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1. Oral Disease in Patients with HIV Infection CAPT G. Todd Smith, ret
Phoenix Indian Medical Center
2. Contributors of photos and data: aidsetc.org
HIVdent.org
Nebraska and New Mexico AIDS Educational Training Centers
cdc.gov/hiv
Ann Lyles, USC School of Dentistry
4. Epidemiology Nearly 25% of the 1 million Americans with HIV are unaware they are infected.
Women account for 29% of HIV/AIDS diagnoses among AI/ANs.
In 2005, an estimated 1,581 AI/ANs were living with AIDS.
9 years after dx with AIDS, 67% of AI/ANs were alive.
A 21 y.o. infected with HIV today will live to age 60.
5. Oral Disease in HIV Infection Oral infections and neoplasms occur with immunosuppression
90% of HIV + patients have at least one oral manifestation
Oral disease is rarely self-limiting
Untreated oral disease may lead to systemic infection, weight loss, dehydration, and malnutrition One study only 9% get treated for oral manifs
90%- from NY State Dept of HealthOne study only 9% get treated for oral manifs
90%- from NY State Dept of Health
6. Occupational Transmission of HIV HIV is present in low levels in saliva (Yeung, 1993)
There is no convincing evidence that plain saliva can transmit HIV infection.
Risk is ˜ 1/200 (0.3%) with a needlestick
Starting antiretroviral therapy within 1-4 h of an exposure can reduce incidence of transmission by more than 80% MMWR’95
Post exposure prophylaxis usu with HAART
“Extremely unlikely” needlestick transmission during dental carePost exposure prophylaxis usu with HAART
“Extremely unlikely” needlestick transmission during dental care
7. Before we treat these oral maifes of HIV….
HCV in almost 50% HIV cases
Viral load > 3000 increase oral manifestations
T count- CD4s 500 normal
PO complications no greater risk, routine abx contraindicated.
ANC<1000 abx
ANC < 500 delay tx
Platelets 60-80 limit tx. < 60 physician consult. Possibly platelet transfusion? INR doesn’t tell whole story.
Before we treat these oral maifes of HIV….
HCV in almost 50% HIV cases
Viral load > 3000 increase oral manifestations
T count- CD4s 500 normal
PO complications no greater risk, routine abx contraindicated.
ANC<1000 abx
ANC < 500 delay tx
Platelets 60-80 limit tx. < 60 physician consult. Possibly platelet transfusion? INR doesn’t tell whole story.
8. Oral Manifestations of HIV/AIDS:9 times higher prevalence when CD4+ T-cell count is less than 200 cells/mm3 (Shiboski, 1994) Microorganisms
Fungal
Viral
Bacterial
Neoplasms
Iatrogenic
9. Pseudomembranous Candidiasis
10. Fungal Pseudomembranous Candidiasis
Opportunistic fungal infection caused most frequently by Candida albicans
Primary locations include the tongue, buccal mucosa, hard and soft palate
Considered asymtomatic; some may experience burning, pain, and altered taste
Multi-focal, ill-defined, irregular white plaques that can be rubbed off
11. Atrophic/Erythematous Candidiasis
12. Fungal Erythematous Candidiasis
Opportunistic fungal infection caused most frequently by Candida albicans
Primary locations include the tongue and hard palate
Burning sensation and dry mouth
Multi-focal, ill-defined, irregular red patches (median rhomboid glossitis)
13. Linear Gingival Erythema
14. Angular cheilitis
15. Fungal Linear gingival erythema (LGE)- gingival disease of fungal origin
Angular cheilitis
Ulcerative, crusting lesions with erythema at the commissures.
Hyperplastic candidiasis
Multi-focal, hair-like projections on the cheek mucosa along the linea alba.
When T count < 100 can develop into esophageal candidiasis
16. Topical Treatment of Oral Candidiasis Clotrimazole (Mycelex) 10 mg troches dissolved in the mouth 5x /day for 7-14 days
Nystatin (Mycostatin) rinse, 100,000units/ml. Hold 1 tsp in mouth for 2 min and swallow or spit 4x/day
Clotrimazole 1% cream- for angular cheilitis Mycelex troches have sugar
Edentulous soak denture in dilute bleach.Mycelex troches have sugar
Edentulous soak denture in dilute bleach.
17. Systemic Treatment of Oral Candidiasis (consider when CD4 count is lower than 150) Fluconazole (Diflucan) 100 mg daily for 14 days
Ketoconazole (Nizoral) 200 mg daily for 14 days
18. Oral Hairy Leukoplakia
19. Viral Lesions Oral Hairy Leukoplakia-
Epstein-Barr (EBV) virus
Regarded as a marker of immunosuppression
Predictive of disease progression to AIDS
Affects the lateral borders of the tongue, ventral tongue and buccal vestibule
Usually asymptomatic
Usually treatment not indicated
20. Verruca vulgaris
21. Viral Lesions Oral warts
Human papillomaviruses (HPV)
Appears as smooth-surfaced, flesh-colored or white papules
Oral verruca vulgaris is a papillary or pedunculated form of HPV
Occur mostly on keratinized mucosa
Treatment is excision when indicated
On the rise- concern with HPV/CA link
22. Herpes Simplex Virus
23. Viral Lesions Oral Herpes Simplex/ Herpes Labialis (fever blisters)
Herpes Simplex Virus (HSV)
Generally more widespread, aggressive, prolonged, and atypically distributed than in non-immunosuppressed patients
Typical sites include the hard palate and the attached gingiva but oral mucosal surfaces may be involved
Appear as small vesicles that coalesce with weeping crusts or yellow border
24. Viral Lesions HSV Cont’d:
Lesions are painful and may interfere with nutrition
Treatment options
Acyclovir (Zovirax) 400-800 mg 3x/day for 7 days
Valacyclovir 500 mg twice daily for 7 days ($$$$)
Palliative support- 1:2:3 mouthrinse
Topical acyclovir ointment for recurrent herpes-questionable effectiveness
25. Viral Lesions Cytomegalovirus (CMV)
26. Viral Lesions Cytomegalovirus (CMV)
Painful, large, sharply demarcated, nonspecific ulcerations, usually represented by dissemination of CMV
Occurs on both keratinized and nonkeratinized mucosa and clinically cannot be distinguished from major aphthous ulcerations
Diagnosis only rendered by deep biopsy
CMV causes retinitis in AIDS patients
Rx Ganciclovir, especially when retinitis
27. Periodontal disease
28. Periodontal Diseases Most common oral bacterial infection among HIV-infected persons
Contributing factors include poor diet, poor oral hygiene, and xerostomia
Regular cleanings and good oral hygiene needed
Greater prevalence with increased viral load and presence of Candida and herpesviruses LOA increases with decrease in CD4sLOA increases with decrease in CD4s
29. Necrotizing Ulcerative Periodontitis
30. Necrotizing periodontal diseases
PAINFUL
Prevalence up to 6.3% Lamster 1997
Necrotizing ulcerative gingivitis (NUG)
Characterized by ulceration and necrosis of the interproximal gingiva with mucosal sloughing
Often responsible for rapid tissue destruction
Necrotizing ulcerative periodontitis (NUP)
When extends into the adjacent tissues and bone
31. Necrotizing Periodontal Diseases Treatment of NUG/NUP involves the use of aggressive tissue debridement to remove pathogens and the administration of systemic antibiotics
Povidone-iodine as irrigant during debridement
Flagyl (metronidazole) 250 mg 3 x/day x 5days
Amoxicillin 500mg with Flagyl 3X/day x 5days
Antimicrobial rinses (0.12% Chlorhexidine)
32. Aphthous Ulcers
33. Other Ulcerative Lesions Recurrent Aphthous Stomatitis (canker sores)
Idiopathic problem that affects 40% of the general population
Occurs with increased frequency with HIV infection
Minor are small ulcerations ( < 1 cm)
Major are large ulcerations ( > 1 cm)
34. Other Ulcerative Lesions Recurrent Aphthous Stomatitis
Topical steroids such as dexamethasone 0.5mg/5ml-swish 30 secs then spit 4x/day
OTCs to cauterize or cover smaller lesions
Systemic steroids in severe cases and major apthous
prednisone 20mg 3X/day X4 days then reduce 5mg each day. Debacterol
Colgate “Orabase Soothe N seal”Debacterol
Colgate “Orabase Soothe N seal”
35. Kaposi Sarcoma
36. Neoplasms Kaposi’s Sarcoma (KS)
Most common malignancy associated with HIV
Human Herpesvirus 8 (HH-8) has been implicated as a possible co-factor for KS
Oral cavity may be the initial site in 50% of cases
Early lesions appear as asymptomatic reddish-purple macules
37. KS
Lesions progress to painful papules and nodules that may ulcerate and bleed
Presence of KS always associated with immunodeficiency
Also seen in kidney transplant recipients
Treat with localized injection of chemotherapeutic agents or surgical removal. With extraoral lesions, systemic chemo.
Oncology referral Local chemo- vinblastine sulfateLocal chemo- vinblastine sulfate
38. Lymphoma
39. Neoplasms Non-Hodgkin’s lymphoma
second most common malignancy in AIDS
can be painful
tumors present intraorally as soft tissue masses, frequently with secondary ulcerations, and may resemble KS
most commonly occurs on the palate, retromolar area, and gingiva
Oncology referral Lymphoma of the parotid common oral site.Lymphoma of the parotid common oral site.
40. Salivary Gland Dysfunction/Xerostomia Side effect of nearly all medications
Dry Mouth promotes dental caries and periodontal disease
Treatment is to restore hydration and avoid irritating foods/habits
Possible link between Viral Load and Salivary Gland Dysfunction 30% incidence 1 study30% incidence 1 study
41. Salivary Gland Dysfunction/Xerostomia Paraparotid fat disposition-lipodystrophy syndrome-refer to MD Mandel 2008
Avoid cinnamon, abrasive foods, acidic foods, spicy or overly sweet foods, and desiccants
Encourage high protein foods, cool or frozen foods, and low sucrose carbohydrates
42. Xerostomia
43. Treatment of Dryness Saliva substitutes
Oralbalance gel
Salivart spray
Cholinergic Medications
Pilocarpine (Salagen) - 5 mg TID 30 min. before meals to 30 mg daily maximum
Biotene Products
44. Medication induced hyperpigmentation especially AZT AZT 1st antiretroviral protease inhibitor- 1987
Azidothymidine usually called zidovudine (zidoVOOdineAZT 1st antiretroviral protease inhibitor- 1987
Azidothymidine usually called zidovudine (zidoVOOdine
45. Other Oral Manifestations Fungal-
Histoplasmosis
Cryptococcosis
Bacterial Infections
Actinomyces
Enterobacter
Mycobacterium (Tuberculosis)
Viral- Varicella-Zoster virus (shingles)
Lichen Planus
Erythema Multiforme
EM- palliative tx. MD referral to R/O systemic infec (HSV, toxoplasmosis
LP- Med induced. Change dose?
Histo- common systemic fungal infec. Develop immunity in 2-3 weeks in healthy pts. Granulomatous lesions orally
Crypto- survival in MONTHS. Crater like ulcers
Molluscum contagiosum- DNA poxsvirus. Spont remission 6-9 months. Crater like lesions
TB- one leading cause of death HIV+. HIV+ 400X > risk TB infection
Now multiple drug resistant TB.EM- palliative tx. MD referral to R/O systemic infec (HSV, toxoplasmosis
LP- Med induced. Change dose?
Histo- common systemic fungal infec. Develop immunity in 2-3 weeks in healthy pts. Granulomatous lesions orally
Crypto- survival in MONTHS. Crater like ulcers
Molluscum contagiosum- DNA poxsvirus. Spont remission 6-9 months. Crater like lesions
TB- one leading cause of death HIV+. HIV+ 400X > risk TB infection
Now multiple drug resistant TB.
46. Use of HAART Significant decrease in prevalence of opportunistic diseases like candidiasis, hairy leukoplakia and NUP.
Generally safe to use analgesics, local anesthesia, and antibiotics. Few drug-drug interactions.
Immune Reconstitution Syndrome
Paradoxical transient deterioration in immune function during initial response to HAART. Increase in some oral lesions like KS initially. Highly Active antiretroviral therapy
Bactrim- 50% allergic
HAART- usually 3 or 4 in combo
Reverse transcriptase inhibitors
Protease inhibitors
Integrase inhibitors
Entry inhibitors
Efavirenz + zidovudine + lamivudine
Lopinavir +ritonavir +…..
Drug-drug interactions-
ritonavir (Norvir)- in Kaletra
AVOID sedatives versed and halcion (mid- and triaz-) and demerol
standard abx and pain meds no add’n concerns except bactrim- 50% w allergies
Highly Active antiretroviral therapy
Bactrim- 50% allergic
HAART- usually 3 or 4 in combo
Reverse transcriptase inhibitors
Protease inhibitors
Integrase inhibitors
Entry inhibitors
Efavirenz + zidovudine + lamivudine
Lopinavir +ritonavir +…..
Drug-drug interactions-
ritonavir (Norvir)- in Kaletra
AVOID sedatives versed and halcion (mid- and triaz-) and demerol
standard abx and pain meds no add’n concerns except bactrim- 50% w allergies
47. Primary Care Providers Oral examination should be provided at every physical examination by the medical provider
Current blood data e.g. white blood count with differential, the absolute neutrophil count and the platelet count should communicated to the dental professional
Only 9% of oral manifs get treatment one study
Only 9% of oral manifs get treatment one study
48. Primary Care Providers Refer to a dental care provider when
Patient not seen within one year
Bleeding gums
Loose or cavitated teeth
Ill-fitting dentures
Dry mouth
Soft tissue lesions
73% in urban free dental clinic willing to take a free rapid HIV screening test. Called OraQuick- simple intraoral swab.73% in urban free dental clinic willing to take a free rapid HIV screening test. Called OraQuick- simple intraoral swab.
49. Questions?