PERIODONTICS

1. GOOD MORNING !

2. PATHOLOGY AND
MANAGEMENT OF
PERIODONTAL PROBLEMS IN
PATIENTS WITH HIV
INFECTION
YASMIN MOIDIN
2008 Batch
Al Azhar Dental College
Thodupuzha

3. PATHOGENESIS

HIV has a strong affinity for cells of the immune
system, most specifically those that carry the
CD4 cell surface receptor molecule

Helper T lymphocytes (T4 cells) are most
profoundly affected

Combined therapeutic regimens consisting of
antiretroviral agents and protease-inhibiting drugs
resulted in improvement in the health status of
HIV infected individuals

4. 
Overall effect is gradual impairment of the
immune
system
by
interference
with
T4
lymphocytes

B lymphocytes are not infected, but the altered
function of infected T4 lymphocytes secondarily
results
in
B-cell
neutrophil function
dysregulation
and
altered

5. 
HIV-positive individual at increased risk for
malignancy,
disseminated
infections
with
microorganisms and adverse drug reactions
because of altered antigenic regulation


HIV has been detected in most body fluids
It is found in high quantities only
blood, semen, and cerebrospinal fluid
in

6. 





Transmission occurs by :
Sexual contact
Illicit use of injection drugs
Exposure to blood or blood products
Organ transplantation and artificial insemination
Heterosexual transmission -common cause of
AIDS

7. 
High risk population includes :

Homosexual and bisexual men

Users of illegal injection drugs

Persons with hemophilia/coagulation disorders

Recipients of blood transfusions before april 1985

Infants of HIV-infected mothers

Promiscuous heterosexuals

Individuals who engage in unprotected sex with HIV positive
cohorts

8. CDC SURVEILLANCE CASE
CLASSIFICATION

Category A : includes patients with acute
symptoms or asymptomatic diseases, along
with individuals with persistent generalised
lymphadenopathy, with or without malaise
, fatigue , or low grade fever

9. 





Category B : patients have symptomatic
conditions such as :
Oropharyngeal or vulvovaginal candidiasis
Herpes zoster
Oral hairy leukoplakia
Idiopathic thrombocytopenia
Constitutional symptoms of fever, diarrhoea
, and
weight loss

10. 
Category C : patients are those with outright
AIDS , as manifested by life-threatening
conditions or identified through CD4+ T
lymphocyte levels of less than 200 cells /mm3
(< 14% of total lymphocytes)

11. ORAL AND PERIODONTAL
MANIFESTATIONS OF HIV INFECTION

Oral candidiasis

Oral hairy leukoplakia

Kaposi’s sarcoma and other
malignancies

Bacillary (epitheliod) angiomatosis

Oral hyperpigmentation

Atypical ulcers

12. ORAL CANDIDIASIS

Most oral candidal infections are associated with
candida albicans

Candidiasis is the most common oral lesion in HIV
diseases and found in 90% AIDS patients

1.
2.
3.
4.
It has 4 clinical presentations :
pseudomembraneous candidiasis
erythematous candidiasis
hyperplastic candiasis
angular cheilitis

13. 
Pseudomembraneous candidiasis

Thrush
Painless or slightly sensitive
Yellow white curdlike lesion
Common on hard and soft palate, buccal and
labial mucosa




14. 
Erythematous candidiasis

Appears as red patches
Seen on buccal mucosa or palatal mucosa
Associated with depapillation of the tongue



15. 
Hyperplastic candidiasis

Least common form
Seen in buccal mucosa and tongue
More resistant to removal than other types



16. 
Angular cheilitis

Seen on commissures of lips
Appear as erythematous with surface crusting
and fissuring


17. 
Diagnosis

Microscopic - hyphae and yeast forms of
organisms
Esophageal candidiasis – diagnostic sign of
AIDS


18. 

Treatment
Topical drugs





Clotrimazole
Nystatin
Miconazole
Amphotericin B oral suspension
Systemic drugs



Ketoconazole 200mg tablets
Fluconazole 100mg tablets
Itraconazole 100mg capsules

19. ORAL HAIRY LEUKOPLAKIA






Epstein-Barr virus
Lateral borders of tongue, buccal
mucosa, floor of the mouth , retromolar area
and soft palate
Asymptomatic ,poorly demarcated keratotic
area
Vertical striations
Corrugated appearance
Surface may be shaggy and
appear hairy

20. 
Microscopic features




hyperparakeratotic surface
acanthosis
balloon cells resembles koilocytes
Treatment


HAART
Acyclovir and valacyclovir

21. KAPOSI’S SARCOMA







An HIV-positive individual with non-Hodgkin’s
lymphoma (NHL) or Kaposi’s sarcoma (KS) is
categorised as having AIDS
KS is most common oral malignancy associated
with AIDS
Multifocal vascular neoplasm
Human herpesvirus-8
First site - Oral cavity
Painless , reddish purple macules
Lesions manifests : nodules , papules and non
elevated macules

22. 
Diagnosis
 BASED
ON HISTOLOGIC FINDINGS




Endothelial cell proliferation
Extravascular hemorrhage
Spindle cell proliferation
Inflammatory infiltrate

23. 






Treatment
Antiretroviral agents
Laser excision
Cryotherapy
Radiation therapy
Intralesional injection with vinblastine dose
0.1mg/cm2
Chemotherapeutic drugs

24. BACILLARY ANGIOMATOSIS



Infectious vascular proliferative disease with
clinical and histologic features similar to that of
Kaposi sarcoma.
Rickettsiae like organisms
Red, purple, or blue edematous soft tissue
lesions that may cause destruction of
periodontal ligament and bone

25. 
Diagnosis
Epithelioid proliferation of angiogenic cells
accompanied by an acute inflammatory cell
infiltrate.
 WarthenTreatment Starry Silver staining or electron
microscopy.
 Erythromycin or doxycycline


 Gingival
therapy
lesions - antibiotic + conservative periodontal

26. ORAL HYPERPIGMENTATION




Spots or striations on the buccal
mucosa, palate, gingiva or tongue.
Cause - Prolonged use of drugs for
HIV like zidovudine, ketoconazole
or clofazimine.
Zidovudine-excessive
pigmentation of the skin and nails.
Adrenocorticoid insufficiency – due
to prolonged use of ketoconazole ,
or by Pneumocystis carinii
infection or cytomegalovirus.

27. ATYPICAL ULCERS



HIV-infected patients have a higher incidence
of recurrent herpetic lesion and aphthous
stomatitis
Atypical large , persistent , non
specific, painful ulcers
Caused by herpes simplex virus
(HSV),
varicella-zoster virus (VZV)
, epstein-barr virus (EBV) , cytomegalovirus
(CMV)

28. 


Herpes labialis in HIV infected individuals
responsive to topical antiviral therapy
Acyclovir , pencyclovir , doconasol
Reduces healing time of lesion

29. 
Recurrent aphthous stomatitis

Sites : oropharynx, oesophagus, or other areas of
GIT.

Treatment:- Topical or intralesional
corticosteroids,chlorhexidine, antimicrobial mouth
rinses, oral tetracycline rinses

30. DENTAL TREATMENT
COMPLICATIONS

Adverse Drug Effects

Foscarnet, Interferon & DDC - Oral ulcerations

Didanosine - Erythema Multiforme

Zidovudine & Ganciclovir - Leucopenia

Dithiocarb - Xerostomia & Altered taste
sensation

HIV-positive patients more susceptible to druginduced Mucositis & Lichenoid drug reactions

31. 
HAART drugs

Insulin resistance, gynecomastia, blood
dyscrasias, nausea, development of kidney
stones, TEN, oral warts

Individuals with Hepatitis C + HIV co- infection
are susceptible to liver cirrhosis

32. 
Lipodystrophy :-

Redistribution of body fat

Gaunt facial features yet display excessive abdominal
fat or even a fat pad on the rear of the shoulders (buffalo
hump)

Severe systemic hyperlipidemia

Oral or perioral adverse effects :- oral lichenoid
reactions, xerostomia, altered taste sensation, perioral
parasthesia, and exfoliative cheilitis

33. GINGIVAL AND PERIODONTAL
DISEASES

Linear Gingival Erythema

Necrotizing Ulcerative Gingivitis

Necrotizing Ulcerative Periodontitis

Necrotizing Ulcerative Stomatitis

Chronic Periodontitis

34. Linear Gingival Erythema







A persistent, linear, easily bleeding, erythematous
gingivitis
Microflora of LGE similar to periodontitis
Linear gingivitis lesions :Generalized
Localized
Most commom among IDUs
Lesion usually undergo
spontaneous remission

35. 




Management
The affected sites should be sealed and
polished
Subgingival irrigation with chlorhexidine or 10
% povidone-iodine
Oral hygiene instructions
Reevaluation after 2 to 3 weeks

36. Necrotizing Ulcerative Gingivitis



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Lesions are punched-out, crater-like depressions at
the crest of the interdental papillae
Painful
Cleaning and debridement of affected areas with a
cotton pellet soaked in peroxide after application of
a topical anaesthetic
Avoid tobacco, alcohol and
condiments
0.12% chlorhexidine gluconate
Metronidazole or amoxicillin
Antifungal medication

37. Necrotizing Ulcerative
Periodontitis






Necrosis and ulceration of the
coronal portion of interdental papillae
and gingival margins
Extension of NUG in which bone loss
and periodontal attachment loss
occur
It is characterized by soft tissue
necrosis,
rapid
periodontal
destruction and interproximal bone
loss
Both localized and generalized
NUP is severely painful at onset, and
immediate treatment is necessary
Painless
& deep interproximal
craters

38. 


Therapy
for
NUP
includes
local
debridement, scaling and root planing, in-office
irrigation with an effective antimicrobial agent
such as chlorhexidine gluconate, or povidoneiodine
Metronidazole (250 mg with two tablets taken
immediately and then one tablet 4 times daily
for 5-7 days)
Prophylactic prescription of a topical or
systemic antifungal agent

39. Necrotizing Ulcerative Stomatitis



Severe progressive lesion
with extension into the
vestibular area and the
palate
NUS may be severely
destructive
and
acutely
painful, affects significant
areas of oral soft tissue and
underlying bone.
NUS is often associated with

40. 



Management
Metronidazole
Antimicrobial mouth rinse
If osseous necrosis is present, its necessary to
remove the affected bone to promote wound
healing

41. Chronic Periodontitis



It is reported that the incidence and severity of
chronic periodontitis are similar in HIV +ve and HIV –
ve groups
Gingival recession and early attachment loss
Tongue lesions consistent with hairy leukoplakia
were most common among seropositive homosexual
males

42. 




Management
Periodontal therapy and implant replacement
Based on the overall health status of the
patient
The degree of periodontal involvement
The motivation and ability of the patient to
perform effective oral hygiene

43. PERIODONTAL TREATMENT
PROTOCOL

Health status

CD4 + T4 lymphocyte level
Current and previous viral load
HIV infection identified
Medication




44. 
Infection control measures

Strict adherence to established methods of
infection control, based on guidance from ADA
and CDC
Compliance, with universal precautions , will
minimise risk to patients and dental staff


45. 
Goals of therapy

Restoration and maintenance of oral health
Comfort and function
Conservative , nonsurgical periodontal
therapy, performance of elective surgical
periodontal procedures, implant placements
should be a treatment option



46. 
Maintenance
therapy

Meticulous personal oral
hygiene
Periodontal recall visits at
short intervals
Systemic
antibiotic
therapy administered with
caution
Blood and other medical
laboratory tests
Coordination
with
the
patient’s physician





47. 
Psychologic factors

HIV infection of neuronal cells
may affect brain function 
dementia

Influence the responsiveness of
affected patients to dental
treatment

Coping with a life-threatening
disease may elicit depression
, anxiety and anger

48. 
Treatment should be provided in a calm, relaxed
atmosphere and stress to the patient must be
minimized

Early diagnosis and treatment of HIV infection
can have a profound effect on the patient’s life
expectancy and quality of life