ORAL HEALTH IN WOMEN ORAL MANIFESTATIONS OF HIV INFECTION

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ORAL HEALTH IN WOMENORAL MANIFESTATIONS OF HIV
INFECTION
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DENTAL HEALTH CARE PROVIDER TEAM APPROACH
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EPIDEMIOLOGY OF HIV-RELATED ORAL MANIFESTATIONS
IN WOMEN
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Epidemiology of HIV-Related Oral Manifestations
in Women A Review

• Oral Lesions in 15 of HIV-Infected Women
• Most Common Oral Lesion - Candidiasis
• Prevalence of Hairy Leukoplakia and Kaposi's
  Sarcoma Significantly Less Common in Women

Oral Dis 1997 Sep3(3)206.
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Many Manifestations of HIV Disease are Similar in
Men Women

• Other Conditions Differ In Frequency
• HIV-Infected Men 8 Xs More Likely to Develop
  Kaposi's Sarcoma
• Women Have Higher Rates of Esophageal Candidiasis
  Herpes Simplex Infections

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CHANGING PREVALENCE OF ORAL MANIFESATIONS
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• Overall Prevalence of Oral Lesions Has Decreased
  (47.6-37.5)
• Hairy Leukoplakia (25.8-11.4) Necrotizing
  Periodontal Diseases (4.8-1.7) Decreased

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• HIV Salivary Gland Disease Increased (1.8-5.0)
• Candidiasis (20.3-16.7), Aphthae (3.7-3.0),
  Oral Warts (2.2-4.0), Herpes Simplex Virus
  Lesions (1.8-2.0) and Kaposis Sarcoma
  (1.1-0.3) Unchanged

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HIV/AIDS Women's Health Oral Lesions in
HIV-Positive Women Reduced in HAART Therapy

• 503 HIV women over 6 years
• Incidence of EC fell to 2.99 percent from 5.48
  percent
• PC fell to 2.85 percent from 6.70 percent
• No changes were seen in HL or warts

• Women's Health Weekly (03.25.04)

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CANDIDIASIS
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Reported in 7-93 of HIV /AIDS Patients
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FOUR MAJOR TYPES

• Pseudomembranous
• Hyperplastic
• Erythematous (Atrophic)
• Angular Cheilitis

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PSEUDOMEMBRANOUS

• White or Yellow Patches
• Easily Removed w/ Scraping Yielding Bleeding
  Surface
• Any Mucosal Surface (Palate, Buccal or Labial
  Mucosa, Tongue)

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HYPERPLASTIC CANDIDIASIS

• White Plaques Cant Be Removed w/ Scraping
• Buccal Mucosa Most Common Site in HIV Patients

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ERYTHEMATOUS (ATROPHIC)

• Fiery Red Surfaces to Hardly Discernible Pink
  Spots
• Most Common Location - Palate Dorsum of Tongue
• Spotty Areas in Buccal Mucosa

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ANGULAR CHEILITIS

• Common in Elderly
• Fissures Radiating From Angles of Mouth

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PREDISPOSING FACTORS
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SYSTEMIC FACTORS

• Age
• Use of Antibiotics
• Xerostomia
• Nutritional Deficiencies
• Immunosuppression
• Gastric Reflux

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LOCAL FACTORS

• Ill-Fitting Dentures
• Poor Prosthesis Hygiene
• Heavy Smoking
• Topical Medications

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CANDIDIASIS TREATMENT

• Nystatin Oral Susp
• 480 ml
• Rinse w/ One Tablespoonful QID
• Clotrimazole (Mycelex) Troches
• 10 mg Troches
• 3-5 Times a Day for 7-14 Days

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• Ketoconazole (Nizoral)
• 200 mg
• 200-400 mg Daily for 7-14 Days
• Fluconazole (Diflucan)
• 100 mg Tabs
• 2 Tabs First Day, Then 1 Tab Daily for 14 Days
• Itraconazole (Sporanox)
• 100 mg Tablets
• 1 tablet B.I.D. for 14 days

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OROFACIAL VIRAL INFECTIONS IN IMMUNOCOMPROMISED
HOST
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HAIRY LEUKOPLAKIA

• First Identified Among HIV Individuals
• Never Described Before AIDS Epidemic

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CLINICAL PRESENTATION

• Painless White Patches
• Do Not Rub Off
• Lateral Borders of the Tongue
• Surface May Be Smooth, Corrugated or Markedly
  Folded
• Thick, Hair-Like Projections

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DIFFERENTIAL DIAGNOSIS

• Hyperplastic Candidiasis
• Geographic Tongue
• Lichen Planus
• Frictional Keratosis
• Leukoplakia

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HAIRY LEUKOPLAKIA - PATHOGENESIS

• Epstein-Barr Virus

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HAIRY LEUKOPLAKIA TREATMENT

• Appears to Be Little Advantage in Treating
• Surgical Removal
• Laser
• Acyclovir
• Topical Vitamin A

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HUMAN PAPILLOMA VIRUS LESIONS
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HUMAN PAPILLOMA VIRUSES

• More Than 100 Human Papilloma Virus (HPV) Types
• 24 Associated with Oral Lesions

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HPV ORAL LESIONS

• Warts, Papillomas
• Condyloma Acuminatum
• Verruca Vulgaris
• Focal Epithelial Hyperplasia
• Dysplasia / Carcinoma

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HUMAN PAPILLOMA VIRUS LESIONS
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CONDYLOMA ACUMINATUM

• Sexually Transmitted
• Appears 1-3 Months After Exposure
• Multiple Wart-Like Lesions
• Lips, Lingual Frenum Tongue

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TREATMENTCONDYLOMA ACUMINATUM

• Surgical Removal
• Cryotherapy
• Laser Therapy
• Medications

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KAPOSIS SARCOMA
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Originally Described in 1872 - Idiopathic
Multiple Sarcomas of the Skin
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Previously Uncommon in USA

• Elderly Jewish Men of Eastern European or
  Mediterranean Descent
• Usually Involved Lower Extremities
• Indolent Course
• 1981 - Fulminant, Aggressive Form Occurring in
  Young Homosexual Men w/ AIDS

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• gt50 of AIDS Patients w/ KS Display Oral Lesions
• Remains Significant Cause of Morbidity
  Mortality in HIV Infected Patients

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CLINICAL PRESENTATION

• Angiomatous Malignancy of Skin, Mucosa, and
  Internal Organs
• Most Common Intraoral Locations
• Palate
• Gingiva
• Non-Elevated Macules, Nodules or Papules
• Brown, Blue, Purple

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KAPOSIS SARCOMAPATHOGENESIS

• Sexually Transmitted Cofactor
• Human Herpes Virus 8 (HHV 8)

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TREATMENT

• Treatment Reserved for Lesions Which Interfere w/
  Function or Esthetics
• Laser Excision
• Cryotherapy
• Radiation
• Intralesional Injection w/ Vinblastine

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CANCER IN PATIENTS WITH AIDS
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AIDS AND CANCER

• Roche et al, NJ Med 2001,Jan98(1)27-36
• 2460 Persons w/ AIDS and Cancer
• 2159 Males, 301 Females
• 50 Kaposis Sarcoma
• 33 Non-Hodgkins Lymphoma
• Lung, Oral, Cervical, Hodgkins Lymphoma, Other
  Digestive

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RECURRENT ORAL ULCERATIONS
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RECURRENT APHTHOUS STOMATITIS
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EPIDEMIOLOGY

• Prevalence in General Population 10-20
• 67-85 Develop Prior
• to Age 30
• Familial Disposition

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MINOR APHTHAE

• Superficial Erosion with Fibrinous Coating Red
  Halo
• Single or Multiple Lesions
• 2-3 mms to Over 10 mms in Diameter
• Persists for 7-10 Days
• Painful

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MAJOR APHTHAE

• Large Painful Ulcerations
• Single or Multiple Lesions
• Persists Up to 6 Weeks
• Heal w/ Scarring

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GENERAL RULE

• Aphthae Occur on Mobile Mucosa
• Herpetic Lesions Occur on Tissue That is Firmly
  Bound Down

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FACTORS ASSOCIATED WITH APHTHAE

• Psychological (Stress) Trauma
• Socio-Economic S. sanguis
• Endocrine
• Immunosuppression
• Hereditary
• Hypersensitivity
• Chemicals in Food

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TREATMENT

• Chlorhexidine
• Topical Steroids
• Lidex Gel .05
• Aphthasol Cream 5

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HERPES SIMPLEX INFECTIONS
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RECURRENT HERPETIC STOMATITIS

• Attenuated Form of Primary Infection
• Tissue Firmly Bound Down
• Vesicles Burst to Form Ulcers
• Coalesce
• Heals in 7-10 Days

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HERPES LABIALIS
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SYSTEMIC ANTIVIRALS

• Acyclovir (Zovirax) 200 mg CapsulesOne Capsule 5
  Times a Day
• Valacyclovir (Valtrex) 1 gm CapletsTwo Caplets
  Twice a Day
• Famciclovir (Famvir) 125 mg TabletsOne Tablet
  Twice Daily

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TOPICAL ANTIVIRALS

• Zovirax (Acyclovir) Ointment 5
• 15 Gram Tube
• Apply TID
• Denavir (Penciclovir) Cream 1
• 2 Gram Tube
• Apply Every Two Hours

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AIDS RELATED PERIODONTAL DISEASE

• Linear Gingival Erythema
• Necrotizing Ulcerative Gingivitis
• Necrotizing Ulcerative Periodontitis
• Necrotizing Ulcerative Stomatitis

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LINEAR GINGIVAL ERYTHEMA

• A Persistent, Linear Erythematous Gingivitis
  Which Bleeds Easily
• Resistant to Treatment
• Spontaneous Remission

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NECROTIZING ULCERATIVE GINGIVITIS

• Also Known as ANUG
• Acute Gingivitis Characterized by Ulceration
  Necrosis of the Gingival Margin Destruction of
  the Interdental Papilla
• Gingival Pain

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NECROTIZING ULCERATIVE GINGIVITIS

• Profuse Gingival Bleeding
• Fetid Odor
• No Involvement of Osseous Tissues
• Associated w/ Stress, Anxiety, Malnutrition
  Smoking

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NECROTIZING ULCERATIVE PERIODONTITIS

• Severe Deep Pain
• Spontaneous Gingival Bleeding
• Extensive Soft Tissue Necrosis
• Severe Loss of Periodontal Attachment

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NECROTIZING ULCERATIVE PERIODONTITIS

• Rapid Onset Progression
• Bone May Be Exposed
• Associated with Low CD4 Counts

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NECROTIZING ULCERATIVE STOMATITIS

• Necrosis of Significant Areas of the Oral Soft
  Tissue Underlying Bone

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INTRAORAL PIGMENTATION

• Racial Pigmentation Smoking
• Amalgam Tattoo Addisons Disease
• Heavy Metal Poisoning Puetz-Jeger Syndrome
• Medications
• Birth Control Pills
• Minocycline
• AZT

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SALIVARY GLAND DISEASE

• Xerostomia
• Bilateral Parotid Gland Enlargement Occurs in HIV
  Infected Individuals
• Histology Has Been Described as Resembling
  Autoimmune Salivary Gland Disease w/ Cystic
  Changes

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Thanks for Coming!
Jacqueline M. Plemons DDS, MS 6031 Sherry
Lane Dallas, TX 75225 [phone] drplemons_at_yah
oo.com