1

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

Roseann Mulligan DDS, MSUSC School of Dentistry

and the

Pacific AIDS Education and Training Center

2

Impact of Oral Conditions – HIV+ Patients

High rate of oral manifestationsOral lesions may be harbinger of change in HIV conditionRelative ease of access to identification of lesions by those in clinical practicesPotential impact on systemic health care outcomesPotential 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

3

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

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

4

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.

Oral lesions ~ Harbinger of Δ HIV status

5

Medical history

1. Questionnaires2. Patient observation3. Medical Interview

4. Risk Assessment

5. Head/Neck Exam6. Diagnostic tests

6

Normal Range Lab ValuesLymphocytes

Type of Lymphocyte Percentage of Total Lymphocytes

Total T, CD3 60- 87%

Total T/ mm3 630 - 3170

B cell 1- 25%

Suppressor, CD8 10- 40%

Suppressor/ mm3 240 – 1200

Helper, CD4 30 - 55%

Helper / mm3 600 – 1700

H:S (CD4/CD8) 0.8 - 3.0

7

CD % Description CD4 Count

30-55 Normal value >600 cell/mm³

< 29 Initial Immune Suppression <500 cell/mm³

<29 Manifestations of opportunistic infection including oral lesions

<400 cell/mm³

14 -18 Increase in number of opportunistic infections

>201-400 cell/mm³

<14 Severe Immune Suppression (e.g. Apthous Major)

<200 cell/mm³ AIDS Dx

Continuing decreases

Fatal opportunistic infection (e.g. CMV,MAC)

<100 cell/mm³

CD4 Status and Relationship to Outcomes CD4 Status and Relationship to Outcomes

8

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

9

Neutrophils

• Normal range: 3,000-7,000/ mm

• Neutropenia: <1000/mm3

• Severe neutropenia <500/mm3

**May require antibiotic prophylaxis before

invasive dental treatment

10

Oral Manifestations of HIV Infection

Infection Oral Disease

Fungal Candidiasis - Pseudomembranous, Erythematous, and Angular Cheilitis Invasive Fungal Infections - Histoplasmosis, Cryptococcosis

Viral

Herpes Simplex Herpes Zoster Cytomegalovirus Hairy Leukoplakia (Epstein Barr Virus) Oral Warts (Human Papilloma Virus) Human Hominus Virus–8 [K.S.]

Bacterial Linear Gingival Erythema Necrotizing Ulcerative Periodontitis Tuberculosis* Mycobacterium avium complex* Bacillary angiomatosis*

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

11

Oral Manifestations of HIV Infection

Type of Lesion Oral Disease

Neoplastic Kaposi’s Sarcoma (KS) [HHV-8]

Lymphoma

Squamous Cell Carcinoma*

Other HIV- Necrotizing Ulceration

HIV-Salivary Gland Disease/ Xerostomia

Thrombocytopenic Purpura*

Abnormal Mucosal Pigmentation

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

12

Oral Candidiasis

Most Common + often predicts HIV progression

Candida albicans is the most prevalent

3 types: pseudomembranous ª; erythematous ª; hyperplastic.

13

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

14

15

• 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 Candidiasis

16

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

17

18

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”

19

Oral Candidiasis

Angular cheilitis

20Perspective – Oral Manifestations Volume 13 Issue 5 December 2005/January 2006Perspective – Oral Manifestations Volume 13 Issue 5 December 2005/January 2006

21

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.

22

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

Epstein-Barr Virus (EBV)

Oral Hairy Leukoplakia

23

24

25

Treatment

Treat for cosmetic reasons; otherwise no

treatment is warranted

Epstein-Barr Virus (EBV)Oral Hairy Leukoplakia

26

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) .

27

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“

28

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 palatePhoto ftom VI Meeks, DDS, U Md Dental School

29

Human Papilloma Virus (HPV)

Treatment indicated

(1) Lesion may become traumatized

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

(3) For cosmetic reasons

30

Human Papilloma Virus (HPV)

Treatment

Cryotherapy; laser or surgical excision.

Lesions often recur

31

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

32

33

• Extensive soft tissue necrosis exposing alveolar bone

• Severe pain, odor and spontaneous bleeding

• Compare appearance to aphthous ulcer on right

Necrotizing Ulcerative PeriodontitisNUP

34

Necrotizing Ulcerative Periodontitis (NUP)

35

Povidone Iodine /Chlorexidine

36

Salivary Gland Involvement

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

37

MedicationsMedications (side effects) -> xerostomia (side effects) -> xerostomia

Salivary Gland InvolvementTable: Absence of saliva on palpation of salivary glands the WIHSTable: 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.

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.

38Greenspan D, Gange S, Phelan J, Navazesh M, Alves M, MacPhail L, Mulligan R, Greenspan J. J Dent Res 83(2):145-150, 2004Greenspan D, Gange S, Phelan J, Navazesh M, Alves M, MacPhail L, Mulligan R, Greenspan J. J Dent Res 83(2):145-150, 2004

Data from the Women’s Interagency HIV StudyData from the Women’s Interagency HIV Study

39

Prevalence of Oral Lesions During HIV Medication Usage

Greenspan, D et alThe Lancet Vol 357 May 5, 2001

40

• 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

In SummaryIn Summary

41

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

42