HIVAIDS ORAL DISEASE

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HIV/AIDS ORAL DISEASE
WHAT WE ARE SEEING BEFORE AND AFTER HAART

Abbe Barron MEd, DMD Clinical Assistant
Professor USC School of Dentistry Assistant
Clinical Director, Oral Health Programs Pacific
AIDS Education and Training Center
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PRESENTATION GOALS

• RECOGNIZE ORAL LESIONS SEEN WITH
• IMMUNOSUPPRESSION
• EFFECTS OF HAART ON PREVALENCE OF
• THESE LESIONS

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WHAT DO WE SEE IN HIV/AIDS?

• IMMUNOSUPPRESION
• n. The inhibition of the normal immune
  response
• because of disease.
• OPPORTUNISTIC INFECTION
• adj. A microorganism causing disease only
• under certain conditions, as when a
• persons immune system is impaired.

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WHAT ARE SOME OF THE FACTS

• Approximately 70 to 80 percent of people with
• HIV/AIDS will experience an oral manifestation
• Treating routine problems as soon as possible
• can prevent more serious infections
• Almost all of the infections we see, appear in
• people who are not infected with HIV/AIDS, but
• they appear more frequently and with more
• severity in people who are infected

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RECOMMENDATIONS FOR AN ORAL EXAMINATION

• LIPS AND GUMS
• CHEEKS
• TONGUE
• FLOOR OF THE MOUTH
• ROOF OF THE MOUTH
• LYMPH NODES

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DIFFERENTIAL DIAGNOSIS The process

• Recognition of the lesion
• History of the condition
• Observation
• Palpation

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CAUSES OF ORAL LESIONS

• FUNGAL
• VIRAL
• BACTERIAL
• ULCERATIVE
• NEOPLASTIC

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FUNGAL
ANGULAR CHELITIS
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FUNGAL
ANGULAR CHELITIS

• Inflammation/irritation
• Cracking and fissuring
• Pain upon opening the mouth
• Susceptible to infection

• TREATMENT
• Antifungal medication
• Correct vertical dimension

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FUNGAL
PSEUDOMEMBRANOUS CANDIDIASIS
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FUNGAL
PSEUDOMEMBRANOUS CANDIDIASIS

• Multiple white to yellow soft plaques
• Plaques easily removed by gauze
• Areas may bleed and burn
• Taste alterations
• Xerostomia

• TREATMENT
• Antifungal medication

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FUNGAL
ATROPHIC OR ERYTHEMATOUS
CANDIDIASIS
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FUNGAL
ATROPIC CANDIDIASIS

• Spotty appearance
• May look like pizza burn
• Mistaken for trauma, infections, radiation,
• xerostomia
• Pain is less severe than pseudomembranous
• candidiasis

• TREATMENT
• Antifungal medications

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VIRAL
ORAL HAIRY LEUKOPLAKIA
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VIRAL
ORAL HAIRY LEUKOPLAKIA

• Asymptomatic
• Predictive of disease progression
• Affects the lateral border and ventral tongue,
• and buccal vestibule
• Can result from epithelial hyperplasia,
• secondary to a reactivation of latent EBV

• TREATMENT
• usually none
• occasionally antivirals

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VIRAL
HERPES SIMPLEX VIRUS
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VIRAL
HERPES SIMPLEX VIRUS

• Vesicles that coalesce into bullae and break
• Some report a tingling sensation
• Occur on fixed and keratinized tissue
• Painful
• May have systemic manifestations

• TREATMENT
• Antivirals
• Palliative support

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VIRAL
HUMAN PAPILLOMA VIRUS
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VIRAL
HUMAN PAPILLOMA VIRUS (HPV)

• Some begin as a smooth-surface papule
• Rough fingerlike projections
• Occur mainly on keratinized mucosa
• Tend to reoccur
• May interfere with eating and swallowing
• and may bleed
• Not painful
• Transmissible

• TREATMENT
• Excision

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BACTERIAL
PERIODONTAL DISEASE
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BACTERIAL
PERIODONTAL DISEASE

• Most common oral bacterial infection among
• HIV infected persons
• Contributing factors include poor diet, poor
• oral hygiene, and lack of saliva
• Mainly due to overgrowth of normal flora

• TREATMENT
• Deep scaling and root planning
• Good home care
• Antimicrobial rinses

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BACTERIAL
LINEAR GINGIVAL ERYTHEMA
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BACTERIAL
LINEAR GINGIVAL ERYTHEMA (LGE)

• Inflammation
• Spontaneous bleeding
• Not always painful
• May occur without the presence of plaque
• Microbiologic profile of gingival fluids is
• same as for Periodontal Disease
• Early manifestation of HIV

• TREATMENT
• Periodontal scaling
• Peridex

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ULCERATIVE
APTHOUS ULCER
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ULCERATIVE
APTHOUS ULCER

• Crater type sore on mucous membrane
• Pus formation
• Painful
• Interference with speech and swallowing
• Stress, Acidic Foods, Trauma, and Medication
• CMV (Cytomegalovirus) are clinically identical

• TREATMENT
• Topical steroids mixed with
• Orabase

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BACTERIAL
NECROTIZING ULCERATIVE PERIODONTITIS (NUP)
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NEOPLASM
KAPOSIS SARCOMA (KS)
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NEOPLASM
KAPOSIS SARCOMA (KS)

• Lesions begin flat and painless and can
• progress to painful papules and nodules
• It is mainly seen in men with AIDS
• Recent studies indicate that it may be caused
• by a sexually transmitted herpes virus-HHV
  8

• TREATMENT
• Radiation therapy
• Chemotherapy
• Immuno-modulator drugs

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NEOPLASM
NON-HODGKINS LYMPHOMA
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NEOPLASM
NON-HOGKINS LYMPHOMA

• Second most common malignancy in AIDS
• Tumors present intraorally as soft tissue
• masses
• Grows faster and spreads outside the lymph
• system in those with AIDS

• TREATMENT
• Radiation therapy
• Chemotherapy
• Immuno-modulator drugs

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WHAT HAVE WE SEEN SINCE THE ADVENT OF HAART?
WHAT DOES THE RESEARCH SHOW?
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WHAT ADVERSE EFFECTS OF HAART ARE WE SEEING IN
THE ORAL CAVITY?

• Salivary Hypofunction
• Increase in Salivary Gland Disease
• Increase of Oral Warts (HPV) for those on a
  Protease
• Inhibitor
• Decrease in Oral Candidiasis

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SALIVARY GLAND HYPOFUNCTION

• HAART and other medications
• Results in overgrowth of organisms in the mouth
• Periodontal disease and root caries
• Difficulty swallowing and loss of ability to
  taste food
• Difficulty wearing denture with lack of
  retention
• and tissue injury

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SALIVARY HYPOFUNCTION
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SALIVARY GLAND ENLARGEMENT
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SALIVARY GLAND DISEASE IN WOMEN

• WOMENS INTERAGENCY LONGITUDINAL HIV STUDY
  (WIHS)
• Multicenter Project funded by the NIH
• 486 HIV and 122 HIV- Women At-Risk
• Longitudinal study 9th Consecutive Year
  (1993-present)
• Documents the Natural History of Oral Findings
  in the
• HIV Women over time
• Studies disease progression, due to treatment
  and behavior
• Noted an overall increase in SGD

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Mulligan, R. et.al 2001 IADR
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Mulligan, R.. et. al. 2002 IADR
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A Retrospective Study Effects of HAART on
frequency of oral warts

• 1280 HIV Patients were seen between July 1990
  
• and June 1999 in a UCSF AIDS Clinic
• Evaluated oral lesions in patients who were on
  either
• HAART or ART (without PI) therapy
• Changes in prevalence were observed

Greenpan, D et.al. The Lancet Vol 357 May 5, 2001
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CHANGE IN PREVALENCE OF ORAL LESIONS
Greenspan, D et. al. The Lancet Vol 357 May 5,
2001
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ORAL LESIONS AND USE OF ANTIRETROVIRAL THERAPY
Greenspan, D et al The Lancet Vol 357 May 5,
2001
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WHAT DO WE NEED?
MORE PROSPECTIVE RESEARCH IN THIS AREA
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WHAT HAVE WE SEEN?

• Oral lesions are important indicators
• for HIV diagnosis and disease progression
• HAART has changed the prevalence of
• specific types of lesions
• The oral cavity can be a window to overall
• health

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QUESTIONS OR COMMENTS?