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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