Medical Evaluation of the HIV Dental Patient Module 1.

Medical Evaluation of the HIV Dental Patient


Module 1Module 1



Louis G. DePaola, DDS, MSProfessor,

Department of Diagnostic Sciences and PathologyDental School

University of Maryland BaltimoreDirector, Dental Training

Pennsylvania-MidAtlantic AIDS ETC

Michael Glick, DMDProfessor and Chairman,

Department of Diagnostic SciencesUniversity of Medicine and Dentistry of New Jersey

Director, Dental TrainingNew Jersey, AIDS ETC

Dr. Valli I. Meeks, DDS, MS RDHDepartment of Diagnostic Sciences and Pathology

Dental SchoolUniversity of Maryland Baltimore

Louis G. DePaola, DDS, MSProfessor,

Department of Diagnostic Sciences and PathologyDental School

University of Maryland BaltimoreDirector, Dental Training

Pennsylvania-MidAtlantic AIDS ETC

Michael Glick, DMDProfessor and Chairman,

Department of Diagnostic SciencesUniversity of Medicine and Dentistry of New Jersey

Director, Dental TrainingNew Jersey, AIDS ETC

Dr. Valli I. Meeks, DDS, MS RDHDepartment of Diagnostic Sciences and Pathology

Dental SchoolUniversity of Maryland Baltimore



• Dental management of HIV infected patients does not differ from that of non-HIV infected patients. Most treatment can be performed by general practitioners. No special facility or equipment is required.

“Standard Precautions” are followed. • HIV infected patients who require specialist care

should be appropriately referred according to the same referral protocol as for the non-HIV infected patient. e.g. oral medicine, oral pathology, oral surgery,

endodontics, periodontal therapy, orthodontics, pedodontics, prosthodontics

• Dental management of HIV infected patients does not differ from that of non-HIV infected patients. Most treatment can be performed by general practitioners. No special facility or equipment is required.

“Standard Precautions” are followed. • HIV infected patients who require specialist care

should be appropriately referred according to the same referral protocol as for the non-HIV infected patient. e.g. oral medicine, oral pathology, oral surgery,

endodontics, periodontal therapy, orthodontics, pedodontics, prosthodontics



• A comprehensive medical and oral health assessment is an essential component for safe and appropriate oral health care. HIV infected persons often present with

medical problems resulting from HIV-related immune suppression and co-morbid conditions.

Early recognition and intervention for opportunistic infections (OIs) can significantly reduce morbidity and improve the quality of life for patients infected with HIV disease.

• A comprehensive medical and oral health assessment is an essential component for safe and appropriate oral health care. HIV infected persons often present with

medical problems resulting from HIV-related immune suppression and co-morbid conditions.

Early recognition and intervention for opportunistic infections (OIs) can significantly reduce morbidity and improve the quality of life for patients infected with HIV disease.



• HIV-infected patients are living longer and develop chronic diseases, many secondary to the toxicity of their medications, including - Lipodystrophy Hyperglycemia Liver disease

• HIV-infected patients are living longer and develop chronic diseases, many secondary to the toxicity of their medications, including - Lipodystrophy Hyperglycemia Liver disease

Medical ConcernsMedical Concerns

• Patient’s susceptibility to infections

• Impaired hemostasis

• Drug actions and interactions

• Ability to withstand the stress and trauma due to dental care

• Patient’s susceptibility to infections

• Impaired hemostasis

• Drug actions and interactions

• Ability to withstand the stress and trauma due to dental care

Medical Problem ListMedical Problem List

• Patient’s susceptibility to infections Hemodialysis Bacterial endocarditis Poorly controlled diabetes mellitus

• Patient’s susceptibility to infections Hemodialysis Bacterial endocarditis Poorly controlled diabetes mellitus


• Impaired hemostasis Hemophilia Liver disease due to:

• Hepatitis B infection and/or • Hepatitis C infections and/or• Alcohol, substance use/abuse

Idiopathic thrombocytopenia purpura

• Impaired hemostasis Hemophilia Liver disease due to:

• Hepatitis B infection and/or • Hepatitis C infections and/or• Alcohol, substance use/abuse

Idiopathic thrombocytopenia purpura


• Drug actions and interactions Avoid acetaminophen in patients

with severe liver disease Avoid NSAIDs, including aspirin, in

patients with impaired hemostasis Recognize side-effects and

drug-interactions with antiretroviral medications• See Module 3, part 3

• Drug actions and interactions Avoid acetaminophen in patients

with severe liver disease Avoid NSAIDs, including aspirin, in

patients with impaired hemostasis Recognize side-effects and

drug-interactions with antiretroviral medications• See Module 3, part 3


• Ability to withstand the stress and trauma due to dental care Cardiovascular disease Stroke Poorly controlled diabetes mellitus

• Ability to withstand the stress and trauma due to dental care Cardiovascular disease Stroke Poorly controlled diabetes mellitus

Medical HistoryMedical HistoryMedical HistoryMedical History• A medical history (MHx) should be

recorded for each patient.

• A thorough MHx should be recorded every 6 months.

• An abbreviated updated MHx should be recorded at every visit.

• A medical history (MHx) should be recorded for each patient.

• A thorough MHx should be recorded every 6 months.

• An abbreviated updated MHx should be recorded at every visit.

Medical HistoryMedical History

• Medical history should include: Chief complaints and history of present illnessChief complaints and history of present illness Review of past medical historyReview of past medical history Hospitalizations and surgeriesHospitalizations and surgeries Current/recent illnessesCurrent/recent illnesses MedicationsMedications AllergiesAllergies Substance abuse historySubstance abuse history Review of systemsReview of systems

• Medical history should include: Chief complaints and history of present illnessChief complaints and history of present illness Review of past medical historyReview of past medical history Hospitalizations and surgeriesHospitalizations and surgeries Current/recent illnessesCurrent/recent illnesses MedicationsMedications AllergiesAllergies Substance abuse historySubstance abuse history Review of systemsReview of systems

Systems ReviewSystems Review

Cardiovascular systemCardiovascular system Respiratory systemRespiratory system Central nervous systemCentral nervous system Gastrointestinal systemGastrointestinal system Genitourinary systemGenitourinary system Musculoskeletal systemMusculoskeletal system Endocrine systemEndocrine system SkinSkin Head and neckHead and neck

Cardiovascular systemCardiovascular system Respiratory systemRespiratory system Central nervous systemCentral nervous system Gastrointestinal systemGastrointestinal system Genitourinary systemGenitourinary system Musculoskeletal systemMusculoskeletal system Endocrine systemEndocrine system SkinSkin Head and neckHead and neck

Dental ExaminationDental Examination

• Document base line pulse and blood pressure

• Record pulse and blood pressure every visit for patients with hypertension or who are taking anti-hypertensive medications

• Intra and extra-oral examination

• Document base line pulse and blood pressure

• Record pulse and blood pressure every visit for patients with hypertension or who are taking anti-hypertensive medications

• Intra and extra-oral examination

HIV Disease HistoryHIV Disease HistoryHIV Disease HistoryHIV Disease History

• Date of HIV infection if knownDate of HIV infection if known• Current HIV disease progression Current HIV disease progression

CD4 count - trend (up, down, stable)CD4 count - trend (up, down, stable) Viral load - trend (up, down, stable)Viral load - trend (up, down, stable)

• History of opportunistic infection(s)History of opportunistic infection(s)• Medication(s)Medication(s)

• Date of HIV infection if knownDate of HIV infection if known• Current HIV disease progression Current HIV disease progression

CD4 count - trend (up, down, stable)CD4 count - trend (up, down, stable) Viral load - trend (up, down, stable)Viral load - trend (up, down, stable)

• History of opportunistic infection(s)History of opportunistic infection(s)• Medication(s)Medication(s)

MedicationsMedications• Current Medications including:

Prescription medications, OTC, herbal, naturopathic and homeopathic remedies and treatments, and nutritional supplements

• HIV patients are frequently on numerous antiretroviral medications with complex dosing regimens.

• Numerous drug-to-drug interactions have been well documented.

• A complete listing of all medications is essential to minimize potential adverse drug interaction to medications that may be prescribed by the dental provider.

• Current Medications including: Prescription medications, OTC, herbal,

naturopathic and homeopathic remedies and treatments, and nutritional supplements

• HIV patients are frequently on numerous antiretroviral medications with complex dosing regimens.

• Numerous drug-to-drug interactions have been well documented.

• A complete listing of all medications is essential to minimize potential adverse drug interaction to medications that may be prescribed by the dental provider.

Opportunistic InfectionsOpportunistic Infections

• History of opportunistic infections• Previous viral, fungal or bacterial

infections• Current or previous antibiotic prophylaxis

for opportunistic infections• Malignancies (including site)

Kaposi’s sarcoma (KS) Non-Hodkins Lymphoma (NHL) Other

• History of opportunistic infections• Previous viral, fungal or bacterial

infections• Current or previous antibiotic prophylaxis

for opportunistic infections• Malignancies (including site)

Kaposi’s sarcoma (KS) Non-Hodkins Lymphoma (NHL) Other

Medical Consultation Medical Consultation and Laboratory Testingand Laboratory TestingMedical Consultation Medical Consultation

and Laboratory Testingand Laboratory Testing

• Patients with HIV infection often have chronic/systemic disease(s) that is unrelated to HIV. When providing treatment for HIV infected

patients, as with any non-infected patient, a medical consultation may be indicated.

• The following additional information is indicated and can usually be obtained from the patients physician:

• Patients with HIV infection often have chronic/systemic disease(s) that is unrelated to HIV. When providing treatment for HIV infected

patients, as with any non-infected patient, a medical consultation may be indicated.

• The following additional information is indicated and can usually be obtained from the patients physician:

Hematological Blood

Values

Hematological Blood

ValuesIndication of patient’s risk for infection and bleeding tendencies• Complete Blood Count (CBC)

Platelet count Differential blood cell count

• Liver enzymes• Coagulation tests

Indication of patient’s risk for infection and bleeding tendencies• Complete Blood Count (CBC)

Platelet count Differential blood cell count

• Liver enzymes• Coagulation tests

HematologyCBC

HematologyCBC

• CBC includes: White blood cell count (WBC) Red blood cell count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelets (Plt)

• CBC includes: White blood cell count (WBC) Red blood cell count (RBC) Hemoglobin (Hgb) Hematocrit (Hct) Platelets (Plt)

HematologyCBC

HematologyCBC

• Total white and red blood cell count, hematocrit, and platelet counts are important in managing HIV patients: Many HIV+ patients are neutropenic,

thrombocytopenic, and anemic Values indicate susceptibility to infection

and bleeding Should be repeated at 3-6 month intervals

• Patients with advanced HIV disease may require more frequent evaluation

• Total white and red blood cell count, hematocrit, and platelet counts are important in managing HIV patients: Many HIV+ patients are neutropenic,

thrombocytopenic, and anemic Values indicate susceptibility to infection

and bleeding Should be repeated at 3-6 month intervals

• Patients with advanced HIV disease may require more frequent evaluation

Total WBC: 4,000 – 11,000 cells/mm3

Neutrophils: 3,000-6,000 cells/mm3

– 30% – 70% of total WBC

• Lymphocytes: 1,500 – 4,000 cells/mm3

– 20% - 50% of total WBC

• Monocytes: 200 - 900 cells/mm3


• Eosinophils: 100 - 700 cells/mm3


• Basophils: 20 - 50 cells/mm3


Total WBC: 4,000 – 11,000 cells/mm3

Neutrophils: 3,000-6,000 cells/mm3

– 30% – 70% of total WBC

• Lymphocytes: 1,500 – 4,000 cells/mm3


• Monocytes: 200 - 900 cells/mm3


• Eosinophils: 100 - 700 cells/mm3


• Basophils: 20 - 50 cells/mm3


Hematology Differential White Blood Cell Count

Hematology Differential White Blood Cell Count

Hematology WBC

Hematology WBC

• Neutropenia Normal neutrophil count:

• 4,500-10,000 cells/mm3

Mild neutropenia: • 2,500- 4,500 cells/mm3

Severe neutropenia:• Below 1,000 cells/mm3

Antibiotic prophylaxis is indicated with neutroplils < 500 cells/mm3 • Many clinicians use American Heart Association Regimen.

However, others feel that antibiotic therapy should continue for as long as open wounds are present in the oral cavity.

• Neutropenia Normal neutrophil count:

• 4,500-10,000 cells/mm3

Mild neutropenia: • 2,500- 4,500 cells/mm3

Severe neutropenia:• Below 1,000 cells/mm3

Antibiotic prophylaxis is indicated with neutroplils < 500 cells/mm3 • Many clinicians use American Heart Association Regimen.

However, others feel that antibiotic therapy should continue for as long as open wounds are present in the oral cavity.

HematologyRed Blood Cells

HematologyRed Blood Cells

• Red Blood Cells Anemia is common in HIV disease Decrease in RBCs or Hgb

often caused by antiretroviral therapy and other medications

Normal RBC: 4.5 - 5.5 x 106 cells/mm3

• Red Blood Cells Anemia is common in HIV disease Decrease in RBCs or Hgb

often caused by antiretroviral therapy and other medications

Normal RBC: 4.5 - 5.5 x 106 cells/mm3

HematologyHemoglobin HematologyHemoglobin

• Hemoglobin: Carries oxygen in the RBC • Decreased hemoglobin means less ability for

oxygenation Normal varies from men to women:

• Males: 12-16 g/dl • Females: 14-18 g/dl

Causes for hemoglobin decrease:• Decrease RBC production• Impaired production

• Hemoglobin: Carries oxygen in the RBC • Decreased hemoglobin means less ability for

oxygenation Normal varies from men to women:

• Males: 12-16 g/dl • Females: 14-18 g/dl

Causes for hemoglobin decrease:• Decrease RBC production• Impaired production

HematologyPlatelet CountHematology

Platelet Count Normal platelet count: 150,000 -

400,000 cells/mm3

Thrombocytopenia: Decreased platelet count

100,000 - 140,000 cells/mm3

> 50-60,000 cells/mm3, adequate for routine dental care including simple extractions

< 20,000 may see spontaneous bleeding

Thromboytopenia is associate with bruising, and petechiae of skin and mucosa

Normal platelet count: 150,000 - 400,000 cells/mm3

Thrombocytopenia: Decreased platelet count

100,000 - 140,000 cells/mm3

> 50-60,000 cells/mm3, adequate for routine dental care including simple extractions

< 20,000 may see spontaneous bleeding

Thromboytopenia is associate with bruising, and petechiae of skin and mucosa

HematologyHematocritHematologyHematocrit

• Hematocrit Measure of packed cell

volume (PCV) of RBCs Normal: 37% - 54% indication of anemia and

especially vitamin B12 deficiency

• Hematocrit Measure of packed cell

volume (PCV) of RBCs Normal: 37% - 54% indication of anemia and

especially vitamin B12 deficiency

HematologyLiver Enzymes

HematologyLiver Enzymes

• ALT, AST values Non-specific transaminases

• Often elevated with acute liver disease

• Marked elevation may indicate decreased liver function

• Patients may be prone to hemorrhage

• Drug metabolism may be impaired

• ALT, AST values Non-specific transaminases

• Often elevated with acute liver disease

• Marked elevation may indicate decreased liver function

• Patients may be prone to hemorrhage

• Drug metabolism may be impaired

HematologyCoagulation Tests


Indicates patient’s clotting ability Increase indicates:

Coagulation abnormality due to liver disease Other systemic diseases Anticoagulant therapy Medications

Significantly elevated coagulation test results may require modification of dental treatment

Indicates patient’s clotting ability Increase indicates:

Coagulation abnormality due to liver disease Other systemic diseases Anticoagulant therapy Medications

Significantly elevated coagulation test results may require modification of dental treatment



Coagulation tests: Prothrombin time (PT)

• Normal: 9-11 seconds Activated partial thromboplastin time (aPTT)

• Normal: 28-38 seconds INR (international normalized ratio)

• Normal: 1.0• >2.0 indicative of possible use of

anticoagulation medications such as Coumadin®

Coagulation tests: Prothrombin time (PT)

• Normal: 9-11 seconds Activated partial thromboplastin time (aPTT)

• Normal: 28-38 seconds INR (international normalized ratio)

• Normal: 1.0• >2.0 indicative of possible use of

anticoagulation medications such as Coumadin®

Immunological Blood Values CD4 Count

Immunological Blood Values CD4 Count

• CD4 Count Indicates HIV progression and degree of

immune suppression Normal CD4 count 800-1000 cells/mm3

• Major opportunistic infections frequently seen with CD4 cell count <200 cells/mm3 • CD4 cell count < 200 cells/mm3 is an AIDS

diagnosis

• CD4 Count Indicates HIV progression and degree of

immune suppression Normal CD4 count 800-1000 cells/mm3

• Major opportunistic infections frequently seen with CD4 cell count <200 cells/mm3 • CD4 cell count < 200 cells/mm3 is an AIDS

diagnosis

CD4 Counts (T-4 Helper

Lymphocyte)

CD4 Counts (T-4 Helper

Lymphocyte) Absolute CD4 helper count

Total number of CD4 cells/mm3

CD4 % Percent of CD4 cells of the total lymphocytes

• “Healthy” and usually asymptomatic patients

–CD4 cell count >500 cells/mm3 (>29%)

• Symptomatic patient

–CD4 cell count of 200-499 cells/mm3 (14-28%) AIDS:

–CD4 cell count <200 cells/mm3 (<14%)

Absolute CD4 helper count Total number of CD4 cells/mm3

CD4 % Percent of CD4 cells of the total lymphocytes

• “Healthy” and usually asymptomatic patients

–CD4 cell count >500 cells/mm3 (>29%)

• Symptomatic patient

–CD4 cell count of 200-499 cells/mm3 (14-28%) AIDS:

–CD4 cell count <200 cells/mm3 (<14%)

Immunological Plasma Viral Load

Immunological Plasma Viral Load

• Plasma Viral Load: Indication of degree of viral replication and

suggestion of immune suppression • Destruction of CD4 lymphocytes

Measure of therapeutic (HAART) success or failure

Prognostic: • The higher the viral load, the faster the progression of

HIV disease and the poorer the long term prognosis

• Plasma Viral Load: Indication of degree of viral replication and

suggestion of immune suppression • Destruction of CD4 lymphocytes

Measure of therapeutic (HAART) success or failure

Prognostic: • The higher the viral load, the faster the progression of

HIV disease and the poorer the long term prognosis

Viral LoadViral Load Listed (usually) on lab results as:

HIV-1 RNA by PCR

< 10,000 copies/ml suggests a mean survival rate of >10 years

> 30,000 copies/ml suggest a mean survival rate of <5 years

Listed (usually) on lab results as: HIV-1 RNA by PCR

< 10,000 copies/ml suggests a mean survival rate of >10 years

> 30,000 copies/ml suggest a mean survival rate of <5 years

ConfidentialityConfidentiality

• At all times, confidentiality must be maintained for all patients, regardless of HIV serostatus.

• Proper consent should be obtained before any confidential medical or dental information is released to other medical or dental providers.

• At all times, confidentiality must be maintained for all patients, regardless of HIV serostatus.

• Proper consent should be obtained before any confidential medical or dental information is released to other medical or dental providers.

Dental Treatment Plan Dental Treatment Plan PrioritiesPriorities

Dental Treatment Plan Dental Treatment Plan PrioritiesPriorities

• Alleviate painAlleviate pain

• Prevent further oral diseasePrevent further oral disease

• Restore functionRestore function

• Restore estheticsRestore esthetics

• Improve quality of lifeImprove quality of life

• Alleviate painAlleviate pain

• Prevent further oral diseasePrevent further oral disease

• Restore functionRestore function

• Restore estheticsRestore esthetics

• Improve quality of lifeImprove quality of life

Restorative/Prosthodontic Restorative/Prosthodontic ConsiderationsConsiderations

Restorative/Prosthodontic Restorative/Prosthodontic ConsiderationsConsiderations

• Ability to perform oral hygiene Ability to perform oral hygiene

• Caries indexCaries index

• Reduced salivary flowReduced salivary flow

• Presence of oral lesionsPresence of oral lesions

• ““End of life” concerns/issuesEnd of life” concerns/issues

• Ability to perform oral hygiene Ability to perform oral hygiene

• Caries indexCaries index

• Reduced salivary flowReduced salivary flow

• Presence of oral lesionsPresence of oral lesions

• ““End of life” concerns/issuesEnd of life” concerns/issues

Management of Management of XerostomiaXerostomia

Management of Management of XerostomiaXerostomia

Replacement or stimulation of salivary Replacement or stimulation of salivary flowflow• Secretory stimulantsSecretory stimulants

1. Pilocarpine1. Pilocarpine

2. Salagen2. Salagen 3. Bethanecol3. Bethanecol

• Salivary substitutesSalivary substitutes 1. Xerolube1. Xerolube 2. Salivart2. Salivart 3. Unimist3. Unimist

Replacement or stimulation of salivary Replacement or stimulation of salivary flowflow• Secretory stimulantsSecretory stimulants

1. Pilocarpine1. Pilocarpine

2. Salagen2. Salagen 3. Bethanecol3. Bethanecol

• Salivary substitutesSalivary substitutes 1. Xerolube1. Xerolube 2. Salivart2. Salivart 3. Unimist3. Unimist

Treatment Plan Modifications For HIV Patients


• No need for special facility• Treatment plan based on

medical status• Modify dental procedures

according to ability of the patient to withstand dental treatment

• No need for special facility• Treatment plan based on

medical status• Modify dental procedures

according to ability of the patient to withstand dental treatment



• Treatment plan based on: Medical status Finances Patient acceptance

• Modify dental procedures according to ability of the patient to tolerate dental procedures

• Treatment plan based on: Medical status Finances Patient acceptance

• Modify dental procedures according to ability of the patient to tolerate dental procedures

Antibiotic ProphylaxisAntibiotic Prophylaxis

Indicated when: Neutrophils: <500 cells/mm3

According to AHA guidelines if patient has heart/valvular problems

Need for antibiotic prophylaxis is not based on CD4 count

Indicated when: Neutrophils: <500 cells/mm3

According to AHA guidelines if patient has heart/valvular problems

Need for antibiotic prophylaxis is not based on CD4 count

Antibiotic ProphylaxisAntibiotic Prophylaxis

Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted.

Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.

Patients with indwelling catheters such as a Hickman catheter may require antibiotic prophylaxis prior to dental care. Medical consultation may be warranted.

Renal dialysis patients with shunts for hemodialysis require antibiotic prophylaxis prior to invasive dental care.

Selected BibliographySelected Bibliography1. The American Academy of Oral Medicine. Clinicians Guide to HIV-Infected Patients, 2001, 3rd Edition,

Editors: Patton L & Glick M, Baltimore, MD 21209. 2. Molinari JA, Glick M. Infectious Diseases. In Burket’s Oral Medicine. Greenberg MS, Glick M. Eds. BC

Decker Inc. Hamilton, Ontario, Canada. 2002 pp. 525-5623. Bartlett J and Gallant J. Medical Management of HIV Infection, 2001-2002 Edition, Publisher: Johns

Hopkins University School of Medicine, Department of Infectious Diseases, Baltimore, MD.4. Department of Health and Human Services (DHHS) and the Henry J. Kaiser Family Foundation.

Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents; May 2001. Available for download at: http://www.hivatis.org.

5. Department of Health and Human Services (DHHS). USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with Human Immunodeficiency Virus. July 2001. Available for download at: http://www.hivatis.org.

6. Infection Control Recommendations for the Dental Office and the Dental Laboratory ADA Council on Scientific Affairs and ADA Council on Dental Practice available for download at https://w3.ada.org/prof/prac/issues/topics/icontrol/ic-recs/index.html.

7. HIVDENT. Dental Treatment Considerations, August 2001; available for download at http://www.hivdent.org/dtc.htm.

8. The Dental Alliance for AIDS/HIV Care. Principles for the Oral Health Management of the HIV/AIDS Patient, 2001; available for download at http://www.critpath.org/daac/standards.html

9. Infection Control Guidelines: September,1997; Organization for Safety & Asepsis Procedures (OSAP); available for download at http://www.osap.org/resources/IC/icguide97.htm.

10. Centers for Disease Control and Prevention (CDC). Recommended Infection Control Practices for Dentistry, 1993. MMWR Morb Mortal Wkly Rep. 1993; 42(RR-8) 1-20.

http://www.hivatis.org/

http://www.hivatis.org/

https://w3.ada.org/prof/prac/issues/topics/icontrol/ic-recs/index.html

http://www.hivdent.org/dtc.htm

http://www.critpath.org/daac/standards.html

http://www.osap.org/resources/IC/icguide97.htm

Medical Evaluation of the HIV Dental Patient Module 1.

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