Managing the care of patients infected with bloodborne diseases
LOUIS G. DePAOLA, D.D.S., M.S.
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ABSTRACT
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Background. The emergence of the bloodborne pathogens HIV, the cause of AIDS; hepatitis B virus, or HBV; and hepatitis C virus, or HCV, has been a milestone in the history of the dental profession. In the early 1980s, new cases of AIDS increased dramatically, and fear of acquiring this disease compelled clinicians to modify the delivery of medical and dental care to allay fears of transmission on the part of both patients and health care workers. Arguably, the AIDS pandemic has been the most significant factor in the evolution and delivery of modern medical and dental care in the last century.
Overview. To help ally fears and remove barriers to caring for the HIV population, the Centers for Disease Control and Prevention, or CDC, introduced the concept of universal precautions in 1983. This was followed by the Occupational Safety and Health Administration’s Bloodborne Pathogens Standard in 1991. Specific to the dental profession was the development of the principles of infection control in dentistry recommended by the CDC (1993); the American Dental Association (1995) and the Organization for Safety & Asepsis Procedures (1997). While initially difficult for some clinicians to acknowledge, these recommendations now are universally accepted throughout the profession, and provision of oral health care to patients infected with bloodborne disease is becoming commonplace. Compliance with recommended infection control practices remains an important component of dental practice. But it must be accompanied by an understanding of infectious and bloodborne diseases and the medical/dental management of the care of infected dental patients.
Conclusions and Practice Implications. The emergence of the bloodborne pathogens and the increasing number of infected patients who seek oral health care compel clinicians to have a thorough knowledge about bloodborne diseases and the medical/dental management of the care of patients presenting with HIV, HBV or HCV infection.
More than 20 years have passed since the first report on June 5, 1981, of an unusual cluster of cases of Pneumocystis carinii pneumonia and other opportunistic infections in five homosexual men in Los Angeles that heralded the arrival of AIDS in the United States.1 This emergence of HIV disease and other bloodborne pathogens has significantly affected the practice of dentistry. Perhaps no other single disease entity has affected the profession as much as has HIV/AIDS. HIV has infected more than 42 million people worldwide2 and approximately 800,000 to 900,000 Americans are infected with HIV disease, 30 percent of whom are unaware of their infection.2–4 In the United States alone, an estimated 40,000 people are newly infected each year.3,4 Some of the important events that occurred in the first 20 years of the AIDS pandemic are listed in Box 1
.1,5–15
Compliance with recommended infection control practices must be accompanied by an understanding of infectious and bloodborne diseases.
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HIV DISEASE
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Although a cure for HIV infection remains elusive, significant advancements in the medical management of HIV disease have markedly reduced the morbidity of this disease in the United States and have improved the overall life expectancy of those infected with HIV (Box 1
). The use of highly active antiretroviral therapy, or HAART, has evolved into the standard of care for the management of HIV/AIDS. It has resulted in prolonged suppression of the viral load and significant improvement in immune function, as well as a 60 to 80 percent reduction in new AIDS-defining conditions, hospitalizations and deaths.7,8,16–18 While highly effective in inhibiting the replication of HIV and reconstituting immune function, many of the drugs in the HAART regimens cause significant adverse reactions16–18 and have well-documented, multiple, adverse drug reactions and interactions (Table 1).16–18 These adverse side effects include nausea, vomiting, diarrhea and other gastrointestinal and systemic symptomatology that often can be severe and sometimes can be fatal.16–18
Additionally, a class of antiretroviral agents called the protease inhibitors has been implicated in a number of significant side effects that include development of insulin-resistant diabetes, abnormally high glucose tolerance test values, lipodystrophy (blood lipid changes, hypertriglyceridemia and hypercholesterolemia) and fat redistribution (increased abdominal girth, thin extremities, buffalo hump, enlarged breasts).16–24 The implications of these reactions have not been determined completely, but several studies suggest that elevated levels of lipids, triglycerides and glucose, known to increase cardiovascular risk in patients without HIV, may predispose patients receiving HAART to increased risk of cardiovascular disease.16,25
In the early years of the epidemic, patients usually died of complications from one or more of the opportunistic infections, or OIs, that developed as a result of profound immunosuppression (CD4 count < 200 cells/cubic millimeter).16,26,27 With HAART and subsequent immune reconstitution, OIs, although still encountered in patients with HIV/AIDS, are seen less frequently.16,27 However, appropriate prophylaxis for OIs, when indicated, is frequently instituted when the CD4 count falls below 200 cells/mm3, but this may be safely stopped as long as adequate evidence of immune reconstitution persists.16,27–30 The most common OIs found in patients with HIV/AIDS and the currently recommended therapy are listed in Table 2.16 The mouth and pharynx frequently are the site of OIs, and oral health care providers play a critical role in the early diagnosis and treatment of these lesions.
People with HIV infection commonly receive HAART and one or more of the antiviral/antifungal regimens listed in Table 2.16 A patient’s lack of anticipated clinical response to a combined HAART/antiviral/antifungal regimen may suggest that he or she has developed resistance, which is becoming more frequent and problematic.16 This developing resistance pattern, coupled with multiple adverse drug reactions and interactions—which are common in patients receiving HAART—compel clinicians to be attentive to the drugs each patient is currently taking, any new drugs to be prescribed and the potential interactions that can occur with the introduction of new medication(s) into existing treatment regimens. Therefore, a thorough evaluation of each HIV patient’s dental, medical and treatment regimens must be examined and assessed before any dental care is delivered.
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HEPATITIS
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At least two other significant bloodborne pathogens are frequently encountered in modern dental practice: hepatitis B virus, or HBV, and hepatitis C virus, or HCV.
HBV.
HBV is transmitted very efficiently by contact with blood and blood products, by sexual contact and, to a lesser extent, perinatally. This bloodborne infection causes approximately 300,000 acute infections annually in the United States. Chronic HBV infection develops in approximately 15,000 to 30,000 (10–15 percent) of these cases, and there are an estimated approximately 1 million HBV carriers in the U.S. population.31 Fortunately, the infection resolves in 90 to 95 percent of those infected with HBV. For the small minority who develop chronic disease, persistent infection can lead to chronic progressive hepatitis, cirrhosis or hepatocellular carcinoma32,33 and causes 5,000 to 6,000 deaths per year owing to liver failure.32,33
HCV.
Infection with HCV also accounts for significant morbidity and mortality in the estimated four million Americans (1.8 percent) who are carriers of the virus. HCV is transmitted efficiently by blood and blood products and is rapidly transmitted by injection drug use, or IDU; however, sexual and perinatal transmission of HCV seems to be infrequent.34 More selective and specific HCV assays have reduced the incidence of transfusion-transmitted HCV significantly, but IDU remains a major risk factor in the acquisition of HCV infection.34,35
Through multiple mechanisms that have yet to be completely understood, HCV seems to escape immune surveillance. This results in more than 85 percent of those infected being in a chronic carrier state. Symptoms, if present, generally are benign, and most affected patients are relatively asymptomatic for the two decades after infection. Because of the lack of symptoms, the majority of those infected remain unaware of their serostatus.34 However, as time progresses, so does the disease, leading to necrosis, cirrhosis with associated decreased liver function and an increased incidence of hepatocellular carcinoma.35 Early diagnosis is critical, and anyone who has ever performed behavior that places him or her at risk of developing HCV should be encouraged to be tested for the virus, as well as other blood-borne diseases.34–36
People with HCV infection should be followed closely for evidence of progression of liver disease, because anti-HCV therapy may be indicated.34,36 New therapies such as interferon-alfa, antiviral therapy (such as ribavirin) and, most recently, pegylated interferon alfa have met with some success.34,36,37 However, HCV replicates very rapidly and is genetically diverse, resulting in numerous mutations, viral resistance and therapeutic failure.34–37 Anti-HCV therapy is long (six to 12 months) and arduous, and its side effects (such as profound fatigue, depression, malaise and myalgia) are frequent and pronounced.34,36,37 Unfortunately, because of the severity of side effects, many patients elect to discontinue anti-hepatitis C therapy and may be unwilling and/or unable to undergo elective dental care.33 Therefore, the clinician should consider deferring elective dental procedures until the interferon regimen has been completed. However, because of the depression and lassitude that often accompany interferon therapy, oral hygiene may deteriorate, and routine preventive appointments should be encouraged. Despite therapy and the large numbers of liver transplantations being performed on patients with HCV,34,36 an estimated 8,000 to 10,000 deaths attributable to HCV occur annually.
Coinfection.
As HIV, HBV and HCV are transmitted in a similar manner, many patients have coinfection. HIV, HBV and/or HCV coinfection significantly complicates the medical management of the diseases and enhances the probability of the patient’s experiencing liver dysfunction.33 Therefore, clinicians must perform a thorough evaluation of liver function to be knowledgeable about the presence of chronic liver disease, the degree of dysfunction and any potential treatment modifications necessitated by the degree of hepatic disease. Although coinfection with HCV or HBV does not seem to accelerate the progression of HIV disease, the immune decomposition caused by HIV can accelerate the progression of HCV/HBV significantly, lessening the patient’s quality of life and reducing his or her overall life expectancy.16
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DENTAL MANAGEMENT OF THE CARE OF PATIENTS WITH HIV INFECTION
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The dental management of the care of patients infected with HIV usually is straightforward; no special facility or equipment is required. Such patients who require the care of a specialist should be appropriately referred, but most treatment can be performed by general practitioners. Specialist referral is indicated using criteria identical to those for referral of patients who do not have HIV infection. Clinicians should comply with the current CDC,38 OSAP39 and ADA40 infection control recommendations with every patient, regardless of the presence or absence of blood-borne disease.
A comprehensive oral health assessment is paramount for the early recognition of and intervention in OIs. Thus, oral health care providers play a significant role in reducing morbidity and improving the quality of life for patients infected with bloodborne diseases. At all times, clinicians must maintain confidentiality for all patients, regardless of HIV serostatus. Proper consent should be obtained before the clinician releases any confidential medical or dental information to other medical or dental care providers.41–45
Clinicians should obtain a thorough medical history, including a comprehensive review of systems inclusive of current medications, for all patients. Clinicians should evaluate the patient with HIV infection for susceptibility to infection and bleeding, potential problems with adverse drug reactions and interactions, and the potential overall inability to withstand dental care-related stress and trauma due to HIV-related immunosuppression and systemic manifestations. Clinicians should prescribe antibiotic prophylaxis for patients who are severely neutropenic. Elective dental procedures are contraindicated in patients with a neutrophil count of less than 500 cells/mm3 and a platelet count of less than 50,000 cells/mm3. Patients with profound neutropenia and thrombocytopenia may receive urgent care as indicated, but they may require hospitalization.41–45
Patients with HIV infection are living longer and can develop chronic diseases, many secondary to the toxicity of their medications. Abnormalities in lipid metabolism, lipodystrophy and hyperglycemia due to antiretroviral therapy, or ART, possibly increase the patient’s risk of experiencing adverse cardiovascular sequelae and the development of diabetes. Thus, clinicians should carefully monitor patients receiving ART for cardiovascular and diabetes-related symptomatology, and they should record the patient’s blood pressure at each appointment.42
Comorbidities commonly found in conjunction with HIV—such as HBV and HCV—often result in impaired hepatic function. Clinicians must recognize the side effects of, and drug interactions possible with, antiretroviral medications. Clinicians should avoid using acetaminophen in patients with severe liver disease because of its hepatotoxicity. Aspirin and non-steroidal anti-inflammatory drugs, or NSAIDs, which can decrease coagulation, should not be used in patients with impaired hemostasis.33 Box 2 outlines further information for clinicians to consider when providing treatment for patients with HIV infection.16,40–46
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DENTAL TREATMENT CONSIDERATIONS: HEPATITIS
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The dental management of the care of patients with hepatitis and subsequent liver disease is similar to the management of the care of patients with HIV infection. Clinicians should comply with the current infection control recommendations of the CDC,38 the Organization for Safety & Asepsis Procedures, or OSAP,39 and ADA.40 Referral and confidentiality guidelines are the same as those for patients with HIV disease. Clinicians should evaluate patients with hepatitis for susceptibility to infection and bleeding, potential problems with adverse drug reactions or interactions and the potential overall inability to withstand the stress and trauma of dental care due to hepatitis-related liver dysfunction. As many drugs and medications are metabolized by the liver, it is essential that the clinician perform a thorough medical history with a review of systems, inclusive of medications the patient is taking.33,42 Clinicians should be aware of the level of liver function as reflected by the alanine aminotransferase test, the aspartate aminotransferase test and other liver function tests. This information will relate to the patient’s ability to metabolize drugs.33,42
With advanced liver disease, the level of vitamin K—the precursor of the prothrombin-dependent clotting factors that is produced in the liver—can be reduced significantly, resulting in a decrease in clotting factor production. Additionally, in a patient with advanced liver disease, portal vein hypertension can sequester platelets formed in the spleen, resulting in thrombocytopenia and possibly impairing his or her ability to form a clot. Therefore, hemorrhage, which can be excessive, is one of the most common adverse events encountered during treatment of patients with decreased liver function. In light of this, the clinician should perform coagulation tests (prothrombin time/international normalized ratio and platelet count) and evaluate the values before performing any surgical procedures.33,42 Clinicians should defer elective procedures for patients with abnormal coagulation, and these patients may require hospitalization for urgent dental care. As with patients who have HIV infection, clinicians should avoid using acetaminophen in patients with severe liver disease and avoid using aspirin and NSAIDs in patients with impaired hemostasis.33,42
The clinician must consult with the patient’s physician before performing invasive dental procedures with any patient in this population.33,42 Box 3 provides additional information the clinician should consider when providing treatment for patients with hepatitis.16,33,42
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SUMMARY
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Clinicians should follow CDC, OSAP and ADA infection control recommendations for all patients, regardless of their bloodborne serostatus. When treating a patient infected with a bloodborne disease, the clinician should take a thorough medical history, make a record of medications the patient is taking and assess the patient’s immunologic and hepatic function to provide safe and efficacious dental care.
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FOOTNOTES
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Dr. DePaola is a professor, Department of Oral Medicine and Diagnostic Sciences, Dental School, University of Maryland at Baltimore, and director of dental training, Pennsylvania–Mid-Atlantic AIDS Education and Training Center, Pittsburgh. Address reprint requests to Dr. DePaola at Department of Oral Medicine and Diagnostic Sciences, Dental School, University of Maryland at Baltimore, 666 W. Baltimore St., Baltimore, Md. 21201, e-mail "lgd001{at}dental.umaryland.edu".
The preparation of this manuscript was supported in part by U.S. Department of Health and Human Services Health Resources and Services Administration, grant 1 H4A HA 00060 01.
"Practical Science" is prepared each month by the ADA Council on Scientific Affairs and Division of Science, in cooperation with The Journal of the American Dental Association. The mission of "Practical Science" is to spotlight what is known, scientifically, about the issues and challenges facing today’s practicing dentists.
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ABSTRACT
HIV DISEASE
