Oral Manifestations of HIV

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

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Disclosure of Financial Relationships

• This speaker has no significant financial
  relationships with commercial entities to
  disclose.

This slide set has been peer-reviewed to ensure
that there are no conflicts of interest
represented in the presentation.
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Objectives

• Oral-Systemic Link
• Oral Manifestations of HIV
• Significance
• Identification
• Management

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Importance of Oral Health Oral Systemic
Connection

• Diabetes
• Heart Disease
• Pregnancy

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Importance of Oral Health in
HIV-infected

• Even more critical
• Enhanced susceptibility to all oral infections
• and neoplasms
• Impact on systemic health
• Impact on attitude and psychological health

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Oral Exams

• Performed when?
• By Whom?

Say Aaahh!
7

Resource HIV Oral Health Curriculum for
Nursing Professionals
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Mouth is a mirror
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Oral Health
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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
• Impact Q of L and attitude

CDC
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Spectrum 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)
• Histoplasmosa capsulatum (Histoplasmosis)
• Viral
• Oral hairy leukoplakia (Epstein-Barr virus)
• Herpes simplex virus (HSV)
• Herpes Zoster Shingles ( Varicella-zoster)
• Human Papilloma Virus (HPV)
• Cytomegalovirus (CMV)
• Periodontitis (NUP)
• Necrotizing periodontal disease

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Classification of Oral Conditions by Degree of
Immune Suppression (ODHIS)

• lt 500 CD4 count lt 200 CD4 count
• Erythematous candidiasis Hyperplastic
  candidiasis
• Oral Hairy Leukoplakia Major aphthous
  ulcers
• Hyposalivation Chronic HSV
• Linear gingival Necrotizing ulcerative
• erythema (LGE) periodontitis (NUP)
• Human papilloma Histoplasmosis
• virus (HPV)

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Erythematous Candidiasis
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Angular cheilitis
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Angular cheilitis
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Oral Hairy Leukoplakia (OHL)
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Oral Hairy Leukoplakia (OHL)
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OHL?
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Diagnosis?
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OHL?
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SCCA of base of tongue

• Dental referral to assess for extractions before
  radiation therapy
• Need 14 days healing time before RT

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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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Hyposalivation

• Inadequate saliva production - common
• HIV infection will alter quantity and quality of
  saliva, increasing susceptibility to dental decay
  and fungal infections.
• May occur early in the course of the disease

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Xerostomia Management

• Brush three times per day
• Use fluoride toothpaste
• Floss once per day
• Xylitol sweetened gum (If allowed)
• Minimize carbonated sugared beverages

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Meth Mouth?
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Extraction Considerations

• Incidence of alveolar osteitis dry socket is
  no greater among HIV infected
  than general population
• Patients with CD4 counts lt 100/mm3 should be
  evaluated for neutropenia
• Absolute neutrophil count lt 500/mm3 should
  receive antibiotics pre- and post- operatively

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Attempt Intraoral Drainage
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Discourage the application of hot compresses to
the skin overlaying the swelling
Extra-oral drainage leads to significant scarring

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Human Papilloma Virus (HPV)

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

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Human Papilloma Virus (HPV)
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Papillomavirus and Oropharyngeal Cancer

• Increased risk with
• High lifetime number of vaginal sex partners and
  oral-sex partners
• Assoc. with HPV 16 L1
• Increased association regardless of tobacco and
  alcohol use

D-Souza NEJM 20073561944-56
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Pseudomembranous Candidiasis

CDC
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Pseudomembranous Candidiasis

• Hard Palate Gingiva

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Candidiasis Treatment

• Topical (EC)
• Nystatin pastilles or swish
• Clotrimazole 10 mg (Mycelex)
• Systemic
• Fluconazole
• Intrconzaole
• Treat the dental appliance
• Order a new toothbrush

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Candidiasis plus OHL
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Hyperplastic Candidiasis

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

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Periodontal Disease

• Etiology
• Bacterial - Initiated by microbial dental plaque
• Disease behavior is dependent on host defenses

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Gingival inflammation from local factors
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Linear Gingival Erythema (LGE)

• Mild pain, Responds poorly to conventional
  treatment
• mild more
  advanced

Tx Peridex or PerioGard Rinses (chlorhexidine
gluconate 0.12)
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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
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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

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Assessment?
Fever, Lymphadenopathy, Purulence, Pain, and
Dehydration URGENT workup
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Intraoral Bleeding

• Ineffective Coagulation Urgent

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Herpes Simplex Virus (HSV)

• In HIV, reactivation clinically appearssimilar
  to primary herpes

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Herpes Simplex Virus (HSV)

• Vesicles may become ulcerated and coalesce to
  appear as large ulcers - rapidly

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Varicella-Zoster Virus (Shingles)

• Result of reactivation of latent Varicella-Zoster
  virus
• Painful clusters of vesicles usually localized
  to one neurodermatome
• Generally stops at midline

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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
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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), Apply qid
• Clobetasol 0.05 (Temovate) Apply bid ..very
  potent
• Systemic corticosteroid therapy
  for major or non-responsive lesions

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Histoplasmosis

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

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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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Chronic non-healing ulcerSquamous cell CA
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SCCA of base of tongue

• Dental referral to assess for extractions before
  radiation therapy
• Need ? days before RT

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Nodules, Masses or Ulcers
Possible Non-Hodgkins Lymphoma

• Mouth may be initial site
• Palate and gingiva most common location, but
  could be anywhere
• Appear as nodules, growths, painful mass or
  non-specific ulcer

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Kaposis Sarcoma

• Early lesions

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Kaposis Sarcoma palate
CDC
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Predictive Value of Oral Lesions

• lt 200 CD4 cells/mm3
• Viral load gt 20,000 copies/ml
• Nicolatou-Galitis O, Velegraki A, Paikos S,
  Economopoulou P, Stefaniotis T, Papanikolaou IS,
  Kordossis T. Oral Dis 2004 10(3)145-50.

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Summary

• Oral health is an integral component of systemic
  health
• A decline in oral health may reflect a decline in
  overall health

• Website www.FAETC.org

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Thank You!!

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

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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.