1. Oral Lesions of HIV in the Era of HAART
Roseann Mulligan DDS, MS
USC School of Dentistry
and the
Pacific AIDS Education and Training Center

2. Impact of Oral Conditions – HIV+ Patients
High rate of oral manifestations
Oral lesions may be harbinger of change in HIV condition
Relative ease of access to identification of lesions by those in clinical practices
Potential impact on systemic health care outcomes
Potential impact on quality of life
Adapted from Sifri R, Diaz V, Gordon L, Glick M, Anapol H. et al. Oral health care issues in HIV disease: developing a core curriculum for primary care physicians. J Am Board Fam Pract 1998; 11(6):434-44

3. High rate of oral manifestations
More than 90% of patients have at least one oral lesion during their disease course. 1
Are almost always accompanied by symptoms
Take a variety of appearances that are for the most part characteristic
1 New York State Dept of Health AIDS Institute's Best Practices. Promoting oral health care for people with HIV infection. January 2004.

4. Oral lesions ~ Harbinger of Δ HIV status
Often the first clinical feature of HIV infection is an oral lesion. 1
New lesions in HIV-infected patient - a sign that HIV disease is progressing.
Untreated HIV infected with oral candidiasis progress to AIDS within two years. 1
May indicate need for prophylaxis against specific opportunistic infections.
1New York State Dept of Health AIDS Institute's Best Practices. Promoting oral health care for people with HIV infection. January 2004.

5. Medical history
1. Questionnaires 2. Patient observation 3. Medical Interview
4. Risk Assessment
5. Head/Neck Exam 6. Diagnostic tests

6. Normal Range Lab Values Lymphocytes
Type of Lymphocyte
Percentage of
Total Lymphocytes
Total T, CD3
60- 87%
Total T/ mm3
B cell
1- 25%
Suppressor, CD8
10- 40%
Suppressor/ mm3
240 – 1200
Helper, CD4 %
Helper / mm3
600 – 1700
H:S (CD4/CD8)

7. CD4 Status and Relationship to Outcomes
Description
CD4 Count
30-55
Normal value
>600 cell/mm³
< 29
Initial Immune Suppression
<500 cell/mm³
<29
Manifestations of opportunistic infection including oral lesions
<400 cell/mm³
14 -18
Increase in number of opportunistic infections
> cell/mm³
<14
Severe Immune Suppression (e.g. Apthous Major)
<200 cell/mm³
AIDS Dx
Continuing decreases
Fatal opportunistic infection (e.g. CMV,MAC)
<100 cell/mm³

8. Platelets Number of platelets in a drop (uL) of blood
Normal range: 150, ,000/uL
Unsafe to do invasive dental tx <60,000
Spontaneous bleeding <50,000

9. Neutrophils Normal range: 3,000-7,000/ mm Neutropenia: <1000/mm3
Severe neutropenia <500/mm3
**May require antibiotic prophylaxis before
invasive dental treatment

10. Oral Manifestations of HIV Infection
Oral Disease
Fungal
Candidiasis
- Pseudomembranous, Erythematous,
and Angular Cheilitis
Invasive Fungal Infections
- Histoplasmosis, Cryptococcosis
Viral
Herpes Simplex
Herpes Zoster
Cytomegalovirus
Hairy Leukoplakia (Epstein Barr Virus)
Oral Warts (Human Papilloma Virus)
Human Hominus Virus–8 [K.S.]
Bacterial
Linear Gingival Erythema
Necrotizing Ulcerative Periodontitis
Tuberculosis*
Mycobacterium avium complex*
Bacillary angiomatosis*

11. Oral Manifestations of HIV Infection
Type of Lesion
Oral Disease
Neoplastic
Kaposi’s Sarcoma (KS) [HHV-8]
Lymphoma
Squamous Cell Carcinoma*
Other
HIV- Necrotizing Ulceration
HIV-Salivary Gland Disease/ Xerostomia
Thrombocytopenic Purpura*
Abnormal Mucosal Pigmentation

12. Oral Candidiasis Candida albicans is the most prevalent
Most Common + often predicts HIV progression
Candida albicans is the most prevalent
3 types: pseudomembranous ª; erythematous ª; hyperplastic.

13. Oral Candidiasis
Pseudomembranous (Thrush) Characterized by the presence of white curds or creamy cotton like appearance
Can be easily removed. The underlying mucosa is erythematous and may bleed slightly.
Immunosuppresion

15. Oral Candidiasis Atrophic (Erythematous) In non-immunosuppressed
Associated in patients w/ ill-fitting dentures or in those who wear their dentures continuously
Generalized red area of atrophic tissue, commonly on the palate
Burning sensation, palate, tongue
Culture, smear not very effective

16. Oral Candidiasis
In tongue loss of the filiform papilla, a generalized thinning of the epithelium, and excessive inflammation of the connective tissue
Median Rhomboid Glossitis

18. Oral Candidiasis
Chronic Hyperplastic usually presents as a white mucosal plaque.
Most common location: buccal mucosa along the occlusal line in the commissure, latero-dorsal surface of tongue and the alveolar ridges
Frequently term
“candidal leukoplakia”

19. Oral Candidiasis
Angular cheilitis

20. Perspective – Oral Manifestations Volume 13 Issue 5 December 2005/January 2006

21. Herpes Simplex
Recurrent herpes labialis : lips: dry mucosa or skin, fluid-filled vesicle, that rupture, ulcerate, and resolve as crusted brownish lesions.
Recurrent intraoral herpes: maxillary gingiva, palate: wet and fragile mucous membranes. Lesions are punctate with red or white bases that slowly disappear.

22. Epstein-Barr Virus (EBV) Oral Hairy Leukoplakia
White, often corrugated in appearance, plaque-like or hair-like projections that are non- wipeable, lateral borders of tongue.
It appears in late latency stages HIV or precursor of AIDS.
Definitive Dx: Histopathology

25. Epstein-Barr Virus (EBV) Oral Hairy Leukoplakia
Treatment
Treat for cosmetic reasons; otherwise no treatment is warranted

26. Human Papilloma Virus (HPV)
HAART  
Assoc. w/ ~ fold  incidence of oral warts
 aphthous ulcers & salivary gland dz→caries
Diz Dios P, Ocampo A, Miralles C. (2000) ; Patton LL, et al. (2000); Patton LL, (2003) .

27. Human Papilloma Virus (HPV)
In the oral cavity the most common are, squamous papilloma HPV 6 & 11; verruca vulgaris HPV 2-4 and condyloma acuminatum HPV 6 & 11
Clinically may appear exophitic, keratinized, sessile papules or nodules “cauliflower-like 2-5mm“

28. Human Papilloma Virus (HPV)
SP: High incidence on the soft palate, faucial pillars, uvula.
VV: Lips,hard palate and gingiva→hands and fingers.
CA: Presents as a pinkish, sessile papules or plaques w/ pebbled surfaces. Oral lesions occur in nonkeratinized mucosa of lips, floor of the mouth, lateral and ventral surface of tongue, buccal mucosa and soft palate
Photo ftom VI Meeks, DDS, U Md Dental School

29. Human Papilloma Virus (HPV)
Treatment indicated
(1) Lesion may become traumatized
(2) In area that may lead to auto-inoculation
(3) For cosmetic reasons

30. Human Papilloma Virus (HPV)
Treatment
Cryotherapy; laser or surgical excision.
Lesions often recur

31. Human Papilloma Virus (HPV)
Vaccine was approved last June by the FDA
Women 9-26 yrs (prefer yrs old)
70% cervical cancers HPV 16,18,31,45
Vaccine 6, 11, 16, 18
HPV 16 related to 25% of oral cancer.
$ total for 3 dose series

33. Necrotizing Ulcerative Periodontitis
NUP
Extensive soft tissue necrosis exposing alveolar bone
Severe pain, odor and spontaneous bleeding
Compare appearance to aphthous ulcer on right

34. Necrotizing Ulcerative Periodontitis (NUP)

35. Povidone Iodine /Chlorexidine

36. Salivary Gland Involvement

37. Salivary Gland Involvement
Table: Absence of saliva on palpation of salivary glands the WIHS
Mulligan R. et al. Salivary gland disease in human immunodeficiency virus-positive women from the WIHS study. Women's Interagency HIV Study. Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 89(6):702-9, 2000 Jun.
Medications (side effects) -> xerostomia

38. Data from the Women’s Interagency HIV Study
Greenspan D, Gange S, Phelan J, Navazesh M, Alves M, MacPhail L,
Mulligan R, Greenspan J. J Dent Res 83(2): , 2004

39. Prevalence of Oral Lesions During HIV
Medication Usage
Greenspan, D et al
The Lancet Vol 357 May 5, 2001

40. In Summary
Oropharyngeal Candidiasis (OPC) improves or resolves with response to HAART
Oral lesions are fewer as a result of HAART
Cavities increase as a result of hyposalivary function due to meds
Warts seem to increase

41. Preventive Oral Health Care
Recalls every 3 to 6 months
Antimicrobial mouth rinses for patients with periodontal disease, including past history of NUP and LGE
Fluoride supplements

42. Thank You !!