Aids and Periodontium and its Management

Aids-Acquired Immune Deficiency Syndrome Introduction Aids-Acquired Immune Deficiency Syndrome Devil’s disease Epidemic proportions Impairment of the immune system Death is caused by opportunistic infections and neoplastic processes Oral manifestations – First significant clinical manifestation

Pathogenesis: Strong affinity for cells of the immune system Specifically that carry the CD4 receptor molecules T lymphocytes B lymphocytes – Although not infected the altered function of infected T lymphocytes results in B-cell deregulation and altered neutrophil function. Macrophages, Monocytes, Langerhans cells brain cells may also be involved

HIV is detected in most body fluids including – Mode of Transmission HIV is detected in most body fluids including – Blood Semen Vaginal secretions Cerebrospinal fluid Breast milk Urine

Common Methods of Transmission Sexual contact Blood transfusion Needle sharing Perinatal transmission - Intrauterine ,Postnatal Occupational exposure Organ transplantation

Classification and Staging Centers for Disease Control (CDC - 1993) Based on opportunistic infection and malignancies Presence of any 25 specific clinical conditions in a patient will confirm the diagnosis of AIDs Commonly encountered Candidiasis Cryptococcosis Cytomegalovirus disease Kaposi’s sarcoma Burkitts lymphoma Mycobacterium tuberculosis Wasting syndrome Most recent significant change - CD4 - T4 lymphocyte count less than 200 / mm3 or less than 14% total lymphocyte is definitive for AIDS.

CDC Surveillance Case Classification AIDS patients have been grouped as follows, according to the CDC Surveillance Case Classification (1993) - Category A - includes patients with acute symptoms or asymptomatic diseases, along with individuals with persistent generalized lymphadenopathy, with or without malaise, fatigue, or low-grade fever. Category B - patients have symptomatic conditions such as oropharyngeal or vulvovaginal candidiasis; herpes zoster; oral hairy leukoplakia; idiopathic thrombocytopenia; or constitutional symptoms of fever, diarrhea, and weight loss. Category C - patients are those with outright AIDS as manifested by life-threatening conditions identified by CD4+T lymphocyte levels of less than 200 per cubic millimeter.

Systemic Manifestation Symptoms Fever Malaise Headache Diarrhea Lymphadenopathy Hematological abnormalities Neurological Diseases Non-healing dermatological lesions

Oral lesions associated with HIV infection can be broadly grouped as Oral & Periodontal Manifestations Of HIV Infection Oral lesions associated with HIV infection can be broadly grouped as Fungal Bacterial Viral infections Neoplasms

Oral Manifestations Associated with HIV Infection include Candidiasis Oral hairy leukoplakia Atypical periodontal disease Kaposi’s sarcoma Non hodgkins lymphoma In addition Melanotic hyperpigmentation Atypical ulcerations Viral infections caused by herpes simplex herpes zoster are common

Periodontal Diseases Associated with HIV Infection Linear Gingival Erythema ANUG Necrotizing Ulcerative Stomatitis NUP

Four clinical presentations Candidiasis Most common in HIV +ve patients Oppurtunistic infection – Normal oral flora Fungal infection Four clinical presentations Pseudomembranous Erythematous Hyperplastic Angular chelitis Diagnosis - Microscopic examination of tissue sample or smear of material scraped from the lesion

Clinical Picture Pseudomembranous - painless, senstive, white lesion readily scraped from oral mucosa , palate,buccal mucosa Erythematous - red patches on the buccal or palatal mucosa associated with depappillation of the tongue Hyperplastic - least common in buccal mucosa and tongue. Resistant to removal Angular cheilitis - commissures appear erythematous with surface fissuring

Oral Hairy Leukoplakia Asymptomatic, keratotic lesion Lateral borders of the tongue affected Vertical striations imparting corrugated appearance Appears hairy when dried Caused by Epstein Barr virus Diagnosis – Biopsy – lesion suggestive of OHL HIV test to be performed

KAPOSI’S SARCOMA Rare multifocal vascular neoplasm Painless reddish purple macules or nodules in the mucosa Different from classic form, more aggressive lesion Most common site of involvement are the palate and the gingiva Virus designated as human herpes virus – 8 ( HHV – 8) Oral cavity may be the first or only site of the lesion Diagnosis based on histological findings

Atypical Ulcers and Delayed Healing Non specific oral ulceration in HIV individuals – multiple etiology like lymphoma,KS, sq ca. HIV associated neutropenia may feature oral ulceration HIV infected pts – recurrent herpetic lesion and aphthous stomatitis CDC includes mucocutaneous herpes present for more than one month as a sign of AIDS Herpes Simplex virus, Varicella Zoster virus, Epstein Bar virus or Cyto Megalo virus frequently are retrieved from non specific oral ulcers –possible etiologic role ATYPICAL ulcers more severe and persistent in pt. with low CD4 cell count

Non Hodgkin’s Lymphoma Most frequent malignant neoplasia Caused due to Epstein Barr virus. Fast growing mass generally on the palate, tongue or gingiva and soon it ulcerates and presents areas of extensive necrosis Pain may not be present Clinically the mass may be erythematous or purplish in colour with a boggy consistency.

Linear Gingival Erythema Persistent, linear, easily bleeding erythematous gingiva May or may not serve as precursor to rapidly progressive necrotizing ulcerative periodontitis. Often unresponsive to corrective therapy yet such lesions may undergo spontaneous remission.

Nerotizing Ulcerative Stomatitis Severely destructive acute painful (NUS) present in HIV +ve pt Necrosis of oral soft tissue and underlying bone Occurs separately or as extension of NUP and associated with severe depression of CD4 immune cells Identical to cancrum oris (NOMA)

Necrotizing Ulcerative Gingivitis Punched out crater like depressions, at the crest of interdental papillae, - extending to marginal gingiva Surface of gingival crater – covered by gray, pseudomembranous slough. Crater is demarcated from the remainder by a linear erythema.

Necrotizing Ulcerative Periodontitis Characterized by soft tissue necrosis, rapid periodontal destruction and interproximal bone loss NUP is present after marked CD4 cell depletion and usually localized to few teeth Bone undergoes necrosis and subsequent sequestration

ACCORDING TO STUDY REPORTS Susceptibility increases as immune system becomes more compromised Injectable drug abusers - Oral candidiasis and linear gingival erythema

Diagnosis Immunological tests Total leukocyte and lymphocyte count T-cell subset assays Platelet count IgG and IgA levels Lymph node biopsy

Specific tests for HIV infection Antigen detection Antibody detection Virus isolation Serological tests

Screening for HIV ELISA test – Enzyme linked immunosorbent assay Blood sample obtained and sent to lab Targeted antibody is linked to an enzyme If target substance is in the sample, the test solution turns a different color CONFIRMATORY – Western blot test Gold standard Analytic technique used to detect specific proteins in the sample of tissue extract

Periodontal Treatment Protocol Health status Infection control measures Psychological factors Line of Treatment Prophylactic treatment of opportunistic infections Antiretroviral therapy Vaccines Psychological therapy

Candidasis Early Oral lesions – topical drugs Advanced oral lesions – systemic drugs Topical Drugs: Clotrimazole Clotrimazole ointment, 15-g tube: Apply to affected area Systemic Drugs Ketoconazole Fluconazole Itraconazole

Oral Hairy Leukoplakia Laser or conventional surgery Antretroiviral therapy – Acyclovir Zidovudine Lamivudine

Kaposi’s Sarcoma Antiretroiviral agents Laser excision Radiation therapy Intralesional injection Other chemotherapeutic drugs

Treatment of periodontal diseases associated with HIV infection Debridement - Povidone iodine Local Antimicrobial Therapy - Chlorhexidine gluconate 0.12% Immediate follow up care Systemic antimicrobial therapy Metronidazole - 250 mg 4times/days for 5 days

Non Specific Oral Ulceration's And Recurrent Apthae Acyclovir - 200 to 800mg 5 times daily for 10 days Maintenance dose 200 mg 2 to 5 times daily to prevent recurrence Recurrent apthous ulcer - topical corticosteroids (fluocinonide gel) applied three to six times daily Large apthae systemic corticosteriod (prednisone 40 to 60 mg daily)

Infection Control Personal protection through vaccines, masks, gloves, etc. Decontamination of used instruments. Sterilization of instruments Asepsis of the operating environment. Surface disinfection Aseptic surgical techniques Postoperative aseptic techniques.

HIV Vaccines Small parts of the HIV virus Vaccines being tested should produce either antibodies or cytotoxic T cells to fight infection They cannot cause HIV or AIDS. Types Peptide vaccine Recombinant sub-unit protein vaccine Live vector vaccine DNA vaccine Virus- like particle vaccine (Pseudovirion )

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