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