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 Categories Category 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, mycobacterial infections, necrotizing ulcerative stomatitis, miscellaneous oral 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 against Candida 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.

Kaposis Sarcoma
Multifocal, vascular neoplasm. Probable causative organism-human herpes virus-8 (HHV-8). HIV-infected individuals are 7000fold 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 candidiasisCandida 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 papillaepunched-out appearance. yellowish-grayish white sloughpsuedomembrane. 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.