Oral Surgery with HIV

[Charles.M]

I was recently reffered to an oral surgeon, my dentist want my wisdom theeth removed along with two failed bootom teeth (failed rootcanals). I have an appointment today with the oral sugeon on this. My dentints tells me i need this because I am expericing infection and bone loss. I believe the two failed root canals can go but not surfe i want my wisdom teeth taken out. My last CD4 was 163 almost 2 months ago, I may be over 200 now as I have been gaining back about 45 CD4 a month since I started treatment. I know its not necessary linear but its a best assumption, and i still have no OIs and feel great.

Anyway My Id doctor wants me to postpone this until My CD4 count is higher. She wants me to tell the oral surgeon about my HIV. I am worried that the oral surgeon will tell me to leave the office and refuse to see or work on me. I have been virally supressed for 3 months now and last test a two weeks ago I was <20 but not UD.

My biggest fear is that I will be blacklisted from any dental care whatsoever, not sure if I should tell the oral sugeon or not. Please help here it driving me nuts

[Jim Allen]

Sorry to hear about the wisdom teeth. Had mine out only a few years ago for the same reasons, I wish you well with the recovery once removed.

I have been virally supressed for 3 months now and last test a two weeks ago I was <20 but not UD.

Below 20 copies is UD.

Undetectable as a term is a bit of a misleading or misunderstood phrase from the lab; that's the first thing to get your head around.

The goal is a fully suppressed "undetectable" viral load, not to have zero copies as that's not possible. Your doctor's lab has a threshold of 20 copies, meaning they can't count viral copies below that threshold. Results will often still read something like "Detected x copies" if above the threshold or "Detected but less than X copies" if the value is below the threshold that can be measured.

You can also get a result that is just "undetectable." However, even that does not mean zero viral load. It just means it was too low to detect for the test in the small sample.

In new HIV treatment studies, the goal is to suppress below 50. From the clinical (treatment) standpoint, anything below 50 copies is also considered fully suppressed*, Although tests nowadays can often detect down to 20 copies.

*Even the 50 copies are a tad dramatic as a goal as overall is very little & contradicted evidence that even a couple of hundred copies would make any difference in terms of treatment or clinic outcomes. Many PLHIV will never have below 50 copies and would have VLs of a few hundred without any major concern.

In some research studies, hypersensitive testing detects and counts as low as a single copy. There, however, is no point in having that in the clinical setting as these low values are often defective copies, not viable HIV, and there is simply no clinical benefit.

Anyway My Id doctor wants me to postpone this until My CD4 count is higher. She wants me to tell the oral surgeon about my HIV. I am worried that the oral surgeon will tell me to leave the office and refuse to see or work on me.

I can appreciate waiting to wait until prehaps there is a more stable CD4 count over 200 before getting surgery in the mouth. It depends on the urgency that the wisdom teeth need to be removed vs. managing infection afterwards.

I would also tell the surgeon, as they know, to provide closer attention to post-surgical infection risk and more importantly that they don't give me anything that would interact with my HIV meds.

My biggest fear is that I will be blacklisted from any dental care whatsoever, not sure if I should tell the oral sugeon or not. Please help here it driving me nuts

Dental surgeons/dentists here can't refuse based on HIV status and certainly not blacklist anyone; if such a thing happened, it would be a lawsuit waiting to happen. Not saying refusal doesn't happen in the real world; my ex-partner was refused by a dentist a few years back, sued and won, of course.

I don't know about the USA but I would have presumed it's covered by Title III of the ADA which prohibits health care providers from discriminating against people with disabilities and that also includes HIV. Don't take that as legal advice but you can check that with a "lawyer" as you call them in the states if you like.

Now, I admit nurses have refused me care, doctors and dentists in the past, but I then choose to educate them on the law and HIV, and if that doesn't drive it home, I also point out that they might want to avoid being sued.

Unfortunately, as with many things, living with HIV means sometimes dealing with the ignorant, standing up, and fighting for your rights and fair treatment.

However, 99% of the time, I am treated perfectly fine by healthcare professionals and have had several surgeries, and my HIV status has not been in an issue.

I understand being new to this is overwhelming at times, particularly when something happens for the first time since being diagnosed, but I believe you are anticipating an issue that doesn't really exist and certainly doesn't exist yet for you based on fear, not fact.

[Jim Allen]

Below 20 copies is UD.

Undetectable as a term is a bit of a misleading or misunderstood phrase from the lab; that's the first thing to get your head around.

The goal is a fully suppressed "undetectable" viral load, not to have zero copies as that's not possible. Your doctor's lab has a threshold of 20 copies, meaning they can't count viral copies below that threshold. Results will often still read something like "Detected x copies" if above the threshold or "Detected but less than X copies" if the value is below the threshold that can be measured.

You can also get a result that is just "undetectable." However, even that does not mean zero viral load. It just means it was too low to detect for the test in the small sample.

In new HIV treatment studies, the goal is to suppress below 50. From the clinical (treatment) standpoint, anything below 50 copies is also considered fully suppressed*, Although tests nowadays can often detect down to 20 copies.

*Even the 50 copies are a tad dramatic as a goal as overall is very little & contradicted evidence that even a couple of hundred copies would make any difference in terms of treatment or clinic outcomes. Many PLHIV will never have below 50 copies and would have VLs of a few hundred without any major concern.

In some research studies, hypersensitive testing detects and counts as low as a single copy. There, however, is no point in having that in the clinical setting as these low values are often defective copies, not viable HIV, and there is simply no clinical benefit.

P.S. Not related to your topic but just for anyone reading my reply I should add: To confuse matters a bit more, regarding sexually passing on HIV (TaSP) (U=U), undetectable is defined differently again. Once you have achieved an undetectable viral load defined as (below 200 copies) for at least six months, you can't sexually pass on HIV.

[Charles.M]

Thanks Jim,
went to the appointment and the questionare asked that I list all medications and when you list Biktarvy it does not take a rocket scientist. There was also a question about immune system and exspoure to HIV. I was at odds with myself as to whether or not to lie or answer honestly. I answered honestly and when I went into the exam room it was out in the open. The oral sugeon informed me he was also a medical doctor  and asked about my VL and CD4 counts. He agreed with the ID doc that we should wait till my CD4 are higher and the ID doctor greenlights it. He did not agree with removing my wisdom teeth only the two infected rootcanal failures. He stated as I felt that while the lower ones were impacted they were healthy and the uppers were fine as well. He further stated that at 62 years old removing them presented signifigant risk of nervre damage and bone loss.

For some reason my dentist who is also my wifes dentist wants wisdom teeth removed just because. My wife had hers removed on the dentist reccomendation and suffered permanent never damage as a result. Lesson "always get a second opinion!"

Anyways my fears were perhaps a bit excessive, the sugeon and his nurse were the utmost professional. I know there will be times where that may not always be the case though.

[Jim Allen]

I am glad that the appointment went okay and that somewhat less invasive surgery is an option.

Anyways my fears were perhaps a bit excessive, the sugeon and his nurse were the utmost professional. I know there will be times where that may not always be the case though.

Great that they were professional, as they should be.

I think it's totally understandable fear though, we have all been through having to tell someone in a medical setting and fearing the reaction at some point. Hopefully, now that this is out of the way, the next time will be less stressful.