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CDHO Advisory: HIV/AIDS

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with HIV/AIDS.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory HIV/AIDS, 2023-06-15

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

HIV/AIDS

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have HIV/AIDS, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Record keeping.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents or guardians of children and young persons with HIV/AIDS.

MAJOR OUTCOMES CONSIDERED

For persons who have HIV/AIDS: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Adapted from

Nomenclature of HIV/AIDS

HIV/AIDS is a disease called acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV).

Other terminology includes the following.

  1. Acquired immunodeficiency syndrome, a severe immunological disorder that 
    1. is caused by the retrovirus, HIV
    2. results in a defect in the cell-mediated immune response which is manifested by increased susceptibility to
      1. opportunistic infections
      2. certain rare cancers, especially Kaposi’s sarcoma
    3. is transmitted primarily by exposure to contaminated body fluids, especially
      1. blood
      2. semen.
  2. Aphthous mouth ulcer, a painful sore that 
    1. occurs anywhere inside the mouth
    2. is the most common type of mouth ulcer 
    3. affects women more often than men. 
  3. Cardiomyopathy, disease of the heart muscle which reduces the ability of the heart to pump blood.
  4. Cell-mediated immune response, also named cellular immune response, is the immune response produced when sensitized T cells
    1. directly attack foreign antigens
    2. secrete lymphokines. 
  5. Foreign antigens targeted by the cell-mediated immune response chiefly include
    1. viruses
    2. fungi
    3. transplanted tissue.
  6. Herpes simplex infection of the mouth, often referred to as cold sore(s)
    1. is caused by the herpes simplex virus
    2. may be asymptomatic
    3. may present as painful blisters, which
      1. usually heal completely 
      2. may reappear unpredictably.
  7. Human immunodeficiency virus (HIV), a virus which
    1. causes acquired immune deficiency syndrome 
    2. replicates in and kills T cells
    3. progressively destroys the body’s immune system.
  8. Human papillomaviruses, a group of more than 100 related viruses that cause papillomas. 
  9. Kaposi’s sarcoma, a form of skin cancer that 
    1. can involve the mouth
    2. is most often found in patients with acquired immunodeficiency syndrome 
    3. may be fatal.
  10. Leukoplakia, white patches on the mucous membranes of the mouth.
  11. Linear gingival erythema, also called HIV gingivitis, a bright red  band of inflammation of the gingivae adjacent to the teeth, that
    1. is out of proportion to the amount of visible plaque
    2. is not very painful
    3. is not usually associated with heavy bleeding
    4. does not resolve despite scaling, root planing or curetting.
  12. Lymphokines, soluble substances released by sensitized lymphocytes on contact with foreign antigens that stimulate the defensive activity of the white cells of the blood.
  13. Necrotizing ulcerating periodontitis
    1. is a sign of severe immunosuppression
    2. affects the gums and extends to the underlying bone or periodontium.
  14. Neutropenic ulceration, associated with neutropenia, that includes 
    1. painful mouth ulcers
    2. gum infections
    3. periodontal disease.
  15. Opportunistic infection, infection which is enabled by the weakening of the immune system, which is a particular danger in AIDS because the opportunistic infection rather than the AIDS is most likely to be the cause of death.
  16. Oral hairy leukoplakia, a condition that occurs chiefly in HIV-positive persons and that is
    1. characterized by irregular white patches on the side of the tongue and occasionally elsewhere on the tongue or in the mouth
    2. a form of leukoplakia.
  17. Papilloma, benign (noncancerous) tumor, also called a wart.
  18. Periodontium, also termed parodontium, the tissues clothing and supporting the teeth, including the cementum, periodontal ligament, alveolar bone, and gingiva.
  19. T cell, also called CD4 cell, is a particular type of lymphocyte, which 
    1. leads the attack against infections
    2. is most severely infected by the HIV, which 
      1. merges with the T cell
      2. reproduces itself within the T cell. 
  20. Thrush, also termed oral candidiasis or oral moniliasis, is 
    1. a yeast infection of the mouth or throat 
    2. most commonly caused by Candida albicans.
  21. Xerostomia, abnormal dryness of the mouth resulting from decreased secretion of saliva.

Overview of HIV/AIDS

Adapted from 

Acquired immunodeficiency syndrome 

  1. results from the HIV’s progressive weakening of the body’s immune system until it can no longer fight off opportunistic infection, a continuing threat, such as 
    1. histoplasmosis
    2. mycobacterium avium complex
    3. pneumocystis jiroveci pneumonia
    4. toxoplasmosis
    5. thrush.
  2. has been transformed by advances in treatment especially with medications and increased medical knowledge into a chronic, usually manageable condition which nevertheless remains incurable.
  3. begins with infection by the HIV, which 
    1. is acquired by transmission 
      1. through unprotected sexual intercourse with someone who is already infected with HIV
      2. through infected blood or blood products
      3. through the sharing of contaminated needles
      4. from an infected woman to her baby before birth, during delivery, or through breast-feeding
    2. is not acquired through normal, day-to-day contact. 
  4. develops
    1. at a pace that varies widely among individuals so that full progression may take a few months or as many as 10 years or even more
    2. from the time of first infection with the HIV, which
      1. induces an infectious disease, meaning that the infected person can infect others with the HIV
      2. results in symptoms that 
        1. may develop within several days or weeks as a flu-like illness that
          1. is manifested as 
            1. fever
            2. headache
            3. tiredness
            4. enlarged cervical lymph nodes 
          2. disappears after a few weeks
        2. may be delayed in onset for months or years
    3. as a result of continuing, active multiplication of the HIV, which occurs within and kills the T Cells (CD4) cells of the immune system.
  5. into full-blown AIDS in the later stages of the chronic HIV infection.
  6. in Canada is represented statistically by the
    1. number of people living with HIV and AIDS, which has overall declined from an estimated 65,000 in 2008 to 63,110 in 2016 to 62,790 in 2020 (prevalence) 
    2. estimated number of new HIV infections, which is estimated to be 1,520 in 2020 (incidence)
    3. estimated 10 percent of people who are living with HIV in Canada in 2020 who remain undiagnosed or who are unaware that they have HIV.
  7. is associated  with oral conditions such as
    1. papillomas caused by the human papilloma virus 
    2. Kaposi’s sarcoma
    3. oral hairy leukoplakia
    4. periodontal diseases, such as 
      1. linear gingival erythema
      2. necrotizing ulcerative periodontitis
    5. thrush
    6. ulcerative conditions, such as
      1. herpes simplex virus infection
      2. recurrent aphthous ulcers
      3. neutropenic ulcers
    7. xerostomia.
  8. is diagnosed when
    1. the T Cell, CD4 cell count falls below the defined threshold
    2. the person has 
      1. unusual opportunistic infections 
      2. particular types of cancers, such as
        1. Kaposi’s sarcoma 
        2. lymphoma (CDHO Advisory) in the brain
  9. presents risks associated with infectivity.

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with HIV/AIDS but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

In HIV/AIDS, the comorbidities, complications and associated conditions include medically compromising conditions that increase in incidence with age, such as

  • cardiomyopathy
  • co-infection with other viruses that share similar routes of transmission, such as
    hepatitis B, hepatitis C, and human herpes virus
  • high cholesterol, with the possibility of coronary artery disease
  • kidney disease
  • liver disease, often associated with hepatitis
  • medication non-adherence associated with substance abuse that is comorbid with psychiatric illness
  • osteoporosis
  • psychiatric illness
  • respiratory problems
  • substance misuse
  • tuberculosis

Oral health considerations

  1. As the number of people living with HIV infection and AIDS continues to be substantial, the dental hygiene profession shares in the responsibility to help reduce their unmet needs for oral care. 
  2. A large segment of the at-risk population is not connected to the health system, and is therefore unlikely to be receiving adequate or any oral healthcare.
  3. The disparity between need for and availability of oral care 
    1. arises because of
      1. lack of dental insurance
      2. gaps in healthcare and social programs
      3. competing medical and social needs
    2. should not arise because of reticence on the part of oral healthcare providers to provide oral healthcare to persons who are HIV positive.
  4. AIDS is increasingly understood as a chronic inflammatory disease, making the mouth a likely candidate for signs and symptoms of HIV/AIDS.
  5. HIV-related oral conditions 
    1. occur in a large proportion of persons with HIV/AIDS
    2. are often 
      1. misdiagnosed 
      2. inadequately treated
    3. require awareness of HIV/AIDs and relevant oral healthcare expertise and experience
    4. occur in many persons with HIV/AIDs who do not receive adequate oral healthcare.
  6. Oral healthcare is important because
    1. as many as 90 percent of persons living with HIV develop at least one oral condition 
    2. the oral healthcare provider may be the first to identify an oral manifestation of HIV, even in persons who are
      1. not known to be HIV positive
      2. unaware that they are HIV positive
    3. HIV-related oral lesions may develop at any time during the course of HIV/AIDS
    4. routine oral healthcare is an important component of the management of HIV/AIDS
    5. persons who are known to be HIV positive should 
      1. receive routine oral healthcare
      2. be watched for oral manifestations of HIV.
  7. As part of the provision of oral healthcare to an HIV-positive patient/client communication with the primary treating physician
    1. should occur 
      1. prior to the Procedures and include information about
        1. the health status of the patient/client
        2. comorbidities, complications and associated conditions
        3. current medications 
        4. any bleeding tendency
        5. anemia or other blood conditions
        6. requirements for antibiotic prophylaxis.
  8. Oral healthcare providers should be aware that the continued success of a patient/client’s HIV therapy
    1. depends on strict adherence to the medication regimen, with no missed doses, because 
      1. the missing of even ten percent of doses may cause
        1. development of medication resistance in the HIV
        2. regimen failure
      2. HAART which is properly planned and reliably adhered to provides
        1. durable viral suppression
        2. immune reconstitution
        3. clinical benefit while minimizing drug resistance 
        4. the potential for adding decades of acceptable quality of life
    2. is not normally jeopardised by standard antibiotics used in oral healthcare
    3. may require medical advice in the choice of pain medication if there is a history of substance abuse.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 

Types of medication treatments

Adapted from

Warnings

Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.

Medications

  1. HAART (highly active antiretroviral therapy) medications
    1. cannot cure HIV infection but promise to
      1. prevent virus replication
      2. retard disease progression
      3. extend life expectancy and significantly reduce the number of new HIV-related diseases and AIDS-related deaths
      4. reduce the transmission rates of HIV
      5. promote significant immune restoration to levels that are sufficient to prevent opportunistic infections and otherwise restore good health
    2. are subject to growing concerns about
      1. long-term toxicity of the medications
      2. medication adherence, the absolute requirement for preventing medication resistance
      3. complications of decisions about which therapy to use, when to begin it, change it, interrupt it, or stop it
      4. modern antiretroviral regimens for HIV, which may within 8 years 
        1. lose their effect on the HIV
        2. be associated to the development of medication resistance 
    3. include
      1. nucleoside/nucleotide reverse transcriptase inhibitors (including nucleoside analogues), which work by slowing the spread of HIV in the body
      2. non-nucleoside reverse transcriptase inhibitors, which are used to treat HIV infection in patients with or without AIDS
      3. protease inhibitors, which slow the spread of HIV infection in the body 
      4. HIV fusion inhibitors, which stop HIV from infecting healthy cells 
      5. HIV integrase strand transfer inhibitors, which work by slowing the spread of HIV in the body
      6. pharmokinetic enhancers of protease inhibitors
      7. combined medications
        • Atripla® (as a combination product containing tenofovir, efavirenz, and emtricitabine) see tenofovir
        • Combivir®  see lamivudine and zidovudine  
        • Combivir® (as a combination product containing lamivudine and zidovudine) see lamivudine 
        • Combivir® (as a combination product containing zidovudine and lamivudine) see zidovudine oral 
        • Epzicom® (as a combination product containing abacavir and lamivudine) see abacavir 
        • Epzicom® (as a combination product containing lamivudine and abacavir Sulfate) see lamivudine 
        • Genvoya® (as a combination product containing elvitegravir, cobicistat, emtricitabine, and tenofir)
        • Juluca® (as a combination product containing dolutegravir and rilpivirine)
        • Stribild® (as a combination product containing elvitegravir, cobicistat, emtricitabine, and tenofir)
        • Triumeq® (as a combination product containing abacavir, dolutegravir, and lamivudine)
        • Trizivir® see abacavir 
        • Truvada® (as a combination product containing emtricitabine and tenofovir disoproxil fumarate) see emtricitabine  
        • Truvada® (as a combination product containing tenofovir and emtricitabine) see tenofovir.
  2. Medications for pain relief in dental hygiene include the following, which are considered appropriate for persons with HIV/AIDS
    1. acetaminophen
    2. ibuprofen.

Side effects of medications

  1. With HIV-related medications considerable potential exists for drug–drug interactions.
  2. For the side-effects of specific medications, see the links above.

THE MEDICAL AND MEDICATIONS HISTORY

The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions.
  2. Explore the need for advice from the appropriate primary care provider(s).
  3. Inquire about
    1. the patient/client’s understanding and acceptance of the need for oral healthcare
    2. status of the HIV/AIDS and the degree of debilitation
    3. medications considerations, including over-the-counter medications, herbals and supplements
    4. problems with previous dental/dental hygiene care
    5. problems with infections generally and specifically associated with dental/dental hygiene care
    6. how the patient/client’s state of health is at this moment
    7. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

Occupational and other exposure to HIV infection

Adapted from

  1. Risks associated with HIV infectivity, such as those 
    1. of transmission of HIV infection in the dental office, a risk which
      1. is reportedly very low, despite the frequency of accidental skin punctures from instruments or needlestick injuries, probably because
        1. HIV is rarely transmitted through saliva (which must be blood-contaminated) 
        2. only small quantities of blood are involved in oral healthcare
        3. most percutaneous injuries associated with oral health care generally reportedly occur during extraoral procedures such as laboratory work 
      2. must nevertheless be anticipated and mitigated 
        1. specifically in the transmission pathways of
          1. patient to provider
          2. provider to patient
          3. patient to patient
        2. by risk-reduction strategies integral to routine clinical practice regardless of the chances of HIV infection; these chiefly involve
          1. standard precautions and routine practices such as those in the Recommendations published by the Centers for Disease Control and Prevention and the Infection Prevention and Control (IPAC) Guidelines published by the CDHO
          2. clinical practice procedures, such as
            1. safety in the handling, use, assembly and cleaning of contaminated 
              1. instruments
              2. equipment
            2. use of sharps containers
          3. an ongoing office infection prevention and control program 
          4. selection of instruments and equipment designed to reduce the risk of skin-penetrating injuries
          5. a written plan for post-exposure prophylaxis of percutaneous injury with known HIV contamination; covering at a minimum
            1. first aid 
            2. referral as a medical emergency
          6. require continuing application of routine practices for all patients/clients and not only those with known positive HIV status. 
  2. Risks of complications of tuberculosis, which require advice from the primary care physician whether the tuberculosis is active and , if so, whether
    1. prophylaxis or other treatment is underway
    2. oral healthcare should be deferred for any reason.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

Prior to implementing the Procedures for an HIV-positive patient/client, the dental hygienist should consult with the primary care physician to obtain advice about the patient/client’s

  1. degree of debility 
  2. comorbidities, complications and associated conditions with implications for oral healthcare
  3. bleeding tendency
  4. need for antibiotic prophylaxis
  5. medications with implications for oral healthcare. 

Unless the primary care or specialist physician’s advice indicates otherwise, there is usually no contraindication to the Procedures for an asymptomatic HIV-positive patient/client. For an HIV-positive patient/client for whom the dental hygienist has previously provided oral health care, the Procedures may be postponed pending medical advice if the patient/client reports

  1. changes in his or her health status
  2. increasing debility (including potentially significant immunosuppression)
  3. oral signs  and symptoms suggestive of complications of HIV/AIDS or side effects of medications
  4. recent changes in medications, under medical advice or otherwise.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2)

For a patient/client with a history of HIV/AIDS, the dental hygienist should specifically record

  1. A summary of the medical and medications history.
  2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.
  3. The decision made by the dental hygienist, with reasons.
  4. Compliance with the precautions required.
  5. All Procedure(s) used.
  6. Any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of HIV/AIDS.

As appropriate, discuss 

  1. The importance of a good diet in the maintenance of oral health.
  2. The need for regular oral health examinations and preventive oral healthcare. 
  3. Home oral hygiene including information about choice of toothpaste, tooth-brushing devices, dental flossing, mouth rinses and saliva control. 
  4. The role of the family caregiver for persons at an advanced stage of the disease, with emphasis on maintaining an infection-free environment, and advice on wearing gloves. 
  5. Medication side effects such as dry mouth, and recommend treatment.
  6. Scheduling and duration of appointments for patients/clients who are debilitated.
  7. Comfort level while reclining, and stress and anxiety related to the Procedures.
  8. Mouth ulcers and other conditions of the mouth relating to HIV/AIDS, comorbidities, medications or diet.
  9. Pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promotion of health through oral hygiene for persons who have HIV/AIDS.
  2. Reduction of the adverse effects by
    1. early detection of oral signs and symptoms of HIV/AIDS
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  3. Reduction of risk of oral health needs being unmet.

POTENTIAL HARMS

  1. Causing harm by failing to detect or obtain advice about HIV-related oral lesions.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the HIV/AIDS patient/client’s condition requires medical advice and this is not obtained 
      1. prior to implementation of the Procedure
      2. in response to concerns expressed or detected during a course of dental hygiene
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with HIV/AIDS.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2010-07-15

DATE OF LAST REVIEW

2019-08-29; 2023-06-15

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2010, 2019, 2023 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.