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PATHOLOGY AND MANAGEMENT OF PERIODONTAL PROBLEMS IN PATIENTS WITH HIV INFECTION
 

PATHOLOGY AND MANAGEMENT OF PERIODONTAL PROBLEMS IN PATIENTS WITH HIV INFECTION

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  • It should be determined from the health history, physical evaluation, and consultation with the patient’s physician.

PATHOLOGY AND MANAGEMENT OF PERIODONTAL PROBLEMS IN PATIENTS WITH HIV INFECTION PATHOLOGY AND MANAGEMENT OF PERIODONTAL PROBLEMS IN PATIENTS WITH HIV INFECTION Presentation Transcript

  • GOOD MORNING !
  • PATHOLOGY AND MANAGEMENT OF PERIODONTAL PROBLEMS IN PATIENTS WITH HIV INFECTION YASMIN MOIDIN 2008 Batch Al Azhar Dental College Thodupuzha
  • PATHOGENESIS  HIV has a strong affinity for cells of the immune system, most specifically those that carry the CD4 cell surface receptor molecule  Helper T lymphocytes (T4 cells) are most profoundly affected  Combined therapeutic regimens consisting of antiretroviral agents and protease-inhibiting drugs resulted in improvement in the health status of HIV infected individuals
  •  Overall effect is gradual impairment of the immune system by interference with T4 lymphocytes  B lymphocytes are not infected, but the altered function of infected T4 lymphocytes secondarily results in B-cell neutrophil function dysregulation and altered
  •  HIV-positive individual at increased risk for malignancy, disseminated infections with microorganisms and adverse drug reactions because of altered antigenic regulation   HIV has been detected in most body fluids It is found in high quantities only blood, semen, and cerebrospinal fluid in
  •       Transmission occurs by : Sexual contact Illicit use of injection drugs Exposure to blood or blood products Organ transplantation and artificial insemination Heterosexual transmission -common cause of AIDS
  •  High risk population includes :  Homosexual and bisexual men  Users of illegal injection drugs  Persons with hemophilia/coagulation disorders  Recipients of blood transfusions before april 1985  Infants of HIV-infected mothers  Promiscuous heterosexuals  Individuals who engage in unprotected sex with HIV positive cohorts
  • CDC SURVEILLANCE CASE CLASSIFICATION  Category A : includes patients with acute symptoms or asymptomatic diseases, along with individuals with persistent generalised 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 Constitutional symptoms of fever, diarrhoea , and weight loss
  •  Category C : patients are those with outright AIDS , as manifested by life-threatening conditions or identified through CD4+ T lymphocyte levels of less than 200 cells /mm3 (< 14% of total lymphocytes)
  • ORAL AND PERIODONTAL MANIFESTATIONS OF HIV INFECTION  Oral candidiasis  Oral hairy leukoplakia  Kaposi’s sarcoma and other malignancies  Bacillary (epitheliod) angiomatosis  Oral hyperpigmentation  Atypical ulcers
  • ORAL CANDIDIASIS  Most oral candidal infections are associated with candida albicans  Candidiasis is the most common oral lesion in HIV diseases and found in 90% AIDS patients  1. 2. 3. 4. It has 4 clinical presentations : pseudomembraneous candidiasis erythematous candidiasis hyperplastic candiasis angular cheilitis
  •  Pseudomembraneous candidiasis  Thrush Painless or slightly sensitive Yellow white curdlike lesion Common on hard and soft palate, buccal and labial mucosa   
  •  Erythematous candidiasis  Appears as red patches Seen on buccal mucosa or palatal mucosa Associated with depapillation of the tongue  
  •  Hyperplastic candidiasis  Least common form Seen in buccal mucosa and tongue More resistant to removal than other types  
  •  Angular cheilitis  Seen on commissures of lips Appear as erythematous with surface crusting and fissuring 
  •  Diagnosis  Microscopic - hyphae and yeast forms of organisms Esophageal candidiasis – diagnostic sign of AIDS 
  •   Treatment Topical drugs      Clotrimazole Nystatin Miconazole Amphotericin B oral suspension Systemic drugs    Ketoconazole 200mg tablets Fluconazole 100mg tablets Itraconazole 100mg capsules
  • ORAL HAIRY LEUKOPLAKIA       Epstein-Barr virus Lateral borders of tongue, buccal mucosa, floor of the mouth , retromolar area and soft palate Asymptomatic ,poorly demarcated keratotic area Vertical striations Corrugated appearance Surface may be shaggy and appear hairy
  •  Microscopic features     hyperparakeratotic surface acanthosis balloon cells resembles koilocytes Treatment   HAART Acyclovir and valacyclovir
  • KAPOSI’S SARCOMA        An HIV-positive individual with non-Hodgkin’s lymphoma (NHL) or Kaposi’s sarcoma (KS) is categorised as having AIDS KS is most common oral malignancy associated with AIDS Multifocal vascular neoplasm Human herpesvirus-8 First site - Oral cavity Painless , reddish purple macules Lesions manifests : nodules , papules and non elevated macules
  •  Diagnosis  BASED ON HISTOLOGIC FINDINGS     Endothelial cell proliferation Extravascular hemorrhage Spindle cell proliferation Inflammatory infiltrate
  •        Treatment Antiretroviral agents Laser excision Cryotherapy Radiation therapy Intralesional injection with vinblastine dose 0.1mg/cm2 Chemotherapeutic drugs
  • BACILLARY ANGIOMATOSIS    Infectious vascular proliferative disease with clinical and histologic features similar to that of Kaposi sarcoma. Rickettsiae like organisms Red, purple, or blue edematous soft tissue lesions that may cause destruction of periodontal ligament and bone
  •  Diagnosis Epithelioid proliferation of angiogenic cells accompanied by an acute inflammatory cell infiltrate.  WarthenTreatment Starry Silver staining or electron microscopy.  Erythromycin or doxycycline    Gingival therapy lesions - antibiotic + conservative periodontal
  • ORAL HYPERPIGMENTATION     Spots or striations on the buccal mucosa, palate, gingiva or tongue. Cause - Prolonged use of drugs for HIV like zidovudine, ketoconazole or clofazimine. Zidovudine-excessive pigmentation of the skin and nails. Adrenocorticoid insufficiency – due to prolonged use of ketoconazole , or by Pneumocystis carinii infection or cytomegalovirus.
  • ATYPICAL ULCERS    HIV-infected patients have a higher incidence of recurrent herpetic lesion and aphthous stomatitis Atypical large , persistent , non specific, painful ulcers Caused by herpes simplex virus (HSV), varicella-zoster virus (VZV) , epstein-barr virus (EBV) , cytomegalovirus (CMV)
  •    Herpes labialis in HIV infected individuals responsive to topical antiviral therapy Acyclovir , pencyclovir , doconasol Reduces healing time of lesion
  •  Recurrent aphthous stomatitis  Sites : oropharynx, oesophagus, or other areas of GIT.  Treatment:- Topical or intralesional corticosteroids,chlorhexidine, antimicrobial mouth rinses, oral tetracycline rinses
  • DENTAL TREATMENT COMPLICATIONS  Adverse Drug Effects  Foscarnet, Interferon & DDC - Oral ulcerations  Didanosine - Erythema Multiforme  Zidovudine & Ganciclovir - Leucopenia  Dithiocarb - Xerostomia & Altered taste sensation  HIV-positive patients more susceptible to druginduced Mucositis & Lichenoid drug reactions
  •  HAART drugs  Insulin resistance, gynecomastia, blood dyscrasias, nausea, development of kidney stones, TEN, oral warts  Individuals with Hepatitis C + HIV co- infection are susceptible to liver cirrhosis
  •  Lipodystrophy :-  Redistribution of body fat  Gaunt facial features yet display excessive abdominal fat or even a fat pad on the rear of the shoulders (buffalo hump)  Severe systemic hyperlipidemia  Oral or perioral adverse effects :- oral lichenoid reactions, xerostomia, altered taste sensation, perioral parasthesia, and exfoliative cheilitis
  • GINGIVAL AND PERIODONTAL DISEASES  Linear Gingival Erythema  Necrotizing Ulcerative Gingivitis  Necrotizing Ulcerative Periodontitis  Necrotizing Ulcerative Stomatitis  Chronic Periodontitis
  • Linear Gingival Erythema        A persistent, linear, easily bleeding, erythematous gingivitis Microflora of LGE similar to periodontitis Linear gingivitis lesions :Generalized Localized Most commom among IDUs Lesion usually undergo spontaneous remission
  •      Management The affected sites should be sealed and polished Subgingival irrigation with chlorhexidine or 10 % povidone-iodine Oral hygiene instructions Reevaluation after 2 to 3 weeks
  • Necrotizing Ulcerative Gingivitis        Lesions are punched-out, crater-like depressions at the crest of the interdental papillae Painful Cleaning and debridement of affected areas with a cotton pellet soaked in peroxide after application of a topical anaesthetic Avoid tobacco, alcohol and condiments 0.12% chlorhexidine gluconate Metronidazole or amoxicillin Antifungal medication
  • Necrotizing Ulcerative Periodontitis       Necrosis and ulceration of the coronal portion of interdental papillae and gingival margins Extension of NUG in which bone loss and periodontal attachment loss occur It is characterized by soft tissue necrosis, rapid periodontal destruction and interproximal bone loss Both localized and generalized NUP is severely painful at onset, and immediate treatment is necessary Painless & deep interproximal craters
  •    Therapy for NUP includes local debridement, scaling and root planing, in-office irrigation with an effective antimicrobial agent such as chlorhexidine gluconate, or povidoneiodine Metronidazole (250 mg with two tablets taken immediately and then one tablet 4 times daily for 5-7 days) Prophylactic prescription of a topical or systemic antifungal agent
  • Necrotizing Ulcerative Stomatitis    Severe progressive lesion with extension into the vestibular area and the palate NUS may be severely destructive and acutely painful, affects significant areas of oral soft tissue and underlying bone. NUS is often associated with
  •     Management Metronidazole Antimicrobial mouth rinse If osseous necrosis is present, its necessary to remove the affected bone to promote wound healing
  • Chronic Periodontitis    It is reported that the incidence and severity of chronic periodontitis are similar in HIV +ve and HIV – ve groups Gingival recession and early attachment loss Tongue lesions consistent with hairy leukoplakia were most common among seropositive homosexual males
  •      Management Periodontal therapy and implant replacement Based on the overall health status of the patient The degree of periodontal involvement The motivation and ability of the patient to perform effective oral hygiene
  • PERIODONTAL TREATMENT PROTOCOL  Health status  CD4 + T4 lymphocyte level Current and previous viral load HIV infection identified Medication   
  •  Infection control measures  Strict adherence to established methods of infection control, based on guidance from ADA and CDC Compliance, with universal precautions , will minimise risk to patients and dental staff 
  •  Goals of therapy  Restoration and maintenance of oral health Comfort and function Conservative , nonsurgical periodontal therapy, performance of elective surgical periodontal procedures, implant placements should be a treatment option  
  •  Maintenance therapy  Meticulous personal oral hygiene Periodontal recall visits at short intervals Systemic antibiotic therapy administered with caution Blood and other medical laboratory tests Coordination with the patient’s physician    
  •  Psychologic factors  HIV infection of neuronal cells may affect brain function  dementia  Influence the responsiveness of affected patients to dental treatment  Coping with a life-threatening disease may elicit depression , anxiety and anger
  •  Treatment should be provided in a calm, relaxed atmosphere and stress to the patient must be minimized  Early diagnosis and treatment of HIV infection can have a profound effect on the patient’s life expectancy and quality of life