Treatment Planning and Ongoing Care
From the JADA (Journal of the American Dental Association)
Dental Management of the HIV-Infected Patient, 1995 & the
American Academy of Oral Medicine

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.