management of periodontal disease in hiv-infected patients
TRANSCRIPT
Module 8
Management of Periodontal Disease in HIV-Infected Patients
Module 8
Management of Periodontal Disease in HIV-Infected Patients
Management of Periodontal Disease in HIV-Infected Patients
Management of Periodontal Disease in HIV-Infected Patients
Mark A. Reynolds, D.D.S., Ph.D.
Niki M. Moutsopoulos, D.D.S.Department of Periodontics
Dental School
University of Maryland Baltimore
and the
Pennsylvania/Mid-Atlantic AIDS ETC
Mark A. Reynolds, D.D.S., Ph.D.
Niki M. Moutsopoulos, D.D.S.Department of Periodontics
Dental School
University of Maryland Baltimore
and the
Pennsylvania/Mid-Atlantic AIDS ETC
Program OutlineProgram Outline
• Classification of Periodontal Diseases and Conditions
• Periodontal Diseases and Conditions in HIV-Infected Patients
• Periodontal Management of HIV-Infected Patients
• Classification of Periodontal Diseases and Conditions
• Periodontal Diseases and Conditions in HIV-Infected Patients
• Periodontal Management of HIV-Infected Patients
Program ObjectivesProgram ObjectivesThe objectives of this program are to:
(1) Outline the current classification of periodontal diseases and conditions based on the 1999 international workshop for a classification of periodontal diseases and conditions;
(2) Review selected periodontal diseases and conditions in HIV-infected patients
(3) Provide an overview of considerations and approaches in the periodontal management of HIV-infected patients
The objectives of this program are to:
(1) Outline the current classification of periodontal diseases and conditions based on the 1999 international workshop for a classification of periodontal diseases and conditions;
(2) Review selected periodontal diseases and conditions in HIV-infected patients
(3) Provide an overview of considerations and approaches in the periodontal management of HIV-infected patients
International Workshop for the Classification of Periodontal Diseases and Conditions, 1999
International Workshop for the Classification of Periodontal Diseases and Conditions, 1999
I. Gingival Diseases
II. Chronic Periodontitis
III. Aggressive Periodontitis
IV. Periodontitis as a Manifestation of Systemic Diseases
I. Gingival Diseases
II. Chronic Periodontitis
III. Aggressive Periodontitis
IV. Periodontitis as a Manifestation of Systemic Diseases
Annals of Periodontology, 1999Annals of Periodontology, 1999
Recent Changes in ClassificationRecent Changes in Classification
• 1989 World Workshop in Periodontics provided a widely recognized classification system
• Concerns included:a. Overlap in disease categoriesb. Absence of gingival disease componentc. Inappropriate emphasis on age of onset of diseased. Inadequate or unclear classification criteria
Armitage, Annals of Periodontology, 1999
• 1989 World Workshop in Periodontics provided a widely recognized classification system
• Concerns included:a. Overlap in disease categoriesb. Absence of gingival disease componentc. Inappropriate emphasis on age of onset of diseased. Inadequate or unclear classification criteria
Armitage, Annals of Periodontology, 1999
International Workshop for the Classification of Periodontal Diseases and Conditions, 1999
International Workshop for the Classification of Periodontal Diseases and Conditions, 1999
V. Necrotizing Periodontal Diseases
VI. Abscesses of the Periodontium
VII. Periodontitis Associated with Endodontic Lesions
VIII. Developmental or Acquired Deformities and Conditions
V. Necrotizing Periodontal Diseases
VI. Abscesses of the Periodontium
VII. Periodontitis Associated with Endodontic Lesions
VIII. Developmental or Acquired Deformities and Conditions
Annals of Periodontology, 1999Annals of Periodontology, 1999
I. Gingival DiseasesI. Gingival DiseasesA. Dental plaque-induced gingival diseases
1. Gingivitis associated with dental plaque only
a. With or without local contributing factors
2. Gingival diseases modified by systemic factors
a. Associated with the endocrine system
b. Associated with blood dyscrasias
3. Gingival diseases modified by medications
4. Gingival diseases modified by malnutrition
A. Dental plaque-induced gingival diseases
1. Gingivitis associated with dental plaque only
a. With or without local contributing factors
2. Gingival diseases modified by systemic factors
a. Associated with the endocrine system
b. Associated with blood dyscrasias
3. Gingival diseases modified by medications
4. Gingival diseases modified by malnutrition
Annals of Periodontology, 1999Annals of Periodontology, 1999
I. Gingival Diseases; ContinuedI. Gingival Diseases; Continued
B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin
E.g., Bacillary (epithelioid) Angiomatosis
2. Gingival diseases of viral origin
E.g., Herpes simplex virus
3. Gingival diseases of fungal origin
E.g., Linear gingival erythema
4. Gingival lesions of genetic origin
B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin
E.g., Bacillary (epithelioid) Angiomatosis
2. Gingival diseases of viral origin
E.g., Herpes simplex virus
3. Gingival diseases of fungal origin
E.g., Linear gingival erythema
4. Gingival lesions of genetic origin
Annals of Periodontology, 1999Annals of Periodontology, 1999
I. Gingival DiseasesI. Gingival Diseases
B. Non-plaque-induced gingival lesionsContinued
5. Gingival manifestations of systemic conditions
1. Mucocutaneous disorders
2. Allergic reactions
6. Traumatic lesions (factitious, iatrogenic, accidental)
7. Foreign body reactions
8. Not otherwise specified
B. Non-plaque-induced gingival lesionsContinued
5. Gingival manifestations of systemic conditions
1. Mucocutaneous disorders
2. Allergic reactions
6. Traumatic lesions (factitious, iatrogenic, accidental)
7. Foreign body reactions
8. Not otherwise specified
Annals of Periodontology, 1999Annals of Periodontology, 1999
II. Chronic PeriodontitisII. Chronic Periodontitis
A. Localized
B. Generalized
A. Localized
B. Generalized
Annals of Periodontology, 1999Annals of Periodontology, 1999
III. Aggressive PeriodontitisIII. Aggressive Periodontitis
A. Localized
B. Generalized
A. Localized
B. Generalized
IV. Periodontitis as a Manifestation of Systemic Diseases
IV. Periodontitis as a Manifestation of Systemic Diseases
A. Associated with hematological disorders
B. Associated with genetic disorders
C. Not otherwise specified (NOS)
A. Associated with hematological disorders
B. Associated with genetic disorders
C. Not otherwise specified (NOS)
Annals of Periodontology, 1999Annals of Periodontology, 1999
V. Necrotizing Periodontal DiseasesV. Necrotizing Periodontal Diseases
A. Necrotizing ulcerative gingivitis (NUG)
B. Necrotizing ulcerative periodontitis (NUP)
A. Necrotizing ulcerative gingivitis (NUG)
B. Necrotizing ulcerative periodontitis (NUP)
Annals of Periodontology, 1999Annals of Periodontology, 1999
Annals of Periodontology, 1999Annals of Periodontology, 1999
VI. Abscesses of the Periodontium
VII. Periodontitis Associated with Endodontic Lesions
VIII. Developmental or Acquired Deformities and Conditions
VI. Abscesses of the Periodontium
VII. Periodontitis Associated with Endodontic Lesions
VIII. Developmental or Acquired Deformities and Conditions
Periodontal Diseases and Conditions in HIV-Infected Patients
Periodontal Diseases and Conditions in HIV-Infected Patients• Unclear whether there are periodontal lesions
specific to HIV infection
• Exacerbation of periodontal conditions and disease, such as chronic periodontitis, may result from severe immunodeficiency or immunosuppression
• Mixed infections Opportunistic
Poly-microbial
• Unclear whether there are periodontal lesions specific to HIV infection
• Exacerbation of periodontal conditions and disease, such as chronic periodontitis, may result from severe immunodeficiency or immunosuppression
• Mixed infections Opportunistic
Poly-microbial
Selected Gingival Diseases and Conditions in HIV-Infected Patients
Selected Gingival Diseases and Conditions in HIV-Infected Patients
A. Dental plaque-induced gingival diseases
i.e., common gingivitis (not “HIV-gingivitis”)
B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin
A. Dental plaque-induced gingival diseases
i.e., common gingivitis (not “HIV-gingivitis”)
B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin
Gingival Diseases and Conditions in HIV-Infected Patients
Gingival Diseases and Conditions in HIV-Infected Patients
B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin
1. Mycobacterium
2. Gingival diseases of viral origin1. Herpesvirus infections2. Primary herpetic gingivostomatitis3. Recurrent oral herpes4. Varicella-zoster infections5. Other
3. Gingival diseases of fungal origin1. Linear gingival erythema2. Histoplasmosis3. Other
B. Non-plaque-induced gingival lesions1. Gingival diseases of specific bacterial origin
1. Mycobacterium
2. Gingival diseases of viral origin1. Herpesvirus infections2. Primary herpetic gingivostomatitis3. Recurrent oral herpes4. Varicella-zoster infections5. Other
3. Gingival diseases of fungal origin1. Linear gingival erythema2. Histoplasmosis3. Other
Factors that Predispose to Oral Lesions
Factors that Predispose to Oral Lesions
• CD4+ counts < 200cells/mm3
• Viral load > 3000copies/mm3
• Xerostomia
• Poor oral hygiene
• Smoking
• CD4+ counts < 200cells/mm3
• Viral load > 3000copies/mm3
• Xerostomia
• Poor oral hygiene
• Smoking
M0 6 12 18 24 30 36 42 48 54 60 66 72 780
200
400
600
800
1000
CD4Virus
Time (months post infection)
CD
4 T
ce
ll c
on
ce
ntr
ati
on
HIV PROGRESSION
CD4 < 200 = AIDS• Immune deterioration• Opportunistic Infections• Oral Manifestations
Adapted from Fauci et al., 1983Adapted from Fauci et al., 1983
Linear Gingival ErythemaLinear Gingival Erythema
• Linear erythematous band involving the free marginal gingiva without demonstrable attachment loss Erythema may extend to attached gingiva Possible precursor of necrotizing ulcerative
periodontal conditions Prevalence: 4% -50% (Holmstrup et al., 2002)
• Spontaneous hemorrhage• Minimal plaque deposits• Associated with Candida albicans• Responds poorly to conventional treatment
• Linear erythematous band involving the free marginal gingiva without demonstrable attachment loss Erythema may extend to attached gingiva Possible precursor of necrotizing ulcerative
periodontal conditions Prevalence: 4% -50% (Holmstrup et al., 2002)
• Spontaneous hemorrhage• Minimal plaque deposits• Associated with Candida albicans• Responds poorly to conventional treatment
Linear Gingival ErythemaLinear Gingival Erythema
Photograph courtesy of Dr. Louis DePaola, Baltimore, MDPhotograph courtesy of Dr. Louis DePaola, Baltimore, MD
Periodontal Diseases and Conditions in HIV-Infected Patients
Periodontal Diseases and Conditions in HIV-Infected Patients• Aggressive periodontitis
Severe localized forms reported in literature
• Chronic periodontitis modified by immunosuppression
Recent interest in potential for accelerated rate of chronic periodontitis occurring in HIV+ patients
Rate of progression may be dependent upon the immunologic competency of the host as well as local inflammatory response to typical and atypical subgingival microorganisms (Lamster et al., 1997)
• Aggressive periodontitis
Severe localized forms reported in literature
• Chronic periodontitis modified by immunosuppression
Recent interest in potential for accelerated rate of chronic periodontitis occurring in HIV+ patients
Rate of progression may be dependent upon the immunologic competency of the host as well as local inflammatory response to typical and atypical subgingival microorganisms (Lamster et al., 1997)
Chronic PeriodontitisChronic Periodontitis
• It is not clear whether HIV+ patients develop a more progressive form of conventional periodontitis
• One study demonstrated a three fold increase in the odds ratios of bone loss for males (Tomar et al., 1995)
• Chronic periodontitis modified by immunosuppression
Recent interest in potential for accelerated rate of chronic periodontitis occurring in HIV+ patients
Rate of progression may be dependent upon the immunologic competency of the host as well as local inflammatory response to typical and atypical subgingival microorganisms (Lamster et al., 1997)
• It is not clear whether HIV+ patients develop a more progressive form of conventional periodontitis
• One study demonstrated a three fold increase in the odds ratios of bone loss for males (Tomar et al., 1995)
• Chronic periodontitis modified by immunosuppression
Recent interest in potential for accelerated rate of chronic periodontitis occurring in HIV+ patients
Rate of progression may be dependent upon the immunologic competency of the host as well as local inflammatory response to typical and atypical subgingival microorganisms (Lamster et al., 1997)
Periodontal Diseases and Conditions in HIV-Infected Patients
Periodontal Diseases and Conditions in HIV-Infected Patients
• Necrotizing Periodontal Diseases
Necrotizing ulcerative gingivitis (NUG)
Necrotizing ulcerative periodontitis (NUP)
• Necrotizing Periodontal Diseases
Necrotizing ulcerative gingivitis (NUG)
Necrotizing ulcerative periodontitis (NUP)
Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis• Primarily affects the papillary and marginal gingiva• Gingival erythema and edema, with spontaneous
bleeding • Yellowish-grayish (“pseudomembranous”) areas
of marginal and/or papillary necrosis of gingiva
Loss of interdental papillae
Pain
Rapid progression and extension possible
• Primarily affects the papillary and marginal gingiva• Gingival erythema and edema, with spontaneous
bleeding • Yellowish-grayish (“pseudomembranous”) areas
of marginal and/or papillary necrosis of gingiva
Loss of interdental papillae
Pain
Rapid progression and extension possible
Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis
Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MDPhotograph courtesy of Dr. Valli I. Meeks, Baltimore, MD
Necrotizing Ulcerative GingivitisNecrotizing Ulcerative Gingivitis
Gingival tissues appear
erythematous and
edematous, with
evidence of papillary
necrosis and cratering
Gingival tissues appear
erythematous and
edematous, with
evidence of papillary
necrosis and cratering
Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MDPhotograph courtesy of Dr. Valli I. Meeks, Baltimore, MD
Necrotizing Ulcerative PeriodontitisNecrotizing Ulcerative Periodontitis
• Interproximal ulceration, necrosis and cratering
• Foetor is often present
• Pain (severe, deep, localized in jaw)
• Spontaneous bleeding
• Soft tissue necrosis and rapid periodontal destruction
• Prevalence: 1%-88% (Holmstrup et al., 2002).
One large study found a rate of 6.3% (Glick et al., 1994)
• Interproximal ulceration, necrosis and cratering
• Foetor is often present
• Pain (severe, deep, localized in jaw)
• Spontaneous bleeding
• Soft tissue necrosis and rapid periodontal destruction
• Prevalence: 1%-88% (Holmstrup et al., 2002).
One large study found a rate of 6.3% (Glick et al., 1994)
Necrotizing Ulcerative PeriodontitisNecrotizing Ulcerative Periodontitis
Prominent changes in
gingival contour are
associated with tissue
necrosis and loss of
periodontal attachment
and bone
Prominent changes in
gingival contour are
associated with tissue
necrosis and loss of
periodontal attachment
and bone Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MDPhotograph courtesy of Dr. Valli I. Meeks, Baltimore, MD
General Considerations in the Management of HIV+ Patients
General Considerations in the Management of HIV+ Patients
• Universal precautions
• Medical consultation
a. Overall medical status
b. Current medications
c. Opportunistic infection(s)
d. Stage of HIV disease
a. CD4 lymphocyte count
b. Viral load
• Management of oral infections
• Comprehensive preventive and restorative oral
health care
• Universal precautions
• Medical consultation
a. Overall medical status
b. Current medications
c. Opportunistic infection(s)
d. Stage of HIV disease
a. CD4 lymphocyte count
b. Viral load
• Management of oral infections
• Comprehensive preventive and restorative oral
health care
General Considerations in the Management of HIV+ Patients
General Considerations in the Management of HIV+ Patients
• In the absence of significant immunosuppression,
the periodontal treatment of HIV+ patients should
be guided by the same parameters of care
appropriate for HIV- individuals.
• In the absence of significant immunosuppression,
the periodontal treatment of HIV+ patients should
be guided by the same parameters of care
appropriate for HIV- individuals.
Management of Linear Gingival ErythemaManagement of Linear Gingival Erythema
• Scaling and debridement
• Topical and/or subgingival irrigation with antimicrobial chemotherapeutic agent Povidine iodine 10%, chlorhexidine gluconate
irrigation 0.12%-0.2%, or Listerine Antiseptic
• Prescribe daily microbial mouth rinse Chlorhexidine gluconate mouth 0.12% (Rx)1
Listerine Antiseptic (OTC)2
• Recommendation for tobacco cessation
• Re-evaluate in 2-3 weeks.
• Scaling and debridement
• Topical and/or subgingival irrigation with antimicrobial chemotherapeutic agent Povidine iodine 10%, chlorhexidine gluconate
irrigation 0.12%-0.2%, or Listerine Antiseptic
• Prescribe daily microbial mouth rinse Chlorhexidine gluconate mouth 0.12% (Rx)1
Listerine Antiseptic (OTC)2
• Recommendation for tobacco cessation
• Re-evaluate in 2-3 weeks.
1. Available only by Rx; Many State drug plans do not cover this agent2. Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious1. Available only by Rx; Many State drug plans do not cover this agent2. Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious
Management of Linear Gingival ErythemaContinuedManagement of Linear Gingival ErythemaContinued
• For nonresponsive lesions, evaluate for Candidal infection, and consider antifungal agentRefer to module 6
• Selected narrow-spectrum antibiotics sparing gram-positive organisms may be beneficial Metronidazole (250mg, tid 7-10 days)
In the absence of resolution, consideration should be given to other possible lesions, such as lymphomas, including referral for appropriate diagnostic testing (i.e., biopsy)
• Meticulous oral hygiene and frequent supportive maintenance
• For nonresponsive lesions, evaluate for Candidal infection, and consider antifungal agentRefer to module 6
• Selected narrow-spectrum antibiotics sparing gram-positive organisms may be beneficial Metronidazole (250mg, tid 7-10 days)
In the absence of resolution, consideration should be given to other possible lesions, such as lymphomas, including referral for appropriate diagnostic testing (i.e., biopsy)
• Meticulous oral hygiene and frequent supportive maintenance
Periodontal Diseases and Conditions in HIV-infected Patients
Periodontal Diseases and Conditions in HIV-infected Patients
• Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Necrotizing stomatitis
• Necrotizing Periodontal Diseases Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Necrotizing stomatitis
Management of Necrotizing Ulcerative GingivitisManagement of Necrotizing Ulcerative Gingivitis
• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%. Povidine iodine provides some analgesic properties.
• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12% 1
Listerine Antiseptic 2
• Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary
• Reevaluation 1 mo following resolution of acute symptoms
• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%. Povidine iodine provides some analgesic properties.
• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12% 1
Listerine Antiseptic 2
• Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary
• Reevaluation 1 mo following resolution of acute symptoms
1. Available only by Rx; Many State drug plans do not cover this agent
2. Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious
Management of Necrotizing Ulcerative GingivitisManagement of Necrotizing Ulcerative Gingivitis
• Systemic antibiotics
Metronidazole (250mg tid, 7-10 days)
When necessary, should administered concurrently with topical (e.g, clotrimazole troches or nystatin vaginal tablets and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole)
• Reevaluation 1 mo following resolution of acute symptoms
• Systemic antibiotics
Metronidazole (250mg tid, 7-10 days)
When necessary, should administered concurrently with topical (e.g, clotrimazole troches or nystatin vaginal tablets and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole)
• Reevaluation 1 mo following resolution of acute symptoms
Management of Necrotizing Ulcerative Periodontitis
Management of Necrotizing Ulcerative Periodontitis
• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%.
Povidine iodine provides some analgesic properties.
• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12%
Listerine Antiseptic
• Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary
• Local debridement, scaling and root planing, and irrigation of affected areas with either povidine iodine 10% or chlorhexidine gluconate 0.12-0.2%.
Povidine iodine provides some analgesic properties.
• Daily rinses with antimicrobial Chlorhexidine gluconate mouth 0.12%
Listerine Antiseptic
• Frequent (daily or every-other-day) follow up for 7-10 days, repeating scaling and debridement as necessary
Management of Necrotizing Ulcerative Periodontitis
Management of Necrotizing Ulcerative Periodontitis
• Systemic antibiotics
Metronidazole (250mg tid, 7-10 days; Robinson et al.,1998)
Consideration should also be given to the prophylactic administration of topical (e.g, clotrimazole troches or nystatin vaginal tablets) and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole 100mg, 1 td, 7 to 10 days)
• Reevaluation 1 mo following resolution of acute symptoms
• 3 mo supportive periodontal maintenance 30% of patients experience recurrence in 2 years (Patton et al.,
2000) History of NUP predisposes to Necrotizing Ulcerative Stomatitis
(Robinson, 2002)
• Systemic antibiotics
Metronidazole (250mg tid, 7-10 days; Robinson et al.,1998)
Consideration should also be given to the prophylactic administration of topical (e.g, clotrimazole troches or nystatin vaginal tablets) and, in severe immunosuppression, systemic antifungal medication (e.g, fluconazole 100mg, 1 td, 7 to 10 days)
• Reevaluation 1 mo following resolution of acute symptoms
• 3 mo supportive periodontal maintenance 30% of patients experience recurrence in 2 years (Patton et al.,
2000) History of NUP predisposes to Necrotizing Ulcerative Stomatitis
(Robinson, 2002)
Management of Necrotizing Ulcerative Stomatitis
Management of Necrotizing Ulcerative Stomatitis
• Debridement of affected areas
• Daily rinses with antimicrobial Chlorhexidine gluconate mouth rinse 0.12% Listerine Antiseptic
• Daily (or every-other-day) follow up for the first week, repeating debridement at each visit
• Systemic antibiotics (e.g., metronidazole 250 tid, 7-10 days). Consideration should also be given to the prophylactic
administration of an antifungal medication (fluconazole 100mg, 1td or Itraconazole 200mg, 1td; for 7 to 10 days)
• Reevaluation 1 mo following resolution of acute symptoms
• Debridement of affected areas
• Daily rinses with antimicrobial Chlorhexidine gluconate mouth rinse 0.12% Listerine Antiseptic
• Daily (or every-other-day) follow up for the first week, repeating debridement at each visit
• Systemic antibiotics (e.g., metronidazole 250 tid, 7-10 days). Consideration should also be given to the prophylactic
administration of an antifungal medication (fluconazole 100mg, 1td or Itraconazole 200mg, 1td; for 7 to 10 days)
• Reevaluation 1 mo following resolution of acute symptoms
Abscesses of the PeriodontiumAbscesses of the Periodontium
• Rapid palatal enlargement, smooth and shiny
swelling associated with pain
• Treatment:
Establish drainage by debriding pocket and
removing plaque, calculus and irritants
Monitor for resolution of symptoms –
failure to resolve may be due to incomplete
debridement
In severely immunocompromized patients
(CD4<200) as well as non-resolving lesions
consider systemic antibiotics (e.g.,
Amoxicillin 1.0 gm loading dose and 500
mg tid for 3 days)
• Consideration should be given to prophylatic
administration antifungal agent(s)
• Culture and sensitivity testing is advisable
• Rapid palatal enlargement, smooth and shiny
swelling associated with pain
• Treatment:
Establish drainage by debriding pocket and
removing plaque, calculus and irritants
Monitor for resolution of symptoms –
failure to resolve may be due to incomplete
debridement
In severely immunocompromized patients
(CD4<200) as well as non-resolving lesions
consider systemic antibiotics (e.g.,
Amoxicillin 1.0 gm loading dose and 500
mg tid for 3 days)
• Consideration should be given to prophylatic
administration antifungal agent(s)
• Culture and sensitivity testing is advisable
Photograph courtesy of Dr. Louis DePaola, Baltimore, MDPhotograph courtesy of Dr. Louis DePaola, Baltimore, MD
Periodontal Microflora in HIV+ PatientsPeriodontal Microflora in HIV+ Patients
• No major differences in the microbial composition of periodontal lesions between HIV and non-HIV infected patients
• Colonization includes:A.actinomycetemcomitans
P.gingivalis
P. intermedia
F. nucleatum in LGE and NUP
• Recovery of human herpes virus types 6, 7, and 8, found in 90% of HIV+ patients Over 2X higher than in HIV- controls (Mardirossian et al, 1999)
• No major differences in the microbial composition of periodontal lesions between HIV and non-HIV infected patients
• Colonization includes:A.actinomycetemcomitans
P.gingivalis
P. intermedia
F. nucleatum in LGE and NUP
• Recovery of human herpes virus types 6, 7, and 8, found in 90% of HIV+ patients Over 2X higher than in HIV- controls (Mardirossian et al, 1999)
Considerations in the Use of Antibiotics Considerations in the Use of Antibiotics
• Preferred use of narrow spectrum antibiotics (e.g., Metronidazole) to minimize development of antibiotic resistance
• Possibility of presence of antibiotic resistant strainsCulture and antibiotic sensitivity may be indicated
• Use of antibiotics may lead to overgrowth of Candida albicans Antifungal treatment may be indicated in conjunction
with systemic antibiotics
• Local delivery antibiotics may be useful but have not been evaluated
• Preferred use of narrow spectrum antibiotics (e.g., Metronidazole) to minimize development of antibiotic resistance
• Possibility of presence of antibiotic resistant strainsCulture and antibiotic sensitivity may be indicated
• Use of antibiotics may lead to overgrowth of Candida albicans Antifungal treatment may be indicated in conjunction
with systemic antibiotics
• Local delivery antibiotics may be useful but have not been evaluated
Antibiotic and Antifungal RegimensAntibiotic and Antifungal Regimens
Antibiotics
Rx
Metronidazole tabs 250 mg
Disp: 30 to 40 tabs
Sig: Two tablets as a loading dose and thereafter 250 mg qid for 7-10 days
Antibiotics
Rx
Metronidazole tabs 250 mg
Disp: 30 to 40 tabs
Sig: Two tablets as a loading dose and thereafter 250 mg qid for 7-10 days
Antibiotic and Antifungal RegimensAntibiotic and Antifungal Regimens
Topical Antifungal Agents
Rx
Clotrimazole troche 10mg
Sig: Dissolve 3-5/day for 7-10 days
or
Nystatin vaginal tablets (100,000 U):
Sig: dissolve 1 tablet in mouth tid 7-10 days
Topical Antifungal Agents
Rx
Clotrimazole troche 10mg
Sig: Dissolve 3-5/day for 7-10 days
or
Nystatin vaginal tablets (100,000 U):
Sig: dissolve 1 tablet in mouth tid 7-10 days
Antibiotic and Antifungal RegimensAntibiotic and Antifungal Regimens
Systemic Antifungal Agents
Rx
Fluconazole tablets 100mg
Disp: 9 to 16 tabs
Sig: two tablets immediately and
then 1 tablet daily for 7-10 days
Systemic Antifungal Agents
Rx
Fluconazole tablets 100mg
Disp: 9 to 16 tabs
Sig: two tablets immediately and
then 1 tablet daily for 7-10 days
Antibiotic and Antifungal RegimensAntibiotic and Antifungal Regimens
Systemic Antifungal Agents
Rx
Itraconazole capsules 100mg
Disp: 14 capsules
Sig: 200mg once daily for 7days
Systemic Antifungal Agents
Rx
Itraconazole capsules 100mg
Disp: 14 capsules
Sig: 200mg once daily for 7days
Pediatric PatientsPediatric Patients• Oral lesions have been reported in HIV+ pediatric
populations. The CDC revised the classification system for HIV infection in children <13 years of age to include oral lesions as markers of severity of HIV infection (1994)
• Linear gingival erythema has been reported in approximately 10% of HIV+ children exhibit
• Periodontal conditions and diseases, such as necrotizing ulcerative gingivitis and periodontitis, have been infrequently described
• Oral lesions have been reported in HIV+ pediatric populations. The CDC revised the classification system for HIV infection in children <13 years of age to include oral lesions as markers of severity of HIV infection (1994)
• Linear gingival erythema has been reported in approximately 10% of HIV+ children exhibit
• Periodontal conditions and diseases, such as necrotizing ulcerative gingivitis and periodontitis, have been infrequently described
Considerations in Periodontal Therapy
Considerations in Periodontal Therapy
• The effects of systemic bacteremia created
following Sc/RP have not been studied
• The response of HIV+ patients to periodontal
surgery has not been studied
• The presence of antibiotic resistant oral
bacteria has not been evaluated
• The effects of systemic bacteremia created
following Sc/RP have not been studied
• The response of HIV+ patients to periodontal
surgery has not been studied
• The presence of antibiotic resistant oral
bacteria has not been evaluated
Oral Manifestations in the HAART EraOral Manifestations in the HAART Era
• Overall prevalence of oral infections has changed since
introduction of highly active antiretroviral treatment (HAART)
• Overall reductions in oral infections from 47.6% to 37.5%
(Patton et al., 2000)
• Reductions in oral hairy leukoplakia and necrotizing
ulcerative periodontitis
• Increase in oral warts (Greenspan, 2002)
• No change noted for oral candidiasis, oral ulcers, or Kaposi
sarcoma
• Overall prevalence of oral infections has changed since
introduction of highly active antiretroviral treatment (HAART)
• Overall reductions in oral infections from 47.6% to 37.5%
(Patton et al., 2000)
• Reductions in oral hairy leukoplakia and necrotizing
ulcerative periodontitis
• Increase in oral warts (Greenspan, 2002)
• No change noted for oral candidiasis, oral ulcers, or Kaposi
sarcoma
Web ResourcesWeb Resources
1. http://www.hivatis.org.
2. https://w3.ada.org/prof/prac/issues/topics/icontrol/ic-recs/index.html
.
3. http://www.hivdent.org/dtc.htm.
4. http://www.critpath.org/daac/standards.html
Resources and Contact InformationResources and Contact Information
• Mark A. Reynolds, D.D.S., Ph.D.• Niki M. Moutsopoulos, D.D.S.
University of Maryland
Dental School
Department of Periodontics
666 West Baltimore Street
Baltimore, Maryland 21201
(410) 706-7152
ReferencesReferences• Classification and diagnostic criteria for oral lesions in HIV infection. EC-
Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. Oral Pathol Med 1993;22:289-91.
• Fauci, AS. The acquired immune deficiency syndrome. The ever-broadening clinical spectrum. JAMA 1983 May 6;249:2375-6.
• Glick, M., et al. Necrotizing ulcerative periodontitis: a marker for immune deterioration and a predictor for the diagnosis of AIDS. J Periodontol 1994; 65: 393-397.
• Greenspan, JS. Periodontal complications of HIV infection.Compend Suppl 1994;18:S694-8.
• Greenspan D., Canchola A., MacPhail C, Cheikh B, Greenspan J. Effect of Highly Active Antiretroviral Therapy on Frequency of Oral Warts. Lancet 2002;357:1411-1412.
• Horning, GM Necotizing gingivostomatitis: NUG to noma. Compend Contin Educ Dent 1996;17:951-4, 956, 957-8
• Holmstrup, P. and Glick, M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000. 2002;28:190-205.
• Classification and diagnostic criteria for oral lesions in HIV infection. EC-Clearinghouse on Oral Problems Related to HIV Infection and WHO Collaborating Centre on Oral Manifestations of the Immunodeficiency Virus. Oral Pathol Med 1993;22:289-91.
• Fauci, AS. The acquired immune deficiency syndrome. The ever-broadening clinical spectrum. JAMA 1983 May 6;249:2375-6.
• Glick, M., et al. Necrotizing ulcerative periodontitis: a marker for immune deterioration and a predictor for the diagnosis of AIDS. J Periodontol 1994; 65: 393-397.
• Greenspan, JS. Periodontal complications of HIV infection.Compend Suppl 1994;18:S694-8.
• Greenspan D., Canchola A., MacPhail C, Cheikh B, Greenspan J. Effect of Highly Active Antiretroviral Therapy on Frequency of Oral Warts. Lancet 2002;357:1411-1412.
• Horning, GM Necotizing gingivostomatitis: NUG to noma. Compend Contin Educ Dent 1996;17:951-4, 956, 957-8
• Holmstrup, P. and Glick, M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000. 2002;28:190-205.
ReferencesReferences
• Holmstrup P, Glick M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000 2002;28:190-205. • Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis D, Reynolds HS, Zambon JJ Oral Dis 1997;3 Suppl 1:S141-8.• Murray, PA. Periodontal diseases in patients infected by human immunodeficiency virus. Periodontol 2000 1994;6:50-67.• Narani N, Epstein JB. Classifications of oral lesions in HIV infection J Clin Periodontol 2001;28:137-45.• Patton LL, McKaig R, Straauss R, Rogers D, Enron JJ Jr. Changing prevalence of oral manifestations of human immunodeficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:299-304.• Parameter on Acute Periodontal Disease. Parameters of Care Supplement J Periodontol May 2000.• Rees, TD. Periodontal Management of HIV-Infected Patients. In MG Newman, HH Takei, FA Carranza (Eds) Carranza's Clinical Periodontology 9th Edition, Chicago: W B Saunders, 2001.
• Holmstrup P, Glick M. Treatment of periodontal disease in the immunodeficient patient. Periodontol 2000 2002;28:190-205. • Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis D, Reynolds HS, Zambon JJ Oral Dis 1997;3 Suppl 1:S141-8.• Murray, PA. Periodontal diseases in patients infected by human immunodeficiency virus. Periodontol 2000 1994;6:50-67.• Narani N, Epstein JB. Classifications of oral lesions in HIV infection J Clin Periodontol 2001;28:137-45.• Patton LL, McKaig R, Straauss R, Rogers D, Enron JJ Jr. Changing prevalence of oral manifestations of human immunodeficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:299-304.• Parameter on Acute Periodontal Disease. Parameters of Care Supplement J Periodontol May 2000.• Rees, TD. Periodontal Management of HIV-Infected Patients. In MG Newman, HH Takei, FA Carranza (Eds) Carranza's Clinical Periodontology 9th Edition, Chicago: W B Saunders, 2001.
ReferencesReferences
• Robinson PG, Sheiham A, Challacombe SJ, Wren MW, Zakrzewska JM. Gingival ulceration in HIV infection. A case series and case control.study. J Clin Periodontol 1998 Mar;25:260-7.
• Robinson PG, Periodontal diseases and HIV infection. Oral Dis 2002;8 Suppl 2:144-50.
• Ryder, MI. Periodontal management of HIV-infected patients. Periodontol 2000, 2000;23:85-93.
• Ryder, MI. State of the Art: An Update on HIV and Periodontal Disease. J. Periodontol 2002;73: 1083-1090.
• Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-seropositive military personnel. J Periodontol 1995 Jun;66:421-8.
• Winkler JR, Murray PA, Grassi M, Hammerle C. Diagnosis and management of HIV-associated periodontal lesions.J Am Dent Assoc 1989;Suppl:25S-34S.
• Winkler JR, Robertson PB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:145-50.
• 1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Annals of Periodontol 1999;4:1-112.
• Robinson PG, Sheiham A, Challacombe SJ, Wren MW, Zakrzewska JM. Gingival ulceration in HIV infection. A case series and case control.study. J Clin Periodontol 1998 Mar;25:260-7.
• Robinson PG, Periodontal diseases and HIV infection. Oral Dis 2002;8 Suppl 2:144-50.
• Ryder, MI. Periodontal management of HIV-infected patients. Periodontol 2000, 2000;23:85-93.
• Ryder, MI. State of the Art: An Update on HIV and Periodontal Disease. J. Periodontol 2002;73: 1083-1090.
• Tomar SL, Swango PA, Kleinman DV, Burt BA. Loss of periodontal attachment in HIV-seropositive military personnel. J Periodontol 1995 Jun;66:421-8.
• Winkler JR, Murray PA, Grassi M, Hammerle C. Diagnosis and management of HIV-associated periodontal lesions.J Am Dent Assoc 1989;Suppl:25S-34S.
• Winkler JR, Robertson PB. Periodontal disease associated with HIV infection. Oral Surg Oral Med Oral Pathol 1992;73:145-50.
• 1999 International Workshop for a Classification of Periodontal Diseases and Conditions. Annals of Periodontol 1999;4:1-112.