Module 8 Management of Periodontal Disease in HIV-Infected Patients

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Module 8Management of Periodontal Disease in
HIV-Infected Patients
2
Management of Periodontal Disease in HIV-Infected
Patients

• 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

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Program Outline

• Classification of Periodontal Diseases and
  Conditions
• Periodontal Diseases and Conditions in
  HIV-Infected Patients
• Periodontal Management of HIV-Infected Patients

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Program Objectives

• The objectives of this program are to
• Outline the current classification of periodontal
  diseases and conditions based on the 1999
  international workshop for a classification of
  periodontal diseases and conditions
• Review selected periodontal diseases and
  conditions in HIV-infected patients
• Provide an overview of considerations and
  approaches in the periodontal management of
  HIV-infected patients

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

1. Gingival Diseases
2. Chronic Periodontitis
3. Aggressive Periodontitis
4. Periodontitis as a Manifestation of Systemic
   Diseases

Annals of Periodontology, 1999
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Recent Changes in Classification

• 1989 World Workshop in Periodontics provided a
  widely recognized classification system
• Concerns included
• Overlap in disease categories
• Absence of gingival disease component
• Inappropriate emphasis on age of onset of
  disease
• Inadequate or unclear classification criteria
• Armitage, Annals of Periodontology, 1999

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

1. Necrotizing Periodontal Diseases
2. Abscesses of the Periodontium
3. Periodontitis Associated with Endodontic Lesions
4. Developmental or Acquired
   Deformities and Conditions

Annals of Periodontology, 1999
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I. Gingival Diseases

• Dental plaque-induced gingival diseases
• Gingivitis associated with dental plaque only
• With or without local contributing factors
• Gingival diseases modified by systemic factors
• Associated with the endocrine system
• Associated with blood dyscrasias
• Gingival diseases modified by medications
• Gingival diseases modified by malnutrition

Annals of Periodontology, 1999
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I. Gingival Diseases Continued

• Non-plaque-induced gingival lesions
• Gingival diseases of specific bacterial origin
• E.g., Bacillary (epithelioid) Angiomatosis
• Gingival diseases of viral origin
• E.g., Herpes simplex virus
• Gingival diseases of fungal origin
• E.g., Linear gingival erythema
• Gingival lesions of genetic origin

Annals of Periodontology, 1999
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I. Gingival Diseases

• Non-plaque-induced gingival lesionsContinued
• Gingival manifestations of systemic conditions
• Mucocutaneous disorders
• Allergic reactions
• Traumatic lesions (factitious, iatrogenic,
  accidental)
• Foreign body reactions
• Not otherwise specified

Annals of Periodontology, 1999
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II. Chronic Periodontitis

1. Localized
2. Generalized

III. Aggressive Periodontitis

1. Localized
2. Generalized

Annals of Periodontology, 1999
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IV. Periodontitis as a Manifestation
of Systemic Diseases

• Associated with hematological disorders
• Associated with genetic disorders
• Not otherwise specified (NOS)

Annals of Periodontology, 1999
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V. Necrotizing Periodontal Diseases

1. Necrotizing ulcerative gingivitis (NUG)
2. Necrotizing ulcerative periodontitis (NUP)

Annals of Periodontology, 1999
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VI. Abscesses of the Periodontium VII. Periodont
itis Associated with Endodontic Lesions VIII.
Developmental or Acquired Deformities and
Conditions
Annals of Periodontology, 1999
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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

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Selected Gingival Diseases and Conditions in
HIV-Infected Patients

• Dental plaque-induced gingival diseases
• i.e., common gingivitis (not HIV-gingivitis)
• Non-plaque-induced gingival lesions
• Gingival diseases of specific bacterial origin

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Gingival Diseases and Conditions in HIV-Infected
Patients

• Non-plaque-induced gingival lesions
• Gingival diseases of specific bacterial origin
• Mycobacterium
• Gingival diseases of viral origin
• Herpesvirus infections
• Primary herpetic gingivostomatitis
• Recurrent oral herpes
• Varicella-zoster infections
• Other
• Gingival diseases of fungal origin
• Linear gingival erythema
• Histoplasmosis
• Other

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Factors that Predispose to Oral Lesions

• CD4 counts lt 200cells/mm3
• Viral load gt 3000copies/mm3
• Xerostomia
• Poor oral hygiene
• Smoking

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HIV PROGRESSION

• CD4 lt 200 AIDS
• Immune deterioration
• Opportunistic Infections
• Oral Manifestations

Adapted from Fauci et al., 1983
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Linear 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

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Linear Gingival Erythema
Photograph courtesy of Dr. Louis DePaola,
Baltimore, MD
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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)

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Chronic 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)
• 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)

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Periodontal Diseases and Conditions in
HIV-Infected Patients

• Necrotizing Periodontal Diseases
• Necrotizing ulcerative gingivitis (NUG)
• Necrotizing ulcerative periodontitis (NUP)

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Necrotizing 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

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Necrotizing Ulcerative Gingivitis
Photograph courtesy of Dr. Valli I. Meeks,
Baltimore, MD
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Necrotizing Ulcerative Gingivitis

• Gingival tissues appear erythematous and
  edematous, with evidence of papillary necrosis
  and cratering

Photograph courtesy of Dr. Valli I. Meeks,
Baltimore, MD
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Necrotizing 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)

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Necrotizing Ulcerative Periodontitis

• 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, MD
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General Considerations in the Management of HIV
Patients

• Universal precautions
• Medical consultation
• Overall medical status
• Current medications
• Opportunistic infection(s)
• Stage of HIV disease
• CD4 lymphocyte count
• Viral load
• Management of oral infections
• Comprehensive preventive and restorative
  oral health care

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General Considerations in the Management of HIV
Patients

• 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.

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Management 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.

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

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Management of Linear Gingival ErythemaContinued

• For nonresponsive lesions, evaluate for Candidal
  infection, and consider antifungal agent
• Refer 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

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Periodontal Diseases and Conditions in
HIV-infected Patients

• Necrotizing Periodontal Diseases
• Necrotizing ulcerative gingivitis
• Necrotizing ulcerative periodontitis
• Necrotizing stomatitis

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Management 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

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

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Management 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)
• Reevaluation 1 mo following resolution of acute
  symptoms

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

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Management of Necrotizing Ulcerative Periodontitis

• Systemic antibiotics
• 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)
• Reevaluation 1 mo following resolution of acute
  symptoms
• 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)

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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)
• Reevaluation 1 mo following resolution of acute
  symptoms

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Abscesses 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 (CD4lt200)
  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, MD
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Periodontal 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)

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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
  strains
• Culture 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

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Antibiotic 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

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Antibiotic and Antifungal Regimens

• 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

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Antibiotic and Antifungal Regimens

• 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

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Antibiotic and Antifungal Regimens

• Systemic Antifungal Agents
• Rx
• Itraconazole capsules 100mg
• Disp 14 capsules
• Sig 200mg once daily for 7days

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Pediatric Patients

• Oral lesions have been reported in HIV pediatric
  populations. The CDC revised the classification
  system for HIV infection in children lt13 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

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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

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Oral 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

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Web Resources

1. http//www.hivatis.org.
2. https//w3.ada.org/prof/prac/issues/topics/icontro
   l/ic-recs/index.html.
3. http//www.hivdent.org/dtc.htm.
4. http//www.critpath.org/daac/standards.html

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Resources 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
• [phone]

52
References

• Classification and diagnostic criteria for oral
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• Fauci, AS. The acquired immune deficiency
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• Greenspan, JS. Periodontal complications of HIV
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• Holmstrup, P. and Glick, M. Treatment of
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53
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References

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