Guide to Oral Health Care for People Living with HIV/AIDS - PowerPoint Presentation

1. Guide to Oral Health Care for People Living with HIV/AIDSOral Diseases, Dental Emergencies and Patient Education March 28, 2014

2. IntroductionHRSA/HAB sponsored curriculum designed to assist primary care providers to recognize and manage oral health and disease for people living with HIV/AIDS. Benefits of oral health integration in primary care:Improve earlier linkage to oral health careReduce avoidable complications including oral-systemic Reduce burden/costs of preventable diseasesImprove OH literacy of health care professionals and public Webinar seriesChapters 1-2: was conducted on March 7 Chapters 3-5: March 28, 2-4 PM Webcasts on TARGET Center: (https://careacttarget.org)2

3. HousekeepingEveryone is in listen only modeQ&A will be taken during designated breaks through presentationQuestions will be handled via chat pod or operator assistanceIf you are viewing the webinar in a group, please provide the total number of people viewing the webinar in the appropriate pod.3

4. Guide to Oral Health Care for People Living with HIV/AIDSChapter 3: Oral Diseases

5. Chapter 3:Course Authors:Jeffery D. Hill, D.M.D.Carol M. Stewart, D.D.S., M.S.Consultant:Vincent C. Marconi, M.D.Series Editor:David A. Reznik, D.D.S.HRSA, HIV/AIDS Bureau Consultant:Mahyar Mofidi, D.M.D., Ph.D.5

6. Chapter 3: Learning ObjectivesAfter viewing this presentation the learner should be able to:1. Be familiar with recognition and management of oral lesions commonly seen in HIV disease.2. Enhance ability of the medical team to recognize emergency dental needs vs. routine dental care.3. Discuss with patient key elements to maintain oral health.6

7. Clinical PresentationCategorizing lesions by clinical characteristics helps to focus the differential diagnosisWhite lesionsRed lesionsUlcerated lesionsPapillary lesionsPigmented lesions7

8. Pseudomembranous candidiasisWhite LesionsClinical presentationSigns: -multiple white plaques -any mucosal surface -can be scraped off -red surface beneathSymptoms: -burning sensation -metallic tasteEtiologyCandida albicans (most common)C. glabrataDiagnosisclinical appearance cytological smear Treatment (14 days)topical anti-fungalsystemic anti-fungal8

9. Oral hairy leukoplakiaWhite LesionsClinical presentationSigns: -vertical corrugations -lateral border of tongue -usually bilateral -hairy or shaggy appearance -cannot be wiped offSymptoms: -painlessEtiologyEpstein-Barr virusDiagnosisclinical appearance Treatmentusually none required high-dose anti-virals9

10. Erythematous candidiasisRed LesionsClinical presentationSigns: -macular, papillary atrophy -dorsal tongue, hard palate -edentulous ridge under denture or removable partial dentureSymptoms: -asymptomatic or burning sensationEtiologyCandida albicans (most common)C. glabrataDiagnosisclinical appearance cytological smear Treatmenttopical anti-fungal10

11. Angular cheilitisRed LesionsClinical presentationSigns: -labial commissure -fissured, scaley patches -unilateral or bilateralSymptoms: -pain, bleeding -burning sensationEtiologyCandida albicansContributing factors: nutritional deficiencyloss of vertical dimensionDiagnosisclinical appearance Treatmenttopical anti-fungalresolve contributing factors11

12. Linear gingival erythemaRed LesionsClinical presentationSigns: -distinctive red band -free gingival margin -minimal edemaSymptoms: -minimal bleeding -mild pain/tendernessEtiologyunknownDiagnosisclinical appearance Treatmentthorough dental cleaningchlorhexidine rinse12

13. Aphthous ulcersUlcerated LesionsClinical presentationSigns: -non-keratinized mucosa -erythematous border -yellowish-gray pseudomembraneSymptoms: -very painfulEtiologyimmunologic defect triggers include physical trauma and stressDiagnosisclinical presentation Treatmentoften heal spontaneouslytopical corticosteroidssystemic steroids13

14. Recurrent intraoral herpesUlcerated LesionsClinical presentationSigns: -keratinized mucosa -whitish-yellow border -red interiorSymptoms: -painfulEtiologyHSV-1Diagnosisclinical presentation viral culture Treatmentsystemic anti-virals14

15. Herpes zosterUlcerated LesionsClinical presentationSigns: -trigeminal nerve, v2 & v3 -unilateral clustered vesicles rupture & form small ulcersSymptoms: -severe pain/paresthesiaEtiologyvaricella-zoster virus Diagnosisclinical presentation Treatmentantiviralspain medications15

16. Necrotizing gingivitisUlcerated LesionsClinical presentationSigns: -usually localized -marginal necrosis -papillary necrosisSymptoms: -spontaneous bleeding -very painfulEtiologybacteria (gram-negative)Diagnosisclinical appearance Treatmentdebridementantimicrobial rinseantibiotics16

17. Necrotizing “ulcerative” periodontitisUlcerated LesionsClinical presentationSigns: -localized or generalized -soft tissue necrosis -alveolar bone necrosisSymptoms: -tooth mobility -spontaneous bleeding -fetid odor -very painful (“deep-seated” jaw pain)Etiologybacteria (gram-negative)Diagnosisclinical appearance Treatmentdebridementantimicrobial rinseantibiotics17

18. Squamous cell carcinomaUlcerated LesionsClinical presentationSigns: *most common locations -posterior lateral tongue -floor of mouth -ventral tongue -soft palate *highly variable appearance -ulceration with raised, rolled margins -red, velvety lesion with induration -exophytic ulcerated mass -mixed red/white lesion -white plaqueSymptoms: sometimes painful18

19. Squamous cell carcinomaUlcerated LesionsEtiology/risk factorsetiology unknowntobaccoalcoholnutritional deficiencieshuman papillomavirusDiagnosisincisional biopsy Treatmentsurgical excisionradiation therapychemotherapyPre- & Post- treatmentsmoking cessationalcohol cessationaggressive oral health careclose follow-up & periodic re-evaluation19

20. Squamous papilloma Verruca vulgarisPapillary Lesions (oral warts)Clinical presentationSigns: -single or multiple -any mucosal surface -sessile or pedunculated -small fingerlike projections -rough, pebbled surface -whitish or light pinkSymptoms: -non-painful (unless traumatized)Etiologyhuman papillomavirusDiagnosisclinical appearance Treatmentsurgical excisioncryotherapy20

21. Condyloma acuminatum Focal epithelial hyperplasiaPapillary Lesions (oral warts)Clinical presentationSigns: -multiple/clustered -any mucosal surface -sessile -slightly grainy surface -whitish or light pinkSymptoms: non-painfulEtiology/risk factorshuman papillomavirusDiagnosisclinical appearance Treatmentsurgical excisioncryotherapy21

22. Kaposi Sarcoma - earlyPigmented LesionsClinical presentation - earlySigns: -lateral posterior hard palate or gingiva -dorsal tongue -slightly diffuse, macular -purplish-brown Symptoms: -non-painfulEtiologyHHV-8 (KSHV)DiagnosisbiopsyTreatmentHAART (optimal)chemotherapysurgical excision22

23. Kaposi Sarcoma – “mid-stage”Pigmented LesionsClinical presentation – “mid-stage”Signs: -slightly raised -more diffuse -darker purple-brown -ulcerationsSymptoms: -painful ulcerations, especially secondary to trauma23

24. Kaposi Sarcoma - advancedPigmented LesionsClinical presentation – advancedSigns: -multiple sites or solitary lesions -nodular dark red or purple-brownSymptoms: -painful ulcerations -bulky, interfere with function -spontaneous bleeding24

25. Questions?25

26. Guide to Oral Health Care for People Living with HIV/AIDSChapter 4: Diagnosis and Management of Dental Emergencies in the Medical Office

27. Chapter 4:Course Author:Carol M. Stewart, D.D.S., M.S.Consultant:Vincent C. Marconi, M.D.Series Editor:David A. Reznik, D.D.S.HRSA, HIV/AIDS Bureau Consultant:Mahyar Mofidi, D.M.D., Ph.D.27

28. Chapter 4: Learning Objectives For the medical team to recognize emergency dental needs vs. routine dental careBe able to understand when and what dental care could be started in the medical office28

29. Course OverviewAssessment of oral concerns presenting in any medical practiceReview of treatment options in the medical officePatient educationUse of analgesicsUse of antibioticsReferralDiscussion and case presentations of dental emergencies requiring rapid referral to an emergency roomDiscussion and case presentations of dental emergencies requiring referral to a dentist and an appropriate time frame for that referral29

30. IntroductionOral health care consistently ranks among the top unmet needs in Statewide Statement of HIV/AIDS Needs Surveys (1-4)Dental disease often occurs from lack of routine care, which may be due to: (5-7)lack of understanding regarding importance of oral health to overall healthinadequate financial resourcesinadequate access to dental providersdental fear/anxietyfear of discriminationfear of breach of confidentiality30

31. A Healthy MouthGingiva – pink, firm, stippled, without pain, and without bleeding upon brushingTeeth – lack of unrestored decay, without pain or sensitivity to sweets, hot or cold foods or beverages31

32. Triage Levels for ReferralsRoutine (2-4 weeks)Urgent (24-48 hours)Emergency (Same day)32

33. Routine Dental Referral (2-4 weeks)Teeth:Bothersome for several days, weeks, months Discomfort is mild, not disruptive to routineOTC meds will relieve painPain is not spontaneous, may start after eating sweet foods, cold fluids; Does not persistGingiva/Periodontal:Plaque, calculus Mildly inflamed gingiva visible Mild pain or discomfort33

34. Urgent Referral 2 days (1)Teeth:Pain is severe, disruptive to daily routinePain is constant, sharp, spontaneous and may be localized to one or two teethInability to eatExtreme tenderness to palpation or tapping on the infected tooth34

35. Urgent Referral 2 days (2)Gingiva/ Periodontal:Spontaneous and /or prolonged bleeding of gingivaSeverely altered gingival architectureFever, infection, purulence35

36. Emergency Referral (Same day)Compromised airway, often presenting as difficulty breathing, altered voice, and trismusRapidly spreading infectionInfection/ swelling approaching eyeFever, lymphadenopathy, weight loss, extreme fatigue or lethargy, dehydrationSpontaneous intraoral hemorrhage36

37. Case 1History: A 24 year old female presents to the medical office for a routine follow-up evaluation. She has a non-detectable viral load and CD4 count of 550. Chief concern: “Sore gums for 2 months”37

38. Case 1 (Gingival concerns) Finding: Gingival inflammation, which started a week after using a new toothpaste. Diagnosis: HypersensitivityIrritation is due to irritation from abrasive agents in “tartar control” toothpastes, or hypersensitivity to agents. Medical Office Management: Recommend a fluoride containing toothpaste with no abrasives, whiteners, or “tartar control” agentsReferral: Routine38

39. Case 1 (Tooth-related concerns)Finding: Asymptomatic, long-standing fractured tooth in mandibular left posterior quadrantMedical Office Management: No urgent care required for fractured toothReferral: Routine39

40. Case 2: “Gums hurt” “Bad breath & a nasty taste”History: 42 yr. male presents for follow up medical appointmentChief concern: “Gums hurt” “Bad breath & nasty taste” Pain is diffuse, intermittent, for 3 months Clinical findings: Plaque and gingivitis40

41. Case 2 – Treatment for gingivititsClinical Diagnosis: Chronic plaque-induced gingivitis Medical Office Management:Rx: 0.12% chlorhexidine gluconate rinse (Peridex or PerioGard) Sig: Rinse with 15 mL and expectorate morning and at bedtime Rx: Prevident Boost 5000 Toothpaste with Fluoride (1.1% NaF)Sig: Use at bedtime every night according to manufacturer's directionsDental Referral: Routine41

42. Case 3History: A 22 year- old male complains of “red tender gums.” He has a history of injection drug use, which he discontinued 2 years ago when he was diagnosed with HIV infection. He is somewhat compliant with ART therapy. He brushes once per day. Findings: Erythematous band-like gingival inflammation, especially prominent in the anterior teeth. If the gingival condition does not improve following a periodontal debridement and improved home care, Linear Gingival Erythema (LGE) may be considered.Photo 242

43. Case 4Treatment: Endodontic procedure “root canal” or extraction. The accumulation of purulence eventually results in creating a tract through the bone and associated expansion of the gingival tissue. The pain often diminishes due to pressure being released when purulence breaks through the bone. Medical Office Management: Recommend warm salt water rinses. Consider antibiotics for 7 days. Penicillin or AmoxicillinDental Referral: Within one week if possible. These may become acutely painful again within 1-2 weeks.43

44. Antibiotics in DentistryIf no penicillin allergyPenicillin VK (500mg) Two tablets stat, then one q 6 h for 7 daysORAmoxicillin 500 mg q 8 h for 7 daysIf allergic to penicillinClindamycin 300 mg q 8 h for 7 days44

45. Case 5 – PericornitisClinical: 19 year old male with CD4+ of 310 and Viral Load non-detectable. Compliant with ART.CC: Moderate pain in lower right for one weekObservation: Inflamed flap of tissue over erupting third molar45

46. Case 5 – Management of pericornitisClinical diagnosis: Pericornitis (bacterial infection) Medical Office Management Considerations:Warm salt water rinses bidRX: Chlorhexidine 0.12% rinse bid until definitive dental managementRx: If swelling and fever, consider po antibiotics i.e., penicillin (PCN) or amoxicillin, if no PCN allergy historyIf PCN allergy, consider po clindamycinAnalgesics consistent with mild-moderate pain level (NSAIDS or Acetaminophen) Referral: Appointment within 1 week. * Patient should be instructed to call or return to clinic if pain, fever, or swelling increase before dental appointment can be scheduled, or report to ED46

47. Case 6: Floor of mouthHistory: 31 yr male with rapidly increasing right facial swelling; Poorly controlled diabetic.Chief concern: “Toothache” started in right lower wisdom tooth, five days ago. Dentist provided penicillin, but it is not working. Clinical Findings: (as noted in photo)Trismus indicates an infection in the posterior mouthDo not “force” the mouth open to evaluate the area The trismus will resolve once the infection is resolvedTemp 101◦ FDiagnosis: Abscess with multiple space infectionManagement: Emergency referral to emergency department.47

48. Case 7 – Oral disease secondary to methamphetamine useHistory: 23 year male, diagnosed with HIV 1 yr ago. “All my teeth are crumbling, but the top left eye tooth is killing me”. “Also, my gums and the roof of my mouth burn.” Findings: He has used methamphetamine for 1 year. He is rinsing with OTC peroxide tid, and using OTC topical benzocaine for pain 4-5 times per day. Exam: Tapping on tooth #11 with a finger elicited sharp pain.48

49. Case 7 – Management of severe dental disease Clinical diagnoses: Acute pain from dental infection due to advanced decay on tooth #11 (Maxillary left cuspid) Methamphetamine associated advanced generalized dental decayHyposalivation “dry mouth” from recreational drugs49

50. Case 7 – Management of severe dental disease Medical Management Considerations:Instruct patient to discontinue use of OTC peroxide and excessive benzocaine Pain management and nutritional supplementation are very important as a patient in this much discomfort will have trouble eating and taking medicationsOTC Biotene rinse for oral dryness Refer for rehabilitation counseling Appropriate pain management Nutritional counseling/supplementation Referral: Urgent referral oral and maxillofacial surgeon for extraction of tooth #11 and plan for extraction of non-restorable teeth.50

51. OTC agents for xerostomia or ‘dry mouth’MouthrinseBiotene - Xylitol -sweetened, alcohol-free with helpful enzymes. Coating agent.Artificial SalivaGumShould be sugar-free, recommend xylitol sweetened51

52. Minor Aphthous UlcersEtiology: An altered local immune responseAppearance: Round shallow ulcer, < 0.5 cm diameter, with grey/white covering membrane, and red haloUsually found on lips, tongue, and soft palate52

53. Treatment of Aphthous UlcersTopical Corticosteroids:Triamcinolone Acetonide Dental Paste 0.1% (Kenalog and Orabase) Apply small amount with cotton swab to area after meals. Dexamethasone elixir 0.5mg/5mL. Disp: 100mL have patient rinse with 5 mL for one minite, then expectorate. Instruct patient not to eat or drink for at least 30 minutes0.05% fluocinonide ointment (Lidex) with 50:50 orabase. Apply small amount on a cotton swab to area after meals.153

54. Antibacterial, Analgesic, and Coating Agents for Oral UlcerationsAntibacterial:Chlorhexidine gluconate oral rinse 0.12% Rinse with 15 ml for 30 seconds and spit out bid for 7 daysCoating agent:Benadryl elixir (12.5 mg/ml of diphenhydramine) or (alcohol-free solution) and Maalox 50:50 Swish with 5 ml and expectorate tidAnalgesic: 2% viscous lidocaineApply to ulcer with a Q-tip. (Do not swish due to possible loss of gag reflex.)54

55. Case 8History: 23 yr male with extreme oral pain, “Loose teeth and bad breath for at least a month”. Findings: Edematous, erythematous, gingiva that easily bleeds upon palpation. Note the loss of gingival architecture.Differential diagnosis: Necrotizing periodontitisUncontrolled insulin dependent diabetes Blood dyscrasia such as leukemia Drug induced immune suppressionDental Referral: UrgentOffice Management:AnalgesicsAntibiotics that cover both gram+ bacteria(Penicillin or Amoxicillin) plusgram – bacteria (Metronidazole)Chlorhexidine gluconate 0.12% rinse bidNutritional supplementation55

56. Case 9Clinical: 28 yr male presents as walk-in emergency to your office “mouth is bleeding”.Findings: Intraoral spontaneous gingival bleeding and ecchymosis lateral tongue, lips and buccal mucosa. No skin ecchymosis was detected.Medical Management is key here, there could be an issue with clotting factors or idiopathic thrombocytopenia purpura.Diagnosis: Spontaneous bleeding due to inadequate clotting factors56

57. SummaryThe enhanced ability of the medical team:1. to screen and triage oral health concerns and 2. to provide education and initial therapyis a critical step in improving outcomes for patients with HIV infection.57

58. Questions?58

59. Guide to Oral Health Care for People Living with HIV/AIDSChapter 5: Patient Oral Health Education for Individuals Living with HIV/AIDS

60. Chapter 5:Course Author:Jill A. York, D.D.S.Consultant:Vincent C. Marconi, M.D.Series Editor:David A. Reznik, D.D.S.HRSA, HIV/AIDS Bureau Consultant:Mahyar Mofidi, D.M.D., Ph.D.60

61. Chapter 5: Learning Objectives Be familiar with proper oral hygiene instructions and home careUnderstand the importance of nutrition on oral health for people living with HIV disease61

62. Oral Hygiene Instructions

63. Good Dental HealthHealth issues in the mouth can be one of the first signs of HIV infection and is a predictor of HIV progression probability.A weakened immune system can be further stressed by poor dental health.Soft tissue ulcers, gingival/periodontal disease, and decayed teeth can be portals that allow bacteria and other infectious organisms into the blood stream.Identifying oral health concerns early allows for treatment before those concerns progress to other more serious infections.Poor dental health including loose or painful teeth can severely impact the HIV positive patient’s ability to eat and take medications.63

64. Proper Brushing TechniqueTilt the brush at a 45° angle against the gumline and sweep or roll the brush away from the gumline.Gently brush the outside, inside and chewing surface of each tooth using short back-and-forth strokes.Gently brush your tongue to remove bacteria and freshen breath.64

65. Brushing TipsBrush at least twice a day.Brush for at least two minutes.Have a standard routine for brushing.Always use a toothbrush with soft- or extra-soft bristle.Change your tooth brush regularly.Choose a brush that has a seal of approval by the American Dental Association (ADA).Electric is fine, but not always necessary.Choose a toothpaste that contains fluoride and has the ADA seal of acceptance.65

66. Proper Flossing TechniqueUse about 18" of floss, leaving an inch or two to work with.Hold the floss around the front and back of one tooth, making it into a “C” shape.Gently follow the curves of your teeth.Be sure to clean beneath the gumline, but avoid snapping the floss on the gums.66

67. Flossing TipsFloss once a day.Take your time.Choose your own time.Don’t skimp on the floss.Choose the type that works best for you.Waxed and unwaxedFlavored and unflavoredRibbon and threaded67

68. Oral Hygiene ProductsInterdental BrushesEnd-Tufted BrushesOral IrrigatorsInterdental TipsMouthwashes and RinsesFluoride rinsesAntiseptic mouthwashesCombination mouthwashesTongue Scrapers68

69. Denture CareRemove and rinse dentures after eating.Clean your mouth after removing your dentures.Scrub your dentures at least daily.Handle your dentures carefully.Soak dentures overnight.Rinse dentures before putting them back in your mouth, especially if using a denture-soaking solution.Schedule regular dental checkups.Do not use toothpaste or any household cleaning products.69

70. Nutrition and Oral Health

71. HIV/AIDS and NutritionTreatment for HIV/AIDS:Medications can have serious side effects including nausea, vomiting and diarrhea among others that can also affect nutritional status.Antiretroviral Medication and Nutrition:Medications can have many side effects that can negatively affect how the body absorbs and processes food.Nutrition Implications:Improving nutritional status in HIV/AIDS patients can improve clinical outcomes.71

72. Nutrition InterventionsGood nutritional statusWeight regained or maintained; no macronutrient or micronutrient deficienciesNutritional needs metAdditional energy needs met; consumption of adequate diet with foods from all food groups; nutritional management of symptomsStrengthened immune systemImproved ability to fight HIV and other infectionsReduce vulnerability to infectionsReduced frequency and duration of opportunistic infections and possibly slower progression to AIDS72

73. Healthy EatingAdequate Calories: 35 to 40 calories per kilogram – or 16 to 18 calories per pound.Adequate Proteins: 2 to 2.5 grams of protein per kilogram of body weight, or 0.9 to 1.1 grams per pound.Fats: less than 30% of your daily calories.Adequate Minerals: Selenium and zinc are important to your immune system.Vitamins: B vitamins and vitamins A and C are essential in maintaining your immune system.73

74. Nutritional RecommendationsFruits and VegetablesHigh-Quality ProteinWhole GrainsHealthy FatsAnti-Inflammatory FoodsEliminate Non-nutritious FoodsAvoid Canned and Processed Foods74

75. Major Nutrients for Oral HealthVitamin DCalcium and phosphorous absorptionBuilds skeletal bones and teethAlveolar process supportVitamin AForms oral epitheliumEnhances immune systemWound healingB-Complex VitaminsFormation of new cellsCofactor for nutrientsProteinSupports growth of cellsResist infectionMakes antibodiesVitamin CSupports collagen formationPromotes capillary integrityEnhances immune responseIron, Zinc, CopperSupports collagen formationWound healingRegulates inflammation75

76. Counseling TipsTo reduce cariogenicity of the diet, for adults suggest limiting eating events three times a day with no more than two between meal snacks and eliminating very sticky food rich in carbohydrates and sugars such as potato chips or sticky candies such as taffy.For children who need the energy provided by between meal snacks, they should be healthy food choices low in cariogenic potential such as cheese, raw vegetables, meat roll-ups, and fresh fruit.When oral hygiene does not follow a meal, suggest rinsing with water or chewing sugar-free gum.76

77. Counseling Tips (continued)To stimulate salivary flow, include cool, sour, or tart (sugar free) foods, increase water intake, and suck on sugar free mints.Incorporate low-fat calcium rich foods in the diet, spaced throughout the day for the best absorption rate.When reading a food label, don’t forget to look at the serving size and multiply accordingly.Resources for patient education:http://www.ada.org/2392.aspxhttp://www.eatright.org/77

78. Patient Education Handouts78

79. Questions?79