HIV/AIDs part 2 Flashcards
(80 cards)
1
Q
The average dental practice is predicted to encounter at least ____ patients infected with HIV per year.
A
two
2
Q
In the United States, ____% of individuals who have acquired HIV are unaware of their status,
contributing to as high as 40% of continuous HIV spread
A
15%
3
Q
The risk of HIV transmission from infected patients to health care workers is very low, reportedly about ________ through a needlestick or other sharp instrument contaminated with the virus
A
3 of every 1000 cases (0.3%)
the risk of infection from a needlestick is 30% for hepatitis B and is 3% for hepatitis C
4
Q
The CDC recommends __________ as soon as possible after exposure to HIV-infected blood
A
postexposure prophylaxis (PEP)
5
Q
After occupational exposure, tests for seroconversion should be performed ______________
A
at 3, 6, and 12 months
6
Q
A less severe exposure (i.e., superficial), an asymptomatic source patient or has a low viral load (<1500 viral copies/mL) use a ____-drug PEP
A
two
7
Q
A more severe exposure (i.e., deep), or when the patient is symptomatic, has AIDS, or a high viral load use of at least a _____-drug PEP
A
three
8
Q
The risk of transmission from healthcare
personnel to patients is also minimized by…
A
adherence to standard infection control procedures
9
Q
__________ must be used for all patients
A
Standard precautions
10
Q
What are the guidelines for the rights of dentists and patients with AIDS?
A
- Dental treatment may not be withheld if the patient refuses to undergo testing for HIV exposure
- A patient with AIDS who needs emergency dental treatment may not be refused care simply because the dentist does not want to treat patients with AIDS
- No medical or scientific reason exists to justify why patients with AIDS who seek routine dental care may be declined treatment by the dentist, regardless of the practitioner’s personal reason
- If the dentist and the patient agree, the dentist may refer the patient to another provider who is more willing or better suited (in keeping with the patient’s oral health status) to provide treatment
- A patient who has been under the care of a dentist and then develops AIDS or a related condition must be treated by that dentist or receive a referral that is satisfactory for and agreed to by the patient
- The CDC and the American Dental Association recommend that infected dentists inform their patients of their HIV serostatus and should receive consent or refrain from performing invasive procedures
11
Q
Two major considerations in dental treatment for patients living with HIV/AIDS
A
- Current CD4+ lymphocyte count
- Level of viral load
Other: neutrophils, platelets
12
Q
Dental treatment of HIV-infected patients without symptoms is no different from that provided for…
A
any other patient in the practice
- Generally, this is true for patients with a CD4+cell count of more than 350/μL.
13
Q
Patients who are symptomatic for the early stages of AIDS (i.e., CD4+ cell count <200/μL) have increased susceptibility to opportunistic infections and may be…
A
medicated with prophylactic drugs
14
Q
Patients with AIDS can receive almost any dental care needed and desired after the
possibility of ______________________________ has been ruled out
A
significant immunosuppression, neutropenia, or thrombocytopenia
15
Q
For invasive dental procedures (including scaling and curettage)
A
- Medical consultation (adverse reactions with ART and/or current blood dyscrasias)
- Patients with CD4+ cell counts below 200/μL or severe neutropenia (neutrophil count <500/μL): use prophylactic antibiotics; in patients with severe thrombocytopenia special measures my be indicated (platelet replacement)
16
Q
When considering perio, adjunctive antibacterial measures may be required if the patient’s CD4+ cell count is below _______/μL or if tissues remain unresponsive to routine therapy.
A
200
17
Q
Root canal therapy has good success in patients with HIV infection, and _____ modifications are required
A
no
18
Q
Oral lesions can present as an __________________ of HIV disease soon after seroconversion alerting clinicians for further investigation in the appropriate clinical scenario
A
early clinical sign
19
Q
_______ manifestations have been acknowledged to represent a major component of HIV infection that can correlate with treatment responses and disease progression
A
Oral
20
Q
What are the main oral and maxillofacial manifestations of HIV infection in adults?
A
- Fungal
—Candidiasis (Candidaalbicans)
—Aspergillosis (Aspergillusspecies)
—Mucormycosis (Mucoraceae)
—Histoplasmosis (Histoplasmacapsulatum)
—Cryptococcosis (Cryptococcusneoformans)
—Penicillinosis (Penicilliummarneffei) - Viral
—HSV lesions
—Varicella-zoster virus lesions (Chickenpox and Shingles)
—Oral hairy leukoplakia (Epstein-Barrvirus)
—Cytomegalovirus lesions
—HPV lesions (Condylomata and squamous papillomas)
—Molluscum contagiosum - Bacterial
— Tuberculosis
—Actinomyces israelii, Escherichia coli, and Klebsiella pneumonia infections
— Cat-scratch disease and bacillary angiomatosis (Bartonella henselae)
—Periodontal diseases :Linear gingivitis, necrotizing ulcerative gingivitis, and necrotizing periodontitis
—Necrotizing ulcerative stomatitis - Salivary Gland Disease
—Dry mouth
—Swelling of major salivary glands - Immune-mediated
—Persistent generalized lymphadenopathy
—HIV-related ulceration
—Recurrent Aphthous Stomatitis
—Thrombocytopenic purpura
—Melanotic hyperpigmentation - Neoplastic
—Kaposi sarcoma
—Non-Hodgkin lymphomas
—Squamous Cell Carcinoma - Neurological
— Facial palsy
— Trigeminal neuralgia - Drug-related eruptions
—Drug-related ulceration
—Erythema multiforme
—Lichenoid
—Toxic epidermolysis
—Drug-induced mucosal hyperpigmentation
21
Q
Oral healthcare providers should be familiar with HIV related oral manifestations and comfortable in…
A
managing and referring patients with HIV/AIDS
22
Q
True/false
It is unlikely to encounter many of the oral lesions associated with HIV in general dental practice
A
True
23
Q
What are the most common oral manifestations of HIV?
A
- Candidiasis - 35%
- Oral hairy leukoplakia - 15%
- Mucosal hyperpigmentation - 9%
- Periodontal & gingival disease - 8.2%
- HIV-related salivary gland disease - 8%
- Recurrent aphthous stomatitis - 7%
- HIV-related non-specific oral ulcerations - 5%
- Kaposi sarcoma - 5%
- Herpes simplex virus (HSV) infections - 4.5%
- Human papillomavirus (HPV) infections - 3.5%
24
Q
The increased prevalence of tuberculosis, HSV infections, HPV infections, and herpes zoster following the initiation of ART is most likely the result…
A
of immune reconstitution syndrome (IRS)
25
What is immune reconstitution syndrome (IRS)?
an exaggerated immune response towards infectious agents and pathological conditions that results from ART-mediated restored immunity
26
After seroconversion, HIV disease often remains silent except for...
PGL
- Persistent generalized lymphadenopathy
27
What is Persistent generalized lymphadenopathy (PGL)?
lymphadenopathy that has been present for > 3 months and involves two or more extrainguinal sites
28
The most frequently involved sites for PGL are the...
posterior and anterior cervical, submandibular, occipital, and axillary nodes
29
Because lymphoma is known to occur in this population, a lymph node biopsy may be indicated for localized or bulky adenopathy, when...
cytopenia or an elevated ESR is present, or when requested for patient reassurance
30
In Persistent generalized lymphadenopathy (PGL), the histopathologic examincation reveals...
florid follicular hyperplasia
31
_________ is the most common intraoral manifestation of HIV infection and often is the presenting sign that leads to the initial diagnosis
Candidiasis
## Footnote
The most common organism identified in oral candidiasis is Candida albicans
32
Approximately one-third of HIV-infected individuals and more than _____% of patients with AIDS develop oral candidiasis at some time during their disease course
90%
33
________________ candidiasis (appears when the CD4+ lymphocyte count <200 cells/mm3)
Pseudomembranous
34
_____________ candidiasis (appears when the CD4+ lymphocyte count <400 cells/mm3)
Erythematous
35
_________ multifocal oral involvement is common in HIV-infected patients
Chronic
36
Oral candidiasis can be painful and associated with a reduction in ________, which may lead to decreased food intake and further wasting
taste and smell
37
What is the treatment for oral candidiasis for HIV patients?
* Nystatinoften is ineffective
* Topical clotrimazole is effective but has high rate of recurrence
* Systemic fluconazole and itraconazole are effective but have a number of drug interactions and may result in drug-resistant candidiasis
* If azoles fail, then IV amphotericin B can be administered (nephrotoxicity)
38
What type of stain is good for oral candidiasis?
PAS
39
The most common EBV-related lesion in patients with AIDS is...
Oral hairy leukoplakia
40
The presence of oral hairy leukoplakia in HIV-infected patients is a sign of what stage of disease?
severe immunosuppression and advanced disease
41
How does oral hairy leukoplakia present?
- white mucosal plaque that does not rub off
- Most cases occur on the lateral border of the tongue and range in appearance from faint, white vertical streaks to thickened, furrowed areas of leukoplakia with a shaggy surface
42
What does the histology of oral hair leukoplakia show?
* Thickened parakeratin (corrugated or thin projections)
* Epithelium is acanthotic and exhibits a bandlike zone of lightly stained cells with abundant cytoplasm (“**balloon cells**”) in the upper spinous layer
* Characteristic pattern of peripheral margination of chromatin termed **nuclear beading** caused by extensive EBV replication that displaces the chromatin to the nuclear margin
* **Dysplasia is not noted**
43
When definitive diagnosis is necessary, demonstration of EBV can be achieved by...
- in situ hybridization
- PCR
- immunohistochemistry (IHC)
- Southern blotting
- electron microscopy
44
Hyperpigmentation in HIV patients can be induced by...
- 1. A variety of drugs taken by HIV/AIDS patients such as zidovudine and emtricitabine-based HIV regimens
- 2. **Drugs used to control microbial infections** in these patients such as ketoconazole (fungal infections), clofazimine (leprosy and some TB), and pyrimethamine (toxoplasmosis/antiparasitic).
- 3. Destruction of the adrenal cortex by **disseminated infections** (e.g. deep fungal infections) in this immunocompromised population is another possible cause of the observed hyperpigmentation.
- 4. Pigmentation with no apparent cause has arisen in HIV-infected patients, and some investigators have theorized that this may be a direct result of HIV infection.
45
Where is hyperpigmentation seen in HIV patients?
Mucosal, cutaneous, and/or nail(s)
46
What is the treatment for hyperpigmentation in HIV patients?
* Usually, no treatment is indicated
* Single lesions may have to be biopsied so that melanoma can be ruled out
* Patients with adrenal insufficiency may require corticosteroids
47
What are the features of linear gingivitis in an HIV patient?
- distinctive linear band of erythema that involves the free gingival margin and extends 2 to 3 mm apically.
- alveolar mucosa and gingiva may demonstrate punctate or diffuse erythema in a significant percentage of cases
- results from an abnormal host immune response to subgingival bacteria or may represent an unusual pattern of candidiasis
48
Diagnosis of linear gingivitis in an HIV patient should be reserved for gingivitis that does not respond to ___________ and exhibits a greater degree of erythema than would be expected for the amount of plaque present
improved plaque control
49
What are the features of necrotizing ulcerative gingivitis (NUG) in an HIV patient?
- appears as ulceration and necrosis of one or more interdental papillae with **no periodontal attachment loss**
- Patients have interproximal gingival necrosis, bleeding, pain, and halitosis
50
What are the features of necrotizing ulcerative periodontitis (NUP) in an HIV patient?
- characterized by gingival ulceration and necrosis associated with **rapidly progressing loss of periodontal attachment**
- Although severe cases can affect all teeth, multiple isolated defects often are seen and contrast with the diffuse pattern associated with typical chronic periodontitis
- Edema, severe pain, and spontaneous hemorrhage are common.
- Deep pocketing usually is not seen because extensive gingival necrosis typically coincides with loss of the adjacent alveolar bone
51
What are the features of necrotizing stomatitis in an HIV patient?
- may be seen as an extension of NUP or may involve oral mucosa separate from the gingiva
- involves predominantly soft tissue or extend into the underlying bone, resulting in extensive sequestration
52
How do you treat linear gingivitis in an HIV patient?
may be treated with...
- debridement
- povidone-iodine irrigation
- chlorhexidine mouth rinse
- antifungal medication
53
How do you treat NUG or NUP in an HIV patient?
- debridement
- antimicrobial therapy
- pain management
- immediate follow-up care
- long-term maintenance
54
What is the specific regimen for treating NUP and NUG in HIV patients?
* The initial removal of necrotic tissue typically is combined with povidone-iodine irrigation
* The use of systemic antibiotics usually is not necessary, but metronidazole has been administered to patients with extensive involvement and severe acute pain
* All patients should use chlorhexidine mouth rinses initially and for long-term maintenance.
* After initial debridement, removal of additional diseased tissue should be performed within 24 hours and again every 7 to 10 days for two to three appointments, depending on the patient's response. At this point, monthly recalls are necessary until the process stabilizes; evaluations then are performed every 3 months
55
The prevalence of oral recurrent HSV infection among HIV-infected individuals increases significantly once the CD4+ cell count < ___/mm 3
50
56
Persistence of active HSV infection for more than ______ in a patient infected with HIV is one accepted definition of AIDS
1 month
57
Evaluation for _____ should be performed on all persistent oral ulcerations in HIV-infected individuals
HSV
58
What is the treatment for HSV in HIV patients?
Systemic acyclovir, valacyclovir, or famciclovir for at least 5 days can be effective. Higher doses may be needed during severe immunosuppression
59
Severe intraoral involvement of varicella-zoster virus may lead to...
bone sequestration and loss of teeth; these sequelae may be delayed a month or more after the initial onset of herpes zoster
60
In patients with well-controlled HIV disease, herpes zoster usually is confined to ________ dermatome but persists longer than usual
a single
61
What is the treatment for varicella-zoster virus lesions in an HIV patient?
* Valacyclovir 1 g PO tid; famciclovir 500 mg PO tid; acyclovir 800 mg PO 5 times per day
* IV acyclovir maybe needed for severe herpes zoster in patients with immunosuppression
* Routine zoster vaccination for HIV-infected patients is not recommended currently; however, according to some experts, zoster vaccination may be considered for those with well-controlled HIV disease and CD4+ cell counts > 200/ mm 3
62
HIV-associated salivary gland disease can arise anytime during HIV infection and is considered a...
localized manifestation of diffuse infiltrative lymphocytosis syndrome (DILS)
63
Diffuse infiltrative lymphocytosis syndrome (DILS) is characterized by ______ lymphocytosis with diffuse lymphocytic infiltration of various sites, such as the major or minor salivary glands, lacrimal glands, lungs, kidneys, muscle, nerve, and liver
CD8+
64
The main clinical sign of HIV-related salivary gland disease is ________________, particularly affecting the parotid.
salivary gland enlargement
| Bilateral involvement is seen in about 60% of cases
## Footnote
Xerostomia is a variable finding
65
What is the treatment for diffuse infiltrative lymphocytosis syndrome (DILS)?
oral prednisone and antiretroviral therapy, although some patients have been treated with surgery or radiation therapy
66
Microscopic changes within the affected
glands of HIV-related salivary gland disease may include...
lymphocytic infiltration, hyperplasia of intraparotid lymph nodes, and, in long-standing cases, lymphoepithelial cyst formation
67
What are the features of recurrent aphthous stomatitis in HIV patients?
* Most lesions are of the more uncommon forms—major and herpetiform
* With more severe reduction of CD4+ cell count, major lesions become more prevalent
* Lesions that are chronic or atypical or that do not respond to treatment should be biopsied
* Treatment of persistent lesions involves potent topical or intralesional corticosteroids. Systemic steroids generally are avoided to prevent further immunosuppression
68
What are the types of oral ulcerations in HIV patients?
- Recurrent aphthous stomatitis (RAS)
- HIV-related (non-specific) oral ulceration
- Antiretroviral therapy induced-oral ulceration
69
What are the features of HPV infections in HIV patients?
* Among HIV-infected individuals, most HPV lesions arise in the anogenital region, although oral involvement also is possible
* Benign HPV lesions: Oral squamous papilloma, verruca vulgaris, condyloma acuminatum, and multifocal epithelial hyperplasia
* The labial mucosa, tongue, buccal mucosa, and gingiva are most frequently involved
* The lesions may exhibit a cluster of white, spikelike projections, pink cauliflower-like growths, or slightly elevated sessile papules
70
What is the histopathology of HPV in HIV patients?
* Lesions may be sessile or papillary and covered by acanthotic or hyperplastic stratified squamous epithelium
* The affected epithelium often demonstrates vacuolization of numerous epithelial cells and occasionally may exhibit mild variation in nuclear size
* **Dysplasia has been noted within HPV related lesions in patients with AIDS and mandates close observation for development of squamous cell carcinoma**
71
What is the treatment for HPV in HIV patients?
* Surgical excision is the most commonly used treatment for oral HPV lesions; additional surgical options include cryosurgery, electrocautery, and laser ablation
* All of these surgical methods are associated with frequent recurrence
* **Electrocautery and laser ablation may expose the surgical team and patient to a plume containing infectious HPV**
72
______________ currently represents the most common malignancy among the AIDS population in the United States
Non-Hodgkin lymphoma (NHL)
73
The marked reduction in CD4+ T-helper lymphocytes, to a great degree, explains the lack of an effective immune response seen in patients with AIDS and contributes to the increase in malignant disease that has been found to be associated with AIDS, including...
Kaposi sarcoma, lymphoma, and carcinomas
74
What are the features of lymphoma in HIV patients?
* Most cases represent high-grade, aggressive B-cell neoplasms. Maybe associated with EBV and/or HHV-8.
* Lymphoma in patients with AIDS usually occurs in extranodal locations
75
What are the oral manifestations of lymphoma in HIV patients?
* Oral lesions are seen in approximately 4% of patients with AIDS-related NHL and most frequently involve the gingiva, palate, and tongue.
* Intraosseous involvement also has been documented and may resemble diffuse progressive periodontitis with loss of periodontal attachment and loosening of teeth. In these cases, **widening of the periodontal ligament and loss of lamina dura may represent radiographic clues to the diagnosis**
76
What are the features of kaposi sarcoma in HIV patients?
- The lesion most likely arises from endothelial cells, which may express markers for both lymphatic and blood vessel differentiation and is caused by human herpes virus 8 (HHV-8)
- Kaposi sarcoma currently represents the **second** most common malignancy among people with AIDS in the United States
77
The four clinical presentations of kaposi sarcoma are...
1. Classic
2. Endemic (African)
3. Iatrogenic (transplant-associated)
4. **Epidemic (AIDS-related)**
78
In kaposi sarcoma, relatively high titers of ______ have been found in saliva, and exhibits tropism for oral and oropharyngeal epithelial cell
HHV-8
79
In Western countries, Kaposi sarcoma has been reported primarily in HIV-infected, adult, male homosexuals and is thought to be related to ______________ of HHV-8
sexual transmission
80
What are the features of oral squamous cell carcinoma in HIV patients?
* Relative to the general population, HIV-infected individuals have an estimated two fold increased risk of developing oral cavity and pharyngeal cancer
* Oral squamous cell carcinoma tends to occur at a younger age among HIV-infected individuals than non-HIV-infected individuals
* Treatment also is not significantly different for HIV-infected patients and consists of surgical resection, radiation therapy, and/or chemotherapy
* Most HIV-infected patients with a diagnosis of oral squamous cell carcinoma have advanced disease and an unfavorable prognosis
