3 Feller, L., Wood, N.H., Chikte, U.M. et al. (2009). Tuberculosis part 4: control of Mycobacterium tuberculosis transmission in dental care facilities. SADJ 64: 408–410.
4 González Mediero, G., Vázquez Gallardo, R., Pérez Del Molino, M.L., and Diz Dios, P. (2015). Evaluation of two commercial nucleic acid amplification kits for detecting Mycobacterium tuberculosis in saliva samples. Oral Dis. 21: 451–455.
5 Jensen, P. A., Lambert, L. A., Iademarco, M. F., Ridzon, R., & CDC ( 2005). Guidelines for preventing the transmission of Mycobacterium tuberculosis in health‐care settings, 2005. MMWR Recomm Rep. 54 (RR‐17): 1–141.
6 Rinaggio, J. (2003). Tuberculosis. Dent. Clin. North Am. 47: 449–465.
7 Sharma, S., Bajpai, J., Pathak, P.K. et al. (2019). Oral tuberculosis – current concepts. J. Family Med. Prim. Care. 8: 1308–1312.
4.2 Human Immunodeficiency Virus (HIV) Infection/AIDS
Section I: Clinical Scenario and Dental Considerations
Clinical Scenario
A 45‐year‐old man is referred by his physician for assessment of extensive but painless oral papillomatous lesions.
Medical History
Stage 3 human immunodeficiency virus (HIV) infection (HIV infection diagnosed 14 years ago)
Cryptococcal meningitis (without sequelae)
Kaposi sarcoma of the skin
Chronic hepatitis B virus (HBV) infection
Anal squamous cell carcinoma
Adjustment disorder and depressed mood
Medications
Ritonavir (RTV)
Emtricitabine (FTC) + tenofovir (TDF)
Citalopram
Dental History
Irregular dental attender
Moderate level of co‐operation
Patient brushes his teeth twice a day
Social History
Lives with his male partner (who is HIV negative)
Works in a car company as a welder
Alcohol and tobacco consumption: discontinued 10 years ago
Oral Examination
Fair oral hygiene
Numerous exophytic lesions (sessile/flat and pedunculated) that preferentially involve the lips, retrocommissural area and palate; clinically suggestive of warts
Generalised periodontal disease with numerous pathological periodontal pockets (≥6 mm)
Caries in #15, #34 and #46
Lost teeth: #27 and #36
Radiological Examination
Orthopantomogram undertaken
No intraoral radiographs due to large number of oral papilloma‐type lesions (Figure 4.2.1)
Restorable caries in #34, #38 and #45
Extensive, deep and unrestorable caries in #15 and #46
Periapical osteolytic lesion in #46
Structured Learning
1 What is the cause of the oral lesions?The oral lesions are likely to be due to human papilloma virus (HPV) infection and are benign – oral papilloma/condyloma with focal epithelial hyperplasiaHIV and HPV are both infections that can be transmitted sexuallyFigure 4.2.1 Oral HPV‐associated papillomatosis in AIDS.Immunosuppression is known to increase the risk of HPV infectionHPV oral lesions in patients with HIV infection and taking antiretrovirals may be related with the longer life expectancy of individuals with an impaired immune system rather than a direct effect of antiretroviral therapy (ART)
2 The patient's primary concern is removal of the oral lesions as the teeth are asymptomatic. What additional information do you need first regarding his HIV infection?Current viral load: the results are given as the number of copies of HIV per millilitre of bloodCurrent CD4 count: normal CD4 count is from 500 to 1400 cells per microlitre of blood
3 The physician advises you that the last test results are: viral load 13 000 copies/mL and CD4 count of 100 cells/μL. What factors are important to consider when assessing the risk of managing this patient?SocialPhysical stigma in a work setting that is probably unaware of his HIV infection (i.e. oral warts)Risk of patient not attending appointments due to low mood/depression (see Chapter 15.2)MedicalHIV infection in the acquired immune deficiency syndrome (AIDS) stage – CD4 count low leading to an increased risk of infection; viral load high (increased infectivity)Ritonavir may cause thrombocytopeniaChronic HBV infection (see Chapter 4.3) linked to bleeding risk, reduced drug metabolismAnal carcinoma – may be uncomfortable for the patient to sit down if the lesion is symptomaticDentalOral lesions may impair access to toothbrushingOral hygiene not optimal – may increase the risk of postoperative infection after removal of the oral papillomasLesions may recur after removalDental caries and periodontal disease presentFollow‐up compromised by the depressive syndrome and previous irregular attendance
4 As the lesions are widespread and some are sessile, vaporisation of the papillomatous lesions using CO2 laser is planned. What precautions should be in place?Perform the necessary laboratory tests (e.g. complete blood count with differential and coagulation study)Administer antibiotic prophylaxis because the patient has <200 CD4+ T‐cells/μLTake a sample with a cold scalpel beforehand to conduct histopathologyMaximise protection measures with subsequent use of the CO2 laser to prevent dissemination of the papillomavirus:Powerful surgical aspiratorFacemasks and eye protectorsSchedule the appointment for the last hour of the workday and ventilate the dental office after completing the procedure
5 The patient is nervous about the proposed vaporisation of the oral lesions and has been prescribed diazepam to take before he attends. What considerations should be taken into account?Ritonavir can boost the sedative effects of benzodiazepinesIf the hepatic impairment caused by the HBV is moderate to severe, the use of diazepam should be avoided (liaise with the physician and preferably use lorazepam)
6 The patient returns to you for extraction of the #15 and #46. What laboratory test results should be undertaken before proceeding and why?Full blood count and coagulation study should be undertakenAnaemia, thrombocytopenia and leucopenia/neutropenia may be presentThrombocytopenia can occur in people with HIV due to multiple factors, including HIV infiltration of the bone marrow, as a side‐effect of drugs used to treat HIV (e.g. ritonavir), or due to the development of autoimmune (idiopathic) thrombocytopenic purpuraNeutropenia is observed in 10% of patients with early asymptomatic HIV infections and in 50% of patients with AIDS (again related to bone marrow infiltration and as a side‐effect of some medications)HBV infection can impair the hepatic synthesis of coagulation factors
General Dental Considerations
Oral