Inside Dental Assisting

May/Jun 2009, Volume 5, Issue 6

Published by AEGIS Communications

Table 1

Table 2

Table 3

Dental Treatment Issues for Patients With HIV/AIDS

Margaret I. Scarlett, DMD

Today, HIV/AIDS is being managed by medical and dental teams as they manage other chronic
diseases. This articlethe second part of a two-part series for dental assistants on AIDSaddresses
the care and treatment of persons known to be infected with HIV/AIDS. This second article provides a
thumbnail description of treatment issues for patients with HIV/AIDS and a body of resources for the
dental team to review about the constantly changing issues in current medical treatment modalities for
HIV/AIDS. Special oral conditions and the available evidence on appropriate treatments for conditions
associated with HIV/AIDS are reviewed. Finally, because drug treatment, treatment monitoring, and
the progression of illness varies among individuals living with HIV/AIDS, a customized approach to
the spectrum of care is recommended, in consultation with the patients physician or case manager.

Medical Treatment for HIV/AIDS

Today, HIV is managed as a chronic disease, with impressive results. For example, the impact of
highly active antiretroviral therapy (HAART)also called ARV or antiretro-viral therapyis dramatic.
The number of deaths from AIDS declined rapidly by 43 percent between 1995 and 1997 when these
drugs were introduced.1 Current estimates are that with proper treatment, persons living with HIV can
survive up to 23 years and beyond.1 Therefore, it is reasonable that persons living with HIV would
seek routine dental care and palliative care for conditions associated with HIV or declining immunity.
The decrease in deaths and the large number of people living with HIV/AIDS (PLWHAs) means that
more patients are living with AIDS.1
Dental team members should know that HAART or ARV therapy controls HIV infection only when
combination drug therapies are used consistently, monitored, and appropriately prescribed. Oral
healthcare providers can ask about drug regimens and note this on the chart if patients disclose their
HIV status confidentially. It is important that PLWHA follow nearly complete adherence to prescribed
drug treatments to receive the optimal benefit of drugs and prevent drug resistance. If drugs are not
taken daily, the virus may change, as it self-replicates, resulting in drug resistance. Many of the drugs
are taken throughout the day with multiple pills taken at several times. The dental team can reinforce
the message to take drugs as prescribed, consistently and correctly.

Unfortunately, one-third of people infected with HIV/AIDS have either not been tested, or are unaware
of their status because they did not obtain their test results.2 Only two-thirds of people living with
HIV/AIDS are aware of their status, and fewer than half of these people are taking advantage of
effective antiretroviral therapy.
More than 20 drugs have been approved by the Food and Drug Administration for treatment of
persons living with HIV/AIDS. Usually, the drugs are given in combination, targeting different parts of
the lifecycle of the virus. Each of these drugs has a variety of side effects. Treatment of HIV is
extremely complex and best managed by a physician specializing in infectious diseases. On
November 3, 2008, the Department of Health and Human Services revised the drug treatment
recommendations for HIV3. At the time of this writing, drug treatments, based on patient needs,
included combinations of the following: 8 nucleoside/nucleotide reverse transcriptase inhibitors
(NRTIs/NtRTIs), 4 nonnucleoside reverse transcriptase inhibitors (NNRTIs), 10 protease inhibitors, a
single fusion inhibitor, an entry inhibitor (maraviroc), and an integrase inhibitor (raltegravir) available
for the treatment of HIV infection. However, because of selected drug toxicities and reactions in some
persons, drug resistance issues, and the rapidly changing nature of the virus, new drugs and new
strategies continue to emerge. Check with your local infectious disease specialist for the latest trends
in HIV care and updates on treatment.
Individuals with HIV should be in the care of a licensed health care provider, preferably one with
experience treating people living with the virus. Internal medicine practitioners and infectious disease
specialists can give patients important, up-to-date treatment information and guidance.3 In addition,
the entire dental team can assist in providing support to patients by working in conjunction with the
primary care provider and even the case manager or patient navigator.
To assist healthcare professionals, the Health Resources and Services Administration (HRSA) has
published A Guide to Primary Care for People with HIV/AIDS4. It covers a comprehensive range of
topics, from basic elements of care to where additional sources of information can be found to help
providers keep up to date on the latest therapies and drugs. HRSA also publishes and constantly
updates guidelines for antiretroviral treatments. A Pocket Guide to Adult HIV/AIDS Treatment,
February 20065 (available at hab.hrsa.gov/tools/HIVpocketguide/index.htm) includes drug information
and occupational HIV postexposure prophylaxis issues. Should someone on the dental team
accidentally incur a needlestick or puncture wound from an instrument used to treat a person with
HIV, immediate referral and management of this exposure is necessary, as explained in this
document. At a minimum, HAART for a month under a physicians supervision is recommended to
prevent infection for health workers.

Common Oral Conditions Associated with HIV/AIDS

Common oral conditions found in persons who are HIV-positive include a host of conditions. While
PLWHAs often develop oral health issues similar to those encountered by healthy people, there are
some conditions that occur concomitantly with HIV/AIDS infection. The science of the relationship
between oral-systemic health and HIV progression has not been fully explored: science arrives at
partial answers slowly, and this is certainly true for HIV and oral health issues.
 The exact range and timing of any oral conditions in the progression of HIV is not fully known.
However, the best science is from cohorts of prospective epidemiologic studies.6 For example,
researchers correlated oral health with other features of HIV disease among 729 women. Baseline
oral examinations were performed by dental clinicians on 577 HIV-positive and 152 HIV-negative
women. There were significant differences between the infected and uninfected women for certain
oral lesions (see Table 1).6 Among the women who were HIV-positive, the presence of oral
candidiasis was associated with CD4 cell counts below 200, cigarette smoking, and
heroin/methadone use. A high viral load of HIV was associated with hairy leukoplakia. 6
Some of these common conditions associated with HIV infection are listed in Table 2. Since early in
the epidemic, oral lesions have been identifiers for HIV/AIDS, including oral candidiasis, oral hairy
leukoplakia, severe herpetic ulcers, and oral Kaposis sarcoma.
Data on oral lesions with HAART is still in progress: it is important to remain current with the literature
on this topic. The same study of women with HIV mentioned above was analyzed after HAART
initiation.7 In the analysis, new oral lesions with erythematous candidiasis (EC), pseudomembranous
candidiasis (PC), hairy leukoplakia (HL), and warts were computed in follow-up visits. The authors
compared conditions after HAART initiation with those before HAART initiation. There was a
significant decrease in candidiasis after HAART initiation7 (see Table 3). Higher viral loads were
associated with greater likelihood of candidiasis and HL, but not warts. Analysis of these data
indicates that recurrence and incidence of candidiasis are reduced by HAART, and that recurrence is
reduced independently of CD4 and HIV-RNA.

HIV Testing
How do you know if a person is infected with HIV? The answer is: if they have a test and disclose this
to you with the medical history. Because of new test procedures, testing is more widely available. In
2006, new guidelines on testing and counseling from the Centers for Disease Control and Prevention
promote testing in healthcare and non-medical settings.2 Many people do not know that they are
infected with HIV, although knowledge of test status is essential to receiving the benefits of available
treatments. However, even when patients know their test results, they might not disclose them to the
dental team for fear of stigma, discrimination, or loss of confidentiality.

Types of HIV Tests

According to the CDC, The standard screening test used in the United States to detect the presence
of HIV antibodies is the EIA (enzyme immunoassay). This test is performed on blood drawn from a
vein. If the EIA is positive (reactive), it must be followed by a second confirmatory test, such as the
Western blot, to make a positive diagnosis.1

EIA tests that use body fluids other than blood to screen for HIV antibodies include the following:

Oral Fluid Tests use oral fluid (not saliva) collected from the mouth using a
special collection device. This is an EIA antibody test similar to the
standard blood EIA test and requires a follow-up confirmatory Western blot
using the same oral fluid sample.
Urine Tests use urine instead of blood. The sensitivity and specificity
(accuracy) are somewhat less than that of the blood and oral fluid tests.
Urine tests use an EIA antibody test similar to blood EIA tests and require a
follow-up confirmatory Western blot using the same urine sample.1-3
Rapid test is a screening test that produces very quick results. This is not a confirmatory test, but a
screening test that takes 20-60 minutes with blood or oral fluids. In addition, there are home collection
test kits available in some consumer outlets for purchase. The patient collects blood from a finger
prick or saliva and mails the kit into a laboratory for testing. Results are requested through a customer
 identification number assigned to each test kit. Regardless of the type of test, remember that testing
should occur at least 2 to 8 weeks after any exposure to detect sufficient quantities of antibodies. 2

Results Management and Data Storage

Positive or negative HIV test results should be documented in the patients confidential medical record
and should be readily available to all healthcare providers involved in the patients clinical
management. HIPAA guidelines should be followed at all times. It is not recommended that the HIV
status of the patient be written on the outside of the record.2Check with your state and local
regulations or state board of dentistry for requirements in this regard.

Dental Treatment for Persons Living with HIV/AIDS

Immunosuppression for patients with HIV is a critical factor associated with oral lesions. 6,7 As with
other immunosuppressed patients, such as cancer patients, proper nutrition is important. For these
patients, keeping them comfortable so that they can eat is very important, especially as many drugs
must be taken in conjunction with food. Treating patients who have painful oral lesions with
appropriate analgesics or medicines for oral lesions is especially important. Treat these lesions as
you would for patients who are HIV-negative. In addition, you may wish to consider saliva
enhancements or lemon drops for dry mouth, which may be a side effect of HAART.3 The appropriate
treatment and prevention of Candida is especially important.8 Many dental offices refer hairy
leukoplakia and Kaposis to an oral surgeon or oral pathologist for follow-up. Other periodontal
conditions may require referral to a periodontist, if the severity of the condition cannot be managed in
your office.
As with other issues, the science base for management of persons with HIV is still advancing as drug
treatments evolve. It is clear that lower viral loads in patients who are on HAART are associated with
fewer oral lesions.7 More information will be available over time as the science progresses. Although
evidence based reviews by the Cochrane Collaboration are planned, they have not yet been
released.8 The Agency for Healthcare Quality and Review contracted for an evidence based review of
dental and medical literature in 2002 to determine the quality of evidence related to the management
of dental patients who are HIV positive.9 The questions included whether:
1. invasive but common dental procedures present added risk of
complications for patients with HIV/AIDS;
2. selected oral conditions are useful (A) markers of recent change in HIV
serostatus or (B) indicators of immunosuppression; and
3. specific available antifungal drugs can (A) efficaciously prevent or (B)
effectively treat oral candidiasis.
In general, evidence-based information about the effectiveness of management of dental patients who
are HIV-positive is uneven. There is lack of evidence that persons with HIV/AIDS have any greater
risks from routine dental treatment, such as prophylaxis or restorations, than any other patients. 9
There is fair evidence that two conditions (oral candidiasis and Kaposis sarcoma) are reasonable
clinical indicators of severe immunosuppression based on their positive predictive values, and that
another (oral ulcers) is not. The evidence is good that hairy leukoplakia is not a reasonable indicator
of severe immunosuppression, even in a clinical setting.9
In reviewing the literature, only four studies addressed whether persons with HIV/AIDS are at greater
risk of complications from specific invasive dental procedures than similar patients without HIV/AIDS.
Invasive procedures were defined only as extractions and endodontics. This did not include a full
range of services, such as orthognathic surgery, periodontal therapy, dental implants, prophylaxis, or
root planing and scaling. The reviewers found insufficient evidence to judge the impact of endodontic
treatment and the safety of extractions.9 More and better research is needed to address this question.
For this review performed in 2002, there was insufficient evidence that certain conditions, such as
hairy leukoplakia, oral candidiasis, necrotizing ulcerative periodontitis, oral ulcers, or parotid swelling,
could be markers of recent HIV seroconversion. There was evidencejudged as fair to goodthat
hairy leukoplakia and oral candidiasis are indicators of HIV infection.9
Regarding treatment of HIV-related conditions, there was insufficient evidence for the prophylactic
effectiveness of treating any HIV-specific conditions, except fluconazole for oral candidiasis, among
available antifungal agents. The evidence was judged to be good that fluconazole is effective in
preventing new and recurrent episodes of oral candidiasis. The evidence was insufficient with regard
to amphotericin B suspension as a treatment for oral candidiasis. Although all treatments were found
to be effective, fluconazole and itraconazole seemed to be more effective than the other antifungals
reviewed. The evidence of effectiveness was best for questions involved with prevention or treatment
of oral candidiasis in persons who were HIV-positive. The evidence of effectiveness as a preventive
treatment was good for fluconazole and nystatin, but insufficient for other antifungals. There was also
good evidence of treatment effectiveness against oral candidiasis for fluconazole, itraconazole,
nystatin, ketoconazole, and clotrimazole. Other studies indicate that managing candidiasis
prophylactically10,11 with fluconazole makes patients more comfortable in obtaining adequate nutrition.

Conclusion
Today, HIV is a chronic disease that is carefully managed, much like other chronic diseases.
Treatment of HIV by medical providers is complex and requires periodic adjustments over time.
Following initial diagnosis of HIV by appropriate testing procedures, proper medical treatment will vary
among patients. Current recommendations for medical treatment are continually revised as new
medical research becomes available.

The dental team provides care to patients living with HIV/AIDS in consultation with the medical home
for these patients. Many treatment issues for persons living with HIV/AIDS are similar to other
patients; some unique oral conditions associated with HIV infection and immune compromised
function have been summarized in this review. Common therapies for these conditions for prevention
and treatment and the evidence to support their use were also reviewed.

References
1. Centers for Disease Control and Prevention. Fact sheets on
HIV/AIDS. www.cdc.gov/hiv/resources/factsheets/.
2. Branson BM, Handsfield HH, Lampe MA, et al. Centers for Disease Control and Prevention.
Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care
settings. MMWR Recomm Rep.2006;55(RR14);1-
17. www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm .
3. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of
antiretroviral agents in HIV-1 infected adults and adolescents. Department of Health and Human
Services. November 3, 2008. 1-139. Available
ataidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf .
4. Health Resources and Services Administration. A Guide to Primary Care for People with
HIV/AIDS. Rockville, MD: HRSA; 2004: 1-167.
5. Health Resources and Services Administration. A Pocket Guide to Adult HIV/AIDS
Treatment. Rockville, MD: HRSA; 2006:1-57.
6. Greenspan D, Komaroff E, Redford M, et al. Oral mucosal lesions and HIV viral load in the
Womens Interagency HIV Study (WIHS). J Acquir Immune Defic Syndr. 2000;25(1):44-50.
7. Greenspan D, Gange SJ, Phelan JA, et al. Incidence of oral lesions in HIV-1-infected women:
reduction with HAART. J Dent Res. 2004;83(2): 145-150.
 8. Kuteyi,Teslim. Topical treatments for HIV-induced oral ulcerations. Title registered 26 April
2007.http://summaries.cochrane.org/CD007975/topical-treatments-for-hiv-related-oral-ulcers.

9. Bonito AJ, Patton LL, Shugars DA, et al. Management of dental patients who are HIV-positive.
Evidence Report/Technology Assessment No. 37 (Contract 290-97-0011 to the Research Triangle
Institute-University of North Carolina at Chapel Hill Evidence-based Practice Center). AHRQ
Publication No. 01-E042. Rockville (MD): Agency for Healthcare Research and Quality. March 2002.

10. Goldman M, Cloud GA, Wade KD, et al. A randomized study of the use of fluconazole in
continuous versus episodic therapy in patients with advanced HIV infection and a history of
oropharyngeal candidiasis: AIDS Clinical Trials Group Study 323/Mycoses Study Group Study
40. Clin Infect Dis. 2005;41(10):1473-1480.
11. Cauda R, Tacconelli E, Tumbarello M, et al. Role of protease inhibitors in preventing recurrent
oral candidiasis in patients with HIV infections: a prospective case control study. J Acquir Immune
Defic Syndr. 1999;21(1): 20-25.

Web Resources
Centers for Disease Control and Prevention (CDC): www.cdc.gov/hiv
Food and Drug Administration (FDA), Center for Biologics Evaluation and Research (information on
HIV testing):www.fda.gov/cber/products/testkits.htm
HIVDent (basic information about dentistry or items related to dental treatment and
HIV): www.hivdent.org
Health Resources and Services Administration (HRSA), HIV/AIDS Bureau: www.hab.hrsa.gov

National HIV and STD Testing Resources: www.hivtest.org or call the CDC at 1-800-CDC-

INFO FREE (232-4636), 1-888-232-6348 FREE (TTY)

National Institutes of Health
(NIH): www.niaid.nih.gov/publications/aids.htm andhttp://www.nih.gov/about/discovery/infectiousdisea
ses/hiv.htm

About the Author

Margaret I. Scarlett, DMD
President
Scarlett Consulting International
Atlanta, Georgia