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April 2009 | Modern Hygienist
HIV 101 Treating immunocompromised patients, as seen through a student's eyes. Treating patients with medical conditions can be both a challenging and interesting experience. The practitioner needs to be aware of many factors to provide the best possible care. The patient’s medical history, medications, as well as dental history and oral home care are important components when trying to create a hygiene treatment plan. As a dental hygiene student I have had the opportunity to treat several patients with complex medical histories, but with one patient in particular I found myself challenged beyond the typical scope of my practice. This patient’s conditions had many intraoral findings that needed to be addressed and made creating an appropriate dental hygiene treatment plan more interesting. Patient history Mr. Smith* is a 48-year-old Caucasian male. He was diagnosed with HIV 15 years ago. At the date of our appointment, Mr. Smith was taking a multi-vitamin supplement rather than medications to treat his condition. To be treated at the school, the patient must have an up-to-date medical consultation and lab values. From his most recent consult, he was found to be HIV asymptomatic with a CD4 cell count of 674/l and a viral load of 14527 copies. Along with being HIV positive, Mr. Smith also had a condition known as myotonic dystrophy. He was diagnosed three years ago, and also is not taking any medications to treat this. Having never treated a patient with this condition, I did some research to prepare myself for the appointment. I found myotonic dystrophy is a genetic, chronic, slowly progressing type of muscular dystrophy in which the patient loses the ability to control muscle function. Mr. Smith’s periodontal diagnosis was generalized moderate chronic periodontitis. The treatment plan called for scaling and root planing throughout all four quadrants. His periodontal condition is impacted by numerous things including tobacco use and poor oral hygiene. The patient only brushes his teeth once a day. Because of his myotonic dystrophy, he has limited dexterity and can only brush by holding an electric toothbrush between his knees. Mr. Smith also has been using cigarettes for 25 years and smokes between one and three packs per day. Oral hygiene instruction is crucial for Mr. Smith’s periodontal condition to reach a manageable level. Despite his urgent need for proper oral hygiene instruction, there were several other findings during the intraoral examination that needed to be addressed. Patients suffering from HIV are prone to intraoral lesions that can range in size and appearance; Mr. Smith was no exception. Although he had no complaints of soreness or areas of concern, he presented with a candidiasis infection on the mandibular edentulous alveolar processes, which is a common finding among HIV-positive patients. He also displayed a red-line marginal edema bilaterally on his buccal mucosa. I knew I needed to educate him about managing his candida infection, but I found the lesions on his buccal mucosa to be concerning. After discussing Mr. Smith’s condition with faculty, a biopsy was done. It revealed the lesion to be non-specific mucositis. This often can be one of the first signs of an HIV infection and, unfortunately, often goes unnoticed. If left untreated, it will lead to further complications such as oral ulcers that can become infected, posing significant risks for immunocompromised patients. With all of the components of Mr. Smith’s case, I knew I needed to learn more about possible complications with an HIV-positive patient.
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