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  • Consequently, Screening for dental disease and oral lesions is an essential component of a patient evaluation and would hopefully occur at the first or second visit. I’m Dr. Stewart – and during the next few minutes, I’d like to share with you some of the common oral signs and symptoms one might see during that oral screening evaluation. an HIV infected patient might present with.
  • The recognition of the link between oral and systemic health is growing - and receiving significant interest in scientific literature and in NIH as well. Let’s look the non-HIV infected population as a place to start. Periodontal health and diabetes – Pts with diabetes may be more likely to develop periodontal disease than non diabetics History of poorly controlled chronic periodontal disease can disrupt diabetic /glycemic- control. Perio and Heart Disease – reports indicate that oral bacteria associated with perio can affect the heart when entering blood stream – by attaching to fatty plaques in the coronary arteries. Oral health and Pregnancy – Severe periodontal disease in pregnant women can lead to significant increase in the risk of delivery of preterm low birth weight babies.
  • Oral infections present event greater challenge for the HIV infected patient. If these are not recognized or addressed, an adverse impact is noted regarding: chewing, nutrition, medication compliance, social well-being and quality of life.
  • Oral Concerns are among the most frequent problems associated with HIV infection.
  • observed in 60-80% of individuals with HIV (pre-HAART)
  • May be first sign of HIV –
  • To confirm diagnosis, a culture, KOH prep, or cytologic smear may be obtained.
  • Usually need cream for corners of mouth in addition to systemic therapy
  • Partials and/or Dentures, Mouth guards, Bite splints may be carriers of candidia if the mouth has been affected. These must be cleaned.
  • Vesicles contain live virus
  • Intraoral or perioral, gingiva, palate, buccal mucosa, covering large areas
  • Counseling important
  • Bacterial infection. There are many organisms identified in periodontal pockets- but primarily gram negative anaerobic rods, and some Gram positive facultative and anerobic cocci and rods, and gram negative facultative rods.
  • Rapid destruction of gingival tissue and supporting bone
  • Salivary gland enlargement sometimes observed – usually the parotid gland. Lymphocytosis (CD8) and Lymphoproliferative response with cystic lesions May need biopsy and imaging to determine diagnosis
  • Nurse Practitioers..easy to do this
  • Dental abscess produces lesion pictured.
  • CDC slide
  • Affects any oral site - gingiva most common, also tongue, buccal mucosa and palate Usually has ill-defined margins and may be accompanied by submandibular lymphadenopathy 30-50% of patients with disseminated histoplasmosis may present with oral lesions May present as a non-healing ulcer –
  • Diagnostic for AIDS in HIV positive individual. MUCH less prevalent in era of ART/HAART. (VERY rare finding now.) Most common oral malignant neoplasm associated with AIDS Associated with sexually transmitted virus (HHV-8) Initial presentation often intraoral site Appear as macules, patches, nodules or ulcerations, bluish, brownish, or reddish Location: Intra-orally - hard and soft palate and gingiva Found anywhere - GI tract, skin or viscera If diagnosed, communication with physician, dermatologist, oncologist, and dentist is essential
  • Any ulcer that persists over 2-3 weeks, without a diagnosis or explanation, must be biopsied.
  • Non-Hodgkin’s Lymphoma - Stable
  • Cellulitis involving bilateral sublingual, submandibular and submental spaces Tongue is elevated to palate Rapid spread of the infection into the lateral- and retro-pharyngeal spaces can cause airway obstruction Feel like it’s interfering with swallowing or breathing Change the way the patient speaks Differentiate between Cellulitis and Abscess
  • Oral health should be included in the patient’s total care plan..
  • 02_STEWART_Oral_Evaluations.ppt

    1. 1. 14 th Annual HIV Conference <ul><li>Oral Health Evaluations </li></ul><ul><li>Carol M. Stewart DDS, MS </li></ul><ul><ul><li>Director of Oral Diagnostic Sciences </li></ul></ul><ul><ul><li>University of Florida College of Dentistry </li></ul></ul><ul><ul><li>Florida/Caribbean AETC Dental Director </li></ul></ul>
    2. 2. Importance of Oral Health – Oral Systemic Links <ul><li>Diabetes </li></ul><ul><ul><li>Heart Disease </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul><ul><li>Osteoporosis </li></ul>
    3. 3. Importance of Oral Health in HIV-infected <ul><li>Even more critical </li></ul><ul><ul><li>Enhanced susceptibility to all oral infections </li></ul></ul><ul><ul><li> and neoplasms </li></ul></ul><ul><ul><li>Impact on systemic health </li></ul></ul><ul><ul><li>Impact on quality of life </li></ul></ul>
    4. 4. Objectives <ul><li>Procedure for an Oral Examination </li></ul><ul><li>Identification and Management of Oral Lesions </li></ul><ul><li>Emergency Dental Concerns </li></ul><ul><li>Preventive Dental Care </li></ul>
    5. 5. <ul><li>Extraoral </li></ul><ul><li>Intraoral </li></ul><ul><li>(Similar to Oral Cancer Exam) </li></ul><ul><li>Questions? </li></ul>Oral Screening Exam Video
    6. 6. Significance of Oral Lesions <ul><li>Often first clinical sign of HIV disease </li></ul><ul><li>Signify disease progression </li></ul><ul><li> HAART failure ? </li></ul><ul><ul><li>HIV viral resistance? </li></ul></ul><ul><ul><li>Medication non-compliance? </li></ul></ul><ul><li>Impact nutrition </li></ul><ul><li>Impact medication compliance </li></ul>CDC
    7. 7. Oral Lesions and HAART <ul><li>Appear to be Decreasing: </li></ul><ul><ul><li>Candidiasis </li></ul></ul><ul><ul><li>Oral Hairy Leukoplakia </li></ul></ul><ul><ul><li>Kaposi’s Sarcoma </li></ul></ul><ul><ul><li>Necrotizing Periodontitis </li></ul></ul><ul><li>Appear to be Increasing: </li></ul><ul><ul><li>HPV assoc. Condyloma acuminata “Oral Warts” </li></ul></ul><ul><ul><li>Xerostomia </li></ul></ul><ul><ul><li>Dental decay </li></ul></ul>
    8. 8. Traditional Outline of Oral Conditions <ul><li>Fungal </li></ul><ul><ul><li>Candidia albicans (Candidiasis) “Thrush” </li></ul></ul><ul><ul><li>Histoplasmosa capsulatum (Histoplasmosis) </li></ul></ul><ul><ul><li>Cryptococcus neoformans </li></ul></ul><ul><li>Viral </li></ul><ul><ul><li>Oral hairy leukoplakia (Epstein-Barr virus) </li></ul></ul><ul><ul><li>Herpes simplex virus (HSV) </li></ul></ul><ul><ul><li>Herpes Zoster “Shingles” ( Varicella-zoster virus) </li></ul></ul><ul><ul><li>Human Papilloma Virus (HPV) </li></ul></ul><ul><ul><li>Cytomegalovirus (CMV) </li></ul></ul><ul><li>Periodontal disease </li></ul><ul><li> Linear gingival erythema (LGE) </li></ul><ul><li> Necrotizing ulcerative periodontitis (NUP) </li></ul><ul><li>Malignant neoplasms </li></ul><ul><li> Kaposi’s sarcoma (KS) </li></ul><ul><li> Non-Hodgkins Lymphoma </li></ul><ul><li>Squamous cell carcinoma </li></ul><ul><li>Stomatitis/ Ulcers </li></ul><ul><li> Aphthous (major/minor) </li></ul><ul><li> Stomatitis NOS </li></ul><ul><li>Salivary Gland Disease </li></ul><ul><ul><li>Xerostomia </li></ul></ul><ul><li>Dental Decay </li></ul>
    9. 9. Predictive Value of Oral Lesions <ul><li>< 200 CD4 cells/mm3 </li></ul><ul><li>Viral load > 20,000 copies/ml </li></ul>
    10. 10. Fungal Diseases <ul><li>Candidiasis </li></ul><ul><li>Histoplasmosis </li></ul>
    11. 11. Oral Candidiasis, Candida albicans <ul><li>fungal infection associated with: </li></ul><ul><ul><li>HIV infection </li></ul></ul><ul><ul><li>antibiotic treatment </li></ul></ul><ul><ul><li>corticosteroid treatment (inhaled and systemic) </li></ul></ul><ul><ul><li>diabetes, xerostomia, smoking </li></ul></ul><ul><ul><li>removable dental appliances </li></ul></ul><ul><ul><li>defects in cell-mediated immunity </li></ul></ul>
    12. 12. Erythematous Candidiasis <ul><li> Red, flat patches on any oral mucosal surface </li></ul><ul><li>Dorsal tongue Hard Palate </li></ul>
    13. 13. Diagnostic Tools for “yeast” <ul><li>Cytologic smear </li></ul><ul><li>KOH Prep </li></ul><ul><li>3. Culture </li></ul>Buccal mucosal cells showing fungal hyphae
    14. 14. Angular cheilitis <ul><li>Fissures and redness radiating from the either or both corners of the mouth </li></ul>
    15. 15. <ul><li>Creamy white or yellowish curd-like plaques on any oral mucosal surface </li></ul><ul><li>Usually on red mucosa, easily wiped off - </li></ul><ul><li>may bleed </li></ul><ul><li> </li></ul>Pseudomembranous Candidiasis (“thrush”) CDC
    16. 16. Oral Candidiasis – Topical Treatment <ul><li>nystatin pastilles </li></ul><ul><li>clotrimazole (Mycelex) </li></ul><ul><li>Note: many contain sugar </li></ul><ul><li>Mycelex, Nystatin Oral Suspension </li></ul><ul><li>Mycostatin pastilles </li></ul><ul><li>* May consider using a topical fluoride in addition to an antifungal agent that contains sugar </li></ul>
    17. 17. Candidiasis Treatment - for Removable appliances <ul><li>Remove and thoroughly clean daily </li></ul><ul><li>Soak in an antifungal agent </li></ul><ul><li>May use nystatin powder on tissue </li></ul><ul><li> side of denture before insertion </li></ul><ul><li>**Get a NEW toothbrush </li></ul>
    18. 18. Systemic Antifungals <ul><li>Fluconazole 100 mg tabs (Diflucan) </li></ul><ul><li>Two tabs day one, then 1 per day for two weeks. </li></ul>Intraconazole 100 mg (Sporanox) if no response to fluconazole for oropharyneal candidiasis
    19. 19. Hyperplastic Candidiasis <ul><li>Larger areas of white or </li></ul><ul><li>discolored or coalesced </li></ul><ul><li>plaques </li></ul><ul><li>Cannot be wiped off </li></ul><ul><li>Sign of severe </li></ul><ul><li>immune suppression </li></ul>
    20. 20. Viral Conditions <ul><li>Oral Hairy Leukoplakia (OHL) </li></ul><ul><li>Herpes Simplex (HSV) </li></ul><ul><li>Varicella-zoster (VZV) </li></ul><ul><li>Human Papilloma Virus (HPV) </li></ul>
    21. 21. Oral Hairy Leukoplakia (OHL) <ul><li>White lesion, usually present on lateral borders of tongue, </li></ul><ul><li>Vertically corrugated hyperkeratotic patches </li></ul>CDC
    22. 22. Herpes Simplex Virus (HSV) <ul><li>Affects peri-oral areas, lips, palate, gingiva, and intraoral mucosa </li></ul><ul><li>Vesicles may become ulcerated and coalesce to appear as large ulcers </li></ul>CDC
    23. 23. Human Papilloma Virus (HPV) <ul><li>Condyloma Acuminatum - also called “Oral Warts” </li></ul><ul><li>Single or multiple </li></ul><ul><li>Cauliflower-like or flat </li></ul><ul><li>at site of sexual contact </li></ul>
    24. 24. Human Papilloma Virus (HPV) <ul><li>Maybe sessile, flat, or raised </li></ul><ul><ul><li>High recurrence rate </li></ul></ul><ul><ul><li>Lips Inside lips and cheek </li></ul></ul>
    25. 25. Human Papilloma Virus Assoc. with Oral Cancer? * <ul><li>HPV is associated with cervical cancer </li></ul><ul><li>Found HPV DNA in nearly 4% of cancers of mouth and 18% of cancers of oropharynx </li></ul><ul><li>Conc: HPV appears to play etiologic role in many cancers of oropharynx and possibly small subgroups of cancers of the oral cavity. </li></ul><ul><ul><li>More common in subjects who with more than one sexual partner or who practiced oral sex </li></ul></ul><ul><ul><li>More common in tobacco users </li></ul></ul><ul><li>*Journal of the National Cancer Institute 2003;95(23):1772-1783 </li></ul>
    26. 26. Oral Warts and Dysplasia* <ul><li>Results: </li></ul><ul><ul><li>20 of 22 dysplastic warts stained positive for HPV </li></ul></ul><ul><li>Conclusions: </li></ul><ul><ul><li>Invasion-associated proteins are under-expressed in oral dysplastic warts in HIV positive men. </li></ul></ul><ul><ul><li>Need long-term follow-up to determine risk of SCC from oral dysplastic warts. </li></ul></ul><ul><li>*Regezi JA, Dekker NP, Ramos DM, Li X, Macabeo-Ong M, Jordan RC. Proliferation and invasion factors in HIV-associated dysplastic and nondysplastic oral warts and in oral squamous cell carcinoma: an immunohistochemical and RT-PCR evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol Enddod 2002 Dec 94(6) 724-31. </li></ul>
    27. 27. Dental Concerns observed in the Medical Office <ul><li>What initial management can be provided in the medical office? </li></ul><ul><ul><li>Most periodontal conditions </li></ul></ul><ul><ul><li>Pain and infections associated with dental decay </li></ul></ul><ul><ul><li>Aphthous ulcers </li></ul></ul><ul><li>What requires urgent referral? </li></ul><ul><ul><li>Suspected neoplasia or oral cancer </li></ul></ul>
    28. 28. Dental Concerns observed in the Medical Office <ul><li>What requires direct referral to hospital ER? </li></ul><ul><ul><li>Swelling, infection encroaching on airway </li></ul></ul><ul><ul><li>Swelling involving eye </li></ul></ul><ul><ul><li>Intraoral hemorrhage </li></ul></ul><ul><ul><li>Dehydration, fever, lymphadenopathy, signs of severe immune suppression </li></ul></ul>
    29. 29. Periodontal Disease <ul><li>Etiology </li></ul><ul><li>Bacterial - Initiated by microbial dental plaque </li></ul><ul><li>Disease behavior is dependent on host defenses </li></ul><ul><li>Types </li></ul><ul><li>Linear Gingival Erythema (LGE) </li></ul><ul><li>Necrotizing Ulcerative Periodontitis (NUP) </li></ul>
    30. 30. Linear Gingival Erythema (LGE) <ul><li>Profound red band along gingiva where tissue meets the teeth </li></ul><ul><li>Mild pain, Responds poorly to conventional treatment </li></ul><ul><li> mild more advanced </li></ul>
    31. 31. Necrotizing Ulcerative Periodontitis (NUP) <ul><li>Marker of severe immune suppression </li></ul><ul><li>VERY painful,“deep jaw pain” </li></ul><ul><li>Exacerbated by tobacco & xerostomia </li></ul>
    32. 32. Necrotizing Ulcerative Periodontitis Urgent Treatment <ul><li>Antibiotics </li></ul><ul><ul><li>Metronidazole 250 mg 3 times per day for 7-10 days OR </li></ul></ul><ul><ul><li>Clindamycin 300 mg 3 times per day for 7-10 days </li></ul></ul><ul><li>Peridex or PerioGard Rinses </li></ul><ul><li>(chlorhexidine gluconate 0.12%) </li></ul><ul><li>Nutritional supplements </li></ul><ul><li>Dental Tx within one week </li></ul>
    33. 33. Extensive Dental Decay (Caries)
    34. 34. Xerostomia – “Dry Mouth” Signs and symptoms <ul><li>Xerostomia is the subjective feeling of oral dryness </li></ul><ul><ul><li>Patient states they can’t eat a meal without water </li></ul></ul><ul><ul><li>Frequent thirst </li></ul></ul><ul><li>Objective evidence of hyposalivation </li></ul><ul><ul><li>Gloved hand will stick to mucosa </li></ul></ul><ul><ul><li>No “pooling” of saliva observed in floor of mouth </li></ul></ul><ul><ul><li>Significant dental decay </li></ul></ul>
    35. 35. Xerostomia Management <ul><li>Sugar free gum ( Xylitol ) </li></ul><ul><li>Sugar free hard lozenges </li></ul><ul><li>Artificial saliva products - </li></ul><ul><ul><li>- OTC Optimoist, Oral moisturizer, </li></ul></ul><ul><li> - Mouth-Kote, Oralube </li></ul><ul><li>Products for “dry mouth” such as Biotene products </li></ul><ul><li>may offer relief. </li></ul>
    36. 36. Anti-caries Treatment <ul><li>Fluorides OTC: Gel-Kam </li></ul><ul><li>(0.4% stannous fluoride) </li></ul><ul><li>Rx: Prevident Gel </li></ul><ul><li>or Prevident 5000 Plus </li></ul><ul><li>(toothpaste plus fluoride) </li></ul>
    37. 37. Parulis or Dental Abscess Antibiotics - if febrile and lymphadenopathy Analgesics - if painful If chronic and asymptomatic, refer to dentist for next available appointment. Requires endodontic therapy or extraction.
    38. 38. HIV related Soft Tissue Concerns <ul><li>Ulcers </li></ul><ul><li>Malignancies </li></ul>
    39. 39. Minor Aphthous Ulcer “canker sores” <ul><li>Lesions found on buccal mucosa, posterior oropharynx, sides of tongue </li></ul><ul><li>Variable in size - 2-5 mm. diameter </li></ul><ul><li>History of ulcers </li></ul>
    40. 40. Major Aphthous Ulcers <ul><li>Greater than 5 mm in diameter, painful, </li></ul><ul><li>and may persist for many weeks </li></ul><ul><li>Biopsy if non-responsive to treatment </li></ul><ul><li>Necessary to r/o opportunistic </li></ul><ul><li> infection or malignancy </li></ul>CDC
    41. 41. Aphthous Ulcer Treatment <ul><li>Topical steroids: </li></ul><ul><li> Dexamethasone elixir (0.5 mg/5 cc) </li></ul><ul><ul><ul><li>- Hold 1-2 teaspoonfuls in mouth 2 minutes, swish and expectorate, qid (for multiple ulcers) </li></ul></ul></ul><ul><li> Fluocinonide 0.05% ointment (Lidex), with 1:1 Orabase Apply qid </li></ul><ul><ul><li>Clobetasol 0.05% (Temovate) Apply bid ..very potent </li></ul></ul><ul><li>Systemic corticosteroid therapy: for major or non-responsive lesions – as advised by physician </li></ul>
    42. 42. Histoplasmosis <ul><li>Clinical - chronic ulcer, Silver stain (GMS) erythema, and swelling </li></ul><ul><li>Always biopsy </li></ul>
    43. 43. Neoplasms - all need urgent care <ul><li>Kaposi’s Sarcoma </li></ul><ul><li>Squamous Cell Carcinoma </li></ul>
    44. 44. Kaposi’s Sarcoma – palate CDC
    45. 45. Signs of Oral Cancer or Malignancy Urgent Referral to Oral Surgeon or ENT <ul><li>Squamous Cell Carcinoma </li></ul><ul><li>Non-healing ulcer anywhere </li></ul><ul><li>Red patch, white patch, or ulcer that is non-responsive to treatment (persists 2 weeks) </li></ul>
    46. 46. <ul><li>Increase seen in: </li></ul><ul><ul><li>Head and neck CA </li></ul></ul><ul><ul><li>Assoc with declining CD4 counts and </li></ul></ul><ul><ul><ul><li>Increased smoking rates </li></ul></ul></ul><ul><li>* Patel, 11 th Conference on Retroviruses and Opportunistic Infections </li></ul>Malignancies in HIV-Infected Patients*
    47. 47. What is a true dental emergency? <ul><li>The presence of pain does not necessarily constitute a dental emergency </li></ul><ul><li>An acute emergency may include: </li></ul><ul><ul><li>Bleeding </li></ul></ul><ul><ul><li>Swelling </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Purulence (pus) </li></ul></ul>
    48. 48. Emergency Situations Send to Hospital ER <ul><li>Swelling if compromising the airway </li></ul><ul><ul><li>(Ludwig’s angina) </li></ul></ul><ul><li>Swelling if involving the eye </li></ul><ul><li>Intraoral hemorrhage (bleeding) </li></ul><ul><li>Extreme fever & lymphadenopathy </li></ul>
    49. 49. Intraoral Bleeding <ul><li>Ineffective Coagulation </li></ul><ul><li>Intraoral bleeding and/or areas of ecchymosis may be observed with very low platelet counts or </li></ul>
    50. 50. When to Admit for an Odontogenic Infection <ul><li>Deep fascial space infection which threatens the airway </li></ul><ul><li>Patient is dehydrated and requires IV fluids </li></ul><ul><li>Patient requires general anaesthesia for surgical procedures </li></ul>
    51. 51. Oral Preventive Care Plan <ul><li>Initial dental exam for every patient </li></ul><ul><li>Recall every 6 months, sooner if oral conditions include: </li></ul><ul><ul><li>High caries rate or Xerostomia </li></ul></ul><ul><ul><li>Periodontal disease </li></ul></ul><ul><ul><li>Fungal, Viral, or Bacterial infections </li></ul></ul><ul><ul><li>Neoplastic lesions </li></ul></ul>
    52. 52. Patient Home Care <ul><li>Brush 2 times per day ; Floss daily </li></ul><ul><li>Dental debridement every 6 months </li></ul><ul><li>Non-abrasive toothpaste </li></ul><ul><li>Fluoride </li></ul><ul><li>Avoid tobacco </li></ul><ul><li>Avoid excessive alcohol </li></ul><ul><li>Adequate Nutrition </li></ul><ul><ul><li>If ingest sugary snacks frequently, </li></ul></ul><ul><ul><li>brush frequently </li></ul></ul>
    53. 53. Goals of Oral Health Program <ul><li>Treat pain, eliminate sources of infection, and identify/diagnose pathology </li></ul><ul><li>Facilitate maintenance of adequate nutrition by stabilizing and preserving function </li></ul><ul><li>Educate patient regarding health maintenance </li></ul><ul><li>4. Contribute to self-esteem and quality of life </li></ul>
    54. 54. Summary <ul><li>Good oral health will help maintain: </li></ul><ul><li>Systemic health </li></ul><ul><li>Quality of life </li></ul><ul><li>Website: www.FAETC.org </li></ul>
    55. 55. Thank You!! <ul><ul><ul><li>Questions? </li></ul></ul></ul><ul><li>? </li></ul><ul><li>? </li></ul><ul><li>? </li></ul><ul><li>Email: [email_address] </li></ul>
    56. 56. Additional References <ul><li>Patton LL, McKaig R, Strauss R, Rogers D, Eron JJ Jr. Changing prevalence of oral manifestations of human immuno-deficiency virus in the era of protease inhibitor therapy. Oral Surg, Oral Med Oral Pathol Oral Radiol Endod 2000;89:299-304. </li></ul><ul><li>Tappuni AR, Fleming GJ. The effect of antiretroviral therapy on the prevalence of oral manifestations in HIV-infected patients: a UK study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:623-8. </li></ul><ul><li>Margiotta V, Campisi G, Mancuso S, Accurso V, Abbadessa V. HIV infection : oral lesions, CD4+ cell count and viral load in an Italian study population. J Oral Pathol Med 1999;28:173-7. </li></ul><ul><li>Flint S, Glick M, Patton L, Tappuni A, Shirlaw P, Robinson P. Consensus guidelines on quantifying HIV-related oral mucosal disease. Oral Dis 2002;8 Suppl 2:115-9. </li></ul>
    57. 57. Additional References <ul><li>Patton LL, Phelan JA, Ramos-Gomez FJ, Nittayananta W, Shibioski CH, Mbuguye TL. Prevalence and classification of HIV-associated oral lesions. Oral Dis 2002;8 Suppl 2:98-109. </li></ul><ul><li>Flint S, Glick M, Patton L, Tappuni A, Shirlaw P, Robinson P. Consensus guidelines on quantifying HIV-related oral mucosal disease. Oral Dis 2002;8Suppl 2:115-9. </li></ul><ul><li>Patton LL. HIV Disease. Dent Clin North Am 2003; Jul 47(3):467-92. </li></ul>