Treating patients with HIV

Patient Confidentiality And Rights

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.

Legal Implication

Overview

As the Human Immunodeficiency Virus (HIV) epidemic continues to spread across the world, it presents increasing challenges to human survival at both national and global levels. Given the rapidity with which it is advancing in India, it is the most serious public health challenge that India is facing today with implications beyond the health sector, which include socio economic discrimination. It is marked by discrimination against population groups living on the fringes of society. They are assumed to be at risk of infection because of behaviours, race, ethnicity, sexual orientation, gender or social characteristics that are stigmatised in a particular society. A lack of respect for human rights continues to augment vulnerability to HIV infection of individuals and the entire society.

India’s socio-economic status, traditional social norms, cultural myths on sex and sexuality, large-scale migration and a huge population of marginalized people makes them extremely vulnerable to Acquired Immune Deficiency Syndrome (AIDS). HIV related discrimination, stigmatisation and denial surfaces within the family and local community, employment and workplace and the health care system. It evokes a variety of responses. The most common are ostracism and rejection.

The few Indian studies that have documented social responses to the epidemic show an overwhelmingly negative social reaction to people with AIDS. A study found that although a majority of those who had shared their HIV status with their families receive care and support, it was largely the men who qualified for it. Forms of discrimination against women with HIV include- being refused shelter, denied a share of household property, access to treatment and care. The health care sector is perhaps the most conspicuous where discrimination, stigmatisation and denial are concerned. In fact AIDS related fear and anxiety and denial of their status could be traced to traumatic experiences in health care settings. There has also been a rise in the number of cases of employment related discrimination and denial of education to children.

Legal Rights For PLWHAs

The law in India is still underdeveloped. There is no legislation to protect the rights of the PLWHAs (People Living With HIV/AIDS). Given the social milieu, the absence of legislation addressing HIV/AIDS in India only adds to the problem. Since the Constitution of India is the only existing law available against discrimination to protect their rights, PLWHAs are dependent on the few Supreme Court decisions for redressal.

The Articles within the Constitution pertinent to the rights of PLWHA (People Living With HIV/AIDS) include:

• Article 14: Guarantees equality to all persons within the territory of India.
• Article 16: Provides for equality of opportunity in public employment.
• Article 191(d): Guarantees right to freedom of movement.
• Article 21: Guarantees the rights to life, health, livelihood and the right to live
• Article 21-A: Guarantees the right to Education for children upto 14 years of age.

Consent and Confidentiality

Although the judiciary’s role has been proactive, there are certain apparent gaps in the understanding of the epidemic from public health perspective. The concept of informed consent and confidentiality are underdeveloped in India.

The International Perspective

HIV laws in countries like USA, South Africa and Canada are very progressive. In most countries these laws fall under National Disabilities Acts, Constitutional Guarantees, Common law and Other acts (confidentiality, public health, etc). Case law have two general themes:

1. One should be able to keep ones HIV status confidential.
2. If one decides to disclose ones HIV status or it becomes public, one should not be discriminated against.

Right to Treatment

Bragdon v. Abbott [1998]: This was a landmark judgement by the US Supreme Court. Bragdon, a private dentist at his office, refused Abbott, who was HIV positive, treatment even though he offered to treat her at a hospital. The Court held that a healthcare professional could refuse treatment only in the case of significant risk, but what constituted such risks would depend on the objective medical and scientific data available and not on his perception of the risk.

Howe v. Hull, (N.D. Ohio 1994): A patient infected with HIV was denied admission to a hospital for treatment of severe allergic reaction, which was not related to AIDS or HIV infection. The patient was referred to another hospital where he was treated. The Court held that this was a denial of the opportunity to receive medical treatment under the Americans with Disability Act.

International Treaties

Health and government responsibility for health in the context of the HIV epidemic has been codified in international human rights treaties. In almost all of them, the right to the highest attainable standard of physical and mental health takes precedence. More importantly, nearly every document has clear implications for health and HIV/AIDS. Everything from the right to information and association to the right to social security or to the benefits of scientific progress and its applications has clear implications for HIV/AIDS and for the work of public health.

India is a party to the Universal Declaration of Human Rights, International Covenant on Civil and Political Rights (ICPPR), International Covenant on Economic Social and Cultural Rights, the Elimination of All Forms of Discrimination against Women, Convention on the Rights of the Child and International Convention on the Elimination of All Forms of Racial Discrimination. These are legally binding on the Government of India.

Meanwhile in the absence of legislations, there is no reason why international conventions and norms cannot be used for constructing the fundamental rights expressly guaranteed in the Constitution as these embody the basic concept of gender equality in all spheres of human activity. For example in Vishaka v. State of Rajasthan , in the absence of an enacted law to provide for effective enforcement of basic human rights of gender equality, more particularly against sexual harassment at work place, the Apex Court laid down guidelines and norms for due observance until a legislation is enacted on the basis of India’s commitment on CEDAW. Similarly, in the case of Nilabati Behra v. State of Orissa , a provision in the ICCPR was referred to support the view taken that ‘an enforceable right to compensation is not alien to the concept of enforcement of a guaranteed right’. In light of its international commitments and duty towards protecting human rights, including right to health, the government should consider enacting national legislation on HIV/AIDS as the existing laws have proved to be extremely inadequate. Till such time that it does, PLWHAs will have to depend on Court judgements and international conventions for redressal.

Ethical Implication"

The IDA code of ethics elaborates on the ethical obligations of dentists while dealing with patients with blood borne pathogens.The text below outlines the text relevant to HIV patients.

Justice

Advisory Opinions

Patients with Bloodborne Pathogens- A dentist has the general obligation to provide care to those in need. A decision against providing treatment to an individual because the individual is infected with Human Immunodeficiency Virus, Hepatitis B Virus, Hepatitis C Virus or another bloodborne pathogen, based solely on that fact, is unethical. Decisions with regard to the type of dental treatment provided or referrals made or suggested should be made on the same basis as they are made with other patients. As is the case with all patients, the individual dentist should determine if he or she has the need of another’s skills, knowledge, equipment or experience. The dentist should also determine, after consultation with the patient’s physician, if appropriate, if the patient’s health status would be significantly compromised by the provision of dental treatment.

In accordance with the FDI policy:

1. Ethical Matters

   Patients with HIV and other blood borne infections should not be denied oral health care solely because of their infection.

   • Members of the oral health care team are obliged to take adequate measures to protect themselves and their patients against HIV and other blood borne infections during
   • Patients with signs and symptoms indicative of HIV infection should be encouraged to undergo appropriate investigatory tests (which may be mandatory for major surgical procedures, in some regions). Such advice should be provided in a supportive environment with due regard to the sensitivity of the information disclosed.
   • All information related to the disease status should be kept confidential, within the dental team. The patient’s consent should be obtained in order to divulge his/her clinical status to any other individual including other health care professionals.
   • Dentists or members of an oral health care team who believe they are infected with HIV should obtain medical advice and if found to be infected, should submit to appropriate monitoring.
   • An HIV-infected dental care provider should heed the medical advice given; this may include the cessation of dental practice or its modification, if in exceptional circumstances, necessary.
   • Dentists must be competent in recognition, documentation and management of oral manifestations of HIV infection and AIDS.
     
2. Infection Control
   • Universal infection control procedures should be employed for all patients irrespective of their health status.
   • Dental care workers should be familiar with protocols for the immediate management of occupational exposure to blood borne pathogens, and dentists must institute and publicize policies to ensure appropriate management of such incidents.
3. Liaison between the Dental and Medical Care Providers
   • Dental and medical practitioners at all times should develop multidisciplinary, co-operative approaches for patient care, in order to deliver optimal health care for patients with HIV and other blood borne Infections
4. Public Education and Health Promotion
   • National dental associations should actively disseminate information to the profession with regard to HIV and other blood borne infections, infection control and the significance of oral manifestations of HIV infection
   • All dental curricula shall incorporate education and training in oral care of HIV-infected patients.
   • Continuing education programmes on all aspects of HIV and other blood borne infections should be provided for all oral health care personnel.
   • It is an obligation of all oral health care workers to keep up to date through attendance of continuing education programmes on appropriate aspects of HIV infection and other blood borne infections.
   • The public should be informed of infection control procedures it has a right to expect in all dental care delivery environments.

Medical evolution of HIV 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 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

• Susceptibility To Infections

  • Hemodialysis.
  • Bacterial endocarditis.
  • Poorly controlled diabetes mellitus.

• Impaired Hemostasis

  • Hemophilia.
  • Liver disease due to:
    • Hepatitis B infection and/or
    • Hepatitis C infections and/or
    • Alcohol, substance use/abuse.
  • Idiopathic thrombocytopenia purpura.

• 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.

• Ability To Withstand The Stress And Trauma Due To Dental Care

  • Cardiovascular disease.
  • Stroke.
  • Poorly controlled diabetes mellitus.

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 abuse history
  • Review of systems

Systems Review

• 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.

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.

Hematological Blood Values

Indication of patient’s risk for infection and bleeding tendencies.

Hematology

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

Differential White Blood Cell Count

• 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

WBC

• Neutropenia
  • 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.

Red Blood Cells

• Red Blood Cells
  • Anaemia 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.

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

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.   

Hematocrit

• Measure of packed cell  volume (PCV) of RBCs.
• Normal: 37% - 54%.
• indication of anemia and especially vitamin B12 deficiency.

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.

Coagulation Tests

• Indicates patient’s clotting ability.
• Increase indicates:
  • Coagulation abnormality due to liver disease.
  • Other systemic diseases.
  • Anticoagulant therapy.
  • Medications.
• Significantly elevated coagulation test results may require modification of dental treatment.

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.

Dental management of HIV infected persons

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/Universal 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.  
• 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.

Dental Treatment Plan Priorities

• Alleviate pain
• Prevent further oral disease
• Restore function
• Restore esthetics
• Improve quality of life

Restorative/Prosthodontic Considerations

• 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

With HIV-disease progression and the possibility of changing medical and/or mental status, the patient's ability to attend multiple appointments or to tolerate long, complicated dental procedures may be compromised.

Careful consideration must be given to addressing the patient's immediate needs, especially the elimination of pain and infection.

Special attention should be given to sensitive esthetic issues related to the patient's self-esteem with immediate temporary measures taken if necessary. Further restoration of function and esthetics may follow with a conservative approach. As the patient's health improves, treatment may become more aggressive as needed.

Antibiotic Coverage

Routine antibiotic coverage for HIV -positive patients is not recommended. The decision to provide antibiotic coverage should not be based on HIV status, CD4+ cell count or viral load alone.

A thorough past medical history to identify tendencies for infections and complications, along with current laboratory values is needed to make an informed decision.

The potential for allergic reactions and drug resistance increases over time with increased usage and may increase with decreased immune function; therefore, the judicious use of antibiotics is warranted.

The decision to use antibiotics or antimicrobials should always be made on an individual case-by-case basis.

Antibiotic prophylaxis is required for patients with the following conditions:

1. Neutropenia (neutrophil count < 500 cells/mm3) occurs in approximately 10-30% of patients with early symptomatic HIV -infection and up to 75% of those with AIDS. Antibiotic prophylaxis is recommended for immunocompromised patients with neutropenia prior to procedures likely to cause bleeding.The standard American Heart Association guideline for the prevention of bacterial endocarditis should be followed. To decrease the oral bacterial load and the risk for transient systemic bacteremia in neutropenic patients, an antimicrobial mouth rinse, such as 0.12% chlorhexidine gluconate, may be used 2-3 days pre- and post-procedure in severe cases, or immediately prior to emergency and routine procedures.
2. In patients with CD4+ cell counts < 200, prophylactic antibiotics for the prevention of pneumocystis pneumonia and mycobacterium avium complex (MAC) may be instituted by the physician.
3.  For those patients who may also require antibiotic prophylaxis prior to dental procedures for the prevention of bacterial endocarditis due to valvular deficiency or for prosthetic joint replacement, an appropriate antibiotic should be selected from an alternate drug class and administered following the American Heart Association guidelines. For  example, if a patient with mitral valve prolapse with regurgitation and a CD4+ cell count of 100 is taking Azithromycin 1200mg once weekly for the prevention of MAC, the patient may be given 2 grams of Amoxicillin, one hour prior to their dental appointment for the prevention of bacterial endocarditis. Immunocompromised patients should always be considered in the "high risk" category.

Bleeding Abnormalities

Many HIV -positive patients have bleeding disorders such as thrombocytopenia (platelet counts < 150,000). Approximately 30-60% of patients are affected at some time throughout the course of HIV disease.

For those patients with platelet counts> 60,000, no increased complications with routine treatment are expected. However, with platelets < 60,000, increased bruising and bleeding may be observed. Spontaneous bruising and bleeding may occur when platelet counts drop below 20,000.

In immunocompromised patients with platelets> 60,000 and PT/PTT values no more than 2 times normal, routine procedures, including simple extractions, can be safely performed without increase in post-operative complications.

If the patient's past medical history includes increased bleeding tendencies or platelets are below 60,000, a conservative tooth-by-tooth approach should be taken.

All screening tests for platelet counts should be no more than 1-2 days prior to procedure, with same-day values being optimal.

Anemia

Anemia is a common hematologic abnormality seen in patients with HIV infection, affecting approximately 10-20% of patients in early HIV-infection and as many as 85% of those with late-stage AIDS.

A thorough past medical history, including pertinent laboratory values, is needed to establish a baseline for each patient. In general, with hemoglobin levels> 7g/dl, no increased complications with routine treatment are expected

When hemoglobin levels drop below 7 g/dl, conservative tooth-by-tooth treatment is recommended.

If extensive surgical treatment is needed, close consult with the patient's physician to formulate an acceptable strategy for treatment is advised

Pain and Anxiety Control

HIV-infection is not a contraindication for the use of chemical agents for the control of pain and anxiety in dental patients.

HIV-infection is not a contraindication for the use of chemical agents for the control of pain and anxiety in dental patients.

As with all patients, a thorough review of the past medical history and all current medications, both prescribed and over-the-counter, should be conducted, preferably with an update at each appointment.

Familiarity with the patient's complete medication list and possible drug-drug interactions is essential.

• Nitrous Oxide: The judicious use of nitrous oxide and other short-acting antianxiolytics is acceptable for the temporary relief of the symptoms of anxiety associated with dental procedures.
• Local Anesthetics: For procedural pain control, there are no contraindications for the use of local topical and injectable anesthetics with or without epinephrine. However, bleeding abnormalities are not uncommon in HIV -positive patients; therefore, in patients with increased bleeding tendencies, deep block injections should be avoided in favor of local infiltration, intraligamentary and crestal injections.
• Non-steroidal anti-inflammatory drugs and non-narcotic and narcotic pain relievers: Non-steroidal anti-inflammatory drugs (NSAIDS), non-narcotic and narcotic pain relievers are acceptable for post-operative pain control. If the patient has an existing narcotic prescription for other pain control issues, consultation with the patient's physician is advised before prescribing additional pain control medications.

Preventive Treatment

Preventive dental treatment is highly stressed early in HIV disease.

• Patients should be introduced to oral healthcare as an integral part of their disease management strategy as soon as possible following an HIV diagnosis.
• Establishing and maintaining good oral health helps to ensure that the patient is free of pain and infection, is able to take medications as prescribed and sustain proper nutrition, is able to communicate effectively, and is comfortable with their appearance. Routine dental prophylaxis, fluoride treatment, sealants and patient education are all essential to an effective preventive programme.
• Proper home-care techniques, including daily brushing and flossing to remove plaque and decrease bacterial load and where available, the use of over-the-counter fluoride rinses to reduce caries incidence, should be reinforced at each recall appointment. Asymptomatic patients should be seen for routine cleanings and evaluation at least every 6 months.
• For symptomatic patients or those who are unable to maintain optimal oral hygiene, a more frequent recall interval is indicated and should be appropriate to assure the maintenance of good oral hygiene.
• Additionally, oral soft tissue lesions are common throughout the course of HIV infection; therefore, a thorough soft tissue examination should be performed at each recall appointment.
• Xerostomia, either drug-induced or salivary gland disease related, is common among HIV -infected patients. "Dry mouth" contributes to an increased caries rate, especially cervical and root caries and along with poor oral hygiene, increases the likelihood of developing soft tissue lesions such as ulcers and fungal infections.
• Patient counseling should include the importance of meticulous oral hygiene, diet modification, the use of at-home fluoride treatment and sugarless sialogogues. Smoking, caffeine, alcohol including alcohol- containing mouth rinses, and sugar sweetened and acidic drinks should be avoided.

Periodontal Disease

Many HIV -infected persons suffer from periodontal disease.

In HIV -positive patients, periodontal disease is often severe, aggressive and difficult to manage.

Management of Necrotizing Ulcerative Periodontitis (NUP)

• The appearance of necrotizing ulcerative periodontitis (NUP) is associated with severe immune deterioration. Patients may experience intense deep-seated pain, spontaneous bleeding, mobile teeth and fetid breath.
• Routine periodontal treatment modalities may need to be modified or intensified to gain control over the rapidly destructive process.
• Intervention methods should include immediate gross debridement of all plaque, calculus and necrotic tissue, followed by sulcular lavage with 10% povidone-iodine solution and thorough irrigation with 0.12% chlorhexidine gluconate.
• The use of ultrasonic scalers is acceptable if preceded by a minimum 30-second rinse with an antimicrobial solution and proper infection control measures are observed. Frequent follow-up appointments every 1-3 days for the debridement of additional affected tissues may be necessary during the first 2-3 weeks, depending on patient response
• Stabilization is closely followed by fine scaling and root planing to further eliminate etiological factors.
• Diligent home care is extremely important and should include an oral antimicrobial rinse twice daily during the initial phase and may be helpful for long-term maintenance as well.
• Systemic antibiotics are usually indicated for the first 4-5 days.
• Pain medication and nutritional supplements may be needed as well. If moderate to severe tooth mobilization is noted, a stint may be fabricated to aid in stabilization of the teeth and protection of the soft tissues, especially while eating, during the healing process. Monthly recall is suggested until the patient's overall periodontal condition has stabilized. Evaluation every 3-4 months thereafter is recommended.

Management of Linear Gingival Erythema (LGE)

Linear gingival erythema (LGE) presents as a distinctive linear band of erythema at the free gingival margin, extending 2-3mm apically. Mild pain and occasional bleeding are often reported.

• LGE can be distinguished from conventional gingivitis in its failure to respond to routine plaque control measures and proper home care maintenance.
• Also, the affected gingival tissue may appear somewhat "clear" or have a gelatinous quality, with little or no edema noted.
• Thorough prophylaxis and irrigation with 10% povidone-iodine solution should be performed, followed by a 0.12% chlorhexidine gluconate rinse twice daily for 2 weeks. Frequent follow-ups and a daily maintenance dose of an antimicrobial mouthrinse may be required.
• Some studies have associated LGE with intraoral candida infection; therefore, persistent lesions may be treated empirically with an appropriate antifungal medication.

Endodontic Procedures

No substantial evidence exists to suggest that patients should not receive endodontic therapy where indicated based on their HIV status alone. Consideration should be given to the overall health of the patient and the strategic importance of the tooth to the treatment plan.

• In severely immunosuppressed patients, the ability to resolve chronic periapical lesions versus healing time following extraction has not been adequately studied.
• Anecdotal evidence suggests that for symptomatic patients with low CD4+ cell counts, extraction and curettage followed by an appropriate course of antibiotics may provide faster resolution of chronic infection.

Oral Surgery

Oral surgical procedures may be safely performed in mY-seropositive patients following standard protocols. In well-controlled, asymptomatic patients, no increase in post-operative complications and no delay in healing time is expected. Routine antibiotic coverage is not indicated.

• Pre-procedural antimicrobial mouthrinse, especially in patients with poor oral hygiene, may help decrease bacterial load, and thus reduce the risk of systemic bacteremia, prior to traumatic procedures where bleeding is likely to occur.
• Intraoral fungal infections should be cleared prior to procedures likely to cause bleeding to reduce the risk for systemic fungemia.
• For emergency procedures, the use of an antimicrobial pre- procedural rinse is indicated. An appropriate course of antifungal therapy should be started immediately following. Severely immunocompromised patients may experience delayed healing, but do not appear to be at greater risk for post-operative complications, including alveolar osteitis and local infections. However, clinical signs of post-operative infections, such as inflammation and purulence, may be reduced or absent due to the patient's inability to mount a proper immune response.

Restorative Procedures

Routine restorative procedures, including operative and fixed and removable prosthodontics, may proceed as per the standard of care.

• Non-restorable (due to extensive caries) and periodontally hopeless teeth should be removed as soon as possible to reduce bacterial and fungal reservoirs.
• In severe cases where restorability is questionable, excavation and temporization of large carious lesions, in conjunction with intense periodontal therapy, may be indicated until stabilization can be achieved.
• The employment of immediate temporary or interim prosthesis is acceptable until such time that definitive restorations may be fabricated.
• Restoration of proper function is extremely important for HIV - positive patients who must maintain adequate diet and nutrition as part of their comprehensive disease management strategy.
• The ability to eat a variety of foods is essential due to the complexities of the absorption and metabolism mechanisms of many antiretroviral medications. Additionally, due to the sometimes overwhelming psychosocial factors associated with HIV disease, special consideration should be given to sensitive esthetic issues relating to the patient's self esteem.

Orthodontic Considerations

There is no evidence that HIV infection is a contraindication for orthodontic treatment. Asymptomatic HIV patients respond to orthodontic treatment in the same manner as do non HIV orthodontic patients. Late- stage AIDS however, is a primary contraindication for orthodontic treatment.

Choice of Drugs

Resistance occurs rapidly when patients miss drug doses (better than 90% adherence is needed to prevent resistance) or when inadequate ART is prescribed. Clinicians who work with patients on ART need a thorough understanding of the medications and their actions, side effects, potential drug interactions, and contraindications. Consultation with the patient’s physician is normally indicated to assess lab values and to make decisions about prescriptions for dental problems.

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.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.

Potential Risks

To minimize complications after dental procedures, a thorough and appropriate medical assessment is necessary.

The main concern for dentists treating HIV infected cases are-

1. Increased bleeding tendencies.
2. Post operative infections.
3. Drug interactions.
4. Adverse reactions. 
5. Prognosis for survival.

• The mode of HIV transmission influence the provision of dental care. Hemophiliacs demand modifications of dental care, moreover, they have a high prevalence of Hepatitis B, Hepatitis C and Hepatitis delta virus infection.
• Intravenous drug users(IVDUs) also have a high prevalence of Hepatitis B and Hepatitis C viral infections. IVDUs are highly susceptible to develop bouts of bacterial endocarditis. The use of appropriate analgesics is another concern while treating IVDUs.
• Homosexual men show a propensity to develop certain types of oral lesions, such as necrotizing ulcerative periodontitis, oral hairy leukoplakia and Kaposi’s sarcoma. Prevalence of Hepatitis B virus infection is also high in this patient population.
• Children with perinatally acquired HIV are considered to be at greater risk for caries than their siblings, more so with advancing disease.
• During the course of HIV disease, patients take increasing number of medications. Dentists need to be aware of the medications that can cause neutropenia and anemia. These include zidovudine and trimethoprim- sulphamethoxazole (Septra, Bactrim). Zidovudine may also cause reduced salivary flow.
• Many HIV infected patients are started on trimethoprim- sulphamethoxazole when their CD4 cell count drops below 200 cells/ mm3. More than 50%, however, develop severe adverse reactions and need to stop taking the medication. Patients also show increased adverse reactions toward other antibiotics, including amoxicillin- clavulanic acid, ciprofloxacin, dicloxacillin, erythromycin and clindamycin, when their CD4 cell count decreases.
• During the course of HIV disease, all patients develop oral alterations, but none of these lesions are specific for HIV disease, and they can be present in other immune suppressed individuals. These lesions range from asymptomatic, subtle changes of the oral mucosa that are secondary to a decreased salivary flow or candidiasis to rapidly destructive lesions, such as necrotizing stomatitis, necrotizing ulcerative periodontitis, deep mycoses and cancers.
• The treatment of some of these oral lesions can be handled in a dental office on an outpatient basis. When treatment includes radiation, cancer chemotherapy and long term intravenous medication for neoplasms, it is advantageous for the dentist to be a part of the treatment team instead of being the primary provider.
• The treatment team may have a general internal medicine specialist who takes care of the patient’s non- infectious needs and an infectious disease specialist to attend to all HIV related care. Community based organizations and social support networks are also involved with a multitude of services, including psychological counseling and drug rehabilitation.
• Based on the current epidemiological evidences, Epstein and others have reported that infectious diseases, specially blood borne pathogens such as Hepatitis B, Hepatitis C and HIV are not transmitted from patient to patient via dental instruments.
• Though it has been suggested that dental handpieces are capable of transmitting HIV in a dental setting, there has never been any reports that such a transmission has occurred.

Special attention should be paid to dentists who are more susceptible to diseases potentially transmitted in a dental setting, They include pregnant women, due to their immunologic changes and the developing foetus; dentists with the habit of excessive alcohol intake; those who had undergone splenectomy, radiotherapy, and long term corticosteroid therapy; also, dentists suffering from diseases that have an impact on the first and secondary defense against infections such as diabetes mellitus, chronic renal failure, leukemia or HIV.