HUMAN IMMUNODEFICIENCY VIRUS (AIDS)

BY DR. SAIMA B. JAFFRI

 AIDS is a chronic, potentially life-threatening condition caused by the human immunodeficiency virus (HIV). By damaging your immune system, HIV interferes with your body's ability to fight the organisms that cause disease. HIV is a sexually transmitted infection. It can also be spread by contact with infected blood, or from mother to child during pregnancy, childbirth or breast-feeding.

INTRODUCTION

Symptoms The symptoms of HIV and AIDS vary, depending on the phase of infection. Primary infection The majority of people infected by HIV develop a flu-like illness within a month or two after the virus enters the body. This illness, known as primary or acute HIV infection, may last for a few weeks. Possible symptoms include: Fever Muscle soreness Rash Headache Sore throat Mouth or genital ulcers Swollen lymph glands, mainly on the neck Joint pain Night sweats Diarrhea Although the symptoms of primary HIV infection may be mild enough to go unnoticed, the amount of virus in the blood stream (viral load) is particularly high at this time. As a result, HIV infection spreads more efficiently during primary infection than during the next stage of infection.

 Early symptomatic HIV infection As the virus continues to multiply and destroy immune cells, you may develop mild infections or chronic symptoms such as: Fever Fatigue Swollen lymph nodes often one of the first signs of HIV infection Diarrhea Weight loss Cough and shortness of breath Progression to AIDS If you receive no treatment for your HIV infection, the disease typically progresses to AIDS in about 10 years. By the time AIDS develops, your immune system has been severely damaged, making you susceptible to opportunistic infections . The signs and symptoms of some of these infections may include: Night sweats Shaking chills or fever higher than 100 F (38 C) for several weeks Cough and shortness of breath Chronic diarrhea Persistent white spots or unusual lesions on your tongue or in your mouth Headaches Persistent, unexplained fatigue Blurred and distorted vision Weight loss Skin rashes

 How HIV is transmitted To become infected with HIV, infected blood, semen or vaginal secretions must enter your body. You can't become infected through ordinary contact hugging, kissing, dancing or shaking hands with someone who has HIV or AIDS. HIV can't be transmitted through the air, water or via insect bites. You can become infected with HIV in several ways, including: During sex. Blood transfusions. Sharing needles. From mother to child. But if women receive treatment for HIV infection during pregnancy, the risk to their babies is significantly reduced.

Group 1 (lesions strongly associated with HIV): 1. Oral candidal infections -Erythematous -Hyperplastic -Pseudomembranous 2. Hairy leukoplakia 3.HIV associated periodontitis - HIV gingivitis - HIV periodontitis - Necrotizing ulcerative gingivitis - Necrotizing ulcerative stomatitis 4. Kaposi sarcoma 5. Non-Hodgkins lymphoma

Oral manifestations

ORAL CANDIDIASIS

HIV ASSOCIATED PERIODONTITIS

HAIRY LEUKOPLAKIA

HIV ASSOCIATED GINGIVITIS

NECROTIZING ULCERATIVE GINGIVITIS

NECROTIZING ULCERATIVE STOMATITIS

KAPOSI SARCOMA
Patch stage

Plaque stage

Nodular stage

Group 2 (lesions less commonly associated with HIV):

1. Aphthous ulcers (oropharyngeal region) 2. Idiopathic thrombocytopenia 3. Salivary gland disorders - Dry mouth and decreased salivary flow - Uni or bilateral swelling of major glands 4. Viral infections (apart from EBV) - Cytomegalovirus - Herpes simplex virus - Human papilloma virus - Varicella - zoster virus

Oral manifestations

HIV ASSOCIATED APHTHOUS ULCERS

HIV ASSOCIATED HPV INFECTION

HIV ASSOCIATED HERPETIC ULCERS

DIAGNOSIS
1. Screening test: ELISA is most
commonly used test. But it can show false positive results.

2. Western Blot test: It is a test to

detect viral antibodies. More accurate than ELISA.

CONDITION /DISEASE

SALIENT CLINICAL FEATURES

DIAGNOSI S

TREATMENT

2: Summary of Oral Manifestations of HIV/AIDS

REMARKS

Pseudome mbranous Candidosi s

Soft white/yell ow, curdlike plaques on oral mucosa. Deposits easily removabl e by gentle scraping

Clinical grounds; smear stained by Grams or PAS stain show candidal hyphae; candidal culture.

Topical antifungals: Mycostatin Pastilles: Dissolve 1 tablet in mouth until gone, q.d x 14 days Mycostatin Oral Suspension: Use 1 teaspoon q.d, rinse and hold in mouth as long as possible before swallowing or spitting out (approximately 2 minutes). Mycostatin Ointment or Cream: Apply liberally to affected areas q.d.
Mycele Troche: 10mg: dissolve 1 tablet in the mouth q.d x 2 weeks Nizoral 200mg: take 1 tablet q.d x 10-14 days.

Contains nystatin 200,000 units/tablet. Pastilles are more effective than oral suspension due to prolonged contact

Contains nystatin 100,000 units/ml. Do not eat or drink for 30 minutes following application

Contains nystatin 100,000 units/g. Denture-wearers should apply to denture surface prior to each insertion. For edentulous patients, mycostatin powder can be sprinkled on the denture Contains clotrimazole. Tablets contain sucrose; risk of dental caries with prolonged use (>3 months); care must be exercised in diabetic patients
Contains ketoconazole. To be taken if Candida infection does not respond to Mycostatin. Potential for liver toxicity exists. LFT should be monitored with long term use (>3 months). Contains nystatin.

Nystatin: (100,000 units) vaginal tablet dissolved in the mouth t.i.d x 2 weeks Diflucan 100mg: 2 tablets the first day and 1 tablet q.d x 10-14 days Mycolog Cream: Apply to affected area after each meal and before bedtime.
Fungizone Oral Suspension: 1ml swish and swallow q.i.d between meals.

Contains fluconazole

Contains nystatin and triamcinolone. For candidal angular cheilitis. This often represents a mixed infection of Candida and other organisms Contains amphotericin B. NOTE:When amphotericin B is used, pharmacologic antagonism may occur with ketoconazole and miconazole. It may increase toxicity of cyclosporin. Antineoplastic agents may increase the risk of toxicity of amphotericin induced nephrotoxicity, bronchospasm, and hypotension. Patients receiving digitalis may present toxicity.

CONDITION/DISE SALIENT ASE CLINICAL FEATURES

DIAGNOSIS

TREATMENT

REMARKS

Erythematous Candidosis

Flat ,red As above. patches on the dorsal surface of the tongue and hard palate

As above.

As above.

Candidal Angular Cheilitis

Red, ulcerated, and fissured lesion at the angle of the mouth.

As above.

Mycolog Cream: (See above.)

Occasionally this may be caused by a mixed infection.

CONDITION/DISEASE

SALIENT CLINICAL FEATURES

DIAGNOSIS

TREATMENT

REMARKS

Hairy Leukoplakia (Oral Hairy Leukoplakia)

Asymptomatic bilateral, vertically corrugated or hairy white lesions on the lateral borders of the Tongue.

Clinical and histological;demonstratio n of the virus; (EBV) by in situ hybridisation techniques or PCR

Zovirax(Acyclovir): 200mg: 1 capsule q.6h x 2 weeks. Surgery, cryotherapy, or application of podophyllin. No treatment is necessary.

Systemic administration causes some regression of HL. HL is not a premalignant lesion

Linear Gingival Erythema

Well-demarcated, linear band of intense redness along the gingival Margins.

Clinical

Does not respond to oral Prophylaxis.

Necrotising Ulcerative Gingivitis

Painful ulceration of the interdental papillae associated with halitosis and spontaneous gingival bleeding

Clinical; smear for identification of fusospirochetal organisms.

Metronidazole: 500mg: t.i.d x 7 days. Oral prophylaxis (scaling and debridement) is needed for these patients.

Use with caution in patients with blood dyscrasias, liver impairment, CNS/renal disease. Metronidazole increases the bleeding tendency in those on warfarin. No alcohol to be consumed during the treatment with metronidazole. May recur. Referral to dentist for management.

CONDITION/DISE SALIENT ASE CLINICAL FEATURES

Necrotising Ulcerative Periodontitis (NUP) Rapidly progressive periodontal disease resulting in bone loss.

DIAGNOSIS

TREATMENT

REMARKS

Clinical; radiological As above. Debridement of necrotic tissue.

Common cause of tooth loss; referral to dentist for management.

Necrotising Ulcerative Stomatitis

Extension of NUP into soft tissues. Bone Sequestra.

Clinical; radiological As above. Debridement of necrotic tissue.

Referral to dentist for management.

Kaposis Sarcoma

Painless Clinical; histological purple/violaceous lesions on palatal/anterior gingival mucosa; later becomes raised and ulcerated.

Surgery Cryotherapy Radiotherapy and intralesional injection of vincristine

Referral to an oncologist or specialist for management.

CONDITION/DISEASE

SALIENT CLINICAL FEATURES

DIAGNOSIS

TREATMENT

REMARKS

Non-Hodgkins Sarcoma

Rapidly enlarging rubbery mass in the tonsillar fossa, palate, or Gingival.

Clinical; histological

Surgery Radiotherapy Chemotherapy

Referral to an oncologist.

Herpes Simplex (HSV)

Clusters of painful, small vesicles/ulcers on palate or gingivae. Most cases of HSV infections are recurrent. Herpes labialis lesions are on the vermilion or mucocoetaneous junction on the lips; form crusts on rupture. Herpes labialis is also known as cold sores.

Clinical; smear for viral inclusion bodies

Zovirax, (Acyclovir): 200mg: 1 capsule q.6h x 2 weeks. Denavir,(Penciclovir) 1% Cream: Apply locally q.2h x 4 days. Vira-A 1% (Vidarabine) Ointment: Apply to affected areas q.i.d.

Use with caution in patients with renal, neurologic, and hepatic diseases. Contraindications: hypersensitivity to the drug.

CONDITION/DISEA SE Herpes Zoster

SALIENT CLINICAL FEATURES

DIAGNOSIS

TREATMENT

REMARKS

Prodrome of pain, Clinical multiple vesicles on facial skin, lips, and intraoral structures. Follows the nerve distribution. May be complicated by postherpetic neuralgia.

As above. Carbamazepine (for post-herpetic neuralgia): 200mg: b.i.d to start; 800-1,200mg q.d (in divided doses) x 2 weeks.

Condyloma Acuminata (Verruca Vulgaris)

Warts are nodular or cauliflower-like in appearance, often multiple.

Clinical; histological

Surgery CO2 laser surgery

Caused by human papillomavirus; uncommon in oral tissues.

CONDITION/DISEAS E

SALIENT CLINICAL FEATURES

DIAGNOSIS

TREATMENT

REMARKS

Xerostomia

Dry mouth, often with fissured tongue. Promotes dental caries.

Clinical

Artificial saliva Sodium Carboxymethylcellulose (BakerPerkins) 0.5% Aqueous Solution: To be used as a rinse as needed. Any of the following: Xerolube/MoiStir/MouthKote/Optimoist/Saliv art If xerostomia is present, as above.

Sucking ice cubes or lemon drops can be helpful.

Salivary Gland Swelling

Unilateral/bilateral salivary gland swellings.

Clinical

If xerostomia is present, as above

Thrombocytopaeni c Purpura

Bleeding tendencies; petechiae on oral Mucosa. Melanotic linear lesions On the gingivae.

Clinical; platelet Count

Platelet transfusions in severe platelet Deficiency

Melanotic Hyperpigmentatio n Cryptococcosis

Clinical

No treatment is necessary.

No dental surgical intervention unless platelet numbers are restored. Due to ARV drug reaction.

Necrotic ulcerative lesions.

Clinical; smear culture

Antifungal treatment.

Oral involvement is rare.

Histoplasmosis

Necrotic growth/ulcers

As above.

As above.

As above.

Erythema Multiforme

Ulcerative lip and intraoral lesions

Clinical

Withdrawal of the drug. Sometimes antiviral drugs help.

Referral to a specialist (Dr Hammad Ul-Haq ).

Lichenoid Reactions

White lace-like lesions on the oral mucosa.

Clinical; histological

Topical steroid application. Kenalog(triamcinolone acetonide) in Orabase cream q.d x 1 week.

Withdrawal of cause if known

CONDITION/DIS EASE Tuberculous Ulcers

SALIENT CLINICAL FEATURES

Ulcerative lesions usually on the tongue or gingivae. Usually patient has Pulmonary TB.

DIAGNOSIS TREATMENT
Clinical; histological (AFB stain); chest xray; tests for TB Treat the systemic disease with anti-TB drugs

REMARKS

Though TB is on the increase, oral involvement is uncommon

Trigeminal Neuralgia

Shock-like pain along the distribution of the trigeminal nerve.

History

Carbamazepine

Uncommon

Facial Palsy

Unilateral paresthaesia Of the face.

History; clinical

Sometimes antiviral medications help. Early detection and appropriate treatment

Uncommon

Dental Caries

Dental decay.

Clinical

Increased dental caries experience in HIV patients due to poor oral hygiene, xerostomia, etc.

FUNGAL INFECTIONS
BY DR.SAIMA B.JAFFRI

CANDIDIASIS

Most common oral fungal infection. It is a component of normal oral flora. Can occur in persons who are debilitated by other diseases or in otherwise healthy individuals also.

a) Local Factors :

PREDISPOSING FACTORS: -

- Mucosal trauma - Denture wearers - Denture hygiene - Tobacco smoking - Carbohydrate rich diet - Drugs (Broad spectrum antibiotics, steroids, immunosuppressant / cytotoxic - Xerostomia

agents)

b) Systemic factors : - Iron deficiency anaemia

- Megaloblastic anaemia - Acute leukaemia - Diabetes mellitus - HIV infection - Other immunodeficiency states

Group 1 (Conditions confined to the oral mucosa): Acute Chronic - Acute pseudomembranous candidiasis - Acute atrophic candidiasis - Chronic atrophic candidiasis - Candida associated angular cheilitis - Chronic hyperplastic candidiasis

CLASSIFICATION OF CANDIDIASIS: -

Group 2 (oral manifestations of generalized candidiasis)

- Chronic mucocutaneous candidiasis

ACUTE PSEUDOMEMBRANEOUS CANDIDIASIS

(THRUSH )

Best recognized form of candidiasis. Characterized by development of white plaques that can be scraped off with tongue blade. Can be initiated by broad spectrum antibiotics or immune dysfunction.

Thrush
Occurs characteristically on buccal mucosa, palate and dorsal tongue. Usually asymptomatic or patients may c/o burning sensation of mucosa or unpleasant taste in mouth. Can occur in infants also.

Managemant
Topical therapy: Amphotericin lozenges(10mg) OR Nystatin pastilles (100,000 units) Dissolve slowly in mouth after meals, use 4 times daily, usual course is 1-4 weeks. Systemic therapy: Fluconazole, 50-100mg daily for 2-3 weeks OR Itraconazole 150mg daily for 2 weeks

ATROPHIC CANDIDIASIS
(Erythematous candidiasis)

Several presentations seen 1. Acute atrophic candidiasis 2. Median rhomboid glossitis 3. Chronic multifocal candidiasis 4. Angular cheilitis 5. Chronic atrophic (denture sore mouth) candidiasis

1. ACUTE ATROPHIC CANDIDIASIS: Also called antibiotic sore mouth, as it follows course of broad spectrum antibiotics. Patients c/o pain and burning sensation of mucosae. Seen as diffuse loss of filliform papillae resulting in a bald appearance of tongue.

 Topical therapy: Amphotericin lozenges(10mg) OR Nystatin pastilles (100,000 units) Dissolve slowly in mouth after meals, use 4 times daily, usual course is 1-4 weeks. Systemic therapy: Fluconazole, 50-100mg daily for 2-3 weeks OR Itraconazole 150mg daily for 2 weeks

Managemant

2. MEDIAN RHOMBOID GLOSSITIS:

Also called central papillary atrophy of tongue. Well demarcated erythematous zone affecting midline of dorsum of tongue. Often asymptomatic. Erythema due to loss of filliform papillae. The lesion is rhomboid in shape Its surface may be red, yellow, or white in appearance. Sometimes, other areas of oral cavity like hard palate and angles of mouth also show lesions (Chronic multifocal

candidiasis).

3. CHRONIC ATROPHIC CANDIDIASIS: -

It is also known as denture sore mouth. Characterized by varying degrees of erythema in denture bearing areas of usually maxillary prostheses. Usually asymptomatic. Patients give h/o wearing denture continuously.

CHRONIC ATROPHIC CANDIDIASIS: Newton introduced a classification for this condition: Type 1: Pin point hyperemia Type 2: Diffuse erythema, limited to the fitting surfaces of denture Type 3: Nodular appearance of palatal mucosa

Managemant
Topical therapy: Amphotericin or nystatin If compliance poor: Miconazole gel applied to palatal surface of denture 4times daily for 1-4 weeks Miconazole lacquer Chlorohexidine 0.2% rinse, 4 times daily (do not use with nystatin) Systemic therapy: Occasionlly required

4. ANGULAR CHEILITIS: -

Also called perleche. Characterized by erythema, fissuring and scaling of corners of mouth. Typically occurs either along with multifocal candidiasis or in old patients with reduced vertical dimension. Saliva pools in these areas, keeping them moist and thus favoring fungal infection

Managemant
Topical therapy: o Nystatin cream: apply to corners of mouth 3-4 times daily, until resolution If microbial report not available or in case of mixed infection o Miconazole gel or cream apply 3-4 times daily to angles Systemic therapy: May be required

5. CHRONIC HYPERPLASTIC CANDIDIASIS:

Least common of all types. Appears as non scrapable white patch resembling leukoplakia (candidal

leukoplakia) It is a fixed white patch at the commisures of mouth, palate may also be affected and tongue is rarely affected

Believed that it represents candidiasis superimposed on pre-existing leukoplakia. White raised white plaues which may be speckled or nodular in appearance Diagnosis confirmed by demonstration of candidal hyphae within the lesion and resolution of lesion after antifungal therapy.

Managemant
Topical therapy: Amphotericin lozenges(10mg) OR Nystatin pastilles (100,000 units) Dissolve slowly in mouth after meals, use 4 times daily, usual course is 1-4 weeks. Systemic therapy: Fluconazole, 50-100mg daily for 2-3 weeks OR Itraconazole 150mg daily for 2 weeks

CHRONIC MUCOCUTANEOUS CANDIDIASIS: -

Severe oral candidiasis can also occur as a component of a rare immunological disorder called mucocutaneous candidiasis. Autosomal recessive disorder. Immune dysfunction becomes evident in early life patient develops candidiasis of mouth, nails, skin and other mucosae. Oral lesions appear as thick, white non scrapable patches.

CHRONIC MUCOCUTANEOUS CANDIDIASIS SYNDROME

Type
FAMILIAL CMC

Features
1ST decade, persistant candidosis, mouth nails, skin, iron deficiency

DIFFUSE CMC

1st 5 years, chronic candidosis, mouth, nails, skin, pharynx. Susceptible to bacterial infections

CANDIDOSIS ENDOCRINOPATHY SYNDROME

Hypothyrodism, hypoadrenocorticism and mild chronic hyperplastic candidosis involving the mouth

CANDIDOSIS-THYMOMA SYNDROME

Haematological disorders, pseudomembranous or hyperplastic candidosis, nails, skin, mouth

Management
Systemic antifungal therapy for long term Fluconazole :100mg daily for more then 3weeks

THANKS FOR YOUR PATIENCE !