New Classification of Dental Diseases
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Transcript of New Classification of Dental Diseases
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New Classificationof Dental DiseasesNew Classificationof Dental Diseases
Cesar Augusto Migliorati DDS, MS, PhDCesar Augusto Migliorati DDS, MS, PhD
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New ClassificationJune 2004
New ClassificationJune 2004
Classification of oral diseases of HIV- associated immune suppression (ODHIS)
Glick M, Abel SN, Flaitz CM, Migliorati CA, Patton LL, Phelan JA, Reznik DA (ODHIS Workshop
Group-USA, Dental Alliance for AIDS/HIV CARE – DAAC)
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Classification of oral diseases of HIV – associated immune
suppression (ODHIS)
Classification of oral diseases of HIV – associated immune
suppression (ODHIS)• Present classification systems for HIV –
associated oral lesions developed in the early 1990’s
• HAART
• Changing pattern of oral conditions
• New system needed
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Classification of oral diseases of HIV – associated immune
suppression (ODHIS)
Classification of oral diseases of HIV – associated immune
suppression (ODHIS)• System should reflect:
• Changes in epidemiology of oral lesions
• Therapeutics
• Development of lesions and immune systems
• Oral lesions to oral disease
• Oral disease: abnormality characterized by a defined set of signs and symptoms in the oral cavity, extending from the vermilion border of the lip to the oropharynx, with the exception of salivary gland disease
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New ClassificationNew Classification
• Group 1 – ODHIS associated with severe immune suppression (CD4<200 cells/mm3)
• Group 2 – ODHIS associated with immune suppression (CD4<500 cells/mm3)
• Group 3 – ODHIS assumed associated with immune suppression• A) More commonly observed• B) Rarely reported
• Group 4 – Therapeutically-induced oral diseases• Group 5 – Emerging oral diseases
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Classification of oral disease of HIV- associated immune
suppression (ODHIS)
Classification of oral disease of HIV- associated immune
suppression (ODHIS)• Oral diseases do not belong exclusively to
one classification Group
• Overlap may exist
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Use for the New Classification
Use for the New Classification
• Identifying undiagnosed individuals
• Provides additional rationale for HIV testing
• Affects access and type of HIV-related healthcare
• Provides clinical markers for therapeutic interventions and efficacy
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Group 1. ODHIS associated with severe immune
suppression (CD4<200 cells/mm3)
Group 1. ODHIS associated with severe immune
suppression (CD4<200 cells/mm3)• Major recurrent aphthous ulcer
• Neutropenia-induced ulcers• Necrotizing ulcerative periodontitis• Necrotizing stomatitis• Cytomegalovirus (CMV)• Chronic HSV• Histoplasmosis• Esophageal, pseudomembranous, and
hypertrophic candidiasis• Oral hairy leukoplakia• Kaposi’s sarcoma
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Pseudomembranous Candidiasis
Pseudomembranous Candidiasis
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Esophageal CandidiasisEsophageal Candidiasis
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Hyperplastic CandidiasisHyperplastic Candidiasis
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Pseudomembranous Candidiasis / KS
Pseudomembranous Candidiasis / KS
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Kaposi’s SarcomaKaposi’s Sarcoma
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Kaposi’s SarcomaKaposi’s Sarcoma
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HistoplasmosisHistoplasmosis
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PeriodontitisPeriodontitis
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Consider:•Bacterial•Viral•Fungal•Combination
Silverman, Eversole, Truelove. Essentials of Oral Medicine. London, B.C. Decker, 2001.
Idiopathic Necrotizing Stomatitis
Idiopathic Necrotizing Stomatitis
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Necrotizing StomatitisNecrotizing Stomatitis
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Chronic HSVChronic HSV
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• Major recurrent aphthous ulcer• Increased frequency, harder to treat, atypical location
• Erythematous candidiasis• Salivary gland disease
• Drug induced low salivation• Facial palsy• Neuropathies
• Hyposalivation• Human papilloma virus (HPV)• Linear gingival erythema• Non-Hodgkin’s lymphoma
Group 2. ODHIS associated with immune suppression
(CD4,500 cells/mm3)
Group 2. ODHIS associated with immune suppression
(CD4,500 cells/mm3)
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Aphthous UlcerAphthous Ulcer
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Erythemathous CandidiasisErythemathous Candidiasis
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Linear Gingival ErythemaLinear Gingival Erythema
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Lymphoepithelial CystLymphoepithelial Cyst
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Human Papilloma VirusHuman Papilloma Virus
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Group 3. ODHIS assumed associated with immune
suppression
Group 3. ODHIS assumed associated with immune
suppression• More commonly observed
• Angular candidiasis• Herpes labialis• Intra-oral herpes• Minor aphthous ulcers
• Rarely reported• Bacillary epithelioid angiomatosis• Tuberculosis• Deep-seated mycosis (except histoplasmosis)• Molluscum contagiosum• Varicella Zoster Virus (VZV)
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Angular CandidiasisAngular Candidiasis
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HSV LabialisHSV Labialis
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Intra-oral HerpesIntra-oral Herpes
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Silverman, Eversole, Truelove. Essentials of Oral Medicine. London, B.C. Decker, 2001.
Minor Aphthous UlcersMinor Aphthous Ulcers
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CoccidiomycosisCoccidiomycosis
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Group 4. Therapeutically-induced oral diseases
Group 4. Therapeutically-induced oral diseases
• Side-effect• Melanotic hyperpigmentation• Ulcers• Hyposalivation• Lichenoid drug reaction• Neutropenia-induced ulcers• Thrombocytopenia• Lypodystrophy-associated oral changes• Perioral paresthesia• Steven Johnson’s?• Exfoliative cheilitis?
• Resistance-induced disease• Different Candida spp and strains• HSV
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• Adverse reactions• Oral ulcers
• Stevens Johnson’s
• Taste changes
• Dryness
• Perioral paresthesia
• Thrombocytopenia
Antiretrovirals and Adverse ReactionsAntiretrovirals and Adverse Reactions
• Drugs• Indinavir
• Saquinavir
• Amprenavir
• Nevirapine
• Delavirdine
• Efavirenz
• Stavudine
• Didanosine
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Silverman, Eversole, Truelove. Essentials of Oral Medicine. London, B.C. Decker, 2001.
Ulcers – Medication Induced
Ulcers – Medication Induced
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Recurrent HSVRecurrent HSV
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Group 5. Emerging oral diseases
Group 5. Emerging oral diseases
• Human papilloma virus, several HPV types (may be associated with immune reconstitution)
• Erythema migrans
• Variants of Non-Hodgkin’s Lymphoma (NHL B-cell types)
• Epithelial neoplasms
• Aggressive interproximal dental caries
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HPV Genotypes
6 & 11
Condyloma AccuminatumCondyloma Accuminatum
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Squamous Cell CarcinomaSquamous Cell Carcinoma
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Patel, P. et al. Incidence of non-AIDS defining malignancies in the HIV Outpatient Study. 11 th CROI, San Francisco, CA 2004. Abstract 81
Trends in Cancer and HIVTrends in Cancer and HIV
- Between 1996-2002, KS and cervical cancer declined, not NHL
- Among Chicago clinic patientslung (RR = 3.63),HD (RR = 77.43),anorectal (RR = 5.03),melanoma (RR = 4.10),head/neck (RR = 9.96)
- Compared to general population, incidence has notably increased in HIV-infected individuals
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Aggressive Interproximal Caries
Aggressive Interproximal Caries