Oral Disease in Patients with HIV Infection

1. Oral Disease in Patients with HIV Infection CAPT G. Todd Smith, ret Phoenix Indian Medical Center

2. Contributors of photos and data: aidsetc.org HIVdent.org Nebraska and New Mexico AIDS Educational Training Centers cdc.gov/hiv Ann Lyles, USC School of Dentistry

4. Epidemiology Nearly 25% of the 1 million Americans with HIV are unaware they are infected. Women account for 29% of HIV/AIDS diagnoses among AI/ANs. In 2005, an estimated 1,581 AI/ANs were living with AIDS. 9 years after dx with AIDS, 67% of AI/ANs were alive. A 21 y.o. infected with HIV today will live to age 60.

5. Oral Disease in HIV Infection Oral infections and neoplasms occur with immunosuppression 90% of HIV + patients have at least one oral manifestation Oral disease is rarely self-limiting Untreated oral disease may lead to systemic infection, weight loss, dehydration, and malnutrition One study only 9% get treated for oral manifs 90%- from NY State Dept of HealthOne study only 9% get treated for oral manifs 90%- from NY State Dept of Health

6. Occupational Transmission of HIV HIV is present in low levels in saliva (Yeung, 1993) There is no convincing evidence that plain saliva can transmit HIV infection. Risk is � 1/200 (0.3%) with a needlestick Starting antiretroviral therapy within 1-4 h of an exposure can reduce incidence of transmission by more than 80% MMWR�95 Post exposure prophylaxis usu with HAART �Extremely unlikely� needlestick transmission during dental carePost exposure prophylaxis usu with HAART �Extremely unlikely� needlestick transmission during dental care

7. Before we treat these oral maifes of HIV�. HCV in almost 50% HIV cases Viral load > 3000 increase oral manifestations T count- CD4s 500 normal PO complications no greater risk, routine abx contraindicated. ANC<1000 abx ANC < 500 delay tx Platelets 60-80 limit tx. < 60 physician consult. Possibly platelet transfusion? INR doesn�t tell whole story. Before we treat these oral maifes of HIV�. HCV in almost 50% HIV cases Viral load > 3000 increase oral manifestations T count- CD4s 500 normal PO complications no greater risk, routine abx contraindicated. ANC<1000 abx ANC < 500 delay tx Platelets 60-80 limit tx. < 60 physician consult. Possibly platelet transfusion? INR doesn�t tell whole story.

8. Oral Manifestations of HIV/AIDS:9 times higher prevalence when CD4+ T-cell count is less than 200 cells/mm3 (Shiboski, 1994) Microorganisms Fungal Viral Bacterial Neoplasms Iatrogenic

9. Pseudomembranous Candidiasis

10. Fungal Pseudomembranous Candidiasis Opportunistic fungal infection caused most frequently by Candida albicans Primary locations include the tongue, buccal mucosa, hard and soft palate Considered asymtomatic; some may experience burning, pain, and altered taste Multi-focal, ill-defined, irregular white plaques that can be rubbed off

11. Atrophic/Erythematous Candidiasis

12. Fungal Erythematous Candidiasis Opportunistic fungal infection caused most frequently by Candida albicans Primary locations include the tongue and hard palate Burning sensation and dry mouth Multi-focal, ill-defined, irregular red patches (median rhomboid glossitis)

13. Linear Gingival Erythema

14. Angular cheilitis

15. Fungal Linear gingival erythema (LGE)- gingival disease of fungal origin Angular cheilitis Ulcerative, crusting lesions with erythema at the commissures. Hyperplastic candidiasis Multi-focal, hair-like projections on the cheek mucosa along the linea alba. When T count < 100 can develop into esophageal candidiasis

16. Topical Treatment of Oral Candidiasis Clotrimazole (Mycelex) 10 mg troches dissolved in the mouth 5x /day for 7-14 days Nystatin (Mycostatin) rinse, 100,000units/ml. Hold 1 tsp in mouth for 2 min and swallow or spit 4x/day Clotrimazole 1% cream- for angular cheilitis Mycelex troches have sugar Edentulous soak denture in dilute bleach.Mycelex troches have sugar Edentulous soak denture in dilute bleach.

17. Systemic Treatment of Oral Candidiasis (consider when CD4 count is lower than 150) Fluconazole (Diflucan) 100 mg daily for 14 days Ketoconazole (Nizoral) 200 mg daily for 14 days

18. Oral Hairy Leukoplakia

19. Viral Lesions Oral Hairy Leukoplakia- Epstein-Barr (EBV) virus Regarded as a marker of immunosuppression Predictive of disease progression to AIDS Affects the lateral borders of the tongue, ventral tongue and buccal vestibule Usually asymptomatic Usually treatment not indicated

20. Verruca vulgaris

21. Viral Lesions Oral warts Human papillomaviruses (HPV) Appears as smooth-surfaced, flesh-colored or white papules Oral verruca vulgaris is a papillary or pedunculated form of HPV Occur mostly on keratinized mucosa Treatment is excision when indicated On the rise- concern with HPV/CA link

22. Herpes Simplex Virus

23. Viral Lesions Oral Herpes Simplex/ Herpes Labialis (fever blisters) Herpes Simplex Virus (HSV) Generally more widespread, aggressive, prolonged, and atypically distributed than in non-immunosuppressed patients Typical sites include the hard palate and the attached gingiva but oral mucosal surfaces may be involved Appear as small vesicles that coalesce with weeping crusts or yellow border

24. Viral Lesions HSV Cont�d: Lesions are painful and may interfere with nutrition Treatment options Acyclovir (Zovirax) 400-800 mg 3x/day for 7 days Valacyclovir 500 mg twice daily for 7 days ($$$$) Palliative support- 1:2:3 mouthrinse Topical acyclovir ointment for recurrent herpes-questionable effectiveness

25. Viral Lesions Cytomegalovirus (CMV)

26. Viral Lesions Cytomegalovirus (CMV) Painful, large, sharply demarcated, nonspecific ulcerations, usually represented by dissemination of CMV Occurs on both keratinized and nonkeratinized mucosa and clinically cannot be distinguished from major aphthous ulcerations Diagnosis only rendered by deep biopsy CMV causes retinitis in AIDS patients Rx Ganciclovir, especially when retinitis

27. Periodontal disease

28. Periodontal Diseases Most common oral bacterial infection among HIV-infected persons Contributing factors include poor diet, poor oral hygiene, and xerostomia Regular cleanings and good oral hygiene needed Greater prevalence with increased viral load and presence of Candida and herpesviruses LOA increases with decrease in CD4sLOA increases with decrease in CD4s

29. Necrotizing Ulcerative Periodontitis

30. Necrotizing periodontal diseases PAINFUL Prevalence up to 6.3% Lamster 1997 Necrotizing ulcerative gingivitis (NUG) Characterized by ulceration and necrosis of the interproximal gingiva with mucosal sloughing Often responsible for rapid tissue destruction Necrotizing ulcerative periodontitis (NUP) When extends into the adjacent tissues and bone

31. Necrotizing Periodontal Diseases Treatment of NUG/NUP involves the use of aggressive tissue debridement to remove pathogens and the administration of systemic antibiotics Povidone-iodine as irrigant during debridement Flagyl (metronidazole) 250 mg 3 x/day x 5days Amoxicillin 500mg with Flagyl 3X/day x 5days Antimicrobial rinses (0.12% Chlorhexidine)

32. Aphthous Ulcers

33. Other Ulcerative Lesions Recurrent Aphthous Stomatitis (canker sores) Idiopathic problem that affects 40% of the general population Occurs with increased frequency with HIV infection Minor are small ulcerations ( < 1 cm) Major are large ulcerations ( > 1 cm)

34. Other Ulcerative Lesions Recurrent Aphthous Stomatitis Topical steroids such as dexamethasone 0.5mg/5ml-swish 30 secs then spit 4x/day OTCs to cauterize or cover smaller lesions Systemic steroids in severe cases and major apthous prednisone 20mg 3X/day X4 days then reduce 5mg each day. Debacterol Colgate �Orabase Soothe N seal�Debacterol Colgate �Orabase Soothe N seal�

35. Kaposi Sarcoma

36. Neoplasms Kaposi�s Sarcoma (KS) Most common malignancy associated with HIV Human Herpesvirus 8 (HH-8) has been implicated as a possible co-factor for KS Oral cavity may be the initial site in 50% of cases Early lesions appear as asymptomatic reddish-purple macules

37. KS Lesions progress to painful papules and nodules that may ulcerate and bleed Presence of KS always associated with immunodeficiency Also seen in kidney transplant recipients Treat with localized injection of chemotherapeutic agents or surgical removal. With extraoral lesions, systemic chemo. Oncology referral Local chemo- vinblastine sulfateLocal chemo- vinblastine sulfate

38. Lymphoma

39. Neoplasms Non-Hodgkin�s lymphoma second most common malignancy in AIDS can be painful tumors present intraorally as soft tissue masses, frequently with secondary ulcerations, and may resemble KS most commonly occurs on the palate, retromolar area, and gingiva Oncology referral Lymphoma of the parotid common oral site.Lymphoma of the parotid common oral site.

40. Salivary Gland Dysfunction/Xerostomia Side effect of nearly all medications Dry Mouth promotes dental caries and periodontal disease Treatment is to restore hydration and avoid irritating foods/habits Possible link between Viral Load and Salivary Gland Dysfunction 30% incidence 1 study30% incidence 1 study

41. Salivary Gland Dysfunction/Xerostomia Paraparotid fat disposition-lipodystrophy syndrome-refer to MD Mandel 2008 Avoid cinnamon, abrasive foods, acidic foods, spicy or overly sweet foods, and desiccants Encourage high protein foods, cool or frozen foods, and low sucrose carbohydrates

42. Xerostomia

43. Treatment of Dryness Saliva substitutes Oralbalance gel Salivart spray Cholinergic Medications Pilocarpine (Salagen) - 5 mg TID 30 min. before meals to 30 mg daily maximum Biotene Products

44. Medication induced hyperpigmentation especially AZT AZT 1st antiretroviral protease inhibitor- 1987 Azidothymidine usually called zidovudine (zidoVOOdineAZT 1st antiretroviral protease inhibitor- 1987 Azidothymidine usually called zidovudine (zidoVOOdine

45. Other Oral Manifestations Fungal- Histoplasmosis Cryptococcosis Bacterial Infections Actinomyces Enterobacter Mycobacterium (Tuberculosis) Viral- Varicella-Zoster virus (shingles) Lichen Planus Erythema Multiforme EM- palliative tx. MD referral to R/O systemic infec (HSV, toxoplasmosis LP- Med induced. Change dose? Histo- common systemic fungal infec. Develop immunity in 2-3 weeks in healthy pts. Granulomatous lesions orally Crypto- survival in MONTHS. Crater like ulcers Molluscum contagiosum- DNA poxsvirus. Spont remission 6-9 months. Crater like lesions TB- one leading cause of death HIV+. HIV+ 400X > risk TB infection Now multiple drug resistant TB.EM- palliative tx. MD referral to R/O systemic infec (HSV, toxoplasmosis LP- Med induced. Change dose? Histo- common systemic fungal infec. Develop immunity in 2-3 weeks in healthy pts. Granulomatous lesions orally Crypto- survival in MONTHS. Crater like ulcers Molluscum contagiosum- DNA poxsvirus. Spont remission 6-9 months. Crater like lesions TB- one leading cause of death HIV+. HIV+ 400X > risk TB infection Now multiple drug resistant TB.

46. Use of HAART Significant decrease in prevalence of opportunistic diseases like candidiasis, hairy leukoplakia and NUP. Generally safe to use analgesics, local anesthesia, and antibiotics. Few drug-drug interactions. Immune Reconstitution Syndrome Paradoxical transient deterioration in immune function during initial response to HAART. Increase in some oral lesions like KS initially. Highly Active antiretroviral therapy Bactrim- 50% allergic HAART- usually 3 or 4 in combo Reverse transcriptase inhibitors Protease inhibitors Integrase inhibitors Entry inhibitors Efavirenz + zidovudine + lamivudine Lopinavir +ritonavir +�.. Drug-drug interactions- ritonavir (Norvir)- in Kaletra AVOID sedatives versed and halcion (mid- and triaz-) and demerol standard abx and pain meds no add�n concerns except bactrim- 50% w allergies Highly Active antiretroviral therapy Bactrim- 50% allergic HAART- usually 3 or 4 in combo Reverse transcriptase inhibitors Protease inhibitors Integrase inhibitors Entry inhibitors Efavirenz + zidovudine + lamivudine Lopinavir +ritonavir +�.. Drug-drug interactions- ritonavir (Norvir)- in Kaletra AVOID sedatives versed and halcion (mid- and triaz-) and demerol standard abx and pain meds no add�n concerns except bactrim- 50% w allergies

47. Primary Care Providers Oral examination should be provided at every physical examination by the medical provider Current blood data e.g. white blood count with differential, the absolute neutrophil count and the platelet count should communicated to the dental professional Only 9% of oral manifs get treatment one study Only 9% of oral manifs get treatment one study

48. Primary Care Providers Refer to a dental care provider when Patient not seen within one year Bleeding gums Loose or cavitated teeth Ill-fitting dentures Dry mouth Soft tissue lesions 73% in urban free dental clinic willing to take a free rapid HIV screening test. Called OraQuick- simple intraoral swab.73% in urban free dental clinic willing to take a free rapid HIV screening test. Called OraQuick- simple intraoral swab.

49. Questions?