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HIV Medical Management: PrEP and PEP 10 HIV and Dentistry 15 tients when risk factors are controlled and
Newer therapeutics now exist that include Most HIV-positive patients who are man- cell counts are in the normal range. When
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pre-exposure (PrEP) and post-exposure aged medically and are compliant with their more invasive dental therapies are planned,
prophylaxis (PEP) medications. Patients on regiment(s) do not require major alterations medical consultation is recommended to
PrEP and PEP are, by definition, HIV-neg- in the delivery of their dental care. As den- minimize complications such as bleeding
ative and do not require laboratory testing tists and healthcare providers, we should in- secondary to thrombocytopenia, poor or
prior to dental care. PrEP is commonly used clude this information (medical regimen(s), delayed wound healing from glucose intol-
by patients who are HIV-negative and have compliance) in our taking of medical histo- erance or diabetes, and/or the need for ad-
a higher risk for exposure. Two medications ries and performing risk assessments of our ditional procedures if the disease is poorly
commonly used as PrEP are Truvada and patients. controlled.
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Descovy . PrEP can cause mild side effects
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(such as headache, and nausea) and is be- Medical consultation before invasive dental In certain instances, pre-operative labora-
tween 74-99% effective in reducing the therapy may be indicated when HIV-posi- tory studies such as platelet count and/or
transmission of disease. Patients on PrEP tive patients are not under the management neutrophil count may also be indicated. A
must be HIV-negative and be tested every of a physician and/or are not compliant with platelet count of fewer than 60,000 cells/mL
three months. HIV positivity is a contraindi- prescribed medications for their HIV. Such may warrant an alteration in treatment and a
cation for its use. patients are more vulnerable to developing neutrophil count of fewer than 500 cells/mL
infections secondary to their immunocom- may necessitate the use of antibiotics pro-
PEP is an anti-retroviral medication that promised states and may require the use phylactically. It is important to remember
must be started within 72 hours of HIV ex- of antibiotics after invasive dental proce- that antibiotics should only be used in cas-
posure and its use continues for four weeks. dures (such as surgical extractions, alveol- es in which they are clearly indicated to be
It can cause mild side effects and is highly oplasty, or torus reduction surgery). When used; the over-prescribing of antibiotics can
effective in blocking transmission. For PEP, laboratory abnormalities are noted, such as promote resistance and the development of
the CDC recommends the use of medications CD4 suppression or an elevated viral load, super-infections. ANC is not needed in most
such as tenofovir and emtricitabine (taken to- alterations in the medical regimen may be patients and prophylactic antibiotics do not
gether in one pill), and either raltegravir or required. This is done by the primary care play a role for patients who are managed
dolutegravir. The use of PEP is reserved only physician or infectious disease specialist medically for their HIV diagnosis. The ben-
for emergencies and not routine prophylaxis. who is responsible for prescribing these efits of the use of antibiotics must be bal-
medications. As dentists, we do not routine- anced against their risks.
Patients Living with HIV ly make alterations to these regimens.
Over the past two and a half decades, ART The Americans with Disabilities Act (ADA)
has dramatically revolutionized the course Patients who are more prone to excessive provides federal civil rights protections to
of HIV infection. Opportunistic diseases bleeding, either due to thrombocytopenia individuals with disabilities. HIV-positive
have become less common and mortality or from ART, may also benefit from treat- patients who experience discrimination
has declined. Most patients who are man- ment in a monitored setting especially when due to their disease are protected by feder-
aged medically now can expect to have a invasive procedures are planned, such as al law. Dentists should be aware that the
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near-normal life expectancy in the US. Pa- multiple extractions in more than one quad- laws that govern the various jurisdictions in
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tients who are managed medically and liv- rant, torus reduction, or more extensive oral the United States are not uniform and some
ing with HIV are at risk for certain medical surgery. Other oral conditions such as bac- confidentiality laws may prohibit the trans-
comorbidities which can have an impact on terial or fungal infections can also be seen in fer of pertinent information related to HIV
their ability to tolerate dental treatment. patients with neutropenia. Thrush, oral ul- seropositivity. 19
cerations, and purulence are signs that white
These comorbidities include cardiovascular blood cell function is negatively affected Disease Transmission in the Dental Office
disease, pulmonary dysfunction, and diabe- and warrant evaluation and treatment. The risk of HIV transmission in the dental
tes. HIV has a significant negative impact office seems very low compared to other
on white blood cell function and can lead HIV-positive patients should undergo rou- healthcare facilities. The risk of HIV infec-
to neutropenia. Neutropenia can be caused tine comprehensive dental evaluations, the tion after percutaneous exposure 0.3%, and
by many things including the HIV infection same as those who are not infected with after a mucous membrane exposure, ap-
itself, HIV-related autoimmune disorders, HIV. Patients with HIV may be more sus- proximately 0.09%, can be reduced by 81%
secondary infections, malignancies, and ceptible to oral disease and should be prop- with zidovudine post-exposure prophylaxis
pharmacological agents used to manage HIV erly counseled about smoking cessation and (PEP). 20,21 The newer regimens no longer in-
itself. 12,13 It is important to remember that in alcohol reduction, as these factors can both clude zidovudine, instead they use a nucle-
most patients who are medically managed increase the likelihood of the development oside/tide (NRTI) combination (Truvada )
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for HIV, HIV-related neutropenia does not of oral disease and cancer. Maintaining plus an integrase inhibitor(Tivicay ), which
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carry the same risk of infection. The overall good oral hygiene is critical to reducing have fewer side effects. 22,23
prevalence of cytopenias has declined over periodontal complications and promoting
the course of the HIV epidemic and this is wound healing. Routine preventative and re- The need for prophylactic treatment after
likely due to a combination of early diagno- storative dental care can safely be provided exposure to HIV is based on an assessment
sis and the use of less-toxic ART. Only those to patients with HIV. Recent evidence-based of the risk of infection and this varies with
patients with severe neutropenia (with bone reviews have concluded that HIV infection the type of exposure, type and quantity of
marrow suppression and an absolute neu- does not pose a serious threat to implant body fluid transferred, and viral load of the
trophil count (ANC) value of <500/microL) survival on short-term evaluation. Dental source. 23
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are at an increased risk for infection. implants can be used for HIV-positive pa-
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