Part II: Diagnosis, Treatment and Prevention of Common Oral Manifestations

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• Part II Diagnosis, Treatment and Prevention of
  Common Oral Manifestations
• Mona Van Kanegan DDS, MS
• 1.17.04

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Non-HIV Associated Dental Diseases

• Common dental diseases- of teeth and supporting
  periodontal structures
• Compromise oral health/function/esthetics
• Compromise general health
• everybody gets them

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But in the HIV infected person

• Who is under constant immune system pressure
• Increase risk of opportunitistic oral infections
• Increased risk for HIV disease progression

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So we as oral health professionals need to

• Promote and support optimal oral health and
  provide dental care

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Diagnosis Of HIV Related Oral Lesions

• Oral examination procedures are the same for HIV
  patients as for all dental patients
• Diagnostic procedures must be appropriate to the
  identified problem
• Treatment should be based on either a provisional
  or definitive diagnosis
• Diagnosis should be re-evaluated if treatment is
  not effective

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Oral Manifestations Of HIV Infection

• Opportunistic diseases--manifestations of immune
  deficiency or derangement.
• Not caused directly by HIV.
• The same lesions occur in association with other
  immune deficiency disorders.

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Basic principle of health care ethics and
professional behaviors

• all dentists are obligated to provide care to
  patients who se it if the indicated treatment is
  within the scope of their practice.

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Diagnosis Management of Oral Lesions

• Clinical appearance and symptoms
• Non-specific, atypical
• Incidence may indicate disease progression
• Require careful diagnostic techniques
• Lab tests for Viruses, fungi, bacterial
• Biopsy of lesions

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Treating Oral Lesions

• Require aggressive treatments
• slow to respond
• Relapse/recurrence is common
• resistance
• Provide palliative care to minimize poor
  nutrition
• Address nutritional deficiencies that contribute
  to lesions

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Oral signs of nutritional deficiencies

• Xerostomia vit A, B12
• Bleeding Gingiva vit C vit K
• Angular Cheilitis iron, B vitamins
• Nutritional deficiencies decrease resistance of
  oral tissues to bacteria, fungus and increase
  inflammation

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Oral lesions and Eating

• Avoid carbonated beverages and salty or acidic
  foods,
• Drink apple juice, fruit nectars and milk,
• Choose soft moist foods such as mashed potatoes,
  pastas etc.,
• Use melted butter or gravy to soften foods,
• Drink water with meals

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Oral Lesions in HIV infection

• Fungal
• Candidiasis- Psuedomemebraneous, Erythematous,
  Chronic hyperplastic and Angular Cheilitis
• Invasive Fungal Infections
• Histoplasmosis, mucormycosis, Crytococcosis

• Viral
• Herpes Simplex virus
• Herpes Zoster virus
• Cytomegalovirus
• Epstein Barr Virus
• Human Papilloma virus
• Human Herpes Virus-8 KS

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Oral Lesions in HIV infection

• Bacterial
• Linear Gingival Erythema
• Necrotizing Ulcerative Gingivitis
• Necrotizing Ulcerative Periodontitis
• Mycobacterium avium complex
• Bacillary angiomatosis

• Neoplastic
• Kaposis sarcoma
• Lymphoma
• Squamous Cell carcinoma

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Oral Lesions in HIV infection

• Other
• Aphthous Ulcerations
• HIV associated salivary gland disease
• Immune thrombocytopenic purpura
• Abnormal mucosal pigmentation
• Fibroma

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Low Incidence Infections

• Viral
• Varicella-Zoster
• Cytomegalovirus
• Fungal
• Histoplasmosis
• Bacterial
• Tuberculosis
• Syphilis

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Factors that Predispose to Oral Lesions

• CD4 counts lt200 cells/mm3
• Viral load gt 3000 copies/mm3
• Xerostomia
• Poor oral Hygiene/nutrition
• Smoking

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CD4 Count Risk of Clinical Disease
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Fungal Disease

• Candidiasis- Primarily Candida albicans

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Oral Candidiasis

• Occurs in persons with poorly controlled
  diabetes, pregnancy, hormone imbalance, those
  receiving broad spectrum antibiotics, long term
  steroid treatment, cancer therapy and other
  immunocompromised individuals
• Oral lesions may be erythematous,
  pseudomembranous, hyperplastic or angular
  cheilitis

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Oral Candidiasis / Thrush
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Oral Candidiasis / Thrush
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Oral Candidiasis / Chronic
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Oral Candidiasis / Chronic
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Oral Candidiasis / Erythematous
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Oral Candidiasis / Angular Cheilitis
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Invasive Fungal Infections
Histoplasmosis
Mucormycosis
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Candidiasis- Treatment

• Mild to Moderate- Topical Therapies
• Nystatin (suspension 100KU/mL, or 1 cream),
  Clotrimazole (troche, 10mg)
• Moderate to Sever- Systemic Therapies
• Fluconazole (100mg/day), Itraconzole (oral
  suspension 10mg/mL)

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Candidiasis Treatment

• Topical therapy with nystatin or clotrimazole is
  effective. Treatment length is usually 10-14
  days, follow up
• Clotrimazole 10mg, 1 tab 5x/day, dissolve slowly
  and swallow, 10 day treatment
• Systemic treatment with fluconazole 100 mg/day
  for 10 days for oropharyngeal/esophageal disease,
  follow up

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Viral Diseases

• Herpes Simplex ulceration
• Herpes Zoster ulceration
• Cytomegalovirus ulceration
• Epstein Barr Virus
• Human Papillomatous growth
• Human Herpes Virus-8 KS

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Herpes Simplex Ulceration

• 10 or recurrent- one or more small lesions
  usually on keratinized mucosa - hard palate,
  gingiva but may also be on vermilion border of
  lips and adjacent facial skin
• Begins as painful multiple lesions and may
  coalesce to large, erosive ulceration
• Treat with oral acyclovir for 10-14 days, follow
  up, other agents-famciclovir, valacyclorvir

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Oral Herpes Simplex
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Oral Herpes Simplex
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Oral Herpes Simplex
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Oral Herpes Simplex
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Varicella Zoster Virus

• Recurrent VZV infectionHerpes zoster
• Vesicular/ulcerative lesions
• Follow dermatome of trigeminal nerve
• Severe neuritic pain
• Post-herpetic neuralgia
• Treatment acyclovir, valacyclovir

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Varicella Zoster Virus
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Cytomegalovirus Ulceration

• Usually in severely immunocompromised
  individuals, CD4lt50
• Painful ulceration on any mucosal surface with
  nonindurated borders

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Cytomegalovirus Ulceration Cont.

• Biopsy lesion to confirm diagnosis
• Inform medical doctor, ophthalmologic
  consultation to rule out CMV retinitis
• Treatment - oral or IV gangciclovir, foscarnet,
  follow up in 1 week

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Cytomegalovirus Ulceration
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Hairy Leukoplakia

• Bilateral symmetrical white corrugated lesions
  on the lateral borders of the tongue as a result
  of reactivation of EBV
• Usually asymptomatic, requires no treatment but
  podophyllum resin peels may be used
• DD - tobacco associated leukoplakia, lichen
  planus, epithelial dysplasia, hyperplastic
  candidiasis

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Oral Hairy Leukoplakia
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Oral Hairy Leukoplakia
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Oral Human Papilloma Virus Infection

• Exophytic papillary lesions with a
  cauliflower-like surface to raised, flat, smooth
  lesion, solitary or multiple
• Treatment
• Cryotherapy
• CO2 laser ablation
• Interferon-alpha

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Oral Papilloma
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Oral Papilloma
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Kaposis sarcoma

• Reddish, purple flat or raised lesion usually on
  gingiva or hard palate. DD-hemangioma,
  hemorrhage. Biopsy shows neoplastic proliferation
  of endothelial cells
• Inform patients medical provider to rule out KS
  in other locations

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Oral Kaposi sarcoma
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Oral Kaposi sarcoma
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Oral Kaposi sarcoma
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Kaposis sarcoma Treatment

• Treatment - intra-lesional injection with
  vinblastin (1x/week, 3-4 weeks), surgical
  excision, or radiation therapy, or both. Follow
  up every 4 weeks for 3 months

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Bacterial Diseases

• Linear Gingival Erythema
• Necrotizing Ulcerative Gingivitis
• Necrotizing Ulcerative Peridontitis

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Linear Gingival Erythema

• Linear Gingival Erythema - profound erythema of
  the free gingival margin without attachment loss
• Possible precursor of necrotizing ulcerative
  conditions
• Minimal plaque deposits
• Spontanteous hemorrhage
• Responds poorly to treatment, usually
  asymptomatic
• May be associated with Candida albicans

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Management of Linear Gingival Erythema

• Treatment - plaque removal and reinforce good
  oral hygiene
• Topical and/or subgingival irrigation with
  chlorhexadine, Povidine Iodine10 or Listerine
  Anaseptic
• Perscribe daily antimicrobial mouth rinse
• Recommendation for tobacco cessation
• Re-evaluate 2 weeks

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Management of Linear Gingival Erythema

• Treatment For unresponsive lesions, consider
  anti fungal agent
• Select narrow spectrum antibiotics sparing
  Gram-positive organisms may be beneficial
• Metronidazole 250 mg RID 7-10 days, Clindamycin,
  Augmentin
• Consider other possible lesions- lymphoma and
  refer for appropriate diagnostic testing(biopsy)
• Meticulous oral hygiene and frequent recalls

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Linear Gingival Erythema
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Periodontal Diseases

• Chronic periodotitis modified by
  immunosuppression
• HIV necrotizing ulcerative gingivitis- severe
  localized forms
• HIV necrotizing ulcerative periodontits- severe
  localized forms
• HIV stomatitis

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Chronic periodontitis

• Not clear whether HIV patients develop a more
  progressive form on conventional periodontitis
• Rate may be dependant of immunologigical
  competency of the host as well as local
  inflammatory response

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HIV necrotizing ulcerative gingivitis

• HIV Necrotizing Gingivitis- erythema with
  ulceration and loss of interdental papillae,
  rapid progression and extension possible
• Treatment - aggressive plaque removal,
  debridement, and reinforce good oral hygiene,
  follow up in 1 week, frequent recalls,
  chlorhexadine

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Management of necrotizing ulcerative gingivitis

• Treatment Local debridement, scaling and root
  planning and topical and/or sub gingival
  irrigation with chlorhexadine, povidine
  Iodine10(provides some analgesic properties)
• Prescribe daily anti-microbial mouth rinse
  chlorhexadine or Listerine
• Recommendation for tobacco cessation
• Re-evaluate 7-10 weeks, repeat scaling and
  debridement as necessary

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Management of necrotizing ulcerative gingivitis

• Metronidazole 250 mg RID 7-10 days
• Consider use of antifungal agents
• Reevaluation 1 month following resolution of
  acute symptoms

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HIV Necrotizing ulcerative Gingivitis
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HIV Necrotizing ulcerative Gingivitis
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Necrotizing ulcerative periodontitis

• HIV Necrotizing Periodontitis - erythema,
  spontaneous bleeding necrotic tissue soft and
  hard, cratering, halitosis, severe deep pain, and
  loose teeth rapid periodontal destruction.
• Prevalence 1-88 (Holmstrup et al., 2002
• One large study found a rate of 6.3 (Glick et
  al., 1994)

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Management of Necrotizing ulcerative periodontitis

• Treatment Local debridement, scaling and root
  planning and topical and/or sub gingival
  irrigation with chlorhexadine, povidine
  Iodine10(provides some analgesic properties),
  stop smoking
• Frequent follow up for 7-10 days, repeat scaling
  and debridement as necessary

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Management of Necrotizing ulcerative periodontitis

• Prescribe daily anti-microbial mouth rinse
  chlorhexadine or Listerine
• Metronidazole 250 mg RID 7-10 days, consider use
  of antifungal agents
• Re evaluation 1 month following resolution of
  acute symptoms
• 3 month recall, possible extraction of teeth
• History of NUP predisposes to necrotizing
  ulcerative stomatitis

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HIV Necrotizing ulcerative Periodontitis
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HIV Necrotizing ulcerative Periodontitis
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HIV Necrotizing ulcerative Periodontitis
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Bacillary (epthelioid) angiomatosis

• Bacterial infection
• Bartonella henselae
• Bartonella quintana
• Rochalimaea henselae
• Treatment
• Erythromycin 500 mg qid or
• Azithromax 500 mg q day x 3-4 weeks

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Bacillary (epthelioid) angiomatosis-gt

• Bacterial infection Bartonella henselae,
• Bartonella
  quintana,
• Rochalimaea henselae
• Treatment
• Erythomycin 500 mg qid or
• Azithromax 500 mg q day x 3-4 weeks

?Periodontal Abscess
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Neoplastic Diseases

• Kaposis Sarcoma
• Non-Hodgekins Lymphoma
• Squamous Cell Carcinoma

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Non-Hodgekins Lymphoma

• rapidly enlarging necrotic soft tissue mass that
  is red and inflamed, painful, may be ulcerated
• Diagnosis biopsy, histogical evaluation
• Inform medical provider to coordinate treatment
• Treatment - systemic combination of chemotherapy,
  radiation and excision

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Lymphoma
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Non-Hodgkins Lymphoma
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Other Diseases

• Aphthous Ulcerations
• HIV associated salivary gland disease
• Immune thrombocytopenic purpura
• Abnormal mucosal pigmentation
• Fibroma

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Salivary Gland Disease

• Bilateral parotid gland enlargement resulting in
  xerostomia, increased frequency with HAART
• Xerostomia 29 of HIV patients
• HIV realated salivary gland disease
• Side effects of medications
• May result in rampent caries
• Poor nutrition

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Salivary Gland Disease
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Salivary Gland Involvement
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Xerostomia

• Minimize use of alcohol and alcohol based
  mouthwashes, use of saliva substitutes
• Increase consumption of water, sugarless chewing
  gums, xylitol based gums, pilocarpine
• At home use of flouridated pastes and gels
• Treat associated xerostomia with pilocarpine (5mg
  TID), sugarless chewing gum, sugarless lemon
  drops, topical fluorides and frequent dental
  cleanings

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Management of Xerostomia

• Replacement or stimulation of salivary flow
• Secretory stimulants
• 1. Pilocarpine
• 2. Salagen
• 3. Bethanecol
• Salivary substitutes
• 1. Xerolube
• 2. Salivart
• 3. Unimist

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Root Decay
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Recurrent Decay, Root Decay
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Root Decay, Rampant Caries
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Root Decay, Major Apthous Ulcer
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Aphthous Ulceration- Minor

• Hormonal and medication (hydroxyurea and
  ddC/HIVID) induced
• Nonkeratinized mucosa, cheeks, lips, soft palate,
  floor of mouth, ventral tongue
• Less than 1cm, self-limiting, minor discomfort
• Treatment - application of topical steriod
  ointment and/or topical anesthetic, follow up

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Aphthous Ulcers of Primary HIV Infection
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Aphthous Ulcers - Minor
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Aphthous Ulcers - Minor
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Aphthous Ulceration- Major

• Hormonal and medication (hydroxyurea and
  ddC/HIVID) induced
• Nonkeratinized mucosa, cheeks, lips, soft palate,
  floor of mouth, ventral tongue
• Greater than 1cm, deep into connective tissue,
  dysphagia
• Treatment - short course of systemic steroid
  (prednisone, 80mg/day for 7 days)

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Aphthous Ulcer- Major
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Aphthous Ulcer- Major
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Aphthous Ulcer- Major
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Aphthous Ulcer- Major
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Aphthous Ulcer- Major
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Abnormal mucosal pigmentation

• Present in some darker skinned individuals
• As a result of AZT intake
• Rule out Kaposis sarcoma

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Oral Pigmentation

• AZT-induced pigmentation
• Rule-out Kaposis sarcoma

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Fibroma

• Traumatically induced overgrowth of underlying
  connective tissue
• May be calcified
• Treatment - complete surgical removal, follow up
  1-2 weeks for healing

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Fibroma
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Fibroma
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Principles of Ethics and Code of Professional
Conduct of the ADA

• Patient self governance
• Do no harm
• Do good
• Fairness
• Truthfulness

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Clinical resourcesPrinciples of Oral Health
Management for the HIV/AIDS Patientorder single
copies 1-888-275-4772 or www.ask.hrsa.gov,
publication code HAB00230
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Clinical resources

• hivdent.org
• New York State Department of Health AIDS
  Institute and John Hopkins University School of
  Medicine developed HIV Clinical Guidelines
  available at www.hivguidelines.org

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PEP Resources
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Other HIV Resources

• National Prevention Information Network
  800-458-5231
• National AIDS Clearinghouse
• P.O.Box 6003
• Rockville, Maryland 20849-6003
• 800-458-5231