AIDS AND PERIODONTIUM

SUBMITTED BY
ANTO ANTONY

Acquired immunodeficiency syndrome (AIDS) is character-

ized by profound impairment of the immune system

a viral pathogen, the human immunodeficiency virus
(HIV), was identified in 1984
HIV has a strong affinity for cells of the immune system,
(CD4 cell, T4 cells)
monocytes, macrophages, Langerhans cells, and some
neuronal and glial brain. cells may also be involved.
Viral replication occurs continuously in the
lymphoreticular tissues of lymph nodes, spleen, gutassociated lymphoid cells, and macrophages.
B lymphocytes are not infected, but the altered function of
infected T4 lymphocytes secondarily results in B-cell
dysregulation and altered neutrophil function

HIV-positive individual are at increased risk for

malignancy and disseminated infections
HIV-positive individuals are also at increased risk
for adverse drug reactions because of altered
antigenic regulation.
HIV has been detected in most body fluids,
although it is found in high quantities only in
blood, semen, and cerebrospinal fluid
Transmission occurs almost exclusively by sexual
contact, illicit use of injection drugs, or exposure
to blood or blood products

HIGH RISK POPULATION

homosexual and bisexual men
users of illegal injection drugs
persons with hemophilia or other coagulation
disorders
recipients of blood transfusions before April
1985
infants of HIV-infected mothers (transmission
occurs by fetal transmission, at delivery,
breastfeeding)
promiscuous heterosexual

individuals who engage in unprotected sex

with HIV-positive cohorts.
HIV-infected individuals with a high plasma
bioload of the virus
organ transplantation and artificial
insemination

CDC Surveillance Case Classification

AIDS patients have been grouped as follows (1993)

Category A includes patients with acute symptoms
or asymptomatic diseases, along with individuals with
persistent generalized lymphadenopathy, with or without
malaise, fatigue, or low-grade fever
Category B patients have symptomatic conditions such as
oropharyngeal or vulvovaginal candidiasis, herpes zoster,
oral hairy leukoplakia, idiopathic thrombocytopenia, or
constitutional symptoms of fever, diarrhea, and weight
loss.
Category C patients are those with outright AIDS, as
manifested by life-threatening conditions or identified
through CD4+ T lymphocyte levels of less than 200
cells/mm3.

Oral candidiasis
Oral hairy leukoplakia
Kaposis sarcoma
Bacillary angiomatosis
Oral hyperpigmentation
Atypical ulcers

Linear gingival erythema

Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Necrotizing ulcerative stomatitis
Chronic periodontitis

Candida, a fungus found in normal oral flora

A major factor associated with overgrowth of
Candida is diminished host resistance,
immunosuppressive therapy
Candidiasis is the most common oral lesion
in HIV
It usually has one of four clinical
presentations: pseudomembranous,
erythematous, or hyperplastic candidiasis or
angular cheilitis.lsl

Pseudomembranous candidiasis ("thrush")

Painless or 'slightly sensitive, yellow-white
curd like lesions that can be readily scraped
and separated from the surface of the oral
mucosa
Most common on the hard and soft palate
and the buccal or labial mucosa but can occur
anywhere in the oral cavity

Erythematous candidiasis
Present as a component of the
pseudomembranous type, appearing as red
patches on the buccal or palatal mucosa
Associated with depapillation of the tongue
If gingiva is affected, it may be misdiagnosed
as desquamative gingivitis

Hyperplastic candidiasis
Least common form and may be seen in the
buccal mucosa and tongue
More resistant to removal than the other
types

The commissures of the lips appear

erythematous with surface crusting and fissuring.
DIAGNOSIS
clinical evaluation,
culture analysis
microscopic examination of a tissue sample
smear of material scraped from the lesion, which
shows hyphae and yeast forms of the organisms

Topical Drugs
Clotrimazole (Mycelex)
10-mg tablets
Dissolve in mouth
3-5 tablets daily for 7-14 days.

Nystatin (Mycostatin, Nilstat).

Oral suspension.(100,000 U/ml)
Tablets (500,000 U)
Pastilles (200,000 U
Vaginal tablets (100,000 U)
Ointment (for angular cheilitis), 15-g tube
Amphotericin B
oral suspension (Fungizone), 100 mg

Systemic Drugs
Ketoconazole (Nizoral), 200-mg tablets
Fluconazole (Diflucan), 100-mg tablets
Itraconazole (Sporanox), 100-mg capsules

Recent reports indicate that the administration of

HAART in HIV infections has resulted in a significant
decrease in incidence of oropharyngeal candidiasis
and oral candidal carriage and has reduced the rate
of fluconazole resistance

Oral hairy leukoplakia (OHL) primarily occurs in persons

with HIV infection
Found on the lateral borders of the tongue, OHL frequently
has a bilateral distribution and may extend to the ventrum
This lesion is characterized by an asymptomatic, poorly
demarcated keratotic area ranging in size from a few
millimeters to several centimeters
Characteristic vertical striations are present, imparting a
corrugated appearance, or the surface may be shaggy and
appear "hairy" when dried
The lesion does not rub off and may resemble other
keratotic oral lesions
Associated with EBV

DIFFERENTIAL DIAGNOSIS

White lesions

dysplasia, carcinoma
frictional and idiopathic keratosis
lichen planus
tobacco related Leukoplakia
secondary syphilis
psoriasiform lesions (e.g., geographic tongue)
hyperplastic candidiasis

antiviral agents such as acyclovir or

valacyclovir
Lesions can be successfully removed with
laser or conventional surgery

An HIV-positive individual with non-Hodgkin's lymphoma (NHL)

or Kaposi's sarcoma (KS) is categorized as having AIDS
KS is the most common oral malignancy associated with AIDS
This angiomatous tumor is a rare, multifocal, vascular neoplasm
Caused by HHV-8
KS is a malignant tumor, in its classic form it is a localized and
slowly growing lesion
In the early stages the oral lesions are painless, reddish purple
macules of the mucosa. As they progress, the lesions frequently
become nodular
Lesions manifest as nodules, papules, or non-elevated macules
that are usually brown, blue, or purple in color

pyogenic granuloma,
hemangioma
atypical Hyperpigmentation
sarcoidosis
bacillary angiomatosis
angiosarcoma
pigmented nevi
cat-scratch disease (skin

HAART Therapy
antiretroviral agents
laser excision
cryotherapy
radiation therapy
intralesional injection with vinblastine
interferon-a, sclerosing agents
other chemotherapeutic drugs
injections of 3% sodium tetradecyl sulfate, a
sclerosing agent

Infectious vascular proliferative disease with clinical and

histologic features similar to those of KS
caused by rickettsia-like organisms (e.g., Bartonellaceae,

Rochalimaea quintana).

Diagnosis of bacillary angiomatosis is based on biopsy, which

reveals an "epithelioid" proliferation of angiogenic cells
accompanied by an acute inflammatory cell infiltrate
The causative organism in the biopsy specimen may be identified
using Warthen-Starry silver staining or electron microscopy
Bacillary angiomatosis is usually treated using broad-spectrum
antibiotics such as erythromycin or doxycycline
Gingival lesions may be managed using the antibiotic in
conjunction with conservative periodontal therapy and possibly
excision of the lesion.

Oral pigmented areas often appear as spots

or striations on the buccal mucosa, palate,
gingiva, or tongue
pigmentation may relate to prolonged use of
drugs such as zidovudine, ketoconazole, or
clofazimine. Zidovudine is also associated
with excessive pigmentation of the skin and
nails

HIV-associated neutropenia may also feature oral

ulcerations
Recurrent herpetic lesions and aphthous
stomatitis
Oral ulcerations have been described in association with enterobacterial organisms such as
Klebsiella pneumoniae, Enterobacter cloacae, and

Escherichia coli

Herpes simplex virus (HSV), varicella-zoster virus

(VZV), Epstein-Barr virus (EBV), and
cytomegalovirus (CMV) are frequently retrieved
from nonspecific oral ulcers

Management
Herpes labialis in HIV infected individuals may
be responsive to topical antiviral therapy
(e.g., acyclovir, pencyclovir, doconasol)
Neutropenia can be treated with recombinant
human granulocyte colony stimulating factor
Recurrent aphthous stomatitis (RAS): Topical
corticosteroid therapy (fluocinonide gel
applied three to six times daily). Systemic
corticosteroids (e.g., prednisone, 40-60 mg
daily). Chlorhexidine mouth wash

Adverse Drug Effects

Foscarnet, interferon, and 2'-3'-dideoxycytidine

(DDC) occasionally induce oral ulcerations, and
erythema multiforme
Zidovudine and ganciclovir may induce leukopenia,
resulting in oral ulcers
Xerostomia and altered taste sensation have been
described in conjunction with diethyldithiocarbamate
(Dithiocarb)
HAART drugs may induce adverse side
Nausea
Kidney stones
Liver cirrhosis

Lipodystrophy

Insulin resistance
Gynecomastia
Toxic epidermal necrolysis
Blood dyscrasias
Oral warts
Oral lichenoid reactions
Xerostomia
Altered taste sensation
Perioral paresthesia
Exfoliative cheilitis

LINEAR GINGIVAL ERYTHEMA

A persistent, linear, easily bleeding, erythematous gingivitis has

been described in some HIV-positive patients
Linear gingival erythema (LGE) may or may not serve as a
precursor to rapidly progressive necrotizing ulcerative
periodontitis (NUP)
Linear gingivitis lesions may be localized or generalized in
nature
The erythematous gingivitis (1) may be limited to marginal
tissue, (2) may extend into attached gingiva in a punctate or a
diffuse erythema, or (3) may extend into the alveolar mucosa.
Concomitant oral candidiasis and LGE lesions have been
identified, suggesting a possible etiologic role for candidial
species in LGE
LGE is more common among HIV infected

MANAGEMENT
The affected sites should be scaled and
polished
Subgingival irrigation with chlorhexidine or
10% povidone-iodine
meticulous oral hygiene procedures

condition should be reevaluated 2 to 3 weeks

after initial therapy
If the patient is compliant with home care
procedures and the lesions persist, the possibility
of a candidial infection should be considered
empiric administration of a systemic antifungal
agent such as fluconazole for 7 to 10 days
the patient should be carefully monitored for
developing signs of more severe periodontal
conditions (e.g., NUG, NUP, NUS). The patient
should be placed on a 2- to 3-month recall
maintenance interval and re-treated as necessary

sudden onset, bleeding on brushing

pain and characteristic halitosis
the gingiva appears fiery red and swollen and yellow
to grayish necrosis is observed on the tip of the
interdental papilla and margins of the gingiva
mostly anterior gingiva is affected and normally
limited to the soft tissue of the periodontium
Basic treatment may consist of cleaning and debridement of affected areas with a cotton pellet soaked in
peroxide after application of a topical anesthetic
oral rinses such as hydrogen peroxide should only
rarely be used

The patient should be seen daily or every other day for the
first week
debridement of affected areas is repeated at each visit,
and plaque control methods are gradually introduced
The patient should avoid tobacco, alcohol, and condiments
An antimicrobial oral rinse such as chlorhexidine
gluconate 0.12% is prescribed
Systemic antibiotics such as metronidazole or amoxicillin
may be prescribed for patients with moderate to severe
tissue destruction, localized lymphadenopathy or systemic
symptoms, or both
The use of prophylactic antifungal medication should be
considered if antibiotics are prescribed.

A necrotizing, ulcerative, rapidly progressive form of periodontitis

occurs more frequently among HIV-positive individual
Necrotizing ulcerative periodontitis (NUP) may represent an extension of
NUG in which bone loss and periodontal attachment loss occur.
NUP is characterized by soft tissue necrosis, rapid periodontal
destruction, and interproximal bone loss
Lesions may occur anywhere in the dental arches and are usually
localized to a few teeth, although generalized NUP is sometimes present
after mar.ked CD4+ cell depletion.
Bone is often exposed, resulting in necrosis and subsequent sequestration.
NUP is severely painful at onset, and immediate treatment is necessary
The lesion may undergo spontaneous resolution leaving painless inter
proximal craters that are difficult to clean and may lead to periodontitis
May be presented with candidial or Herpes infection

MANAGEMENT
local debridement
scaling
root planing,
in-office irrigation with an effective antimicrobial
agent such as chlorhexidine gluconate or
povidone-iodine (Betadine)
establishment of meticulous oral hygiene,
including home use of antimicrobial rinses or
irrigation.

NUS may be severely destructive and acutely painful

and may affect significant areas of oral soft tissue
and underlying bone
It may occur separately or as an extension of NUP and
is often associated with severe suppression of CD4
immune cells
The condition appears to be identical to cancrum oris
(noma), a rare destructive process reported in
nutritionally deprived individuals, especially in Africa

Treatment for NUS may include an antibiotic such as

metronidazole and use of an antimicrobial mouth
rinse such as chlorhexidine gluconate. If osseous
necrosis is present, it is often necessary to remove
the affected bone to promote wound healing

Health Status
CD4+ T4 lymphocyte level
viral load,
history of drug abuse, sexually transmitted
diseases, multiple infections, or other factors
that might alter immune response
medications taken
adverse side effects from medications

Infection Control Measures

universal precautionary methods should be taken

Goals of Therapy

The primary goals of dental therapy should be

the restoration and maintenance of oral health,
comfort, and function
control of HIV-associated mucosal diseases,
such as chronic candidiasis and recurrent oral
ulcerations
Acute periodontal and dental infections should
be managed, and the patient should receive
detailed instructions in performance of effective
oral hygiene procedures

Maintenance Therapy
Blood and other medical laboratory tests may be
required to monitor the patient's overall health
status, and close consultation and coordination with
the patient's physician are necessary.

Psychological Factors
HIV infection of neuronal cells may affect brain
function and lead to outright dementia
elicit depression, anxiety, and anger in such patients
The dentist should be prepared to advise and counsel
patients on their oral health status
Early diagnosis and treatment of HIV infection can
have a profound effect on the patient's life
expectancy and quality of life, and the dentist should
be prepared to assist the patient in obtaining testing