CC
A 58-year-old male who is seropositive for the human immunodeficiency virus (HIV) is referred to your office. He complains, “I am having pain in my mouth, and I need my teeth out in order to get dentures.”
HPI
The patient has been receiving routine dental care, but during a recent yearly checkup, he was found to have multiple mobile teeth. (Accelerated periodontal disease is seen with HIV infection.) This sudden change in his oral health has coincided with a recent exacerbation of his HIV infection, as measured by an increase in his viral load, a decrease in his CD4 cell count, and the onset of gastrointestinal and constitutional symptoms. He has had several previous hospital admissions. Currently, he complains of a foul-smelling mouth odor (halitosis), gingival pain, loosening teeth, gingival bleeding, and exposed roots. The onset of pain has contributed to difficulty with hygiene and further accumulation of calculus.
PMHX/PDHX/medications/allergies/SH/FH
The patient tested positive for HIV 6 years ago. (HIV antigen-antibody testing is the main diagnostic HIV test when a prior history is not available or if the viral load is low or undetectable. An initial HIV test usually will either be an antigen–antibody test or an antibody test. In case of a positive initial HIV rapid test result, follow-up testing is necessary.) He believes he acquired the virus through unprotected sexual contact. Otherwise, his medical history is noncontributory.
Examination
General. The patient is a cooperative male with evidence of muscle wasting (cachexia) who appears anxious. (Generalized muscle wasting is seen with advancing acquired immunodeficiency syndrome [AIDS].)
Vital Signs. Blood pressure is 121/79 mm Hg, heart rate is 90 bpm, respirations are 14 per minute, and temperature 37.8°C. (With advanced AIDS, it is common to have a normal temperature despite the presence of an acute infection; this is due to the failure or deficiency of available white blood cells [WBCs] to mount an appropriate inflammatory response, which results in fever.) His oxygen saturation is 92% on room air. (A recent history of pneumonia can result in a decrease in baseline oxygen saturation on room air.)
Maxillofacial. There is no evidence of hair loss or patchy ulceration on the scalp. (Scalp ulceration may be seen in patients with disseminated fungal diseases, such as cryptococcal infection. These ulcerations may also present in the oral cavity or on the peripheral extremities. A biopsy can be used to confirm the diagnosis. This finding can be used as a sign to evaluate other organs for fungal invasion.) Bilateral temporal wasting and prominent zygomatic arches are noted. Examination of the neck reveals a soft dorsal hump. (Lipodystrophy may result either directly from HIV or as a side effect of antiretroviral therapy, particularly protease inhibitors. Other physical signs to investigate are seborrheic dermatitis [dandruff], vesicular rash with central umbilication in the forehead [molluscum contagiosum], and enlargement of the parotid glands [differential diagnoses consist of lymphoepithelial cyst, lipodystrophy, and lymphoma].)
Intraoral. Oral hygiene is poor, and the breath is fetid. Generalized inflammation of the maxillary and mandibular gingivae, exposed buccal bone, and mobility of the teeth are noted. Gentle palpation of the gingival tissue results in bleeding and pain. There is no facial or intraoral fluctuance, and there is no obvious swelling. (In addition to HIV gingivitis and HIV periodontitis, the oral examination should concentrate on the presence of warts [human papillomavirus]; oral neoplastic growths, such as Kaposi sarcoma [human herpesvirus 8]; hairy leukoplakia [Epstein-Barr virus]; candidiasis; and other fungal infections. Aphthous ulcers, lymphoma, herpes, and cytomegalovirus ulcerations also may be seen in patients with AIDS.)
Chest. The chest is clear on auscultation. (If the patient presents with crackles, a chest radiograph is indicated.)
Cardiovascular. Regular rate and rhythm, S1 and S2, and no gallops, rubs, or murmurs. (HIV may affect the heart, resulting in dilated cardiomyopathy, but this is not common.)
Imaging
A routine preoperative chest radiograph is not indicated unless the patient’s history or clinical examination is suggestive of symptoms such as shortness of breath, a decrease in oxygen saturation on room air, or a productive cough. However, a chest radiograph, along with arterial blood gas analysis, may be valuable.
For the current patient, the panoramic radiograph demonstrates areas of moderate and severe vertical interproximal bone loss consistent with severe to moderate periodontal disease.
Labs
During the perioperative evaluation of a patient with HIV infection, a complete blood count (CBC) is valuable but should be used with caution. An increase in the WBC count may not be seen in response to physiologic or inflammatory demands, as would be seen in immune-competent individuals. The lymphocyte subset can be used to assess the susceptibility to opportunistic infections. The neutrophil count may be elevated with bacterial infections. The hemoglobin and hematocrit levels may be used to assess volume status. (Hemoglobin would be falsely elevated.) Hemoglobin and platelet levels may be depleted, and patients may require packed red blood cell or platelet transfusions before major surgery.
In patients with HIV, HIV RNA test (viral load) should be performed every 4 to 6 weeks after initiation of antiretroviral therapy (ART) until viral RNA level is less than 50 copies/mL and then every 3 to 4 months. If viral suppression and stable CD4 count are consistent for more than 2 years, viral load can be measured every 6 months. The CD4 count is initially checked every 3 to 6 months for 2 years after starting ART. This regimen is also followed if the CD4 cell count is less than 300/mm 3 or if viremia develops. If the CD4 count is within 300 to 500/mm 3 and viral suppression is maintained for 2 years, CD4 can be measured annually. Despite popular belief, neither the CD4 count nor the viral load alters maxillofacial surgical intervention. Nonetheless, a patient with a rapidly declining lymphocyte count or an increase in viral load should be reassessed before any surgical intervention. Additional tests may be helpful, depending on the extent of the surgical procedures or the presence of concurrent comorbidities associated with immune suppression. Arterial blood gas analysis is helpful for assessing the pulmonary status of a patient with active pneumonia. A basic metabolic panel may be used to evaluate intravascular fluid status in dehydrated and volume-depleted patients. A blood urea nitrogen–to–creatinine ratio greater than 20 is suggestive of volume depletion. The coagulation factors are rarely depleted in patients with HIV, but HIV or other infections may predispose a patient to disseminated intravascular coagulation. Coagulation studies should be obtained as needed. Evaluation of hepatic function is also important. Although HIV may affect liver function directly, of more concern is a concurrent infection with hepatitis B or C virus. (Note that the route of transmission is similar for HIV and the hepatitis B and C viruses.)
On our patient’s most recent hospital admission, his CD4 count was 108 cells/μL; therefore, he was diagnosed with AIDS. (An absolute CD4 count <200 cells/μL is an AIDS-defining feature in adults; in pediatric patients, the CD4 cell percentage is more accurate.) The patient’s internist indicated that the patient’s recent episode of pneumonia was caused by the recent decline in his CD4 count. His platelets and hemoglobin were within normal ranges. His absolute neutrophil count (ANC) was 2300 cells/μL. The normal range of ANC in a healthy person is between 2500 and 6000 cells/μL. The ANC is calculated by multiplying the WBC count by the percent of blood neutrophils. Neutropenia is an ANC below 1000 cells/μL.
Assessment
AIDS secondary to HIV infection, now complicated by acute necrotizing ulcerative periodontitis, requiring full-mouth extraction.
Treatment
With the advances in ART, patients with HIV now are expected to live a normal life span, without developing AIDS or transmitting the disease to their partners or infants. This is primarily dependent on a long-term adherence to ARTs to keep the viral load undetectable. The HIV Medicine Association of the Infectious Diseases Society of America has recently updated its published guidelines on the primary care of these patients. There are also other guidelines available from similar organizations, including the European AIDS Clinical Society. The recommendations put forward by these references and other similar publications have consistently emphasized the necessity of providing patient-centered, stigma-free care and overcoming barriers to care at the societal, health system, clinic, and individual levels. Clinicians must pay especial attention to the treatment needs of pediatric and geriatric patients and those of persons of childbearing potential, including care during preconception and pregnancy. Managing the comorbidities in these patients is both challenging and crucial.
There used to be some controversy regarding the optimal time to initiate treatment for patients who are seropositive for HIV. With few exceptions (e.g., coinfection with cryptococcal meningitis or tuberculosis), current standard of care is to start the patients on ART either on the day of diagnosis or as soon thereafter as possible. Rapid ART initiation is endorsed by the Adult and Adolescent Antiretroviral Guidelines Panel of the Department of Health and Human Services, as well as the International Antiviral Society–USA Antiretroviral Panel and New York Department of Health AIDS Institute. Evidence shows that rapid entry programs have excellent retention and effective viral suppression in long term. On the other hand, it is also evident that a long wait time before ART initiation is a predictor of treatment failure. Regardless of ART initiation timing, it is important to obtain baseline laboratory tests, including viral load, CD4 cell count, resistance testing, and safety assessments. CD8 cell count and the CD4/CD8 ratio are not necessary. HIV diagnosis should be ascertained, preferably using rapid testing with a fourth-generation antigen-antibody test if results of HIV screening are not available for review. In appropriate racial or ethnic groups, glucose-6-phosphate dehydrogenase deficiency may be assessed before initiating oxidant drugs including dapsone, primaquine, and sulfonamides. A pregnancy test is a must in any patient of childbearing potential and may modify the choice of ART.
Antiretroviral therapy medications include nucleoside reverse transcriptase inhibitors (NRTIs; Table 99.1 ), non–nucleoside reverse transcriptase inhibitors (NNRTIs; Table 99.2 ), protease inhibitors (PIs; Table 99.3 ), integrase inhibitors (INIs; bictegravir, cabotegravir, dolutegravir, elvitegravir, and raltegravir), and entry inhibitors (including fusion inhibitors [enfuvirtide] and C-C motif chemokine receptor [CCR5] antagonists [Maraviroc]). INIs consist of two main classes: integrase strand transfer inhibitors (INSTIs) and protein–protein interaction inhibitors (PPIIs). A combination of these medications is commonly referred to as highly active antiretroviral therapy (HAART).
| Nucleotide Reverse Transcriptase Inhibitor | Abbreviation | Side Effects |
|---|---|---|
| Retrovir | AZT | Anemia, neutropenia |
| Videx | DDI | Pancreatitis, peripheral neuropathy |
| Hivid | DDC | Pancreatitis, peripheral neuropathy |
| Zerit | D4T | Pancreatitis, peripheral neuropathy |
| Epivir | 3TC | Also used for hepatitis B virus infection |
| Ziagen | ABC | Rash, death |
| Nonnucleoside Reverse Transcriptase Inhibitor | Side Effects |
|---|---|
| Nevirapine (Viramune) | Hepatotoxicity, hepatic necrosis during the first 4 weeks |
| Delavirdine (Rescriptor) | Rash, headache |
| Efavirenz (Sustiva) | Teratogenic; Stevens-Johnson rash, hallucinations, nightmares |
| Protease Inhibitor | Number of Pills Taken Daily | Common Side Effects |
|---|---|---|
| Indinavir (Crixivan) | 6 | Nephrolithiasis |
| Ritonavir (Norvir) | 12 | Weakness, loss of appetite, nausea and vomiting |
| Saquinavir (Invirase–Fortovase) | 9 | Gastrointestinal disturbances |
| Nelfinavir (Viracept) | 10 | Gastrointestinal disturbances (most commonly diarrhea) |
| Amprenavir (Agenerase) | 16 | Severe rash |
| Lopinavir–ritonavir (Kaletra) | 6 | Hepatitis |
Stay updated, free dental videos. Join our Telegram channel
VIDEdental - Online dental courses
