control measures should be appliedThe treatment plan will be determined by the HIV disease prognosis and the previous oral health condition, among other factorsThe dental treatment needs of patients with HIV infection are significantly greater for those with a history of parenteral drug useRecent blood test results should be available including:CD4+ T‐lymphocyte countViral loadFull blood count (risk of anaemia, leucopenia, neutropenia, thrombocytopenia)Coagulation study (in case of liver disease)If invasive dental procedures are planned, it is advisable to administer antibiotic prophylaxis to patients with <200 CD4+ T‐cells/μL and/or those who with moderate neutropenia (500–1000 cells/μL)For cases of severe neutropenia (<500 cells/μL), antibiotic prophylaxis is mandatoryDuringApply conventional measures for infection controlIn the event of accidental exposure in the dental clinic, the contaminated area should be washed with soap and water, and the reference physician should be immediately informed so that they can evaluate the risk of exposure and the advisability of diagnostic tests and prophylactic administration of antiretroviral agentsAfterThe prevalence and severity of complications after an extraction are similar to those observed in healthy controlsThe success rates of osseointegrated implants, sinus lifts and bone regeneration surgery are similar for patients with well‐controlled HIV infection and the HIV‐negative populationBasic periodontal treatment procedures and periodontal surgery have been successfully performed in this contextThe rate of postoperative complications and the elimination of periapical lesions following a root canal are similar to those detected in the general populationDrug prescriptionThere is an increased risk of hypersensitivity to some drugs such as beta‐lactamsMetronidazole can cause a disulfiram‐like reaction in patients who take ritonavirThe risk of haematological toxicity and bleeding in patients who take zidovudine can increase if non‐steroidal anti‐inflammatory agents are administered concomitantlyEducation/preventionIf a patient is aware of their HIV‐positive condition and potential impact on the oral cavity, this can promote the need to maintain a healthy mouth and result in an improvement in their oral hygiene habitsPatients should be counselled regarding oral hygiene, xerostomia treatment, smoking cessation and reducing sugar in their dietMaintaining good oral health can prevent the onset of rapidly progressive periodontal diseaseEmphasis should be placed on cleaning the dental prosthesis and disinfecting toothbrushes (with antiseptic solutions such as chlorhexidine)Patients with peripheral neuropathy might have limited manual dexterity for performing proper oral hygiene
Stage 2: Latency period/chronic infectionGenerally characterised by persistent generalised lymphadenopathyCan also be asymptomatic until the first opportunistic infections appear, such as oral candidiasisVery low viral load; if taking antiretroviral therapy, viral load may be undetectable with effectively no risk of viral transmission
Stage 3: AIDSCharacterised by the onset of conditions that have been called ‘AIDS‐defining’These include oesophageal candidiasis, systemic mycosis (histoplasmosis, coccidioidomycosis, cryptococcosis), cerebral toxoplasmosis, pneumonia by Pneumocystis carinii (Figure 4.2.5), retinitis by Cytomegalovirus, encephalitis by HIV, tuberculosis and extrapulmonary infections by non‐tuberculosis Mycobacterium, cervical cancer, Kaposi sarcoma, lymphoma, progressive multifocal leucoencephalopathy and HIV wasting syndrome
Diagnosis
The initial diagnostic test is the enzyme‐linked immunosorbent assay (ELISA), which detects the viral protein p24, an HIV‐1 antigen; there can be a window of up to 6 months from exposure to the virus to when it becomes detectable
If the ELISA is positive, the HIV‐1/HIV‐2 antibody differentiation immunoassay confirmation test is applied (Western Blot, which was used prior to this test, could not differentiate between HIV‐1 and HIV‐2). If the result is negative or indeterminate, the nucleic acid test (NAT) may be employed to confirm that this is not an acute infection or a false positiveFigure 4.2.5 Pneumonia by Pneumocystis carinii as an AIDS‐defining condition.
Rapid HIV antibody detection tests have been marketed and employ samples of oral mucosa exudate
The immunosuppression level is established based on the concentration of CD4+ T‐cells in peripheral blood and is the best predictor available for the onset of opportunistic infections, disease progression and survival (stage 1, ≥500 cells/μL; stage 2, 200–499 cells/μL; stage 3, <200 cells/μL)
Determining the viral load consists of quantifying the number of copies of HIV ribonucleic acid (HIV‐RNA) in peripheral blood, using the real‐time polymerase chain reaction (RT‐PCR); this test is applied as a predictor of disease progression and to select the antiretroviral regimen
A patient is considered to be in the AIDS stage when they have <200 CD4+ T‐cells/μL, their CD4+ T‐cell count is <14% of the total or they have an AIDS‐defining condition
Management
ART (antiretroviral therapy) is the combination of several antiretroviral agents, and should be commenced as soon as possible after diagnosis
Antiretrovirals seek to reduce the viral load (below 20–50 copies/mL is considered undetectable, depending on the test employed), increase the CD4+ T‐cell count, prevent opportunistic infections and reduce transmission to others
The most widely used families of antiretrovirals are:Nucleoside/nucleotide reverse transcriptase inhibitors (NRTI)Non‐nucleoside reverse transcriptase inhibitors (NNRTI)Protease inhibitors (PI)Entry or fusion inhibitorsIntegrase strand transfer inhibitors (INSTIs)
An initial HIV drug regimen typically includes 3 HIV medications from 2 or more different drug classes:Two NRTIs with an INSTI, NNRTI, or PIRitonavir (PI) or cobicistat as a booster (cytochrome P450 3A inhibitor)
The regime varies according to the patient's response and associated side‐effects
ART is associated with adverse effects that are not always predictable and include:Nausea and vomiting, diarrhoea, difficulty sleeping, dry mouth, headache, rash, dizziness, fatigue, and painThrombocytopenia caused by ritonavir
Prognosis
The main markers of disease progression are CD4+ T helper cell counts and the HIV replication rate (viral load)
The life expectancy of individuals with HIV infection who do not undergo ART is 2–3 years
About 85% of patients who undergo ART survive for more than 10 years
A World/Transcultural View
Africa remains the most affected region of the world due to HIV infection/AIDS, especially the sub‐Saharan region in which more than 30 million infected individuals live
The prevalence of HIV‐associated oral lesions remains significant in low‐income countries. Hairy leucoplakia is more common in Europe and America than in Africa and Asia. Paradoxically, the prevalence of salivary gland disease has decreased in the industrialised world and increased in low‐income countries
Dentists' willingness to provide dental treatment to patients with HIV varies depending on the dentists' origin and country in which they were trained
Recommended Reading
1 Diz Dios, P. and Scully, C. (2014). Antiretroviral therapy: effects on orofacial health and health care. Oral Dis. 20: 136–145.
2 Gay‐Escoda, C., Pérez‐Álvarez, D., Camps‐Font, O., and Figueiredo, R. (2016). Long‐term outcomes of oral rehabilitation with dental implants in HIV‐positive patients: a retrospective case series. Med. Oral Patol. Oral Cir. Bucal 21: e385–e391.
3 Ghosn, J., Taiwo, B., Seedat, S. et al. (2018). HIV. Lancet 392: 685–697.
4 Patton,