management hiv patients ,symptoms ,treatment

1. MANAGEMENT OF HIV PATIENTS

2. CONTENTS
 Introduction
 Definition
 Epidemiology
 Etiology and modes of transmission
 Pathogenesis
 Diagnosis
 Prevention
 Global AIDS strategy
 AIDS vaccine
 Drugs used for AIDS
 Conclusion
 Reference

3. INTRODUCTION
 The human immunodeficiency virus infection (HIV)
is of major interest and concern to dentists and
other oral health care workers because of the
pandemic nature of the disease.

4. DEFINITION
 Acquired Immuno Deficiency Syndrome (AIDS) can
be defined as presence of antibodies to HIV and
opportunistic infections.

5. EPIDEMIOLOGY
 WHO reported that one million children were
infected with HIV by the end of 1992 and estimated
that 10 million children will be born infected by the
year 2000.

6. ETIOLOGY AND MODES OF TRANSMISSION
 AIDS is caused by human
immunodeficiency virus (HIV), a
human retrovirus.
 The most common cause of
AIDS throughout the world is HIV
I.

7. MODES OF TRANSMISSION

9. DIAGNOSIS
 Clinical screening and serologic
confirmation
 WHO defined pediatric AIDS as an
infant or child presenting with at least a
major criterion along with at least 2
minor criteria in the absence of any
immunosuppression.

10. Major signs
 Chronic diarrhoea for more than one month
 Prolonged fever for more than one month
 Weight loss
Minor signs
 Oropharyngeal conditions
 Repeated cough for more than one month
 Generalised lymphadenopathy
 Generalised dermatitis
 Maternal HIV infection

11. Typical pediatric findings (Rubenstein, 1986)
 Pulmonary lymphoid hyperplasia
 Salivary gland enlargement
 Pyogenic bacterial infection such as otitis media
 Developmental craniofacial features
 Chronic recurrent diarrhea
 Hepatosplenomegaly
 Chronic pneumonitis
 Progressive encephalopathy

12. Oral and perioral findings of aids in children
 Fungal infection like candidiasis of different types like:
 Angular cheilitis
 Hyperplastic
 Bacterial infections either generalised, localized or
pyogenic
 Viral infections like:
 Herpes zoster
 Herpes simplex
 Hairy leukoplakia
 Herpetic stomatitis
 Unknown etiology lesions
 Parotid enlargement with xerostomia
 Petechiae

13.  Aphthous stomatitis
 Linear gingival erythema
 Cervical lymphadenopathy
 Gingival and periodontal lesions like ANUG and
necrotising ulcerative periodontitis
 Oral ulcerations
 Dysmorphic craniofacial features

14. Other malignancies
 Hepatic fibrosarcoma,
 Hepatic leiomyosarcoma,
 Hepatoblastoma,
 Acute lymphoblastic leukemia,
 Hodgkin’slymphoma
 Ewing’s sarcoma

15. Group I
Lesions strongly associated with HIV infection
Candidiasis
Erythematous
Pseudomembranes
Hairy leukoplakia
Kaposi’s sarcoma
Non-Hodgkin’s lymphoma
Periodontal disease
Linear gingival erythema
Necrotising ulcerative gingivitis
Necrotising ulcerative periodontitis
Revised classification of HIV infection (1993)

16. Group II
Lesions less commonly associated with HIV
infection
Bacterial infection
Mycobacterium avium-intercellulare
Mycobacterium tuberculosis
Melanotic hyperpigmentation
Necrotising ulcerative stomatitis

17. Group III
Lesions seen in HIV infection
Bacteial infections
Actinomyces israelii
Escherichia coli
Klebsiella pneumoniae
Cat-scratch disease
Drug reactions(ulcerative,erythema multiforme,
lichenoid reaction, toxic epidermolysis)
Epithelioid(bacillary) angiomatosis

18. Group III
Fungal infections other than candidiasis
cryptococcus neoformans
Geotrichum candidum
Mucomycosis (zygomycosis)
Aspergillus flavus
Neurologic disturbances
Facial palsy
Trigeminal neuralgia
Recurrent aphthous stomatitis(RAS)
Viral infections
CMV
Molluscum contagiosum

19. CANDIDIASIS
 Recurrent candidiasis which is persistent for long
period and often resistant to conventional antifungal
therapy, is a frequent oral manifestation in pediatric
HIV infection/AIDS
Oral manifestations
 Pseudo membranous plaques
 Erythematous patches
 Angular cheilitis (appears as fissures or cracks at
the commissures of the lips)
 Hyperplastic plaques

21. Treatment
 Lesion may subside or disappear with treatment,
but relapse is common.
 Treatment can be either topical or systemic

22. DRUGS DOSE
Topical
1. Nystatin suspension (100000 v/ml) 1-2ml to be applied to the affected
area tds or qds
2. Amphotericin suspension (100
mg/ml) qds for 14 days
1 ml to be held in the mouth or
applied to the affected area after food
Older children
1. Nystatin pastilles (100000b/ml) 1 pastille should be sucked qds for 7
days
2. Amphotericin lozenges (10 mg) 1 lozenge to be dissolved in the
mouth for 10-15 days
3. Clotrimazole 10mg troches <5 /day orally

23. Systemic
1. Fluconazole By mouth or IV by infusion of 3-6
mg/kg on first day followed by
3mg/kg daily thereafter, every 72 hr
in neonates up to 2 weeks old and
every 48 hr in neonates 2-4 weeks
old
2. Ketoconazole Orally with food, 3mg/kg daily with
food for 2-3 weeks
3. Amphotericin B 0.25 mg/kg/day IV

24. VIRAL INFECTION
 In HIV infection, several viruses are able to colonise
or react, producing lesions in the mouth. These
include herpes-group viruses and papilloma
viruses.
Includes
 Herpes simplex (HSV I)
 Herpes zoster (varicella zoster)
 Oral hairy leukoplakia (EBV)
 Oral warts (HPV)

25. TREATMENT OF VIRAL INFECTIONS
 Herpetic lesions may be treated with systemic
doses of Acyclovir ranging from 1 to 2 g daily taken
orally or IV in individuals with more severe
oropharyngeal lesions or in those unable to swallow

26. BACTERIAL INFECTION
 Includes Mycobacterium avium intracellulare and
Klebsiella pneumoniae

27. HIV ASSOCIATED GINGIVITIS (HIV-G) AND HIV
ASSOCIATED PERIODONTITIS (HIV-P)
 Gingival and periodontal diseases (NUG&NUP) -
first sign of HIV infection.
 Gingivitis in HIV infected children appears as an
intensely erythematous band that extends 2 to 3
mm apically from the free marginal and attached
gingiva.

28. FEATURES
 Gingiva :
 reddened,
 edematous
 spontaneous bleeding with punctate lesions
 NUP -rapid loss of supporting periodontal structures
and loose teeth with no pocket formation
 Other features are
 soft tissue and bone necrosis
 pain and bleeding
 The distinguishing feature of HIV G and HIV P is a
lack of response to removal of plaque and good
oral hygiene maintenance

29. TREATMENT
 Aggressive curettage
 Peridex (0.12 %chlorhexidine digluconate) rinses 3
times daily
 Antibiotic treatment

30. PAROTID ENLARGEMENT WITH XEROSTOMIA
INVOLVING SALIVARY GLANDS
 The parotid glands are diffusely swollen and firm
without evidence of inflammation or tenderness with
unilateral or bilateral involvement
TREATMENT
 Chronic parotid enlargement does not require
treatment
 Drugs like Zidovudine can be given but usually
there may recurrence of the lesion

31. ORAL ULCERATIONS
 Recurrent aphthous ulcers
 well circumscribed ulcers
 erythematous margin
 Three types- major, minor& herpetiform
 Minor -0.5 to 1 cm
 Herpetic form-clusters of small ulcers (1-2 mm) on the
soft palate and oropharynx
 Major ulcers -large necrotic ulcers of 2-4 cm which are
painful and last for several weeks

32. TREATMENT
 Fluconamide ointment (0.5%)
 Orabase 3-6 times/day
 Dexamethasone 0.5 mg/ml

33. PREVENTION
The various approaches are:
 If a pregnant lady on testing proves that the foetus
is also HIV positive, she should be allowed to
medically terminate pregnancy
 Blood and blood products to be screened for any
contamination
 Needles should not be re-used
 Educating & creating awareness among the
population
 Safe sex

34.  In dentistry there is a little scope of HIV
transmission but precautions should be taken like:
1. Proper medical history of the patient
2. Proper sterilization
3. Barrier techniques like:
i. Eye protection in terms of eye glasses
ii. Mouth mask
iii. Disposable needles
iv. Gloves (double)
v. Change of clothes

35. GLOBAL AIDS STRATEGY
o Prevent sexual transmission by
a) Information and education
b) Health and social services
c) A supportive environment to prevent sexual
transmission of HIV
o Prevent blood borne transmission of HIV
o Prevent perinatal transmission of HIV

36. AIDS VACCINE
 Since the genetic make up of HIV is constantly
changing from one method of transmission to the
other AIDS vaccine development is not successful
 Still a lot of research on this aspect is coming up

37. DRUGS USED FOR AIDS
 Mainly antiviral drugs like:
1. Acyclovir 1to 2 g daily orally or IV
2. Zidovudine (AZT) which attacks the virus through the
enzyme reverse transcriptase
3. Three other inhibitors namely
1. Dideoxycytosine
2. Dideoxyinosis
3. stavudine
4. Use of protease inhibitors like Saquinavir, Indinavir and
Ritonavir
5. Triple drug therapy combines Indinavir with Zidovudine
and Lamivudine to reduce HIV copies in the plasma of
infected patients.

38. POSTEXPOSURE PROPHYLAXIS (PEP)
 Following exposure, postexposure prophylaxis may
be required
 Basic two drug regimen-Zidovudine 300 mg BD and
Lamivudine 150 mg BD
 Expanded three drug regimen contains Lopinavir
400 mg BD or 800 mg OD or Ritonavir 100mg BD
or 200 mg OD as third drug.

39.  To be effective these drugs must be started within
the first 72 hours and ideally within 2 hours.
 PEP should be continued for a period of four weeks
 Besides PEP, injured site on the wound should be
thoroughly washed with soap and water
 Antiseptics may also be used

40. CONCLUSION
 All the professional should take detailed history
before commencing the treatment
 Universal precautions should be taken regardless
of the patient condition
 All health care professionals need to participate
appropriately in the care of those in our population
who are HIV-infected, including the children

41. REFERENCE
 Text book of edodontics -2nd edition-Shobha Tandon
 Principles and Practice of Pedodontics-3rd edition-
Arathi Rao
 Shafer’s textbook of oral pathology-7th edition
 Textbook of Microbiology for Dental students-Prof.
C P Baveja