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April 2003
Oral HealthMark M. Schubert, DDS, MSD
Dental Director, NW-AETC
April 2003
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MMWR 1981 June 5: 30:250-25 cases of Pneumocystis carinii pneumonia at 3 different LA hospitals in homosexully active males. Concurrent CMV infection and candidal mucosal infections
April 2003
Oral Manifestations of HIV/AIDS
• May be first sign of HIV infection– May lead to testing and diagnosis– Oral conditions develop as immunosuppression
progresses• Indicators of change in immune status
• Require definitive management
• Oral manifestations of HIV infection– Certain conditions associated with risk of AIDS– May be first AIDS defining condition
Overall average prevalence: 30 - 50%In late stage AIDS – upwards of 90%
April 2003
Oral Manifestations of HIV InfectionType of Infection Oral Disease
Fungal Candidiasis - Pseudomembranous, Erythematous, and Angular Cheilitis
Invasive Fungal Infections - Histoplasmosis, Mucormycosis, Crytococcosis
Viral
Herpes Simplex Herpes Zoster Cytomegalovirus Hairy Leukoplakia (Epstein Barr Virus) Oral Warts (Human Papilloma Virus) Human Herpes Virus–8 [Kaposi’s sarcoma]
Bacterial Linear Gingival Erythema Necrotizing Ulcerative Periodontitis Tuberculosis* Mycobacterium avium complex* Bacillary angiomatosis*
April 2003
Oral Manifestations of HIV Infection
Type of Lesion Oral Disease
Neoplastic Kaposi’s Sarcoma (KS) [HHV-8]
Lymphoma
Squamous Cell Carcinoma*
Other HIV-associated Necrotizing Ulceration
HIV-Salivary Gland Disease/Xerostomia
Immune Thrombocytopenic Purpura*
Abnormalities of Mucosal Pigmentation
April 2003
Medical Management of HIV Infection: HAART Therapy
• Highly Active Antiretroviral Therapy• Combination antiretroviral drug therapy
– Targets different steps of viral cell replication
– Decreased HIV viral load– Increased CD4 counts
• Significant reduction in oral lesions– Frequency and severity
April 2003
Quarter-Year
Nu
mb
er
of
Case
s/D
eath
s
*Adjusted for reporting delays
1985198619871988198919901991199219931994199519961997199819990
5,000
10,000
15,000
20,000
25,0001993 definitionimplementationDeaths
Prevalence
AIDS
0
150,000
100,000
50,000
200,000
250,000
300,000
350,000
Estimated Incidence of AIDS, Deaths, and Prevalence by Quarter-Year of Diagnosis/Death, US 1985-1999*
Pre
vale
nce
Does not address change in risk of transmission
HAART
April 2003
Any lesion 47.6 37.5 0.014
Hairy leukoplakia 25.8 11.4 .00001
Candidiasis 20.3 16.7 .272
Ulcerative periodontitis 4.8 1.7 0.33
Aphthous ulcers 3.7 3.0 .652
HPV 2.2 4.0 .220
Salivary gland disease 1.8 5.0 .040
HSV 1.8 2.0 .888
Kaposi’s sarcoma 1.1 0.3 .270
Oral Lesion Early (%)a Late (%)b P-value
a) n = 271 b) n = 299
Changing Prevalence of Oral Manifestations of HIV: 1996 - 1999
Patton et al., Oral Surg Oral Med Oral Pathol 89:299-304, 2000
April 2003
Changes in Prevalence of Oral Lesions: 1990 - 1999
n = 1280 HIV(+) individuals 7/1/90 – 6/30/99 Greenspan D et al. The Lancet 357(9266), 1411-12, 2001
April 2003
• Increasing risk behaviors among groups that had previously shown marked decline in previous years despite recognition that risk behaviors related to spread of disease
• Obvious continued need to recognize HIV infections and manage complications:
Recognition of oral manifestation of HIV
Incidence of AIDS
April 2003
Fungal Infections: Candidiasis
• Pseudomembraneous Candidiasis• White “curd-like” raised material that wipes off
• Erythematous / Atrophic Candidiasis• Mucosal erythema and/or patchy depapillation of the
tongue
• Hyperplastic Candidiasis• White/red hyperplastic lesions
• Angular Cheilitis• Erythema and/or fissuring-ulceration at the corner of the
mouth
April 2003
Pseudomembraneous Candidiasis
April 2003
Atrophic / Erythematous Candidiasis
April 2003
Hyperplastic Candidiasis
April 2003
Angular Cheilitis
April 2003
Azole Resistant Oral Candidiasis
Candida albicans Candida glabrata
April 2003
Treatment of Candidiasis
• Consider the extent of the infection – Mild to moderate disease: Topical therapies
• Nystatin, Clotrimazole
– Moderate to severe disease: Systemic Therapies • Fluconazole, Itraconazole
• Continue antifungal therapy for two weeks– Reduce colony forming units – Reduce risk factors / increase time to recurrence
• Consider prophylactic regimens with frequent recurrences
April 2003
Management of Oral Candidiasis
• Topical agents Clotrimazole troches 10 mg
Clotrimazole 1% cream Nystatin oral suspension 100,000 units/ml Nystatin pastilles 100,000 units
• Systemic agents Fluconazole 100mg
Itraconazole oral suspension 10mg/10ml
Amphotericin B, Voriconazole
April 2003
Invasive Fungal Infections
Mucormycosis Histoplasmosis
April 2003
Oral Viral Infections
• Herpes Simplex Virus (HSV)
• Varicella Zoster Virus (VZV)
• Cytomegalovirus (CMV)
• Epstein-Barr Virus (EBV)
• Human Papilloma Virus (HPV)
• Human Herpes Virus - 8
April 2003
Oral HSV Infections
• Primary and recurrent disease
• Typical to Atypical Appearance– Herpes labialis Herpetic stomatitis– Large persistent painful ulcers
• Severity of mucocutaneous disease increases as CD4 counts decrease• Can be an AIDS defining condition• Treatment: Acyclovir, Valacyclovir
and Famciclovir
April 2003
Herpetic Stomatitis
April 2003
Oral VZV Infections
• Recurrent VZV infection: Herpes zoster– Vesicular / ulcerative lesions – Follow dermatome for trigeminal nerve – Severe neuritic pain– Can involve multiple dermatomes
• Post-herpetic neuralgia
• Can be marker for HIV progression• Treatment: Acyclovir, Valacyclovir
April 2003
Varicella Zoster Virus
April 2003
Cytomegalovirus
• Associated with advanced AIDS• Painful granulomatous ulcers with punched-out
irregular margins• Treatment: Ganciclovir, Foscarnet
CMV + HSV
CMV
April 2003
Oral Epstein Barr Infections
• Oral Hairy Leukoplakia– White corrugated hyperkeratotic lesion of the
lateral borders of the tongue / other areas– Asymptomatic– Clinical Diagnosis:
• Marker for disease progression (CD4 <300 cells/mm3)
• Definitive diagnosis requires identification of EBV in infected epithelial cells
• Marker for immune suppression (non-HIV patients)
– Treatment: Acyclovir, Podophyllum resin
April 2003
Hairy Leukoplakia
April 2003
Oral Human Papilloma Virus Infection
• Variety of lesions:– Exophytic, papillary lesions with a cauliflower-
like surface to raised, flat, smooth lesions– Several different types of HPV have been
reported to cause lesions– May be solitary or multiple
• Treatment: Cryotherapy Surgical excision
CO2 laser ablation Interferon-alpha
April 2003
Human Papilloma Virus
April 2003
Peridontal Infections
• Linear Gingival Erythema – Appearance: A distinct band of erythema of the gingival margin
– Erythema does not respond to removal of local factors (bacterial plaque/calculus)
– Cause is not known
– Treatment• Intense oral hygiene• Professional cleanings• 0.12% chlorhexidine / povidone iodine
April 2003
Linear Gingival Erythema
April 2003
Necrotizing Periodontal Diseases
• Necrotizing ulcerative gingivitis
• Necrotizing ulcerative periodontitis
• Rapid destruction of tissues– Gingiva, alveolar bone and periodontal tissues– Tends to involved localized areas– Management
• Antibiotics: Metronidazole, Clindamycin, Augmentin
• Aggressive curettage / debridement of necrotic tissue
• Meticulous home care
• Extraction of involved teeth / Sequestrectomy
April 2003
Necrotizing Ulcerative Diseases:Gingivitis & Periodontitis
April 2003
Necrotizing Oral Ulcerations
• Aphthous ulcers Necrotizing stomatitis• Range in size: 2-5 mm to 2 -3 cm • Frequency increases with HIV progression• Can be very persistent and very painful• Diagnosis by exclusion• Treatment:
– Film-forming surface protecting agents– Topical steroids– Thalidomide
April 2003
Recurrent Aphthous Ulcerations
April 2003
Necrotizing Stomatitis
April 2003
Neoplasms
• Kaposi’s Sarcoma (KS)– Associated with HHV-8 infection – Appearance: Red, bluish, or purplish macular
or nodular lesion– Size ranges from small to extensive– Definitive Diagnosis
• Biopsy and histologic examination
– Therapy• Radiation treatment • Vinblastine• Sclerosing agents
April 2003
Kaposi’s Sarcoma
April 2003
Oral Pigmentation
AZT-induced pigmentation Rule-out Kaposi’s sarcoma
April 2003
Bacterial Infections
Periodontal Abscess
Bacterial infection: Bartonella henselae, Bartonella quintana, Rochalimaea henselae•Treatment: Erythomycin 500 mg qid or Azithromax 500 mg q day x 3-4 weeks
Bacillary (epithelioid) Angiomatosis
April 2003
Non-Hodgkin’s Lymphoma
• Clinical appearance: – Rapidly enlarging necrotic masses
– Ulcerated or nonulcerated masses
– Palate and gingivae most common sites
– Prognosis is very poor
• Diagnosis: – Biopsy and histologic evaluation
– Aggressive oncology therapy
April 2003
Non-Hodgkin’s Lymphoma
April 2003
Salivary Gland Involvement
• Salivary Gland Disease– Bilateral parotid gland enlargement
• Increased frequency with HAART
– Xerostomia: 29% of HIV(+) Patients• HIV-related salivary gland disease
• Side effect of medications
• Rampant caries
April 2003
Salivary Gland Involvement
April 2003
Considerations in the Use of Antibiotics
• Narrow spectrum antibiotics preferred – Minimize development of antibiotic resistance
– Metronidazole for periodontal infections
• Consider presence of antibiotic resistant strains– Culture and antibiotic sensitivity may be indicated
• Antibiotic use may lead to overgrowth of Candida – Antifungal treatment may be indicated in conjunction
with systemic antibiotics
– Local / topical delivery antibiotics may be useful but have not been evaluated
April 2003
Oral Bacterial Infections
Mycobacterium Tuberculosis
Oral Syphilis (I°)
April 2003
Diagnosis & Managementof Oral Manifestations of HIV/AIDS
• Clinical appearance and symptoms– Non-specific – Atypical
• Incidence may indicate disease progression • Require careful diagnostic techniques
– Laboratory test for: Viruses – Fungi – Bacteria– Biopsy of lesions
• Require aggressive treatments– Slow to respond– Relapse / Recurrence is common– Concern about resistance
April 2003
Non-HIV-Associated Dental Disease
• Gingivitis / Periodontitis / Dental Abscesses– Common dental diseases
– Compromise oral health / function / esthetics
– Compromise general health
• Constant immune system pressure
• Increases risk of opportunistic oral infections
• Increased risk for HIV disease progression
Promote / Support Oral Health & Basic Dental Care