April 2003 Oral Health Mark M. Schubert, DDS, MSD Dental Director, NW-AETC

April 2003 MMWR 1981 June 5: 30: cases of Pneumocystis carinii pneumonia at 3 different LA hospitals in homosexully active males. Concurrent CMV infection and candidal mucosal infections

April 2003 Oral Manifestations of HIV/AIDS May be first sign of HIV infection –May lead to testing and diagnosis –Oral conditions develop as immunosuppression progresses Indicators of change in immune status Require definitive management Oral manifestations of HIV infection –Certain conditions associated with risk of AIDS –May be first AIDS defining condition Overall average prevalence: % In late stage AIDS – upwards of 90%

April 2003 Oral Manifestations of HIV Infection Type of InfectionOral Disease Fungal Candidiasis - Pseudomembranous, Erythematous, and Angular Cheilitis Invasive Fungal Infections - Histoplasmosis, Mucormycosis, Crytococcosis Viral Herpes Simplex Herpes Zoster Cytomegalovirus Hairy Leukoplakia (Epstein Barr Virus) Oral Warts (Human Papilloma Virus) Human Herpes Virus–8 [Kaposi’s sarcoma] Bacterial Linear Gingival Erythema Necrotizing Ulcerative Periodontitis Tuberculosis* Mycobacterium avium complex* Bacillary angiomatosis*

April 2003 Oral Manifestations of HIV Infection Type of LesionOral Disease Neoplastic Kaposi’s Sarcoma (KS) [HHV-8] Lymphoma Squamous Cell Carcinoma* Other HIV-associated Necrotizing Ulceration HIV-Salivary Gland Disease/Xerostomia Immune Thrombocytopenic Purpura* Abnormalities of Mucosal Pigmentation

April 2003 Medical Management of HIV Infection: HAART Therapy Highly Active Antiretroviral Therapy Combination antiretroviral drug therapy –Targets different steps of viral cell replication –Decreased HIV viral load –Increased CD4 counts Significant reduction in oral lesions –Frequency and severity

April 2003 Quarter-Year Number of Cases/Deaths *Adjusted for reporting delays ,000 10,000 15,000 20,000 25, definition implementation Deaths Prevalence AIDS 0 150, ,000 50, , , , ,000 Estimated Incidence of AIDS, Deaths, and Prevalence by Quarter-Year of Diagnosis/Death, US * Prevalence Does not address change in risk of transmission HAART

April 2003 Any lesion Hairy leukoplakia Candidiasis Ulcerative periodontitis Aphthous ulcers HPV Salivary gland disease HSV Kaposi’s sarcoma Oral Lesion Early (%) a Late (%) b P-value a) n = 271 b) n = 299 Changing Prevalence of Oral Manifestations of HIV: Patton et al., Oral Surg Oral Med Oral Pathol 89: , 2000

April 2003 Changes in Prevalence of Oral Lesions: n = 1280 HIV(+) individuals 7/1/90 – 6/30/99 Greenspan D et al. The Lancet 357(9266), , 2001

April 2003 Increasing risk behaviors among groups that had previously shown marked decline in previous years  despite recognition that risk behaviors related to spread of disease Obvious continued need to recognize HIV infections and manage complications: Recognition of oral manifestation of HIV Incidence of AIDS

April 2003 Fungal Infections: Candidiasis Pseudomembraneous Candidiasis White “curd-like” raised material that wipes off Erythematous / Atrophic Candidiasis Mucosal erythema and/or patchy depapillation of the tongue Hyperplastic Candidiasis White/red hyperplastic lesions Angular Cheilitis Erythema and/or fissuring-ulceration at the corner of the mouth

April 2003 Pseudomembraneous Candidiasis

April 2003 Atrophic / Erythematous Candidiasis

April 2003 Hyperplastic Candidiasis

April 2003 Angular Cheilitis

April 2003 Azole Resistant Oral Candidiasis Candida albicansCandida glabrata

April 2003 Treatment of Candidiasis Consider the extent of the infection –Mild to moderate disease: Topical therapies Nystatin, Clotrimazole –Moderate to severe disease: Systemic Therapies Fluconazole, Itraconazole Continue antifungal therapy for two weeks –Reduce colony forming units –Reduce risk factors / increase time to recurrence Consider prophylactic regimens with frequent recurrences

April 2003 Management of Oral Candidiasis Topical agents  Clotrimazole troches 10 mg  Clotrimazole 1% cream  Nystatin oral suspension 100,000 units/ml  Nystatin pastilles 100,000 units Systemic agents  Fluconazole 100mg  Itraconazole oral suspension 10mg/10ml  Amphotericin B, Voriconazole

April 2003 Invasive Fungal Infections Mucormycosis Histoplasmosis

April 2003 Oral Viral Infections Herpes Simplex Virus (HSV) Varicella Zoster Virus (VZV) Cytomegalovirus (CMV) Epstein-Barr Virus (EBV) Human Papilloma Virus (HPV) Human Herpes Virus - 8

April 2003 Oral HSV Infections Primary and recurrent disease Typical to Atypical Appearance –Herpes labialis  Herpetic stomatitis –Large persistent painful ulcers Severity of mucocutaneous disease increases as CD4 counts decrease Can be an AIDS defining condition Treatment: Acyclovir, Valacyclovir and Famciclovir

April 2003 Herpetic Stomatitis

April 2003 Oral VZV Infections Recurrent VZV infection: Herpes zoster –Vesicular / ulcerative lesions –Follow dermatome for trigeminal nerve –Severe neuritic pain –Can involve multiple dermatomes Post-herpetic neuralgia Can be marker for HIV progression Treatment: Acyclovir, Valacyclovir

April 2003 Varicella Zoster Virus

April 2003 Cytomegalovirus Associated with advanced AIDS Painful granulomatous ulcers with punched-out irregular margins Treatment: Ganciclovir, Foscarnet CMV + HSV CMV

April 2003 Oral Epstein Barr Infections Oral Hairy Leukoplakia –White corrugated hyperkeratotic lesion of the lateral borders of the tongue / other areas –Asymptomatic –Clinical Diagnosis: Marker for disease progression (CD4 <300 cells/mm 3 ) Definitive diagnosis requires identification of EBV in infected epithelial cells Marker for immune suppression (non-HIV patients) –Treatment: Acyclovir, Podophyllum resin

April 2003 Hairy Leukoplakia

April 2003 Oral Human Papilloma Virus Infection Variety of lesions: –Exophytic, papillary lesions with a cauliflower- like surface to raised, flat, smooth lesions –Several different types of HPV have been reported to cause lesions –May be solitary or multiple Treatment: Cryotherapy Surgical excision CO 2 laser ablation Interferon-alpha

April 2003 Human Papilloma Virus

April 2003 Peridontal Infections Linear Gingival Erythema –Appearance: A distinct band of erythema of the gingival margin –Erythema does not respond to removal of local factors ( bacterial plaque/calculus ) –Cause is not known –Treatment Intense oral hygiene Professional cleanings 0.12% chlorhexidine / povidone iodine

April 2003 Linear Gingival Erythema

April 2003 Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis Necrotizing ulcerative periodontitis Rapid destruction of tissues –Gingiva, alveolar bone and periodontal tissues –Tends to involved localized areas –Management Antibiotics: Metronidazole, Clindamycin, Augmentin Aggressive curettage / debridement of necrotic tissue Meticulous home care Extraction of involved teeth / Sequestrectomy

April 2003 Necrotizing Ulcerative Diseases: Gingivitis & Periodontitis

April 2003 Necrotizing Oral Ulcerations Aphthous ulcers  Necrotizing stomatitis Range in size: 2-5 mm to 2 -3 cm Frequency increases with HIV progression Can be very persistent and very painful Diagnosis by exclusion Treatment: –Film-forming surface protecting agents –Topical steroids –Thalidomide

April 2003 Recurrent Aphthous Ulcerations

April 2003 Necrotizing Stomatitis

April 2003 Neoplasms Kaposi’s Sarcoma (KS) –Associated with HHV-8 infection –Appearance: Red, bluish, or purplish macular or nodular lesion –Size ranges from small to extensive –Definitive Diagnosis Biopsy and histologic examination –Therapy Radiation treatment Vinblastine Sclerosing agents

April 2003 Kaposi’s Sarcoma

April 2003 Oral Pigmentation AZT-induced pigmentation  Rule-out Kaposi’s sarcoma

April 2003 Bacterial Infections Periodontal Abscess Bacterial infection: Bartonella henselae, Bartonella quintana, Rochalimaea henselae Treatment: Erythomycin 500 mg qid or Azithromax 500 mg q day x 3-4 weeks Bacillary (epithelioid) Angiomatosis

April 2003 Non-Hodgkin’s Lymphoma Clinical appearance: –Rapidly enlarging necrotic masses –Ulcerated or nonulcerated masses –Palate and gingivae most common sites –Prognosis is very poor Diagnosis: –Biopsy and histologic evaluation –Aggressive oncology therapy

April 2003 Non-Hodgkin’s Lymphoma

April 2003 Salivary Gland Involvement Salivary Gland Disease –Bilateral parotid gland enlargement Increased frequency with HAART –Xerostomia: 29% of HIV(+) Patients HIV-related salivary gland disease Side effect of medications Rampant caries

April 2003 Salivary Gland Involvement

April 2003 Considerations in the Use of Antibiotics Narrow spectrum antibiotics preferred –Minimize development of antibiotic resistance –Metronidazole for periodontal infections Consider presence of antibiotic resistant strains –Culture and antibiotic sensitivity may be indicated Antibiotic use may lead to overgrowth of Candida –Antifungal treatment may be indicated in conjunction with systemic antibiotics –Local / topical delivery antibiotics may be useful but have not been evaluated

April 2003 Oral Bacterial Infections Mycobacterium Tuberculosis Oral Syphilis (I°)

April 2003 Diagnosis & Management of Oral Manifestations of HIV/AIDS Clinical appearance and symptoms –Non-specific –Atypical Incidence may indicate disease progression Require careful diagnostic techniques –Laboratory test for: Viruses – Fungi – Bacteria –Biopsy of lesions Require aggressive treatments –Slow to respond –Relapse / Recurrence is common –Concern about resistance

April 2003 Non-HIV-Associated Dental Disease Gingivitis / Periodontitis / Dental Abscesses –Common dental diseases –Compromise oral health / function / esthetics –Compromise general health Constant immune system pressure Increases risk of opportunistic oral infections Increased risk for HIV disease progression Promote / Support Oral Health & Basic Dental Care