Oral Lesions of HIV in the Era of HAART

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Oral Lesions of HIV in the Era of HAART

Roseann Mulligan DDS, MS USC School of Dentistry
and the Pacific AIDS Education and Training
Center
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Impact of Oral Conditions HIV Patients

• High rate of oral manifestations
• Oral lesions may be harbinger of change in HIV
  condition
• Relative ease of access to identification of
  lesions by those in clinical practices
• Potential impact on systemic health care outcomes
• Potential impact on quality of life
• Adapted from Sifri R, Diaz V, Gordon L, Glick M,
  Anapol H. et al. Oral health care issues in HIV
  disease developing a core curriculum for primary
  care physicians. J Am Board Fam Pract 1998
  11(6)434-44

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High rate of oral manifestations

• More than 90 of patients have at least one oral
  lesion during their disease course. 1
• Are almost always accompanied by symptoms
• Take a variety of appearances that are for the
  most part characteristic
• 1 New York State Dept of Health AIDS Institute's
  Best Practices. Promoting oral health care for
  people with HIV infection. January 2004.

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Oral lesions Harbinger of ? HIV status

• Often the first clinical feature of HIV infection
  is an oral lesion. 1
• New lesions in HIV-infected patient - a sign that
  HIV disease is progressing.
• Untreated HIV infected with oral candidiasis
  progress to AIDS within two years. 1
• May indicate need for prophylaxis against
  specific opportunistic infections.
• 1New York State Dept of Health AIDS Institute's
  Best Practices. Promoting oral health care for
  people with HIV infection. January 2004.

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Medical history

• 1. Questionnaires2. Patient observation3.
  Medical Interview
• 4. Risk Assessment
• 5. Head/Neck Exam6. Diagnostic tests

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Normal Range Lab ValuesLymphocytes
Type of Lymphocyte Percentage of Total Lymphocytes
Total T, CD3 60- 87
Total T/ mm3 630 - 3170
B cell 1- 25
Suppressor, CD8 10- 40
Suppressor/ mm3 240 1200
Helper, CD4 30 - 55
Helper / mm3 600 1700
HS (CD4/CD8) 0.8 - 3.0
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CD4 Status and Relationship to Outcomes
CD Description CD4 Count
30-55 Normal value gt600 cell/mm³
lt 29 Initial Immune Suppression lt500 cell/mm³
lt29 Manifestations of opportunistic infection including oral lesions lt400 cell/mm³
14 -18 Increase in number of opportunistic infections gt201-400 cell/mm³
lt14 Severe Immune Suppression (e.g. Apthous Major) lt200 cell/mm³ AIDS Dx
Continuing decreases Fatal opportunistic infection (e.g. CMV,MAC) lt100 cell/mm³
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Platelets

• Number of platelets in a drop (uL) of blood
• Normal range 150,000-400,000/uL
• Unsafe to do invasive dental tx lt60,000
• Spontaneous bleeding lt50,000

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Neutrophils

• Normal range 3,000-7,000/ mm
• Neutropenia lt1000/mm3
• Severe neutropenia lt500/mm3
• May require antibiotic prophylaxis before
• invasive dental treatment

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Oral Manifestations of HIV Infection
Infection Oral Disease
Fungal Candidiasis - Pseudomembranous, Erythematous, and Angular Cheilitis Invasive Fungal Infections - Histoplasmosis, Cryptococcosis
Viral Herpes Simplex Herpes Zoster Cytomegalovirus Hairy Leukoplakia (Epstein Barr Virus) Oral Warts (Human Papilloma Virus) Human Hominus Virus8 K.S.
Bacterial Linear Gingival Erythema Necrotizing Ulcerative Periodontitis Tuberculosis Mycobacterium avium complex Bacillary angiomatosis
http//www.aids-ed.org/ppt/nw_schubert_oralupdate_
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Oral Manifestations of HIV Infection
Type of Lesion Oral Disease
Neoplastic Kaposis Sarcoma (KS) HHV-8 Lymphoma Squamous Cell Carcinoma
Other HIV- Necrotizing Ulceration HIV-Salivary Gland Disease/ Xerostomia Thrombocytopenic Purpura Abnormal Mucosal Pigmentation
http//www.aids-ed.org/ppt/nw_schubert_oralupdate_
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Oral Candidiasis

• Most Common often predicts HIV progression
• Candida albicans is the most prevalent
• 3 types pseudomembranous ª erythematous ª
  hyperplastic.

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Oral Candidiasis

• Pseudomembranous (Thrush) Characterized by the
  presence of white curds or creamy cotton like
  appearance
• Can be easily removed. The underlying mucosa is
  erythematous and may bleed slightly.
• Immunosuppresion

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Oral Candidiasis

• Atrophic (Erythematous)
• In non-immunosuppressed
• Associated in patients w/ ill-fitting dentures or
  in those who wear their dentures continuously
• Generalized red area of atrophic tissue, commonly
  on the palate
• Burning sensation, palate, tongue
• Culture, smear not very effective

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Oral Candidiasis

• In tongue loss of the filiform papilla, a
  generalized thinning of the epithelium, and
  excessive inflammation of the connective tissue
• Median Rhomboid Glossitis

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Oral Candidiasis

• Chronic Hyperplastic usually presents as a white
  mucosal plaque.
• Most common location buccal mucosa along the
  occlusal line in the commissure, latero-dorsal
  surface of tongue and the alveolar ridges
• Frequently term
• candidal leukoplakia

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Oral Candidiasis

• Angular cheilitis

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• Perspective Oral Manifestations Volume 13 Issue
  5 December 2005/January 2006

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Herpes Simplex

• Recurrent herpes labialis lips dry mucosa or
  skin, fluid-filled vesicle, that rupture,
  ulcerate, and resolve as crusted brownish
  lesions.
• Recurrent intraoral herpes maxillary gingiva,
  palate wet and fragile mucous membranes. Lesions
  are punctate with red or white bases that slowly
  disappear.

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• Epstein-Barr Virus (EBV)
• Oral Hairy Leukoplakia

• White, often corrugated in appearance,
  plaque-like or hair-like projections that are
  non- wipeable, lateral borders of tongue.
• It appears in late latency stages HIV or
  precursor of AIDS.
• Definitive Dx Histopathology

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Epstein-Barr Virus (EBV) Oral Hairy Leukoplakia

• Treatment
• Treat for cosmetic reasons otherwise no
  treatment is warranted

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Human Papilloma Virus (HPV)

• HAART ? ?
• Assoc. w/ 2.6 -6-fold ? incidence of oral warts
• ? aphthous ulcers salivary gland dz?caries
• Diz Dios P, Ocampo A, Miralles C. (2000)
  Patton LL, et al. (2000) Patton LL, (2003) .

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Human Papilloma Virus (HPV)

• In the oral cavity the most common are, squamous
  papilloma HPV 6 11 verruca vulgaris HPV 2-4
  and condyloma acuminatum HPV 6 11
• Clinically may appear exophitic, keratinized,
  sessile papules or nodules cauliflower-like
  2-5mm

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Human Papilloma Virus (HPV)
SP High incidence on the soft palate, faucial
pillars, uvula. VV Lips,hard palate and
gingiva?hands and fingers. CA Presents as a
pinkish, sessile papules or plaques w/ pebbled
surfaces. Oral lesions occur in nonkeratinized
mucosa of lips, floor of the mouth, lateral and
ventral surface of tongue, buccal mucosa and soft
palate
Photo ftom VI Meeks, DDS, U Md Dental School
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Human Papilloma Virus (HPV)

• Treatment indicated
• (1) Lesion may become traumatized
• (2) In area that may lead to auto-inoculation
• (3) For cosmetic reasons

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Human Papilloma Virus (HPV)

• Treatment
• Cryotherapy laser or surgical excision.
• Lesions often recur

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Human Papilloma Virus (HPV)

• Vaccine was approved last June by the FDA
• Women 9-26 yrs (prefer 11-12 yrs old)
• 70 cervical cancers HPV 16,18,31,45
• Vaccine 6, 11, 16, 18
• HPV 16 related to 25 of oral cancer.
• 300-500 total for 3 dose series

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Necrotizing Ulcerative Periodontitis NUP

• Extensive soft tissue necrosis exposing alveolar
  bone
• Severe pain, odor and spontaneous bleeding
• Compare appearance to aphthous ulcer on right

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Necrotizing Ulcerative Periodontitis (NUP)
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Povidone Iodine /Chlorexidine
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Salivary Gland Involvement
http//www.aids-ed.org/ppt/nw_schubert_oralupdate_
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Salivary Gland Involvement
Table Absence of saliva on palpation of salivary
glands the WIHS
Mulligan R. et al. Salivary gland disease in
human immunodeficiency virus-positive women from
the WIHS study. Women's Interagency HIV Study.
Oral Surgery Oral Medicine Oral Pathology Oral
Radiology Endodontics. 89(6)702-9, 2000 Jun.

• Medications (side effects) -gt xerostomia

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Data from the Womens Interagency HIV Study
Greenspan D, Gange S, Phelan J, Navazesh M, Alves
M, MacPhail L, Mulligan R, Greenspan J. J Dent
Res 83(2)145-150, 2004
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Prevalence of Oral Lesions During HIV Medication
Usage
Greenspan, D et al The Lancet Vol 357 May 5, 2001
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In Summary

• Oropharyngeal Candidiasis (OPC) improves or
  resolves with response to HAART
• Oral lesions are fewer as a result of HAART
• Cavities increase as a result of hyposalivary
  function due to meds
• Warts seem to increase

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Preventive Oral Health Care

• Recalls every 3 to 6 months
• Antimicrobial mouth rinses for patients with
  periodontal disease, including past history of
  NUP and LGE
• Fluoride supplements

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Thank You !!