Management of Periodontal Disease in HIV-Infected Patients ...

Module 8

Management of Periodontal Disease in HIV-Infected Patients

Module 8




Mark A. Reynolds, D.D.S., Ph.D.

Niki M. Moutsopoulos, D.D.S.Department of Periodontics

Dental School

University of Maryland Baltimore

and the

Pennsylvania/Mid-Atlantic AIDS ETC

Mark A. Reynolds, D.D.S., Ph.D.

Niki M. Moutsopoulos, D.D.S.Department of Periodontics

Dental School

University of Maryland Baltimore

and the

Pennsylvania/Mid-Atlantic AIDS ETC

Program OutlineProgram Outline

• Classification of Periodontal Diseases and Conditions

• Periodontal Diseases and Conditions in HIV-Infected Patients

• Periodontal Management of HIV-Infected Patients

• Classification of Periodontal Diseases and Conditions

• Periodontal Diseases and Conditions in HIV-Infected Patients

• Periodontal Management of HIV-Infected Patients

Program ObjectivesProgram ObjectivesThe objectives of this program are to:

(1) Outline the current classification of periodontal diseases and conditions based on the 1999 international workshop for a classification of periodontal diseases and conditions;

(2) Review selected periodontal diseases and conditions in HIV-infected patients

(3) Provide an overview of considerations and approaches in the periodontal management of HIV-infected patients

The objectives of this program are to:

(1) Outline the current classification of periodontal diseases and conditions based on the 1999 international workshop for a classification of periodontal diseases and conditions;

(2) Review selected periodontal diseases and conditions in HIV-infected patients

(3) Provide an overview of considerations and approaches in the periodontal management of HIV-infected patients

International Workshop for the Classification of Periodontal Diseases and Conditions, 1999


I. Gingival Diseases

II. Chronic Periodontitis

III. Aggressive Periodontitis

IV. Periodontitis as a Manifestation of Systemic Diseases

I. Gingival Diseases

II. Chronic Periodontitis

III. Aggressive Periodontitis


Annals of Periodontology, 1999Annals of Periodontology, 1999

Recent Changes in ClassificationRecent Changes in Classification

• 1989 World Workshop in Periodontics provided a widely recognized classification system

• Concerns included:a. Overlap in disease categoriesb. Absence of gingival disease componentc. Inappropriate emphasis on age of onset of diseased. Inadequate or unclear classification criteria

Armitage, Annals of Periodontology, 1999

• 1989 World Workshop in Periodontics provided a widely recognized classification system

• Concerns included:a. Overlap in disease categoriesb. Absence of gingival disease componentc. Inappropriate emphasis on age of onset of diseased. Inadequate or unclear classification criteria

Armitage, Annals of Periodontology, 1999



V. Necrotizing Periodontal Diseases

VI. Abscesses of the Periodontium

VII. Periodontitis Associated with Endodontic Lesions

VIII. Developmental or Acquired Deformities and Conditions

V. Necrotizing Periodontal Diseases





I. Gingival DiseasesI. Gingival DiseasesA. Dental plaque-induced gingival diseases

1. Gingivitis associated with dental plaque only

a. With or without local contributing factors

2. Gingival diseases modified by systemic factors

a. Associated with the endocrine system

b. Associated with blood dyscrasias

3. Gingival diseases modified by medications

4. Gingival diseases modified by malnutrition

A. Dental plaque-induced gingival diseases

1. Gingivitis associated with dental plaque only

a. With or without local contributing factors

2. Gingival diseases modified by systemic factors

a. Associated with the endocrine system

b. Associated with blood dyscrasias

3. Gingival diseases modified by medications

4. Gingival diseases modified by malnutrition


I. Gingival Diseases; ContinuedI. Gingival Diseases; Continued

B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin

E.g., Bacillary (epithelioid) Angiomatosis

2. Gingival diseases of viral origin

E.g., Herpes simplex virus

3. Gingival diseases of fungal origin

E.g., Linear gingival erythema

4. Gingival lesions of genetic origin


E.g., Bacillary (epithelioid) Angiomatosis

2. Gingival diseases of viral origin

E.g., Herpes simplex virus

3. Gingival diseases of fungal origin

E.g., Linear gingival erythema

4. Gingival lesions of genetic origin


I. Gingival DiseasesI. Gingival Diseases

B. Non-plaque-induced gingival lesionsContinued

5. Gingival manifestations of systemic conditions

1. Mucocutaneous disorders

2. Allergic reactions

6. Traumatic lesions (factitious, iatrogenic, accidental)

7. Foreign body reactions

8. Not otherwise specified

B. Non-plaque-induced gingival lesionsContinued

5. Gingival manifestations of systemic conditions

1. Mucocutaneous disorders

2. Allergic reactions

6. Traumatic lesions (factitious, iatrogenic, accidental)

7. Foreign body reactions

8. Not otherwise specified


II. Chronic PeriodontitisII. Chronic Periodontitis

A. Localized

B. Generalized

A. Localized

B. Generalized


III. Aggressive PeriodontitisIII. Aggressive Periodontitis

A. Localized

B. Generalized

A. Localized

B. Generalized



A. Associated with hematological disorders

B. Associated with genetic disorders

C. Not otherwise specified (NOS)

A. Associated with hematological disorders

B. Associated with genetic disorders

C. Not otherwise specified (NOS)


V. Necrotizing Periodontal DiseasesV. Necrotizing Periodontal Diseases

A. Necrotizing ulcerative gingivitis (NUG)

B. Necrotizing ulcerative periodontitis (NUP)

A. Necrotizing ulcerative gingivitis (NUG)

B. Necrotizing ulcerative periodontitis (NUP)









Periodontal Diseases and Conditions in HIV-Infected Patients

Periodontal Diseases and Conditions in HIV-Infected Patients• Unclear whether there are periodontal lesions

specific to HIV infection

• Exacerbation of periodontal conditions and disease, such as chronic periodontitis, may result from severe immunodeficiency or immunosuppression

• Mixed infections Opportunistic

Poly-microbial

• Unclear whether there are periodontal lesions specific to HIV infection

• Exacerbation of periodontal conditions and disease, such as chronic periodontitis, may result from severe immunodeficiency or immunosuppression

• Mixed infections Opportunistic

Poly-microbial

Selected Gingival Diseases and Conditions in HIV-Infected Patients

Selected Gingival Diseases and Conditions in HIV-Infected Patients


i.e., common gingivitis (not “HIV-gingivitis”)



i.e., common gingivitis (not “HIV-gingivitis”)


Gingival Diseases and Conditions in HIV-Infected Patients

Gingival Diseases and Conditions in HIV-Infected Patients


1. Mycobacterium

2. Gingival diseases of viral origin1. Herpesvirus infections2. Primary herpetic gingivostomatitis3. Recurrent oral herpes4. Varicella-zoster infections5. Other

3. Gingival diseases of fungal origin1. Linear gingival erythema2. Histoplasmosis3. Other


1. Mycobacterium

2. Gingival diseases of viral origin1. Herpesvirus infections2. Primary herpetic gingivostomatitis3. Recurrent oral herpes4. Varicella-zoster infections5. Other

3. Gingival diseases of fungal origin1. Linear gingival erythema2. Histoplasmosis3. Other

Factors that Predispose to Oral Lesions

Factors that Predispose to Oral Lesions

• CD4+ counts < 200cells/mm3

• Viral load > 3000copies/mm3

• Xerostomia

• Poor oral hygiene

• Smoking

• CD4+ counts < 200cells/mm3

• Viral load > 3000copies/mm3

• Xerostomia

• Poor oral hygiene

• Smoking

M0 6 12 18 24 30 36 42 48 54 60 66 72 780

200

400

600

800

1000

CD4Virus

Time (months post infection)

CD

4 T

ce

ll c

on

ce

ntr

ati

on

HIV PROGRESSION

CD4 < 200 = AIDS• Immune deterioration• Opportunistic Infections• Oral Manifestations

Adapted from Fauci et al., 1983Adapted from Fauci et al., 1983

Linear Gingival ErythemaLinear Gingival Erythema

• Linear erythematous band involving the free marginal gingiva without demonstrable attachment loss Erythema may extend to attached gingiva Possible precursor of necrotizing ulcerative

periodontal conditions Prevalence: 4% -50% (Holmstrup et al., 2002)

• Spontaneous hemorrhage• Minimal plaque deposits• Associated with Candida albicans• Responds poorly to conventional treatment

• Linear erythematous band involving the free marginal gingiva without demonstrable attachment loss Erythema may extend to attached gingiva Possible precursor of necrotizing ulcerative

periodontal conditions Prevalence: 4% -50% (Holmstrup et al., 2002)

• Spontaneous hemorrhage• Minimal plaque deposits• Associated with Candida albicans• Responds poorly to conventional treatment

Linear Gingival ErythemaLinear Gingival Erythema

Photograph courtesy of Dr. Louis DePaola, Baltimore, MDPhotograph courtesy of Dr. Louis DePaola, Baltimore, MD


Periodontal Diseases and Conditions in HIV-Infected Patients• Aggressive periodontitis

Severe localized forms reported in literature

• Chronic periodontitis modified by immunosuppression

Recent interest in potential for accelerated rate of chronic periodontitis occurring in HIV+ patients

Rate of progression may be dependent upon the immunologic competency of the host as well as local inflammatory response to typical and atypical subgingival microorganisms (Lamster et al., 1997)

• Aggressive periodontitis

Severe localized forms reported in literature




Chronic PeriodontitisChronic Periodontitis

• It is not clear whether HIV+ patients develop a more progressive form of conventional periodontitis

• One study demonstrated a three fold increase in the odds ratios of bone loss for males (Tomar et al., 1995)




• It is not clear whether HIV+ patients develop a more progressive form of conventional periodontitis

• One study demonstrated a three fold increase in the odds ratios of bone loss for males (Tomar et al., 1995)






• Necrotizing Periodontal Diseases

Necrotizing ulcerative gingivitis (NUG)

Necrotizing ulcerative periodontitis (NUP)

• Necrotizing Periodontal Diseases

Necrotizing ulcerative gingivitis (NUG)

Necrotizing ulcerative periodontitis (NUP)

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis• Primarily affects the papillary and marginal gingiva• Gingival erythema and edema, with spontaneous

bleeding • Yellowish-grayish (“pseudomembranous”) areas

of marginal and/or papillary necrosis of gingiva

Loss of interdental papillae

Pain

Rapid progression and extension possible

• Primarily affects the papillary and marginal gingiva• Gingival erythema and edema, with spontaneous

bleeding • Yellowish-grayish (“pseudomembranous”) areas

of marginal and/or papillary necrosis of gingiva

Loss of interdental papillae

Pain

Rapid progression and extension possible

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MDPhotograph courtesy of Dr. Valli I. Meeks, Baltimore, MD

Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis

Gingival tissues appear

erythematous and

edematous, with

evidence of papillary

necrosis and cratering

Gingival tissues appear

erythematous and

edematous, with

evidence of papillary

necrosis and cratering

Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MDPhotograph courtesy of Dr. Valli I. Meeks, Baltimore, MD

Necrotizing Ulcerative PeriodontitisNecrotizing Ulcerative Periodontitis

• Interproximal ulceration, necrosis and cratering

• Foetor is often present

• Pain (severe, deep, localized in jaw)

• Spontaneous bleeding

• Soft tissue necrosis and rapid periodontal destruction

• Prevalence: 1%-88% (Holmstrup et al., 2002).

One large study found a rate of 6.3% (Glick et al., 1994)

• Interproximal ulceration, necrosis and cratering

• Foetor is often present

• Pain (severe, deep, localized in jaw)

• Spontaneous bleeding

• Soft tissue necrosis and rapid periodontal destruction

• Prevalence: 1%-88% (Holmstrup et al., 2002).

One large study found a rate of 6.3% (Glick et al., 1994)

Necrotizing Ulcerative PeriodontitisNecrotizing Ulcerative Periodontitis

Prominent changes in

gingival contour are

associated with tissue

necrosis and loss of

periodontal attachment

and bone

Prominent changes in

gingival contour are

associated with tissue

necrosis and loss of

periodontal attachment

and bone Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MDPhotograph courtesy of Dr. Valli I. Meeks, Baltimore, MD

General Considerations in the Management of HIV+ Patients


• Universal precautions

• Medical consultation

a. Overall medical status

b. Current medications

c. Opportunistic infection(s)

d. Stage of HIV disease

a. CD4 lymphocyte count

b. Viral load

• Management of oral infections

• Comprehensive preventive and restorative oral

health care

• Universal precautions

• Medical consultation

a. Overall medical status

b. Current medications

c. Opportunistic infection(s)

d. Stage of HIV disease

a. CD4 lymphocyte count

b. Viral load

• Management of oral infections

• Comprehensive preventive and restorative oral

health care



• In the absence of significant immunosuppression,

the periodontal treatment of HIV+ patients should

be guided by the same parameters of care

appropriate for HIV- individuals.

• In the absence of significant immunosuppression,

the periodontal treatment of HIV+ patients should

be guided by the same parameters of care

appropriate for HIV- individuals.

Management of Linear Gingival ErythemaManagement of Linear Gingival Erythema

• Scaling and debridement

• Topical and/or subgingival irrigation with antimicrobial chemotherapeutic agent Povidine iodine 10%, chlorhexidine gluconate

irrigation 0.12%-0.2%, or Listerine Antiseptic

• Prescribe daily microbial mouth rinse Chlorhexidine gluconate mouth 0.12% (Rx)1

Listerine Antiseptic (OTC)2

• Recommendation for tobacco cessation

• Re-evaluate in 2-3 weeks.

• Scaling and debridement

• Topical and/or subgingival irrigation with antimicrobial chemotherapeutic agent Povidine iodine 10%, chlorhexidine gluconate

irrigation 0.12%-0.2%, or Listerine Antiseptic

• Prescribe daily microbial mouth rinse Chlorhexidine gluconate mouth 0.12% (Rx)1

Listerine Antiseptic (OTC)2

• Recommendation for tobacco cessation

• Re-evaluate in 2-3 weeks.

1. Available only by Rx; Many State drug plans do not cover this agent2. Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious1. Available only by Rx; Many State drug plans do not cover this agent2. Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious

Management of Linear Gingival ErythemaContinuedManagement of Linear Gingival ErythemaContinued

• For nonresponsive lesions, evaluate for Candidal infection, and consider antifungal agentRefer to module 6

• Selected narrow-spectrum antibiotics sparing gram-positive organisms may be beneficial Metronidazole (250mg, tid 7-10 days)

In the absence of resolution, consideration should be given to other possible lesions, such as lymphomas, including referral for appropriate diagnostic testing (i.e., biopsy)

• Meticulous oral hygiene and frequent supportive maintenance

• For nonresponsive lesions, evaluate for Candidal infection, and consider antifungal agentRefer to module 6

• Selected narrow-spectrum antibiotics sparing gram-positive organisms may be beneficial Metronidazole (250mg, tid 7-10 days)

In the absence of resolution, consideration should be given to other possible lesions, such as lymphomas, including referral for appropriate diagnostic testing (i.e., biopsy)

• Meticulous oral hygiene and frequent supportive maintenance

Periodontal Diseases and Conditions in HIV-infected Patients

Periodontal Diseases and Conditions in HIV-infected Patients

• Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis

Necrotizing ulcerative periodontitis

Necrotizing stomatitis

• Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis

Necrotizing ulcerative periodontitis

Necrotizing stomatitis

Management of Necrotizing Ulcerative GingivitisManagement of Necrotizing Ulcerative Gingivitis

• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%. Povidine iodine provides some analgesic properties.

• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12% 1

Listerine Antiseptic 2

• Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary

• Reevaluation 1 mo following resolution of acute symptoms

• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%. Povidine iodine provides some analgesic properties.

• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12% 1

Listerine Antiseptic 2



1. Available only by Rx; Many State drug plans do not cover this agent

2. Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious

Management of Necrotizing Ulcerative GingivitisManagement of Necrotizing Ulcerative Gingivitis

• Systemic antibiotics

Metronidazole (250mg tid, 7-10 days)

When necessary, should administered concurrently with topical (e.g, clotrimazole troches or nystatin vaginal tablets and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole)



Metronidazole (250mg tid, 7-10 days)

When necessary, should administered concurrently with topical (e.g, clotrimazole troches or nystatin vaginal tablets and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole)


Management of Necrotizing Ulcerative Periodontitis


• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%.

Povidine iodine provides some analgesic properties.

• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12%

Listerine Antiseptic


• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%.

Povidine iodine provides some analgesic properties.

• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12%

Listerine Antiseptic





Metronidazole (250mg tid, 7-10 days; Robinson et al.,1998)

Consideration should also be given to the prophylactic administration of topical (e.g, clotrimazole troches or nystatin vaginal tablets) and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole 100mg, 1 td, 7 to 10 days)


• 3 mo supportive periodontal maintenance 30% of patients experience recurrence in 2 years (Patton et al.,

2000) History of NUP predisposes to Necrotizing Ulcerative Stomatitis

(Robinson, 2002)


Metronidazole (250mg tid, 7-10 days; Robinson et al.,1998)

Consideration should also be given to the prophylactic administration of topical (e.g, clotrimazole troches or nystatin vaginal tablets) and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole 100mg, 1 td, 7 to 10 days)


• 3 mo supportive periodontal maintenance 30% of patients experience recurrence in 2 years (Patton et al.,

2000) History of NUP predisposes to Necrotizing Ulcerative Stomatitis

(Robinson, 2002)

Management of Necrotizing Ulcerative Stomatitis

Management of Necrotizing Ulcerative Stomatitis

• Debridement of affected areas

• Daily rinses with antimicrobial Chlorhexidine gluconate mouth rinse 0.12% Listerine Antiseptic

• Daily (or every-other-day) follow up for the first week, repeating debridement at each visit

• Systemic antibiotics (e.g., metronidazole 250 tid, 7-10 days). Consideration should also be given to the prophylactic

administration of an antifungal medication (fluconazole 100mg, 1td or Itraconazole 200mg, 1td; for 7 to 10 days)


• Debridement of affected areas

• Daily rinses with antimicrobial Chlorhexidine gluconate mouth rinse 0.12% Listerine Antiseptic

• Daily (or every-other-day) follow up for the first week, repeating debridement at each visit

• Systemic antibiotics (e.g., metronidazole 250 tid, 7-10 days). Consideration should also be given to the prophylactic

administration of an antifungal medication (fluconazole 100mg, 1td or Itraconazole 200mg, 1td; for 7 to 10 days)


Abscesses of the PeriodontiumAbscesses of the Periodontium

• Rapid palatal enlargement, smooth and shiny

swelling associated with pain

• Treatment:

Establish drainage by debriding pocket and

removing plaque, calculus and irritants

Monitor for resolution of symptoms –

failure to resolve may be due to incomplete

debridement

In severely immunocompromized patients

(CD4<200) as well as non-resolving lesions

consider systemic antibiotics (e.g.,

Amoxicillin 1.0 gm loading dose and 500

mg tid for 3 days)

• Consideration should be given to prophylatic

administration antifungal agent(s)

• Culture and sensitivity testing is advisable

• Rapid palatal enlargement, smooth and shiny

swelling associated with pain

• Treatment:

Establish drainage by debriding pocket and

removing plaque, calculus and irritants

Monitor for resolution of symptoms –

failure to resolve may be due to incomplete

debridement

In severely immunocompromized patients

(CD4<200) as well as non-resolving lesions

consider systemic antibiotics (e.g.,

Amoxicillin 1.0 gm loading dose and 500

mg tid for 3 days)

• Consideration should be given to prophylatic

administration antifungal agent(s)

• Culture and sensitivity testing is advisable

Photograph courtesy of Dr. Louis DePaola, Baltimore, MDPhotograph courtesy of Dr. Louis DePaola, Baltimore, MD

Periodontal Microflora in HIV+ PatientsPeriodontal Microflora in HIV+ Patients

• No major differences in the microbial composition of periodontal lesions between HIV and non-HIV infected patients

• Colonization includes:A.actinomycetemcomitans

P.gingivalis

P. intermedia

F. nucleatum in LGE and NUP

• Recovery of human herpes virus types 6, 7, and 8, found in 90% of HIV+ patients Over 2X higher than in HIV- controls (Mardirossian et al, 1999)

• No major differences in the microbial composition of periodontal lesions between HIV and non-HIV infected patients

• Colonization includes:A.actinomycetemcomitans

P.gingivalis

P. intermedia

F. nucleatum in LGE and NUP

• Recovery of human herpes virus types 6, 7, and 8, found in 90% of HIV+ patients Over 2X higher than in HIV- controls (Mardirossian et al, 1999)

Considerations in the Use of Antibiotics Considerations in the Use of Antibiotics

• Preferred use of narrow spectrum antibiotics (e.g., Metronidazole) to minimize development of antibiotic resistance

• Possibility of presence of antibiotic resistant strainsCulture and antibiotic sensitivity may be indicated

• Use of antibiotics may lead to overgrowth of Candida albicans Antifungal treatment may be indicated in conjunction

with systemic antibiotics

• Local delivery antibiotics may be useful but have not been evaluated

• Preferred use of narrow spectrum antibiotics (e.g., Metronidazole) to minimize development of antibiotic resistance

• Possibility of presence of antibiotic resistant strainsCulture and antibiotic sensitivity may be indicated

• Use of antibiotics may lead to overgrowth of Candida albicans Antifungal treatment may be indicated in conjunction

with systemic antibiotics

• Local delivery antibiotics may be useful but have not been evaluated

Antibiotic and Antifungal RegimensAntibiotic and Antifungal Regimens

Antibiotics

Rx

Metronidazole tabs 250 mg

Disp: 30 to 40 tabs

Sig: Two tablets as a loading dose and thereafter 250 mg qid for 7-10 days

Antibiotics

Rx

Metronidazole tabs 250 mg

Disp: 30 to 40 tabs

Sig: Two tablets as a loading dose and thereafter 250 mg qid for 7-10 days


Topical Antifungal Agents

Rx

Clotrimazole troche 10mg

Sig: Dissolve 3-5/day for 7-10 days

or

Nystatin vaginal tablets (100,000 U):

Sig: dissolve 1 tablet in mouth tid 7-10 days

Topical Antifungal Agents

Rx

Clotrimazole troche 10mg

Sig: Dissolve 3-5/day for 7-10 days

or

Nystatin vaginal tablets (100,000 U):

Sig: dissolve 1 tablet in mouth tid 7-10 days


Systemic Antifungal Agents

Rx

Fluconazole tablets 100mg

Disp: 9 to 16 tabs

Sig: two tablets immediately and

then 1 tablet daily for 7-10 days


Rx

Fluconazole tablets 100mg

Disp: 9 to 16 tabs

Sig: two tablets immediately and

then 1 tablet daily for 7-10 days



Rx

Itraconazole capsules 100mg

Disp: 14 capsules

Sig: 200mg once daily for 7days


Rx

Itraconazole capsules 100mg

Disp: 14 capsules

Sig: 200mg once daily for 7days

Pediatric PatientsPediatric Patients• Oral lesions have been reported in HIV+ pediatric

populations. The CDC revised the classification system for HIV infection in children <13 years of age to include oral lesions as markers of severity of HIV infection (1994)

• Linear gingival erythema has been reported in approximately 10% of HIV+ children exhibit

• Periodontal conditions and diseases, such as necrotizing ulcerative gingivitis and periodontitis, have been infrequently described

• Oral lesions have been reported in HIV+ pediatric populations. The CDC revised the classification system for HIV infection in children <13 years of age to include oral lesions as markers of severity of HIV infection (1994)

• Linear gingival erythema has been reported in approximately 10% of HIV+ children exhibit

• Periodontal conditions and diseases, such as necrotizing ulcerative gingivitis and periodontitis, have been infrequently described

Considerations in Periodontal Therapy

Considerations in Periodontal Therapy

• The effects of systemic bacteremia created

following Sc/RP have not been studied

• The response of HIV+ patients to periodontal

surgery has not been studied

• The presence of antibiotic resistant oral

bacteria has not been evaluated

• The effects of systemic bacteremia created

following Sc/RP have not been studied

• The response of HIV+ patients to periodontal

surgery has not been studied

• The presence of antibiotic resistant oral

bacteria has not been evaluated

Oral Manifestations in the HAART EraOral Manifestations in the HAART Era

• Overall prevalence of oral infections has changed since

introduction of highly active antiretroviral treatment (HAART)

• Overall reductions in oral infections from 47.6% to 37.5%

(Patton et al., 2000)

• Reductions in oral hairy leukoplakia and necrotizing

ulcerative periodontitis

• Increase in oral warts (Greenspan, 2002)

• No change noted for oral candidiasis, oral ulcers, or Kaposi

sarcoma

• Overall prevalence of oral infections has changed since

introduction of highly active antiretroviral treatment (HAART)

• Overall reductions in oral infections from 47.6% to 37.5%

(Patton et al., 2000)

• Reductions in oral hairy leukoplakia and necrotizing

ulcerative periodontitis

• Increase in oral warts (Greenspan, 2002)

• No change noted for oral candidiasis, oral ulcers, or Kaposi

sarcoma

Web ResourcesWeb Resources

1. http://www.hivatis.org.

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

.

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

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

http://www.hivatis.org/



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

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





Resources and Contact InformationResources and Contact Information

• Mark A. Reynolds, D.D.S., Ph.D.• Niki M. Moutsopoulos, D.D.S.

University of Maryland

Dental School

Department of Periodontics

666 West Baltimore Street

Baltimore, Maryland 21201

(410) 706-7152

ReferencesReferences• Classification and diagnostic criteria for oral lesions in HIV infection. EC-

Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. Oral Pathol Med 1993;22:289-91.

• Fauci, AS. The acquired immune deficiency syndrome. The ever-broadening clinical spectrum. JAMA 1983 May 6;249:2375-6.

• Glick, M., et al. Necrotizing ulcerative periodontitis: a marker for immune deterioration and a predictor for the diagnosis of AIDS. J Periodontol 1994; 65: 393-397.

• Greenspan, JS. Periodontal complications of HIV infection.Compend Suppl 1994;18:S694-8.

• Greenspan D., Canchola A., MacPhail C, Cheikh B, Greenspan J. Effect of Highly Active Antiretroviral Therapy on Frequency of Oral Warts. Lancet 2002;357:1411-1412.

• Horning, GM Necotizing gingivostomatitis: NUG to noma. Compend Contin Educ Dent 1996;17:951-4, 956, 957-8

• Holmstrup, P. and Glick, M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000. 2002;28:190-205.

• Classification and diagnostic criteria for oral lesions in HIV infection. EC-Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. Oral Pathol Med 1993;22:289-91.

• Fauci, AS. The acquired immune deficiency syndrome. The ever-broadening clinical spectrum. JAMA 1983 May 6;249:2375-6.

• Glick, M., et al. Necrotizing ulcerative periodontitis: a marker for immune deterioration and a predictor for the diagnosis of AIDS. J Periodontol 1994; 65: 393-397.

• Greenspan, JS. Periodontal complications of HIV infection.Compend Suppl 1994;18:S694-8.

• Greenspan D., Canchola A., MacPhail C, Cheikh B, Greenspan J. Effect of Highly Active Antiretroviral Therapy on Frequency of Oral Warts. Lancet 2002;357:1411-1412.

• Horning, GM Necotizing gingivostomatitis: NUG to noma. Compend Contin Educ Dent 1996;17:951-4, 956, 957-8

• Holmstrup, P. and Glick, M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000. 2002;28:190-205.

ReferencesReferences

• Holmstrup P, Glick M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000 2002;28:190-205. • Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis D, Reynolds HS, Zambon JJ Oral Dis 1997;3 Suppl 1:S141-8.• Murray, PA. Periodontal diseases in patients infected by human immunodeficiency virus. Periodontol 2000 1994;6:50-67.• Narani N, Epstein JB. Classifications of oral lesions in HIV infection J Clin Periodontol 2001;28:137-45.• Patton LL, McKaig R, Straauss R, Rogers D, Enron JJ Jr. Changing prevalence of oral manifestations of human immunodeficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:299-304.• Parameter on Acute Periodontal Disease. Parameters of Care Supplement J Periodontol May 2000.• Rees, TD. Periodontal Management of HIV-Infected Patients. In MG Newman, HH Takei, FA Carranza (Eds) Carranza's Clinical Periodontology 9th Edition, Chicago: W B Saunders, 2001.

• Holmstrup P, Glick M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000 2002;28:190-205. • Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis D, Reynolds HS, Zambon JJ Oral Dis 1997;3 Suppl 1:S141-8.• Murray, PA. Periodontal diseases in patients infected by human immunodeficiency virus. Periodontol 2000 1994;6:50-67.• Narani N, Epstein JB. Classifications of oral lesions in HIV infection J Clin Periodontol 2001;28:137-45.• Patton LL, McKaig R, Straauss R, Rogers D, Enron JJ Jr. Changing prevalence of oral manifestations of human immunodeficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:299-304.• Parameter on Acute Periodontal Disease. Parameters of Care Supplement J Periodontol May 2000.• Rees, TD. Periodontal Management of HIV-Infected Patients. In MG Newman, HH Takei, FA Carranza (Eds) Carranza's Clinical Periodontology 9th Edition, Chicago: W B Saunders, 2001.

ReferencesReferences

• Robinson PG, Sheiham A, Challacombe SJ, Wren MW, Zakrzewska JM. Gingival ulceration in HIV infection. A case series and case control.study. J Clin Periodontol 1998 Mar;25:260-7.

• Robinson PG, Periodontal diseases and HIV infection. Oral Dis 2002;8 Suppl 2:144-50.

• Ryder, MI. Periodontal management of HIV-infected patients. Periodontol 2000, 2000;23:85-93.

• Ryder, MI. State of the Art: An Update on HIV and Periodontal Disease. J. Periodontol 2002;73: 1083-1090.

• Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-seropositive military personnel. J Periodontol 1995 Jun;66:421-8.

• Winkler JR, Murray PA, Grassi M, Hammerle C. Diagnosis and management of HIV-associated periodontal lesions.J Am Dent Assoc 1989;Suppl:25S-34S.

• Winkler JR, Robertson PB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:145-50.

• 1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Annals of Periodontol 1999;4:1-112.

• Robinson PG, Sheiham A, Challacombe SJ, Wren MW, Zakrzewska JM. Gingival ulceration in HIV infection. A case series and case control.study. J Clin Periodontol 1998 Mar;25:260-7.

• Robinson PG, Periodontal diseases and HIV infection. Oral Dis 2002;8 Suppl 2:144-50.

• Ryder, MI. Periodontal management of HIV-infected patients. Periodontol 2000, 2000;23:85-93.

• Ryder, MI. State of the Art: An Update on HIV and Periodontal Disease. J. Periodontol 2002;73: 1083-1090.

• Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-seropositive military personnel. J Periodontol 1995 Jun;66:421-8.

• Winkler JR, Murray PA, Grassi M, Hammerle C. Diagnosis and management of HIV-associated periodontal lesions.J Am Dent Assoc 1989;Suppl:25S-34S.

• Winkler JR, Robertson PB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:145-50.

• 1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Annals of Periodontol 1999;4:1-112.

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