J Am Board Fam Pract: first published as 10.3122/jabfm.11.6.434 on 1 November 1998. Downloaded from Oral Health Care Issues in HIV Disease: Developing a Core Curriculum for Primary Care Physicians

Randa Sijri, MD, Victor A. Diaz, Jr, MD, Larry Gordon, DDS, Michael Glick DMD, Howard Anapol, MD, Ronald Goldschmidt, MD, Deborah Greenspan, BDS, DSc, Richard Sadovsky, MD, MS, Barbara Turner, MD, and Howard K. Rabinowitz, MD

Background: Given the high occurrence of oral manifestations in patients infected with human immunodeficiency virus (IIIV), the relative ease in recognizing these manifestations on physical examination, and their potential impact on the health care and quality of life in these patients, it is critical to provide adequate training for primary care physicians in this area. Methods: Based on a review of the published literature and the consensus of a national panel of primary care physicians and dentists with clinical and research expertise in this area, a core curriculum was developed for primary care physicians regarding oral health care issues in IIIV disease. Results and Conclusions: We describe the process of developing the core curriculum of knowledge, skills, and attitudes regarding oral health care issues in HIV disease. The final curriculum is in a format that allows for easy accessibility and is organized in a manner that is clinically relevant for primary care physicians. (J Am Board Fam Pract 1998;11:434-44.)

Educating and training primary care physicians in tion, oral lesions are among the most frequent the areas of human immunodeficiency virus (HIV) problems associated with HIV infection, with infection and acquired immunodeficiency syn­ more than 90 percent of patients having at least drome (AIDS) are critically important because the one oral manifestation during the course of their disease is widespread, the geographic distribution disease. of the disease is expanding, and the move toward Oral problems almost always produce symp­ managed care will likely result in an increasing toms, and mouth pain and dysphagia, if untreated, number of primary care physicians caring for can lead to decreased oral intake and result in these patients in the future. Oral manifestations weight loss, dehydration, and malnutrition. Ap­

are an especially important component of HIV propriate recognition of these lesions is important http://www.jabfm.org/ disease, because oral lesions are often the first not only for diagnosis and treatment, but also be­ overt clinical feature of HIV infection. In addi- cause many oral manifestations ofHIV disease can be markers for deteriorating immune function and can influence recommendations for prophylaxis Submitted, revised, 29 Mar 1998. l From the Department 0 Family Medicine, Center for against specific opportunistic infections. Addi­ Medical Education Research and Policy (RS, VD, HKR), the

tionally, patients with HIV disease might qualify on 25 September 2021 by guest. Protected copyright. Division of General Dentistry (LG), Department of Medi­ cine, Center for Research in Medical Education and Health for various clinical trials based entirely on the Care (BT), Jefferson Medical College of Thomas Jefferson presence of an oral lesion. 2 University, Philadelphia; Infectious Disease Program, Uni­ versity of Pennsylvania School of Dental Medicine (MG), Despite their importance, however, dental and Philadelphia; Student Health Services, University of Miami oral problems of HIV infe~tion can be over­ (HA), Miami, Fla; Department of Family Practice, San Fran­ cisco General Hospital, University of California (RG), San looked by physicians, whose education and train­ Francisco; Department of Stomatology, University of Cali­ ing in the areas of dental medicine and oral health fornia (DG), San Francisco; and Department of Family Prac­ are often inadequate.3 Given that many of these tice, SUNY - Health Science Center at Brooklyn (RS), Brooklyn, NY. Address reprint requests to Randa Sifri, MD, oral lesions are common and can be seen and pal­ Department of Family Medicine, Jefferson Medical College pated easily on physical examination, one might of Thomas Jefferson University, Suite 401 Curtis, 1015 Wal­ nut St, Philadelphia, PA 19107. expect a general comfort level among physicians This project was supported by the Bureau of Health Pro­ in managing oral manifestations. Yet, in one study fessions, under a cooperative agreement for medical educa­ tion research centers No. l-U76-MB00002-01, contract No. assessing the ability of primary care physicians to 103HR960411P, and purchase order No. 97-0300(P)-BHPR. recognize oral findings associated with HIV dis-

434 JABFP Nov.-Dec.1998 Vol. 11 No.6 J Am Board Fam Pract: first published as 10.3122/jabfm.11.6.434 on 1 November 1998. Downloaded from ease, only 22.7 percent were able to diagnose oral published literature and consensus of the national hairy leukoplakia.4 advisory committee, developed the core curricu­ To address these issues, we undertook a project lum of knowledge, skills, and attitudes needed by to develop a core curriculum for primary care primary care physicians regarding the oral mani­ physicians regarding the oral manifestations of festations of lIIV disease. The final curricular HIV disease in adults. document was organized in a manner that is clini­ cally relevant for primary care physicians: patients Methods who are seronegative or whose lIIV status is un­ Under a cooperative agreement and contract with known, lIIV-infected patients with no oral symp­ the Bureau of Health Professions (Health Re­ toms or lesions, lIIV-infected patients who have sources and Services Administration), a 5-member oral symptoms or oral lesions, and other provider­ project staff including 3 family physicians and 1 related issues. The entire curriculum, including general dentist from Jefferson Medical College of the bibliography, was reviewed and approved by Thomas Jefferson University initially sought to the national advisory committee. describe the core oral health care issues for pri­ mary care physicians regarding HIV disease. Results These issues were then translated into a core cur­ The completed core curriculum, including pho­ riculum that could be used by primary care resi­ tographs of common oral lesions (courtesy of dents. Project consultation was provided by a den­ Michael Glick, DMD) and a bibliography, is in­ tist with nationally recognized expertise in HIV cluded in Appendix 1. The main goals of the cur­ disease (MG) and a national advisory committee of riculum are to emphasize the importance of oral 2 family physicians (RG, RS) and 2 general in­ health issues and HIV disease and to provide a ternists (HA, BT) who have experience and exper­ sound knowledge base for recognizing and man­ tise in this area, and a dentist nationally known for aging the common oral problems related to HIV her HIV research (DG). infection. The information was categorized to fa­ Upon completion of a comprehensive review cilitate easy reference and to reflect the way in of the literature by the project staff, the consul­ which primary care physicians usually approach tant and national advisory committee members the care ofHIV-infected patients. independently selected those issues that were To implement this curriculum into a primary considered important for primary care physicians care residency program, we recommend integrat­ http://www.jabfm.org/ regarding the oral manifestations of HIV disease ing it into a broader curriculum that includes in adults. This information was then reviewed, management of general oral health problems. collated, and prioritized by the project staff and Given the 3-year duration of the primary care res­ by faculty physicians from the Department of idency, we recommend that initial exposure to this Family Medicine at Jefferson Medical College. document occur early during the first year. Be­ Special effort was made to assure that the critical cause most first-year training is done in the hospi­ core issues were included and that these issues tal, however, the goals during this year should be on 25 September 2021 by guest. Protected copyright. would be relevant from the primary care perspec­ limited to learning how to take an oral history and tive. This consensus document was then validated perform a basic oral examination and to under­ using both the published literature and the data­ standing the concepts of oral health for HIV-in­ base of encounters or questions received from fected and non-HIV-infected patients. In years 2 1991 through 1993 by the National HIV Tele­ and 3 of residency training, didactic conferences phone Consultation Service (Warmline) in San for lIIV-related issues should include specific Francisco, a service of the Health Resources and mention of oral health management. Clinical ex­ Services Administration AIDS Education and posure and teaching should be incorporated dur­ Training Centers. The national advisory commit­ ing inpatient and outpatient care of HIV-infected tee then continued participation in an iterative patients, and if possible, residents should rotate process to refine further and finalize these issues through the clinical specialties that commonly by telephone conference call and follow-up writ­ care for HIV-infected patients who have oral ten communication. problems, including dentists and infectious dis­ In a similar fashion, the project staff, using the ease specialists.

Oral Health Care and HIVDisease 435 J Am Board Fam Pract: first published as 10.3122/jabfm.11.6.434 on 1 November 1998. Downloaded from

Discussion training for resident and practicing physicians in This curriculum, developed through a multidisci­ this area. This document, which can be read easily plinary approach combining both primary care and quickly in its outline format, will help facili­ physician and expert dental perspectives and pro­ tate this training. vided in a format that allows for easy accessibility, is particularly suited for use by primary care physi­ Rosemary Duffy, DDS, MPH, fonner Deputy Director, Division of Associated Dental Public Health Professions, Health Re­ cians. Although this curriculum was originally de­ sources and Services Administration, participated in this project as signed for implementation at the residency level, an initial member of the national advisory committee; and the core knowledge content, based on the pub­ Christina E. Hazelwood coordinated this project. lished literature and on expert consensus, could be References used as easily by the practicing primary care physi­ 1. Glick M, Muzyka BC, Lurie D, Salkin LM. Oral cian. Future plans are to distribute this curriculum manifestations associated with HIV-related disease to all family practice and internal medicine resi­ as markers for immune suppression and AIDS. Oral dency programs, as well as to make it available on Surg OralMed Oral PathoI1994;77:344-9. the World Wide Web. 2. Schulten EA, ten Kate RW, van der Waal I. The im­ pact of oral examination on the Centers for Disease Generalist physicians are increasingly being Control classification of subjects with human im­ asked to expand their knowledge base to incorpo­ munodeficiency virus infection. Arch Intern Med rate areas frequently within the purview of other 1990;150:1259-61. specialists, including dentists. Given the wide­ 3. Curtis JW Jr, Garrison R, Camp M. Dentistry in spread oral manifestations of HIV-infected pa­ medical education: Results of a comprehensive sur­ tients, the relative ease in discovering oral lesions vey.J Med Educ 1985;60:16-20. 4. Paauw DS, Wenrich MD, Curtis JR, Carline JD, on physical examination, and the potential impact Ramsey PG. Ability of primary care physicians to on improving the health care and quality of life in recognize physical findings associated with HIV in­ these patients, it is critical to provide adequate fection.JAMA 1995;274:1380-2.

APPENDIX 1. CORE CURRICULUM FOR PRIMARY CARE PHYSICIANS REGARDING ORAL HEALDI CARE ISSUES HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

KNOWLEDGE Oral Symptoms and Oral Lesions and lbeir Association With HlV Infection http://www.jabfm.org/ Patients Who Are Seronegative or Whose IIIV 1. Oral candidiasis can be associated with antibiot­ Status Is Unknown ic treatment, corticosteroid treatment (inhaled General Guidelines and Recommendations for Oral or systemic), diabetes, xerostomia, dentures (or and Dental Care any removable dental appliance), smoking, and 1. The US Preventive Services Task Force defects in cell-mediated immunity

states that health care providers should coun­ 2. No specific literature addresses whether pa­ on 25 September 2021 by guest. Protected copyright. sel patients to visit a dental care provider on a tients with oral candidiasis should routinely regular basis, floss daily, and brush daily with be tested for HIV infection. in patients with­ a fluoride-containing toothpaste out a clear predisposing condition, however, 2. There is little scientific evidence regarding the consideration of immunosuppression should optimal frequency of dental examinations, but occur many preventive care guidelines do recom­ 3. Oral hairy leukoplakia and Kaposi sarcoma are mend dental examinations every 6 to 12 rarely seen in immunocompetent patients, months and patients who have with these conditions 3. Although there are no specific guidelines for should be encouraged to undergo HIV testing physicians regarding when to do an oral his­ tory review and physical examination on a IIIV-Infected Patients With Neither Oral noninfected patient, it is clear that all patients Symptoms nor Lesions should be counseled to avoid the use of to­ Guidelines and Recommendations for Oral and bacco and to use alcohol only in moderation Dental Care (including who should and when and

436 ]ABFP Nov.-Dec. 1998 Vol. 11 No.6 J Am Board Fam Pract: first published as 10.3122/jabfm.11.6.434 on 1 November 1998. Downloaded from how to perform an appropriate oral history review 3. It is generally accepted that sharing tooth­ and physical examination) brushes with patients with lIIV should be dis­ 1. Based on recommendations from the Agency couraged for Health Care Policy and Research, HIV-in­ , fected patients should see a dentist at least IIIV-Infected Patients With Common Oral every 6 months, or more frequently if severely Symptoms or Lesions immunocompromised General 2. An oral examination should be done on HIV­ 1. Oral care infected patients at every physical examination a. Routine dental VISItS are recommended by the medical provider. every 3 to 6 months if the patient has an oral 3. Routine examinations should include careful lesion inspection and palpation of these areas: b. Use of antimicrobial mouth rinses (eg, a. Lips, especially the comers of the mouth chlorhexidine gluconate 0.12 percent [Peri­ b. Soft palate and oropharynx dex, PerioGard] 1 tablespoon as a 30-second c. Buccal mucosa (inside lips, cheeks), and sali­ mouth rinse twice a day) is indicated if the vary glands patient has a history of periodontal disease d. Tongue (including lateral margins, under­ c. Counseling and patient education as dis­ neath) cussed above e. Teeth (including mobility) 2. Pain management f. Gingiva a. Management of pain is essential to avoid 4. All mucosal surfaces should be examined using malnutrition and decreased medication gloves, a tongue blade, gauze squares for ex­ compliance. Because many symptomatic pa­ tending the tongue, and a light source. A tients might be unable to tolerate swallow­ mouth mirror might be necessary for adequate ing capsules or tablets, elixirs should be con­ visualization sidered for both analgesic and HIV-related medications Counseling and Patient Education b. Treatment options include analgesic-anes­ 1. Physicians should recommend daily brushing, thetic mouth rinses and topical medications flossing, and regular professional care (eg, viscous lidocaine), systemic nonnarcotic 2. Patients should be instructed to report symp­ medications (eg, nonsteroidal anti-inflam­ http://www.jabfm.org/ toms of oral pain, dryness, and decreased sali­ matory drugs, acetaminophen), and narcotic vary flow; bleeding; dysphagia; change in taste; agents for acute pain episodes, or psycho­ and loosening of teeth. Physicians might need tropic medications (eg, tricyclic antidepres­ to ask the patient about these symptoms sants, selective serotonin reuptake inhibi­ 3. Patients should be counseled to avoid the use tors) for chronic pain syndromes of chewing and smoking tobacco and to use al­ 3. Nutrition cohol in moderation a. Patients at risk might need to use anti­ on 25 September 2021 by guest. Protected copyright. emetic or antidiarrheal agents to help them HIV Prevention, Transmission, and Risk Factors avoid precipitation or exacerbation of mal­ 1. HIV is found in the saliva, and although oral nutrition transmission is thought to be rare, unpro­ b. Complete and supplemental nutritional tected receptive oral intercourse, even in the products (eg, Ensure) are available for pa­ absence of mucosal lesions, is a risk for trans­ tients at risk for malnutrition mission ofHIV c. Physicians should consider referring pa­ 2. Casual contact through closed-mouth or social tients for nutritional counseling in certain kissing is not a risk for transmission of HIv. cases Because of the potential for contact with blood d. Physicians should be aware of possible Bl2 during French or open-mouth kissing, the and folate deficiency and be able to recog­ Centers for Disease Control and Prevention nize these clinical conditions (CDC) recommend against engaging in this 4. Patient education and patient support network activity with an infected person a. Physicians should instruct the patient's part-

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Figure 1. Pseudomembranous candidiasis. Figure 2. Pseudomembranous candidiasis. ,- 1';' I -' • .' C •• ~"

l ' , ' . ,..

\ , Figure 3. Erythematous candidiasis. Figure 4. Erythematous candidiasis.

ners, relatives, and friends on how to per­ recognition, and diagnosis form an appropriate oral screening exami­ a. Oral candidiasis can manifest in 4 different nation ways: b. Written materials, on-line sites, and other i. Pseudomembranolls candidiasis or th17Jsh national and local resources are available for (Figures 1 and 2): removable whitish http://www.jabfm.org/ patients and their partners, relatives, and plaques that can occur on any oral mu­ friends cosal surface. PI :!sumptive diagnosis can 5. HIV-related medication side effects be made based on clinical appearance and a. Common medications used to treat HIV response to antifungal medications disease have side effects that can include in­ ii. Erythematous candidiasis (Figures 3 and 4):

creased caries; xerostomia (see Other Oral smooth, red, atrophic patches that can on 25 September 2021 by guest. Protected copyright. Conditions, below); discoloration of skin, occur on the hard or soft palate, buccal mucosa, and saliva; oral and esophageal ul­ mucosa, or the tongue. Differential diag­ cers (see Recurrent Aphthous Ulcers, be­ nosis includes geographic tongue and nu­ low); sore throat and mouth; and perioral tritional deficiencies. Diagnosis can be parestbesias based on clinical appearance, nutritional b. Anecdotal evidence suggests that protease history, duration and stability of the le­ inhibitors may lead to an increased inci­ sion, and treannent response dence of caries iii. Hyperplastic candidiasis (Figures 5 and 6): nonremovable whitish plaques, some­ Oral Candidiasis times associated with a burning sensation, 1. Epidemiology: Oral candidiasis is a very com­ that can be found on any mucosal surface. mon fungal infection that is seen in more than The differential diagnosis can include 95 percent ofHIV-infected patients during the oral hairy leukoplakia (see Oral Hairy course of their illness Leukoplakia, below) 2. Appearance (including various presentations), iv. Angulo?" cheilitis: fissures radiating from

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Figure 5. Hyperplastic candidiasis. Figure 6. Hyperplastic candidiasis.

Figure 7. Oral hairy leukoplakia. Figure 8. Oral hairy leukoplakia.

the corners of the moudl that are some­ days after the disappearance of clinical signs times covered with a removable white h. There are no CDC guidelines for prophy­ membrane. These fissures are sometimes laxis against candidal infections based on found in conjtmction with xerostomia CD4+ cell counts; however, prophylaxis

b. Because candida I organisms are ubiquitous with antifungal medications might be rec­ http://www.jabfm.org/ in healthy oral mucosa, potassium hydrox­ onul1ended in cases of high recurrence ide testing of these lesions is rarely helpful 4. Clinical and prognostic importance 3. Treatment and resistance a. Oral candidiasis is commonly seen in both a. Management can depend on the patient's HIV-positive and uninfected patients and is CD4+ (I-helper) lymphocyte count and the therefore not considered a diagnostic resistance of the organisms to medication marker for AIDS (see raj Symptoms and b. Empiric therapy may be initiated based on a Oral Lesions, and Their Association with on 25 September 2021 by guest. Protected copyright. presumptive diagnosis of oral candidiasis HIV Infection above). Nevertheles , oral c. First-line oral topical therapy includes nys­ candidiasis in HIV-positive patients has tatin pastilles and vaginal clotrimazole be'en established as a precursor to AIDS troches; oral troches and suspensions are within 1 to 2 years of its app arance more cariogenic than vaginal troches b. The frequency and type of candidia is are d. Topical therapy is most useful when CD4+ usually indicative of disea e progre sion. cell counts are higher than 150/pL Hyperplastic candidiasis is usually associ­ e. At lower CD4+ cell counts, systemic therapy ated with severe immunosuppression and al­ might be necessary. Oral fluconazole is of­ most always requires treatment with intra­ ten the first drug of choice venous therapy f. In cases of drug resistance, other imidazoles, c. TI~e DC recommends Pneu1l1ocystis carinii eg, itraconazole, or intravenous amphoteri­ pneumonia (PCP) prophylaxi in all HIV­ cin, might be required positive patients with a lu tOlyof ral can­ g. Treatment should be continued until 2 to 3 didiasis, regardless of D4+ c II c unto It i J Am Board Fam Pract: first published as 10.3122/jabfm.11.6.434 on 1 November 1998. Downloaded from

Figure 9. Kaposi sarcoma. Figure 10. Kaposi sarcoma.

Figure 11. Necrotizing ulcerative periodontitis. Figure 12. Linear gingival erythema.

unclear how often this recommendation is not essential followed 3. Management and treatment 5. Esophageal candidiasis a. Treatment is palliative only and is not neces­ a. Patients with oral candidiasis who com­ sary if the lesion is asymptomatic

plain of dysphagia, dysgeusia (abnormal b. Lesions can respond to acyclovir, ganci­ http://www.jabfm.org/ taste), or retrosternal discomfort are at risk clovir, tricyclic antidepressants, podophyl­ for esophageal candidiasis and should be lin, and retinoids, but usually recur after examined by endoscopy treatment is completed 4. Clinical and prognostic importance; trans­ Oral Hairy Letlkoplakia mission 1. Epidemiology a. Oral hairy leukoplakia can be a marker for on 25 September 2021 by guest. Protected copyright. a. Oral hairy leukoplakia is found most com­ disease progression and immunosuppression monly in male homosexual AIDS patients b. There is no known shedding of dle Epstein­ but is not considered diagnostic for AIDS Barr virus; transmissibility through intimate b. The lesions are associated widl the Epstein­ contact is unknown Barr virus. 2. Appearance, recognition, and diagnosis (Fig­ Kaposi Sarcoma ures 7 and 8) 1. Epidemiology a. Lesions are whitish, nonremovable, verti­ a. Kaposi sarcoma is a Iymphoproliferative cally corrugated hyperkeratotic patches typ­ neoplasm found most commonly in male ically found on the lateral margin of the homosexual AIDS patients tongue 2. Appearance, recognition, and diagnosis (Fig­ b. A presumptive diagnosis can be based on ures 9 and 10) clinical appearance and location. A defini­ a. Lesions can appear as macules, patches, tive diagnosis requires finding dle Epstein­ nodules, or ulcerations that are bluish, Barr virus on a biopsy of the lesion, but it is brownish, or reddish

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Figure 13. Minor apthous ulcer. Figure 14. Major apthous ulcer.

Figure 15. Herpes simplex ulcer. Figure 16. Herpes simples ulcer.

b. Kaposi sarcoma can be found anywhere in oral bacterial infection among HIV-infected the gastrointestinal tract and is commonly patients, and a very destructive type is seen seen on the hard or soft palate and gingiva more commonly in homosexual and bisex­ c. Differential diagnosis can include non­ ual men and smokers

Hodgkin lymphoma (ulcerative), bacillary b. There are no clearly known specific causa­ http://www.jabfm.org/ angiomatosis, and physiologic pigmentation tive agents; the periodontal flora ofHIV-in­ (macular) fected patients is no different from that of d. Definitive diagnosis of Kaposi sarcoma as an non-HIV-infected patients. Poor diet, poor AIDS-defining lesion requires biopsy oral hygiene, and xerostomia can increase 3. Management and referral the incidence of plaque, which can lead to a. Management requires referral to an oral on­ periodon ti tis cologist or an experienced oral health care c. Conventional or non-HIV-linked periodon­ on 25 September 2021 by guest. Protected copyright. provider tal disease is as common in HIV-infected b. Treatments include radiation, intralesional patients as in the general population chemotherapy, and less often, surgery 2. Symptoms, appearance, and recognition 4. Clinical and prognostic importance a. The most common manifestations fHIV­ a. Kaposi sarcoma in an HIV-infected patient associated periodontal disease include nec­ is diagnostic for AIDS and is indicative of rotizing ulcerative periodontitis and linear severe immunosuppression gingival eryth.ema b. Kaposi sarcoma can occur intraorally, either b. Necrotizing ulcerative periodontitis (Figure 11) alone or in association with skin, visceral, is rapidly progressive, causes extensive de­ and lymph node lesions struction of bone and periodontal tissue, i extremely painful, and is accompanied by Periodontal Disease spontaneous bl eeding and hali tosis. It is dis­ 1. Epidemiology tinguished from conventional periodontitis a. Periodontal disease is the most common by its accelerated rate of progression and its

Oral Health are and HIVDisease 441 J Am Board Fam Pract: first published as 10.3122/jabfm.11.6.434 on 1 November 1998. Downloaded from

deep-seated nongingival pain. It can also re­ e. Presumptive diagnosis can be made clini­ quire biopsy to differentiate it from other le­ cally; biopsy rules out other causes (eg, ma­ sions, eg, non-Hodgkin lymphoma and cy­ lignancy, opportunistic infections) and is tomegalovirus infection recommended for major ulcers and for c. Linear gingival erythema (Figure 12) occurs those ulcers that do not improve as a 2- to 3-mm erythematous band on the 3. Differential diagnosis gingiva accompanied by mild pain and a. Iatrogenic ulcers can result from treatment spontaneous bleeding. This condition re­ with zalcitabine, foscarnet, interferon, vin­ sponds poorly to conventional therapy cristine, or radiation 3. Treatment and referral b. Herpetic ulcers (Figures 15 and 16) can occur a. Management requires referral to a dentist intraorally, involving the keratinized (non­ for frequent visits movable) oral mucosa, and periorally, in­ b. Dental treatment includes antibiotics, mouth volving the lips and skin; they can be rinses, irrigation with povidone iodine, and painful, solitary or multiple, and vesicular; mechanical cleaning and they might coalesce. These ulcers can 4. Clinical and prognostic importance; trans­ be treated with acyclovir mission c. Cytomegalovirus ulcers are painful, with a. Necrotizing ulcerative periodontitis is asso­ punched-out, nonindurated borders and ciated with severe immune deterioration. are usually associated with disseminated Linear gingival erythema might be a precur­ disease. They can be treated with acyclovir sor to necrotizing ulcerative periodontitis or ganciclovir b. Transmissibility through intimate contact is d. Other ulcers can be caused by severe neutro­ unknown penia, squamous cell carcinoma, syphilis, 5. Prevention and oral care deep fungal infections, and mycobacterial a. Patients should rinse with chlorhexidine, as infections well as brush their teeth and gums and floss 4. Therapeutic management regularly a. Palliative therapy includes analgesic-anes­ thetic mouth rinses and topical ointments Recurrent Aphthous Ulcers b. Corticosteroids can be effective as a topical

1. Epidemiology medication, a mouth rinse, or an oral medi­ http://www.jabfm.org/ a. There is no known etiologic agent for recur­ cation. Prolonged use of oral corticosteroids rent aphthous ulcers, but stress, acidic foods, can exacerbate immunosuppression and tissue-barrier breakdown have been re­ c. Alternative treatment options include tha­ ported to precipitate their occurrence lidomide given orally, or Mile's mixture (tet­ b. Ulcers can be found in both HIV-infected racycline, nystatin, hydrocortisone) given as and uninfected patients a mouth rinse c. Ulcers can be more severe and prolonged in d. Lesions should be reevaluated after 1 to 2 on 25 September 2021 by guest. Protected copyright. HIV-infected patients but occur no more months of treatment commonly than in the general population 5. Clinical and prognostic importance 2. Appearance, recognition, and diagnosis a. Major ulcers are associated with severe im­ a. Ulcers are variable in size and can be shallow munosuppression or deep b. Minor ulcers (Figure 13) are 2 to 5 mm in Other Oral Conditions diameter, covered by a pseudomembrane, 1. Parotid gland enlargement is found more com­ and surrounded by an erythematous halo monly in HIV-infected children, is usually c. Major ulcers (Figure 14) are greater than 10 nontender, and can be either unilateral or bi­ mm in diameter, painful, persist for months, lateral. It can occur during the course ofHIV and can cause odynophagia and impairment disease or as a medication side effect. Xerosto­ of speech and swallowing mia can occur secondarily and should be d. Lesions usually involve the nonkeratinized treated. Surgery is indicated only for cosmetic (movable) oral mucosa reasons

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2. Xerostomia," or reduced salivary flow, promotes ATTITUDES dental caries and periodontitis. Patients will complain of dry mouth and require frequent Physician Attitudes Should Reflect the Following: dental visits. Treatment is symptomatic and in­ 1. Compassion and objectivity when dealing with cludes artificial saliva, chewing or sucking sug­ issues related to lIIV disease arless candy, cholinergics, etc. Xerostomia can 2. Awareness of the value of a comprehensive be caused by medications (eg, zidovudine, di­ oral examination for early detection and care danosine, foscamet) of patients with lIIV disease 3. Awareness that primary care physicians, as well Provider Issues as dentists, are responsible for oral health care Unit'ersal Precautions and Occupational Exposure 4. Awareness of one's own abilities and limita­ 1. Universal precautions are adequate protection tions and the need for further consultation for the medical and dental provider, unless the when appropriate patient has also been diagnosed with active tu­ 5. Acceptance of responsibility to act as the pa­ berculosis tient's advocate and to help with access within the health care system Medical Issues Related to I1IV-Infected Patients Who 6. Recognition of the importance of educating I1ave Oral Manifestations and involving HIV-infected patients, their 1. Indications for antibiotic prophylaxis for den­ partners, and caregivers in their oral care tal procedures 7. Understanding of the impact that oral lesions a. Guidelines set by the American Heart Asso­ can have on a patient's overall health and well­ ciation for subacute bacterial endocarditis being prophylaxis are the same for both HIV-in­ fected and uninfected patients SKILLS b. If the absolute neutrophil count is less than 500/pL and the patient is not receiving bac­ Physician Skills Should Enable the Physician to tericidal antibiotics, the patient should re­ Do the Follo\ling: ceive prophylactic antibiotics. A low CD4+ 1. Take an appropriate oral history and perform a cell count as such does not definitively sug­ comprehensive oral examination

gest the need for antibiotics 2. Perform appropriate screening and preventive http://www.jabfm.org/ 2. Bleeding precautions oral health care a. In patients with a history of impaired hemo­ 3. Recognize and manage common oral health stasis, the platelet count, prothrombin time problems seen in lIIV-infected patients (PT), partial thromboplastin time (PIT), 4. Counsel and educate lIIV-infected patients, and complete blood cell count should be de­ their partners, and their caregivers about oral termined before planning extensive surgical care on 25 September 2021 by guest. Protected copyright. intervention 5. Know when and to whom to refer patients for b. Most routine dental procedures can be done further case evaluation and management if the platelet count is greater than 60,0001 6. Access medical resources, including the Inter­ pL and if the PT and PIT are less than two net and MEDLINE, for additional informa­ times the normal range tion 3. There are no major healing differences between HIV-infected patients compared with non­ Bibliography HIV-infected patients, even if the HIV-in­ American Academy of Family Physicians. Recommended fected patient is severely immunosuppressed core educational guidelines for family practice resi­ 4. Most dental needs of the HIV-infected pa­ dents: lIN infection/AIDS. AAFP reprint no 273. Kansas City, Mo: American Academy of Family Physi­ tient can be provided by general dentists, and cians, Feb, 1992 they, as with all other health care providers, Brahim ]S, Roberts MW. Oral manifestations of human are obligated by the Americans with Disabil­ immunodeficiency virus infection. Ear Nose Throat] ities Act to provide care for HIV-infected pa­ 1990;69:464.467-9,472-4. tients Centers for Disease Control and Prevention. Transmission

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