HIV infection

Overview

Board takeaway: Well-controlled HIV generally permits routine dental care with standard precautions. Current health, medicines, neutrophils, and platelets determine procedural modifications; viral load and CD4 count describe HIV control but are not stand-alone dental clearance tests.

How does HIV infection affect dental management?

• Routine care: Standard precautions; routine care for patients who are well controlled
• When to coordinate: Coordinate with the HIV team for advanced disease, active opportunistic infection, significant neutropenia, or uncertain medical stability.
• Possible prophylaxis: AAPD lists HIV with a polymorphonuclear leukocyte count below 500/mm³ among situations where prophylaxis may be considered; it is an individualized decision, not an automatic CD4-based regimen.
• Bleeding: Platelets may be low; check before surgery
• Interactions: Antiretroviral drug interactions with azoles and sedatives (midazolam with protease inhibitors)
• Oral candidiasis: treat uncomplicated oropharyngeal disease for 7–14 days; treatment choice depends on severity. NIH pediatric guidance.

AAPD prophylaxis; NIH PI interaction table.

Exam pearl

What is HIV infection?

Infection with the human immunodeficiency virus, which targets CD4 T lymphocytes and progressively weakens cellular immunity. AIDS is the advanced stage of HIV infection.

What are the main systemic features of HIV infection?

• Perinatal transmission: Perinatal transmission is now rare with maternal antiretroviral therapy
• Adolescent transmission: Adolescents acquire HIV sexually or through injection drug use
• Treatment: Lifelong antiretroviral therapy; opportunistic infections at low CD4 counts

What oral findings occur in HIV infection?

• Candidiasis: Oral candidiasis is the most common lesion
• Glands and gingiva: Parotid enlargement and linear gingival erythema; an oral finding alone does not establish disease progression
• Infection and inflammation: Necrotizing gingivitis and periodontitis, recurrent HSV, aphthous ulcers
• Other lesions: Oral hairy leukoplakia and Kaposi sarcoma (rare in children)
• Caries: Caries risk from sugar-based medications and xerostomia

For HIV infection, which drug interactions matter?

• Protease inhibitors/cobicistat inhibit CYP3A4
• Oral midazolam and triazolam: contraindicated with ritonavir- or cobicistat-boosted atazanavir or darunavir.
• Parenteral exception: The cautious-use/dose-reduction option applies to parenteral midazolam in a monitored setting, not oral midazolam. NIH interaction table.
• Azoles/macrolides also interact

For HIV infection, what labs guide treatment and what values change your plan?

Which results matter?

• HIV control: review CD4 count/percentage and viral load to understand HIV control.
• Procedural risk: review CBC with differential and platelets when immune or bleeding risk affects the planned procedure.
• Timing: obtain clinically relevant, sufficiently recent results with the medical team rather than ordering every test before every routine visit.

What changes care?

• Coordinate before elective invasive care: a polymorphonuclear leukocyte count below 500/mm³, significant thrombocytopenia, an active opportunistic infection, or systemic illness calls for physician coordination before elective invasive care.
• Shared plan: decide timing, antibiotics, hemostatic support, and treatment setting together.
• Urgency: urgent dental infection still needs a coordinated treatment plan.
• Limit: AAPD does not make a low CD4 value alone an automatic antibiotic indication.

Sources

• AAPD dental guidance: AAPD: Antibiotic prophylaxis (2026 revision)
• Supplemental study guide: Pediatric Dental Study Guide: HIV/ AIDS
• Policy on Infection Control
• Dental Management of Pediatric Patients Receiving Immunosuppressive Therapy and/or Head and Neck Radiation