Aids and The Periodontium By Dr Sachin Rathod

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Aids and The Periodontium By Dr Sachin Rathod

  1. 1. Sachin RathodSachin Rathod Email:- drsachin.rathod@yahoo.comEmail:- drsachin.rathod@yahoo.com
  2. 2. • Definition • Epidemiology • Virus • Structure • Pathogenesis • Transmission & Prevention • Classification & Grading • Manifestations • General • Oral • Periodontal • Management of oral diseases • Diagnosis • Treatment of AIDS • The AIDS patient & the dental office
  3. 3. • Bangui (1985) definition • Exclusion criteria • Pronounced malnutrition • Cancer • Immunosuppressive treatment • Inclusion criteria • Important signs • weight loss > 10% body weight 4
  4. 4. • Very frequent signs • continuous attack / repeated bouts of fever 3 • Diarrhoea > 1 month 3 • Other signs • relapsing Herpes 4 • oropharyngeal candidiasis 4 • Nuerological signs 2 • Generalised Kaposi s sarcoma 12 • The diagnosis of AIDS established when the score is equal or more than 12 • 1994 modification…
  5. 5. Group: Group VI (ssRNA-RT) Family: Retroviridae Genus: Lentivirus Species: Human immunodeficiency virus 1 Species: Human immunodeficiency virus 2
  6. 6. • Previous names …. • 120 nm in diameter , roughly spherical in shape • two copies of positive single-stranded RNA that codes for the virus's nine genes enclosed by a conical capsid composed of 2,000 copies of the viral protein p24 • matrix composed of the viral protein p17 surrounds the capsid • viral envelope which is composed of two layers of fatty molecules phospholipids
  7. 7. • High genetic variability • Fast replication • High mutation rate • Recombinogenic property • Three groups – M, N & O – differ in ENV genes • M most common
  8. 8. • Heterosexual / Homosexual intercourse • Exposure to infected body fluids/ tissues • Intrauterine or perinatal
  9. 9. • Some people show resistance to getting infected by HIV 1 or if infected in developing full blown AIDS…??? • Genetic mutation slows / stops progression • CCR5 affects the major coreceptor CKR5 which affects the entry of the virus into the cell • Vaccine for HIV ???
  10. 10. • WHO classification (1990) modified September 2005 • Stage I: HIV disease is asymptomatic and not categorized as AIDS • Stage II: includes minor mucocutaneous manifestations and recurrent upper resp tract infections • Stage III: includes unexplained chronic diarrhoea for longer than a month, severe bacterial infections and pulmonary tuberculosis • Stage IV: includes toxoplasmosis of the brain candidiasis of the esophagus, trachea bronchi or lungs and Kaposi’s sarcoma; these diseases are indicators of AIDS
  11. 11. • CDC (1993) • Category A – acute symptoms / asymptomatic conditions individuals with PGL without malaise , fever (low grade), fatigue • Category B – Symptomatic conditions oropharyngeal candidiasis, Herpes Zoster oral hairy leukoplakia, ITP Constitutional symptoms fever ,weight loss ,diarrhoea
  12. 12. • Category C – full blown AIDS CD4 count < 200/mm3 Candidiasis-trachea, bronchi, lungs Cervical cancer –invasive Toxoplasmosis brain Kaposis Sarcoma
  13. 13. Category Classification CD4 level 1 Asymptomatic >/ 500/ mm3 2 AIDS related complex 200-499 cell/ mm3 3 AIDS < 200/ mm3
  14. 14. • General • Acute – fever, myalgia, arthralgia , pharyngitis diarrhoea, thrush, persistent generalized lymphadenopathy • ARC – Candidiasis mucosal, constitutional symptoms, Herpes Zoster, ITP, oral hairy leukoplakia, peripheral neuropathy • AIDS defining conditions- • Candidiasis ( pulmonary , esophageal) cervical cancer, coccidiomycosis, CMV infection, Kaposi Sarcoma
  15. 15. • Challecombe SJ, Greenspan J, Williams DM J Oral Path 1993; 22: 289-291
  16. 16. • Erythematous Candidiasis – • presumptive – red areas on the palate / dorsum • No definitive criteria-detection of candida organisms • Psuedomembranous Candidiasis- • White /yellow spots plaques, any part of the oral cavity • Response to anti fungal • Hairy Luekoplakia- • Bilateral whitish grey lesions (lateral margins), non scrapable • Demonstration of EBV
  17. 17. • Kaposi’s Sarcoma • Erythematous ,bluish , violaceous macules swellings • Biopsy • Non Hodgkins Lymphoma • firm, elastic reddish purplish • Biopsy
  18. 18. • Oral hairy luekoplakia- lat borders of tongue ,extends to ventral surface asymptomatic, keratotic areas vertical striae, corrugated appearance non scrapable, candidial superinfection strong indicator psuedo hairy luekoplakia in HIV –ve pts H/P…
  19. 19. • Diff diagnosis- lichen planus frictional keratosis geographic tongue cancer , dysplasia • Treatment – antiviral therapy but recurs after stoppage laser or conventional surgery , ART
  20. 20. • 90% patients • Psuedomembranous, • Erythematous and • Hyperplastic • Esophageal candidiasis – diagnostic sign • Diagnosis – smears • Recurrence rate high….
  21. 21. • Vascular proliferative disorder • Rickettsiae like organisms , • Gingival – red, purplish edematous soft tissue destruction of pdl & bone • lesion seen , CD4 levels dip • Biopsy – epitheloid proliferation of angiogenic cells acute inflammatory cell infiltrate organism stains with Warthen starry silver stain
  22. 22. • Treatment – broad spectrum antibiotics conservative periodontal therapy excision of lesion
  23. 23. • Multifocal ,vascular neoplasm • HHV-8 –decreased immunocompetence activates the latent virus • Palate & Gingiva most common sites • Painless red macules, progress to nodular lesions • H/P…. • Diff diagnosis- hemangioma, varicosity bacillary angiomatosis , pyogenic granuloma
  24. 24. • Treatment – intralesional; injections of vinblastine 0.1 mg/cm2 or 0.2mg/ml saline • ART, interferon , • If destruction of periodontium ,conventional periodontal therapy
  25. 25. • Linear gingival erythema • HIV ass gingivitis • Persistent linear, easily bleeding, erythematous gingiva • Disproportionate to amount of plaque, increased chances ofsmokers • No ulcerations , no pockets • No response to plaque control • Localised / generalised • Candida spp…. Candida dubliniensis • Periodontal pathogens seen in periodontitis (Gornisky’91) • CD4 count…. Barr C ’92
  26. 26. • no inflammatory infiltrate and increased blood vessels • Diff diagnosis – lichen planus pemphigoid plasma cell gingivitis • Treatment - Step 1: Instruct the patient in performance of meticulous oral hygiene. Step 2: Scale and polish affected areas, and perform subgingival irrigation with chlorhexidine.
  27. 27. Step 3: Prescribe chlorhexidine gluconate mouthrinse. Step 4: Reevaluate the patient in 2 to 3 weeks. If lesions persist, evaluate for possible candidiasis. Consider empiric administration of a systemic antifungal agent such as fluconazole for 7 to 10 days. Step 5: Re-treat if necessary. Step 6: Place the patient on 2- to 3-month recall.
  28. 28. • Necrotizing gingivitis . No attachment loss • Rapidly progressing into NUP • Difference b/w necrotizing periodontitis and necrotizing stomatitis • Initial – interdental papilla, moderate- att gingiva, tooth mobility , sequestration of crestal bone, extensive bone loss and necrosis of soft tissue • Fetor oris….
  29. 29. • Severe pain…. • No deep pockets, deep interdental craters • Bleeding on probing • Borrelia spp, gram positive spp, ß hemolytic streptococci C. albicans oppurtunistic spp also seen • Progression correlates with HIV disease and vice versa • NP strong predictor of prognosis…Glick ‘94
  30. 30. • Treatment – no improvement with conventional SRP • Adjunctive Metronidazole • Anti mycotic drugs
  31. 31. • Acute ulceronecrotic disorder, extremely painful • Extends from NUP • Exposes underlying bone • More severe but less common • Similar to NOMA • Life threatening strongly related to immune depletion
  32. 32. • HIV – strong indicator for developing periodontitis Lamster ‘98 • Lucht E’91 –correlates more to the CD4 count than Plaque index • Intensive oral care programs as soon as diagnosis of AIDS done….
  33. 33. • Antibody tests • Antigen tests • Virus isolation • Demonstration of viral NA • HIV viral load • CD4 counts • Antiviral susceptibility assays
  34. 34. • ELISA – biochemical technique • detects the presence of an antibody or an antigen in a sample. It uses two antibodies • One antibody is specific to the antigen. The other reacts to Ag-Ab complexes , and is coupled to an enzyme. chromogenic or fluorogenic substrate.
  35. 35. • View/quantify the result using a spectrophotometer or other optical device • Enzyme acts as an amplifier …
  36. 36. • Analysis – qualitative or quantitative • Other types – sandwich competitive
  37. 37. • Western Blot Assay- individual proteins of HIV-1 lysate are separated using polyacrylamide gel electrophoresis. ↓ nitrocellulose paper and reacted with patients serum ↓ colored bands are produced
  38. 38. • Earliest detection –GAG, p24 • All HIV pts- ENV, gp120, gp41 • Positive- p24, p31, gp41, gp120 • All other patterns-indeterminate • Negative – no bands detected , not only viral bands
  39. 39. • Other criteria – presence of any two foll bands gp41, p24, gp120/gp 160 • Red cross – positive test – more than one –GAG, POL & ENV • TRI DOT- rapid HIV testing flow through device with an inbuilt internal control & two separate antigen dots for HIV -1 & 2
  40. 40. • HAART – Different classes of drugs target different stages • Reverse trancriptase inhibitors- • Nucleoside analogues • Non nucleoside analogues • Protease inhibitors – • Fusion inhibitors • Integrase inhibitors • Entry inhibitors-
  41. 41. • Fixed dose combinations • Synergistic enhancers • Combination therapy- • Who should be treated???
  42. 42. • Limitations …. Mega HAART / salvage therapy • To reduce resistance • drug resistance –FOTO, WOWO • ADVERSE EFFECTS – Alopecia, diarrhoea, Fanconi syndrome, Hepatitis ,hyperbilirubinemia, hyperpigmentation, mental confusion peripheral neuropathy , Steven Johnsons syndrome
  43. 43. “ Value conflicts are visible most on the faces of those who suffer…. ”
  44. 44. • Risk of transmission – low • Trace amounts of HIV in saliva- • Saliva inhibits infectivity of free virus & to a lesser extent ,virus within cells
  45. 45. • Principles of infection control - • take action to stay healthy • Avoid contact with blood • Limit the spread of blood • Make objects safe for use • Instruments – Critical, semi critical and non critical
  46. 46. • AIDS-diagnosis, treatment andprevention • Glickman- IX edition • Periodontal medicine- Genco, Rose & Cohen • J Oral Path Med;93 :29:289-294 • Net references
  47. 47. Sachin RathodSachin Rathod Email:- drsachin.rathod@yahoo.comEmail:- drsachin.rathod@yahoo.com

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