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Oral Lesions of HIV in the Era of HAART. Roseann Mulligan DDS, MS USC School of Dentistry and the Pacific AIDS Education and Training Center. Impact of Oral Conditions – HIV+ Patients. High rate of oral manifestations Oral lesions may be harbinger of change in HIV condition

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Oral lesions of hiv in the era of haart

Oral Lesions of HIV in the Era of HAART

Roseann Mulligan DDS, MS

USC School of Dentistry

and the

Pacific AIDS Education and Training Center


Impact of oral conditions hiv patients
Impact of Oral Conditions – HIV+ Patients

  • High rate of oral manifestations

  • Oral lesions may be harbinger of change in HIV condition

  • Relative ease of access to identification of lesions by those in clinical practices

  • Potential impact on systemic health care outcomes

  • Potential impact on quality of life

    Adapted from Sifri R, Diaz V, Gordon L, Glick M, Anapol H. et al. Oral health care issues in HIV disease: developing a core curriculum for primary care physicians. J Am Board Fam Pract 1998; 11(6):434-44


High rate of oral manifestations
High rate of oral manifestations

  • More than 90% of patients have at least one oral lesion during their disease course. 1

  • Are almost always accompanied by symptoms

  • Take a variety of appearances that are for the most part characteristic

    1New York State Dept of Health AIDS Institute's Best Practices. Promoting oral health care for people with HIV infection. January 2004.


Oral lesions of hiv in the era of haart

Oral lesions ~ Harbinger of Δ HIV status

  • Often the first clinical feature of HIV infection is an oral lesion. 1

  • New lesions in HIV-infected patient - a sign that HIV disease is progressing.

  • Untreated HIV infected with oral candidiasis progress to AIDS within two years. 1

  • May indicate need for prophylaxis against specific opportunistic infections.

    1New York State Dept of Health AIDS Institute's Best Practices. Promoting oral health care for people with HIV infection. January 2004.


Medical history
Medical history

1. Questionnaires2. Patient observation3. Medical Interview

4. Risk Assessment

5. Head/Neck Exam6. Diagnostic tests



Oral lesions of hiv in the era of haart

CD4 Status and Relationship to Outcomes


Platelets
Platelets

  • Number of platelets in a drop (uL) of blood

  • Normal range: 150,000-400,000/uL

  • Unsafe to do invasive dental tx <60,000

  • Spontaneous bleeding <50,000


Neutrophils
Neutrophils

  • Normal range: 3,000-7,000/ mm

  • Neutropenia: <1000/mm3

  • Severe neutropenia<500/mm3

    **May require antibiotic prophylaxis before

    invasive dental treatment


Oral manifestations of hiv infection
Oral Manifestations of HIV Infection

http://www.aids-ed.org/ppt/nw_schubert_oralupdate_03.ppt


Oral manifestations of hiv infection1
Oral Manifestations of HIV Infection

http://www.aids-ed.org/ppt/nw_schubert_oralupdate_03.ppt


Oral candidiasis
Oral Candidiasis

  • Most Common+ often predicts HIV progression

  • Candida albicans is the most prevalent

  • 3 types: pseudomembranous ª; erythematous ª; hyperplastic.


Oral candidiasis1
Oral Candidiasis

  • Pseudomembranous (Thrush) Characterized by the presence of white curds or creamy cotton like appearance

  • Can be easily removed. The underlying mucosa is erythematous and may bleed slightly.

  • Immunosuppresion


Oral candidiasis2
Oral Candidiasis

  • Atrophic (Erythematous)

  • In non-immunosuppressed

  • Associated in patients w/ ill-fitting dentures or in those who wear their dentures continuously

  • Generalized red area of atrophic tissue, commonly on the palate

  • Burning sensation, palate, tongue

  • Culture, smear not very effective


Oral candidiasis3
Oral Candidiasis

  • In tongue loss of the filiform papilla, a generalized thinning of the epithelium, and excessive inflammation of the connective tissue

  • Median Rhomboid Glossitis


Oral candidiasis4
Oral Candidiasis

  • Chronic Hyperplastic usually presents as a white mucosal plaque.

  • Most common location: buccal mucosa along the occlusal line in the commissure, latero-dorsal surface of tongue and the alveolar ridges

  • Frequently term

    “candidal leukoplakia”


Oral candidiasis5
Oral Candidiasis

  • Angular cheilitis


Oral lesions of hiv in the era of haart

Perspective – Oral Manifestations Volume 13 Issue 5 December 2005/January 2006


Herpes simplex
Herpes Simplex

  • Recurrent herpes labialis : lips: dry mucosa or skin, fluid-filled vesicle, that rupture, ulcerate, and resolve as crusted brownish lesions.

  • Recurrent intraoral herpes: maxillary gingiva, palate: wet and fragile mucous membranes. Lesions are punctate with red or white bases that slowly disappear.


Oral lesions of hiv in the era of haart

Epstein-Barr Virus (EBV)

Oral Hairy Leukoplakia

White, often corrugated in appearance, plaque-like or hair-like projections that are non- wipeable, lateral borders of tongue.

It appears in late latency stages HIV or precursor of AIDS.

Definitive Dx: Histopathology


Oral lesions of hiv in the era of haart

Epstein-Barr Virus (EBV)

Oral Hairy Leukoplakia

Treatment

  • Treat for cosmetic reasons; otherwise no treatment is warranted


Human papilloma virus hpv
Human Papilloma Virus (HPV)

  • HAART  

  • Assoc. w/ ~2.6 -6-fold  incidence of oral warts

  •  aphthous ulcers & salivary gland dz→caries

    Diz Dios P, Ocampo A, Miralles C. (2000) ; Patton LL, et al. (2000); Patton LL, (2003) .


Human papilloma virus hpv1
Human Papilloma Virus (HPV)

  • In the oral cavity the most common are, squamous papilloma HPV 6 & 11; verruca vulgaris HPV 2-4 and condyloma acuminatum HPV 6 & 11

  • Clinically may appear exophitic, keratinized, sessile papules or nodules “cauliflower-like 2-5mm“


Human papilloma virus hpv2
Human Papilloma Virus (HPV)

SP: High incidence on the soft palate, faucial pillars, uvula.

VV: Lips,hard palate and gingiva→hands and fingers.

CA: Presents as a pinkish, sessile papules or plaques w/ pebbled surfaces. Oral lesions occur in nonkeratinized mucosa of lips, floor of the mouth, lateral and ventral surface of tongue, buccal mucosa and soft palate

Photo ftom VI Meeks, DDS, U Md Dental School


Oral lesions of hiv in the era of haart

Human Papilloma Virus (HPV)

  • Treatment indicated

    (1) Lesion may become traumatized

    (2) In area that may lead to auto-inoculation

    (3) For cosmetic reasons


Oral lesions of hiv in the era of haart

Human Papilloma Virus (HPV)

  • Treatment

  • Cryotherapy; laser or surgical excision.

  • Lesions often recur


Human papilloma virus hpv3
Human Papilloma Virus (HPV)

  • Vaccine was approved last June by the FDA

  • Women 9-26 yrs (prefer 11-12 yrs old)

  • 70% cervical cancers HPV 16,18,31,45

  • Vaccine 6, 11, 16, 18

  • HPV 16 related to 25% of oral cancer.

  • $300-500 total for 3 dose series


Oral lesions of hiv in the era of haart

Necrotizing Ulcerative Periodontitis

NUP

  • Extensive soft tissue necrosis exposing alveolar bone

  • Severe pain, odor and spontaneous bleeding

  • Compare appearance to aphthous ulcer on right




Salivary gland involvement
Salivary Gland Involvement

http://www.aids-ed.org/ppt/nw_schubert_oralupdate_03.ppt


Oral lesions of hiv in the era of haart

Salivary Gland Involvement

Table: Absence of saliva on palpation of salivary glands the WIHS

Mulligan R. et al. Salivary gland disease in human immunodeficiency virus-positive women from the WIHS study. Women's Interagency HIV Study.Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 89(6):702-9, 2000 Jun.

  • Medications (side effects) -> xerostomia


Oral lesions of hiv in the era of haart

Data from the Women’s Interagency HIV Study

Greenspan D, Gange S, Phelan J, Navazesh M, Alves M, MacPhail L,

Mulligan R, Greenspan J. J Dent Res 83(2):145-150, 2004


Oral lesions of hiv in the era of haart

Prevalence of Oral Lesions During HIV

Medication Usage

Greenspan, D et al

The Lancet Vol 357 May 5, 2001


Oral lesions of hiv in the era of haart

In Summary

  • Oropharyngeal Candidiasis (OPC) improves or resolves with response to HAART

  • Oral lesions are fewer as a result of HAART

  • Cavities increase as a result of hyposalivary function due to meds

  • Warts seem to increase


Preventive oral health care
Preventive Oral Health Care

  • Recalls every 3 to 6 months

  • Antimicrobial mouth rinses for patients with periodontal disease, including past history of NUP and LGE

  • Fluoride supplements