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HUMAN IMMUNODEFICIENCY VIRUS (Dental Treatment Considerations (Dry mouth…
HUMAN IMMUNODEFICIENCY VIRUS
Overview
AIDS first reported 1981
HIV recognised as causative agent 1984
Member of the lentivirus group of
retroviruses
Retrovirus --> integrates its genes into host chromosomes
Ensures long-term survival of the virus
Makes it virtually impossible to eliminate
Lies dormant within an infected cell for many years
Two main strains:
HIV-1
- more lethal, transmissable
HIV-2
- generally milder; primarily West Africa
Transmission
- BBFE
Perinatal (vertical)
Sexual
Parenteral (IVDU, transfusions, sharps)
Testing for HIV
ELISA test for blood antibodies (99.9% accurate)
if positive
Confirmation via Western blotting
Risk of Transmission
with HIV-infected blood
After sharps injury 0.3%
After mucous membrane exposure 0.09%
Post-Exposure Prophylaxis
Experimental, not proven therapy
Reduces risk, but not absolute
Significant side-effects, esp. gastrointestinal
4wk therapy with 2-3 oral antiretrovirals
Start within 24-36 hours of exposure (ideally 2hrs)
Follow-up Testing
Baseline +
1, 3, 6 months
& investigate any febrile illness
Infection & Replication
Exposure
via blood/body fluids
Adherence
of virus to host cells
Internalisation
of the virus into the cell*
Reverse transcription
of viral RNA to DNA by reverse transcriptase*
Integration
of viral DNA into host DNA by integrase*
Transcription
of the proviral DNA to mRNA
Translation
of the mRNA to viral proteins
Assembly
of progeny (virions)
Release
from the host cell by budding (using protease*)
Activation
of the host immune response [not cleared]
Types of cells that can be infected:
CD4+ cells (eg. T-cells, Langerhans, macrophages, monocytes, neurons, glial cells, gut epithelial cells)
CD4- cells (eg. endothelial cells, fibroblasts
Clinical Stages
Infection
Seroconversion illness
Variable latent period (3-20yrs, avg. 8yrs)
Eventual development of:
Persistent generalised lymphadenopathy
CD4 counts fall
Immune dysfunction
Presence of
AIDS-defining illness
and/or
CD4 <200
-->
AIDS
TB
Prevention
Condoms
Pre-Exposure Prophylaxis
More effective taken every day, but compliance issues
Viral suppression
(undetectable = untransmissable)
Blood product screening
Vaccination
Not currently available
Highly variable surface proteins
Once infected, further mutation occurs
Signs & Symptoms
Oral Manifestations
Pain - morbidity, nutrition
Sign of disease progression
Chronic infection --> chronic inflammation
Candidoses
(erythematous & pseudomembranous); usually C. albicans; also others; can be fluconazole resistant
Oral hairy leukoplakia
(EBV-related)
Necrotising gingivitis
Necrotising periodontitis
Linear gingival erythema
(fungal)
Kaposi's sarcoma
(HHV-8)
HSV/VZV/CMV infections
- can be severe
Papillomas
- HPV-related; multiple/recurrent
Major aphthous ulceration
Malignancies
-
NHL, SCC
Xerostomia
- autoimmune, stress, medications, CMV salivary infection
Other
: infections, hyperpigmentation
Seroconversion Illness
3-6 weeks after virus exposure
1/4 develop a flu-like acute illness, resolving in a few days
Signs: fever, upper body rash, oral erosions/erythema/aphthae
Disease Progression
Oral hairy leukoplakia
- 80% develop AIDS within 2.5yrs
NHL
- 80% die within 2yrs
Blood markers
Falling CD4 count
CD4:CD8 ratio
p24 antigen level
extent of HIV-related anaemia
ESR
CD4 Counts
600
- lymphadenopathy, thrombocytopenia
500
- oral candidoses, bacterial skin infxns, HSV/VZV lesions
400
- Kaposi's sarcoma
300
- OHL, TB
200
- Pneumocystis carinii pneumonia, unusual infxns
100
- CMV, lymphomas
AIDS-Defining Illnesses
(include)
Oesophageal candidiasis
CMV retinitis
Kaposi's sarcoma
Disseminated mycobacterial infxn; pulm. TB
Recurrent pneumonia, exotic pneumonia
Cerebral toxoplasmosis
HIV wasting syndrome
Invasive cervical carcinoma
HIV encephalopathy
NHL
Treatment
Prophylactic antimicrobials
: antifungals, antivirals, antibacterials
Combination Antiretroviral Therapy (cART)
Entry inhibitors
Nucleoside reverse-transcriptase inhibitors (eg. abacavir, lamivudine, tenofovir)
Non-nucleoside reverse transcriptase inhibitors (eg. nevirapine, efavirenz
Integrase inhibitors (eg. dolutegravir, raltegravir)
Protease inhibitors - (eg. ritonavir, atazanavir)
Current Treatments
Reduced pill burden
Improved compliance
Therefore reduced resistance
Side effects
Gastrointestinal
Metabolic (BGL changes, hyperlipidaemia, lipodystrophy)
Anaemia
Hepatitis, pancreatitis, myositis
Mood changes
Peripheral neuropathy
Dental Treatment Considerations
Dry mouth & lips
(CART)
Salivary gland enlargement
Opp. salivary gland infxn
Salivary gland lymphocytosis
Taste
disturbance
Caries risk
Periodontal pathology
LGE
(fungal)
Necrotising
periodontal diseases (spirochetes + normal perio pathogens)
Accelerated
progression of chronic perio (normal perio pathogens + candida + viruses eg. HHV)
Check
CD4 count, VL
- no strict guidelines but contact ID specialist if CD4 <350 before proceeding
CBE
- neutrophils, platelets, Hb
Peripheral neuropathy, eg.
trigeminal neuralgia
Consent/capacity changes with
HIV dementia
Drug interactions
Beware!
Increased risk of
NHL, SCC, Kaposi's
Regular soft tissue + nodal monitoring
Social/psychological
issues and stigma
Infection control
and sharps Mx
Standard precautions