A Practical Approach to Special Care in Dentistry. Группа авторов

Oral lesions in patients with HIV infection are mainly related to the state of immunosuppression and the adverse effects of the antiretroviral drugs (Tables 4.2.1 and 4.2.2; Figures 4.2.2 and 4.2.3)

Table 4.2.1 Potential consequences of HIV disease.

Category	Associated conditions
GROUP 1 Lesions closely associated with HIV infection	CandidiasisHairy leucoplakiaKaposi sarcomaNon‐Hodgkin lymphomaPeriodontal diseaseLinear gingival erythemaNecrotising gingivitisNecrotising periodontitis
GROUP 2 Lesions less commonly associated with HIV infection	Bacterial infections: Mycobacterium avium‐intracellulare, M. tuberculosisMelanin hyperpigmentationNecrotising stomatitisSalivary gland enlargementThrombocytopenic purpuraUlcer not otherwise specified (NOS)Viral infections: Herpex simplex, Papillomavirus, Varicela‐zoster virus
GROUP 3 Lesions reported in HIV infection	Bacterial infections: Actinomyces israelii, Escherichia coli, Klebsiella pneumoniae, Cat scratch disease (Bartonella henselae)Viral infections: Cytomegalovirus, Molluscum contagiosumDrug reactionsFungal infections other than candidiasisNeurological disorders

      Dental Management

       The dental treatment plan will be determined mainly by the patient's general condition, prognosis and prior oral health (Figure 4.2.4)

       Each procedure should take into account the patient's immunosuppression level, potential complications (e.g. tendency to bleed) and presence of comorbidities (e.g. chronic viral hepatitis) (Table 4.2.3)

Section II: Background Information and Guidelines

      Definition

      The HIV is a retrovirus of the lentivirus group. When transmitted to a patient, HIV mainly targets T helper cells (CD4+ cells), which are essential for the immune response. The initial infection is followed by a long period of gradual deterioration of the immune system, which leads to the AIDS phase. It is estimated that more than 37 million individuals worldwide have HIV/AIDS and that its current rate is 1.7 million new cases per year.

      Aetiopathogenesis

       At this time, the main groups exposed to HIV infection are men who have sex with men, individuals who engage in risky heterosexual contact and parenteral drug users (the risk of perinatal transmission has declined dramatically in recent years)

       Two types of HIV, which share the same mechanism of action, have been identified: HIV‐1, which has a worldwide distribution, and HIV‐2, which is more common among African populations

       HIV infects cells with CD4+ receptors, mainly T‐cells, monocytes, tissue macrophages and dendritic cells. Within the cell, HIV replicates using the reverse transcriptase enzyme. The resulting DNA is imported into the cell nucleus and integrated. The infected cells release new virus particles by gemmation and the cells are ultimately destroyed

      Clinical Presentation (CDC Classification)

       Stage 1: Initial infectionCan be asymptomaticWithin 2–4 weeks after infection, may also present as viral symptoms similar to influenza (fever, headache, lymphadenopathy, myalgia and exanthema)High viral load and infectivityTable 4.2.2 Main antiretroviral drugs with adverse orofacial effects.Drug class Generic nameAdverse orofacial effectsErythema multif.UlcersDry mouthDysgeusiaExfoliative cheilitisMucosal pigm.Cushingoid appear.Lipodys.Nucleoside/nucleotide reverse transcriptase inhibitors Zidovudine (AZT)Didanosine (DDI)Zalcitabine (ddC)Stavudine (d4T)Lamivudine (3TC)Abacavir (ABC)Adefovir (ADF)Tenofovir (TDF)Emtricitabine (FTC)+ + + + + + + + + + + + + + + + + Non‐nucleoside reverse transcriptase inhibitors Etravirine (ETR)Delavirdine (DLV)Efavirenz (EFV)Nevirapine (NVP)+ + + + + + + + + + + + Protease inhibitors Saquinavir (SQV)Ritonavir (RTV)Indinavir (IDV)Nelfinavir (NFV)Amprenavir (APV)Tipranavir (TPV)Fosamprenavir (FPV)Atazanavir (ATV)Darunavir (DRV)+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + Fusion inhibitors Enfuvirtide (ENF)+++Entry inhibitors Maraviroc (MVC)++Integrase strand transfer inhibitors Raltegravir (RAL)++Erythema multif., Erythema multiforme; Mucosal pigm., Mucosal pigmentation; Cushingoid appear., Cushingoid appearance; Lipodys., LipodystrophyFigure 4.2.2 (a–c) Lesions closely associated with HIV infection: oral candidiasis, oral hairy leucoplakia and Kaposi sarcoma.Figure 4.2.3 Exfoliative cheilitis as an adverse oral effect of proteinase inhibitors.Figure 4.2.4 Infection control in the dental clinic.Table 4.2.3 Considerations for dental management.Risk assessmentThere are no absolute contraindications for performing dental treatment on patients with HIV infectionHowever, due to the HIV‐associated immunosuppression, it is important to consider any associated comorbidities (e.g. chronic hepatitis) and side‐effects of medication (e.g. thrombocytopenia related to ritonavir, neutropenia related to zidovudine)The transmission rate is estimated at 0.3% after exposure to contaminated blood by the percutaneous pathway and approximately 0.09% after contact with mucous membranesCriteria for referralMost patients can be treated in a conventional outpatient dental clinicReferral to a specialised clinic or hospital centre is determined mainly by the patient's general condition, presence of severe immunosuppression, presence of comorbidities and/or increased bleeding riskAccess/appointmentA number of barriers to treatment have been identified for these patients and include the anxiety caused by the dental setting, reluctance by the dentist to see them, concerns regarding confidentiality, cumbersome administrative processes, long waiting times and psychological problemsIf the viral load is high, schedule the patient for the last session of the day to minimise the risk of cross‐transmissionCommunicationA significant percentage of patients with HIV infection who receive dental treatment do not report their conditionAn HIV diagnostic test and/or the possibility of referring to the family doctor should be offered to patients with suspicious medical histories or oral findingsConsent/capacityPatients should be warned of the potential complications resulting from the HIV infection, side‐effects of medication and the additional risks associated with existing comorbiditiesNeurological involvement in HIV (HIV‐associated dementia) is commonly associated with cognitive impairment but is rare in those patients receiving antiretroviral drugs; comorbid conditions can also contribute to impairmentAnaesthesia/ sedationLocal anaesthesiaMinimise the risk of pricking with contaminated needles after infiltrative anaesthesia (e.g. single‐use devices)SedationMinimise the risk of pricking with contaminated needles after percutaneous injectionThe activity of benzodiazepines administered for sedation can increase in patients who take protease inhibitorsGeneral anaesthesiaA comprehensive assessment in conjunction with the anaesthetist is essentialThe patient's physician should be consulted and investigations undertaken to assess the risk of bleeding, infection