HIV and the Dental Team

This year marks the 25th anniversary of the identification of the first cases of what is now known as acquired immunodeficiency syndrome (AIDS). On June 5, 1981, the Centers for Disease Control and Prevention (CDC) reported that between October 1980 and May 1981, five young men—all homosexuals—were treated for biopsy-confirmed pneumocystis carinii pneumonia in Los Angeles. The five patients all had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and oral candidiasis (thrush). On July 4, 1981, the CDC reported that during the previous 30 months, 26 cases of Kaposi Sarcoma had been diagnosed in gay men and eight died within 24 months of diagnosis. The virus that causes AIDS, the human immunodeficiency virus (HIV), was not discovered until 1983.

Since these first cases in 1981, more than 1.5 million Americans have been diagnosed with HIV infection and over 500,000 have died from AIDS.¹ More people are living with HIV/AIDS in the United States currently than ever before—an estimated 1,039,000 to 1,185,000.¹ HIV is no longer a disease of gay, white men. The HIV infection rate has doubled among African Americans in the United States over the past decade while holding steady among whites—stark evidence of a widening racial gap in the epidemic. Minority Americans now represent the majority of new AIDS cases (71%) and of those estimated to be living with AIDS (64%) in 2003.¹ Almost half (47%) of all those living with HIV/AIDS in the United States are African Americans.1 Women now account for 30% of new HIV infections as well as a growing percentage of AIDS cases.¹ The majority of women contract HIV through heterosexual contact. Great strides have occurred in preventing mother to child transmission of HIV, but even today approximately 300 children are born with the virus in the United States per year.¹

Medical Management

Remarkable advances have been made in the medical management of HIV disease over the course of the past 25 years. Discoveries, such as therapies to prevent opportunistic infections occuring in association with HIV/AIDS and new medications to better manage HIV viral burden, have greatly improved health outcomes. Americans living with HIV who receive appropriate care and treatment can now look forward to many years of productive life. As we celebrate the advances in care and treatment, we must not forget that still 18,000 Americans die every year from HIV/AIDS, another 40,000 are newly infected, and many who should be receiving care are not.¹

Twenty-five years into the epidemic the question for dentistry becomes, what is the current role of the dental health care worker in managing patients with HIV/AIDS as well as other medically complex conditions? First and foremost it is to provide oral health care, as access to dental services remains a major unmet need for people living with HIV/AIDS. The Ryan White CARE Act, a piece of federal legislation providing funding for care and treatment of underinsured and uninsured Americans living with HIV/AIDS, does allow state and local grantees to set aside funds for oral health care. A second role the dental team can play involves recognition and management of oral disease seen in association with HIV disease, such as candidiasis, oral hairy leukoplakia, and periodontal diseases, including necrotizing ulcerative periodontitis and linear gingival erythema. Finally, an evolving effort currently in discussion is the role, if any, the oral health care team plays in screening for HIV infection using a rapid oral fluid HIV antibody test (OraQuick Advance), which is approved by the Food and Drug Administration (FDA).

DENTAL TREATMENT ISSUES

An evidence-based review of the literature conducted by the Agency for Healthcare Research and Quality and supported by the National Institute of Dental and Craniofacial Research (NIDCR) did not reveal any difference in the post-procedural complications rate for invasive dental procedures when comparing patients living with HIV/AIDS vs HIV negative patients.2 The authors concluded that with the exception of patients with bleeding disorders, there is no reason to take special precautions when treating HIV+ patients who are healthy enough to be seen in an outpatient setting.² A thorough review of pertinent laboratory values is important for the care of this patient population, even though the vast majority of patients living with HIV disease are treated exactly the same as the rest of the patient population. See Table 1 for selected important laboratory values and relevancy to dentistry.

Recent data published from the Women’s Interagency HIV Study, an ongoing evaluation of the course of HIV infection among women, noted that of the 1,729 HIV-infected women followed, 7% presented with absolute neutrophil counts (ANC) less than 1000 cells/mcl.⁴ A lower ANC was associated with a lower CD4 count and a higher viral load. Resolution of a low ANC was associated with a higher CD4 count and use of ART.⁴ This value is particularly important in the dental setting, as patients with an ANC of less than 500 cells/mcl must be premedicated prior to invasive dental procedures.

ORAL MANIFESTATIONS SEEN WITH HIV INFECTION

Oral manifestations of HIV infection are a key indicator of disease progression. These lesions occur in approximately 30% to 80% of the affected patient population.^{5, 6} Factors that predispose oral lesions include CD4 counts less than 200 cells/mm3, viral load greater than 3,000 copies/mL, xerostomia, poor oral hygiene, and smoking.^{5, 6} Oral lesions, in and of themselves, are not diagnostic of HIV infection. However, the value of this information is three-fold:

1. For patients with unknown HIV status, oral lesions may indicate HIV infection. Referral to a primary care physician for a determination of the systemic cause is warranted.
2. For patients with known HIV infection who are asymptomatic and, therefore, not on antiretroviral therapy, the presence of oral lesions may signify progression of disease. Referral to the patient’s primary care provider is indicated to measure HIV viral load and immune status (CD4 count).
3. For patients on antiretroviral therapy who have responded well and have undetectable HIV viral load, the presence of oral lesions may signify treatment failure. Referral to the patient’s primary care provider is indicated to measure HIV viral load and CD4 counts

Although the overall prevalence of HIV-related oral lesions has declined since the advent of combination antiretroviral therapy (ART), these conditions are still frequently seen. All members of the dental health care team need to be able to recognize, manage, and address the significance of the oral manifestations seen in association with HIV/AIDS.

THE DENTAL HEALTH CARE TEAM

Many signs and symptoms of HIV infection first appear in the mouth. Often the first health care provider to notice these changes is the patient’s dental hygienist. When a patient presents with an oral soft tissue disease, such as candidiasis, the dental health care team should offer appropriate therapy and recommend follow-up with the primary care provider to determine the underlying cause. A member of the dental health care team may even suggest HIV testing to patients and make an effort to ensure that patients have followed-up with their primary care provider. The question must be asked: what is our role in screening patients for HIV disease?

Studies show that many who test positive for HIV infection via today’s standard of care do not return for their results.⁷ Traditional HIV testing involves a blood draw and at least a 72 hour period before a person can return for results. With the advent of the OraQuick Advance HIV1/2 Antibody Test for use with oral fluid, preliminary HIV results can now be obtained in 20 minutes. This is the only rapid HIV test approved in the United States by the FDA for use with oral fluid. A reactive HIV test result on oral fluid is a preliminary positive and needs to be confirmed by an additional, more specific test to verify whether HIV antibodies are present.

Knowing one’s HIV status is an important step in fighting this epidemic. Studies also show that once people are aware of their status, if positive they are up to 70% less likely to engage in behaviors that place themselves and others in jeopardy.⁸ Recently published research by Chen et al documented that early entry into care and treatment leads to better outcomes for patients living with HIV infection.⁹ Yet with all of this knowledge, infection rates continue to climb and too many patients present with late stage illness as their disease went undiagnosed and unmanaged for many years.

Discussions are already taking place in the public health sector on the value versus the challenge of offering HIV screening in the dental setting. Any move in this direction will be handled with careful and thorough consideration from all perspectives. The FDA is already considering over-the-counter rapid HIV testing for sale to the general public. The fact that public health and organized dentistry are being proactive and taking the lead on the ethical and medical considerations of HIV screening in the dental setting proves that we are proactively facing the challenges of the 21st century.

The important role oral health professionals play in our patients’ overall health and well-being cannot be understated. For patients living with medically complex conditions such as HIV/AIDS, oral health care is essential. An understanding of important lab values insures that all patients, no matter what their underlying medical condition, are treated appropriately. Additionally, the role of the team is expanded through the recognition, management, and understanding of the significance of oral diseases that many of our medically complex patients may present with. With the advent of new oral fluid-based screening tests for systemic diseases, the future of the dental team will include new and exciting challenges. Whatever the future has in store, oral health is integral to an individual’s primary care and we as dental professionals have the knowledge and skills that lead to improvements in the overall health and well-being of our patients.

References

1. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report. Atlanta; CDC; 2005.
2. Management of Dental Patients Who Are HIV Positive. Rockville, Md: Agency for Healthcare Research and Quality; 2001. AHRQ publication 01-E041.
3. HIVdent. Dental Treatment Considerations. Available at: www.hivdent.org/DTC/dtctreatmen.htm. Accessed May 2, 2006.
4. Levine AM, Karim R, Mack W, et al. Neutropenia in human immunodeficiency virus infection: data from the women’s interagency HIV study. Arch Intern Med. 2006;166:405-410.
5. Tappuni AR, Flemming GJ. The effect of antiretroviral therapy on the prevalence of oral manifestations in HIV-infected patients: a UK study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001; 92:623-628.
6. Aguirre JM, Echebarria MA, Ocina E, Ribacoba L, Montejo M. Reduction of HIV-associated oral lesions after highly active antiretroviral therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;88:114-115.
7. Sullivan PS, Lansky A, Drake A, HITS-2000 Investigators. Failure to return for HIV test results among persons at high risk for HIV infection: results from a multistate interview project. J Acquir Immune Defic Syndr. 2004;15;35:511-518
8.  Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-Analysis of high risk sexual behavior in persons aware and unaware of their HIV status in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446.
9. Chen RY, Accortt NA, Westfall AO, et al. Distribution of health care expenditures for HIV-infected patients. Clin Infect Dis. 2006;42L1003-10010.

From Dimensions of Dental Hygiene. June 2006;4(6): 14-16.