June 2000 Principles of Oral Health Management for the HIV/AIDS Patient A Course of Training for the Oral Health Professional Made possible from a grant to the New York State Department of Health AIDS Institute from the HIV/AIDS Bureau, Division of Community Based Programs, Health Resources and Services Administration, DHHS

June 2000 Oral Manifestations Of HIV Infection: Clinical Characteristics, Diagnosis, And Treatment Recommendations Joan A. Phelan, DDS

June 2000 Diagnosis Of HIV Related Oral Lesions Oral examination procedures are the same for HIV patients as for all dental patientsOral examination procedures are the same for HIV patients as for all dental patients Diagnostic procedures must be appropriate to the identified problemDiagnostic procedures must be appropriate to the identified problem Treatment should be based on either a provisional or definitive diagnosisTreatment should be based on either a provisional or definitive diagnosis Diagnosis should be re-evaluated if treatment is not effectiveDiagnosis should be re-evaluated if treatment is not effective

June 2000 Oral Manifestations Of HIV Infection Opportunistic diseases--manifestations of immune deficiency or derangement.Opportunistic diseases--manifestations of immune deficiency or derangement. Not caused directly by HIV. Not caused directly by HIV. The same lesions occur in association with other immune deficiency disorders.The same lesions occur in association with other immune deficiency disorders.

June 2000 HIV-related Oral Lesions InfectionsInfections –Fungal, Viral, Bacterial NeoplasmsNeoplasms –Kaposi’s Sarcoma, Non-Hodgkin’s Lymphoma OtherOther –Non-specific or Aphthous-like Ulcers, Lichenoid or Drug Reactions, Salivary Gland Disease

June 2000 Oral Candidiasis Pseudomembranous Erythematous Hyperplastic Accompanying angular cheilitis

June 2000

Pseudomembranous Candidiasis Appearance: white “curd-like” material that wipes off revealing an underlying erythematous mucosaAppearance: white “curd-like” material that wipes off revealing an underlying erythematous mucosa Clinical Diagnosis: generally made on the basis of appearanceClinical Diagnosis: generally made on the basis of appearance

June 2000 Erythematous Candidiasis Appearance: mucosal erythema and/or patchy-depapillation of the dorsal tongueAppearance: mucosal erythema and/or patchy-depapillation of the dorsal tongue Definitive diagnosis requires:Definitive diagnosis requires: –Identification of fungal hyphae in the lesion –Response of the lesion(s) to antifungal therapy

June 2000

Hyperplastic Candidiasis Appearance: as a leukoplakia (a white lesion that does not rub off)Appearance: as a leukoplakia (a white lesion that does not rub off) Definitive diagnosis requires:Definitive diagnosis requires: –Identification of fungal hyphae in the lesion –Response of the lesion(s) to antifungal therapy –If unresponsive to antifungal therapy, biopsy must be considered

June 2000

Angular Cheilitis Appearance: erythema and/or fissuring at the corners of the mouthAppearance: erythema and/or fissuring at the corners of the mouth Frequently accompanies intraoral candidiasisFrequently accompanies intraoral candidiasis

June 2000

Treatment Of Oral Candidiasis Topical Antifungal TherapyTopical Antifungal Therapy Systemic Antifungal TherapySystemic Antifungal Therapy

June 2000 Hairy Leukoplakia Appearance: white corrugated lesion on the lateral border of the tongueAppearance: white corrugated lesion on the lateral border of the tongue Clinical Diagnosis:Clinical Diagnosis: –known seropositive patients –patients with unknown HIV status –definitive diagnosis requires identification of Epstein-Barr virus infected epithelial cells

June 2000

Hairy Leukoplakia Treatment and Management:Treatment and Management: –Generally does not require treatment –Antiviral treatment and topical podophyllum resin have been used to treat --the result is temporary –May wax and wane without treatment

June 2000 Oral Ulcers Herpes simplex infectionHerpes simplex infection Varicella zoster infection (“Shingles”)Varicella zoster infection (“Shingles”) Cytomegalovirus infectionCytomegalovirus infection Aphthous ulcersAphthous ulcers Histoplasmosis Lymphoma Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP) Necrotizing stomatitis (NS)

June 2000 Herpes Simplex Infection Atypical herpes simplex ulceration is a frequent cause of mucosal ulcerationAtypical herpes simplex ulceration is a frequent cause of mucosal ulceration Diagnosis may be confirmed using mucosal smear, viral isolation (culture) or biopsyDiagnosis may be confirmed using mucosal smear, viral isolation (culture) or biopsy Ulcers generally respond to systemic anti-viral treatmentUlcers generally respond to systemic anti-viral treatment

June 2000

Low Incidence Infections ViralViral –Varicella-Zoster –Cytomegalovirus FungalFungal –Histoplasmosis BacterialBacterial –Tuberculosis –Syphilis

June 2000

Major Aphthous-like Ulcers Appearance: persistent, nonspecific ulcersAppearance: persistent, nonspecific ulcers Biopsy and histologic examination may be necessary to exclude other causesBiopsy and histologic examination may be necessary to exclude other causes Systemic and topical corticosteroid therapy have been successful managementSystemic and topical corticosteroid therapy have been successful management Topical tetracycline application and systemic thalidomide have also be usedTopical tetracycline application and systemic thalidomide have also be used

June 2000

Non-Hodgkin’s Lymphoma Appearance: necrotic, ulcerated or nonulcerated masses, when occurring in the oral cavityAppearance: necrotic, ulcerated or nonulcerated masses, when occurring in the oral cavity Diagnosis: biopsy and histologic examinationDiagnosis: biopsy and histologic examination

June 2000

Necrotizing Ulcerative Periodontal Disease Characterized by painful gingival ulceration and may result in loss of alveolar boneCharacterized by painful gingival ulceration and may result in loss of alveolar bone Management:Management: –antibiotic therapy –debridement of necrotic tissue –meticulous home care

June 2000

Lesions Caused By Human Papilloma Virus (HPV) Appearance: exophytic, papillary, oral mucosal lesionsAppearance: exophytic, papillary, oral mucosal lesions Several different types of HPV have been reported to cause lesionsSeveral different types of HPV have been reported to cause lesions May be multipleMay be multiple Often difficult to treat due to a high risk of recurrenceOften difficult to treat due to a high risk of recurrence

June 2000

Pigmented And Erythematous Lesions Kaposi’s sarcomaKaposi’s sarcoma Mucosal melanin pigmentationMucosal melanin pigmentation Linear gingival erythemaLinear gingival erythema

June 2000 Kaposi’s Sarcoma Appearance: Oral lesions appear as reddish purple, raised or flatAppearance: Oral lesions appear as reddish purple, raised or flat Size ranges from small to extensiveSize ranges from small to extensive Behavior is unpredictableBehavior is unpredictable Definitive diagnosis: biopsy and histologic examinationDefinitive diagnosis: biopsy and histologic examination No curative therapy--radiation treatment, chemotherapy and sclerosing agents have been, used to control oral lesionsNo curative therapy--radiation treatment, chemotherapy and sclerosing agents have been, used to control oral lesions

June 2000

Mucosal Melanin Pigmentation Single and multiple oral mucosal melanotic macules have been report to occur in HIV infected individualsSingle and multiple oral mucosal melanotic macules have been report to occur in HIV infected individuals Significance is not knownSignificance is not known Some have been associated with zidovudine therapySome have been associated with zidovudine therapy Treatment is not indicatedTreatment is not indicated

June 2000

Linear Gingival Erythema Appearance: a distinct band of erythema of the gingival marginAppearance: a distinct band of erythema of the gingival margin Erythema does not respond to removal of local factorsErythema does not respond to removal of local factors Cause is not knownCause is not known

June 2000

Salivary Gland Disease Bilateral parotid gland enlargement occurs in HIV infected individualsBilateral parotid gland enlargement occurs in HIV infected individuals Histology has been described as resembling autoimmune salivary gland disease with cystic changesHistology has been described as resembling autoimmune salivary gland disease with cystic changes

June 2000

Surgeon General’s Report Oral Health Oral Health In America: A Report of the Surgeon General, Executive Summary, June 2000 “Oral diseases and disorders in and of themselves affect health and well-being throughout life. The burden of oral problems is extensive and may be particularly severe in vulnerable populations. It includes the common dental diseases and other oral infections, such as cold sores and candidiasis, that can occur at any stage of life, as well as birth defects in infancy, and the chronic facial pain conditions and oral cancers seen in later years. Many of these conditions and their treatments may undermine self-image and self-esteem, discourage normal social interaction, and lead to chronic stress and depression as well as incur great financial cost. They may also interfere with vital functions such as breathing, eating, swallowing, and speaking and with activities of daily living such as work, school, and family interactions.”