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

Oral Manifestations in HIV+ Individuals Arlita Jefferson, RN/BSN MPH Candidate ASPH Intern Picture courtesy of www.greenlanesdental.co.uk

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 Viral Bacterial Other www.humanillness.com www.ivis.org

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) Also Known as PC

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. Topical – nystatin, clotrimazole Systemic – fluconazole Therapy should last for 2 weeks to reduce the colony forming units to the lowest level possible to prevent recurrence (2)

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) Also known as EC

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 EC (2) Can occur with or without the presence of PC or EC Image courtesy of: www.mycology.adelaide.edu.au

Angular cheilitis cont. 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

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) Treatment (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) KS in an HIV-infected patient is diagnostic for AIDS and is indicative of severe immunosuppression (1) Frequently missed in AA due to lesion coloration (2)

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 ulcers (3) Image courtesy of HIVdent

Picture courtesy of HIVdent – Dr. David Reznik, D.D.S. 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) Can be a marker for disease progression and immunosuppression

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) Oral hairy leukoplakia can be a marker for disease progression and immunosuppression For patients on antiretroviral drugs, this may indicate the medication regimen is not effective

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 May be confused with aphthous ulcers, NUP, and lymphoma 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

Image courtesy of HIVdent HPV cont. May be cauliflower-like, spiked, or raised with a flat surface (2) Diagnosis Biopsy Treatment (2) Surgical removal Laser surgery Cryotherapy Warts tend to recur after treatment (2) 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) Mostly associated with anterior teeth (2) Treatment: Debridement by a dental professional, oral rinses for 2 weeks, an improved home oral hygiene (2)

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

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) Very painful, especially when eating salty, spicy or acidic foods and beverages or hard, rough foods (2)

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 Major ulcers are associated with severe immunosuppression Palliative therapy includes analgesic mouth rinses and topical ointments Lesions should be re-evaluated after 1-2 months of treatment (1)

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) Usually nontender Can be unilateral or bilateral (1) Picture courtesy of: www.baoms.org.uk

Xerostomia cont. Other Factors Treatment (1,3) 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) Surgery only for cosmetic reasons (1) 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 Antianxiety Courtesy of: www.hopkins-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

Yes, there is a relationship between oral health and HIV. 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 www.massleague.org

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; 11:434-44. Accessed 8/21/06 www.medscape.com/viewarticle/417818_print Reznik, D. Oral Manifestations of HIV disease. Perspective. December 2005/January 2006; 13:143-48. 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?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/

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