INTRODUCTION
As with all patients, the dentist
should recommend treatment, present alternative treatments (if any), and
discuss the probable benefits, limitations and risk associated with
treatment. Any treatment performed should be with the concurrence of the
patient and the dentist. Poor patient prognosis is generally not
justification for denying the patient a viable treatment option.
When dental treatment is indicated,
decisions regarding the appropriateness of ongoing and long-term dental care
of patients with HIV infection should take into account the patient's
general medical status, and should not be based solely on HIV status. The
immunocompetent, asymptomatic HIV-infected individual usually does not
require any special consideration when planning, and in the provision of,
dental treatment. However, as the infection advances to AIDS, laboratory
test evaluating the progression of HIVD may become important in determining
an appropriate treatment plan. Patients with CD4+lymphocyte counts above
200cells/mm3 usually have their immunologic status assessed at least every 6
months by their physician, while those patients with CD4+lymphocyte counts
below 200 cells/mm3 usually have appropriate test preformed at least every
three months. It is important to consider general trends in CD4+lymphoctye
counts and other laboratory values, rather than any single value, as counts
may vary considerably even on a daily basis.
The recommendations below should only
be used as general guidelines. Each patient should be evaluated on a case by
case basis. When there is a requirement for urgent dental care, a degree of
flexibility may be necessary with the critical values outlined below.
PROCEDURES LIKELY TO RESULT IN BLEEDING AND
BACTEREMIA:
Surgical procedures or
instrumentation involving mucosal surfaces or contaminated tissue are
commonly associated with transient bacteremia. However, such procedures have
not been associated with a higher incidence of symptomatic bacteremia in
HIV-infected patients. Therefore, HIV infection itself is not a
contraindication to procedures likely to cause bleeding. Nevertheless, due
to the multiple systemic effects of HIV infection and the evolving nature of
the disease, the patient's medical history may have to be updated prior to
each dental encounter in order to assess the need for antibiotic
prophylaxis/coverage, and the possibility of anemia and abnormal bleeding
tendencies.
ANTIBIOTIC PROPHYLAXISA/COVERAGE:
Persons with AIDS may be taking a
number of systemic medications, many of which have the potential for
interaction with agents prescribed by the dentist. Furthermore, individuals
with AIDS, often develop allergies to a variety of medications. Judicious
use of systemic drugs, based on a thorough knowledge of the patient's
medical history, is therefore recommended.
ANTIBIOTIC PROPHYLAXIS TO PREVENT BACTERIAL
ENDOCARDITIS:
There are no special considerations
for the HIV-infected patient. When indicated by medical history, antibiotics
to prevent bacterial endocarditis should be prescribed according to the
guidelines set forth by the American Heart Association, as adopted by the
Association.
ANTIBIOTIC COVERAGE AND THE HIV-INFECTED
PATIENT:
For the HIV-infected patient, there
are no data supporting the need for routine antibiotic coverage to prevent
bacteremia or septicemia arising from dental procedures. Indeed, persons
with advanced HIVD have shown a higher incidence of allergic reactions to
antibiotics, thus judicious use of antibiotics may be important.
Indications for antibiotic coverage
should not be based solely on a patient’s HIV status, and should not be
based on CD4+lymphocyte counts alone. However, a CD+4lymphocyte count of
less than 200 cells/mm3 may indicate the need for a thorough review of the
patient's medical history prior to initiating procedures likely to cause
bleeding and bacteremia.
Antibiotic coverage, prior to
procedures likely to cause bleeding and bacteremia, is recommended for the
immunocompromised HIV-infected patient when the neutrophil count drops below
500 cells/mm3 (neutropenia). Patients at this advanced stage of disease may
already be taking antibiotics to prevent opportunistic infection, therefore,
additional medications may not always be required. However, when antibiotic
coverage is indicated, regimens similar to those for the prevention of
bacterial endocarditis are considered effective.
An antibiotic mouthrinse (e.g.,
chlorhexidine), prior to and up to three days following procedures, may be a
useful adjunct to antibiotic coverage particularly in patients with poor
oral hygiene.
Furthermore, scaling and subsequent
irrigation of the gingival sulcus with chlorhexidine, prior to tooth
extraction and gingival flap procedures, may also be useful in reducing the
risk of post-procedural complications.
ANTIBIOTICS AND THE TREATMENT OF
POST-PROCEDURAL LOCAL INFECTION:
Available scientific evidence would
suggest that HIV infection does not result in an increased risk for
post-procedural complications. However, should post-procedural local wound
infection occur, oral systemic antibiotics (e.g., amoxicillin, erthromycin,
clindamycin, amoxicillin/clavulanic acid, or metronidazola) may be
prescribed. Bacteriological culture and antibiotic sensitivity test may be
needed for resistant infections. Frequent postoperative evaluation may be
needed.
Signs and symptoms of postoperative
infections in immunosuppressed patients may be different from those in
healthy patients. Inflammation may be reduced, and there may be no
purulence.
BLEEDING
ABNORMALITIES:
Persons with AIDS may become
thrombocytopenic (less than 150,000 platelets/mm3). Patients with a platelet
count of 50,000/mm3 or greater rarely demonstrate any unusual postoperative
complications. However, easy bruising and bleeding secondary to surgery are
encountered when levels fall below 60,000 platelets/mm3. As levels fall
below 20,000 platelets/mm3 spontaneous bruising, petechias, and
gastrointestinal bleeding occur.
Dental procedures, including
extractions, can usually be safely performed in patients with platelet
counts above 60,000 platelets/mm3 and PT/PTT no more than twice their normal
values. For patients with a recent history of, or indications for, increased
bleeding tendencies, periodontal/surgical procedures should be approached
conservatively (i.e., tooth by tooth approach). Consideration may be given
to obtaining a platelet count and/or PT/PTT prior to procedures, especially
if surgical intervention is extensive and likely to result in copious
bleeding. Such screening tests are also important for patients with a
history of fluctuating thrombocytopenia. Screening test, when indicated, are
usually conducted shortly before (i.e., 1-2days) performing procedures.
ANEMIA:
Anemia is common in HIV-infected
individuals and arises either as a direct result of HIV infection or as a
side-effect of antiretroviral therapy. It is often useful to establish a
baseline value for each individual and correlate subsequent levels with the
baseline.
Periodontal and minor surgical
procedures (e.g., single extraction) are usually routine for patients with
hemoglobin level above 7 g/dl and no bleeding abnormalities. Procedures
should be approached conservatively when hemoglobin levels fall below 7g/dl;
consideration should be given to the need for determining hemoglobin levels
prior to procedures likely to cause bleeding. If surgical intervention is
extensive and likely to result in copious bleeding, physician consultation
may be necessary.
Respiratory depressing drugs (e.g.,
opiates) should be avoided in patients with hemoglobin levels below 10g/dl.
LOCAL ANESTHESIA
Local anesthesia has not been
associated with increased risk of intraoral infections. However, deep block
injections can result in medical complications in patients with a recent
history of, or indications for, increased bleeding tendencies. In such
instances, local infiltrations or intrallgamntary injections may be
warranted.
ENDODONTIC
THERAPY
Non-surgical therapy has not been
associated with a higher incidence of post-procedural complications in the
HIV-infected individual. Considerations for endonotic procedures likely to
result in bleeding are the same as for any other procedure likely to result
in bleeding.
RESTORATIVE AND PROSTHETIC DENTAL CARE
There are generally no special
restorative or prosthetic treatment considerations for the immunocompetent
HIV-infected individual. However, as the disease advances and AIDS develops,
treatment decisions (e.g., crowns versus large fillings) may be influenced
by the patient’s ability to attend and/or tolerate dental visits and by the
patients changing medical/mental status. Restorative and prosthetic care may
raise delicate aesthetic issues related to the patient’s self-esteem; the
dentist should be sensitive to these issues when discussing the treatment
plan with the patient.
PREVENTIVE ORAL HYGIENE
The importance of meticulous oral
hygiene should be reinforced for the HIV-infected patient and oral health
established as early as possible in the disease process. Daily brushing and
flossing to remove plaque, the daily use of over-the-counter fluorides to
prevent or reduce caries, and regular professional care are all important
aspects of routine oral hygiene. Asymptomatic HIV-infected patients should
be recalled for periodic evaluations as indicated. The Agency for Health
Care Policy and Research (AHCPR) currently recommends that HIV-infected
patients should be recalled at least two times per year for oral examination
and evaluation; and further suggests that with the appearance of oral
lesions or other complications, more frequent recall may be indicated.
Decreased salivary flow as well as certain medications may increase the
incidence of dental caries. Professionally prescribed fluoride supplements
or topical applications may be need to be considered for such patients. The
institution of daily antiseptic mouthrinses may also be considered for
patients unable to maintain optimum oral health through routine preventive
care. |