Principles of Oral Health Management for the HIV/AIDS Patient

1. Principles of Oral HealthManagement 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

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

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

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

5. HIV-related Oral Lesions • Infections • Fungal, Viral, Bacterial • Neoplasms • Kaposi’s Sarcoma, Non-Hodgkin’s Lymphoma • Other • Non-specific or Aphthous-like Ulcers, Lichenoid or Drug Reactions, Salivary Gland Disease

6. Oral Candidiasis • Pseudomembranous • Erythematous • Hyperplastic • Accompanying angular cheilitis

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

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

13. Hyperplastic Candidiasis • Appearance: as a leukoplakia (a white lesion that does not rub off) • 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

15. Angular Cheilitis • Appearance: erythema and/or fissuring at the corners of the mouth • Frequently accompanies intraoral candidiasis

17. Treatment Of Oral Candidiasis • Topical Antifungal Therapy • Systemic Antifungal Therapy

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

21. Hairy Leukoplakia • 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

22. Herpes simplex infection Varicella zoster infection (“Shingles”) Cytomegalovirus infection Aphthous ulcers Histoplasmosis Lymphoma Necrotizing ulcerative gingivitis (NUG) Necrotizing ulcerative periodontitis (NUP) Necrotizing stomatitis (NS) Oral Ulcers

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

25. Low Incidence Infections • Viral • Varicella-Zoster • Cytomegalovirus • Fungal • Histoplasmosis • Bacterial • Tuberculosis • Syphilis

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

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

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

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

39. Pigmented And Erythematous Lesions • Kaposi’s sarcoma • Mucosal melanin pigmentation • Linear gingival erythema

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

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

45. Linear Gingival Erythema • Appearance: a distinct band of erythema of the gingival margin • Erythema does not respond to removal of local factors • Cause is not known

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

50. 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.”