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COVID-19, HIV, and Oral Health Care

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COVID 19 and Oral Health Carewith Consideration of HIVAIDS
C. Mark Nichols, DDS
Director of Dental Services, Avenue 360 Health and Wellness, Houston
Dental Director, South Central AETC

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Objectives
Review the American Dental Association recommendations for emergency and urgent dental care for Covid 19.
Review the highlights of the American Dental Association Interim Guidance to reduce transmission of Covid 19
Discuss the special considerations in oral health for the HIV/AIDS patient in the era of Covid 19.
Review the oral manifestations of HIV/AIDS
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COVID 19 and Oral Health Care
On March 19, 2020 the American Dental Association issued guidelines for the practice of dentistry during the COVID 19 pandemic. These guidelines recommend that dental healthcare workers postpone elective dental care but continue to provide emergency and urgent dental care to patients.
On April 1, 2020 ADA issued Interim Guidance for Minimizing Risk of COVID-19 Transmission and extended the emergency/urgency care recommendations at least until April 30th
These guidelines were established to protect the public as well as dental healthcare workers, to conserve the availability of PPE, and to reduce the need of patients to access the hospital systems for dental related issues.
These guidelines can be found at ADA website's Coronavirus Center and will probably be continually updated as more information becomes available.
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Why is dental care at a high risk?
Dental health care workers perform procedures in the mouth and head and neck areas. This is where droplets of the coronavirus originate or leave the body.
Most dental procedures involve the use of instruments that produce aerosols. (Dental drills and ultrasonic cleaning instruments.)
The surgical masks that are routinely used in dentistry are worn to protect the mucous membranes of the mouth and nose from splash and splatter, not to filter the air from droplets.
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American Dental Association Urges Dentists to Heed April 30 Interim Postponement Recommendation, Maintain Focus on Urgent and Emergency Dental Care Only
ADA.org March 19, 2020 and updated April 1, 2020
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Dental emergencies are potentially life threatening and require immediate treatment to stop tissue bleeding, alleviate severe pain or infection, and include:
Uncontrolled bleeding
Cellulitis or a diffuse soft tissue bacterial infection with intra-oral or extra-oral swelling that potentially compromise the patient's airway.
Trauma involving facial bones, potentially compromising the patient's airway.
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American Dental Association ada.org

Urgent dental care focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments. These should be treated as minimally invasively as possible.
Severe dental pain from pulpal inflammation
Pericornitis or third molar pain (wisdom teeth)
Surgical post-operative osteitis, dry socket dressing changes
Abscess, or localized bacterial infection resulting in localized pain and swelling
Tooth fracture resulting in pain or causing soft tissue trauma
Dental trauma with avulsion/luxation
Dental treatment required prior to critical medical procedures
Final crown/bridge cementation if the temporary restoration is lost, broken or causing gingival irritation
Biopsy of abnormal tissue
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American Dental Association ada.org

Other urgent dental care:
Extensive dental caries or defective restorations causing pain. (Manage with interim restorative techniques when possible.)
Suture removal
Denture adjustments on radiation/oncology patients
Denture adjustments or repairs when function impeded
Replacing temporary filling on root canal access openings in patients experiencing pain.
Snipping or adjustment of an orthodontic wire or appliance piercing or ulcerating the oral mucosa.
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American Dental Association ada.org

Routine or non-urgent dental procedures includes but are not limited to:
Initial or periodic oral examinations and recall visits, including routine radiographs
Routine dental cleaning and preventive therapies
Orthodontic procedures other than those to address acute issues (e.g. pain, infection, trauma)
Extraction of asymptomatic teeth
Restorative dentistry including treatment of asymptomatic carious lesions.
Aesthetic dental procedures.
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American Dental Association ada.org

COVID 19 Economic Impact on Dental Practices March 23, 2020 Survey
Online survey sent to 68,475 dentists
19,154 responded. (28%)
Current status of the practice
76% - Closed but seeing emergency/urgent cases only
19% - Closed and not seeing any patients
5% - Open but lower patient volume
0% - Open, business as usual.
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American Dental Association surveys. ada.org

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Table of Contents:
Before Dental Care Starts
1. Dentist and Dental Team Preparation Ensuring safety of staff Office set-up Appointment scheduling
2. Screening for COVID-19 Status and Triaging for Dental Treatment Phone screening for COVID-19 Who can be seen in the dental setting? Referrals
3. Instructions for Patient Arrival Social distancing and waiting area Infection control etiquette
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Table of Contents:
During Dental Care
4. Standard and Transmission Precautions and Personal Protective Equipment (PPE) Standard precautions Transmission-based precautions Use of masks and respirators Donning and doffing Equipment and supplies to help protect dental health care personnel from infection
5. Clinical Technique (Handpieces, Equipment, etc.) Technical approaches and equipment to help reduce transmission
6. Steps After Suspected, Unintentional Exposure
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Table of Contents:
After Dental Care is Provided
7. In Between Patients Cleaning and sanitizing surfaces and equipment
8. Post-Operative Instructions for Patients Medications as adjuncts to care
9. When Going Home After a Workday Steps to prevent disease transmission between work and home
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
DHCP experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work. (https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to..., https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html)
DHCP who are of older age, have a pre-existing, medically compromised condition, pregnant, etc., are perceived to be at a higher risk of contracting COVID-19 from contact with known or suspected COVID-19 patients. (https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/people-at-high...). Dental offices "... should consider and address the level(s) of risk associated with various worksites and job tasks workers perform at those sites." It is suggested that providers who do not fall into these categories (older age; presence of chronic medical conditions, including immunocompromising conditions; pregnancy)." should be prioritized to provide care. (https://www.osha.gov/Publications/OSHA3990.pdf)
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ADA.org/InterimGuidance
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ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
"Designate convalescent [DHCP] provision of care to known or suspected COVID-19 patients (those who have clinically recovered from COVID-19 and may have some protective immunity) to preferentially provide care." This means that providers who have recently contracted and recovered from a COVID-19 infection should be the preferred personnel providing care. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/checklistn95-strategy.html)
Schedule appointments apart enough to minimize possible contact with other patients in the waiting room. (https://success.ada.org/en/practice-management/patients/coronavirus-freq...)
Prevent patients from bringing companions to their appointment, except for instances where the patient requires assistance (e.g., pediatric patients, people with special needs, elderly patients, etc.). If companions are allowed for patients receiving treatment, they should also be screened for signs and symptoms of COVID19 during patient check-in and should not be allowed entry into the facility if signs and symptoms are present (e.g., fever, cough, shortness of breath, sore throat). Companions should not be allowed in the dental office if perceived to be at a high risk of contracting COVID-19 (e.g., having a pre-existing medically compromised condition). Any person accompanying a patient should be prohibited in the dental operatory. (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/controlrecom... ncov%2Fhcp%2Finfection-control.html#manage_access)
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
"Make every effort to interview the patient by telephone, text monitoring system, or video conference before the visit." (https://www.cdc.gov/coronavirus/2019-ncov/php/guidance-evaluating-pui.html, https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html)
If an emergency or urgent dental patient does not have a fever and is otherwise without even mild symptoms consistent with COVID-19 infection (e.g., fever, sore throat, cough, difficulty breathing), they can be seen in dental settings with appropriate protocols and PPE in place. (Algorithm 2 and 3).
If an emergency or urgent dental patient has a fever strongly associated with a dental diagnosis (e.g., pulpal and periapical dental pain and intraoral swelling is present), but no other signs/symptoms of COVID-19 infection (e.g., fever, sore throat, cough, difficulty breathing), they can be seen in dental settings with appropriate protocols and PPE in place (Algorithm 2 and 3).
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
If an emergency or urgent dental patient does exhibit signs and symptoms of respiratory illness, the patient should be referred for emergency care where appropriate Transmission-Based Precautions are available. (Algorithm 2). (https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf; https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf)
If patients wish to, or if the waiting room does not allow for appropriate "social distancing" (situated at least 6 feet or 2 meters apart), they may wait in their personal vehicle or outside the facility where they can be contacted by mobile phone when it is their turn to be seen. This can be communicated to patients at the moment of scheduling the appointment, based on established office procedures (see Dentist and Dental Team Preparation Section). (https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/dialysis...) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommen...)
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
DHCP should adhere to Standard Precautions, which "are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered." a. Standard Precautions include: Hand hygiene, use of PPE, respiratory hygiene/etiquette, sharps safety, safe injection practices, sterile instruments and devices, clean and disinfected environmental surfaces. https://www.cdc.gov/oralhealth/infectioncontrol/pdf/safe-care2.pdf
"Wear a surgical mask and eye protection with solid side shields or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures likely to generate splashing or spattering [(large droplets)] of blood or other body fluids." (https://www.cdc.gov/mmwr/PDF/rr/rr5217.pdf)
Surgical masks are one use only, and one mask should be used per patient. (https://www.fda.gov/medicaldevices/personal-protective-equipment-infecti...)

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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
Since SARS-CoV-2 may be vulnerable to oxidation, use 1.5% hydrogen peroxide (commercially available in the US) or 0.2% povidone as a preprocedural mouthrinse.(32127517) There are no clinical studies supporting the virucidal effects of any preprocedural mouthrinse against SARS-CoV-2.
DHCP may use "extraoral dental radiographs, such as panoramic radiographs or cone beam CT, [and] are appropriate alternatives" (32162995) to intraoral dental radiographs during the outbreak of COVID-19, as the latter can stimulate saliva secretion and coughing. (15311240).
Reduce aerosol production as much as possible, as the transmission of COVID-19 seems to occur via droplets or aerosols (32182409), and DHCP should prioritize the use of hand instrumentation. (32127517)
DHCP should use rubber dams if an aerosol-producing procedure is being performed to help minimize aerosol or spatter. (2681303, 15493394
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ADA.org/InterimGuidance
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ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
Follow CDC recommendations in the event of suspected unintentional exposure (e.g., unprotected direct contact with secretions or excretions from the patient). (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hc...) a. Aerosol-generating procedures should be scheduled as the last appointment of the day. For an aerosol-generating procedure performed without N95 masks and only surgical facemasks, regardless of disinfection procedures being effectively executed, subsequent patients and DHCP are at moderate risk for COVID-19 infection and transmission. Given that asymptomatic patients may carry the virus, CDC suggests a 14-day quarantine. Alternatively, take all precautions to prevent transmission and require that the patient is tested for COVID-19 immediately after dental treatment; if positive, DHCP should quarantine for 14 days.
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ADA.org/InterimGuidance

ADA Interim Guidance for Minimizing Risk of COVID-19 Transmission April 1st 2020Highlights:
In light of the controversy regarding whether ibuprofen should be used for patients with a COVID-19 infection, it is recommended to use ibuprofen as normally indicated when managing any type of pain. For example, for the management of pulpal- and periapical-related dental pain and intraoral swelling in immunocompetent adults, it is recommended that NSAIDs in combination with acetaminophen (i.e. 400-600 milligrams ibuprofen plus 1,000 mg acetaminophen) can still be used. (https://twitter.com/WHO/status/1240409217997189128?ref_src=twsrc%5Etfw%7... %7Ctwterm%5E1240409217997189128&ref_url=https%3A%2F%2Fwww.sciencealert.com%2Fwhorecommends-to-avoid-taking-ibuprofen-for-covid...) (31668170)
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ADA.org/InterimGuidance

What can be done to reduce the risks?Additional thoughts or ideas.
Telehealth has minimal applications to dentistry. The only condition that could be diagnosed would be a cellulitis (soft tissue swelling) but it would be difficult to associate it with a specific tooth without a radiograph. The State of Texas has not authorized dentists to use Telehealth.
Triage patients over the phone for COVID 19 symptoms and the probability of need for emergency/urgent care to safeguard staff and reduce patient volume in the clinic.
At arrival, formally screen for COVID 19 symptoms and take temperature before allowing them in waiting area.
Give patients hand sanitizer before entering waiting room. If coughing or sneezing, give them a surgical mask to wear.

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What can be done to reduce the risks?Additional thoughts or ideas.
Mandate social distancing in waiting area or have patients wait in cars or somewhere outside before allowing them into the clinic. (Factors to consider: public transportation, weather, foreign language interpreters.)
If patient has COVID 19 symptoms and a dental emergency, have them wear a mask and remove them from the waiting area ASAP and place them in a private treatment room. Limit staff that examines patients and have staff wear N95 masks, eye protection and disposable gowns, head covering and gloves. Consider postponing any procedures and only diagnosis and pharmcotherapeutic measures. (It's difficult to perform procedures if patient is coughing.)
Refer to medical for testing if COVID 19 if symptoms and related questions indicate.
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COVID 19 screening questions
Have you or anyone in your household travelled internationally in the last 14 days?
Have you been in contact with someone who has been diagnosed with or is under quarantine for possible COVID 19?
Have you been practicing social distancing?
Have you been in groups of 10 or more people in the past week?
Did you attend the 2020 Houston Rodeo or Rodeo Cook Off?
What is your chief dental complaint?
Do you have any of the following symptoms?
Fever
Cough
Trouble breathing
Muscle aches
Record vital signs: BP,P,T, SPO2%
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HIV/AIDS and COVID 19: Oral Health Considerations
Currently, the HIV patient is probably not at an increased risk of COVID 19 transmission if viral load undetectable and CD4 cell count is normal without comorbidities.
If CD4 cell count is less <200 and/or viral load is elevated, patient is probably at an increased risk of COVID 19 transmission, and should increase social distancing parameters, but this information may not be readily available or the front desk staff may not be trained to read laboratory results.
Continue to follow the invasive treatments guidelines for low platelet count, hemoglobin and ANC/WBC.
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Invasive Procedure Risk Assessment for HIV
ITP - Idiopathic thrombocytopenia purpura
< 150,000 plts/mm common in AIDS
> 60,000 plts/mm usually safe for dental/oral surgery
> 20,000 plts/mm usually safe for minor dental proc.
< 20,000 plts/mm any tissue manipulation contraind.
Aspirin (acetylsalicylic acid) - extreme caution with prolonged use
Anemia (Normal hemoglobin 12.7-18.1g/dL)
Minor surgery routine with hemoglobin >7g/dL
Any dental procedure, extreme caution < 7g/dL
Respiratory depressing drugs contraind. <10g/dL
From the JADA (Journal of the American Dental Association)Dental Management of the HIV-Infected Patient, 1995 & The American Academy of Oral Medicine
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Invasive Procedure Risk Assessment for HIV
Antibiotic Prophylaxis for Infective Endocarditis
no special consideration
General Antibiotic Coverage
no specific indication for HIV/AIDS
neutrophils <500 cells/mm & procedure with tissue disruption and or bleeding
chlorhexidine rinse recommended
Antibiotics for Post Procedural Local Infections
HIV/AIDS patients not at increased risk
if one develops, use PO systemic antibiotics (amoxicillin, azithromycin, clindamycin, metronidazole, amoxicillin/clavulanic acid)

From the JADA (Journal of the American Dental Association)Dental Management of the HIV-Infected Patient, 1995 & The American Academy of Oral Medicine
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HIV/AIDS and COVID 19: Oral Health ConsiderationsUrgent Conditions
Oral ulcerations (aphthous major, necrotic ulcerations, viral, bacterial and mycotic lesions) can be extremely painful.
Periodontal disease can be extremely painful. Necrotizing Ulcerative Periodontitis or Gingivitis. (NUP or NUG)
Oral malignancies, such as squamous cell carcinoma or lymphomas would be considered urgent.
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HIV/AIDS and COVID 19: Oral Health Considerations
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Aphthous major ulceration

HIV/AIDS and COVID 19: Oral Health Considerations
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HPV 16 induced squamous cell carcinoma of tonsil

HIV/AIDS and COVID 19: Oral Health Considerations
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Squamous cell carcinoma of lateral posterior tongue

HIV/AIDS and COVID 19: Oral Health Considerations
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Necrotic ulceration of lateral tongue

HIV/AIDS and COVID 19: Oral Health Considerations
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Herpes simplex intraoral ulcerations

HIV/AIDS and COVID 19: Oral Health Considerations
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Histoplasmosis oral ulceration

HIV/AIDS and COVID 19: Oral Health Considerations
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Necrotizing Ulcerative Periodontitis

HIV/AIDS and COVID 19: Oral Health Considerations
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Lymphoma

HIV/AIDS and COVID 19: Oral Health Considerations
Undiagnosed HIV patients can present with painful teeth and/or cellulitis.
Perform a soft tissue exam to identify any possible HIV related lesions.
Following is a brief review of some common HIV-related oral lesions.
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Pseudomembraneous Candidiasis
White, non-adherent lesions on oral mucosa
Usually asymptomatic but may burn or have yeast-like smell
Etiology: candida albicans, globrata
DX: clinical appearance, cytology
Tx: mild- probiotics, mod - topical antifungals, severe - systemic antifungals, eg. Fluconazole.. Length of treatment depends on the level of immune system
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Hyperplastic candidiasis
White adherent lesions on mucosal surfaces
Usually asymptomatic
Etiology: candida albicans or globrata
Dx: biopsy
Tx: systemic antifungals
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Oral hairy leukoplakia
White, adherent flat or corrugated shaggy lesions on mucosal surfaces.
Asyptomatic, or dysgeusia
Etiology: Epstein-Barr Virus with immunosupression (chemical or biological)
Dx: bx or cytology
Tx: keratolytic agents, antivirals not usually recommended
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Erythematous Candidiasis (Atrophic)
Red smooth, depapillated patches on mucosa, most frequently seen on hard palate and dorsal tongue, mild burning or sore feeling, sensitivity to spicy or acidic foods
Etiology candida albicans or globrata
Dx clinical or cytology
Tx topical or systemic antifungal medications

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Linear gingival erythema - LGE
Bright red appearance to free marginal gingiva that bleeds easily, sometimes painful. Can be difficult to respond to tx
Etiology unknown, candida and poor oral hygiene have been implicated
Dx clinical
Tx thorough debridement, antibiotics, chlorhexidine rinses
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Kaposi's sarcoma
Red, purple macules, nodules or exophytic masses on any surface. Some lesions may be non-pigmented. Symptoms range from asymptomatic to pain and hemorrhage. May occur initially in oral cavity.
Etiology HHV8 with HIV predominately seen in MSM
Dx bx mandatory
Tx local or systemic chemotherapy, for mild to moderate lesion, watchful waiting with HAART
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Cytomegalovirus ulcerations
Superficial or deep ulcerations on either keratinized or non-keratinized tissue. Painful. Usually chronic.
Etiology CMV, may be residing in nonspecific ulcer. CD4 <50
Dx: bx, need to sample 4mm into base of ulcer.
Tx: ganciclovir, cidofovir, foscavir, systemic steroids
Need referral to ophthalmology.
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Multifocal epithelial hyperplasia - MEH
Raised or slightly nodular lesion on oral mucosa with stipled surface. Color can vary from normal to white. Usually multiple lesions but can be solitary and most often appear where tissue is easily traumatized by teeth.
Etiology HPV 13,32, most often seen when CD4 <300
Dx clinical, bx preferred for at least one lesion.
Tx excision, keratolytic agents, alpha-interferon

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Molluscum contagiosum
Multiple raised or nodular lesions with a white core usually seen on vermillion border or skin.
Etiology Poxvirus and direct skin contact. Patient can autoinoculate from other sites (genital)
Dx - clinical, bx preferred
Tx enucleation or topical tretinoin gel, systemic acitretin
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References:
cdc.gov/coronavirus (Centers for Disease Control)
osap.org (Organization for Safety Asepsis and Prevention)
ADA.org/InterimGuidance
ADA.org/Coronavirus center
https://www.youtube.com/watch?v=ttidxHuXnWg&feature=youtu.be
JADA (Journal of the American Dental Association)Dental Management of the HIV-Infected Patient, 1995
Previous lectures from HIV Oral Health Symposium
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Thank you for your attention
Follow community safety guidelines and clinical practice guidelines. We will make it through this pandemic

C. Mark Nichols, DDS
[email protected]
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