ORAL HEALTH IN WOMEN

ORAL MANIFESTATIONS OF HIV INFECTION

DENTAL HEALTH CARE PROVIDER

TEAM APPROACH

EPIDEMIOLOGY OF HIV-RELATED ORAL MANIFESTATIONS IN

WOMEN

Epidemiology of HIV-Related Oral Manifestations in Women: A Review

Oral Lesions in 15% of HIV-Infected Women

Most Common Oral Lesion - Candidiasis Prevalence of Hairy Leukoplakia and

Kaposi's Sarcoma Significantly Less Common in Women

Oral Dis 1997 Sep;3(3):206.

Many Manifestations of HIV Disease are Similar in Men & Women

Other Conditions Differ In Frequency:– HIV-Infected Men 8 X’s More Likely to

Develop Kaposi's Sarcoma – Women Have Higher Rates of

Esophageal Candidiasis & Herpes Simplex Infections

CHANGING PREVALENCE OF

ORAL MANIFESATIONS

Overall Prevalence of Oral Lesions Has Decreased (47.6%-37.5%)

Hairy Leukoplakia (25.8%-11.4%) & Necrotizing Periodontal Diseases (4.8%-1.7%) Decreased

HIV Salivary Gland Disease Increased (1.8%-5.0%)

Candidiasis (20.3%-16.7%), Aphthae (3.7%-3.0%), Oral Warts (2.2%-4.0%), Herpes Simplex Virus Lesions (1.8%-2.0%) and Kaposi’s Sarcoma (1.1%-0.3%) Unchanged

HIV/AIDS Women's Health: Oral Lesions in HIV-Positive Women

Reduced in HAART Therapy

503 HIV+ women over 6 years Incidence of EC fell to 2.99 percent

from 5.48 percent PC fell to 2.85 percent from 6.70

percent No changes were seen in HL or warts

Women's Health Weekly (03.25.04)

CANDIDIASIS

Reported in 7-93% of HIV+ /AIDS

Patients

FOUR MAJOR TYPES

Pseudomembranous Hyperplastic Erythematous (Atrophic) Angular Cheilitis

PSEUDOMEMBRANOUS

White or Yellow Patches Easily Removed w/ Scraping

Yielding Bleeding Surface Any Mucosal Surface (Palate,

Buccal or Labial Mucosa, Tongue)

HYPERPLASTIC CANDIDIASIS

White Plaques Can’t Be Removed w/ Scraping

Buccal Mucosa Most Common Site in HIV+ Patients

ERYTHEMATOUS (ATROPHIC)

Fiery Red Surfaces to Hardly Discernible Pink Spots

Most Common Location - Palate & Dorsum of Tongue

Spotty Areas in Buccal Mucosa

ANGULAR CHEILITIS

Common in Elderly Fissures Radiating From

Angles of Mouth

PREDISPOSING FACTORS

SYSTEMIC FACTORS

Age Use of Antibiotics Xerostomia Nutritional Deficiencies Immunosuppression Gastric Reflux

LOCAL FACTORS

Ill-Fitting Dentures Poor Prosthesis Hygiene Heavy Smoking Topical Medications

CANDIDIASIS TREATMENT

Nystatin Oral Susp– 480 ml– Rinse w/ One Tablespoonful QID

Clotrimazole (Mycelex) Troches– 10 mg Troches– 3-5 Times a Day for 7-14 Days

Ketoconazole (Nizoral)– 200 mg– 200-400 mg Daily for 7-14 Days

Fluconazole (Diflucan)– 100 mg Tabs– 2 Tabs First Day, Then 1 Tab Daily for 14

Days Itraconazole (Sporanox)

– 100 mg Tablets– 1 tablet B.I.D. for 14 days

OROFACIAL VIRAL INFECTIONS IN

IMMUNOCOMPROMISED HOST

HAIRY LEUKOPLAKIA

First Identified Among HIV+ Individuals

Never Described Before AIDS Epidemic

CLINICAL PRESENTATION

Painless White Patches Do Not Rub Off Lateral Borders of the Tongue Surface May Be Smooth,

Corrugated or Markedly Folded Thick, Hair-Like Projections

DIFFERENTIAL DIAGNOSIS

Hyperplastic Candidiasis Geographic Tongue Lichen Planus Frictional Keratosis Leukoplakia

HAIRY LEUKOPLAKIA - PATHOGENESIS

Epstein-Barr Virus

HAIRY LEUKOPLAKIA TREATMENT

Appears to Be Little Advantage in Treating

Surgical Removal–Laser

Acyclovir Topical Vitamin A

HUMAN PAPILLOMA VIRUS

LESIONS

HUMAN PAPILLOMA VIRUSES

More Than 100 Human Papilloma Virus (HPV) Types

24 Associated with Oral Lesions

HPV ORAL LESIONS

Warts, Papillomas Condyloma Acuminatum Verruca Vulgaris Focal Epithelial Hyperplasia Dysplasia / Carcinoma

HUMAN PAPILLOMA VIRUS LESIONS

CONDYLOMA ACUMINATUM

Sexually Transmitted Appears 1-3 Months After

Exposure Multiple Wart-Like Lesions Lips, Lingual Frenum & Tongue

TREATMENTCONDYLOMA ACUMINATUM

Surgical Removal Cryotherapy Laser Therapy Medications

KAPOSI’S SARCOMA

Originally Described in 1872 - Idiopathic

Multiple Sarcomas of the Skin

Previously Uncommon in USA

Elderly Jewish Men of Eastern European or Mediterranean Descent

Usually Involved Lower Extremities Indolent Course 1981 - Fulminant, Aggressive Form

Occurring in Young Homosexual Men w/ AIDS

>50% of AIDS Patients w/ KS Display Oral Lesions

Remains Significant Cause of Morbidity & Mortality in HIV Infected Patients

CLINICAL PRESENTATION Angiomatous Malignancy of Skin,

Mucosa, and Internal Organs Most Common Intraoral Locations

– Palate– Gingiva

Non-Elevated Macules, Nodules or Papules

Brown, Blue, Purple

KAPOSI’S SARCOMAPATHOGENESIS

Sexually Transmitted Cofactor Human Herpes Virus 8 (HHV 8)

TREATMENT Treatment Reserved for Lesions

Which Interfere w/ Function or Esthetics

Laser Excision Cryotherapy Radiation Intralesional Injection w/ Vinblastine

CANCER IN PATIENTS WITH

AIDS

AIDS AND CANCER

Roche et al, NJ Med 2001,Jan;98(1);27-36 2460 Persons w/ AIDS and Cancer 2159 Males, 301 Females 50% Kaposi’s Sarcoma 33% Non-Hodgkins Lymphoma Lung, Oral, Cervical, Hodgkins Lymphoma,

Other Digestive

RECURRENT ORAL

ULCERATIONS

RECURRENT APHTHOUS

STOMATITIS

EPIDEMIOLOGY Prevalence in General

Population 10-20% 67-85% Develop Prior

to Age 30 Familial Disposition

MINOR APHTHAE Superficial Erosion with Fibrinous

Coating & Red Halo Single or Multiple Lesions 2-3 mm’s to Over 10 mm’s in

Diameter Persists for 7-10 Days Painful

MAJOR APHTHAE

Large Painful Ulcerations Single or Multiple Lesions Persists Up to 6 Weeks Heal w/ Scarring

GENERAL RULE

Aphthae Occur on Mobile Mucosa

Herpetic Lesions Occur on Tissue That is Firmly Bound Down

FACTORS ASSOCIATED WITH APHTHAE

Psychological (Stress) Trauma Socio-Economic S.

sanguis Endocrine Immunosuppression Hereditary Hypersensitivity Chemicals in Food

TREATMENT

Chlorhexidine Topical Steroids

–Lidex Gel .05% Aphthasol Cream 5%

HERPES SIMPLEX INFECTIONS

RECURRENT HERPETIC STOMATITIS

Attenuated Form of Primary Infection

Tissue Firmly Bound Down Vesicles Burst to Form Ulcers Coalesce Heals in 7-10 Days

HERPES LABIALIS

SYSTEMIC ANTIVIRALS

Acyclovir (Zovirax) 200 mg CapsulesOne Capsule 5 Times a Day

Valacyclovir (Valtrex) 1 gm CapletsTwo Caplets Twice a Day

Famciclovir (Famvir) 125 mg TabletsOne Tablet Twice Daily

TOPICAL ANTIVIRALS

Zovirax (Acyclovir) Ointment 5%– 15 Gram Tube– Apply TID

Denavir (Penciclovir) Cream 1%– 2 Gram Tube– Apply Every Two Hours

AIDS RELATED PERIODONTAL DISEASE

Linear Gingival Erythema Necrotizing Ulcerative Gingivitis Necrotizing Ulcerative Periodontitis Necrotizing Ulcerative Stomatitis

LINEAR GINGIVAL ERYTHEMA

A Persistent, Linear Erythematous Gingivitis Which Bleeds Easily

Resistant to Treatment Spontaneous Remission

NECROTIZING ULCERATIVE GINGIVITIS

Also Known as ANUG Acute Gingivitis Characterized by

Ulceration & Necrosis of the Gingival Margin & Destruction of the Interdental Papilla

Gingival Pain

NECROTIZING ULCERATIVE GINGIVITIS

Profuse Gingival Bleeding Fetid Odor No Involvement of Osseous Tissues Associated w/ Stress, Anxiety,

Malnutrition & Smoking

NECROTIZING ULCERATIVE PERIODONTITIS

Severe Deep Pain Spontaneous Gingival Bleeding Extensive Soft Tissue Necrosis Severe Loss of Periodontal

Attachment

NECROTIZING ULCERATIVE PERIODONTITIS

Rapid Onset & Progression Bone May Be Exposed Associated with Low CD4 Counts

NECROTIZING ULCERATIVE STOMATITIS

Necrosis of Significant Areas of the Oral Soft Tissue & Underlying Bone

INTRAORAL PIGMENTATION

Racial Pigmentation Smoking Amalgam Tattoo Addison’s DiseaseHeavy Metal Poisoning Puetz-Jeger SyndromeMedicationsBirth Control PillsMinocyclineAZT

SALIVARY GLAND DISEASE

Xerostomia Bilateral Parotid Gland Enlargement

Occurs in HIV Infected Individuals Histology Has Been Described as

Resembling Autoimmune Salivary Gland Disease w/ Cystic Changes

Thanks for Coming!

Jacqueline M. Plemons DDS, MS6031 Sherry LaneDallas, TX 75225

(214)369-8585drplemons@yahoo.com