Clinical Scenario

A 45‐year‐old man is referred by his physician for assessment of extensive but painless oral papillomatous lesions.

Structured Learning

1. What is the cause of the oral lesions?
   • The oral lesions are likely to be due to human papilloma virus (HPV) infection and are benign – oral papilloma/condyloma with focal epithelial hyperplasia
   • HIV and HPV are both infections that can be transmitted sexually
     

     

   • Immunosuppression is known to increase the risk of HPV infection
   • HPV oral lesions in patients with HIV infection and taking antiretrovirals may be related with the longer life expectancy of individuals with an impaired immune system rather than a direct effect of antiretroviral therapy (ART)

2. The patient’s primary concern is removal of the oral lesions as the teeth are asymptomatic. What additional information do you need first regarding his HIV infection?
   • Current viral load: the results are given as the number of copies of HIV per millilitre of blood
   • Current CD4 count: normal CD4 count is from 500 to 1400 cells per microlitre of blood
3. The physician advises you that the last test results are: viral load 13 000 copies/mL and CD4 count of 100 cells/μL. What factors are important to consider when assessing the risk of managing this patient?
   • Social
     • Physical stigma in a work setting that is probably unaware of his HIV infection (i.e. oral warts)
     • Risk of patient not attending appointments due to low mood/depression (see Chapter 15.2)
   • Medical
     • HIV infection in the acquired immune deficiency syndrome (AIDS) stage – CD4 count low leading to an increased risk of infection; viral load high (increased infectivity)
     • Ritonavir may cause thrombocytopenia
     • Chronic HBV infection (see Chapter 4.3) linked to bleeding risk, reduced drug metabolism
     • Anal carcinoma – may be uncomfortable for the patient to sit down if the lesion is symptomatic
   • Dental
     • Oral lesions may impair access to toothbrushing
     • Oral hygiene not optimal – may increase the risk of postoperative infection after removal of the oral papillomas
     • Lesions may recur after removal
     • Dental caries and periodontal disease present
     • Follow‐up compromised by the depressive syndrome and previous irregular attendance
4. As the lesions are widespread and some are sessile, vaporisation of the papillomatous lesions using CO₂ laser is planned. What precautions should be in place?
   • Perform the necessary laboratory tests (e.g. complete blood count with differential and coagulation study)
   • Administer antibiotic prophylaxis because the patient has <200 CD4+ T‐cells/μL
   • Take a sample with a cold scalpel beforehand to conduct histopathology
   • Maximise protection measures with subsequent use of the CO₂ laser to prevent dissemination of the papillomavirus:
     • Powerful surgical aspirator
     • Facemasks and eye protectors
     • Schedule the appointment for the last hour of the workday and ventilate the dental office after completing the procedure
5. The patient is nervous about the proposed vaporisation of the oral lesions and has been prescribed diazepam to take before he attends. What considerations should be taken into account?
   • Ritonavir can boost the sedative effects of benzodiazepines
   • If the hepatic impairment caused by the HBV is moderate to severe, the use of diazepam should be avoided (liaise with the physician and preferably use lorazepam)
6. The patient returns to you for extraction of the #15 and #46. What laboratory test results should be undertaken before proceeding and why?
   • Full blood count and coagulation study should be undertaken
   • Anaemia, thrombocytopenia and leucopenia/neutropenia may be present
   • Thrombocytopenia can occur in people with HIV due to multiple factors, including HIV infiltration of the bone marrow, as a side‐effect of drugs used to treat HIV (e.g. ritonavir), or due to the development of autoimmune (idiopathic) thrombocytopenic purpura
   • Neutropenia is observed in 10% of patients with early asymptomatic HIV infections and in 50% of patients with AIDS (again related to bone marrow infiltration and as a side‐effect of some medications)
   • HBV infection can impair the hepatic synthesis of coagulation factors

General Dental Considerations