HIV+Case

= **Case #3 - Patient with HIV** =

===//Whenever we are working with systemic conditions that are precursors to another condition, we always want to make sure that we do not confuse them. This case was presented as a HIV case. The case is incomplete and has inaccuracies. Please complete the case and correct the inaccuracies. Let's make it a thorough teaching case for all to learn from.//=== Human immunodeficiency virus or HIV is a bloodborne pathogen; a virus contracted by sexual contact or IV use. These patients are medically compromised and require special consideration when it comes to dental management. There is no effective treatment or cure for AIDS, however HAART medications do have an inhibitory effect on the disease.
 * __Overview of HIV and its Implications on Oral Health__**

The CDC Surveillance Case Classification has categorized AIDS patients as follows: Category A: Patients that are HIV positive and present with fever, malaise and persistent generalized lymphadenopathy. Category B: Patients that are HIV positive and have symptoms such as oropharyngeal or vulvovaginal candidiasis, herpes zoster, oral hairy leukoplakia, idiopathic thrombocytompenia, or constitutional symptoms of fever, diarrhea and weight loss. Category C: Patients with full blown AIDS, CD4+ T lymphocyte levels of less than 200 cells/mm3.

Important oral signs and symptoms are: candidiasis, hairy leukoplakia, severe periodontal disease, acute necrotizing ulcerative gingivitis, HSV, herpes zoster, recurrent apthous ulcerations, linear gingival erythema, severe forms of stomatitis, oral warts, facial palsy, trigeminal neuropathy, salivary gland enlargement, xerostomia, melanotic pigmentation and herpetic infections, Karposi’s sarcoma and other cancers such as squamous cells carcinoma and lymphomas. Before treating the patient the clinician must obtain a medical consultation from the patients physician indicating if the patient is healthy enough to undergo dental treatment.

The clinician must ask the physician for current INR, PT, CD-4 count, platelet and viral load. HIV patients often will require premedication of antibiotics prior to dental treatment due to their immunocompromised status. In some cases the disease may be advanced to a point where dental treatment must take place in a hospital or not at all. The dental treatment must be weighed against the risk of infection for the patient.

Periodontal disease is more severe and much more rapidly progressing in a patient with HIV. HIV patients with more conventional periodontal diseases such as chronic periodontitis may have increased attachment loss and gingival recession when compared to their HIV-negative counterparts. This pattern of loss of periodontal support may be due in part to an invasion of bacterial infections, viruses, and fungi into the gingival tissue, which results in a more elevated and more destructive response in the periodontal soft and hard tissues. Other than the constant concern about infection and reduced healing, the approaches to treating periodontal diseases in HIV patients remains unchanged from how you would treat any other person without the disease.

__**Medical History**__ Patients may or may not know that they are HIV positive. A recently infected patient usually has no signs or symptoms Within about 1 to 3 weeks of infection about 70% of patients experience fever, diarrhea, nausea, vomiting, weight loss, and lymphadenopathy. These symptoms clear up and the patient enters the latent period (asymptomatic). This can last from 8 to 10 years. About 50% - 70% of patients have persistent generalized lymphadenopathy (PGL). Early symptoms of HIV can include any of the following: PGL, fungal infections, vaginal yeast and trichomonal infections, oral hairy leukoplakia, herpes zoster, herpes simplex, HIV retinopathy, constitutional symptoms, fever, night sweats, fatigue, diarrhea and weight loss. Patients with AIDS are extrememly susceptible to opportunistic infections due to their severely compromised immune system.

Patients will be taking several different medications which would include any of the following: __Protease Inhibitors:__ Amprenavir Indivavir Lopinavir Nelfinavir Ritonavir Saquinavir __Nucleoside Reverse Transcriptase Inhibitors:__ Abacavir Emtricitabine Didamosine Lamivudine Stavudine Zalcitabine Zidovudine __Non-nucleoside Reverse Transcriptase Inhibitors:__ Delavirdine Efavirenz Nevirapine Nucleotides: Adefovir Tenofovir __Fusion Inhibitors:__ Enfuvirtide
 * __Medications__**

These medications are accompanied by many side effects. The patient will experience side effects ranging from xerostomia to diarrhea to hallucinations. There are also drug interactions that must be considered when treating these patients.

__**Gingival Description** Free:__ Generalized erythemic with localized suppuration and exudate,, ulcerative, cratered, fragile, edematous. __Attached:__ Generalized erythemic, edematous, shiny.

NUP: Necrotizing Ulcerative Periodontitis - HIV and AIDS patients are more susceptible to this condition. NUP, according to Carranza, is characterized by necrosis and ulceration of the coronal portion of the interdental papillae and gingival magin. It is painful and is accompanied by a strong odor. Gingival recession is a commonly results from the necrotizing ulceration destroying the marginal epithelium and connective tissue.

Intra Oral Findings - Psuedomembranous candidiasis, because it wipes off. Patient presents with signs and symptoms of NUP. Probing Depths generalized 2 - 6mm with localized 9mm mesial #14. MBI 30% BOP 51% PI 100 % Recession generalized 2 - 3mm on facial surfaces. Mobility - Class II on #1, #2,#25 & #24, Class I on #7, #8, #9, #23 & #26, + on #4 - #6 & #10 - #14, #22 & #27. Fremitus - Class I on #7 - #10 and + on #4 - #6 and #11 - #13. Furcations - Class III on Bucc, Mes & Dist #3, Bucc #14, Bucc & Ling #32. Periodontal Status - Uncontrolled Caries Status - Uncontrolled OHI Status - Uncontrolled ADA IV Generalized Severe Chronic Periodontitis due to plaque and calculus modified by systemic disease. Calculus code Medium/Heavy
 * __Assessments__**



These patients need to have an extremely good oral hygiene regimen. Gentle brushing technique should be implemented due to the fragile nature of their oral gingiva; Bass technique would be good. Use of an electric toothbrush should be recommended to have optimal plaque removed. Brushing 3 times a day, after meals to prevent plaque accumulation. Flossing daily is also important to keep tissue stimulated and to remove interdental plaque. Chlorhexidine rinse to reduce bacteria present in the mouth. At home fluoride tray would be good to help with caries prevention.
 * __Oral Hygiene Instruction__**

1st appt. - Obtain a medical condult from patients physician to see if patient is healthy enough to undergo dental treatment. This should include the patients current INR, CD4 count, viral load, PT and platelet count. Also wether the patient will need to take an antibiotic pre-med prior to treatment. Patient may not be healthy enough to receive dental treatment or may require hospitalization for treatment to prevent infection. 2nd appt. - FMX, DDS Exam, 2nd Check in, PI & OHI 3rd appt. - Anesthesia, Scale LR quad, CHX 4th appt. - Anesthesia, Scale UR quad, CHX 5th appt. - Anesthesia, Scale LL quad, CHX 6th appt. - Anesthesia Scale UL quad, CHX 7th appt. - 4-6 week re-eval: Full mouth scale, Fluoride tx, review OHI NV:1 month recare - to maintain good oral hygiene and to prevent worsening oral condition. Prognosis: Poor - If patients with HIV do not comply with their at home oral hygiene regimen their oral condition will most likely worsen. Fair - if patients with HIV do comply with their at home oral hygiene regimen and keep up with regular hygiene appointments.
 * __Treatment Plan__**


 * Develop 10 multiple choice questions that cause the reader to critically think about this case. Link the questions to an answer page.**

1) Your HIV patient comes in for there 3mos recare, upon examination you notice a break out of oral candidias, what do you think this may be caused by? A) The patient's disease may be advancing B) The patient may need a change in there medications C) You may need to postpone treatment. D) All of the above

2) Before treating you HIV patient you would want to know? A) The viral load count B) What is the CD4 lymphocyte count C) What is the patient's INR D) Does the patient need antibiotic treatment E) all of the above

3) The HIV disease turns to AIDS when the CD4 count drops to 200, Although the CD4 count can increase, the pt will always be diagnosed with AIDS. A) Both statements are true B) Both statements are false C) The first statement is true, the second statement is false D) The first statement is false and the second statement is false

4) The HIV patient will present with many more oral manifestation than the AIDS patient, This is because the Aids patient is so much more immune compromised. A) Both statements are true B) Both statements are false C) The first statement is true, the second statement is false D) The first statement is false and the second statement is false

5) Route of Transmission for HIV includes injection drug users, perinatal and sexual contact. Individuals at high risk are health care providers and dental professionals. A) Both statements are true B) Both statements are false C) The first statement is true, the second statement is false D) The first statement is false and the second statement is false

6) The HIV patient may present with many oral lessions all of the following are common lesions for the HIV patient EXCEPT: a) Kaposi's sarcoma b) Hairy leukoplakia c) Candidiasis d) Gingival hyperplasia

7) A patient who has HIV generally takes many medications. These medications can cause xerostomia, patient education is important to help reduce the xerostomia because ___.

8) What are some of the postoperative complications that are a cause for concern for the HIV patient?

9) Necrotizing Ulcerative Periodontitis occurs more frequently in individuals who are HIV positive. How would you characterize NUP?

10) Patients that are HIV positive and present with fever, malaise and persistent generalized lymphadenopathy are classsified as Catergory B AIDS status. Within about 1 to 3 weeks after contracting HIV, about 70% of patients experience fever, diarrhea, nausea, vomiting, weight loss, and lymphadenopathy. A) Both statements are true B) Both statements are false C) The first statement is true, the second statement is false D) The first statement is false and the second statement is false

Answer Page