ORAL MANIFESTATIONS:
HIV & AIDS
Dr Medhini Madi
Where did HIV come from?
Introduction
Luc Montagnier – 1983 – first described
Received The Nobel Prize in Physiology or Medicine 2008 - discovery of
human immunodeficiency virus
In absolute numbers, South Africa (7.1 million), followed by Nigeria (3.2
million), and India (2.1 million) had the highest HIV/AIDS number of cases
by the end of 2016
HIV – lymphotropic virus
Introduction
• HIV: Etiologic agent of AIDS belonging to
the family Retroviridae and genus
Lentiviridae
• AIDS: Term given to a group of disorders,
characterized by a profound cell mediated
immunodeficiency due to irreversible
suppression of T-lymphocytes by HIV
HIV infection: Pathophysiology
HIV effects : Immune system
T cell suppression
Infections due to B cell dysfunction
compromised immunity
Natural killer cell
dysfunction
Clinical stages
3 4
Persistent
Generalised
Lymphadenopathy
(PGL)
WHO criteria for HIV infections
• Candidal infections
• HSV infections
• Fever (continuous / • Herpes zoster
intermittent >1 month) infections
3 MAJOR • Chronic diarrhea
• Weight loss (>10%)
6 MINOR • Generalised pruritic
dermatitis
CRITERIA CRITERIA • Lymphadenopathy
• Chronic cough
Oral manifestations of HIV infection
7 cardinal oral lesions of HIV:
• Oral candidiasis
• Oral hairy leukoplakia
• Kaposi’s sarcoma
• Linear gingival erythema
• Necrotizing ulcerative gingivitis
• Necrotizing ulcerative periodontitis
• Non-Hodgkin’s lymphoma
Oral manifestations of HIV infection
• Fungal: candidiasis; histoplasmosis; aspergillosis
• Viral: Herpes simplex & zoster inf., OHL, oral wart,
INFECTIONS CMV inf.
• Bacterial: Bacillary angiomatosis, LGE, NUP, TB,
syphilis
• Kaposi’s sarcoma
NEOPLASMS
• NHL
IMMUNE MEDIATED • Recurrent major aphthae
• Xerostomia
NON SPECIFIC • SG enlargement
• Pain
European Community (EC) Clearing House and
WHO Collaborating Centre - Oral
manifestations of HIV in adults (1993)
Oral manifestations
of HIV
Lesions less
Lesions strongly Lesions seen in HIV
commonly
associated with infection
associated with HIV
HIV infection
infection
European Community (EC) Clearing House and WHO
Collaborating Centre - Oral manifestations of HIV in adults
(1993)
LESIONS STRONGLY ASSOCIATED
WITH HIV INFECTION
➢ Candidiasis
✓ Erythematous
✓ Pseudomembranous
✓ Angular cheilitis
➢ Hairy leukoplakia
➢ Kaposi’s sarcoma
➢ Non-Hodgkin’s lymphoma
➢ Periodontal disease
✓ Linear gingival erythema
✓ Necrotizing (ulcerative) gingivitis
✓ Necrotizing (ulcerative)
periodontitis
LESIONS LESS COMMONLY ASSOCIATED WITH HIV INFECTION
➢ Bacterial infections
✓ Mycobacterium avium-intracellulare
✓ Mycobacterium tuberculosis
➢ Viral infections
✓ Herpes simplex virus
✓ Human papillomavirus (wart-like lesions)
o Condyloma acuminatum
o Focal epithelial hyperplasia
✓ Verruca vulgaris
o Varicella zoster virus
o Herpes zoster
o Varicella
➢ Melanotic hyperpigmentation
➢ Necrotizing (ulcerative) stomatitis
➢ Salivary gland disease
✓ Dry mouth due to decreased salivary flow rate
✓ Unilateral or bilateral swelling of the major salivary glands
➢ Thrombocytopenic purpura
➢ Ulceration NOS (not otherwise specified)
LESIONS SEEN IN HIV INFECTION
➢ Bacterial infections
✓ Actinomyces Israel
✓ Escherichia coli
✓ Klebsiella pneumoniae
➢ Fungal infection other than candidiasis
✓ Cryptococcus neoformans
✓ Geotrichum candidum
✓ Histoplasma capsulatum
✓ Mucoraceae (mucormycosis/ zygomycosis)
✓ Aspergillus flavus
➢ Cat-scratch disease
➢ Recurrent aphthous stomatitis
➢ Viral infections
✓ Cytomegalovirus
✓ Molluscum contagiosum
➢ Drug reactions (ulcerative, erythema multiforme, lichenoid, toxic
epidermolysis
➢ Epithelioid (bacillary) angiomatosis
➢ Neurologic disturbances
✓ Facial palsy
✓ Trigeminal neuralgia
Fungal infections: Oral Candidiasis
• Most prevalent fungal
infection in HIV infection
• Clinical marker to define the severity of
HIV infection
• Pseudomembraneous candidiasis is
the most common
• C. albicans most predominant. Others
such as C. glabrata, C. krusei and C.
tropicalis
Viral infections: Epstein Barr virus
infection (EBV)
• Oral hairy leukoplakia (OHL):
• Prevalence varies from 0.42 to 38%
• More common in males
• Associated with a low CD4+ count and
high HIV viral load
• Asymptomatic and has no malignant
potential it rarely requires treatment
Bacterial infections
• The gingival and periodontal
diseases associated with HIV
include
1. Linear gingival erythema: CD4+
count of less than 200
cells/mm3
2. Necrotizing ulcerative gingivitis
3. Necrotizing ulcerative
periodontitis
4. Necrotizing stomatitis
Neoplasms: Oral Kaposi’s sarcoma
• Malignant, multifocal systemic disease
that originates from the vascular
endothelium
• Has a variable clinical course
• KS is caused by human herpes virus 8
(HHV-8), which is transmitted sexually or
via blood or saliva
• Arises when the CD4+ T cell count is less
than 200
• Red to purple macules, papules, or nodules
that may ulcerate and cause local tissue
destruction
• Site: palate, gingiva
Neoplasms: Oral Kaposi’s sarcoma
• Older approaches :
• Radiation, laser therapy, surgical excision, and cytotoxic therapy with vinca alkaloids and
bleomycin
• However, only five agents are currently approved by the FDA for the treatment of KS:
Topical therapy
Alitretinoin gel
Systemic therapy
1. Liposomal daunorubicin
2. Oloxorubucin
3. Paclitaxel
4. Interferon-alpha
Non-Hodgkin’s lymphoma
• Second most common HIV-
associated tumor
• AIDS defining condition
• Soft tissue masses with or without
ulceration and tissue necrosis,
usually involving the gingival,
palatal, and alveolar mucosa
Hodgkin’s disease (HD)
• Increased incidence of HD in HIV-infected individuals
• Peculiar features of HD in the HIV population is the widespread extent of the
disease at presentation
• Frequent involvement of extranodal sites - bone marrow, liver and spleen
Approach to diagnosis
History and risk assessment:
History
Medical history: Fever, night sweats, unintentional
weight loss, generalized lymphadenopathy,
Physical examination diarrhea
HIV testing Sexual/ Social history: to know mode of acquisition
Drug history: if ART is to be initiated to prevent
interactions with other medications
Common indications for HIV testing
Clinical features suggestive of HIV infection
History of high-risk behavior/transfusion
Patients with TB, especially in young patients
Patients having sexually transmitted diseases
Screening of Pregnant patients
Hepatitis B and C co-infection
Laboratory investigations
Direct tests Indirect tests
• ELISA • Lymphocytosis
• Western blot • Raised ESR
• Immunoflouresence • Lymph node biopsy
• Viral assays/culture • Increase in ß2
• P24 antigen detection microglobulin
• Polymerase chain reaction • CD4 counts
❖Current standards are enzyme-linked
immunosorbent assays (ELISAs) for
screening and Western blot (WB) for
confirmation
HIV rapid tests
Currently marketed rapid tests US FDA approved rapid
HIV tests
are essentially ELISAs adapted
for a rapid turnaround time
Oraquick® Advance Rapid
HIV-1/2 Antibody test
(Orasure Technologies)
Results are available from 5 to
20 minutes Reveal® G-2 Rapid HIV-1
Antibody Test (MedMira)
HIV p24 antigen assay
Specific as a diagnostic test but falls
short on sensitivity
The level of p24 rises early soon after
infection but subsequently falls as
specific antibody develops, only to
rise again in the advanced stage of
AIDS
Saliva
test for
HIV
Treatment for HIV
infections
ART: Antiretroviral therapy
• ART includes more than 30 different drugs of six separate classes:
1) Nucleoside reverse transcriptase inhibitors (NRTIs) – Abacavir, Emtricitabine, Lamivudine,
Tenofovir disoproxil fumarate, Zidovudine
2) Non-nucleoside reverse transcriptase inhibitors (NNRTIs) – Doravirine, Efavirenz,
Etravirine, Nevirapine, Rilpivirine
3) Protease inhibitors (PIs) – Atazanavir, Darunavir, Ritonavir, Fosamprenavir, Saquinavir,
Tipranavir
4) Fusion inhibitors – Enfuvirtide
5) CCR5 Antagonist - Maraviroc
6) HIV integrase inhibitors – Dolutegravir, Raltegravir
7) Post attachment Inhibitors - Ibalizumab-uiyk
8) Pharmacokinetic enhancers - Cobicistat
Generally:
2 nucleoside reverse transcriptase inhibitors (NRTIs)
+
A 3rd active ARV drug from one of three drug classes: an integrase strand transfer
inhibitor (INSTI), a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a
protease inhibitor (PI)
+
A pharmacokinetic (PK) enhancer (also known as a booster; the two drugs used for
this purpose are cobicistat and ritonavir)
Data also support the use of the two-drug regimen
Dolutegravir + Lamivudine
for initial treatment
HAART therapy side effects
Significance of oral manifestations
Indicate HIV infection in previously undiagnosed cases
Predict HIV progression
Represent early clinical features of AIDS
Be used in disease staging and classification
Correlate with CD4 levels
Act as marker of immunodeficiency state
Dental care of HIV positive
patients
• Barrier techniques – Gloving, Hand washing, wearing masks,
protective eye wears, drapes, Disposable caps etc.
• Pre treatment CBC
• Prophylactic antibiotic therapy
• Sterilization -
✓Cleaning of instruments using ultrasonic cleaner
✓Heat sterilization – Autoclave, Dry heat
• Disinfection - Ethyl alcohol, isopropyl alcohol, Phenols, Sodium Hypochlorite,
Glutaraldehyde
Dental care of HIV positive patients
❖Asymptomatic / Symptomatic ( > 200 CD4 counts)
▪ Periodic examination of patients: annual
▪ Annual radiologic examination
▪ Treatment of Xerostomia ✓Prophylaxis
✓root planning
▪ Diagnosis and management of infections ✓Caries removal and
restoration
✓ Endodontic
treatment
✓ Complex prosthetic
treatment
✓ Regular fluoride
applications
Dental care of HIV positive patients
• Patients with AIDS (<200 CD4 counts)
AVOID SURGICAL PROCEDURES
• In terminal phase( <50 CD4 counts)
Pain control
AVOID SURGICAL TREATMENTS
Post exposure prophylaxis
Accidental needle stick injury
Wash finger/induce fresh bleeding
Document type, amount, depth of injury
Anti HIV antibodies – physician and exposure source (recheck in 2 weeks)
Start therapy in 72 hours Zidovudine(300) + lamivudine(100) + Emtricitabine (100) --- 4 weeks
HIV antibodies negative ---- stop therapy
Recall in 1,3,6,12 month interval
Take home message!!
• Oral features could be the initial presenting feature for the
underlying HIV infection
• Follow universal precautions
• Plan for comprehensive care
• Never deny treatment!!
BE AWARE
TAKE CARE
Thank you…
