june 2000 principles of oral health management for the hiv/aids patient a course of training for the...
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June 2000
Principles of Oral HealthPrinciples of Oral Health
Management for the HIV/AIDS Management for the HIV/AIDS
PatientPatient
A Course of Training for the A Course of Training for the Oral Health ProfessionalOral 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
June 2000
Oral Manifestations Of Oral Manifestations Of
HIV Infection: HIV Infection:
Clinical Characteristics, Clinical Characteristics,
Diagnosis, And Treatment Diagnosis, And Treatment
RecommendationsRecommendations
Joan A. Phelan, DDS
June 2000
Diagnosis Of HIV Related Diagnosis Of HIV Related
Oral LesionsOral Lesions• Oral examination procedures are the Oral examination procedures are the
same for HIV patients as for all dental same for HIV patients as for all dental patientspatients
• Diagnostic procedures must be Diagnostic procedures must be appropriate to the identified problemappropriate to the identified problem
• Treatment should be based on either a Treatment should be based on either a provisional or definitive diagnosisprovisional or definitive diagnosis
• Diagnosis should be re-evaluated if Diagnosis should be re-evaluated if treatment is not effectivetreatment is not effective
June 2000
Oral Manifestations Of Oral Manifestations Of
HIV InfectionHIV Infection
• Opportunistic diseases--Opportunistic diseases--manifestations of immune manifestations of immune deficiency or derangement.deficiency or derangement.
• Not caused directly by HIV.Not caused directly by HIV.
• The same lesions occur in The same lesions occur in association with other immune association with other immune deficiency disorders.deficiency disorders.
June 2000
HIV-related Oral LesionsHIV-related Oral Lesions
• InfectionsInfections
– Fungal, Viral, BacterialFungal, Viral, Bacterial
• NeoplasmsNeoplasms
– Kaposi’s Sarcoma, Non-Hodgkin’s LymphomaKaposi’s Sarcoma, Non-Hodgkin’s Lymphoma
• OtherOther
– Non-specific or Aphthous-like Ulcers, Non-specific or Aphthous-like Ulcers, Lichenoid or Drug Reactions, Salivary Gland Lichenoid or Drug Reactions, Salivary Gland DiseaseDisease
June 2000
Oral CandidiasisOral Candidiasis
• Pseudomembranous
• Erythematous
• Hyperplastic
• Accompanying angular cheilitis
June 2000
June 2000
June 2000
Pseudomembranous Pseudomembranous
CandidiasisCandidiasis• Appearance: white “curd-like” Appearance: white “curd-like”
material that wipes off revealing material that wipes off revealing an underlying erythematous an underlying erythematous mucosamucosa
• Clinical Diagnosis: generally made Clinical Diagnosis: generally made on the basis of appearanceon the basis of appearance
June 2000
Erythematous CandidiasisErythematous Candidiasis
• Appearance: mucosal erythema Appearance: mucosal erythema and/or patchy-depapillation of the and/or patchy-depapillation of the dorsal tonguedorsal tongue
• Definitive diagnosis requires:Definitive diagnosis requires:– Identification of fungal hyphae in the Identification of fungal hyphae in the
lesionlesion– Response of the lesion(s) to antifungal Response of the lesion(s) to antifungal
therapytherapy
June 2000
June 2000
June 2000
Hyperplastic CandidiasisHyperplastic Candidiasis• Appearance: as a leukoplakia (a Appearance: as a leukoplakia (a
white lesion that does not rub off)white lesion that does not rub off)
• Definitive diagnosis requires:Definitive diagnosis requires:– Identification of fungal hyphae in the Identification of fungal hyphae in the
lesionlesion– Response of the lesion(s) to antifungal Response of the lesion(s) to antifungal
therapytherapy– If unresponsive to antifungal therapy, If unresponsive to antifungal therapy,
biopsy must be consideredbiopsy must be considered
June 2000
June 2000
Angular CheilitisAngular Cheilitis
• Appearance: erythema and/or Appearance: erythema and/or fissuring at the corners of the fissuring at the corners of the mouthmouth
• Frequently accompanies intraoral Frequently accompanies intraoral candidiasiscandidiasis
June 2000
June 2000
Treatment Of Oral Treatment Of Oral
CandidiasisCandidiasis
• Topical Antifungal TherapyTopical Antifungal Therapy
• Systemic Antifungal TherapySystemic Antifungal Therapy
June 2000
Hairy LeukoplakiaHairy Leukoplakia
• Appearance: white corrugated Appearance: white corrugated lesion on the lateral border of the lesion on the lateral border of the tonguetongue
• Clinical Diagnosis:Clinical Diagnosis:– known seropositive patientsknown seropositive patients– patients with unknown HIV statuspatients with unknown HIV status– definitive diagnosis requires definitive diagnosis requires
identification of Epstein-Barr virus identification of Epstein-Barr virus infected epithelial cellsinfected epithelial cells
June 2000
June 2000
June 2000
Hairy LeukoplakiaHairy Leukoplakia• Treatment and Management: Treatment and Management:
– Generally does not require treatmentGenerally does not require treatment– Antiviral treatment and topical Antiviral treatment and topical
podophyllum resin have been used to podophyllum resin have been used to treat --the result is temporarytreat --the result is temporary
– May wax and wane without treatmentMay wax and wane without treatment
June 2000
Oral UlcersOral Ulcers• Herpes simplex Herpes simplex
infectioninfection
• Varicella zoster Varicella zoster infection infection (“Shingles”)(“Shingles”)
• Cytomegalovirus Cytomegalovirus infectioninfection
• Aphthous ulcersAphthous ulcers
• HistoplasmosisHistoplasmosis
• LymphomaLymphoma
• Necrotizing Necrotizing ulcerative gingivitis ulcerative gingivitis (NUG)(NUG)
• Necrotizing Necrotizing ulcerative ulcerative periodontitis (NUP)periodontitis (NUP)
• Necrotizing Necrotizing stomatitis (NS)stomatitis (NS)
June 2000
Herpes Simplex Herpes Simplex
InfectionInfection• Atypical herpes simplex ulceration is Atypical herpes simplex ulceration is
a frequent cause of mucosal a frequent cause of mucosal ulceration ulceration
• Diagnosis may be confirmed using Diagnosis may be confirmed using mucosal smear, viral isolation mucosal smear, viral isolation (culture) or biopsy(culture) or biopsy
• Ulcers generally respond to systemic Ulcers generally respond to systemic anti-viral treatmentanti-viral treatment
June 2000
June 2000
Low Incidence Low Incidence
InfectionsInfections• Viral Viral
– Varicella-ZosterVaricella-Zoster– CytomegalovirusCytomegalovirus
• FungalFungal– HistoplasmosisHistoplasmosis
• BacterialBacterial– TuberculosisTuberculosis– SyphilisSyphilis
June 2000
June 2000
June 2000
Major Aphthous-like Major Aphthous-like
UlcersUlcers• Appearance: persistent, nonspecific Appearance: persistent, nonspecific
ulcersulcers
• Biopsy and histologic examination may Biopsy and histologic examination may be necessary to exclude other causesbe necessary to exclude other causes
• Systemic and topical corticosteroid Systemic and topical corticosteroid therapy have been successful therapy have been successful managementmanagement
• Topical tetracycline application and Topical tetracycline application and systemic thalidomide have also be usedsystemic thalidomide have also be used
June 2000
June 2000
June 2000
Non-Hodgkin’s LymphomaNon-Hodgkin’s Lymphoma
• Appearance: necrotic, ulcerated or Appearance: necrotic, ulcerated or nonulcerated masses, when nonulcerated masses, when occurring in the oral cavityoccurring in the oral cavity
• Diagnosis: biopsy and histologic Diagnosis: biopsy and histologic examinationexamination
June 2000
June 2000
Necrotizing Ulcerative Necrotizing Ulcerative
Periodontal DiseasePeriodontal Disease• Characterized by painful gingival Characterized by painful gingival
ulceration and may result in loss of ulceration and may result in loss of alveolar bonealveolar bone
• Management: Management: – antibiotic therapy antibiotic therapy – debridement of necrotic tissuedebridement of necrotic tissue – meticulous home caremeticulous home care
June 2000
June 2000
June 2000
June 2000
Lesions Caused By Human Lesions Caused By Human
Papilloma Virus (HPV)Papilloma Virus (HPV)• Appearance: exophytic, papillary, oral Appearance: exophytic, papillary, oral
mucosal lesionsmucosal lesions
• Several different types of HPV have been Several different types of HPV have been reported to cause lesions reported to cause lesions
• May be multipleMay be multiple
• Often difficult to treat due to a high risk of Often difficult to treat due to a high risk of recurrencerecurrence
June 2000
June 2000
Pigmented And Pigmented And
Erythematous LesionsErythematous Lesions
• Kaposi’s sarcomaKaposi’s sarcoma
• Mucosal melanin pigmentationMucosal melanin pigmentation
• Linear gingival erythemaLinear gingival erythema
June 2000
Kaposi’s SarcomaKaposi’s Sarcoma• Appearance: Oral lesions appear as Appearance: Oral lesions appear as
reddish purple, raised or flatreddish purple, raised or flat
• Size ranges from small to extensiveSize ranges from small to extensive
• Behavior is unpredictableBehavior is unpredictable
• Definitive diagnosis: biopsy and histologic Definitive diagnosis: biopsy and histologic examinationexamination
• No curative therapy--radiation treatment, No curative therapy--radiation treatment, chemotherapy and sclerosing agents have chemotherapy and sclerosing agents have been, used to control oral lesionsbeen, used to control oral lesions
June 2000
June 2000
June 2000
Mucosal Melanin Mucosal Melanin
PigmentationPigmentation• Single and multiple oral mucosal Single and multiple oral mucosal
melanotic macules have been report melanotic macules have been report to occur in HIV infected individualsto occur in HIV infected individuals
• Significance is not knownSignificance is not known
• Some have been associated with Some have been associated with zidovudine therapyzidovudine therapy
• Treatment is not indicatedTreatment is not indicated
June 2000
June 2000
Linear Gingival Linear Gingival
ErythemaErythema• Appearance: a distinct band of Appearance: a distinct band of
erythema of the gingival marginerythema of the gingival margin
• Erythema does not respond to Erythema does not respond to removal of local factorsremoval of local factors
• Cause is not knownCause is not known
June 2000
June 2000
June 2000
Salivary Gland DiseaseSalivary Gland Disease
• Bilateral parotid gland Bilateral parotid gland enlargement occurs in HIV infected enlargement occurs in HIV infected individualsindividuals
• Histology has been described as Histology has been described as resembling autoimmune salivary resembling autoimmune salivary gland disease with cystic changesgland disease with cystic changes
June 2000
June 2000
Surgeon General’s Report Surgeon General’s Report
Oral HealthOral HealthOral 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.”