Human immunodeficiency virus (HIV) destroys specific cells in the immune system, rendering infected people more susceptible to infection with other organisms and infection-related cancers.1 HIV can be controlled, although not cured, with medical treatment. Over time, in the absence of effective treatment, HIV can develop into acquired immunodeficiency syndrome (AIDS), characterized by a low CD4+ T lymphocyte count (<200 cells/mm3) or one or more opportunistic infections.1 As of 2019, an estimated 1.1 million adults and adolescents in the U.S. were living with HIV, 14% of whom were unaware of their infection.1
Human Immunodeficiency Virus
HIV infection typically begins with a brief acute retroviral syndrome that transitions to a chronic illness that, over a period of years, progressively depletes CD4 T-lymphocytes, which are critical for maintenance of effective immune function; left untreated, this progression can result in symptomatic, life-threatening immunodeficiency. With treatment, this late stage of infection, known as acquired immunodeficiency syndrome (AIDS), develops over months to years, with an estimated median time of approximately 11 years.2
While no cure for HIV currently exists, with effective medical treatment and care, HIV can be controlled. The medication used to treat HIV is termed antiretroviral therapy. When initiated early after infection and taken every day, antiretroviral therapy can dramatically lengthen the lives of those with HIV, keep them healthy, and greatly lower their chance of transmitting the virus to others. Today, a person who is diagnosed with HIV, treated before the disease is far advanced, and stays on treatment can live a nearly as long as someone who does not have HIV.1
An estimated 14% of HIV-positive Americans are not aware of their condition, and early diagnosis is vital to extending life expectancy and reducing costs of care and further infections.1, 2 Oral lesions are among the earliest and most common clinical signs of HIV, and detection of oral lesions may signal progression of HIV disease or increase in the plasma HIV-1 RNA level.3, 4 Still, oral abnormalities alone are not diagnostic of HIV infection.3 HIV infection can be diagnosed by serologic tests that detect antibodies against HIV-1 and HIV-2 and by virologic tests that detect HIV antigens or ribonucleic acid (RNA). Testing begins with a sensitive screening test, usually an antigen/antibody combination or antibody immunoassay. The serologic tests currently available are both highly sensitive and specific. Rapid HIV tests enable clinicians to make a preliminary diagnosis of HIV infection within 30 minutes. Since rapid antibody assays are less able to detect HIV in the first three months after HIV-exposure, follow-up testing after a negative result from a rapid antibody assays should be conducted to verify results.1, 2 Home testing kits can also be purchased online or at a local pharmacy.1 The Centers for Disease Control and Prevention (CDC) recommends that all people between age 13 and 64 get tested for HIV at least once as part of routine health care.2 Depending on the state, oral health care providers may be permitted to perform such tests.5
Avoiding exposure to blood and bodily fluids is the primary way to prevent transmission of HIV in dental care settings.6 Blood has the greatest proportion of infectious viral particles but all bodily fluids, secretions, and excretions other than sweat may contain transmissible infectious agents.7 During dental procedures, saliva tends to become contaminated with blood, increasing the risk of HIV transmission from saliva.8 Standard precautions should be followed with all patients, whether or not they have been diagnosed with HIV. Dental personnel should wear barrier precautions (e.g., gloves, masks, and protective eyewear) whenever there is potential for contact with body fluids, non-intact skin, or mucous membranes. Protective equipment must be removed after leaving work areas, and remember that gloves are never to be reused.7 Though the occupational source of greatest risk of HIV transmission is percutaneous injuries, it is good to understand that after a needlestick exposure to HIV-infected blood, the average risk of HIV transmission is approximately 0.3%. Dental personnel can reduce their risk of percutaneous injuries by following the Standard Precautions, having engineering controls and work-practice controls for all sharps, and following safe injection practices.7 Any direct contact with potentially infectious material is considered an exposure that requires clinical evaluation.7
In the case of exposure to material known or suspected to be infected with HIV, the incident should be reported to a supervisor (if applicable) and the exposed individual should consult with a doctor immediately.7 Antiretroviral drugs may be prescribed as post-exposure prophylaxis (PEP) within the first 72 hours of exposure in order to help prevent HIV infection.6 The sooner PEP is started, the more effective it is.
Dental health care personnel should strive to create a safe, welcoming and nonjudgmental environment for all patients in order to encourage on-going dental care and as a component of providing equitable care as articulated by the ADA House of Delegates policy on Patient Safety and Quality of Care (Trans.2005:321).9 While medical histories should be taken for all patients, this is especially important for those infected with HIV, since they are more likely to be medically complicated. Consultation with the patient’s physician for a complete medical assessment can help establish a safe treatment plan adapted to the medical condition of the patient. Since HIV may be asymptomatic and may go unrecognized, standard precautions for infection control should be observed for all patients.
Oral Manifestations of HIV
Antiretroviral therapies have reduced the overall prevalence of oral manifestations of HIV, but HIV-related oral conditions still occur in 30-80% of HIV-infected individuals.3 These orofacial conditions are readily detectable thorough examinations of the oral cavity.
In pediatric HIV-infected cases, 8.8-18.4% have salivary gland swelling in one or both parotid glands with or without xerostomia.4 Additionally, some antiretroviral agents can reduce salivary output, increasing the risk of dry mouth. In HIV-infected children, the most commonly reported lesion is oral candidiasis, particularly the pseudomembranous, erythematous, and angular cheilitis variants.4 HIV-infected children are also more prone to acquiring opportunistic viral infections in the oral mucosa, including herpes simplex, herpes zoster, Epstein-Barr, and human papilloma virus. Increased rates of viral infection also lead to higher rates of infection-related precancerous lesions such as oral hairy leukoplakia, oral warts, or oral cancer. The gingival and periodontal diseases associated with HIV in children are linear gingival erythema, necrotizing stomatitis, and in 2.2-5% of pediatric patients, necrotizing ulcerative gingivitis or periodontitis. Additionally, long-term use of highly active antiretroviral therapy may be associated with dysregulation of calcium homeostasis, bone loss, or diabetes mellitus and dyslipidemia, which may predispose patients to periodontal disease.10 Caries prevalence in HIV-infected children is higher compared to non-infected children, though similar to that of other children with chronic illnesses.4 Increased caries prevalence may be due to traditional risk factors in addition to a reductions in salivary antibodies, absolute lymphocyte count and salivary flow rate or a diet rich in sucrose or carbohydrates required to prevent or treat caloric deficits.4, 10
From 30-80% of HIV-infected adults will present with HIV-related oral abnormalities.3 As in children, xerostomia is common, occurring in up to 40% of HIV-positive patients.11 Most other HIV-associated oral conditions are caused by opportunistic infections. These include candidiasis (particularly angular cheilitis, erythematous candidiasis, and pseudomembranous candidiasis), bartonellosis, cryptococcosis, cryptosporidiosis, and histoplasmosis. Opportunistic viral infections may predispose patients to other conditions: human papilloma virus may lead to condylomata, warts, or cancer; Epstein-Barr virus can lead to oral hairy leukoplakia; human herpesvirus8 may develop into Kaposi’s sarcoma; cytomegalovirus may lead to cytomegalovirus oral ulcers.11 Herpesvirus infection may also lead necrotizing periodontal conditions to occur more frequently and progress more rapidly.11 Necrotizing ulcerative gingivitis or periodontitis occur in an estimated 2-6% of HIV-positive adults, and conventional periodontitis is found in up to 30% of HIV-positive adults.11 The combination of periodontal disease, reduced salivary flow and antibodies increases the likelihood of caries.
Dental Patient Management
A comprehensive intraoral soft tissue, periodontal and hard tissue examination should be conducted at an HIV-positive patient’s initial assessment.11 Dentists should continuously monitor dental and oral health for disease progression. If any oral manifestations of HIV are present, the first priority is to relieve pain and treat infections.11 To help prevent further disease, dentists can provide counseling about modifiable risk factors, such as use of tobacco, alcohol, or other drugs that may increase risk of oral abnormalities or complications, as well as work with the patient to implement oral hygiene regimens. Prevention is even more important for HIV-positive patients, who are more susceptible to oral disease.
All dental practices should be able to provide routine dental care for adult or pediatric HIV-positive patients. Nearly all patients with HIV are able to tolerate routine dental care and procedures, including oral surgery.12 Still, dental treatment planning must be done on an individual basis, in conjunction with consultations with the patient and their physician as appropriate. HIV and antiretroviral therapies may be associated with abnormal bleeding, glucose intolerance, or hyperlipidemia, which may be identified through consultation with the patient and their physician.11 Other conditions that may require modification of dental treatment are reduced platelet count <60,000 cells/mL, which may affect clotting, or white-blood-cell neutrophil counts <500 cells/mL, which may require antibiotic prophylaxis.11 However, antibiotic use may predispose patients to adverse drug reactions, superinfection and drug resistant microorganisms, so antibiotics should be used judiciously, not routinely.11, 12 Indications for dental extractions and other oral surgical procedures are the same for HIV-positive patients as for any other patient. Preoperative scaling may be performed to help reduce the risk of postoperative complications. All procedures must be performed in a manner to minimize bleeding and avoid bringing oral pathogens into the deeper fascial planes and oral spaces.12
- US Department of Health and Human Services. HIV/AIDS Basics. 2016. Accessed March 7, 2019.
- Centers for Disease Control and Prevention. 2015 Sexually Transmitted Diseases Treatment Guidelines: HIV Infection: Detection, Counseling, and Referral. U.S. Department of Health & Human Services. Accessed March 12, 2019.
- Reznik DA. Oral manifestations of HIV disease. Top HIV Med 2005;13(5):143-8.
- dos Santos Pinheiro R, Franca TT, Ribeiro CM, et al. Oral manifestations in human immunodeficiency virus infected children in highly active antiretroviral therapy era. J Oral Pathol Med 2009;38(8):613-22.
- AIDS Education and Training Center (AETC). HIV Testing in Dental Clinics. Accessed June 11, 2019.
- Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR 2001;50(RR-11).
- Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care.: U.S. Department of Health and Human Services 2016. Accessed June 11, 2019.
- Centers for Disease Control and Prevention. Infection Prevention and Control in Dental Settings: Bloodborne Pathogens & Aerosols. Accessed March 12, 2019.
- American Dental Association. Current Policies Adopted 1954–2017: Patient Safety and Quality of Care (Trans.2005:321), p. 94. 2018. Accessed March 14, 2019.
- Ramos-Gomez FJ, Folayan MO. Oral health considerations in HIV-infected children. Curr HIV/AIDS Rep 2013;10(3):283-93.
- Mosca NG, Rose Hathorn A. HIV-Positive Patients: Dental Management Considerations. Dental Clinics of North America 2006;50(4):635-57.
- Dental Alliance for AIDS/HIV Care. Principles of oral health management for the HIV/AIDS patient. 2000. Accessed March 14, 2019.
Centers for Disease Control and Prevention:
National Institute of Dental and Craniofacial Research: