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Oral Health

Update. Oral Health. Mark M. Schubert, DDS, MSD Dental Director, NW-AETC. MMWR 1981 June 5: 30:250-2 5 cases of Pneumocystis carinii pneumonia at 3 different LA hospitals in homosexully active males. Concurrent CMV infection and candidal mucosal infections. Oral Manifestations of HIV/AIDS.

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Oral Health

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  1. Update Oral Health Mark M. Schubert, DDS, MSD Dental Director, NW-AETC

  2. MMWR 1981 June 5: 30:250-2 5 cases of Pneumocystis carinii pneumonia at 3 different LA hospitals in homosexully active males. Concurrent CMV infection and candidal mucosal infections

  3. 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: 30 - 50% In late stage AIDS – upwards of 90%

  4. Oral Manifestations of HIV Infection

  5. Oral Manifestations of HIV Infection

  6. 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

  7. Estimated Incidence of AIDS, Deaths, and Prevalence by Quarter-Year of Diagnosis/Death, US 1985-1999* 25,000 350,000 1993 definition AIDS implementation Deaths 300,000 Prevalence 20,000 250,000 15,000 200,000 Number of Cases/Deaths Prevalence 150,000 10,000 100,000 5,000 50,000 HAART 0 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Quarter-Year *Adjusted for reporting delays Does not address change in risk of transmission

  8. Changing Prevalence of Oral Manifestations of HIV: 1996 - 1999 Oral Lesion Early (%)a Late (%)b P-value a) n = 271 b) n = 299 Patton et al., Oral Surg Oral Med Oral Pathol 89:299-304, 2000

  9. Changes in Prevalence of Oral Lesions: 1990 - 1999 n = 1280 HIV(+) individuals 7/1/90 – 6/30/99 Greenspan D et al. The Lancet 357(9266), 1411-12, 2001

  10. Incidence of AIDS • 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

  11. 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

  12. Pseudomembraneous Candidiasis

  13. Atrophic / Erythematous Candidiasis

  14. Hyperplastic Candidiasis

  15. Angular Cheilitis

  16. Azole Resistant Oral Candidiasis Candida albicans Candida glabrata

  17. 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

  18. 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

  19. Invasive Fungal Infections Histoplasmosis Mucormycosis

  20. 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

  21. 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

  22. Herpetic Stomatitis

  23. 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

  24. Varicella Zoster Virus

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

  26. 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/mm3) • Definitive diagnosis requires identification of EBV in infected epithelial cells • Marker for immune suppression (non-HIV patients) • Treatment: Acyclovir, Podophyllum resin

  27. Hairy Leukoplakia

  28. 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 CO2 laser ablation Interferon-alpha

  29. Human Papilloma Virus

  30. 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

  31. Linear Gingival Erythema

  32. 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

  33. Necrotizing Ulcerative Diseases: Gingivitis & Periodontitis

  34. 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

  35. Recurrent Aphthous Ulcerations

  36. Necrotizing Stomatitis

  37. 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

  38. Kaposi’s Sarcoma

  39. Oral Pigmentation • AZT-induced pigmentation • Rule-out Kaposi’s sarcoma

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

  41. 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

  42. Non-Hodgkin’s Lymphoma

  43. 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

  44. Salivary Gland Involvement

  45. 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

  46. Oral Bacterial Infections Mycobacterium Tuberculosis Oral Syphilis (I°)

  47. Diagnosis & Managementof 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

  48. 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

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