v. Abott,¹⁷ the Supreme Court decided that HIV may be considered a disability, depending on the situation. The Court made it clear that it was reasonable to expect dentists to treat people with HIV. It is imperative, then, that oral health care providers understand how to evaluate patients with HIV so care can be provided safely.

A more thorough discussion on dentistry, HIV, and the law can be found in the article, "The Dentist, HIV and the Law: Duty to Treat, Need to Understand" by David Schulman.¹⁸

The Health History Review

Medical evaluation of a patient with HIV/AIDS will help the dentist anticipate and prevent complications associated with dental care. As with all patients, a thorough medical history should be obtained, including a complete list of medications. Past and present medical conditions should be discussed and appropriate treatment modifications determined. The name and phone number of the patient’s physician should be noted in the chart so the dentist may contact the physician if additional information is needed before providing dental treatment.

Some dentists indicate a reluctance to discuss HIV infection with their patients because of the sensitive nature of the disease. Patients may be just as uncomfortable discussing their HIV status because of personal or vicarious dental experiences. People with HIV/AIDS often express suspicion and fear that dentists will be judgmental and may even refuse treatment based on HIV status.¹⁹ It is possible that the person with HIV/AIDS has already felt unwelcome in several dental offices. Despite the fact that it may be a violation of the Americans With Disabilities Act to refuse treatment based solely on HIV status, patients still worry that HIV will interfere with their ability to obtain dental care. If the dentist provides a good rationale for asking detailed questions, patients will be more comfortable providing personal information. For example, a dentist might explain: "I need to ask you some more questions about your medical history. Some of the questions are very personal, but I hope they don’t make you feel uncomfortable. It’s important for me to learn more about your health so I don’t do anything that might hurt you."

Once it has been established that the primary concern is the well-being of the patient and it is clear that the dentist intends to provide care, an honest discussion is more likely to occur. The exploration of each medical condition should be documented by noting the date of onset, the current status or level of control, and any treatment that has been rendered for that condition.

Oral health care providers should know how to probe for answers to all positive responses on medical history questionnaires. HIV/AIDS is no exception, and the same questions can be applied to the evaluation of a person who is HIV-positive as to those with other medical problems (Figure 1).

What Was the Date of Onset or Diagnosis?

The dentist should ask how long the patient has been HIV-positive and should find out if and when an AIDS diagnosis was made. In addition to the date of the first positive HIV test, it is useful to determine when the patient became infected with HIV. This may provide a better impression of disease progression. Sometimes, this conversation will lead to a discussion of etiology (route of HIV transmission), but if not, the etiology can be discussed at the end of the conversation when the patient becomes more comfortable discussing personal information.

What Is the Current Status or Level of Disease Control?

To determine the current status or level of HIV disease control, it may be necessary to ask several questions. Is the patient seeing a physician on a regular basis? If not, the dentist should find out why. What was the most recent T-cell or absolute CD4 count, and how does this compare with results from tests over the past year? Has the CD4 count remained stable? Is the viral load undetectable? Changes in CD4 count and viral load may indicate that the level of disease control is changing. Is the patient taking all medications as directed by the physician? Sometimes, the patient is afraid to admit failures to adhere to the treatment regimen to the physician but is willing to reveal these problems to a dentist. Adherence difficulties should be reported to the physician because disease control may suffer. These simple questions can help the practitioner determine whether the HIV disease is well-controlled.

What Treatment Has Been Rendered for This Condition, Including Medications?

The patient’s medications should be documented, as with any patient, and potential drug interactions should be identified. Note that medical treatment for HIV may include more than traditional drugs. For example, psychological and dietary counseling can be important components of disease management. Herbal medications may be used and alternative treatment strategies such as massage therapy, meditation, or prayer may be part of the plan to control HIV infection.

Do You Know How You Got HIV?

As part of the medical history review, the dentist may ask how the patient became infected. However, the patient needs to know that this information request is not based in idle curiosity but is of importance because routes of HIV transmission may have implications for other health conditions. Oral health care providers need a complete medical history before deciding whether treatment modifications and referrals are necessary, such as if there is a history of a blood transfusion or IV drug use. A blood transfusion could indicate the presence of a bleeding disorder that would affect the delivery of dental care. Treatment of any patient who is still injecting drugs can be deadly, so if this is the case, treatment should be delayed until drug use has stopped and the medical condition has stabilized. For example, several carpules of local anesthetic may be safe in the average patient, but may result in drug overdose if a patient has recently used crack cocaine. IV drug use also puts the patient at high risk for development of bacterial endocarditis, so additional information from the patient’s physician might be necessary before initiating care. If HIV was contracted through unprotected sex, the dentist should make sure the patient has been counseled in ways to prevent further transmission of sexually transmitted diseases, including those that appear in the mouth. As primary health care providers, dentists have an obligation to refer patients for counseling if the mode of transmission indicates that the patient is engaging in high-risk behavior. Finally, a dentist may need to know how the patient got HIV in order to prioritize a differential diagnosis for an oral lesion because some lesions are closely associated with specific routes of HIV transmission.

During the course of a medical history review, special attention should be given to the minimum requirements for safe dental treatment:

* Ability to clot;

* Ability to recover from bacteremia;

* Ability to endure treatment in your dental care setting; and

* Absence of potential drug interactions.

Ability to Clot

Bleeding tendency is particularly important to discuss with patients who have HIV/AIDS for two reasons:

* If the patient acquired HIV through a blood transfusion, the dentist should find out if the transfusion was necessary because of a bleeding disorder.

* Hematologic abnormalities are relatively common with HIV infection, either because of the HIV disease process or as consequences of drug therapy.²⁰

Failure to detect a bleeding disorder before dental treatment could result in postoperative complications. Even "routine" care such as quadrant scaling can cause 5-10 ml of bleeding in a patient with a normal bleeding time. In a patient with a bleeding disorder, however, scaling or other invasive dental treatment could result in prolonged bleeding and possibly delayed healing and infection, so the health history questionnaire should ask about bruising or bleeding tendency. It should also ask about risk factors for prolonged bleeding, including anemia, liver disease, renal failure, gastrointestinal disease (with subsequent vitamin K deficiency), cancer and alcoholism. Since drug therapy is the most common cause of a prolonged bleeding time,²¹ it is safest to determine all medications the patient is currently taking as well as any taken within the last six months. Prolonged bleeding can result after the ingestion of aspirin, aspirin-containing compounds, and anti-inflammatory drugs as well as anticoagulants.²² Usually, antibiotics and NSAIDs do not cause a significant change in coagulation and will not interfere with routine dental treatment. However, if the patient is taking anticoagulants such as heparin or coumadin, a medical consultation should be obtained before attempting any treatment that may cause bleeding, including periodontal probing. Once the bleeding time is known, appropriate precautions can be taken to prevent complications.

Some commonly prescribed anti-retroviral medications (such as zidovudine/AZT) are known to cause anemia, but AZT-induced anemia is less common with the doses currently prescribed (500 to 600 mg/day)²³ and is easily managed with dose reduction or use of hematopoietic growth factors.²⁴

Occasionally, a patient provides subjective evaluations of bleeding or bruising tendency, rather than true medical diagnoses. It may be necessary to ask additional questions to confirm or rule out the possibility of a bleeding problem. For example, a patient may tell say, "Well, sometimes I feel a little tired, so I think I might be anemic," or, "I fell down one time and I had a big bruise on my leg for almost a week." Obviously, there is much greater concern if a patient reports three trips to the emergency room for nosebleeds that could not be controlled at home.

To assess the possibility of a bleeding tendency, the dentist may ask these additional questions:

* Do you have a bleeding disorder?

* Have you ever experienced any bleeding problems?

* Specifically, do you have trouble with excessive bleeding or bruising after an injury?

* Have you ever gone to see a doctor about bleeding that wouldn't stop?

* Has your doctor ever recommended that you take iron supplements?

* Have your blood tests ever indicated that you may have trouble clotting (low platelets)?

If the patient gives any indication of a bleeding abnormality, the physician should be asked to help determine the risk of prolonged bleeding after dental treatment. Medical monitoring of people with HIV/AIDS does not include routine testing of bleeding times, but involves complete blood counts and viral load tests. If the physician detects risk factors for prolonged bleeding such as a low platelet count or low hemoglobin, a coagulation panel may be ordered. The 1995 Journal of the American Dental Association supplement, "Dental Care for the HIV-Infected Patient," explained that dental treatment can be safely provided when platelets are greater than 60,000/mm³, hemoglobin greater than 7g/dL, and bleeding time is within two times normal.²⁵ Many dentists are uncomfortable providing dental care when the bleeding time is more than two times normal, but some feel it is safe to do limited procedures (such as local anesthetic infiltrations and intracoronal restorations) when the bleeding time is within 2.5 times normal. Based on the coagulation panel results, the practitioner should decide whether the bleeding condition can be managed in the dental office or refer the patient to a practitioner who can safely provide care.

Ability to Recover From Bacteremia

Occasionally, a dentist will ask if HIV is an indication for antibiotic prophylaxis before dental treatment. Perhaps the weakened immune system makes dentists concerned that they will put patients at risk for bacterial infection. For the HIV-infected patient, there are no data supporting the need for routine antibiotic coverage to prevent bacteremia or septicemia arising from dental procedures.^26-28

For bacterial endocarditis prophylaxis, AHA guidelines be followed the same way for patients with or without HIV.

Neutropenia is a special case requiring consideration of antibiotic prophylaxis. In 1999, the Dental Alliance for AIDS/HIV Care in cooperation with the American Dental Association updated their recommendations for prophylactic use of antibiotics in neutropenic patients with HIV (Table 1).²⁹ The Dental Alliance suggests that topical antimicrobials (i.e., chlorhexidine) are indicated for all dental procedures in cases of severe neutropenia (absolute counts of less than 500/mm³), and prophylactic antibiotics should be used after a discussion with his or her physician. For moderate neutropenia (absolute counts between 500 and 1000/mm³) the Dental Alliance warns that most dental procedures will not require antibiotic prophylaxis, but more-invasive procedures may require systemic antibiotics in addition to topical antimicrobials. Patients with HIV disease and moderate neutropenia do not appear to have an increased risk for bacterial infection,³⁰ but the final decision requires the judgment of the oral health care practitioner.

Though modern drugs and lower doses of AZT have reduced hematologic abnormalities,^31-33 drug-induced neutropenia may still occur in some HIV-infected individuals. This is especially true in more-advanced stages of HIV disease because drugs used to treat manifestations of HIV (gancyclovir, foscarnet, sulfa derivatives, pentamidine) can cause bone marrow suppression and neutropenia.^34-37 Neutropenia is more common in patients with late-stage disease and typically occurs when CD4+ cell counts are very low.³⁸ Neutrophils play an important role in the defense against bacterial infections, and immunocompromised patients are at greater risk for severe infections when the absolute neutrophil count falls below 500 cells/mm³,^39,40 so attempts should be made to reduce the chances of bacteremia. During dental treatment, it is possible for oral bacteria to enter the patient’s bloodstream, resulting in a transient bacteremia, but there is no indication that this bacteremia puts the patient at risk for significant infections. Pretreatment chlorhexidine rinses can reduce the concentration of oral bacteria during dental treatment without posing a significant health risk to the patient.

Debate about systemic antibiotics continues because there is currently no published study supporting the idea that antibiotic prophylaxis will benefit neutropenic immunocompromised dental patients. The issue is complicated by the fact that bacteremias may occur during many routine activities such as brushing and chewing. So, transient bacteremia is not a unique consequence of dental treatment. Overprescribing of antibiotics can lead to selection of resistant bacteria, so dentists and physicians must consider this issue carefully. Perhaps the greatest concern about providing antibiotics that may be medically unnecessary is the risk of anaphylactic reaction. Immunocompromised patients have a greater incidence of drug allergy⁴¹ and there is no proof that the benefit of antibiotic prophylaxis outweighs the risk of allergic reaction for this group. Some even argue that neutropenic patients should not receive routine dental care at all, but should receive only urgent care until neutropenia is resolved..

At the very least, a pretreatment chlorhexidine rinse is recommended to reduce the chance of introducing oral bacteria into the bloodstream during treatment. Localized areas such as injection sites and periodontal pockets may be swabbed or irrigated with Betadine/povodone iodine before treatment to further reduce the chance of bacteremia. The decision about prescribing antibiotics prior to dental treatment should be made on an individual basis after discussing the patient’s status with the patient’s physician.

To assess a patient’s ability to recover from a bacteremia, the dentist should ask the patient about the most recent CD4 count. Most immunocompromised patients follow this number closely. A CD4 count above 100 cells/mm³ indicates that the immune system has some ability to fight infection and suggests that the neutrophil count is probably within normal range. The patient will probably recover from a bacteremia with no difficulty.

If the CD4 count is below 100, the patient’s neutrophil count should be obtained before initiating invasive dental treatment, including periodontal probing. The patient’s physician should be contacted to request the neutrophil count and to discuss consideration of antibiotic use prior to dental treatment.

Ability to Cooperate in a Dental Care Setting

Ironically, anti-retroviral drug therapy can make it difficult to cooperate with dental treatment. Common side effects of anti-retroviral medications include fatigue, nausea, and headaches. People suffering from these adverse effects may find it difficult to keep scheduled appointments or to endure lengthy dental procedures. Patients will have to explain how the medications make them feel so the dental staff can schedule accordingly.

The oral health care team should be sensitive to the fact that patients may not want to take their medications in the dental office. The bottles of pills may be large and cumbersome, side effects may occur soon after dosing, and people may wish to take their medications privately so their HIV status does not become known to others.

Dental personnel must understand that highly active anti-retroviral therapy is only effective when adherence with the treatment regimen is very high; and, as health care providers, they should encourage the greatest possible adherence. Appointments that interfere with the dosing schedule should be avoided. Some medications need to be taken with food, and others should be taken two hours before or after a meal. The patient should suggest the best time for a dental appointment so the routine is not disrupted.

Altered mental status can affect any patient’s ability to receive dental care. Since advanced HIV disease can be associated with changes in mental status, the oral health care provider should determine whether the patient can comply with instructions before, during, and after dental procedures. Psychiatric conditions that may result from damage to the central nervous system include depression, dementia, anxiety/panic disorder, delirium, mania, and psychosis. The practitioner should manage or refer dental patients with any of these conditions based on professional judgment, regardless of the patient’s HIV status.

At one time, AIDS dementia was a common final state in the progression of HIV disease. Due to improved medical management, AIDS dementia is not as prevalent as previously and it no longer means that death is imminent. Many who suffered psychological damage as a result of HIV infection are now stabilized with effective drug therapies. The neurological damage remains, but the medical prognosis may be good if drug adherence is high. Whether or not a patient has HIV/AIDS, psychiatric conditions can interfere with the ability to give informed consent and cooperate with treatment. The practitioner should decide how to manage patients with psychiatric conditions on an individual basis.

Absence of Potential Drug Interactions

None of the drugs currently used in HAART are known to interact with local anesthetics or non-narcotic analgesics. There are, however, relative contraindications to the use of some antibiotics and antifungal medications for patients taking anti-retroviral drugs. To prevent serious complications, the oral health care provider should be familiar with possible interactions of any medications used or prescribed in the dental office (Table 2).

What Is Not Appropriate to Ask a Dental Patient

A written health history questionnaire should not ask intrusive questions unless they are pertinent to patient care. For example, asking a dental patient to check a box indicating "sexual preference" would be inappropriate because this does not reveal information about the patient’s past or present medical conditions. Asking if the patient has ever been tested for HIV also tells a dentist nothing about the patient’s present medical status. In the context of a risk assessment, however, these questions may be quite appropriate, but only after the dentist has explained the reasoning and the patient has agreed to discuss risk factors. The results of this risk assessment should be kept confidential and should be used as a basis for medical referral, if indicated. Private information unrelated to delivery of care should be kept confidential and should not be used as a justification for refusal to treat.

Avoid asking questions in such a way as to label the patient such as, "Are you an I.V. drug user?" or "Are you gay?" because these will not provide specific information about behavior patterns and may offend patients. Questions about the way the patient got HIV will provide more useful information (i.e., from a contaminated needle, through a blood transfusion, or from a sexual partner).

When to Get a Medical Consultation

If a patient cannot provide all the necessary information, the dentist will need to contact the patient’s physician by phone or using a written consultation request (Figure 2). It is only appropriate to request information relevant to dental treatment. Asking questions unrelated to dental care would be an invasion of the patient’s privacy.

Warning signs that more information may be needed:

* History of anemia, bruising or bleeding tendency or risk factors for bleeding problems such as long-term AZT therapy;

* Current CD4 count of less than 100;

* Recent complications of AIDS such as pneumonia or cytomegalovirus infection;

* Incomplete list of medications; and

* Reporting of lab results that seem improbable.

It may be possible to request information by calling the patient’s physician, but due to the especially sensitive nature of HIV disease, some physicians are not comfortable providing details over the phone. It is considerate to fax a written request to the physician, or at least fax a signed consent (Figure 3) to release medical information over the phone.

The patient should understand why personal information has been requested from the physician. Ideally, a consent form would indicate that the dentist is concerned about the patient’s feelings and recognizes the sensitivity of this information. A good consent form can also save time. If the form clearly indicates that the patient has given permission to release information related to HIV status, the physician will not hesitate before sending a response.

Treatment Modifications

Laboratory Markers to Consider

It is important for dental care providers to understand a few basic laboratory markers for the status or progression of HIV disease. The tests that indicate bleeding tendency and ability to combat infection are the most relevant to dental care. The results of these tests will help the practitioner determine whether treatment modifications are necessary.

Typically, every three to four months, a person with HIV/AIDS is evaluated for disease status, effectiveness of treatment, and adverse drug reactions. Periodic laboratory tests include a complete blood count with differential and a viral RNA polymerase chain reaction or "viral load" test. A complete blood count with differential includes the absolute CD4 count and CD4 percentage. These are good indicators of immune function and stage of disease progression. CD4+ cell counts indicate the ability of the immune system to fight disease, and viral load tests indicate the activity of the virus. The two values together give a clearer picture of the status of HIV disease progression. Since the goal of HAART is to reduce the concentration of virus in the blood, viral load tests are used to evaluate the effectiveness of HAART.

CD4

CD4 count (CD4+ cells per cubic mm or microliter of blood) gives a general idea of the health of the HIV-infected patient (Table 3). The lower the CD4 count, the more advanced the patient’s disease. A normal CD4 count in adult patients is 500-1,500. Effective anti-retroviral drugs usually increase the CD4 count, or at the very least, prevent further decreases in CD4 count.

Although a low CD4 count is a reflection of advanced disease, it should be used only as one indicator of a patient’s general health. A low CD4 count is not necessarily the same as a poor prognosis, and it is not a valid reason to withhold or delay dental therapy. It simply indicates that more information may be necessary before care can safely be provided.

Viral Load

Viral load quantifies the amount of HIV in the blood. Specifically, it measures the number of copies of HIV RNA present per milliliter of plasma. Currently, the most sensitive test can measure levels as low as 50 copies/ml. Viral load levels lower than 50 copies/ml are reported as "undetectable."

Within a couple of weeks of initial infection, viral load becomes undetectable. Then, it usually peaks within one to two months of initial infection. This peak is often associated with symptoms of a flu-like syndrome (fever, headache, malaise) known as Acute Retroviral Syndrome. The viral load then declines, and plateaus at a "set point" after three to six months. The magnitude of this set point correlates with how quickly the patient’s HIV disease progresses. Patients with low or undetectable viral loads at the set point may remain asymptomatic for more than a decade, whereas patients with high viral loads progress more quickly (within a few years).

Antiviral drugs are prescribed to decrease the viral load. The goal of antiviral therapy is to get the viral load as low as possible -- ideally, to an undetectable level. This has been shown to improve clinical outcome.

Viral load is an indicator of the rate of disease progression, but it does not give information on current health status. A high viral load is not an indication to withhold or delay dental treatment.

There is a great variation in the levels of medical knowledge among dental patients. Most HIV-infected patients consider it important to keep track of their changes in viral load and CD4 count because they are good indicators of immune function and prognosis. They usually know if the viral load is undetectable because that means the disease is not progressing rapidly. Others seem less interested in the meanings of these numbers, and some don’t even understand the importance of having these tests done on a regular basis. If a patient has not been able to give the most recent viral load or CD4 values in more than six months, the dentist should find out why. The dentist plays an important part in the health care team and can help identify obstacles to treatment and lapses in medical care. The dentist should confer with the physician to verify that CD4 and viral load tests have been done and to advise that the patient isn’t aware of their values.

Treatment

The "golden rule" about dental treatment modifications for patients with HIV is that treatment modifications should be based on manifestations of HIV (or its treatment), not on HIV itself. In other words, treatment is only modified if the patient has significant physical manifestations of HIV or HAART. An asymptomatic patient with HIV should be treated the same as any other dental patient. The vast majority of dental patients with HIV require no treatment modifications.

If the patient has severe symptoms of AIDS that interfere with provision of safe treatment, pain and infection may be managed but all other dental needs should be delayed until the patient’s condition improves. Any patient with oral lesions, bleeding abnormalities, or increased susceptibility to infection should be managed using the same principles whether or not the patient is HIV-infected.

Sometimes a symptomatic patient with HIV presents for care without all the information needed to assess the patient’s medical status. Even if the physician’s office cannot provide critical information immediately, visual and radiographic exams may be done as well as a preliminary evaluation. It would be a waste of the dentist’s time and an inconvenience to the patient to cancel the appointment until a medical consultation is obtained. Instead, the practitioner should determine the patient’s needs and request the appropriate information so treatment can be continued at the next visit. In emergency situations, antibiotics, analgesics, and even infiltrations of local anesthetic may be safely given to provide comfort until more information can be obtained from the physician.

As with any medically complex patient, possible drug interactions should be investigated before prescribing medications. Note that an outdated drug reference will not contain all of the known side effects and interactions for drugs that were recently FDA-approved. The Internet may be a more useful source of information for the rapidly changing arsenal of HIV medications. There are a number of excellent Web sites in this regard:

http://www.ama-assn.org/special/hiv/index.htm

http://www.aidsmeds.com/

http://arvdb.ucsf.edu/index.cfm

http://www.ucsf.edu/warmline/drugcht/c.html

The National HIV Telephone Consultation Service is also available for answers to questions about treatment considerations, including drug interactions of concern to dental care providers. The toll-free number is (800) 933-3413.

Conclusion

With increasingly effective drug therapy and comprehensive strategies to encourage adherence with treatment regimens, the picture of the dental patient with HIV/AIDS has changed. As people with HIV grow healthier, it becomes easier for the dentist to treat them just like everyone else. This article emphasizes the assessment and determination of when treatment should or should not be modified in light of today’s changing therapies for HIV/AIDS.

Author

Ann M. Lyles, DDS, is an assistant professor of clinical dentistry at the University of Southern California School of Dentistry.

References

1. Karon JM, et al, Prevalence of HIV infection in the United States, 1984 to 1992. JAMA 276(2):126-31, 1996.

2. Sweeney PA, et al, Minimum estimate of the number of living HIV-infected persons confidentially tested in the United States. In, Program and abstracts of the Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, Sept. 28 - Oct. 1, 1997. Washington, D.C.: American Society for Microbiology, 1997:245 abstract.

3. Glick, M, Dental Management of Patients with HIV. Quintessence Publishing Co Inc, Chicago, Ill 1994.

4. Dental Management of the HIV-Infected Patient, Supplement to JADA, American Dental Association and American Academy of Oral Medicine, 1995.

5. Glick, M, ed, Clinician’s Guide to Treatment of HIV-Infected Patients. The American Academy of Oral Medicine, 1996.

6. Suljak JP, Leake JL, Haas DA, The occupational risk to dental anesthesiologists of acquiring 3 bloodborne pathogens. Anesth Prog 46(2):63-70, 1999.

7. Maupome G, Acosta-Gio E, et al, Survey on attitudes toward HIV-infected individuals and infection control practices among dentists in Mexico City. Am J Infect Control 2000 28(1):21-4.

8. Neiburger EJ, Are latex gloves a contributing cause of percutaneous injury in dentists? Gen Dent 46(5):467-72, 1998.

9. Avery CM, Gallagher P, Birnbaum W, Double gloving and a glove perforation indication system during the dental treatment of HIV-positive patients: are they necessary? Br Dent J 186(1):27-9, 1999.

10. Terezhalmy GT, Gitto CA, Today's minimal requirements for a practical dental office infection control and exposure control program. Dent Clin North Am 42(4):629-42, 1998.

11. Heir J, Ziccardi VB, Transmission of infectious disease in the dental setting. Mt Sinai J Med 65(5-6):378-82, 1998.

12. Cuny E, Carpenter WM, Occupational exposure to blood and body fluids: new postexposure prophylaxis recommendations. United States Occupational Safety and Health Administration. J Calif Dent Assoc 26(4):261-71, 1998.

13. Daniel SJ, Compliance with infection-control procedures and attitudes of oral health care providers toward patients with HIV/AIDS: a synthesis of the literature. J Dent Hyg 72(3):33-45, 1998.

14. 42nd U.S. Congress, Section 12101.

15. Dental Management of the HIV-Infected Patient, Supplement to JADA, 1995.

16. Brief of the Amicus Curiae: The American Dental Association in Support of Sidney Abbott, et al. September 29, 1998 Document address: http://www.ada.org/prac/position/brag-state.html

17. 524 U.S. 624 (1998)

18. Schulman DI, The dentist, HIV and the law: duty to treat, need to understand. J Cal Dent Assoc 27:7, July 1999.

19. Charbonneau A, Maheux B, Beland F, Do people with HIV/AIDS disclose their HIV-positivity to dentists? AIDS Care 11(1):61-70, 1999.

20. Perkocha L, Rodgers G, Hematologic aspects of human immunodeficiency virus infection: Laboratory and clinical considerations. Am J Hematol 29:94, 1988.

21. Brown BA, Hematology: Principles and Procedures, 6th ed. Lea & Febiger, Philadelphia, 1993, p 268.

22. Brown BA, Hematology: Principles and Procedures, 6th ed. Lea & Febiger, Philadelphia, 1993, p 268.

23. Kreuzer KA, Rockstroh JK, Pathogenesis and pathophysiology of anemia in HIV infection, Ann Hematol 75(5-6):179-87, 1997.

24. McLeod GX, Hammer SM , Zidovudine: five years later. Ann Intern Med 15;117(6):487-501, 1992.

25. Dental Care for the HIV-Infected Patient, JADA supplement, 1995.

26. Lucatorto FM, Franker CK, Maza J, Postscaling bacteremia in HIV-associated gingivitis and periodontitis. Oral Surg Oral Med Oral Pathol 73(5):550-4, 1992.

27. Porter SR, Scully C, Luker J, Complications of dental surgery in persons with HIV disease. Oral Surg Oral Med Oral Pathol 75(2):165-7, 1993.

28. Cooper H, Root canal treatment on patients with HIV infection. Int Endod J 26(6):369-71, 1993.

29. Abel SN, Croser, D, et al, eds, Principles of Dental Management of the HIV/AIDS Patient. Dental Alliance for AIDS/HIV Care, June 1999.

30. Farber BF, Lesser M, et al, Clinical significance of neutropenia in patients with human immunodeficiency virus infection. Infect Control Hosp Epidemiol 12(7):429-34, 1991.

31. Kreuzer KA, Rockstroh JK, Pathogenesis and pathophysiology of anemia in HIV infection. Ann Hematol 75(5-6):179-87, 1997.

32. Kline MW, Van Dyke RB, et al, A randomized comparative trial of stavudine (d4T) versus zidovudine (ZDV, AZT) in children with human immunodeficiency virus infection. Pediatrics 101(2):214-20, 1998 Feb.

33. Koch MA, Volberding PA, et al, Toxic effects of zidovudine in asymptomatic human immunodeficiency virus-infected individuals with CD4+ cell counts of 0.50 x 10(9)/L or less. Arch Intern Med 152(11):2286-92, 1992.

34. Schmitz SH, Scheding S, et al, Side effects of AZT prophylaxis after occupational exposure to HIV-infected blood, Ann Hematol 69(3):135-8, 1994.

35. Richman DD, Fischl MA, et al, The toxicity of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex. A double-blind, placebo-controlled trial. N Engl J Med 317(4):192-7, 1987.

36. Koch MA, Volberding PA, et al, Toxic effects of zidovudine in asymptomatic human immunodeficiency virus-infected individuals with CD4+ cell counts of 0.50 x 10(9)/L or less. Arch Intern Med 152(11):2286-92, 1992.

37. Stambuk D, Hawkins D, Gazzard BG, Zidovudine treatment of patients with acquired immune deficiency syndrome and acquired immune deficiency syndrome-related complex: St Stephen's Hospital experience. J Infect 18 Suppl 1:41-51, 1989.

38. Moore DA, Sullivan A, et al, A retrospective study of neutropenia in HIV disease. Int J STD AIDS 11(1):8-14, 2000.

39. Hermans P, Sommereijns B, et al, Neutropenia in patients with HIV infection: a case control study in a cohort of 1403 patients between 1982 and 1993. J Hematother Stem Cell Res 8 Suppl 1:S23-32, 1999.

40. Wong RJ, Treatment of HIV-related neutropenia. Am J Health Syst Pharm 56 Suppl 5:S17-20, 1999.

41. Bayard PJ, Berger TG, Jacobson MA, Drug hypersensitivity reactions and human immunodeficiency virus disease. J Acquir Immune Defic Syndr 5(12):1237-57, 1992.

To request a printed copy of this article, please contact/Ann M. Lyles, DDS, USC School of Dentistry, 925 W. 34th St., Room 4208, Los Angeles, CA 90089-0641.

Figure 1.

Determine the following for any "yes" answer on the medical history questionnaire:

* What was the date of onset or diagnosis?
* What is the current status or level of disease control?
* What treatment has been rendered for this condition, including medications?

Figure 2. A written consultation request.

Figure 3. A consent form.

Table 1. Summary of Antimicrobial Prophylaxis Considerations

(As suggested by the Dental Alliance for HIV/AIDS Care)

* Patients with CD4+ cell counts below 100 cells/mm3 and patients on long-term anti-retroviral drug therapy should be evaluated for neutropenia.

* Patients with absolute neutrophil counts below 500 cells/mm3 should receive antibiotic prophylaxis before dental therapy.

* The dentist is advised to consult the physician for patients with indwelling catheters and neutrophil counts between 500 and 1000 cells/mm3.

* Bactericidal antibiotics (penicillins and cephalosporins) are the most appropriate antibiotics for prophylactic treatment.

Table 2. Known Anti-Retroviral Drug Interactions in General Dentistry (as of October 2000)

Note: This table contains information about drugs used only in general dentistry. It does not contain all known interactions for general anesthetics used in oral surgery. The information here may serve as a guideline, but it only represents the known adverse drug reactions at this time. New drug interactions are being discovered constantly, so dentists are encouraged to check the latest information before prescribing drugs. For more complete information about all drug interactions and contraindications including general anesthetics, please consult information provided by the drug manufacturer or a recently published drug reference. Current drug information from the American Medical Association can be found by visiting http://www.ama-assn.org/special/hiv/index.htm.

Table 3. CD4 Counts and Their Indications of General Health