5/8/2018

Pathology and Management of Periodontal Problems in Patients with HIV Infection شایع ترین عوارض این عفونت ویروسی در داخل حفره دهان کدام است؟ وضعیت انساج پریودنتال در این بیماران چگونه است؟ آیا طرح درمان ما در این بیماران تفاوتی با افراد سالم دارد؟ به جز آن چه در کتاب مرجع به آن اشاره شده است, چه یافته علمی جدیدی در دسترس است؟ 5/8/2018

ORAL AND PERIODONTAL MANIFESTATIONS Oral Candidiasis Oral Hairy Leukoplakia Kaposi's Sarcoma and Other Malignancies Bacillary (Epithelioid) Angiomatosis Oral Hyperpigmentation Atypical Ulcers GINGIVAL AND PERIODONTAL DISEASES Linear Gingival Erythema Necrotizing Ulcerative Gingivitis Necrotizing Ulcerative Periodontitis Necrotizing Ulcerative Stomatitis Chronic Periodontitis PERIODONTAL TREATMENT PROTOCOL Health Status Infection Control Measures Goals of Therapy Maintenance Therapy 5/8/2018

HIV infected patients In humans, HIV depletes CD4+ lymphocytes (T helper cells) which leads to the development of a variety of fungal, viral, and bacterial oral infections. Oral manifestations of HIV infection have been used to stage HIV disease ,identify prophylactic treatment of other serious infections and indicate disease prognosis. HAART: highly active antiretroviral therapy Increase CD4+ cell count Decrease HIV RNA Extends AIDS free survival Decrease inflammation Activates immune system Higher rates of CVDs Toxic side effects 5/8/2018

Oral and Periodontal diseases strongly associated with HIV infection Seven cardinal oral lesions: Oral Candidiasis OHL: oral hairy leukoplakia KS: kaposi sarcoma Non-Hodgkin lymphoma LGE: linear gingivitis erythema NUG: necrotizing ulcerative gingivitis NUP: necrotizing ulcerative periodontitis 5/8/2018

Candidiasis Oral candidiasis: 39.3% erythematous candidiasis: 39.3% The mean CD4 count of patients with oral lesions (207 cells/mm(3)) without oral lesions (291 cells/mm(3)) . Oral candidiasis was found to be significantly correlated to a reduced CD4 cell count below 200 cells/mm. 5/8/2018 J Oral Sci. 2011 Jun;53(2):203-11

Oral Hairy Leukoplakia 5/8/2018

Kaposi Sarcoma 5/8/2018

Non-Hodgkin Lymphoma 5/8/2018

Abnormal Herpetic Lesions 5/8/2018

Aphthous Ulcer 5/8/2018

Periodontal diseases strongly associated with HIV infection Seven cardinal oral lesions: Oral Candidiasis OHL: oral hairy leukoplakia KS: kaposi sarcoma Non-Hodgkin lymphoma LGE: linear gingivitis erythema NUG: necrotizing ulcerative gingivitis NUP: necrotizing ulcerative periodontitis 5/8/2018

Prevalence of periodontal diseases Age Immune system competence Smoking Oral hygiene level A significant decrease of the overall prevalence of oral lesions from 47-85% to 32-46% before and after introduction of HAART 5/8/2018

LGE formerly known as HIV associated gingivitis A 2-3 mm marginal band of intense erythema in the free gingiva (Winkler et al. 1988). it is more commonly a generalized gingival condition. Relationship of periodontal pathogens and the local host response. does not respond to conventional scaling, root planing, and plaque control, Candida species have been identified with LGE. Reduced proportions of T cells and macrophages and an increased number of IgG plasma cells and PMNs. With the advent of antiretroviral therapy for HIV positive patients, the prevalence of HlV-specific lesions has been dramatically reduced; even so, plaque accumulation with reduced CD4+ counts will still account for a pronounced gingival inflammatory response.(9-50%) 5/8/2018

NPD The disease seems to occur slightly more often among HlV-infected individuals. prevalences of NPD between 0% and 27.7%. However, most studies have included cohorts of individuals connected with hospitals or dental clinics. NP was found in 1% of 200 HlV-seropositive individuals in Washington, DC, this is particularly true after introduction of antiretroviral therapy (Tappuni & Flemming 2001). The clinical signs of NG/NP are similar in HIV-seropositive and -seronegative patients, and are not related to CD4+ T-cell count, to neutrophil count, to gender, or to age. AIDS Res Treat. 2011;2011:638584. Epub 2011 Jun 21. 5/8/2018

NUP 5/8/2018

NUS 5/8/2018

Healthy periodontium is not surprising in well controlled HIV infected patients Of the 54 samples cultured from HIV-positive patients, 44 (82%) were positive for yeast species, 19 (48%) patients were positive for Candida dubliniensis, This study reports for the first time the recovery of C. dubliniensis from subgingival intraoral sites and confirms the presence of Candida species in sites of periodontal disease associated with HIV. J Clin Microbiol. 2001 Dec;39(12):4520-2. 5/8/2018

Treatment Strategy HIV-infected subjects without HAART showed greater risks of having orofacial pain, oral dryness, oral lesions, and periodontal pockets than those with short-term HAART (P < 0.01). The subjects with long-term HAART have a greater risk of having oral lesions than those with short-term HAART (P < 0.05). long-term HAART has adverse effects on oral health status of HIV-infected subjects. 5/8/2018 J Oral Pathol Med. 2010 May;39(5):397-406.

Treatment Strategy Chronic gingivitis (43.8%) was the most frequent in all subjects. A clear improvement in gingival health was registered in 78.2% of subjects after six months of mechanical therapy. No association was registered between CD4 count and gingival/periodontal status or attachment loss with HIV staging. CONCLUSIONS: Oral hygiene using mechanical therapy improves the gingival condition, suggesting that it is an important step in the maintenance of periodontal health. 5/8/2018 Med Oral Patol Oral Cir Bucal. 2010 Mar 1;15(2):e417-21.

Treatment Strategy IRIS hypothesis: P. gingivalis could induce HIV-1 reactivation via chromatin modification and that butyric acid, one of the bacterial metabolites, is responsible for this effect. These results suggest that periodontal diseases could act as a risk factor for HIV-1 reactivation in infected individuals and might contribute to the systemic dissemination of the virus. IRIS hypothesis: immune reconstitution inflammatory syndrome Gaitan Cepeda 2008 5/8/2018 J Immunol. 2009 Mar 15;182(6):3688-95.

چگونه می توان از بروز فراوان بیماری های پریودنتال در افراد مبتلا به ویروس HIV جلوگیری نمود؟ پیش از اقدام به درمان پریودنتال این افراد, چه ملاحظاتی را باید مدنظر داشت؟ 5/8/2018