oral manifestations of hiv...oral hairy leukoplakia •virtually diagnostic of hiv (but not always)...

Oral Manifestations of HIV

Dr Claire McGoldrickConsultant Infectious Diseases Physician

Monklands Hospital

Objectives

• To have a basic understanding of HIV

• To recognise some of the oral clues to an HIV diagnosis and promote referral/signposting for testing

• To recognise oral lesions that can occur in known HIV positive individuals

www.hps.scot.nhs.uk

http://hivinsite.ucsf.edu/InSite-KB-ref.jsp?page=kb-03-01-01&ref=kb-03-01-01-fg-02&no=2

http://www.aidsmap.com/v635494203890000000/file/1187469/drug_chart_october_2014_web.pdf

Transmission

• Graph showing HIV with time and exposure groups in the UK

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf

Oral Manifestations

• Infections

- Reactivation of latent infections normally kept in check by immune

system

- Normally non-pathogenic organisms

- More severe forms of ordinary infections

- Higher exposure to certain pathogens

• Neoplasms

• Other

Why should you know this?

• Unique position to recognise some clues to the presence of HIV – although they are not necessarily pathognomonic of HIV

• You may be responsible for the dental health of a person living with HIV

Oral Candidiasis

Oral Candidiasis

• Pseudomembranous Candidiasis

• Erythematous Candidiasis

• Angular Cheilitis

• Chronic Hyperplastic Candidiasis

Pseudomembranous Candidiasis

• Creamy white or yellow plaques

• Can be scraped off to leave erythematous or bleeding mucosa

• On any intra-oral surface

• No symptoms or mild-moderate pain/burning

• Clinical diagnosis, but can swab

Image courtesy of Dr Rob Laing, Aberdeen Royal Infirmary

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Erythematous Candidiasis

• Patchy red areas – may become diffuse and atrophic

• Mainly hard palate and dorsum of tongue, occasionally buccal mucosa

• No symptoms or mild-moderate pain/burning

• Clinical diagnosis, but can swab

Image courtesy of: AIDS Images Library www.aids-images.ch

Angular Cheilitis

• Erythema an fissures /ulcers at corners of mouth

• No symptoms or mild-moderate pain/burning

• Clinical diagnosis, but can swab

http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf

Chronic Hyperplastic Candidiasis

• Rough and irregular, speckled or homogenous white patches that cannot be wiped off

• Mainly buccal mucosa near labial commisures– less frequent involvement of palate or tongue

• Usually no symptoms, but speckled lesions may cause discomfort

• Clinical diagnosis, but can swab

• May demonstrate dysplasia

Oral Candidiasis

• Early HIV disease associated with mild oral candida

• Late HIV disease leads to extensive oral and oesophageal candidiasis

• Other causes of oral candida– Diabetes– Steroids (inhaled and oral)– Antibiotics

• Treatment: Miconazole Gel, Nystatin, Fluconazole etc

Oral Hairy Leukoplakia

Oral Hairy Leukoplakia

• Virtually diagnostic of HIV (but not always)• Induced and maintained by repeated direct EBV infection of

epithelial cells• More prevalent with lower CD4 counts• Whitish, elevated, non-removable - surface

characteristically has vertical ridges but can be smooth• Located at lateral borders of tongue, but may extend onto

ventral/dorsal surface of tongue and occasionally onto buccal mucosa

• Usually asymptomatic• Clinical diagnosis• No specific treatment

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Oral Ulceration

Oral Ulceration

• Primary HIV Infection (Remember “Window Period”)• Major/Minor/Herpetiform Aphthous Ulcers• Syphilis• HSV• VZV• CMV• Periodontal Infections• Ulcerated Neoplasms• Other

• Consider need for HIV test / swabs / biopsy

Recurrent Aphthous Ulcers

• Unknown cause

• Well circumscribed , erythematous margin

• Usually non-keratinized mucosae

• Minor – solitary and 0.5-1cm

• Herpetiform – clusters of small ulcers – 1-2mm(usually soft palate or oropharynx)

• Major – 2-4cm, necrotic (very painful)

• May require biopsy (especially major)

• Topical vs Systemic Treatment

HSV

• Herpes Labialis – multiple small vesicles/ulcers on lips and sometimes surrounding skin

• Intra-oral HSV = small, round vesicles that rupture leaving shallow ulcers that may coalesce

• Lesions are superimposed on an erythematous base

VZV

• Reactivation of VZV

• Intra-orally, it presents as roughly linear eruption of herpetiform vesicles or bullae that ulcerate (may coalesce)

• Mild-severe pain

• Clinical diagnosis, swab for PCR

• Aciclovir/Famciclovir/Valaciclovir

CMV

• Punched out ulcers (from mm to several cm)

• Can erode into deep tissues

• Mainly palate or gingiva, but occasionally buccal mucosa, tongue and pharynx

• Mild-severe pain and xerostomia

• May be treated with ganciclovir/valganciclovir

Human Papilloma Virus

HPV

• Warts

• HPV-induced condyloma may be pearly, filiform, fungating, cauliflower, or plaque-like

• Not exclusive to HIV, but severe or extensive warts are suggestive

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Kaposi’s Sarcoma

Kaposi’s Sarcoma

• Tumour arising from the endothelium

• Preponderance for the skin, palate, bronchi & gut

• Associated with HHV8

• In mouth, most commonly hard palate involved, followed by gingiva and buccal mucosa

• Usually painless

• Biopsy (but may need platelet count first)

• Treatment: cART, Systemic Chemo, Intra-lesionalChemo, Radiotherapy

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Image courtesy of: AIDS Images Library www.aids-images.ch

Non-Hodgkin’s Lymphoma

NHL

• EBV association

• Lymphoma often occurs in unusual sites in the context of HIV

• Diffuse, rapidly proliferating, slightly purplish mass

• B-symptoms

• Biopsy, CT

• Treatment: Resection, Chemo, Radiotherapy

Image courtesy of: AIDS Images Library www.aids-images.ch

Periodontal Disease

Periodontal disease in HIV-infectedindividuals

• Linear Gingival Erythema

• Necrotising Periodontal Diseases

- Necrotising Ulcerative Gingivitis

- Necrotising Ulcerative Periodontitis

- Necrotising Stomatitis

• Chronic Periodontitis

Linear Gingival Erythema

• HIV Gingivitis, Red-Band Gingivitis

• Erythematous band on gingival margin (extends 2-3mm from gingival margin)

• Erythema is disproportionate to local factors such as plaque and calculus

• Lack of response to oral hygiene measures

• May be tender and bleed easily

http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf

Necrotising Ulcerative Gingivitis

• Characteristic Lesion = punched out, ulcerated and erythematous interdental papilla covered by a greyish necrotic slough

• Moderate-severe pain, bleeding, fetor oris

• Systemic symptoms eg fever, malaise, lymphadenopathy may be present

• Sudden onset and rapid deteropration

• Clinical Diagnosis

Necrotising Ulcerative Gingivitis

http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf

Necrotising Ulcerative Periodontitis

• Ulcerated erythematous gingival tissues, particularly interdental papilla, covered by a greyish necrotic slough

• May be exposed bone, gingival recession and tooth mobility

• Moderate-severe pain, bleeding and fetor oris. May be systemic symptoms eg fever, malaise, lymphadenopathy

• Sudden onset and rapid worsening• Clinical Diagnosis

Necrotising Ulcerative Periodontitis

http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf

Necrotising Ulcerative Stomatitis

• Extensive are of ulceration, tissue necrosis and erythema that extends from gingival into adjacent mucosa

• May involve bone leading to osteonecrosis and sequestration

• Moderate-severe pain, bleeding, fetor oris. Usually associated with systemic symptoms of fever, malaise and lymphadenopathy

• Sudden onset and rapid worsening• Clinical Diagnosis

Necrotising Ulcerative Stomatitis

http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf

Treatment of HIV-Associated Periodontal Disease

• Treat as would in HIV-negative

• Encourage home oral hygiene

• Irrigation and rinsing with povidone iodine or chlorhexidine

• Systemic antibiotics eg metronidazole

Other Conditions

• Other conditions

– Xerostomia

– Bleeding secondary to thrombocytopenia

Effect of cART

• Generally less oral manifestations due to improved immune system

• Some may persist eg aphthous ulceration

• Some may recur even in context of adequate viral control eg periodontal disease

Accessing an HIV Test

• Refer to GP

• THT – Fastest Clinics, Postal Tests

• Sexual Health Clinic (Tel: 0845 6187191)

Conclusions

• Think about the possibility of HIV

• Signpost for testing

• Consider investigations/ treatments that may be needed

Acknowledgments

• Dr Rob Laing, Consultant Infectious Diseases Physician, Aberdeen Royal Infirmary

• Images courtesy of: AIDS Images Library www.aids-images.ch

Information and Images also from: http://www.ashm.org.au

www.hps.scot.nhs.uk

http://hivinsite.ucsf.edu

http://www.aidsmap.com/v635494203890000000/file/1187469/drug_chart_october_2014_web.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf

www.hivdent.org

Reznik DA. Perspective – Oral Manifestations. Topics in HIV Medicine. 2005; 13:143-148.