Oral Health and HIV? Is there a relationship between oral health and human immuno- deficiency virus (HIV)? Oral Manifestations in HIV+ Individuals Picture courtesy of www.greenlanesdental.co.uk Arlita Jefferson, RN/BSN MPH Candidate ASPH Intern Oral manifestations are often the first clinical feature of HIV infection (1) 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. 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. Oral Manifestations observed in HIV+ Individuals • Fungal • Neoplastic www.humanillness.com • Viral • Bacterial www.ivis.org • Other 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 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 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) Pseudomembraneous Candidiasis cont. • Diagnosis – Based on clinical appearance (2), taking into consideration the person’s 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. 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) 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 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) Hyperplastic Candidiasis cont. • Diagnosis – Differential diagnosis can include oral hairy leukoplakia (1) • Treatment – Same with all candidiasis 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 Image courtesy of: www.mycology.adelaide.edu.au EC (2) Angular cheilitis cont. • Diagnosis – Clinical appearance • Treatment (2) – Use of topical antifungal cream or www. ointment directly applied to the affected area 4x a day for 2 weeks – Can exist for a long time if left untreated Image courtesy of: www.windrug.com Neoplastic Oral Manifestations • There are two (2) types of neoplasms associated with oral manifestations in HIV individuals – Kaposi’s Sarcoma (KS) – Non-Hodgkin’s Lymphoma Kaposi’s 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) Kaposi’s Sarcoma cont. • 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) Non-Hodgkin’s 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 Non-Hodgkin’s Lymphoma cont. • Diagnosis – Biopsy (3) • Treatment – Refer to an oncologist (3) Picture courtesy of HIVdent: Dr. David Reznik, D.D.S. Viral Manifestations • Herpes Simplex Virus (HSV) lesions • Herpes Zoster • Oral Hairy Leukoplakia • Cytomegalovirus (CMV) ulcers • Human Papillomavirus (HPV) lesions 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) Herpes Simplex ulcer cont. • Diagnosis – Clinical appearance • Treatment – Self-limiting (2) – Acyclovir (1) 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 Image courtesy of HIVdent ulcers (3) Herpes Zoster cont. • 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. 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) 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) 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 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 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 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) 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) 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) 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 Tuberculosis • Oral lesions in people with tuberculosis are seen rarely. • They have been reported as ulcers on the tongue secondary to pulmonary tuberculosis. Other Oral Manifestations • Aphthous Ulcerations (canker sores) – Minor – Major • Salivary Gland Disease • Xerostomia 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) 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 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 Picture courtesy of: www.baoms.org.uk glands (3) • removal not recommended (3) 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/drymouth 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 Courtesy of: www.hopkins- – Antianxiety arthritis.som.jhmi.edu/other/oral... 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 Conclusion cont. www.massleague.org • 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 References 1. 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; 11:434-44. Accessed 8/21/06 www.medscape.com/viewarticle/417818_print 2. Reznik, D. Oral Manifestations of HIV disease. Perspective. December 2005/January 2006; 13:143- 48. Accessed 7/19/06 www.hivdent.org 3. Greenspan, D. Oral Manifestations of HIV. HIV InSite Knowledge Base Chapter. 1998. Accessed 7/20/06 www.hivinsite.ucsf.edu/InSite?page=kb-04-01-14 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/ Responses or ????Questions????