Oral Health and HIV?

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Oral Health and HIV?

• Is there a relationship between oral health and
  human immuno-deficiency virus (HIV)?

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Oral Manifestations in HIV Individuals

• Arlita Jefferson, RN/BSN
• MPH Candidate
• ASPH Intern

Picture courtesy of www.greenlanesdental.co.uk
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Oral manifestations are often the first clinical
feature of HIV infection (1)
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Objectives

• Become familiar with some of the oral
  manifestations that may present in HIV positive
  individuals.
• List the five (5) categories of oral
  manifestations that may present in HIV
  individuals.
• List one (1) fungal oral manifestation that may
  present in HIV infected individuals.

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Objectives cont.

• List one (1) neoplastic manifestation that may
  present in HIV infected individuals.
• List one (1) viral oral manifestation that may
  present in HIV infected individuals.
• List one (1) bacterial oral manifestation that
  may present in HIV infected individuals.

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Oral Manifestations observed in HIV Individuals

• Fungal
• Neoplastic
• Viral
• Bacterial
• Other

www.humanillness.com
www.ivis.org
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Fungal Manifestations

• Candidiasis very common fungal manifestation
  that is seen in more than 95 of HIV infected
  persons during the course of their illness (1)
• Is seen in HIV and uninfected individuals
  alike. However, when dx in HIV individuals, it
  has been established as a precursor to AIDS
  within 1-2 years of its appearance (1)
• Frequency and type are usually indicative of
  disease progression

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Fungal Manifestations cont.

• Can manifest in 4 different ways (2,3)
• Pseudomembraneous candidiasis
• Erythematous candidiasis
• Hyperplastic candidiasis
• Angular chilitis

Picture courtesy of research.bidmc.harvard.edu
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Pseudomembraneous Candidiasis (thrush)

• Removable whitish plaque that can appear on any
  oral mucosal surface (1)
• When wiped away, it will leave a red or bleeding
  underlying surface (2)

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Pseudomembraneous Candidiasis cont.

• Diagnosis
• Based on clinical appearance (2), taking into
  consideration the persons medical hx (1)
• Treatment
• Based on the extent of the infection, topical
  therapies are utilized for mild to moderate cases
  and systemic therapies used for moderate to
  severe cases.

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Erythematous Candidiasis

• Smooth, red atrophic patches that can occur on
  the hard palate, buccal mucosa, or the tongue
  (1,2)
• Tends to be symptomatic with complaints of oral
  burning while eating salty or spicy foods or
  drinking acidic beverages (2)

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Erythematous Candidiasis cont.

• Diagnosis
• Can be based on clinical appearance (2),
  nutritional history, duration and stability of
  the lesion and treatment response (1)
• Treatment
• Same with all candidiasis

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Hyperplastic Candidiasis

• Nonremovable whitish plaques, sometimes
  associated with a burning sensation, that can be
  found on any mucosal surface (1)
• May be confused with hairy-leukoplakia (3)

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Hyperplastic Candidiasiscont.

• Diagnosis
• Differential diagnosis can include oral hairy
  leukoplakia (1)
• Treatment
• Same with all candidiasis

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Angular Cheilitis

• Fissures radiating from the corners of the mouth
  (3) that are sometimes covered with a removable
  white membrane
• Can be found in conjunction with xerostomia and
  occur with or without PC or EC (2)

Image courtesy of www.mycology.adelaide.edu.au
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Angular cheilitiscont.

• Diagnosis
• Clinical appearance
• Treatment (2)
• Use of topical antifungal cream or ointment
  directly applied to the affected area 4x a day
  for 2 weeks
• Can exist for a long time if left untreated

www.
Image courtesy of www.windrug.com
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Neoplastic Oral Manifestations

• There are two (2) types of neoplasms associated
  with oral manifestations in HIV individuals
• Kaposis Sarcoma (KS)
• Non-Hodgkins Lymphoma

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Kaposis Sarcoma

• Found most commonly in male (3) homosexual AIDS
  patients (1)
• May appear as macules, patches, nodules, or
  ulcerations that are purplish (3), bluish,
  brownish, or reddish in color (1)
• Can be found anywhere in the gastrointestinal
  tract commonly seen on the hard or soft palate
  and gums (1)

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Kaposis Sarcomacont.

• Diagnosis (1)
• Differential diagnosis can include non-Hodgkin
  lymphoma (ulcerative), bacillary angiomatosis,
  and physiologic pigmentation
• Definitive dx requires a biopsy (2)
• Treatment (1)
• radiation, intralesional chemotherapy, and
  surgery (less often)
• Good oral hygiene to minimize complications (3)

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Non-Hodgkins Lymphoma

• AIDS defining condition
• May appear as a large, ulcerated mass anywhere in
  the oral cavity (3)
• May or may not be painful (3)

Photo courtesy David I Rosenstein, DMD, MPH at
hab.hrsa.gov
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Non-Hodgkins Lymphoma cont.

• Diagnosis
• Biopsy (3)
• Treatment
• Refer to an oncologist (3)

Picture courtesy of HIVdent Dr. David Reznik,
D.D.S.
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Viral Manifestations

• Herpes Simplex Virus (HSV) lesions
• Herpes Zoster
• Oral Hairy Leukoplakia
• Cytomegalovirus (CMV) ulcers
• Human Papillomavirus (HPV) lesions

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Herpes Simplex ulcer

• Can occur intraorally, involving the oral mucosa,
  and periorally, involving the lips and skin (1)
• They can be painful, solitary or multiple, and
  vesicular and they might coalesce (1)

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Herpes Simplex ulcercont.

• Diagnosis
• Clinical appearance
• Treatment
• Self-limiting (2)
• Acyclovir (1)

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Herpes Zoster(Shingles)

• Caused by a reactivation of the varicella zoster
  virus (3)
• Occurs in the elderly and immunosuppressed (3)
• Following pain, vesicles appear on the facial
  skin, lips and oral mucosa (3)
• Frequently unilateral (3)
• Skin lesions form crusts and the oral lesions
  coalesce to form large ulcers (3)

Image courtesy of HIVdent
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Herpes Zostercont.

• Diagnosis
• Clinical appearance and the distribution of the
  lesions (3)
• Treatment
• Acyclovir limits the duration of the lesions
• To be taken 7-10 days (3)

Picture courtesy of HIVdent Dr. David Reznik,
D.D.S.
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Oral Hairy Leukoplakia

• Found most commonly in male homosexual patients
  but is not considered diagnostic for AIDS (1)
• Lesions associated with the Epstein-Barr virus
  (1,2)
• Becomes more common as the CD4 count decreases (3)

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Oral Hairy Leukoplakia cont.

• Whitish, nonremovable, vertically corrugated
  patches found on the lateral region of the tongue
  (1)
• Diagnosis based on clinical appearance and
  location (1)
• Definitive diagnosis is by a biopsy (1,3)
• Treatment is palliative only and not necessary
  unless lesion is symptomatic (1)

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Cytomegalovirus (CMV) ulcers

• Painful, with punched-out, nonindurated borders
  (1)
• Appear necrotic with a white halo (3)
• Diagnosis
• Biopsy (3)
• Treatment (1)
• acyclovir or ganciclovir

Combination of HSV and CMV Image courtesy of
HIVdent
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Human Papillomavirus (HPV) lesions

• HPV is associated with oral warts, papillomas,
  skin warts, and genital warts (3)
• May appear as solitary or multiple nodules (3)
• May appear as multiple, smooth-surfaced raised
  masses (3)

Picture courtesy of Dr. D. Reznik, D.D.S. Hivdent
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HPV cont.

• May be cauliflower-like, spiked, or raised with a
  flat surface (2)
• Diagnosis
• Biopsy
• Treatment (2)
• Surgical removal
• Laser surgery
• Cryotherapy

Image courtesy of HIVdent Dr. David Reznik, D.D.S
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Bacterial Manifestations

• Periodontal Disease
• Fairly common in asymptomatic and symptomatic HIV
  infected individuals (3)
• Presenting clinical features of the two (2) forms
  differ from those in individuals not infected
  with HIV
• Two forms
• Linear Gingival Erythema (LGE)
• Necrotizing Ulcerative Periodontitis (NUP)

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Linear Gingival Erythema(red-band gingivitis) (2)

• Occurs as a 2- to 3-mm erythematous band on the
  gingiva accompanied by mild pain and spontaneous
  bleeding (1,2)
• Responds poorly to conventional therapy (1)
• Might be a precursor to necrotizing ulcerative
  periodontitis (1,3)

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Necrotizing Ulcerative Periodonitis

• Rapidly progressive, causes extensive destruction
  an loss of bone and periodontal tissue, is
  painful, and may be accompanied by bleeding and
  halitosis (1,2,3)
• Distinguished from conventional periodontitis by
  its accelerated rate of progression and its
  deep-seated nongingival pain (1)

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Necrotizing Ulcerative Periodonitis cont.

• Associated with severe immune deterioration (1,2)
• Diagnosis
• History and clinical appearance (3)
• Biopsy needed to differentiate from other lesions
  such as non-Hodgkin lymphoma and cytomegalovirus
  infection
• Treatment (1)
• Antibiotics, mouth rinses, irrigation with
  povidone iodine, debridement, and mechanical
  cleaning (3)
• Frequent dental visits

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Tuberculosis

• Oral lesions in people with tuberculosis are seen
  rarely.
• They have been reported as ulcers on the tongue
  secondary to pulmonary tuberculosis.

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Other Oral Manifestations

• Aphthous Ulcerations (canker sores)
• Minor
• Major
• Salivary Gland Disease
• Xerostomia

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Aphthous Ulcerations (canker sores) minor

• 2 to 5 mm in diameter, covered by a
  pseudomembrane, and surrounded by an erythematous
  halo (1)
• No known cause for recurrent ulcers (2)
• stress, acidic foods, and tissue-barrier
  breakdown have been reported to precipitate their
  occurrence (1)

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Aphthous Ulcerations major

• Greater than 10 mm in diameter, painful, persist
  for months, and can cause impairment of speech
  and swallowing (1)
• Diagnosis (1)
• can be made clinically
• biopsy rules out other causes and is recommended
  for major ulcers and for those ulcers that do not
  improve
• Treatment (1)
• Palliative, oral and topical medications, rinses

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Salivary Gland Disease

• Salivary gland disease associated with HIV
  infection can present as xerostomia with or
  without salivary gland enlargement (3)
• Cause unknown (3)
• Soft enlargement of the salivary glands, usually
  involving the parotid glands (3)
• removal not recommended (3)

Picture courtesy of www.baoms.org.uk
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Xerostomia cont.

• Other Factors
• Salivary gland disease (SGD)
• smoking
• Treatment (1,3)
• Salivary stimulants
• Sugarless gum or candy
• Salivary substitutes
• Caries can occur so rinse w/fluoride daily and
  regular dentist visits (2-3 times per year)

Picture courtesy of www.periproducts.co.uk/drymout
h
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Xerostomia (dry mouth)

• Reduced salivary flow
• Major contributing factor in dental decay in HIV
  infected individuals (1,2)
• Many medications lead to xerostomia (1,2)
• DDI, Zidovudine, Foscarnet
• Antidepressants
• Antihistamines
• Antianxiety

Courtesy of www.hopkins-arthritis.som.jhmi.edu/ot
her/oral...
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Conclusion (s)
www.duke.edu

• Dental hygiene of HIV infected individuals is
  very important and should be included in the
  overall care plan of these individuals
• These individuals may need to visit a dentist
  more frequently than twice a year, especially if
  they present with any of the before mentioned
  lesions

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Conclusion cont.

• Yes, there is a relationship between oral health
  and HIV.
• Lesions or other manifestations in the mouth may
  be the initial indicator of a persons HIV status
  or it may indicate a further decrease or
  worsening of an infected individuals immune system

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References

• Sifri, R., Diaz, V., Gordon, L., and Glick, M. et
  al. Oral health care issues in HIV disease
  Developing a core curriculum for primary care
  physicians. J AM Board Fam Pract. 1998
  11434-44. Accessed 8/21/06 www.medscape.com/viewa
  rticle/417818_print
• Reznik, D. Oral Manifestations of HIV disease.
  Perspective. December 2005/January 2006
  13143-48. Accessed 7/19/06 www.hivdent.org
• Greenspan, D. Oral Manifestations of HIV. HIV
  InSite Knowledge Base Chapter. 1998. Accessed
  7/20/06 www.hivinsite.ucsf.edu/InSite?pagekb-04-0
  1-14

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More Information

• For more information on HIV and Oral health, you
  may visit the following websites
• www.hivdent.org
• www.hab.hrsa.gov
• www.hivguidelines.org
• www.health.state.ny.us/nysdoh/aids/index.htm
• http//hiv.bg/tannheilsahiv.english.htm
• http//www.who.int/oral_health/en/

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Responses or????Questions????