14th Annual HIV Conference

1
14th Annual HIV Conference

• Oral Health Evaluations
• Carol M. Stewart DDS, MS
• Director of Oral Diagnostic Sciences
• University of Florida College of Dentistry
• Florida/Caribbean AETC Dental Director

2
Importance of Oral Health Oral Systemic Links

• Diabetes
• Heart Disease
• Pregnancy
• Osteoporosis

3
Importance of Oral Health in
HIV-infected

• Even more critical
• Enhanced susceptibility to all oral infections
• and neoplasms
• Impact on systemic health
• Impact on quality of life

4
Objectives

• Procedure for an Oral Examination
• Identification and Management of Oral Lesions
• Emergency Dental Concerns
• Preventive Dental Care

5

Oral Screening Exam Video

• Extraoral
• Intraoral
• (Similar to Oral Cancer Exam)
• Questions?

6
Significance of Oral Lesions

• Often first clinical sign of HIV disease
• Signify disease progression
• HAART failure ?
• HIV viral resistance?
• Medication non-compliance?
• Impact nutrition
• Impact medication compliance

CDC
7
Oral Lesions and HAART

• Appear to be Decreasing
• Candidiasis
• Oral Hairy Leukoplakia
• Kaposis Sarcoma
• Necrotizing Periodontitis
• Appear to be Increasing
• HPV assoc. Condyloma acuminata Oral Warts
• Xerostomia
• Dental decay

8
Traditional Outline of Oral Conditions

• Malignant neoplasms
• Kaposis sarcoma (KS)
• Non-Hodgkins Lymphoma
• Squamous cell carcinoma
• Stomatitis/ Ulcers
• Aphthous (major/minor)
• Stomatitis NOS
• Salivary Gland Disease
• Xerostomia
• Dental Decay

• Fungal
• Candidia albicans (Candidiasis) Thrush
• Histoplasmosa capsulatum (Histoplasmosis)
• Cryptococcus neoformans
• Viral
• Oral hairy leukoplakia (Epstein-Barr virus)
• Herpes simplex virus (HSV)
• Herpes Zoster Shingles ( Varicella-zoster
  virus)
• Human Papilloma Virus (HPV)
• Cytomegalovirus (CMV)
• Periodontal disease
• Linear gingival erythema (LGE)
• Necrotizing ulcerative periodontitis (NUP)

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Predictive Value of Oral Lesions

• Viral load 20,000 copies/ml

10
Fungal Diseases

• Candidiasis
• Histoplasmosis

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Oral Candidiasis, Candida albicans

• fungal infection associated with
• HIV infection
• antibiotic treatment
• corticosteroid treatment (inhaled and systemic)
• diabetes, xerostomia, smoking
• removable dental appliances
• defects in cell-mediated immunity

12
Erythematous Candidiasis

• Red, flat patches on any oral mucosal
  surface
• Dorsal tongue Hard
  Palate

13
Diagnostic Tools for yeast

• Cytologic smear
  
• KOH Prep
• 3. Culture

Buccal mucosal cells showing fungal hyphae
14
Angular cheilitis

• Fissures and redness radiating from the either
  or both corners of the mouth

15
Pseudomembranous Candidiasis (thrush)

• Creamy white or yellowish curd-like plaques on
  any oral mucosal surface
• Usually on red mucosa, easily wiped off -
• may bleed

CDC
16
Oral Candidiasis Topical Treatment

• nystatin pastilles
• clotrimazole (Mycelex)
• Note many contain sugar
• Mycelex, Nystatin Oral Suspension
• Mycostatin pastilles
• May consider using a topical fluoride in
  addition to an antifungal agent that contains
  sugar

17
Candidiasis Treatment - for Removable appliances

• Remove and thoroughly clean daily
• Soak in an antifungal agent
• May use nystatin powder on tissue
• side of denture before insertion
• Get a NEW toothbrush
• 
  

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Systemic Antifungals

• Fluconazole 100 mg tabs (Diflucan)
• Two tabs day one, then 1 per day for two
  weeks.

Intraconazole 100 mg (Sporanox) if no response
to fluconazole for oropharyneal candidiasis
19
Hyperplastic Candidiasis

• Larger areas of white or
• discolored or coalesced
• plaques
• Cannot be wiped off
• Sign of severe
• immune suppression

20
Viral Conditions

• Oral Hairy Leukoplakia (OHL)
• Herpes Simplex (HSV)
• Varicella-zoster (VZV)
• Human Papilloma Virus (HPV)

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Oral Hairy Leukoplakia (OHL)

• White lesion, usually present on lateral borders
  of tongue,
• Vertically corrugated hyperkeratotic patches

CDC
22
Herpes Simplex Virus (HSV)

• Affects peri-oral areas, lips, palate, gingiva,
  and intraoral mucosa
• Vesicles may become ulcerated and coalesce to
  appear as large ulcers

CDC
23
Human Papilloma Virus (HPV)

• Condyloma Acuminatum - also called
  Oral Warts
• Single or multiple
• Cauliflower-like or flat
• at site of sexual contact

24
Human Papilloma Virus (HPV)

• Maybe sessile, flat, or raised
• High recurrence rate
• Lips Inside lips and cheek

25
Human Papilloma Virus Assoc. with Oral Cancer?

• HPV is associated with cervical cancer
• Found HPV DNA in nearly 4 of cancers of mouth
  and 18 of cancers of oropharynx
• Conc HPV appears to play etiologic role in many
  cancers of oropharynx and possibly small
  subgroups of cancers of the oral cavity.
• More common in subjects who with more than one
  sexual partner or who practiced oral sex
• More common in tobacco users
• Journal of the National Cancer Institute
  200395(23)1772-1783

26
Oral Warts and Dysplasia
Results 20 of 22 dysplastic warts stained
positive for HPV Conclusions
Invasion-associated proteins are under-expressed
in oral dysplastic warts in HIV positive men.
Need long-term follow-up to determine risk of SCC
from oral dysplastic warts. Regezi JA,
Dekker NP, Ramos DM, Li X, Macabeo-Ong M, Jordan
RC. Proliferation and invasion factors in
HIV-associated dysplastic and nondysplastic oral
warts and in oral squamous cell carcinoma an
immunohistochemical and RT-PCR evaluation. Oral
Surg Oral Med Oral Pathol Oral Radiol Enddod 2002
Dec 94(6) 724-31.
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Dental Concerns observed in the Medical Office

• What initial management can be provided in the
  medical office?
• Most periodontal conditions
• Pain and infections associated with dental decay
• Aphthous ulcers
• What requires urgent referral?
• Suspected neoplasia or oral cancer

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Dental Concerns observed in the Medical Office

• What requires direct referral to hospital ER?
• Swelling, infection encroaching on airway
• Swelling involving eye
• Intraoral hemorrhage
• Dehydration, fever, lymphadenopathy, signs of
  severe immune suppression

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Periodontal Disease

• Etiology
• Bacterial - Initiated by microbial dental plaque
• Disease behavior is dependent on host defenses
• Types
• Linear Gingival Erythema (LGE)
• Necrotizing Ulcerative Periodontitis (NUP)

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Linear Gingival Erythema (LGE)

• Profound red band along gingiva where tissue
  meets the teeth
• Mild pain, Responds poorly to conventional
  treatment
• mild more
  advanced

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Necrotizing Ulcerative Periodontitis (NUP)

• Marker of severe immune suppression
• VERY painful,deep jaw pain
• Exacerbated by tobacco xerostomia

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Necrotizing Ulcerative Periodontitis Urgent
Treatment

• Antibiotics
• Metronidazole 250 mg 3 times per day for 7-10
  days OR
• Clindamycin 300 mg 3 times per day for 7-10
  days
• Peridex or PerioGard Rinses
• (chlorhexidine gluconate 0.12)
• Nutritional supplements
• Dental Tx within one week

33
Extensive Dental Decay (Caries)
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Xerostomia Dry MouthSigns and symptoms

• Xerostomia is the subjective feeling of oral
  dryness
• Patient states they cant eat a meal without
  water
• Frequent thirst
• Objective evidence of hyposalivation
• Gloved hand will stick to mucosa
• No pooling of saliva observed in floor of mouth
• Significant dental decay

35
Xerostomia Management

• Sugar free gum ( Xylitol )
• Sugar free hard lozenges
• Artificial saliva products -
• - OTC Optimoist, Oral moisturizer,
• - Mouth-Kote, Oralube
• Products for dry mouth such as Biotene products
• may offer relief.

36
Anti-caries Treatment

• FluoridesOTC Gel-Kam
• (0.4 stannous fluoride)
• Rx Prevident Gel
• or Prevident 5000 Plus
• (toothpaste plus fluoride)

37
Parulis or Dental Abscess
Antibiotics - if febrile and lymphadenopathy Ana
lgesics - if painful If chronic and
asymptomatic, refer to dentist for next available
appointment. Requires endodontic therapy or
extraction.
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HIV related Soft Tissue Concerns

• Ulcers
• Malignancies

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Minor Aphthous Ulcer canker sores

• Lesions found on buccal mucosa, posterior
  oropharynx, sides of tongue
• Variable in size - 2-5 mm. diameter
• History of ulcers

40
Major Aphthous Ulcers

• Greater than 5 mm in diameter, painful,
• and may persist for many weeks
• Biopsy if non-responsive to treatment
• Necessary to r/o opportunistic
• infection or malignancy

CDC
41
Aphthous Ulcer Treatment

• Topical steroids
• Dexamethasone elixir (0.5 mg/5 cc)
• - Hold 1-2 teaspoonfuls in mouth 2 minutes, swish
  and expectorate, qid (for multiple ulcers)
• Fluocinonide 0.05 ointment (Lidex), with 11
  Orabase Apply qid
• Clobetasol 0.05 (Temovate) Apply bid ..very
  potent
• Systemic corticosteroid therapy for major or
  non-responsive lesions as advised by physician

42
Histoplasmosis

• Clinical - chronic ulcer,
  Silver stain (GMS) erythema, and swelling
• Always biopsy

43
Neoplasms - all need urgent care

• Kaposis Sarcoma
• Squamous Cell Carcinoma

44
Kaposis Sarcoma palate
CDC
45
Signs of Oral Cancer or MalignancyUrgent
Referral to Oral Surgeon or ENT

• Squamous Cell Carcinoma
• Non-healing ulcer anywhere
• Red patch, white patch, or ulcer that is
  non-responsive to treatment (persists 2 weeks)

46
Malignancies in HIV-Infected Patients

• Increase seen in
• Head and neck CA
• Assoc with declining CD4 counts and
• Increased smoking rates
• Patel, 11th Conference on Retroviruses and
  Opportunistic Infections

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What is a true dental emergency?

• The presence of pain does not necessarily
  constitute a dental emergency
• An acute emergency may include
• Bleeding
• Swelling
• Fever
• Purulence (pus)

48
Emergency Situations Send to Hospital ER

• Swelling if compromising the airway
• (Ludwigs angina)
• Swelling if involving the eye
• Intraoral hemorrhage (bleeding)
• Extreme fever lymphadenopathy

49
Intraoral Bleeding

• Ineffective Coagulation
• Intraoral bleeding and/or areas of ecchymosis
  may be observed
  with very low platelet counts or

50
When to Admit for an Odontogenic Infection

• Deep fascial space infection which threatens the
  airway
• Patient is dehydrated and requires IV fluids
• Patient requires general anaesthesia for surgical
  procedures

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Oral Preventive Care Plan

• Initial dental exam for every patient
• Recall every 6 months, sooner if oral conditions
  include
• High caries rate or Xerostomia
• Periodontal disease
• Fungal, Viral, or Bacterial infections
• Neoplastic lesions

52
Patient Home Care

• Brush 2 times per day Floss daily
• Dental debridement every 6 months
• Non-abrasive toothpaste
• Fluoride
• Avoid tobacco
• Avoid excessive alcohol
• Adequate Nutrition
• If ingest sugary snacks frequently,
• brush frequently

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Goals of Oral Health Program

• Treat pain, eliminate sources of infection, and
  identify/diagnose pathology
• Facilitate maintenance of adequate nutrition by
  stabilizing and preserving function
• Educate patient regarding health maintenance
• 4. Contribute to self-esteem and quality of
  life

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Summary

• Good oral health will help maintain
• Systemic health
• Quality of life

• Website www.FAETC.org

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Thank You!!

• Questions?
• ?
• ?
• ?
• Email cstewart_at_dental.ufl.edu

56
Additional References

• Patton LL, McKaig R, Strauss R, Rogers D, Eron JJ
  Jr. Changing prevalence of oral manifestations of
  human immuno-deficiency virus in the era of
  protease inhibitor therapy. Oral Surg, Oral Med
  Oral Pathol Oral Radiol Endod 200089299-304.
• Tappuni AR, Fleming GJ. The effect of
  antiretroviral therapy on the prevalence of oral
  manifestations in HIV-infected patients a UK
  study. Oral Surg Oral Med Oral Pathol Oral
  Radiol Endod 200192623-8.
• Margiotta V, Campisi G, Mancuso S, Accurso V,
  Abbadessa V. HIV infection oral lesions, CD4
  cell count and viral load in an Italian study
  population. J Oral Pathol Med 199928173-7.
• Flint S, Glick M, Patton L, Tappuni A, Shirlaw P,
  Robinson P. Consensus guidelines on quantifying
  HIV-related oral mucosal disease. Oral Dis 20028
  Suppl 2115-9.

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Additional References

• Patton LL, Phelan JA, Ramos-Gomez FJ,
  Nittayananta W, Shibioski CH, Mbuguye TL.
  Prevalence and classification of HIV-associated
  oral lesions. Oral Dis 20028 Suppl 298-109.
• Flint S, Glick M, Patton L, Tappuni A, Shirlaw P,
  Robinson P. Consensus guidelines on quantifying
  HIV-related oral mucosal disease. Oral Dis
  20028Suppl 2115-9.
• Patton LL. HIV Disease. Dent Clin North Am 2003
  Jul 47(3)467-92.