Aids and Periodontium and its Management

1. Aids and Periodontium and its Management

2. Introduction • Aids-Acquired Immune Deficiency Syndrome • Devil’s disease • Epidemic proportions • Impairment of the immune system • Death is caused by opportunistic infections and neoplastic processes • Oral manifestations – First significant clinical manifestation

3. Pathogenesis: • Strong affinity for cells of the immune system • Specifically that carry the CD4 receptor molecules • T lymphocytes • B lymphocytes – Although not infected the altered function of infected T lymphocytes results in B-cell deregulation and altered neutrophil function. • Macrophages, Monocytes, Langerhans cells brain cells may also be involved

4. Mode of Transmission • HIV is detected in most body fluids including – • Blood • Semen • Vaginal secretions • Cerebrospinal fluid • Breast milk • Urine

5. Common Methods of Transmission • Sexual contact • Blood transfusion • Needle sharing • Perinatal transmission - Intrauterine ,Postnatal • Occupational exposure • Organ transplantation

6. Classification and StagingCenters for Disease Control (CDC - 1993) • Based on opportunistic infection and malignancies • Presence of any 25 specific clinical conditions in a patient will confirm the diagnosis of AIDs • Commonly encountered • Candidiasis • Cryptococcosis • Cytomegalovirus disease • Kaposi’s sarcoma • Burkitts lymphoma • Mycobacterium tuberculosis • Wasting syndrome • Most recent significant change -CD4 - T4 lymphocyte count less than 200 / mm3 or less than 14% total lymphocyte is definitive for AIDS.

8. CDC Surveillance Case Classification • AIDS patients have been grouped as follows, according to the CDC Surveillance Case Classification (1993) - • Category A- includes patients with acute symptoms or asymptomatic diseases, along with individuals with persistent generalized lymphadenopathy, with or without malaise, fatigue, or low-grade fever. • Category B- patients have symptomatic conditions such as oropharyngeal or vulvovaginal candidiasis; herpes zoster; oral hairy leukoplakia; idiopathic thrombocytopenia; or constitutional symptoms of fever, diarrhea, and weight loss. • Category C- patients are those with outright AIDS as manifested by life-threatening conditions identified by CD4+T lymphocyte levels of less than 200 per cubic millimeter.

9. Systemic Manifestation • Symptoms • Fever • Malaise • Headache • Diarrhea • Lymphadenopathy • Hematological abnormalities • Neurological Diseases • Non-healing dermatological lesions

10. Oral & Periodontal Manifestations Of HIV Infection • Oral lesions associated with HIV infection can be broadly grouped as • Fungal • Bacterial • Viral infections • Neoplasms

11. Oral Manifestations Associated with HIV Infection include • Candidiasis • Oral hairy leukoplakia • Atypical periodontal disease • Kaposi’s sarcoma • Non hodgkins lymphoma • In addition • Melanotic hyperpigmentation • Atypical ulcerations • Viral infections caused by herpes simplex herpes zoster are common

12. Periodontal Diseases Associated with HIV Infection • Linear Gingival Erythema • ANUG • Necrotizing Ulcerative Stomatitis • NUP

13. Candidiasis • Most common in HIV +ve patients • Oppurtunistic infection – Normal oral flora • Fungal infection • Four clinical presentations • Pseudomembranous • Erythematous • Hyperplastic • Angular chelitis • Diagnosis- Microscopic examination of tissue sample or smear of material scraped from the lesion

14. Clinical Picture • Pseudomembranous- painless, senstive, white lesion readily scraped from oral mucosa , palate,buccal mucosa • Erythematous - red patches on the buccal or palatal mucosa associated with depappillation of the tongue • Hyperplastic - least common in buccal mucosa and tongue. Resistant to removal • Angular cheilitis- commissures appear erythematous with surface fissuring

15. Oral Hairy Leukoplakia • Asymptomatic, keratotic lesion • Lateral borders of the tongue affected • Vertical striations imparting corrugated appearance • Appears hairy when dried • Caused by Epstein Barr virus • Diagnosis –Biopsy – lesion suggestive of OHL HIV test to be performed

16. KAPOSI’S SARCOMA • Rare multifocal vascular neoplasm • Painless reddish purple macules or nodules in the mucosa • Different from classic form, more aggressive lesion • Most common site of involvement are the palate and the gingiva • Virus designated as human herpes virus – 8 ( HHV – 8) • Oral cavity may be the first or only site of the lesion • Diagnosis based on histological findings

17. Atypical Ulcers and Delayed Healing • Non specific oral ulceration in HIV individuals – multiple etiology like lymphoma,KS, sq ca. • HIV associated neutropenia may feature oral ulceration • HIV infected pts – recurrent herpetic lesion and aphthous stomatitis • CDC includes mucocutaneous herpes present for more than one month as a sign of AIDS • Herpes Simplex virus, Varicella Zoster virus, Epstein Bar virus or Cyto Megalo virus frequently are retrieved from non specific oral ulcers –possible etiologic role • ATYPICAL ulcers more severe and persistent in pt. with low CD4 cell count

18. Non Hodgkin’s Lymphoma • Most frequent malignant neoplasia • Caused due to Epstein Barr virus. • Fast growing mass generally on the palate, tongue or gingiva and soon it ulcerates and presents areas of extensive necrosis • Pain may not be present • Clinically the mass may be erythematous or purplish in colour with a boggy consistency.

19. Linear Gingival Erythema • Persistent, linear, easily bleeding erythematousgingiva • May or may not serve as precursor to rapidly progressive necrotizing ulcerative periodontitis. • Often unresponsive to corrective therapy yet such lesions may undergo spontaneous remission.

20. Nerotizing Ulcerative Stomatitis • Severely destructive acute painful (NUS) present in HIV +ve pt • Necrosis of oral soft tissue and underlying bone • Occurs separately or as extension of NUP and associated with severe depression of CD4 immune cells • Identical to cancrumoris (NOMA)

21. Necrotizing Ulcerative Gingivitis • Punched out crater like depressions, at the crest of interdental papillae, - extending to marginal gingiva • Surface of gingival crater – covered by gray, pseudomembranous slough. • Crater is demarcated from the remainder by a linear erythema.

22. Necrotizing Ulcerative Periodontitis • Characterized by soft tissue necrosis, rapid periodontal destruction and interproximal bone loss • NUP is present after marked CD4 cell depletion and usually localized to few teeth • Bone undergoes necrosis and subsequent sequestration

23. ACCORDING TO STUDY REPORTS • Susceptibility increases as immune system becomes more compromised • Injectable drug abusers - Oral candidiasis and linear gingival erythema

24. Diagnosis • Immunological tests • Total leukocyte and lymphocyte count • T-cell subset assays • Platelet count • IgG and IgA levels • Lymph node biopsy

25. Specific tests for HIV infection • Antigen detection • Antibody detection • Virus isolation • Serological tests

26. Screening for HIV • ELISA test – Enzyme linked immunosorbent assay • Blood sample obtained and sent to lab • Targeted antibody is linked to an enzyme • If target substance is in the sample, the test solution turns a different color • CONFIRMATORY – Western blot test • Gold standard • Analytic technique used to detect specific proteins in the sample of tissue extract

27. Periodontal Treatment Protocol • Health status • Infection control measures • Psychological factors Line of Treatment • Prophylactic treatment of opportunistic infections • Antiretroviral therapy • Vaccines • Psychological therapy

28. Candidasis • Early Oral lesions – topical drugs • Advanced oral lesions – systemic drugs Topical Drugs: • Clotrimazole • Clotrimazole ointment, 15-g tube: Apply to affected area Systemic Drugs • Ketoconazole • Fluconazole • Itraconazole

29. Oral Hairy Leukoplakia • Laser or conventional surgery • Antretroiviral therapy – Acyclovir • Zidovudine • Lamivudine

30. Kaposi’s Sarcoma • Antiretroiviral agents • Laser excision • Radiation therapy • Intralesional injection • Other chemotherapeutic drugs

31. Treatment of periodontal diseases associated with HIV infection • Debridement - Povidone iodine • Local Antimicrobial Therapy - Chlorhexidinegluconate 0.12% • Immediate follow up care • Systemic antimicrobial therapy Metronidazole - 250 mg 4times/days for 5 days

32. Non Specific Oral Ulceration's And Recurrent Apthae • Acyclovir - 200 to 800mg 5 times daily for 10 days • Maintenance dose 200 mg 2 to 5 times daily to prevent recurrence • Recurrent apthous ulcer - topical corticosteroids (fluocinonide gel) applied three to six times daily • Large apthae systemic corticosteriod (prednisone 40 to 60 mg daily)

33. Infection Control • Personal protection through vaccines, masks, gloves, etc. • Decontamination of used instruments. • Sterilization of instruments • Asepsis of the operating environment. • Surface disinfection • Aseptic surgical techniques • Postoperative aseptic techniques.

34. HIV Vaccines • Small parts of the HIV virus • Vaccines being tested should produce either antibodies or cytotoxic T cells to fight infection • They cannot cause HIV or AIDS. Types • Peptide vaccine • Recombinant sub-unit protein vaccine • Live vector vaccine • DNA vaccine • Virus- like particle vaccine (Pseudovirion )

35. Thank You