Premalignant lesions Opportunistic infection in HIV

1. ORAL MANIFESTATIONS
OF HIV
Guided by:
Dr. Kriti Sao
Submitted by:
Shubhrata Sarangi
B.D.S 3rd Year
2022-23.

2. 1. Human Immunodeficiency Virus
2. Oral manifestations of HIV
3. Oral Candidiasis
4. Angular Cheilitis
5. Oral Hairy Leucoplakia
6. Kaposi’s Sarcoma
7. Non Hodgkin’s Lymphoma
8. Periodontal Disease
9. Aphthous Ulcer
10. Herpes Simplex Virus
11. References
CONTENTS:-

3. HUMAN IMMUNODEFICIENCY VIRUS - HIV

4. INTRODUCTION:-
• The human immunodeficiency viruses (HIV)
belongs to species of Lentivirus group type lll (a
subgroup of retrovirus) that infect humans.
• HIV cause acquired immunodeficiency
syndrome (AIDS), a condition in which
progressive failure of the immune system allows
life-threatening opportunistic infections . Typical Structure of HIV

5. Structure of HIV:-
• The virion is an icosahedral structure .
• It contains external spikes formed by two major
envelope proteins.
• The external gp120 and the transmembrane
gp41,the core protein p17 is found outside the viral
nucleoid and forms the matrix of the virion.
• The HIV glycoprotein antireceptors (GP-41 and
GP-120) make an attachment of their specific
receptors on a human cell membrane.

6. Mode of HIV transmission:-
• Sexual transmission is the predominant mode of infection worldwide,
accounting for more than 75% of all cases of HIV transmission.
• It is also transmitted through infected body fluids such as blood and blood
products, and breast milk.
• HIV has been demonstrated in oral fluids, but their infectivity appears to be
reduced, so saliva is not a significant route of transmission of HIV infection.
• Infection can be transmitted from mother to the child.

7. Pathogenesis of HIV

8. Oral manifestations of HIV:-
In 1995, European Commission (EC)
Clearinghouse on oral
problems related to HIV infection and the
WHO Collaborating
Center on oral manifestations of the
immunodeficiency virus
released the following classification:

9. ORAL CANDIDIASIS
• Oral candidiasis is the most common intraoral opportunistic fungal infection
strongly associated with HIV infection.
• The most common organism associated with oral candidiasis is- Candida albicans.
• But approximately one-third of HIV infected individuals and more than 90% of
patients with AIDS develop oral candidiasis.
• There are mainly four clinical patterns of oral candidiasis seen:-
1.Pseudomembranous Candidiasis
2.Erythematous Candidiasis
3.Hyperplastic Candidiasis
4.Angular Cheilitis

10. Pseudomembranous Candidiasis
• This clinically appears as white to yellowish white plaques which can be easily
scraped off, exposing red areas.
• The lesions are usually extensive, involving more than one site in the oral
cavity.
• It may also extend to involve the oropharynx and esophagus.
Pseudomembranous candidiasis: multiple white
plaque on the soft palate

11. Erythematous Candidiasis
• This is clinically seen as red lesions, which are commonly located on the dorsum
of the tongue, palate, and buccal mucosa.
• Tongue lesions are also referred to as central papillary atrophy.
Erythematous candidiasis. The patchy, denuded
areas (not the white areas) of the dorsal tongue represent
erythematous candidiasis

12. Hyperplastic candidiasis involving the tongue

13. Angular cheilitis
• Erythema and/or fissuring and/or scaling of the angles of the mouth clinically
characterize this lesion.
• Microbiologically, the lesion can be due to mixed infection of Candida albicans
and Staphylococcus aureus or Staphylococcus or Candida alone.
Figure -1 show angular cheilitis, characterized
by fissured, erythematous alterations of the
skin at the corners of the mouth.
Figure -2 show cheliocandidiasis,
characterized by exfoliative lesion of
vermillion zone and perioral skin are due to
superficial Candida infection.

14. ORAL HAIRY
LEUKOPLAKIA
Introduction:- • Oral hairy leukoplakia (OHL) was first reported by
Greenspan and coworkers in 1984 on the lateral margin of the
tongue among young homosexual males.
• The term hairy leukoplakia was given because of the
corrugated surface of the epithelium.
• Initially this lesion was observed exclusively in male
homosexuals.

15. • OHL frequently appears bilaterally on the lateral borders of
the tongue as painless, faint white vertical streaks or
thickened and furrowed areas with a shaggy keratotic surface
with vertical striations imparting a corrugated appearance.
• The floor of the mouth, the buccal mucosa, the tonsillar
region, the soft palate, and the posterior portion of pharynx
are the other areas involved less frequently.
HIV associated oral hairy
leukoplakia (OHL), Vertical
streaks of keratin along the
lateral border of tongue
Oral
manifestations:

16. KAPOSI'S SARCOMA (KS):-
• Kaposi’s sarcoma is an unusual vascular neoplasm , that was first
described in 1872 by Moritz Kaposi, a Hungarian dermatologist.
• Kaposi’s sarcoma became quite common because of its propensity
to develop in individuals infected by the human
immunodeficiency virus (HIV).
• Kaposi’s sarcoma is caused by human herpesvirus 8 (HHV-8;
Kaposi’s sarcoma–associated herpesvirus [KSHV]).

17. AIDS related
• The trunk, arms, head, and
neck are
the most commonly involved
anatomic sites.
• Although any mucosal site
may be involved, the hard
palate, gingiva, and tongue are
affected most frequently.
• With time, the macules
typically develop into plaques
or
nodules.
• Pain, bleeding, and necrosis
may become a problem and
necessitate therapy.
HIV-associated Kaposi’s
sarcoma (KS). Multiple
purple macules on the
right side of the face
HIV-associated Kaposi’s
sarcoma (KS). Large
zones of KS exhibiting as
a fl at, brownish, and M-
shaped discoloration of
the hard palate.
HIV-associated Kaposi’s sarcoma
(KS). Diffuse,
red-blue nodular enlargement of the
left hard palate
HIV-associated
Kaposi’s sarcoma
(KS). Diffuse,
red-blue gingival
enlargement that
demonstrates
widespread
necrosis

18. • The non-Hodgkin’s lymphomas are a heterogeneous group of
lymphoproliferative malignancies which can involve both lymph nodes
and lymphoid organs as well as extranodal organs and tissues.
• The lymph nodes of the head and neck are commonly involved as well as
the extranodal tissues of this area.
Introduction
NON HODGKIN’S LMPHOMA:-

19. Oral manifestations
• The oral lesions are characterized by swellings which may
grow rapidly and then ulcerate.
• In some cases, these become large, fungating, necrotic, foul-
smelling masses .
• Pain is a variable feature.
Non hodgkin's lymphoma
of the oral cavity in AIDS
patient

20. Three atypical patterns of periodontal disease are associated strongly with
HIV infection:
1. Linear gingival erythema
2. Necrotizing ulcerative gingivitis
3. Necrotizing ulcerative periodontitis
• This unusual pattern of
gingivitis appears with a
distinctive linear band of
erythema that involves the
free gingival margin and
extends 2 to 3 mm apically .
Linear gingival erythema
HIV-associated gingivitis. Band of erythema
involving the free gingival margin.
PERIODONTAL LESION

21. Necrotizing ulcerative gingivitis
• It refers to ulceration and necrosis of one or
more interdental papillae with no loss of
periodontal attachment.
• Patients with NUG have interproximal
gingival necrosis, bleeding, pain, and
halitosis
HIV-associated necrotizing ulcerative gingivitis
(NUG). Multiple punched-out interdental papillae of
mandibular gingiva. Note diffuse pseudomembranous
candidiasis of the surrounding mucosa.
Necrotizing ulcerative periodontitis
• NUP is characterized by gingival ulceration
and necrosis associated with rapidly
progressing loss of periodontal attachment.
• Edema, severe pain, and spontaneous
hemorrhage are common.
• Deep pocketing usually is not seen.
HIV-associated periodontitis. Extensive loss of
periodontal support without deep pocketing

22. Mycobacterium tuberculosis
• Tuberculosis (TB) is a chronic infectious disease caused by
Mycobacterium tuberculosis.
Oral manifestations • Oral lesions of TB are uncommon, with most cases
appearing as a chronic painless ulcer.
• Less frequent presentations include nodular, granular,
or (rarely) firm leukoplakic areas.
• When present, primary oral TB usually involves the
gingiva, mucobuccal fold, and areas of infl ammation
adjacent to teeth or in extraction sites .
• Secondary oral lesions are mostly present on the
tongue, palate, and lip .

23. • The affected areas present as chronic ulcerations, granular
leukoplakias, or exophytic proliferative masses.
• Jaw involvement also has been reported
Tuberculosis. Chronic mucosal
ulceration of the ventral surface
of the tongue on the right side
Tuberculosis. Area of
granularity and ulceration of
the lower alveolar ridge and
fl oor of mouth.

24. MELANOTIC HYPERPIGMENTATION
• In HIV-infected patients, hyperpigmentation of the oral mucosa, the
skin and nails has been reported.
• Oral hyperpigmentation may occur suddenly in HIV-infected
individuals .
• Hyperpigmentation in HIV-infected individuals may also be due to a
direct result of the HIV infection.
• Diagnosis is made by the clinical appearance of a recent onset, and
brown to brownish-black intraoral focal or diffuse macules.
Hyperpigmentation of tongue Hyperpigmentation of palate

25. NECROTIZING ULCERATIVE STOMATITIS
• In patients with gingival necrosis, the
process occasionally extends away from the
alveolar ridges and creates massive areas of
tissue destruction termed necrotizing
stomatitis .
• It may involve predominantly soft tissue or
extend into the underlying bone, resulting in
extensive sequestration.
• In the absence of gingival involvement, the
clinical features of necrotizing stomatitis
HIV-associated periodontitis with
necrotizing stomatitis. Diffuse
gingival necrosis with extension onto
alveolar mucosa.
HIV-associated necrotizing
stomatitis. Massive necrosis of soft
tissue and bone of the anterior
maxilla

26. SALIVARY GLAND DISEASE:DRY MOUTH
• Xerostomia refers to a subjective sensation of a dry
mouth; it is frequently, but not always, associated with
salivary gland hypofunction .
• Xerostomia is a common problem that has been reported
in 25% of older adults.
Oral manifestations
• The mucosa appears dry, and the
clinician may notice that the examining
gloves stick to the mucosal surfaces.
• The dorsal tongue often is fi ssured
with atrophy of the fi liform papillae
Salivary gland aplasia. Dry, leathery
tongue and diffuse enamel erosion in
a child with aplasia of the
major salivary glands.

27. • The patient may complain of diffi culty with mastication
and swallowing, and they may even indicate that food
adheres to the oral membranes during eating.
• There is an increased prevalence of oral candidiasis in
patients with xerostomia because of the reduction in the
cleansing and antimicrobial activity normally provided by
saliva .
• In addition, there often is an increase in the caries index
(xerostomia-related caries) .
Xerostomia-related caries. Extensive cervical
caries of mandibular dentition secondary to
radiation-related xerostomia

28. THROMBOCYTOPENIA PURPURA
• Thrombocytopenia has been reported in up to 40% of
patients with HIV infection .
• Clinically, this usually produces pinpoint hemorrhagic
lesions known as petechiae.
• If a larger quantity of blood is extravasated, then an
ecchymosis or bruise results .
• With even larger amounts of extravasated blood, a
hematoma will develop.
• Spontaneous gingival hemorrhage often occurs in these
patients, as does bleeding from sites of minor trauma.

29. Thrombocytopenia. This dark palatal
lesion represents a hematoma
caused by a lack of normal
coagulation, characteristic of
thrombocytopenia

30. • Herpes Simplex ,an acute infectious disease,is probably the most
common viral disease affecting humans with exception of viral
respiratory infections.
HSV -1
predominantly affects the face,
lips, oral cavity, and upper body
skin.
HSV-2
It usually affects the genitals and
the skin of lower half of the body.
Herpes Simplex Virus - HSV

31. Oral manifestations
-Inflamed gingiva
-erythematous
-yellowish, fluid-filled vesicles develop.
-vesicles rupture and form shallow, ragged
and extremely painful ulcers.
-ulcers vary considerably in size, ranging
from several millimeters to centimeter in
diameter.
-They heal spontaneously within 7-14 days
and leave no scar.

32. • Herpes zoster is an acute infectious viral disease of an extremely
painful and incapacitating nature.
HERPES ZOSTER
• Herpes zoster may involve the face by infection of the trigeminal nerve .
This usually consists of unilateral involvement of skin areas supplied by
either the ophthalmic, maxillary or mandibular nerves.
• Lesions of the oral mucosa are fairly common, and extremely painful
vesicles may be found on the buccal mucosa, tongue,uvula, pharynx, and
larynx .
• These generally rupture to leave areas of erosion. One of the
characteristic clinical features of the disease involving the face or oral
cavity is the unilaterality of the lesions.
• Typically, when large, the lesions will extend up to the midline and stop
abruptly.
Oral manifestations

33. Herpes Zoster involving face and oral mucosa

34. • Human papillomavirus (HPV) is responsible for several facial and oral
lesions in immunocompetent patients .
• The most frequent of which are the verruca vulgaris(common wart)
and oral squamous papilloma .
• An increased prevalence of HPV-related lesions is noted in HIV-
infected patient .
HUMAN PAPILLOMA VIRUS
Oral manifestations • The oral lesions usually are multiple and
may be located on any mucosal surface.
• The labial mucosa ,tongue, buccal mucosa,
and gingiva are frequent sites.
• The lesions may exhibit a cluster of white,
spikelike projections, pink caulifl ower-like
growths, or slightly elevated sessile papules
.

35. HIV-associated human papillomavirus
(HPV)
infection. Multiple exophytic and
somewhat papillary
nodules of the lip, buccal mucosa,
and gingiva.

36. ERYTHEMA MULTIFORME
• Erythema multiforme is a blistering, ulcerative mucocutaneous
condition of uncertain etiopathogenesis.
• In about 50% of the cases, the clinician can identify either a
preceding infection such as herpes simplex or Mycoplasma
pneumoniae, or exposure to any of a variety of drugs and
medications, particularly antibiotics or analgesics.

37. Oral manifestations
Ulceration of the labial mucosa
With hemorrhagic crusting of the
vermilion border of the lips.
Diffuse ulcerations and
erosions involving the
dorsal surface of this
patient’s tongue.

39. RECURRENT APHTHOUS
STOMATITIS
It is also known as aphthous ulcer and cancer sore. It is a
common disease characterized by the development of painful
recurring solitary or multiple ulceration of the oral mucosa.

40. Oral manifestations:
Recurrent Aphthous major
• The number of lesions varies
from 1-10
• Lesions may exceed1cm in
diameter
• May persist for 6 weeks and heal
with scarring.
• Age: no age predilection
• Sex: Females>Males
• Site: Lips, Cheeks, Tongue, Soft
Palate and cause severe pain and
• Dysphagia.
Recurrent Aphthous minor
• 1-5 lesions may be present
during each episode
• 2-3mm to >10mm diameter
• Persists for 1-2 weeks and heal
without scarring.
• Age: 10-30years
• Sex: Females> Males
• Site: Buccal and Labial mucosa,
Buccal and Lingual sulci,
Tongue, Soft palate, Pharynx,
Gingiva.

41. MOLLUSCUM CONTAGIOSUM
• Molluscum contagiosum is an infection of the skin caused
by a poxvirus .
• The lesions are small, waxy, dome-shaped papules that
often demonstrate a central depressed crater.
• In immunocompetent individuals, the lesions are self-
limiting and typically involve the genital region or trunk .
• Approximately 5% to 10% of HIV-infected patients are
affected, and the facial skin commonly is involved .

42. Oral manifestations
• Rare intraoral examples of molluscum
contagiosum have been reported, appearing
as erythematous papules.
• These lesions may involve either the
keratinized or nonkeratinized mucosa.
• Lesions are pink, smooth-surfaced, sessile,
nontender, and nonhemorrhagic papules
that are 2 to 4 mm in diameter .
• In immunocompromised patients, atypical
lesions that are unusually large, verrucous,
or markedly hyperkeratotic .
Molluscum contagiosum. Multiple,
smoothsurfaced papules, with
several demonstrating small
keratinlike plugs, are seen on the
neck of a child
HIV-associated molluscum
contagiosum.
Numerous perioral papules.

43. References
Text:
1. Shafer’s Textbook of Oral Pathology.
2. Oral and Maxillofacial Pathology.
Images:
1. Google Images.

44. Thank You