MANAGEMENT OF HIV PATIENTS

CONTENTS

Introduction

Definition

Epidemiology

Etiology and modes of transmission

Pathogenesis

Diagnosis

Prevention

Global AIDS strategy

AIDS vaccine

Drugs used for AIDS

Conclusion

Reference

INTRODUCTION

The human immunodeficiency virus infection (HIV)

is of major interest and concern to dentists and

other oral health care workers because of the

pandemic nature of the disease.

DEFINITION

Acquired Immuno Deficiency Syndrome (AIDS) can

be defined as presence of antibodies to HIV and

opportunistic infections.

EPIDEMIOLOGY

WHO reported that one million children were

infected with HIV by the end of 1992 and estimated

that 10 million children will be born infected by the

year 2000.

ETIOLOGY AND MODES OF TRANSMISSION

AIDS is caused by human

immunodeficiency virus (HIV), a

human retrovirus.

The most common cause of

AIDS throughout the world is HIV

I.

MODES OF TRANSMISSION

DIAGNOSIS

Clinical screening and serologic

confirmation

WHO defined pediatric AIDS as an

infant or child presenting with at least a

major criterion along with at least 2

minor criteria in the absence of any

immunosuppression.

Major signs

Chronic diarrhoea for more than one month

Prolonged fever for more than one month

Weight loss

Minor signs

Oropharyngeal conditions

Repeated cough for more than one month

Generalised lymphadenopathy

Generalised dermatitis

Maternal HIV infection

Typical pediatric findings (Rubenstein, 1986)

Pulmonary lymphoid hyperplasia

Salivary gland enlargement

Pyogenic bacterial infection such as otitis media

Developmental craniofacial features

Chronic recurrent diarrhea

Hepatosplenomegaly

Chronic pneumonitis

Progressive encephalopathy

Oral and perioral findings of aids in children

Fungal infection like candidiasis of different types like:

Angular cheilitis

Hyperplastic

Bacterial infections either generalised, localized or

pyogenic

Viral infections like:

Herpes zoster

Herpes simplex

Hairy leukoplakia

Herpetic stomatitis

Unknown etiology lesions

Parotid enlargement with xerostomia

Petechiae

Aphthous stomatitis

Linear gingival erythema

Cervical lymphadenopathy

Gingival and periodontal lesions like ANUG and

necrotising ulcerative periodontitis

Oral ulcerations

Dysmorphic craniofacial features

Other malignancies

Hepatic fibrosarcoma,

Hepatic leiomyosarcoma,

Hepatoblastoma,

Acute lymphoblastic leukemia,

Hodgkin’slymphoma

Ewing’s sarcoma

Group I

Lesions strongly associated with HIV infection

Candidiasis

Erythematous

Pseudomembranes

Hairy leukoplakia

Kaposi’s sarcoma

Non-Hodgkin’s lymphoma

Periodontal disease

Linear gingival erythema

Necrotising ulcerative gingivitis

Necrotising ulcerative periodontitis

Revised classification of HIV infection (1993)

Group II

Lesions less commonly associated with HIV

infection

Bacterial infection

Mycobacterium avium-intercellulare

Mycobacterium tuberculosis

Melanotic hyperpigmentation

Necrotising ulcerative stomatitis

Group III

Lesions seen in HIV infection

Bacteial infections

Actinomyces israelii

Escherichia coli

Klebsiella pneumoniae

Cat-scratch disease

Drug reactions(ulcerative,erythema multiforme,

lichenoid reaction, toxic epidermolysis)

Epithelioid(bacillary) angiomatosis

Group III

Fungal infections other than candidiasis

cryptococcus neoformans

Geotrichum candidum

Mucomycosis (zygomycosis)

Aspergillus flavus

Neurologic disturbances

Facial palsy

Trigeminal neuralgia

Recurrent aphthous stomatitis(RAS)

Viral infections

CMV

Molluscum contagiosum

CANDIDIASIS

Recurrent candidiasis which is persistent for long

period and often resistant to conventional antifungal

therapy, is a frequent oral manifestation in pediatric

HIV infection/AIDS

Oral manifestations

Pseudo membranous plaques

Erythematous patches

Angular cheilitis (appears as fissures or cracks at

the commissures of the lips)

Hyperplastic plaques

Treatment

Lesion may subside or disappear with treatment,

but relapse is common.

Treatment can be either topical or systemic

DRUGS DOSE

Topical

1. Nystatin suspension (100000 v/ml) 1-2ml to be applied to the affected

area tds or qds

2. Amphotericin suspension (100

mg/ml) qds for 14 days

1 ml to be held in the mouth or

applied to the affected area after food

Older children

1. Nystatin pastilles (100000b/ml) 1 pastille should be sucked qds for 7

days

2. Amphotericin lozenges (10 mg) 1 lozenge to be dissolved in the

mouth for 10-15 days

3. Clotrimazole 10mg troches <5 /day orally

Systemic

1. Fluconazole By mouth or IV by infusion of 3-6

mg/kg on first day followed by

3mg/kg daily thereafter, every 72 hr

in neonates up to 2 weeks old and

every 48 hr in neonates 2-4 weeks

old

2. Ketoconazole Orally with food, 3mg/kg daily with

food for 2-3 weeks

3. Amphotericin B 0.25 mg/kg/day IV

VIRAL INFECTION

In HIV infection, several viruses are able to colonise

or react, producing lesions in the mouth. These

include herpes-group viruses and papilloma

viruses.

Includes

Herpes simplex (HSV I)

Herpes zoster (varicella zoster)

Oral hairy leukoplakia (EBV)

Oral warts (HPV)

TREATMENT OF VIRAL INFECTIONS

Herpetic lesions may be treated with systemic

doses of Acyclovir ranging from 1 to 2 g daily taken

orally or IV in individuals with more severe

oropharyngeal lesions or in those unable to swallow

BACTERIAL INFECTION

Includes Mycobacterium avium intracellulare and

Klebsiella pneumoniae

HIV ASSOCIATED GINGIVITIS (HIV-G) AND HIV

ASSOCIATED PERIODONTITIS (HIV-P)

Gingival and periodontal diseases (NUG&NUP) -

first sign of HIV infection.

Gingivitis in HIV infected children appears as an

intensely erythematous band that extends 2 to 3

mm apically from the free marginal and attached

gingiva.

FEATURES

Gingiva :

reddened,

edematous

spontaneous bleeding with punctate lesions

NUP -rapid loss of supporting periodontal structures and loose teeth with no pocket formation

Other features are

soft tissue and bone necrosis

pain and bleeding

The distinguishing feature of HIV G and HIV P is a lack of response to removal of plaque and good oral hygiene maintenance

TREATMENT

Aggressive curettage

Peridex (0.12 %chlorhexidine digluconate) rinses 3

times daily

Antibiotic treatment

PAROTID ENLARGEMENT WITH XEROSTOMIA

INVOLVING SALIVARY GLANDS

The parotid glands are diffusely swollen and firm

without evidence of inflammation or tenderness with

unilateral or bilateral involvement

TREATMENT

Chronic parotid enlargement does not require

treatment

Drugs like Zidovudine can be given but usually

there may recurrence of the lesion

ORAL ULCERATIONS

Recurrent aphthous ulcers

well circumscribed ulcers

erythematous margin

Three types- major, minor& herpetiform

Minor -0.5 to 1 cm

Herpetic form-clusters of small ulcers (1-2 mm) on the

soft palate and oropharynx

Major ulcers -large necrotic ulcers of 2-4 cm which are

painful and last for several weeks

TREATMENT

Fluconamide ointment (0.5%)

Orabase 3-6 times/day

Dexamethasone 0.5 mg/ml

PREVENTION

The various approaches are:

If a pregnant lady on testing proves that the foetus

is also HIV positive, she should be allowed to

medically terminate pregnancy

Blood and blood products to be screened for any

contamination

Needles should not be re-used

Educating & creating awareness among the

population

Safe sex

In dentistry there is a little scope of HIV

transmission but precautions should be taken like:

1. Proper medical history of the patient

2. Proper sterilization

3. Barrier techniques like:

i. Eye protection in terms of eye glasses

ii. Mouth mask

iii. Disposable needles

iv. Gloves (double)

v. Change of clothes

GLOBAL AIDS STRATEGY

o Prevent sexual transmission by

a) Information and education

b) Health and social services

c) A supportive environment to prevent sexual

transmission of HIV

o Prevent blood borne transmission of HIV

o Prevent perinatal transmission of HIV

AIDS VACCINE

Since the genetic make up of HIV is constantly

changing from one method of transmission to the

other AIDS vaccine development is not successful

Still a lot of research on this aspect is coming up

DRUGS USED FOR AIDS

Mainly antiviral drugs like:

1. Acyclovir 1to 2 g daily orally or IV

2. Zidovudine (AZT) which attacks the virus through the enzyme reverse transcriptase

3. Three other inhibitors namely

1. Dideoxycytosine

2. Dideoxyinosis

3. stavudine

4. Use of protease inhibitors like Saquinavir, Indinavir and Ritonavir

5. Triple drug therapy combines Indinavir with Zidovudineand Lamivudine to reduce HIV copies in the plasma of infected patients.

POSTEXPOSURE PROPHYLAXIS (PEP)

Following exposure, postexposure prophylaxis may

be required

Basic two drug regimen-Zidovudine 300 mg BD and

Lamivudine 150 mg BD

Expanded three drug regimen contains Lopinavir

400 mg BD or 800 mg OD or Ritonavir 100mg BD

or 200 mg OD as third drug.

To be effective these drugs must be started within

the first 72 hours and ideally within 2 hours.

PEP should be continued for a period of four weeks

Besides PEP, injured site on the wound should be

thoroughly washed with soap and water

Antiseptics may also be used

CONCLUSION

All the professional should take detailed history

before commencing the treatment

Universal precautions should be taken regardless

of the patient condition

All health care professionals need to participate

appropriately in the care of those in our population

who are HIV-infected, including the children

REFERENCE

Text book of edodontics -2nd edition-Shobha Tandon

Principles and Practice of Pedodontics-3rd edition-

Arathi Rao

Shafer’s textbook of oral pathology-7th edition

Textbook of Microbiology for Dental students-Prof.

C P Baveja