1. Aids and Periodontium
and its
Management

2. Aids-Acquired Immune Deficiency Syndrome
Introduction
Aids-Acquired Immune Deficiency Syndrome
Devil’s disease
Epidemic proportions
Impairment of the immune system
Death is caused by opportunistic infections and neoplastic processes
Oral manifestations – First significant clinical manifestation

3. Pathogenesis: Strong affinity for cells of the immune system
Specifically that carry the CD4 receptor molecules
T lymphocytes
B lymphocytes – Although not infected the altered function of infected T lymphocytes results in B-cell deregulation and altered neutrophil function.
Macrophages, Monocytes, Langerhans cells brain cells may also be involved

4. HIV is detected in most body fluids including –
Mode of Transmission
HIV is detected in most body fluids including –
Blood
Semen
Vaginal secretions
Cerebrospinal fluid
Breast milk
Urine

5. Common Methods of Transmission
Sexual contact
Blood transfusion
Needle sharing
Perinatal transmission - Intrauterine ,Postnatal
Occupational exposure
Organ transplantation

6. Classification and Staging Centers for Disease Control (CDC - 1993)
Based on opportunistic infection and malignancies
Presence of any 25 specific clinical conditions in a patient will confirm the diagnosis of AIDs
Commonly encountered
Candidiasis
Cryptococcosis
Cytomegalovirus disease
Kaposi’s sarcoma
Burkitts lymphoma
Mycobacterium tuberculosis
Wasting syndrome
Most recent significant change - CD4 - T4 lymphocyte count less than 200 / mm3 or less than 14% total lymphocyte is definitive for AIDS.

8. CDC Surveillance Case Classification
AIDS patients have been grouped as follows, according to the CDC Surveillance Case Classification (1993) -
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 - patients are those with outright AIDS as manifested by life-threatening conditions identified by CD4+T lymphocyte levels of less than 200 per cubic millimeter.

9. Systemic Manifestation
Symptoms
Fever
Malaise
Headache
Diarrhea
Lymphadenopathy
Hematological abnormalities
Neurological Diseases
Non-healing dermatological lesions

10. Oral lesions associated with HIV infection can be broadly grouped as
Oral & Periodontal Manifestations Of HIV Infection
Oral lesions associated with HIV infection can be broadly grouped as
Fungal
Bacterial
Viral infections
Neoplasms

11. Oral Manifestations Associated with HIV Infection include
Candidiasis
Oral hairy leukoplakia
Atypical periodontal disease
Kaposi’s sarcoma
Non hodgkins lymphoma
In addition
Melanotic hyperpigmentation
Atypical ulcerations
Viral infections caused by herpes simplex herpes zoster are common

12. Periodontal Diseases Associated with HIV Infection
Linear Gingival Erythema
ANUG
Necrotizing Ulcerative Stomatitis
NUP

13. Four clinical presentations
Candidiasis
Most common in HIV +ve patients
Oppurtunistic infection – Normal oral flora
Fungal infection
Four clinical presentations
Pseudomembranous
Erythematous
Hyperplastic
Angular chelitis
Diagnosis - Microscopic examination of tissue sample or smear of material scraped from the lesion

14. Clinical Picture
Pseudomembranous - painless, senstive, white lesion readily scraped from oral mucosa , palate,buccal mucosa
Erythematous - red patches on the buccal or palatal mucosa associated with depappillation of the tongue
Hyperplastic - least common in buccal mucosa and tongue. Resistant to removal
Angular cheilitis - commissures appear erythematous with surface fissuring

15. Oral Hairy Leukoplakia
Asymptomatic, keratotic lesion
Lateral borders of the tongue affected
Vertical striations imparting corrugated appearance
Appears hairy when dried
Caused by Epstein Barr virus
Diagnosis – Biopsy – lesion suggestive of OHL HIV test to be performed

16. KAPOSI’S SARCOMA Rare multifocal vascular neoplasm
Painless reddish purple macules or nodules in the mucosa
Different from classic form, more aggressive lesion
Most common site of involvement are the palate and the gingiva
Virus designated as human herpes virus – 8 ( HHV – 8)
Oral cavity may be the first or only site of the lesion
Diagnosis based on histological findings

17. Atypical Ulcers and Delayed Healing
Non specific oral ulceration in HIV individuals – multiple etiology like lymphoma,KS, sq ca.
HIV associated neutropenia may feature oral ulceration
HIV infected pts – recurrent herpetic lesion and aphthous stomatitis
CDC includes mucocutaneous herpes present for more than one month as a sign of AIDS
Herpes Simplex virus, Varicella Zoster virus, Epstein Bar virus or Cyto Megalo virus frequently are retrieved from non specific oral ulcers –possible etiologic role
ATYPICAL ulcers more severe and persistent in pt. with low CD4 cell count

18. Non Hodgkin’s Lymphoma
Most frequent malignant neoplasia
Caused due to Epstein Barr virus.
Fast growing mass generally on the palate, tongue or gingiva and soon it ulcerates and presents areas of extensive necrosis
Pain may not be present
Clinically the mass may be erythematous or purplish in colour with a boggy consistency.

19. Linear Gingival Erythema
Persistent, linear, easily bleeding erythematous gingiva
May or may not serve as precursor to rapidly progressive necrotizing ulcerative periodontitis.
Often unresponsive to corrective therapy yet such lesions may undergo spontaneous remission.

20. Nerotizing Ulcerative Stomatitis
Severely destructive acute painful (NUS) present in HIV +ve pt
Necrosis of oral soft tissue and underlying bone
Occurs separately or as extension of NUP and associated with severe depression of CD4 immune cells
Identical to cancrum oris (NOMA)

21. Necrotizing Ulcerative Gingivitis
Punched out crater like depressions, at the crest of interdental papillae, - extending to marginal gingiva
Surface of gingival crater – covered by gray, pseudomembranous slough.
Crater is demarcated from the remainder by a linear erythema.

22. Necrotizing Ulcerative Periodontitis
Characterized by soft tissue necrosis, rapid periodontal destruction and interproximal bone loss
NUP is present after marked CD4 cell depletion and usually localized to few teeth
Bone undergoes necrosis and subsequent sequestration

23. ACCORDING TO STUDY REPORTS
Susceptibility increases as immune system becomes more compromised
Injectable drug abusers - Oral candidiasis and linear gingival erythema

24. Diagnosis Immunological tests Total leukocyte and lymphocyte count
T-cell subset assays
Platelet count
IgG and IgA levels
Lymph node biopsy

25. Specific tests for HIV infection
Antigen detection
Antibody detection
Virus isolation
Serological tests

26. Screening for HIV ELISA test – Enzyme linked immunosorbent assay
Blood sample obtained and sent to lab
Targeted antibody is linked to an enzyme
If target substance is in the sample, the test solution turns a different color
CONFIRMATORY – Western blot test
Gold standard
Analytic technique used to detect specific proteins in the sample of tissue extract

27. Periodontal Treatment Protocol
Health status
Infection control measures
Psychological factors
Line of Treatment
Prophylactic treatment of opportunistic infections
Antiretroviral therapy
Vaccines
Psychological therapy

28. Candidasis Early Oral lesions – topical drugs
Advanced oral lesions – systemic drugs
Topical Drugs:
Clotrimazole
Clotrimazole ointment, 15-g tube: Apply to affected area
Systemic Drugs
Ketoconazole
Fluconazole
Itraconazole

29. Oral Hairy Leukoplakia
Laser or conventional surgery
Antretroiviral therapy – Acyclovir
Zidovudine
Lamivudine

30. Kaposi’s Sarcoma Antiretroiviral agents Laser excision
Radiation therapy
Intralesional injection
Other chemotherapeutic drugs

31. Treatment of periodontal diseases associated with HIV infection
Debridement - Povidone iodine
Local Antimicrobial Therapy - Chlorhexidine gluconate 0.12%
Immediate follow up care
Systemic antimicrobial therapy
Metronidazole mg 4times/days for 5 days

32. Non Specific Oral Ulceration's And Recurrent Apthae
Acyclovir to 800mg 5 times daily for 10 days
Maintenance dose 200 mg 2 to 5 times daily to prevent recurrence
Recurrent apthous ulcer - topical corticosteroids (fluocinonide gel) applied three to six times daily
Large apthae systemic corticosteriod (prednisone 40 to 60 mg daily)

33. Infection Control
Personal protection through vaccines, masks, gloves, etc.
Decontamination of used instruments.
Sterilization of instruments
Asepsis of the operating environment.
Surface disinfection
Aseptic surgical techniques
Postoperative aseptic techniques.

34. HIV Vaccines Small parts of the HIV virus
Vaccines being tested should produce either antibodies or cytotoxic T cells to fight infection
They cannot cause HIV or AIDS.
Types
Peptide vaccine
Recombinant sub-unit protein vaccine
Live vector vaccine
DNA vaccine
Virus- like particle vaccine (Pseudovirion )

35. Thank You