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AIDS and the Periodontium

Mostly are the opportunistic infections seen in HIV-positive patients are caused by,

protozoan,

fungal,

viral and

bacterial pathogens

Defects in cell-mediated response CD4 and CD8

Bacterial infections caused by encapsulated or enteric bacteria such as

Campylobacter,

Klebsiella,

Salmonella and

Streptococcus

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Classification Of Periodontal Diseases Associated With HIV Infection Four distinct types

1. HIV-associated gingivitis (HIV-G) 2. HIV-associated periodontitis (HIV-P)

3. HIV-necrotizing gingivitis (HIV-NG)

4. Necrotizing stomatitis (NS)

HIV-G has been changed to linear gingivitis.

HIV necrotizing gingivitis has been changed to necrotizing ulcerative gingivitis (NUG).

HIV-P has been changed to necrotizing ulcerative periodontitis (NUP).

Necrotizing stomatitis (NS)

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Linear Gingivitis

It is characterized by: • Marginal linear erythema across the attached gingival generally involving all the teeth • Punctate lesions appear to coalesce giving the entire gingiva a bright-red appearance • Spontaneous bleeding or bleeding on probing • The amount of supragingival plaque is not proportional to the amount of erythema • No ulceration, no loss of attachment is seen • Does not respond to the removal of plaque by intensive scaling, root planing and plaque control measures

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Necrotizing Ulcerative Gingivitis (NUG) • Sudden onset, bleeding on toothbrushing. • Pain and characteristic halitosis. • The gingiva appears fiery-red and swollen tip of the interdental papilla and margins of the gingiva. • Mostly anterior gingiva is affected and

itis (NUG)

• Sudden onset, bleeding on toothbrushing.

red and swollen and yellow to grayish necrosis is observed on the interdental papilla and margins of the gingiva.

erior gingiva is affected and normally limited to the soft tissue of the periodontium.

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is observed on the

of the periodontium.

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Necrotizing Ulcerative Periodontitis • Severe pain, localized soft tissue necrosis • Not associated with deep pocket formation b coinciding with soft tissue destruction • Rapid horizontal bone loss in the absence of severe • Tooth mobility is a common feature • Associated with severe immune suppression with CD4+ cell count below 200 cells/mm3

Necrotizing Ulcerative Periodontitis

necrosis, ulceration and interproximal cratering

• Not associated with deep pocket formation but instead there is a loss of crestal bonedestruction

in the absence of severe gingival inflammation has been reported

is a common feature

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cratering

loss of crestal bone

gingival inflammation has been reported

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Necrotizing Stomatitis • Extensive soft tissue and bony necrosis with sequestration. • It resembles noma and cancrum oris and represents the most severe form of periodontal infection seen in association with HIV

Common feature in all above mentioned PDD a lack of response to the removal of plaque and to the patients maintenance of good oral hygiene.

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CDC Surveillance Care Classification (1993)

AIDS patients have also been grouped as follows:

Category A: Includes patients with acute symptoms or asymptomatic diseases, along with individuals With persistent generalized lymphadenopathy, with or without malaise, fatigue or low grade fever.

Category B: Patients have symptomatic conditions such as oropharyngeal or vulvovaginal candidiasis, herpes zoster, oral hairy leukoplakia, idiopathic thrombocytopenia or constitutional symptoms of fever, diarrhea and weight loss.

Category C: Are those with outright AIDS as manifested by life-threatening conditions identified by CD4+T4 lymphocyte levels of less than 200 cells/mm3

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Most Common Oral And Periodontal Manifestations Of HIV Infection

1. Oral hairy leukoplakia

• Found on lateral borders of tongue • Caused by Human Papillomavirus • Keratotic, asymptomatic area with vertical striations giving a corrugated appearance • When dried appears hairy and does not rub off

2. Oral candidiasis manifested as

• Pseudomembranous (thrush) candidiasis • Erythematous candidiasis • The hyperplastic candidiasis • Angular cheilitis

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3. Kaposi’s sarcoma:

Multifocal,

vascular neoplasm manifest as nodules,

papules or non-elevated macules that are usually brown, blue or purple in color.

4. Bacillary angiomatosis:

It is an infectious vascular, proliferative disease.

It appears as red, purple or blue edematous soft tissue lesions that may cause Destruction of periodontal ligament and bone.

5. Oral hyperpigmentation

6. Atypical ulcers and delayed healing.

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Management

Step I: Thorough medical and dental history (should be kept confidentially).

Step II: Periodontal therapy

Treatment • Medical history

• Scaling of affected areas under local anesthesia

• Intrasulcular irrigation using 10 percent povidone iodine.

• 0.12 percent chlorhexidine mouth-rinse twice daily.

• Antifungal agents like nystatin oral suspension and clotrimazole. Or systemic agaents

• Remove necrotic bone and soft tissue

• Systemic analgesics

• Consider systemic antibiotic such as metronidazole

• Follow-up (1 day to 4 weeks, 1 to 6 months)

• Follow-up (1 day to 4 weeks, 1 to 6 months)

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Role of Antiretroviral Drugs in the Management of HIV/AIDS The agents that are developed so far act at different stages of the life cycle of HIV: a. They can block the binding of virus to the target cell. b. They can block the viral RNA cleavage. c. One that inhibits enzyme reverse transcriptase.

Testing for HIV Antibodies a. Screening test → ELISA (Enzyme Linked Immunosorbent Assay) b. Confirmatory test → Western blot assay → Polymerase chain reac�on