Dental health care personnel should strive to create a safe, welcoming and nonjudgmental environment for all patients in order to encourage ongoing dental care and as a component of providing equitable care, as articulated by the ADA Policy on Patient Safety and Quality of Care.25 While medical histories are important 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.16 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.17 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.17, 26 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 papillomavirus. 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.
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.27 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.28 Caries prevalence in HIV-infected children is higher compared to non-infected children, though similar to that of other children with chronic illnesses.17 Increased caries prevalence may be due to traditional risk factors in addition to a reduction 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.17, 28
From 30-80% of HIV-infected adults will present with HIV-related oral abnormalities.16 As in children, xerostomia is common, occurring in up to 40% of HIV-positive patients.29 Most other HIV-associated oral conditions are caused by opportunistic infections. These include candidiasis (particularly angular cheilitis, erythematous candidiasis, and pseudomembranous candidiasis), salivary gland enlargement, cryptococcosis, cryptosporidiosis, and histoplasmosis.30-32 Opportunistic viral infections may predispose patients to other conditions: human papillomavirus may lead to condylomata, warts, or cancer33; Epstein-Barr virus can lead to oral hairy leukoplakia34; human herpesvirus23 may develop into Kaposi’s sarcoma; cytomegalovirus may lead to cytomegalovirus oral ulcers.29 Herpesvirus infection may also lead necrotizing periodontal conditions to occur more frequently and progress more rapidly.29 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.29 The combination of periodontal disease, reduced salivary flow and antibodies increases the likelihood of caries.