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Oral Lesions of HIV in the Era of HAART

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Most common location: buccal mucosa along the occlusal line in the commissure, ... Oral lesions occur in nonkeratinized mucosa of lips, floor of the mouth, lateral ... – PowerPoint PPT presentation

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Title: Oral Lesions of HIV in the Era of HAART


1
Oral Lesions of HIV in the Era of HAART

Roseann Mulligan DDS, MS USC School of Dentistry
and the Pacific AIDS Education and Training
Center
2
Impact of Oral Conditions HIV Patients
  • High rate of oral manifestations
  • Oral lesions may be harbinger of change in HIV
    condition
  • Relative ease of access to identification of
    lesions by those in clinical practices
  • Potential impact on systemic health care outcomes
  • Potential impact on quality of life
  • Adapted from Sifri R, Diaz V, Gordon L, Glick M,
    Anapol H. et al. Oral health care issues in HIV
    disease developing a core curriculum for primary
    care physicians. J Am Board Fam Pract 1998
    11(6)434-44

3
High rate of oral manifestations
  • More than 90 of patients have at least one oral
    lesion during their disease course. 1
  • Are almost always accompanied by symptoms
  • Take a variety of appearances that are for the
    most part characteristic
  • 1 New York State Dept of Health AIDS Institute's
    Best Practices. Promoting oral health care for
    people with HIV infection. January 2004.

4

Oral lesions Harbinger of ? HIV status
  • Often the first clinical feature of HIV infection
    is an oral lesion. 1
  • New lesions in HIV-infected patient - a sign that
    HIV disease is progressing.
  • Untreated HIV infected with oral candidiasis
    progress to AIDS within two years. 1
  • May indicate need for prophylaxis against
    specific opportunistic infections.
  • 1New York State Dept of Health AIDS Institute's
    Best Practices. Promoting oral health care for
    people with HIV infection. January 2004.

5
Medical history
  • 1. Questionnaires2. Patient observation3.
    Medical Interview
  • 4. Risk Assessment
  • 5. Head/Neck Exam6. Diagnostic tests

6
Normal Range Lab ValuesLymphocytes
Type of Lymphocyte Percentage of Total Lymphocytes
Total T, CD3 60- 87
Total T/ mm3 630 - 3170
B cell 1- 25
Suppressor, CD8 10- 40
Suppressor/ mm3 240 1200
Helper, CD4 30 - 55
Helper / mm3 600 1700
HS (CD4/CD8) 0.8 - 3.0
7
CD4 Status and Relationship to Outcomes
CD Description CD4 Count
30-55 Normal value gt600 cell/mm³
lt 29 Initial Immune Suppression lt500 cell/mm³
lt29 Manifestations of opportunistic infection including oral lesions lt400 cell/mm³
14 -18 Increase in number of opportunistic infections gt201-400 cell/mm³
lt14 Severe Immune Suppression (e.g. Apthous Major) lt200 cell/mm³ AIDS Dx
Continuing decreases Fatal opportunistic infection (e.g. CMV,MAC) lt100 cell/mm³
8
Platelets
  • Number of platelets in a drop (uL) of blood
  • Normal range 150,000-400,000/uL
  • Unsafe to do invasive dental tx lt60,000
  • Spontaneous bleeding lt50,000

9
Neutrophils
  • Normal range 3,000-7,000/ mm
  • Neutropenia lt1000/mm3
  • Severe neutropenia lt500/mm3
  • May require antibiotic prophylaxis before
  • invasive dental treatment

10
Oral Manifestations of HIV Infection
Infection Oral Disease
Fungal Candidiasis - Pseudomembranous, Erythematous, and Angular Cheilitis Invasive Fungal Infections - Histoplasmosis, Cryptococcosis
Viral Herpes Simplex Herpes Zoster Cytomegalovirus Hairy Leukoplakia (Epstein Barr Virus) Oral Warts (Human Papilloma Virus) Human Hominus Virus8 K.S.
Bacterial Linear Gingival Erythema Necrotizing Ulcerative Periodontitis Tuberculosis Mycobacterium avium complex Bacillary angiomatosis
http//www.aids-ed.org/ppt/nw_schubert_oralupdate_
03.ppt
11
Oral Manifestations of HIV Infection
Type of Lesion Oral Disease
Neoplastic Kaposis Sarcoma (KS) HHV-8 Lymphoma Squamous Cell Carcinoma
Other HIV- Necrotizing Ulceration HIV-Salivary Gland Disease/ Xerostomia Thrombocytopenic Purpura Abnormal Mucosal Pigmentation
http//www.aids-ed.org/ppt/nw_schubert_oralupdate_
03.ppt
12
Oral Candidiasis
  • Most Common often predicts HIV progression
  • Candida albicans is the most prevalent
  • 3 types pseudomembranous ª erythematous ª
    hyperplastic.

13
Oral Candidiasis
  • Pseudomembranous (Thrush) Characterized by the
    presence of white curds or creamy cotton like
    appearance
  • Can be easily removed. The underlying mucosa is
    erythematous and may bleed slightly.
  • Immunosuppresion

14
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15
Oral Candidiasis
  • Atrophic (Erythematous)
  • In non-immunosuppressed
  • Associated in patients w/ ill-fitting dentures or
    in those who wear their dentures continuously
  • Generalized red area of atrophic tissue, commonly
    on the palate
  • Burning sensation, palate, tongue
  • Culture, smear not very effective

16
Oral Candidiasis
  • In tongue loss of the filiform papilla, a
    generalized thinning of the epithelium, and
    excessive inflammation of the connective tissue
  • Median Rhomboid Glossitis

17
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18
Oral Candidiasis
  • Chronic Hyperplastic usually presents as a white
    mucosal plaque.
  • Most common location buccal mucosa along the
    occlusal line in the commissure, latero-dorsal
    surface of tongue and the alveolar ridges
  • Frequently term
  • candidal leukoplakia

19
Oral Candidiasis
  • Angular cheilitis

20
  • Perspective Oral Manifestations Volume 13 Issue
    5 December 2005/January 2006

21
Herpes Simplex
  • Recurrent herpes labialis lips dry mucosa or
    skin, fluid-filled vesicle, that rupture,
    ulcerate, and resolve as crusted brownish
    lesions.
  • Recurrent intraoral herpes maxillary gingiva,
    palate wet and fragile mucous membranes. Lesions
    are punctate with red or white bases that slowly
    disappear.

22
  • Epstein-Barr Virus (EBV)
  • Oral Hairy Leukoplakia
  • White, often corrugated in appearance,
    plaque-like or hair-like projections that are
    non- wipeable, lateral borders of tongue.
  • It appears in late latency stages HIV or
    precursor of AIDS.
  • Definitive Dx Histopathology

23
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24
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25
Epstein-Barr Virus (EBV) Oral Hairy Leukoplakia
  • Treatment
  • Treat for cosmetic reasons otherwise no
    treatment is warranted

26
Human Papilloma Virus (HPV)
  • HAART ? ?
  • Assoc. w/ 2.6 -6-fold ? incidence of oral warts
  • ? aphthous ulcers salivary gland dz?caries
  • Diz Dios P, Ocampo A, Miralles C. (2000)
    Patton LL, et al. (2000) Patton LL, (2003) .

27
Human Papilloma Virus (HPV)
  • In the oral cavity the most common are, squamous
    papilloma HPV 6 11 verruca vulgaris HPV 2-4
    and condyloma acuminatum HPV 6 11
  • Clinically may appear exophitic, keratinized,
    sessile papules or nodules cauliflower-like
    2-5mm

28
Human Papilloma Virus (HPV)
SP High incidence on the soft palate, faucial
pillars, uvula. VV Lips,hard palate and
gingiva?hands and fingers. CA Presents as a
pinkish, sessile papules or plaques w/ pebbled
surfaces. Oral lesions occur in nonkeratinized
mucosa of lips, floor of the mouth, lateral and
ventral surface of tongue, buccal mucosa and soft
palate
Photo ftom VI Meeks, DDS, U Md Dental School
29
Human Papilloma Virus (HPV)
  • Treatment indicated
  • (1) Lesion may become traumatized
  • (2) In area that may lead to auto-inoculation
  • (3) For cosmetic reasons

30
Human Papilloma Virus (HPV)
  • Treatment
  • Cryotherapy laser or surgical excision.
  • Lesions often recur

31
Human Papilloma Virus (HPV)
  • Vaccine was approved last June by the FDA
  • Women 9-26 yrs (prefer 11-12 yrs old)
  • 70 cervical cancers HPV 16,18,31,45
  • Vaccine 6, 11, 16, 18
  • HPV 16 related to 25 of oral cancer.
  • 300-500 total for 3 dose series

32
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33
Necrotizing Ulcerative Periodontitis NUP
  • Extensive soft tissue necrosis exposing alveolar
    bone
  • Severe pain, odor and spontaneous bleeding
  • Compare appearance to aphthous ulcer on right

34
Necrotizing Ulcerative Periodontitis (NUP)
35
Povidone Iodine /Chlorexidine
36
Salivary Gland Involvement
http//www.aids-ed.org/ppt/nw_schubert_oralupdate_
03.ppt
37
Salivary Gland Involvement
Table Absence of saliva on palpation of salivary
glands the WIHS
Mulligan R. et al. Salivary gland disease in
human immunodeficiency virus-positive women from
the WIHS study. Women's Interagency HIV Study.
Oral Surgery Oral Medicine Oral Pathology Oral
Radiology Endodontics. 89(6)702-9, 2000 Jun.
  • Medications (side effects) -gt xerostomia

38
Data from the Womens Interagency HIV Study
Greenspan D, Gange S, Phelan J, Navazesh M, Alves
M, MacPhail L, Mulligan R, Greenspan J. J Dent
Res 83(2)145-150, 2004
39
Prevalence of Oral Lesions During HIV Medication
Usage
Greenspan, D et al The Lancet Vol 357 May 5, 2001
40

In Summary
  • Oropharyngeal Candidiasis (OPC) improves or
    resolves with response to HAART
  • Oral lesions are fewer as a result of HAART
  • Cavities increase as a result of hyposalivary
    function due to meds
  • Warts seem to increase

41
Preventive Oral Health Care
  • Recalls every 3 to 6 months
  • Antimicrobial mouth rinses for patients with
    periodontal disease, including past history of
    NUP and LGE
  • Fluoride supplements

42
Thank You !!
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