Oral Disease in Patients with HIV Infection

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Oral Disease in Patients with HIV Infection

• CAPT G. Todd Smith, ret
• Phoenix Indian Medical Center

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Contributors of photos and data

• aidsetc.org
• HIVdent.org
• Nebraska and New Mexico AIDS Educational Training
  Centers
• cdc.gov/hiv
• Ann Lyles, USC School of Dentistry

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Rate of HIV Infection (per 100,000 persons U.S.)
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Epidemiology

• Nearly 25 of the 1 million Americans with HIV
  are unaware they are infected.
• Women account for 29 of HIV/AIDS diagnoses among
  AI/ANs.
• In 2005, an estimated 1,581 AI/ANs were living
  with AIDS.
• 9 years after dx with AIDS, 67 of AI/ANs were
  alive.
• A 21 y.o. infected with HIV today will live to
  age 60.

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Oral Disease in HIV Infection

• Oral infections and neoplasms occur with
  immunosuppression
• 90 of HIV patients have at least one oral
  manifestation
• Oral disease is rarely self-limiting
• Untreated oral disease may lead to systemic
  infection, weight loss, dehydration, and
  malnutrition

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Occupational Transmission of HIV

• HIV is present in low levels in saliva (Yeung,
  1993)
• There is no convincing evidence that plain saliva
  can transmit HIV infection.
• Risk is 1/200 (0.3) with a needlestick
• Starting antiretroviral therapy within 1-4 h of
  an exposure can reduce incidence of transmission
  by more than 80 MMWR95

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Medical Issues

• T cell/CD-4 count
• HIV viral load
• Hepatitis
• CBC
• anemia (Hg lt 0.07g/L)
• neutropenia (ANC lt 1.5k/uL)
• thrombocytopenia (lt 100k/uL)

Moswin 2008
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Oral Manifestations of HIV/AIDS9 times higher
prevalence when CD4 T-cell count is less than
200 cells/mm3 (Shiboski, 1994)

• Microorganisms
• Fungal
• Viral
• Bacterial
• Neoplasms
• Iatrogenic

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Pseudomembranous Candidiasis
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Fungal

• Pseudomembranous Candidiasis
• Opportunistic fungal infection caused most
  frequently by Candida albicans
• Primary locations include the tongue, buccal
  mucosa, hard and soft palate
• Considered asymtomatic some may experience
  burning, pain, and altered taste
• Multi-focal, ill-defined, irregular white plaques
  that can be rubbed off

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Atrophic/Erythematous Candidiasis
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Fungal

• Erythematous Candidiasis
• Opportunistic fungal infection caused most
  frequently by Candida albicans
• Primary locations include the tongue and hard
  palate
• Burning sensation and dry mouth
• Multi-focal, ill-defined, irregular red patches
  (median rhomboid glossitis)

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Linear Gingival Erythema

• Diagnosis should be considered when plaque
  control, scaling and root planing fail to
  alleviate.
• Topical antimicrobial rinses such as 0.12
  chlorhexidine may be helpful.

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Angular cheilitis
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Fungal

• Linear gingival erythema (LGE)- gingival disease
  of fungal origin
• Angular cheilitis
• Ulcerative, crusting lesions with erythema at the
  commissures.
• Hyperplastic candidiasis
• Multi-focal, hair-like projections on the cheek
  mucosa along the linea alba.
• When T count lt 100 can develop into esophageal
  candidiasis

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Topical Treatment of Oral Candidiasis

• Clotrimazole (Mycelex) 10 mg troches dissolved in
  the mouth 5x /day for 7-14 days
• Nystatin (Mycostatin) rinse, 100,000units/ml.
  Hold 1 tsp in mouth for 2 min and swallow or spit
  4x/day
• Clotrimazole 1 cream- for angular cheilitis

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Systemic Treatment of Oral Candidiasis (consider
when CD4 count is lower than 150)

• Fluconazole (Diflucan) 100 mg daily for 14 days
• Ketoconazole (Nizoral) 200 mg daily for 14 days

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Oral Hairy Leukoplakia
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Viral Lesions

• Oral Hairy Leukoplakia-
• Epstein-Barr (EBV) virus
• Regarded as a marker of immunosuppression
• Predictive of disease progression to AIDS
• Affects the lateral borders of the tongue,
  ventral tongue and buccal vestibule
• Usually asymptomatic
• Usually treatment not indicated

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Verruca vulgaris
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Viral Lesions

• Oral warts
• Human papillomaviruses (HPV)
• Appears as smooth-surfaced, flesh-colored or
  white papules
• Oral verruca vulgaris is a papillary or
  pedunculated form of HPV
• Occur mostly on keratinized mucosa
• Treatment is excision when indicated
• On the rise- concern with HPV/CA link

Sroussi 2007
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Herpes Simplex Virus
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Viral Lesions

• Oral Herpes Simplex/ Herpes Labialis (fever
  blisters)
• Herpes Simplex Virus (HSV)
• Generally more widespread, aggressive, prolonged,
  and atypically distributed than in
  non-immunosuppressed patients
• Typical sites include the hard palate and the
  attached gingiva but oral mucosal surfaces may be
  involved
• Appear as small vesicles that coalesce with
  weeping crusts or yellow border

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Viral Lesions

• HSV Contd
• Lesions are painful and may interfere with
  nutrition
• Treatment options
• Acyclovir (Zovirax) 400-800 mg 3x/day for 7 days
• Valacyclovir 500 mg twice daily for 7 days ()
• Palliative support- 123 mouthrinse
• Topical acyclovir ointment for recurrent
  herpes-questionable effectiveness

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Viral Lesions

• Cytomegalovirus (CMV)

Dr. David Reznick
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Viral Lesions

• Cytomegalovirus (CMV)
• Painful, large, sharply demarcated, nonspecific
  ulcerations, usually represented by dissemination
  of CMV
• Occurs on both keratinized and nonkeratinized
  mucosa and clinically cannot be distinguished
  from major aphthous ulcerations
• Diagnosis only rendered by deep biopsy
• CMV causes retinitis in AIDS patients
• Rx Ganciclovir, especially when retinitis

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Periodontal disease
Healthy gums
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Periodontal Diseases

• Most common oral bacterial infection among
  HIV-infected persons
• Contributing factors include poor diet, poor oral
  hygiene, and xerostomia
• Regular cleanings and good oral hygiene needed
• Greater prevalence with increased viral load and
  presence of Candida and herpesviruses

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Necrotizing Ulcerative Periodontitis
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• Necrotizing periodontal diseases
• PAINFUL
• Prevalence up to 6.3 Lamster 1997
• Necrotizing ulcerative gingivitis (NUG)
• Characterized by ulceration and necrosis of the
  interproximal gingiva with mucosal sloughing
• Often responsible for rapid tissue destruction
• Necrotizing ulcerative periodontitis (NUP)
• When extends into the adjacent tissues and bone

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Necrotizing Periodontal Diseases

• Treatment of NUG/NUP involves the use of
  aggressive tissue debridement to remove pathogens
  and the administration of systemic antibiotics
• Povidone-iodine as irrigant during debridement
• Flagyl (metronidazole) 250 mg 3 x/day x 5days
• Amoxicillin 500mg with Flagyl 3X/day x 5days
• Antimicrobial rinses (0.12 Chlorhexidine)

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Aphthous Ulcers
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Other Ulcerative Lesions

• Recurrent Aphthous Stomatitis (canker sores)
• Idiopathic problem that affects 40 of the
  general population
• Occurs with increased frequency with HIV
  infection
• Minor are small ulcerations ( lt 1 cm)
• Major are large ulcerations ( gt 1 cm)

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Other Ulcerative Lesions

• Recurrent Aphthous Stomatitis
• Topical steroids such as dexamethasone
  0.5mg/5ml-swish 30 secs then spit 4x/day
• OTCs to cauterize or cover smaller lesions
• Systemic steroids in severe cases and major
  apthous
• prednisone 20mg 3X/day X4 days then reduce 5mg
  each day.

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Kaposi Sarcoma
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Neoplasms

• Kaposis Sarcoma (KS)
• Most common malignancy associated with HIV
• Human Herpesvirus 8 (HH-8) has been implicated as
  a possible co-factor for KS
• Oral cavity may be the initial site in 50 of
  cases
• Early lesions appear as asymptomatic
  reddish-purple macules

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• KS
• Lesions progress to painful papules and nodules
  that may ulcerate and bleed
• Presence of KS always associated with
  immunodeficiency
• Also seen in kidney transplant recipients
• Treat with localized injection of
  chemotherapeutic agents or surgical removal. With
  extraoral lesions, systemic chemo.
• Oncology referral

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Lymphoma
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Neoplasms

• Non-Hodgkins lymphoma
• second most common malignancy in AIDS
• can be painful
• tumors present intraorally as soft tissue masses,
  frequently with secondary ulcerations, and may
  resemble KS
• most commonly occurs on the palate, retromolar
  area, and gingiva
• Oncology referral

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Salivary Gland Dysfunction/Xerostomia
Iatrogenic

• Side effect of nearly all medications
• Dry Mouth promotes dental caries and periodontal
  disease
• Treatment is to restore hydration and avoid
  irritating foods/habits
• Possible link between Viral Load and Salivary
  Gland Dysfunction

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Salivary Gland Dysfunction/Xerostomia

• Paraparotid fat disposition-lipodystrophy
  syndrome-refer to MD Mandel 2008
• Avoid cinnamon, abrasive foods, acidic foods,
  spicy or overly sweet foods, and desiccants
• Encourage high protein foods, cool or frozen
  foods, and low sucrose carbohydrates

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Xerostomia
With gastric reflux
With periodontitis
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Treatment of Dryness

• Saliva substitutes
• Oralbalance gel
• Salivart spray
• Cholinergic Medications
• Pilocarpine (Salagen) - 5 mg TID 30 min. before
  meals to 30 mg daily maximum
• Biotene Products

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Medication induced hyperpigmentation especially
AZT
Iatrogenic
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Other Oral Manifestations

• Fungal-
• Histoplasmosis
• Cryptococcosis
• Bacterial Infections
• Actinomyces
• Enterobacter
• Mycobacterium (Tuberculosis)
• Viral- Varicella-Zoster virus (shingles)
• Lichen Planus
• Erythema Multiforme

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Use of HAART
Iatrogenic

• Significant decrease in prevalence of
  opportunistic diseases like candidiasis, hairy
  leukoplakia and NUP.
• Generally safe to use analgesics, local
  anesthesia, and antibiotics. Few drug-drug
  interactions.
• Immune Reconstitution Syndrome
• Paradoxical transient deterioration in immune
  function during initial response to HAART.
  Increase in some oral lesions like KS initially.

Feller 2008
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Primary Care Providers

• Oral examination should be provided at every
  physical examination by the medical provider
• Current blood data e.g. white blood count with
  differential, the absolute neutrophil count and
  the platelet count should communicated to the
  dental professional

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Primary Care Providers

• Refer to a dental care provider when
• Patient not seen within one year
• Bleeding gums
• Loose or cavitated teeth
• Ill-fitting dentures
• Dry mouth
• Soft tissue lesions

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Questions?
Questions?
Gregory.Smith3_at_ihs.gov