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Aids and Dentistry

There are about 80,000 AIDS cases in India and 1.5 million people infected with HIV, according to the statistics from the WHO and the Indian government. According to experts, if the trend continues, India could have as many as 30 million people with HIV by the year 2010- about twice today’s worldwide count.

AIDS specialist David Bloom had mentioned in his speech, "Many experts believe that India will soon have the unfortunate distinction of being the AIDS capital of the world."

AIDS, or Acquired Immunodeficiency Syndrome, is a highly lethal, progressively epidemic viral infection that destroys the immune system, increasing the individual’s susceptibility to infectious disease and cancer.

A sensitive immunodetection assay has been developed, which is used to identify antibodies in HIV infected patients and as a tool for studying and measuring the levels of CD4 T cells(lymphocytes that fight infection) present during the course of the disease. A normal CD4 cell count is usually above 600 cells/mm3. Severe immune suppression defined as a CD4 cell count below 200cells /mm3 is, as of Jan 1993, an AIDS diagnosis. For most HIV infected patients, there is a long clinical latency period, often extending to seven to eight years.

There are at least 10 genetic types or clades of the human immunodeficiency virus, each antigenically distinct, with different clades predominant in different parts of the world.

At a recent international conference on AIDS, a new triple drug therapy has been declared to be effective. It combines indinavir(it attacks the viral enzyme, HIV-protease, which the virus needs to replicate itself ) with AZT(or zidovudine, an inhibitor which attacks the virus through the enzyme called reverse transcriptase) and 3TC (or lamivudine, another HIV inhibitor), to reduce or eliminate HIV copies in the plasma of infected patients.

The expanding role of the dentist in the acquired immunodeficiency syndrome era can be classified into six issues.

  1. Provision of routine dental care .
  2. Oral lesions- screening, diagnosis, treatment, and recognition of their significance.
  3. Collaboration with other health care workers and social support systems.
  4. Education of other health care workers.
  5. Education in the community.
  6. Resource to HIV infected health care workers.

Body fluids which contain high concentrations of HIV, which have been linked to transmission of the virus are blood, pre-cum, semen, vaginal secretions, and breast milk. Saliva, tears, sweat, and urine can have the virus in them , but in such low concentrations that nobody has ever been infected through them. If any body fluid is visibly contaminated with blood, the risk of transmission exists.

The HIV virus must get into the blood stream to infect a person. In order for infection to occur, 3 things must happen.

  1. One must be exposed to blood, pre-cum, semen, vaginal secretions, or breast milk.

2. The virus must get directly into the blood stream through some fresh cut, open sore, abrasion etc.,

3. Transmission should go directly from one person to the other very quickly. The virus does not survive more than a few minutes outside the body.

The non specific symptoms of AIDS, which can include fevers, fatigue, weight loss, severe diarrhea, do not begin until an average of 10 years after infection. Generally, any symptoms that last for more than 2 weeks and do not go away, or any symptoms that are very severe, need medical attention.

The ADA strongly affirms that Universal precautions are an effective and adequate means of preventing transmission of HIV virus from dental health care workers to patients and vice versa. Based on the experience of numerous general dentists over the last 10 to 15 years, patients infected with HIV can safely be treated in general dental settings.

However, establishment of dedicated clinics for HIV infected patients may be justified because clinical staff in such settings develop increased clinical experience and will be able to manage more complex patients with greater confidence.

To minimize complications after dental procedures, a thorough and appropriate medical assessment is necessary. The main concern for dentists treating HIV infected cases are;

-increased bleeding tendencies,
-post operative infections.
-drug interactions
-adverse reactions and
-prognosis for survival.

The mode of HIV transmission influence the provision of dental care. Hemophiliacs demand modifications of dental care, moreover, they have a high prevalence of hepatitis B, hepatitis C, and hepatitis delta virus infection.

Intravenous drug users(IVDUs) also have a high prevalence of hepatitis B and hepatitis C viral infections. IVDUs are highly susceptible to develop bouts of bacterial endocarditis. The use of appropriate analgesics is another concern while treating IVDUs.

Homosexual men show a propensity to develop certain types of oral lesions, such as necrotizing ulcerative periodontitis, oral hairy leukoplakia, and Kaposi’s sarcoma. Prevalence of hepatitis B virus infection is also high in this patient population.

Children with perinatally acquired HIV are considered to be at greater risk for caries than their siblings, more so with advancing disease.

During the course of HIV disease, patients take increasing number of medications. Dentists need to be aware of the medications that can cause neutropenia and anemia. These include zidovudine and trimethoprim- sulphamethoxazole (Septra, Bactrim). Zidovudine may also cause reduced salivary flow.

Many HIV infected patients are started on trimethoprim- sulphamethoxazole when their CD4 cell count drops below 200 cells/ mm3. More than 50%, however, develop severe adverse reactions and need to stop taking the medication. Patients also show increased adverse reactions toward other antibiotics, including amoxicillin-clavulanic acid, ciprofloxacin, dicloxacillin, erythromycin and clindamycin, when their CD4 cell count decreases.

During the course of HIV disease, all patients develop oral alterations, but none of these lesions are specific for HIV disease, and they can be present in other immune suppressed individuals. These lesions range from asymptomatic, subtle changes of the oral mucosa that are secondary to a decreased salivary flow or candidiasis to rapidly destructive lesions, such as necrotizing stomatitis, necrotizing ulcerative periodontitis, deep mycoses, and cancers.

The treatment of some of these oral lesions can be handled in a dental office on an outpatient basis. When treatment includes radiation, cancer chemotherapy, and long term intravenous medication for neoplasms, it is advantageous for the dentist to be a part of the treatment team instead of being the primary provider.

The treatment team may have a general internal medicine specialist who takes care of the patient’s non- infectious needs, and an infectious disease specialist to attend to all HIV related care. Community based organizations and social support networks are also involved with a multitude of services, including psychological counseling and drug rehabilitation.

Based on the current epidemiological evidences, Epstein and others have reported that infectious diseases, specially blood borne pathogens such as hepatitis B, hepatitis C and HIV are not transmitted from patient to patient via dental instruments.

Though it has been suggested that dental handpieces are capable of transmitting HIV in a dental setting, there has never been any reports that such a transmission has occurred.

Special attention should be paid to dentists who are more susceptible to diseases potentially transmitted in a dental setting, They include pregnant women, due to their immunologic changes and the developing foetus; dentists with the habit of excessive alcohol intake; those who had undergone splenectomy, radiotherapy, and long term corticosteroid therapy; also, dentists suffering from diseases that have an impact on the first and secondary defense against infections such as diabetes mellitus, chronic renal failure, leukemia or HIV.

  References :

1. JADA 127:1401-1404,Sept 1996

2.The Washington Post Aug 17,1995

3. DCNA 40(2): 343-357,April 1996

4. Council on Dental Practice-Resource manual,1995

5. J Clin Microbiol 30:401,1992

6. Pediatr Dent 18(2):129-136,1996

7. J Can Dent Assoc 62(6): 485-491,1996

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