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14th Annual HIV Conference

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Oral hairy leukoplakia (Epstein-Barr virus) Herpes simplex virus (HSV) ... Oral Hairy Leukoplakia (OHL) White lesion, usually present on lateral borders of tongue, ... – PowerPoint PPT presentation

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Title: 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)

9
Predictive Value of Oral Lesions
  • Viral load 20,000 copies/ml

10
Fungal Diseases
  • Candidiasis
  • Histoplasmosis

11
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


18
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)

21
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.
27
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

28
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

29
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)

30
Linear Gingival Erythema (LGE)
  • Profound red band along gingiva where tissue
    meets the teeth
  • Mild pain, Responds poorly to conventional
    treatment
  • mild more
    advanced

31
Necrotizing Ulcerative Periodontitis (NUP)
  • Marker of severe immune suppression
  • VERY painful,deep jaw pain
  • Exacerbated by tobacco xerostomia

32
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)
34
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.
38
HIV related Soft Tissue Concerns
  • Ulcers
  • Malignancies

39
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

47
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

51
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

53
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

54
Summary
  • Good oral health will help maintain
  • Systemic health
  • Quality of life
  • Website www.FAETC.org

55
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.

57
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.
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