ORAL HEALTH IN WOMEN ORAL MANIFESTATIONS OF HIV

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 u Oral Lesions in 15% of HIV-Infected Women u Most Common Oral Lesion - Candidiasis u 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 u 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

u. Overall Prevalence of Oral Lesions Has Decreased (47. 6%-37. 5%) u. Hairy Leukoplakia (25. 8%11. 4%) & Necrotizing Periodontal Diseases (4. 8% -1. 7%) Decreased

u. HIV Salivary Gland Disease Increased (1. 8%-5. 0%) u. 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 u 503 HIV+ women over 6 years u Incidence of EC fell to 2. 99 percent from 5. 48 percent u PC fell to 2. 85 percent from 6. 70 percent u No changes were seen in HL or Women's Health Weekly (03. 25. 04) warts

CANDIDIASIS

Reported in 7 -93% of HIV+ /AIDS Patients

FOUR MAJOR TYPES u. Pseudomembranous u. Hyperplastic u. Erythematous (Atrophic) u. Angular Cheilitis

PSEUDOMEMBRANOUS u. White or Yellow Patches u. Easily Removed w/ Scraping Yielding Bleeding Surface u. Any Mucosal Surface (Palate, Buccal or Labial Mucosa, Tongue)

HYPERPLASTIC CANDIDIASIS u. White Plaques Can’t Be Removed w/ Scraping u. Buccal Mucosa Most Common Site in HIV+ Patients

ERYTHEMATOUS (ATROPHIC) u. Fiery Red Surfaces to Hardly Discernible Pink Spots u. Most Common Location Palate & Dorsum of Tongue u. Spotty Areas in Buccal Mucosa

ANGULAR CHEILITIS u. Common in Elderly u. Fissures Radiating From Angles of Mouth

PREDISPOSING FACTORS

SYSTEMIC FACTORS u. Age u. Use of Antibiotics u. Xerostomia u. Nutritional Deficiencies u. Immunosuppression u. Gastric Reflux

LOCAL FACTORS u. Ill-Fitting Dentures u. Poor Prosthesis Hygiene u. Heavy Smoking u. Topical Medications

CANDIDIASIS TREATMENT u. Nystatin Oral Susp – 480 ml – Rinse w/ One Tablespoonful QID u. Clotrimazole (Mycelex) Troches – 10 mg Troches – 3 -5 Times a Day for 7 -14 Days

u. Ketoconazole (Nizoral) – 200 mg – 200 -400 mg Daily for 7 -14 Days u. Fluconazole (Diflucan) – 100 mg Tabs – 2 Tabs First Day, Then 1 Tab Daily for 14 Days u. Itraconazole (Sporanox) – 100 mg Tablets – 1 tablet B. I. D. for 14 days

OROFACIAL VIRAL INFECTIONS IN IMMUNOCOMPROMISED HOST

HAIRY LEUKOPLAKIA u. First Identified Among HIV+ Individuals u. Never Described Before AIDS Epidemic

CLINICAL PRESENTATION u. Painless White Patches u. Do Not Rub Off u. Lateral Borders of the Tongue u. Surface May Be Smooth, Corrugated or Markedly Folded u. Thick, Hair-Like Projections

DIFFERENTIAL DIAGNOSIS u. Hyperplastic Candidiasis u. Geographic Tongue u. Lichen Planus u. Frictional Keratosis u. Leukoplakia

HAIRY LEUKOPLAKIA - PATHOGENESIS u. Epstein-Barr Virus

HAIRY LEUKOPLAKIA TREATMENT u. Appears to Be Little Advantage in Treating u. Surgical Removal – Laser u. Acyclovir u. Topical Vitamin A

HUMAN PAPILLOMA VIRUS LESIONS

HUMAN PAPILLOMA VIRUSES u. More Than 100 Human Papilloma Virus (HPV) Types u 24 Associated with Oral Lesions

HPV ORAL LESIONS u. Warts, Papillomas u. Condyloma Acuminatum u. Verruca Vulgaris u. Focal Epithelial Hyperplasia u. Dysplasia / Carcinoma

HUMAN PAPILLOMA VIRUS LESIONS

CONDYLOMA ACUMINATUM u. Sexually Transmitted u. Appears 1 -3 Months After Exposure u. Multiple Wart-Like Lesions u. Lips, Lingual Frenum & Tongue

TREATMENT CONDYLOMA ACUMINATUM u. Surgical Removal u. Cryotherapy u. Laser Therapy u. Medications

KAPOSI’S SARCOMA

Originally Described in 1872 - Idiopathic Multiple Sarcomas of the Skin

Previously Uncommon in USA u. Elderly Jewish Men of Eastern European or Mediterranean Descent u. Usually Involved Lower Extremities u. Indolent Course u 1981 - Fulminant, Aggressive Form Occurring in Young Homosexual Men w/ AIDS

u>50% of AIDS Patients w/ KS Display Oral Lesions u. Remains Significant Cause of Morbidity & Mortality in HIV Infected Patients

CLINICAL PRESENTATION u. Angiomatous Malignancy of Skin, Mucosa, and Internal Organs u. Most Common Intraoral Locations – Palate – Gingiva u. Non-Elevated Macules, Nodules or Papules u. Brown, Blue, Purple

KAPOSI’S SARCOMA PATHOGENESIS u. Sexually Transmitted Cofactor u. Human Herpes Virus 8 (HHV 8)

TREATMENT u. Treatment Reserved for Lesions Which Interfere w/ Function or Esthetics u. Laser Excision u. Cryotherapy u. Radiation u. Intralesional Injection w/ Vinblastine

CANCER IN PATIENTS WITH AIDS

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

RECURRENT ORAL ULCERATIONS

RECURRENT APHTHOUS STOMATITIS

EPIDEMIOLOGY u. Prevalence in General Population 10 -20% u 67 -85% Develop Prior to Age 30 u. Familial Disposition

MINOR APHTHAE u. Superficial Erosion with Fibrinous Coating & Red Halo u. Single or Multiple Lesions u 2 -3 mm’s to Over 10 mm’s in Diameter u. Persists for 7 -10 Days u. Painful

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

GENERAL RULE u. Aphthae Occur on Mobile Mucosa u. Herpetic Lesions Occur on Tissue That is Firmly Bound Down

FACTORS ASSOCIATED WITH APHTHAE u Psychological (Stress) u Socio-Economic u Endocrine u Immunosuppression u Hereditary u Hypersensitivity u Chemicals in Food Trauma S. sanguis

TREATMENT u. Chlorhexidine u. Topical Steroids –Lidex Gel. 05% u. Aphthasol Cream 5%

HERPES SIMPLEX INFECTIONS

RECURRENT HERPETIC STOMATITIS u Attenuated Form of Primary Infection u Tissue Firmly Bound Down u Vesicles Burst to Form Ulcers u Coalesce u Heals in 7 -10 Days

HERPES LABIALIS

SYSTEMIC ANTIVIRALS u Acyclovir (Zovirax) 200 mg Capsules One Capsule 5 Times a Day u Valacyclovir (Valtrex) 1 gm Caplets Two Caplets Twice a Day u Famciclovir (Famvir) 125 mg Tablets One Tablet Twice Daily

TOPICAL ANTIVIRALS u Zovirax (Acyclovir) Ointment 5% – 15 Gram Tube – Apply TID u Denavir (Penciclovir) Cream 1% – 2 Gram Tube – Apply Every Two Hours

AIDS RELATED PERIODONTAL DISEASE u Linear Gingival Erythema u Necrotizing Ulcerative Gingivitis u Necrotizing Ulcerative Periodontitis u Necrotizing Ulcerative Stomatitis

LINEAR GINGIVAL ERYTHEMA u. A Persistent, Linear Erythematous Gingivitis Which Bleeds Easily u Resistant to Treatment u Spontaneous Remission

NECROTIZING ULCERATIVE GINGIVITIS u Also Known as ANUG u Acute Gingivitis Characterized by Ulceration & Necrosis of the Gingival Margin & Destruction of the Interdental Papilla u Gingival Pain

NECROTIZING ULCERATIVE GINGIVITIS u Profuse Gingival Bleeding u Fetid Odor u No Involvement of Osseous Tissues u Associated w/ Stress, Anxiety, Malnutrition & Smoking

NECROTIZING ULCERATIVE PERIODONTITIS u Severe Deep Pain u Spontaneous Gingival Bleeding u Extensive Soft Tissue Necrosis u Severe Loss of Periodontal Attachment

NECROTIZING ULCERATIVE PERIODONTITIS u Rapid Onset & Progression u Bone May Be Exposed u Associated with Low CD 4 Counts

NECROTIZING ULCERATIVE STOMATITIS u Necrosis of Significant Areas of the Oral Soft Tissue & Underlying Bone

INTRAORAL PIGMENTATION Racial Pigmentation Amalgam Tattoo Heavy Metal Poisoning Medications Birth Control Pills Minocycline AZT Smoking Addison’s Disease Puetz-Jeger Syndrome

SALIVARY GLAND DISEASE u Xerostomia u Bilateral Parotid Gland Enlargement Occurs in HIV Infected Individuals u Histology Has Been Described as Resembling Autoimmune Salivary Gland Disease w/ Cystic Changes

Thanks for Coming! Jacqueline M. Plemons DDS, MS 6031 Sherry Lane Dallas, TX 75225 (214)369 -8585 drplemons@yahoo. com