AIDS and the Periodontium

AIDS

• Acquired immunodeficiency syndrome.• First reported in 1981.• Human immunodeficiency virus.• Profound impairment of the immune system (CD4 cell).• Increased risk for malignancy, disseminated infections and

adverse drug reactions.• high quantities of HIV only in blood, semen, and cerebrospinal

fluid.

Modes of Transmission

Risk Groups-Healthcare Professionals

CDC AIDS Surveillance Case Definition (1993)

• All HIV-infected persons who have > 200 CD4+ T-lymphocytes/uL, or > 14% CD4+ T-lymphocyte.

• Criteria for HIV infection for persons ages > 13 years: repeatedly reactive screening tests for HIV antibody

(e.g., enzyme immunoassay) with specific antibody identified by the use of supplemental tests (e.g., Western blot, immunofluorescence assay);

direct identification of virus in host tissues by virus isolation; c) HIV antigen detection; or d) a positive result on any other highly specific licensed test for HIV.

CDC Surveillance Case Classification

1. CD4+ T-Lymphocyte Categories Category 1: greater than or equal to 500 cells/mL Category 2: 200-499 cells/uL Category 3: less than 200 cells/uL

2. Clinical CategoriesCategory A • Asymptomatic HIV infection • Persistent generalized lymphadenopathy • Acute (primary) HIV infection with accompanying illness or

history of acute HIV infection

Category B• Bacillary angiomatosis • Candidiasis, oropharyngeal (thrush) • Candidiasis, vulvovaginal; persistent, frequent, or poorly

responsive to therapy • Cervical dysplasia (moderate or severe)/cervical carcinoma in

situ • Constitutional symptoms, such as fever (38.5 C) or diarrhea

lasting greater than 1 month

• Hairy leukoplakia, oral • Herpes zoster (shingles), involving at least two distinct

episodes or more than one dermatome • Idiopathic thrombocytopenic purpura • Listeriosis • Pelvic inflammatory disease, particularly if complicated by

tubo-ovarian abscess • Peripheral neuropathy

Category C• Clinical conditions listed in the AIDS surveillance case

definition.

Symptoms • Few weeks to months.• Acute symptoms-malaise, fatigue, fever, myalgia,

erythematous cutaneous eruption, oral candidiasis, oral ulcerations, and thrombocytopenia.

• Duration - 2 weeks.• Seroconversion occurs 3 to 8 weeks later.

Oral Manifestations Commonly occuring-• oral candidiasis• oral hairy leukoplakia• atypical periodontal diseases• oral Kaposi's sarcoma, and • oral non-Hodgkin's lymphoma

• Less common - melanotic hyperpigmentation, mycobacterialinfections, necrotizing ulcerative stomatitis, miscellaneousoral ulcerations, and viral infections.

Oral Candidiasis

• Most common - 90% of AIDS patients.• Diminished host resistance – debilitated

patients , patients receiving immunosuppressive therapy.

• Oppurtunistic – prolonged antibiotic therapy.

• Most oral candidal infections (85% to 95%) are associated with Candida albicans.

• Non-C. albicans infections are more common among immunocompromised individuals already receiving antifungal therapy for C. albicans.

Pseudomembranous candidiasis (thrush)• painless or slightly sensitive white lesions• readily scraped and separated from the surface of the oral mucosa• Hard and soft palate and the buccal or labial mucosa

Erythematous candidiasis• red patches on the buccal or palatal mucosa• associated with depapillation of the tongue

Hyperplastic candidiasis• least common• buccal mucosa and tongue• resistant to removal

Angular cheilitis• commissures appear erythematous• surface crusting and fissuring

Diagnosis• microscopic examination of a tissue sample or smear.• hyphae and yeast forms.

Treatment• topical and systemic antifungal agents.• Amphotericin B oral suspension is more effective againstCandida albicans.• Ketaconazole-systemic therapy.• refractory or recurrent.• 30% of AIDS related candidiasis relapse within 4 weeks of

treatment and 60% to 80% within 3 months.

Oral Hairy Leukoplakia

• primarily occurs in persons with HIV infection

• lateral borders of the tongue, bilateral distribution

• asymptomatic, poorly demarcated keratotic area

• Size - few millimeters to several centimeters

• corrugated appearance - characteristic vertical striations

• Microscopically, the lesion shows a hyperparakeratotic surface, acanthosis, koilocytes (containing Epstein-Barr virus)

• surface colonization by Candida organisms

• EBV-infected but HIV-negative individuals suffering from immunosuppressed conditions (e.g., acute myelogenous leukemia, organ transplantation or extensive systemic corticosteroid therapy).

• OHL of the tongue in a high-risk patient is considered to be a specific early sign of HIV infection and a strong indicator that the patient will develop AIDS.

• 83% of HIV-infected patients with hairy leukoplakia would develop AIDS within 31 months, and

• Nearly 100% of patients with hairy leukoplakia will eventually develop AIDS.

Treatment

• Laser or conventional surgery.• systemic antiviral agents such as acyclovir.

Kaposi’s Sarcoma

• Multifocal, vascular neoplasm.• Probable causative organism-

human herpes virus-8 (HHV-8).• HIV-infected individuals are 7000-

fold more likely to develop KS.• localized and slowly growing lesion.

In HIV individuals - aggressive lesion.

• Majority (71%) develop lesions of the oral mucosa, particularly the palate and gingiva.

• Painless, reddishpurple macules of the mucosa.

• Nodules, papules, or nonelevated macules that are usually brown, blue, or purple.

Microscopic features• Atypical vascular channels• extravascular hemorrhage with

hemosiderin deposition• spindle cell proliferation in association• mononuclear inflammatory infiltrate

consisting mainly of plasma cells

• Presence of KS signifies transition to outright AIDS.

Differential Diagnosis• Pyogenic granuloma, hemangioma, atypical hyperpigmentation,

sarcoidosis, bacillary angiomatosis, angiosarcoma, pigmented nevi, and cat-scratch disease.

Management• Antiretroviral agents, laser excision, radiation therapy, or intralesional

injection with vinblastine or interferon a.• Tendency to recur.• Destructive periodontitis – scaling and root planing.

Atypical Periodontal Diseases

• More common in HIV-infected i.v. drug users.

• Related with poor oral hygiene and lack of dental care.

Linear Gingival Erythema• persistent, linear, easily bleeding,

erythematous gingivitis.• localized or generalized; marginal

or diffuse.• Concomitant oral candidiasis-

Candida dubliniensis.

Histopathology• Increased blood vessels.• Lack of infammatory cell infiltrate.

Treatment• Non-responsive to therapy.• Spontaneous remission-some cases.• Meticulous oral hygiene.• Scaling, irrigation with chlorhexidine.• Recall after 2-3 weeks.• Persistent cases-treat for candida infection.

Necrotising Ulcerative Gingivitis

• Inflammatory destructive gingival condition.• Ulcerated, necrotic papillae-”punched-out

appearance”.• yellowish-grayish white slough-

psuedomembrane.• Lesions develop rapidly, painful.• Bleeding-spontaneous or on slight provocation.• Foul breath-pronounced.Histopathology - Fibrin deposits, leukocytes,

erythocytes, masses of bacteria.

Necrotising Ulcerative Periodontitis

• Extension of NUG. • Rapid bone loss and periodontal

attachment loss.• Usually localized to a few teeth.• Bone is exposed with

sequestration.• May undergo spontaneous

remission.• Interproximal craters.

Necrotizing Ulcerative Stomatitis

• Necrosis of significant areas of oral soft tissue and underlying bone.

• Severely destructive and acutely painful.

• Severe depression of CD4 cells.• Similar to cancrum oris (noma).

Management • Cleaning and debridement.• Oral hygiene instructions.• Systemic antibiotics-metronidazole and amoxycillin.• Re-evaluation after 1 month.• Osseous necrosis - remove the affected bone to promote

wound healing.