ORAL HEALTH IN WOMEN ORAL MANIFESTATIONS OF HIV INFECTION

DENTAL HEALTH CARE PROVIDER TEAM APPROACH

EPIDEMIOLOGY OF HIV-RELATED ORAL MANIFESTATIONS IN WOMEN

Epidemiology of HIV-Related Oral Manifestations in Women: A Review u Oral Lesions in 15% of HIV-Infected Women u Most Common Oral Lesion - Candidiasis u Prevalence of Hairy Leukoplakia and Kaposi's Sarcoma Significantly Less Common in Women Oral Dis 1997 Sep;3(3):206.

Many Manifestations of HIV Disease are Similar in Men & Women u Other Conditions Differ In Frequency: –HIV-Infected Men 8 X’s More Likely to Develop Kaposi's Sarcoma –Women Have Higher Rates of Esophageal Candidiasis & Herpes Simplex Infections

CHANGING PREVALENCE OF ORAL MANIFESATIONS

u Overall Prevalence of Oral Lesions Has Decreased (47.6%-37.5%) u Hairy Leukoplakia (25.8%- 11.4%) & Necrotizing Periodontal Diseases (4.8%-1.7%) Decreased

u HIV Salivary Gland Disease Increased (1.8%-5.0%) u Candidiasis (20.3%-16.7%), Aphthae (3.7%-3.0%), Oral Warts (2.2%-4.0%), Herpes Simplex Virus Lesions (1.8%- 2.0%) and Kaposi’s Sarcoma (1.1%-0.3%) Unchanged

HIV/AIDS Women's Health: Oral Lesions in HIV-Positive Women Reduced in HAART Therapy u 503 HIV+ women over 6 years u Incidence of EC fell to 2.99 percent from 5.48 percent u PC fell to 2.85 percent from 6.70 percent u No changes were seen in HL or warts Women's Health Weekly ( )

CANDIDIASIS

Reported in 7-93% of HIV+ /AIDS Patients

FOUR MAJOR TYPES u Pseudomembranous u Hyperplastic u Erythematous (Atrophic) u Angular Cheilitis

PSEUDOMEMBRANOUS u White or Yellow Patches u Easily Removed w/ Scraping Yielding Bleeding Surface u Any Mucosal Surface (Palate, Buccal or Labial Mucosa, Tongue)

HYPERPLASTIC CANDIDIASIS u White Plaques Can’t Be Removed w/ Scraping u Buccal Mucosa Most Common Site in HIV+ Patients

ERYTHEMATOUS (ATROPHIC) u Fiery Red Surfaces to Hardly Discernible Pink Spots u Most Common Location - Palate & Dorsum of Tongue u Spotty Areas in Buccal Mucosa

ANGULAR CHEILITIS u Common in Elderly u Fissures Radiating From Angles of Mouth

PREDISPOSING FACTORS

SYSTEMIC FACTORS u Age u Use of Antibiotics u Xerostomia u Nutritional Deficiencies u Immunosuppression u Gastric Reflux

LOCAL FACTORS u Ill-Fitting Dentures u Poor Prosthesis Hygiene u Heavy Smoking u Topical Medications

CANDIDIASIS TREATMENT u Nystatin Oral Susp –480 ml –Rinse w/ One Tablespoonful QID u Clotrimazole (Mycelex) Troches –10 mg Troches –3-5 Times a Day for 7-14 Days

u Ketoconazole (Nizoral) –200 mg – mg Daily for 7-14 Days u Fluconazole (Diflucan) –100 mg Tabs –2 Tabs First Day, Then 1 Tab Daily for 14 Days u Itraconazole (Sporanox) –100 mg Tablets –1 tablet B.I.D. for 14 days

OROFACIAL VIRAL INFECTIONS IN IMMUNOCOMPROMISED HOST

HAIRY LEUKOPLAKIA u First Identified Among HIV+ Individuals u Never Described Before AIDS Epidemic

CLINICAL PRESENTATION u Painless White Patches u Do Not Rub Off u Lateral Borders of the Tongue u Surface May Be Smooth, Corrugated or Markedly Folded u Thick, Hair-Like Projections

DIFFERENTIAL DIAGNOSIS u Hyperplastic Candidiasis u Geographic Tongue u Lichen Planus u Frictional Keratosis u Leukoplakia

HAIRY LEUKOPLAKIA - PATHOGENESIS u Epstein-Barr Virus

HAIRY LEUKOPLAKIA TREATMENT u Appears to Be Little Advantage in Treating u Surgical Removal –Laser u Acyclovir u Topical Vitamin A

HUMAN PAPILLOMA VIRUS LESIONS

HUMAN PAPILLOMA VIRUSES u More Than 100 Human Papilloma Virus (HPV) Types u 24 Associated with Oral Lesions

HPV ORAL LESIONS u Warts, Papillomas u Condyloma Acuminatum u Verruca Vulgaris u Focal Epithelial Hyperplasia u Dysplasia / Carcinoma

HUMAN PAPILLOMA VIRUS LESIONS

CONDYLOMA ACUMINATUM u Sexually Transmitted u Appears 1-3 Months After Exposure u Multiple Wart-Like Lesions u Lips, Lingual Frenum & Tongue

TREATMENT CONDYLOMA ACUMINATUM u Surgical Removal u Cryotherapy u Laser Therapy u Medications

KAPOSI’S SARCOMA

Originally Described in Idiopathic Multiple Sarcomas of the Skin

Previously Uncommon in USA u Elderly Jewish Men of Eastern European or Mediterranean Descent u Usually Involved Lower Extremities u Indolent Course u Fulminant, Aggressive Form Occurring in Young Homosexual Men w/ AIDS

u >50% of AIDS Patients w/ KS Display Oral Lesions u Remains Significant Cause of Morbidity & Mortality in HIV Infected Patients

CLINICAL PRESENTATION u Angiomatous Malignancy of Skin, Mucosa, and Internal Organs u Most Common Intraoral Locations –Palate –Gingiva u Non-Elevated Macules, Nodules or Papules u Brown, Blue, Purple

KAPOSI’S SARCOMA PATHOGENESIS u Sexually Transmitted Cofactor u Human Herpes Virus 8 (HHV 8)

TREATMENT u Treatment Reserved for Lesions Which Interfere w/ Function or Esthetics u Laser Excision u Cryotherapy u Radiation u Intralesional Injection w/ Vinblastine

CANCER IN PATIENTS WITH AIDS

AIDS AND CANCER u Roche et al, NJ Med 2001,Jan;98(1);27-36 u 2460 Persons w/ AIDS and Cancer u 2159 Males, 301 Females u 50% Kaposi’s Sarcoma u 33% Non-Hodgkins Lymphoma u Lung, Oral, Cervical, Hodgkins Lymphoma, Other Digestive

RECURRENT ORAL ULCERATIONS

RECURRENT APHTHOUS STOMATITIS

EPIDEMIOLOGY u Prevalence in General Population 10-20% u 67-85% Develop Prior to Age 30 u Familial Disposition

MINOR APHTHAE u Superficial Erosion with Fibrinous Coating & Red Halo u Single or Multiple Lesions u 2-3 mm’s to Over 10 mm’s in Diameter u Persists for 7-10 Days u Painful

MAJOR APHTHAE u Large Painful Ulcerations u Single or Multiple Lesions u Persists Up to 6 Weeks u Heal w/ Scarring

GENERAL RULE u Aphthae Occur on Mobile Mucosa u Herpetic Lesions Occur on Tissue That is Firmly Bound Down

FACTORS ASSOCIATED WITH APHTHAE u Psychological (Stress)Trauma u Socio-EconomicS. sanguis u Endocrine u Immunosuppression u Hereditary u Hypersensitivity u Chemicals in Food

TREATMENT u Chlorhexidine u Topical Steroids –Lidex Gel.05% u Aphthasol Cream 5%

HERPES SIMPLEX INFECTIONS

RECURRENT HERPETIC STOMATITIS u Attenuated Form of Primary Infection u Tissue Firmly Bound Down u Vesicles Burst to Form Ulcers u Coalesce u Heals in 7-10 Days

HERPES LABIALIS

SYSTEMIC ANTIVIRALS u Acyclovir (Zovirax) 200 mg Capsules One Capsule 5 Times a Day u Valacyclovir (Valtrex) 1 gm Caplets Two Caplets Twice a Day u Famciclovir (Famvir) 125 mg Tablets One Tablet Twice Daily

TOPICAL ANTIVIRALS u Zovirax (Acyclovir) Ointment 5% –15 Gram Tube –Apply TID u Denavir (Penciclovir) Cream 1% –2 Gram Tube –Apply Every Two Hours

AIDS RELATED PERIODONTAL DISEASE u Linear Gingival Erythema u Necrotizing Ulcerative Gingivitis u Necrotizing Ulcerative Periodontitis u Necrotizing Ulcerative Stomatitis

LINEAR GINGIVAL ERYTHEMA u A Persistent, Linear Erythematous Gingivitis Which Bleeds Easily u Resistant to Treatment u Spontaneous Remission

NECROTIZING ULCERATIVE GINGIVITIS u Also Known as ANUG u Acute Gingivitis Characterized by Ulceration & Necrosis of the Gingival Margin & Destruction of the Interdental Papilla u Gingival Pain

NECROTIZING ULCERATIVE GINGIVITIS u Profuse Gingival Bleeding u Fetid Odor u No Involvement of Osseous Tissues u Associated w/ Stress, Anxiety, Malnutrition & Smoking

NECROTIZING ULCERATIVE PERIODONTITIS u Severe Deep Pain u Spontaneous Gingival Bleeding u Extensive Soft Tissue Necrosis u Severe Loss of Periodontal Attachment

NECROTIZING ULCERATIVE PERIODONTITIS u Rapid Onset & Progression u Bone May Be Exposed u Associated with Low CD4 Counts

NECROTIZING ULCERATIVE STOMATITIS u Necrosis of Significant Areas of the Oral Soft Tissue & Underlying Bone

INTRAORAL PIGMENTATION Racial PigmentationSmoking Amalgam Tattoo Addison’s Disease Heavy Metal Poisoning Puetz-Jeger Syndrome Medications Birth Control Pills Minocycline AZT

SALIVARY GLAND DISEASE u Xerostomia u Bilateral Parotid Gland Enlargement Occurs in HIV Infected Individuals u Histology Has Been Described as Resembling Autoimmune Salivary Gland Disease w/ Cystic Changes

Thanks for Coming! Jacqueline M. Plemons DDS, MS 6031 Sherry Lane Dallas, TX (214)