The role of the OHT in the management of HIV

Question 1

Define HIV and describe how it infects the body and how it leads to AIDS

Answer 1

· HIV (Human Immunodeficiency Virus) belongs to the retrovirus family. They contain 2 copies of single stranded RNA causing

· HIV infects CD4 cells which are the helper T-Cells

· Over time, due to attack from the HIV virus, CD4 cell counts decline, which results in a poorly functioning immune system (immunodeficiency)

· This eventually leads to A.I.D.S which is indicated by the diagnosis of one or more AIDS-defining conditions including opportunistic infections, malignancy, wasting and neurological disorders

Question 2

Discuss the modes of HIV transmission

Answer 2

· HIV is transmitted by exposure to HIV-infected bodily fluids or tissues. Generally blood to blood
· This includes unprotected sex, re-using drug injecting equipment, and vertical transmission from mother-to child
· Cases of mother-to-child transmission are uncommon in Australia, as is transmission via needle stick injuries, tattooing and medical procedures
· There is a low risk of HIV transmission after subcutaneous exposure to HIV infected blood. This because even smaller provided the patients VL is undetectable
· There is no evidence that HIV can be transmitted by contact with tears, sweat, urine or faeces

Question 3

Is HIV transmissible through saliva?

Answer 3

· HIV is present in saliva, but not considered a risk factor as the virus is present in low level
· There are antiviral factors present in saliva which inhibit transmission

Question 4

Describe the diagnostic methods used for HIV, understand the range in health, and the desired range for people with HIV but on retro-viral medication

Answer 4

· Screening for HIV and TCell levels is performed with a blood test
· Saliva tests are available to detect HIV but are quite costly
· In blood testing, the CD4 (TCell) count and Viral load (VL) is examined

· In health WITHOUT HIV: 500 - 1300 CD4 cells/ ml3 of blood

For people with HIV but on retro-viral medication:
· Aim is to have a TCell count above 500 consistently and a Viral Load (VL) which is defined as “Undetectable”
· An “Undetectable” viral load (VL) = no virus can be detected in more than 20 copies/mm3 of blood.

Question 5

State when oral manifestations of HIV are likely

Answer 5

When CD4count falls below 200 and the VL is >3000 copies/3ml of blood in a treated individual

Question 6

List the four categories of oral infections that occur with HIV

Answer 6

· Fungal
· Bacterial
· Viral
· Oral neoplasms

Question 7

Describe the following fungal infections of HIV:

• Erythematous candidiasis
• Pseudomembranous candidiasis
• Angular cheilitis

Answer 7

Erythematous candidiasis:
• Patchy red or presents with erythematous areas that may become diffuse and atrophic

Pseudomembranous candidiasis:
• Creamy white or yellow plaque which, when scraped, reveals an erythematous or bleeding mucosal surface

Angular cheilitis:
• Is commonly associated with a concurrent infection with Staphylococcus aureus and it presents with erythema and red or white fissures or ulcers at the corners of the mouth

Question 8

Describe the following bacterial infections of HIV:

• Necrotising ulcerative gingivitis
• Necrotising ulcerative periodontitis
• Necrotising ulcerative stomatitis
• Linear gingival erythema

Answer 8

Necrotising ulcerative gingivitis:
• Presents with pain, ulceration and gingival bleeding
• The lesion does not involve the alveolar bone
• Lesion is punched out, ulcerated and interdental papilla covered by a greyish necrotic slough

Necrotising ulcerative periodontitis
• Presents like NUG with pain, ulceration and gingival bleeding except the lesion involves the alveolar bone

Necrotising ulcerative stomatitis:
• More extensive area of ulceration and tissue necrosis that extends from gingival into the adjacent mucosa
• May involve periodontal tissues and extend into the maxillary or mandibular bone

• Linear gingival erythema

Question 9

Describe the following viral infections of HIV:

• Herpes
• HPV
• Varicella zoster
• Oral hairy leukoplakia
• Herpetic stomatitis
• Expansive ulceration

Answer 9

Herpes:
• Appears on the lips as herpes labialis

Human papilloma virus (HPV):
• Causes verruca vulgaris: multiple, large and disfiguring
• Occurs in conjunction with HIV infection

Varicella zoster:
• Herpes virus that causes chicken pox and reactivates from a latency to cause herpes zoster (HZ) or shingles

Oral hairy leukoplakia:
• Caused by repeated direct infection of the epithelial cells by Epstein Barr Virus in the saliva
• Associated with immunosuppression

Herpetic stomatitis

Expansive ulceration

Question 10

Describe the following viral infections of HIV:
• Non-Hodgkin’s lymphoma (NHL)
• Kaposi sarcoma-associated herpesvirus

Answer 10

Non-Hodgkin’s lymphoma (NHL):
• Appears diffuse, rapidly proliferating, slightly purplish mass located on the floor of the mouth

Kaposi sarcoma-associated herpesvirus (KSHV):
• Causes Kaposi’s sarcoma, a cancer commonly occurring in A.I.D.S patients

Can present as:
• Multiple painless, non-elevated palatal lesions
• A gingival lesion

Question 11

Discuss the previous medications used to treat HIV

Answer 11

· The first forms of medications were particularly hard on the body and produced significant adverse reactions e.g. lipodystrophy, chronic nausea and malaise

· Some people took 30 tablets per day

Question 12

Identify the 5 different HIV antiviral medical agent classes

Answer 12

Entry inhibitors

Non nucleoside reverse transcriptase inhibitors

Nucleoside analogues

Integrase inhibitors

Protease inhibitors

Question 13

Explain the 5 different HIV antiviral medical agent classes

Answer 13

Entry inhibitors:
· Work outside the cell by preventing HIV from entering the T cell
· They do so by blocking binding and fusion of HIV with the CD4 cell membrane

Non nucleoside reverse transcriptase inhibitors:
· Bind to reverse transcriptase and inhibit the enzyme
· This prevents the formation of HIV DNA and therefore, HIV replication

Nucleoside analogues:
· Acts as false substrates for reverse transcriptase, causing chain termination
· The resulting HIV DNA is incomplete, and prevents HIV replication

Integrase inhibitors:
· Block the integration of HIV with the cell DNA
· This process prevents HIV replication

Protease inhibitors:
· Work at the late stage of HIV replication cycle
· They prevent HIV from being successfully assembled and released from the CD4 cell

Question 14

Discuss the 2 new treatments coming up for HIV

Answer 14

Injectable Medications:
· The efficacy of taking injectable medications every four or eight weeks, instead of the daily oral treatment is being studied
· Studies suggest that is may be as effective as the usual 3-pill daily treatment in suppressing HIV virus inside the body
· Injectable treatment combines two HIV drugs - cabotegravir and rilpivirine

Multi Strain HIV Vaccination to be Trialled end 2019:
· The vaccine is supposed to work iwth multiple strains of the rapidly changing virus
· The structure of the vaccine will have an optimal set of “mosaic” proteins as part of the vaccine that would increase defences against a wide array of strains
· An altered cold virus will be used as the vehicle to make the proteins raise the immunity

Question 15

List the types of comorbidities that are associated with the use of long-term anti-retroviral therapy (4) and mention the types of cancers (6)

Answer 15

· Increased chances of cardiovascular disease
· Osteoporosis
· Minor neurocognitive disorders of the brain and
· Dementia

Increased cancer risk of certain cancers such as
· Lung cancer, rectal cancer, liver cancer and non-melanoma skin cancer
· Kaposi Sarcoma
· Hodgkin’s lymphoma,

Question 16

List the 4 steps in the management of Hep C and HIV

Answer 16

· Take a MHx update
· Educate and provide OHI
· Manage saliva
· Professional care

Question 17

Explain the step of taking a MHx update

Answer 17

Take a MHx update:
• Review the current medications being taken by the patient
• Take an up to date list of the aRT (Antiretroviral Therapy) drugs being taken
• Ask the HIV patient when their last Blood test review took place (generally every 3 months)
• For HEP C an annual blood test is the ideal scenario
• HIV: Ask about Viral Load (VL) and TCell count. Should reply “T cell above 500 and VL undetectable”
• HEP C: What was your VL? Should be “undetectable”

Question 18

Explain the step of educating and providing OHI

Answer 18

Educate and provide OHI:
• Patient education on oral hygiene techniques including regular toothbrushing with fluoridated toothpaste, and flossing
• Products that are sodium laurel sulphate-free (non-foaming)
• Avoid using mouth rinse containing high levels of alcohol e.g. Listerine
• The use of fluoridated toothpastes, employing the “swish and spit” technique in combination with remineralisation products containing CPP-ACP e.g toothmousse
• Dietary analysis and advice e.g. sugar frequency, coffee, alcohol?
• Maintaining optimal denture hygiene i.e. denture tablet use and denture brush
• Encourage smoking cessation

Question 19

Explain the step of managing saliva

Answer 19

Manage saliva:
• Saliva testing to determine quality, quantity and buffering capacity
• Saliva stimulation by chewing sugar-free gum
• Increase periodic sipping of water to improve lubrication and hydration
• Saliva substitutes can provide some moisture replacement and protection of tissues but benefits are usually short-lived e.g Biotene range of products
• Lanolin and papaya products are useful for dry lip

Question 20

Explain the step of professional care

Answer 20

Professional care:
• Regular dental examinations
• Fluoride applications in the case of evident white spot lesions e.g duraphat (localised) Sodium Fluoride (generalised)
• Management of candidiasis, if present, with topical agents prescribed by your supervising dentist
• Prescribed Pilocarpine medication may be used to increase salivary flow, but it has significant side effects and its use is contraindicated in many medical conditions and medications. Its’ use is best left in the hands of medical practitioners and dental specialists

Question 21

Discuss the legal situation around treating HIV and Hepatitis C patients

Answer 21

· In Australia it is an offence to discriminate against a patient on the basis of a blood bourne virus they may be carrying
· People with HIV or Hepatitis C infections are not required by law to disclose their HIV status to dentists, doctors or any other health professionals
· However if you were to suffer a needle stick injury the patient is then legally obliged to disclose their status provided you have asked the question of them directly “Do you have any reason to believe you may be carrying an infective Blood Bourn Virus. e.g HIV or Hepatitis C?”

Question 22

Explain what to do in the event of a needle stick injury

Answer 22

· DON’T PANIC. There is a low 0.3% risk of HIV transmission after subcutaneous exposure to HIV-infected blood

· Remove glove and wash the area thoroughly

· Inform the patient that it has taken place and ask “Do have any reason to believe you may be carrying an infective Blood Bourn Virus. e.g HIV?”

· If No, ideally both you and the patient should be blood tested on the same day for Hep C and HIV and seek the results asap

· If the patient is a known HIV carrier, you should already be aware of what medications they are taking, when the last blood tests were conducted and what the results were

· For HIV you could now seek medical advice and take “PeP”. For HEP C no PeP is currently available

Question 23

Identify what HIV “PeP” is and how be familiar with how it can be accessed

Answer 23

· PeP or Post Exposure Prophylaxis is a 28 day course of Anti-retroviral (aRT) medications that can be taken to reduce the chances significantly of seroconverting to HIV. It is currently free of charge

· The first medications need to taken within 72 hours of initial exposure and the full course taken

· Advice post exposure can be immediately sought via your GP or at any Hospital Accident an Emergency Department around the country

· In Australia there is a 24 hour PeP Hotline you can call to seek advice on whether PeP is right in your case and the registered nurse manning the phone can direct you to the closest location to access it

Question 24

Discuss what “PreP” is and what is it used for

Answer 24

· PrEP is an acronym that stands for pre-exposure prophylaxis. It is effective mainly against HIV 1stains

· It is a “Safe Sex” measure to prevent HIV

· It involves HIV negative people taking antiretroviral drugs to protect them and prevent HIV infection, just one tablet a day

· It is available via PBS in Australia at a cost of a maximum of $41 per script, while for Concessional patients it is $7
PrEP does not protect a patient from sexually transmitted infections