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1. HIV, HEPATITIS AND HERPES WITH PROSTHODONTIC CONSIDERATIONS AND BIOMEDICAL WASTE MANAGEMENT

2. Contents Introduction HIV (Human Immunodeficiency Virus ) infection Hepatitis infection Herpes infection Post exposure prophylaxis Sterilization and disinfection in prosthodontics Biomedical waste management Conclusion References Questionnaire

3. Introduction As dentists have continuous contact with aerosols, patient's saliva and even direct skin contact, it is necessary to know about infectious viral diseases and CDC guidelines for these. Impact of infectious diseases – 1.Increased risk of cross-infection 2.Complexities in treatment planning D iseases covered – 1. HIV (Human Immunodeficiency Virus ): Immunosuppression and oral complications 2. Hepatitis (A, B, C, D, E): Liver dysfunction and bleeding risks 3 . Herpes ( Herpes simplex, herpes zoster): Vesicular painful lesions

4. HIV (Human Immunodeficiency Virus) A retrovirus targets CD4 + T cells - leading to immune deficiency Transmission : Stages of HIV : 1. Acute HIV infection 2. Clinical latency 3. AIDS (Acquired Immunodeficiency Syndrome)

5. Clinical features

6. Oral Manifestations Candidiasis Necrotizing gingivitis Herpes simplex Varicella zoster H airy leukoplakia Kaposi’s sarcoma Lymphadenopathy

7. Candidiasis Site - lesion on hard palate, tongue and soft palate . Four clinical patterns – 1. P seudomembranous (thrush) 2.Hyperplastic 3.Erythematous 4.Angular cheilitis Symptoms - B urning mouth, problems in eating spicy food and changes in taste.

8. A 56-year-old male patient came to the department with the chief complaint of loose pair of denture hence difficulty in eating food and wants replacement of new denture and also complaint of white patches on left posterior buccal mucosa which was developed for 5 months . Journal of Mahatma Gandhi University of Medical Sciences and Technology, 2020 1. Jamdade A, Yadav S, Debbarma S, Yadav NK. Chronic Hyperplastic and Erythematous Candidiasis Induced by Ill-fitting Complete Denture: A Case Report. Journal of Mahatma Gandhi University of Medical Sciences and Technology. 2021 Feb 15;5(1):31–3. ‌

9. Management Jamdade A, Yadav S, Debbarma S, Yadav NK. Chronic Hyperplastic and Erythematous Candidiasis Induced by Ill-fitting Complete Denture: A Case Report. Journal of Mahatma Gandhi University of Medical Sciences and Technology. 2021 Feb 15;5(1):31–3. ‌

10. Hairy Leukoplakia A non-movable, corrugated or “hairy” white lesion on the lateral margins of the tongue occurs in all risk groups for HIV infections . Management Antiviral drugs- Acyclovir (2.5 to 3 mg per day for 2 to 3 weeks ) Topical treatment with retinoid and podophyllin resins Other drugs - Topical clotrimazole (10 mg 5 times a day), nystatin (10000 units/g 5 times a day) and ketoconazole (200 mg BD ).

11. Atypical Periodontal Disease Linear gingival erythema : Also called HIV-related gingivitis. There is distinctive linear band of erythema Necrotizing ulcerative gingivitis : Ulceration and necrosis of interdental papillae occurs Necrotizing ulcerative periodontitis : Also called HIV associated periodontitis in which rapid loss of periodontal attachment is seen . Management Debridement : Removal of necrotic tissue Maintenance: Patient should be done periodic scaling and root planning Antimicrobial therapy: In cases of NUP, metronidazole (250- mg four times daily), amoxicillin/ clavulanate ( Augmentin 250-mg three times daily)

12. Kaposi’s sarcoma A red, blue, or purplish lesion. I t may be flat or raised, solitary or multiple. T ender and painful on palpation. Management- Oral prophylaxis Systemic chemotherapy Intralesional sclerosing agents Intralesional vinblastine - Two injections 0.1 to 0.2 mg per mL solution, monthly for 6 months.

13. J Indian Prosthodontic Soc,2013 Guidelines for Prosthodontic Management of Subjects with HIV/AIDS General Measures: 1. Create safe and empathetic environment. 2. Maintain confidentiality of patient’s information. 3. Use standard precautions. 4. Provide unbiased treatment. 5. Advise regular dental visits. 6. Identify and manage oral manifestations of HIV/AIDS. Nagaraj KR, Savadi R. Prosthodontic Management of HIV/AIDS Subjects: An Overview. The Journal of Indian Prosthodontic Society. 2012 Dec 20;13(4):393–9.

14. Measures in Particular to Prosthodontics : 7. Evaluation of periodontal status of existing dentition during construction of removable and fixed dentures. 8. Evaluation and management of xerostomia . 9. Increased maintenance of dentures for prevention of candidiasis. 10. Evaluation of temporomandibular joint disorders. 11. Precautions during pre-prosthetic and implant surgeries . Nagaraj KR, Savadi R. Prosthodontic Management of HIV/AIDS Subjects: An Overview. The Journal of Indian Prosthodontic Society. 2012 Dec 20;13(4):393–9.

15. Pre-Treatment Assessment Obtain medical history : CD4+ count , viral load, and medication use (e.g., antiretrovirals ). Check for opportunistic infections or oral lesions. During Treatment Standard Precautions Schedule short, stress-free appointments. Good Hand Hygiene-Proper washing and sanitization techniques. Protective Barriers - Use of disposable gloves, masks, eye protection, face shields, and gowns during patient care . Use of disposable items wherever possible . Nagaraj KR, Savadi R. Prosthodontic Management of HIV/AIDS Subjects: An Overview. The Journal of Indian Prosthodontic Society. 2012 Dec 20;13(4):393–9.

16. Management of Accidental Exposures - Immediate reporting of needlestick injuries and initiation of post-exposure prophylaxis (PEP ). Disinfection Protocols - Prefer autoclavable impression materials Safe Handling of Contaminants - Proper disposal and handling of sharps, blood, body fluids, and contaminated items. Regular Dental Visits for HIV-Infected Individuals - For early Detection of Oral Problems and HIV-related complications. Studies highlight significant tooth loss among HIV-positive individuals, emphasizing the need for timely prosthetic interventions. Nagaraj KR, Savadi R. Prosthodontic Management of HIV/AIDS Subjects: An Overview. The Journal of Indian Prosthodontic Society. 2012 Dec 20;13(4):393–9.

17. Inflammatory liver diseases caused by different viral agents . HEPATITIS Types Transmission

18. Causes of Hepatits Viruses ( commonly) Toxic substances (Alcohol, NSAIDs, Amiodrone ) Autoimmune diseases Clinical Features of Hepatitis Acute Symptoms : Fatigue , nausea, jaundice, dark urine, abdominal pain. Chronic Symptoms : Cirrhosis , hepatocellular carcinoma, liver failure.

19. Oral Manifestations Icteric mucosa (yellow discoloration due to jaundice) Petechiae and ecchymosis (in bleeding disorders) Xerostomia (dry mouth due to liver dysfunction) Lichen planus (associated with Hepatitis C ) B leeding abnormalities such as thrombocytopenia (platelet counts < 150,000) Sjogren Sialadenitis HCV

20. Pre-Treatment Evaluation Review liver function tests (ALT, AST, INR, platelet count ). Avoid invasive procedures in acute or advanced liver disease . 2 . During Treatment Minimize bleeding risks by using local hemostatic agents (e.g., tranexamic acid ). Avoid medications metabolized by the liver (e.g., acetaminophen ). 3 . Post-Treatment Care Monitor for delayed healing due to impaired coagulation . Provide dietary counselling to manage xerostomia .

21. 4. Infection Control Ensure Hepatitis B vaccination for all healthcare workers. Double disinfection for blood-contaminated instruments Patient Education and Support Lifestyle Modifications : Oral hygiene reinforcement to prevent secondary infections . Alcohol and smoking cessation. Regular Follow-Ups : Monitor oral and systemic health . Vaccination Advocacy : Encourage HBV vaccination for family and close contacts.

22. Herpes simplex It is a common infection that can cause painful blisters or ulcers. Types : HSV-1 : Oral herpes (cold sores ) HSV-2 : Genital herpes Transmission : Direct contact with infected lesions, saliva, or mucous membranes . Oral Manifestations : Primary Herpetic Gingivostomatitis : Painful ulcers, fever, and malaise (common in children ). Recurrent Herpes Labialis : Vesicles on lips, triggered by stress, UV light, or immunosuppression . Herpetic whitlow ( in dental professionals without PPE).

23. Symptoms of herpetic whitlow include: S welling and pain in your finger B listers or sores on your finger S kin becoming red or darker than your usual skin tone F eeling generally unwell and having a high temperature

24. Management Symptomatic Pain control measures: Topical anaesthetic like 2% lidocaine , 0.1% diclonine hydrochloride, 0.5% benzocaine hydrochloride are used Topical anti-infective agents : 0.2 % chlorhexidine gluconate Supportive Care Good oral hygiene Fluids for hydration

25. Specific Therapies Herpes labialis • Five percent acyclovir, 3% penciclovir and 10% docosanol are applied 4 to 6 times/day. Primary herpetic gingivostomatitis • Acyclovir suspension 15 mg/kg or acyclovir tablets 200 mg five times daily for 5 days. Herpetic whitlow A ntiviral medication like acyclovir ( Zovirax ), valacyclovir (Valtrex), or famciclovir ( Famvir ). Heals within 2 weeks.

26. Herpes zoster It is also called as ‘shingles’ or ‘ zona ’. It is an acute viral infection of extremely painful and incapacitating nature, characterized by inflammation of dorsal root ganglion. A ssociated with vesicular eruptions of skin and mucous membrane of the area supplied by the affected sensory nerve.

27. Oral Manifestations • Site : On buccal mucosa, tongue, uvula, pharynx and larynx Symptoms : Patient notice pain, burning, tenderness usually on the palate on one side Signs : After several days of symptoms, intact vesicles appear which soon rupture to leave areas of erosion or ulcers of 1–5 mm size exfoliation of teeth. Healing : Within 10-14 days.

28. Management Pharmacotherapy - W ith antiviral agents should be initiated within 72 hours of symptoms onset. Systemic acyclovir dosage: Acyclovir 800 mg five times/day, famciclovir 250 mg TDS and valacyclovir 1 gram TDS is a dministered.

29. Needle stick injury - Immediate First Aid Wash the area gently with soap and water . Avoid scrubbing the wound . Do not squeeze or force bleeding. Allow the wound to bleed slightly if possible . Rinse thoroughly . Disinfect the area with an antiseptic solution (e.g., iodine or alcohol-based antiseptic ). 2. Report the Incident - Notify your supervisor or relevant authority immediately . Complete an incident report for documentation. Srivastava P, Wakhlu A, Agarwal V. Managing needle-stick injury. Indian J Rheumatol . [Year of publication];[Volume(Issue)

30. Seek Medical Evaluation Promptly Visit your workplace health center, an occupational health clinic, or an emergency room. Provide details about: 1.The source patient (if known). 2.The type of needle or object. 3.The depth and location of the injury . Testing and Risk Assessment - You may need baseline blood tests for HIV, Hepatitis B (HBV), and Hepatitis C (HCV) . If the source patient is known, they may also be tested for these infections . Post-Exposure Prophylaxis (PEP) HIV Exposure: If there’s a risk of HIV transmission, start PEP (a 28-day course of antiretroviral drugs) within 1-2 hours (ideally within 72 hours ). Hepatitis B: If you are unvaccinated, you may receive Hepatitis B Immune Globulin (HBIG) and start the HBV vaccine series . Hepatitis C: No prophylactic treatment is available, but early monitoring and treatment if needed can be beneficial. Srivastava P, Wakhlu A, Agarwal V. Managing needle-stick injury. Indian J Rheumatol . [Year of publication];[Volume(Issue)

31. According to Guidelines for HIV post-exposure by WHO, PEP should be offered, and as early as possible, to individuals with suspected or known exposure to HIV, ideally within 24 hours but not later than 72 hours.

32. Follow-Up Care - Get follow-up blood tests at appropriate intervals (typically 6 weeks, 3 months, and 6 months) .Watch for signs of infection (e.g., fever, rash, fatigue).Seek counseling and support if needed . Prevention for Future Safety- Ensure proper use of personal protective equipment (PPE ). Follow safe handling and disposal practices for sharps . Attend training on needle stick injury prevention . Prompt action is essential to minimize risks after a needle stick injury. Srivastava P, Wakhlu A, Agarwal V. Managing needle-stick injury. Indian J Rheumatol . [Year of publication];[Volume(Issue)

33. Sterilization and disinfection in prosthodontics Instrument classification based on potential to spread infection (Spaulding's classification) 1.Critical Items Penetrate soft tissue or contact bone, enter into or contact the vascular system or other normally sterile tissue. Must be heat sterilized between use, or sterile single-use, disposable devices must be used. Examples: surgical instruments and periodontal scalers , burs . Summary of Infection Prevention Practices in Dental Settings: CDC guidelines for Safe Care

34. 2.Semi-critical Items Contact mucous membranes or non-intact skin (e.g., exposed skin that is chapped, abraded, or has dermatitis). Lower risk of transmission. Should be heat sterilized or high-level disinfected. Examples: mouth mirrors , amalgam condensers, and reusable impression trays . Dental handpieces - should always be heat sterilized  Summary of Infection Prevention Practices in Dental Settings: CDC guidelines for Safe Care

35. 3. Non - critical Items Contact intact skin. Barrier protect or clean and disinfect (if visibly soiled) using a low to intermediate-level disinfectant . Examples: x-ray head or cone , Digital sensors , facebows , blood pressure cuff. Summary of Infection Prevention Practices in Dental Settings: CDC guidelines for Safe Care

36. Sterilization in prosthodontic practice Diagnostic Instruments Dry the diagnostic instrument with help of wipes. Instruments are autoclaved at 121° C, 15 psi for 15 mins . Impression Trays Washed with running water and are made free from the particles adhering to it. The trays are the properly dried and placed in autoclave for sterilization Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

37. Handpiece Moist heat using saturated water vapor's (autoclave) offers the best results as regards the sterilization of handpieces in the short time. Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

38. Burs Step 1. Meticulous cleaning to remove tooth debris, residues of dental materials, blood clots – use of ultrasonic devices at a temperature of about 60°C, burs vibrate at a frequency of 60-80 kHz for at least 15 minutes. Step 2. After removal from the ultrasonic bath, burs must be dried using absorbent paper and hot air. Step 3. They must then be placed in sterilization pouch- autoclaved for 30 mins at 121 degree Celsius. Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

39. Facebows & Bite forks Parts of facebow which are made of metal can be sterilized in autoclave. It is important to note that earpieces of facebow be removed before sterilization. Dental Implants The following products are delivered non sterile: Transfers, Analogs, Drivers, Overdenture , Abutments, Transfer screws, Drill Extension, Parallel pin and plastic handle. Sterilization using Moist heat (autoclaving), Dry heat, Ethylene Oxide ( EtO ), Vapor phase Hydrogen Peroxide (H 2 O 2), Low temperature gas plasma, Glutaraldehyde solution, are some of the techniques frequently used. Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

40. Disinfection in prosthodontic practice Impressions Alginate Impressions: Can be done with 0.5% sodium hypochlorite . Iodophores immersion disinfection for prolonged periods will cause distortion due to imbibition. Agar- Reversible Hydrocolloid: Found to be stable when immersed in 1:10 dilution sodium hypochlorite or 1:2 iodophor . Recommended immersion time is 10 minutes . Zinc Oxide Eugenol Immersion: It can be disinfected in 2% glutaraldehyde , Iodophores or Chlorine compounds. Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

41. Impression Compound: Immersion in 1:10 dilution sodium hypochlorite or iodophor . Polysulphide and Addition Silicone : Glutaraldehyde , Iodophor , 0.5 % sodium hypochlorite should be used for its disinfection . Polyether: Spraying in iodophor , 0.5% Sodium hypochlorite should be used. Prolonged immersion causes distortion. Polyether shows dimensional changes on immersion in 2% glutaraldehyde . Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

42. Wax Bites & Wax Rims B y the spray wipe spray method using an iodophor . Rinsed again after disinfection. Casts ADA recommends that stone casts be disinfected by the spraying until wet or immersing in a 1:10 dilution of sodium hypochlorite or an iodophor . Microwave irradiation of casts for 5 mins at 900W gives high level disinfection of the gypsum casts Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

43. Custom acrylic resin impression trays Should be disinfected by spraying with surface disinfectants or immersing in either 1:2 iodophor or 1:10 sodium hypochlorite. S hould be rinsed thoroughly to remove any residual disinfectant and allowed to dry fully before use . Rutala WA, Weber DJ. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases [Internet]. 2004 Sep 1;39(5):702–9. Available from: https://academic.oup.com/cid/article/39/5/702/2022846 ‌

44. Biomedical waste management

45. Bio Medical Waste Management Rules, 2016 Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

46. Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

47. Steps involved in Bio-medical Waste Management Bio Medical Waste Segregation Waste must be segregated at the point of generation of source and not in later stages according to colour coding. Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

48. Bio Medical Waste Collection Time of Collection - Bio-medical waste should be collected on daily basis from each ward of the hospital at a fixed interval of time. HCF should ensure collection, transportation, treatment and disposal of bio-medical waste as per BMWM Rules, 2016 Packaging - Bio-medical waste bags and sharps containers should be filled to no more than three quarters full . Labeling - with the Symbol of Bio Hazard Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

49. Transportation Route of transportation preferably be planned in such a way that: 1.Transportation does not occur through high risk areas 2.Supplies and waste are transported through separate routes. 3.Waste is not transported through areas having high traffic of patients and visitors 4.Central Waste collection area can be easy accessed through this route 5.Safe transportation of waste is undertaken to avoid spillage and scattering of waste Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

50. Treatment and Disposal Treatment methods include: - Incineration: High-temperature burning - Maintain 800°C in the primary chamber. -Autoclaving: Steam sterilization - Specific temperature, pressure, and time requirements. - Deep Burial: For rural areas. - Plasma Pyrolysis: Advanced thermal treatment. Spill Management Mercury and chemical spills must be managed using protective gear, containment materials, and proper labeling for disposal. Post-cleanup decontamination is essential. Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

51. Record Keeping Records must be maintained for: - Waste generation and disposal. - Training and health checkups. - Accident reporting. - These records must be kept for five years Training and safety Staff handling waste must receive regular training on safe handling and emergency response. Annual health checkups and vaccinations are mandatory. . Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

52. Dry waste (e.g., paper, plastics) and wet waste (e.g., food scraps) must be segregated and managed per the Solid Waste Management Rules, 2016. Management of General Waste Other Waste Management Special handling and disposal methods apply to: E-waste: Batteries, electronic devices. Radioactive Waste: Managed under Atomic Energy Act guidelines. Jayakumar A, Veerakumar V, Pradeepsankar S, Santhosh K, Mohan AM, Mahadevan S. Biomedical waste management in prosthodontic dentistry. International journal of health sciences. 2022 Mar 30;1727–37. ‌

53. Conclusion Managing patients with HIV, Hepatitis, and Herpes in dentistry requires a comprehensive approach. Understanding the systemic impacts of these infectious diseases, recognizing their oral manifestations, and implementing tailored treatment strategies are key to successful patient outcomes . Strict adherence to infection control protocols, including the use of personal protective equipment, sterilization practices, and post-exposure procedures, ensures safety for both patients and dental practitioners. By maintaining up-to-date knowledge and collaborating with medical professionals, we can provide safe, effective, and compassionate care to this patient population.

54. 1 . Most common neoplasm seen in oral disorder of HIV is Non–Hodgkin’s lymphoma Hodgkins Lymphoma Squamous cell carcinoma Kapoi’s sarcoma 2. Post exposure prophylaxis is adviced to start before __? 24 hrs 18 hrs 72 hrs 48 hrs

55. 3. Failed implants can be segregated in ___? Yellow bag Red bag Blue bag White bag 4. Most common mode of transmission for hepatitis Sexual transmission Injectable drug use Perinatal transmission Others

56. 5. Waste sharps are discarded in which color container? Blue Red Black White

57. References Anil Ghom , Savita Anil Ghom . Textbook of oral medicine. New Delhi ; Philadelphia: Jaypee Brothers Medical Publishers (P) Ltd; 2014 . Glick M, Greenberg MS, Lockhart PB, Challacombe SJ. Burket’s Oral Medicine. John Wiley & Sons; 2021 . Jamdade A, Yadav S, Debbarma S, Yadav NK. Chronic Hyperplastic and Erythematous Candidiasis Induced by Ill-fitting Complete Denture: A Case Report. Journal of Mahatma Gandhi University of Medical Sciences and Technology. 2021 Feb 15;5(1): 31–3. Nagaraj KR, Savadi R. Prosthodontic Management of HIV/AIDS Subjects: An Overview. The Journal of Indian Prosthodontic Society. 2012 Dec 20;13(4): 393–9. Williamson RT. Diagnosis and management of recurrent herpes simplex induced by fixed prosthodontic tissue management: A clinical report. The Journal of Prosthetic Dentistry. 1999 Jul;82(1):1–2 . CDC. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care ‌ ‌ ‌

58. Thank you