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Oral Health and HIV?

Oral Health and HIV?. Is there a relationship between oral health and human immuno-deficiency virus (HIV)?. Oral Manifestations in HIV+ Individuals. Arlita Jefferson, RN/BSN MPH Candidate ASPH Intern. Picture courtesy of www.greenlanesdental.co.uk.

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Oral Health and HIV?

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  1. Oral Health and HIV? Is there a relationship between oral health and human immuno-deficiency virus (HIV)?

  2. Oral Manifestations in HIV+ Individuals Arlita Jefferson, RN/BSN MPH Candidate ASPH Intern Picture courtesyofwww.greenlanesdental.co.uk

  3. Oral manifestations are often the first clinical feature of HIV infection (1)

  4. Objectives • Become familiar with some of the oral manifestations that may present in HIV positive individuals. • List the five (5) categories of oral manifestations that may present in HIV + individuals. • List one (1) fungal oral manifestation that may present in HIV infected individuals.

  5. Objectives cont. • List one (1) neoplastic manifestation that may present in HIV infected individuals. • List one (1) viral oral manifestation that may present in HIV infected individuals. • List one (1) bacterial oral manifestation that may present in HIV infected individuals.

  6. Oral Manifestations observed in HIV+ Individuals • Fungal • Neoplastic • Viral • Bacterial • Other www.humanillness.com www.ivis.org

  7. Fungal Manifestations • Candidiasis – very common fungal manifestation that is seen in more than 95% of HIV infected persons during the course of their illness (1) • Is seen in HIV + and uninfected individuals alike. However, when dx in HIV + individuals, it has been established as a precursor to AIDS within 1-2 years of its appearance (1) • Frequency and type are usually indicative of disease progression

  8. Fungal Manifestations cont. • Can manifest in 4 different ways (2,3) • Pseudomembraneous candidiasis • Erythematous candidiasis • Hyperplastic candidiasis • Angular chilitis Picture courtesy of research.bidmc.harvard.edu

  9. Pseudomembraneous Candidiasis (thrush) • Removable whitish plaque that can appear on any oral mucosal surface (1) • When wiped away, it will leave a red or bleeding underlying surface (2)

  10. Pseudomembraneous Candidiasis cont. • Diagnosis • Based on clinical appearance (2), taking into consideration the person’s medical hx (1) • Treatment • Based on the extent of the infection, topical therapies are utilized for mild to moderate cases and systemic therapies used for moderate to severe cases.

  11. Erythematous Candidiasis • Smooth, red atrophic patches that can occur on the hard palate, buccal mucosa, or the tongue (1,2) • Tends to be symptomatic with complaints of oral burning while eating salty or spicy foods or drinking acidic beverages (2)

  12. Erythematous Candidiasis cont. • Diagnosis • Can be based on clinical appearance (2), nutritional history, duration and stability of the lesion and treatment response (1) • Treatment • Same with all candidiasis

  13. Hyperplastic Candidiasis • Nonremovable whitish plaques, sometimes associated with a burning sensation, that can be found on any mucosal surface (1) • May be confused with hairy-leukoplakia (3)

  14. Hyperplastic Candidiasiscont. • Diagnosis • Differential diagnosis can include oral hairy leukoplakia (1) • Treatment • Same with all candidiasis

  15. Angular Cheilitis • Fissures radiating from the corners of the mouth (3) that are sometimes covered with a removable white membrane • Can be found in conjunction with xerostomia and occur with or without PC or EC (2) Image courtesy of: www.mycology.adelaide.edu.au

  16. Angular cheilitiscont. • Diagnosis • Clinical appearance • Treatment (2) • Use of topical antifungal cream or ointment directly applied to the affected area 4x a day for 2 weeks • Can exist for a long time if left untreated www. Image courtesy of: www.windrug.com

  17. Neoplastic Oral Manifestations • There are two (2) types of neoplasms associated with oral manifestations in HIV individuals • Kaposi’s Sarcoma (KS) • Non-Hodgkin’s Lymphoma

  18. Kaposi’s Sarcoma • Found most commonly in male (3) homosexual AIDS patients (1) • May appear as macules, patches, nodules, or ulcerations that are purplish (3), bluish, brownish, or reddish in color (1) • Can be found anywhere in the gastrointestinal tract; commonly seen on the hard or soft palate and gums (1)

  19. Kaposi’s Sarcomacont. • Diagnosis (1) • Differential diagnosis can include non-Hodgkin lymphoma (ulcerative), bacillary angiomatosis, and physiologic pigmentation • Definitive dx requires a biopsy (2) • Treatment (1) • radiation, intralesional chemotherapy, and surgery (less often) • Good oral hygiene to minimize complications (3)

  20. Non-Hodgkin’s Lymphoma • AIDS defining condition • May appear as a large, ulcerated mass anywhere in the oral cavity (3) • May or may not be painful (3) Photo courtesy David I Rosenstein, DMD, MPH at hab.hrsa.gov

  21. Non-Hodgkin’s Lymphoma cont. • Diagnosis • Biopsy (3) • Treatment • Refer to an oncologist (3) Picture courtesy of HIVdent: Dr. David Reznik, D.D.S.

  22. Viral Manifestations • Herpes Simplex Virus (HSV) lesions • Herpes Zoster • Oral Hairy Leukoplakia • Cytomegalovirus (CMV) ulcers • Human Papillomavirus (HPV) lesions

  23. Herpes Simplex ulcer • Can occur intraorally, involving the oral mucosa, and periorally, involving the lips and skin (1) • They can be painful, solitary or multiple, and vesicular; and they might coalesce (1)

  24. Herpes Simplex ulcercont. • Diagnosis • Clinical appearance • Treatment • Self-limiting (2) • Acyclovir (1)

  25. Herpes Zoster(Shingles) • Caused by a reactivation of the varicella zoster virus (3) • Occurs in the elderly and immunosuppressed (3) • Following pain, vesicles appear on the facial skin, lips and oral mucosa (3) • Frequently unilateral (3) • Skin lesions form crusts and the oral lesions coalesce to form large ulcers (3) Image courtesy of HIVdent

  26. Herpes Zostercont. • Diagnosis • Clinical appearance and the distribution of the lesions (3) • Treatment • Acyclovir limits the duration of the lesions • To be taken 7-10 days (3) Picture courtesy of HIVdent – Dr. David Reznik, D.D.S.

  27. Oral Hairy Leukoplakia • Found most commonly in male homosexual patients but is not considered diagnostic for AIDS (1) • Lesions associated with the Epstein-Barr virus (1,2) • Becomes more common as the CD4 count decreases (3)

  28. Oral Hairy Leukoplakia cont. • Whitish, nonremovable, vertically corrugated patches found on the lateral region of the tongue (1) • Diagnosis based on clinical appearance and location (1) • Definitive diagnosis is by a biopsy (1,3) • Treatment is palliative only and not necessary unless lesion is symptomatic (1)

  29. Cytomegalovirus (CMV) ulcers • Painful, with punched-out, nonindurated borders (1) • Appear necrotic with a white halo (3) • Diagnosis • Biopsy (3) • Treatment (1) • acyclovir or ganciclovir Combination of HSV and CMV Image courtesy of HIVdent

  30. Human Papillomavirus (HPV) lesions • HPV is associated with oral warts, papillomas, skin warts, and genital warts (3) • May appear as solitary or multiple nodules (3) • May appear as multiple, smooth-surfaced raised masses (3) Picture courtesy of Dr. D. Reznik, D.D.S. Hivdent

  31. HPV cont. • May be cauliflower-like, spiked, or raised with a flat surface (2) • Diagnosis • Biopsy • Treatment (2) • Surgical removal • Laser surgery • Cryotherapy Image courtesy of HIVdent Dr. David Reznik, D.D.S

  32. Bacterial Manifestations • Periodontal Disease • Fairly common in asymptomatic and symptomatic HIV infected individuals (3) • Presenting clinical features of the two (2) forms differ from those in individuals not infected with HIV • Two forms • Linear Gingival Erythema (LGE) • Necrotizing Ulcerative Periodontitis (NUP)

  33. Linear Gingival Erythema(red-band gingivitis) (2) • Occurs as a 2- to 3-mm erythematous band on the gingiva accompanied by mild pain and spontaneous bleeding (1,2) • Responds poorly to conventional therapy (1) • Might be a precursor to necrotizing ulcerative periodontitis (1,3)

  34. Necrotizing Ulcerative Periodonitis • Rapidly progressive, causes extensive destruction an loss of bone and periodontal tissue, is painful, and may be accompanied by bleeding and halitosis (1,2,3) • Distinguished from conventional periodontitis by its accelerated rate of progression and its deep-seated nongingival pain (1)

  35. Necrotizing Ulcerative Periodonitis cont. • Associated with severe immune deterioration (1,2) • Diagnosis • History and clinical appearance (3) • Biopsy needed to differentiate from other lesions such as non-Hodgkin lymphoma and cytomegalovirus infection • Treatment (1) • Antibiotics, mouth rinses, irrigation with povidone iodine, debridement, and mechanical cleaning (3) • Frequent dental visits

  36. Tuberculosis • Oral lesions in people with tuberculosis are seen rarely. • They have been reported as ulcers on the tongue secondary to pulmonary tuberculosis.

  37. Other Oral Manifestations • Aphthous Ulcerations (canker sores) • Minor • Major • Salivary Gland Disease • Xerostomia

  38. Aphthous Ulcerations (canker sores) – minor • 2 to 5 mm in diameter, covered by a pseudomembrane, and surrounded by an erythematous halo (1) • No known cause for recurrent ulcers (2) • stress, acidic foods, and tissue-barrier breakdown have been reported to precipitate their occurrence (1)

  39. Aphthous Ulcerations –major • Greater than 10 mm in diameter, painful, persist for months, and can cause impairment of speech and swallowing (1) • Diagnosis (1) • can be made clinically; • biopsy rules out other causes and is recommended for major ulcers and for those ulcers that do not improve • Treatment (1) • Palliative, oral and topical medications, rinses

  40. Salivary Gland Disease • Salivary gland disease associated with HIV infection can present as xerostomia with or without salivary gland enlargement (3) • Cause unknown (3) • Soft enlargement of the salivary glands, usually involving the parotid glands (3) • removal not recommended (3) Picture courtesy of: www.baoms.org.uk

  41. Xerostomia cont. • Other Factors • Salivary gland disease (SGD) • smoking • Treatment (1,3) • Salivary stimulants • Sugarless gum or candy • Salivary substitutes • Caries can occur so rinse w/fluoride daily and regular dentist visits (2-3 times per year) Picture courtesy of www.periproducts.co.uk/drymouth

  42. Xerostomia (dry mouth) • Reduced salivary flow • Major contributing factor in dental decay in HIV infected individuals (1,2) • Many medications lead to xerostomia (1,2) • DDI, Zidovudine, Foscarnet • Antidepressants • Antihistamines • Antianxiety Courtesy of: www.hopkins-arthritis.som.jhmi.edu/other/oral...

  43. Conclusion (s) www.duke.edu • Dental hygiene of HIV infected individuals is very important and should be included in the overall care plan of these individuals • These individuals may need to visit a dentist more frequently than twice a year, especially if they present with any of the before mentioned lesions

  44. Conclusion cont. • Yes, there is a relationship between oral health and HIV. • Lesions or other manifestations in the mouth may be the initial indicator of a persons HIV status or it may indicate a further decrease or worsening of an infected individuals immune system www.massleague.org

  45. References • Sifri, R., Diaz, V., Gordon, L., and Glick, M. et al. Oral health care issues in HIV disease: Developing a core curriculum for primary care physicians. J AM BoardFam Pract. 1998; 11:434-44. Accessed 8/21/06 www.medscape.com/viewarticle/417818_print • Reznik, D. Oral Manifestations of HIV disease. Perspective. December 2005/January 2006; 13:143-48. Accessed 7/19/06 www.hivdent.org • Greenspan, D. Oral Manifestations of HIV. HIV InSite Knowledge Base Chapter. 1998. Accessed 7/20/06 www.hivinsite.ucsf.edu/InSite?page=kb-04-01-14

  46. More Information • For more information on HIV and Oral health, you may visit the following websites: • www.hivdent.org • www.hab.hrsa.gov • www.hivguidelines.org • www.health.state.ny.us/nysdoh/aids/index.htm • http://hiv.bg/tannheilsahiv.english.htm • http://www.who.int/oral_health/en/

  47. Responses or????Questions????

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