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HIV Post-Exposure Prophylaxis (PEP) Oral health and HIV – a watchful eye will discover Rolf Christensen, DDS, MHA Dental Director, Mountain West AIDS Education Training Center University of Washington School of Dentistry May 2020 Disclosures No conflicts of interest or relationships to disclose SARS-CoV-2 very different times Centers for Disease Control Hierarchy of Control Intraoral exams & a few things to watch for Objectives 1. Better understand oral exams (for non-dentists) 2. Recognize oral manifestations of HIV 3. Recognize oral signs of HIV immune dysfunction Intraoral exams & a few things to watch for I. Review briefly intraoral exam technique II. Increase attention to patients with HIV with i. Dry mouth – xerostomia ii. Oral fungal infections – candidiasis + iii. Acute periodontal disease – acute necrotizing Anatomic Areas for Oral Exam vermillion lip upper labial mucosa soft palate right buccal mucosa left buccal mucosa Tongue (dorsal,lateral,ventral) lower labial mucosa vermillion lip Oral Examination Techniques General inspection (start immediately) ▪Body position, movements, asymmetries ▪ Patient interview ▪Examination Techniques • Patient Positioning • Lighting Oral Examination Techniques: Patient positioning Sitting up or reclined Comfortable for pt & examiner Halogen light source Otoscope, ophthalmoscope Flashlight, trans-illuminator Patient Positioning ▪ Comfortable • Don’t bend over -- Don’t lean / tilt sideways ▪ Direct visualization of all surfaces – “eye level is at mouth level” ▪ Retract: fingers, tongue blades, cotton swabs (look under retractor, too!) ▪ Move patient’s head to assure direct vision Light Sources for Oral Examinations • White light sources are best – Halogen light sources • Otoscopes / Ophthalmoscopes / Halogen flashlight – Avoid: a) LEDs with “blue” light b) Flashlights with “yellowish” light and “shadows” from bulb or reflector • Convenient and economical Halogen light Room light Day light Flashlight Oral inspection Soft tissue – lips, cheeks, • Fixed/moveable tongue, floor of mouth, • Draining pharynx • Painful Lesions ? • Swollen • Duration • Lymph node involvement • Location Teeth & periodontal (gums) • Size • Color (red, inflamed…) • Cavities • Shape, texture, contour • Gingivitis (gums) • Surface texture & integrity • Periodontal disease • Fixed/moveable (gums & bone) Buccal Mucosa Buccal Mucosa Light pink color, slightly opaque in middle portion, translucent vestibules Labial Mucosa Light pink color but more translucent with submucosal vasculature evident. Minor salivary glands are noted as small “bumps” Hard Hard Palate Palate Normal: Light pink to white extending from the “vibrating line” anteriorly to the margianal gingivae. Opaque with rough appearing ridges anteriorly (rugae). Soft Palate Normal: Light pink to increasing tranlucency Soft Palate moving anterior to posterior from the junction of the hard and soft palate. The soft palate has a very large number of minor salivary glands. Lateral - Ventral Tongue Lateral / Ventral Tongue Light to dark pink, opague to more translucent starting at the junction of the dorsal tongue (filiform papilla) and extending to where the surface turns onto the floor of the mouth. Ventral tongue can have large veins (varicosities) Buccal Mucosa Linea alba: a horizontal wihte hyperkeratotic line on the inner Linea Alba surface of the cheek, level with the biting (occlusal) plane Fordyce Granules: Ectopic submucosal sebaceous glands seen as light yellow submucosal “deposits” Fordyce Granules Clinical Considerations: Oral and Dental Disease Dental Decay Oral Manifestations Endodontic of HIV Infections Denture Problems Periodontal Diseases Crenated tongue Pseudomembranous Candidiasis Normal tongue Geographic tongue Hairy tongue Impact of Non HIV-Associated Dental Disease on HIV Progression • Gingivitis / Periodontitis / Dental Abscesses • Common dental diseases • Compromise oral health / function / esthetics • Compromise general health • Constant immune system stimulation → activation of lymphocytes: virus production • Increases risk of opportunistic oral infections • Increased risk for HIV disease progression Promote / Support Oral Health & Basic Dental Care Dental Decay 24 Salivary Glands: Xerostomia Decay Progression of decay Decay begins on the smooth surfaces of the teeth – enamel is literally undermined with coincident dentine decay And can lead to teeth fracturing off and endodontic abscesses The Protective Effect of Saliva • Antimicrobial effect • Bacteria responsible for tooth decay • Bacteria causing periodontal disease • Opportunistic mucosal infections • i.e., fungal and viral infections • Cleansing effect • Bacterial attachment • Digestive enzymes • Amylases, Mucins, Lipase Caries Management • Eliminate cause / severity of salivary gland dysfunction when possible • Effective / comprehensive oral hygiene – Brushing / Flossing / Other oral hygiene aids • Daily home Rx fluoride use (1.1% N Na Fl) • Remineralizing products • Dietary modification: sugars / acids / other • Salivary gland stimulation – Taste stimulation (sugar-free products) – Sialogogues (pilocarpine / cevimelene / bethanechol) • Decay “resistant” restorative materials Xerostomia: Other Considerations • Mucosal damage and inflammation • Increased risk for Candida overgrowth • Oral function Wearing a denture (and chewing) Speaking and general sitting comfort Oral & pharyngeal candidiasis Angular cheilitis Atrophic erythematous Erythematous hyperplastic Erythematous hyperplastic 30 Oral & pharyngeal candidiasis Angular cheilitis Pseudomembranous Pseudomembranous Pseudomembranous 31 Oral Infections: Periodontal Diseases 32 Acute necrotizing periodontal disease Think Rx chlorhexidine gluconate 0.12% rinse (BID) + ? ?? 33 Oral hairy leukoplakia Public access Public access 34 Thank you! Rolf Christensen, DDS, MHA University of Washington School of Dentistry [email protected] This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under #u10HA29296, AETC Program, $2,943,253. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government..
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