Recognition and Management of the Most Common Oral Manifestations of HIV Infection

Contents

• Candidiasis (Thrush)
• Hairy Leukoplakia (HL)
• Coated Tongue
• Periodontal (Gum) Problems
• Kaposi's Sarcoma (KS)
• Oral Ulcerations
• Xerostomia (Dry Mouth)
• Resources

It has been estimated that 90% of people with HIV disease will present with at least one oral manifestation at some time during the course of their infection.¹ The ability to differentiate one manifestation from another, as well as manage some of the more common conditions is fundamental to the overall health care of this patient population. As key players in the primary health care of our patients, dentists and dental hygienists have the ability to positively affect the well being of our patients. The following is a review of the more common oral conditions associated with HIV, as well as the clinics experience of the providers of Grady Health System's Infectious Disease Oral Health Center in the management of said conditions.

Candidiasis (Thrush)

There are three predominant types of candidiasis seen in the HIV+ population.

1. Erythematous candidiasis
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   This is a red flat lesion that may appear anywhere in the oral cavity but the majority of time presents on the dorsal surface of the tongue and/or the roof of the mouth. This lesion tends to be symptomatic with the chief complaint being burning, usually associated with eating salty or spicy foods. Resembles pizza burn and traumatic lesions of the hard and soft palate. Erythematous candidiasis is usually an early manifestation of immune dysfunction.² This form of candidiasis is managed with topical antifungal therapies.

2. Pseudomembranous candidiasis

   This is the lesion most often called "thrush." It appears as white patches that can present anywhere in the mouth. These patches or plaques can be wiped away leaving a red and sometimes bleeding surface. Thrush is often the first indicator of HIV-infection. In patients known to be HIV+, thrush may be an indicator of disease progression.³ In late stage patients, thrush may be complicated by xerostomia (dry mouth).⁴

3. Angular Cheilitis

   This lesion is more prevalent in HIV+ individuals when compared to HIV- individuals, but does occur in both populations. Angular cheilitis, of itself is not diagnostic of HIV infection. It appears as cracks or fissures radiating from the corners of the mouth which may or may not be accompanied by intraoral "thrush".⁵

Treatment of Candidiasis

• Initial bouts or mild infections should be treated with topical antifungal preparations for a period of at least two weeks. Acceptable medications include Mycelex troches and Fungizone7Oral Suspension. Nystatin swish and swallow, which needs to be held in the mouth 5 minutes each use, contains a very high sugar content, which can lead to dental caries and should be accompanied by a prescription fluoride.⁶

  It is very important for people who wear partials and/or dentures to treat these appliances when they have candidiasis. The protocol utilized at the Oral Health Center of the Infectious Disease Program involves thoroughly cleaning the partial or denture once a day and soaking it overnight in a 1:1 dilution of a chlorhexidine solution such as PerioGard oral Rinse. Patients are also instructed to place 1 ml of Fungizone7 Oral Suspension on the acrylic of their partial or denture two to four times per day before inserting the prosthesis.

• Moderate to severe candidiasis may require systematic therapies such as ketoconazole, itraconazole or fluconazole. As with topical antifungals, treatment should last two weeks.⁷

• It is important to understand that just because the white plaques are no longer visible, the infection may still be present, therefore treatment should always be complete to help prevent recurrence.³

Oral Hairy Leukoplakia (HL)

• A white lesion that presents on the lateral borders of the tongue that has been associated with the Epstein-Barr virus.⁸

• This lesion does not wipe away which helps to differentiate HL from "thrush."

• Treatment is usually not necessary unless taste or appearance is compromised.

Coated Tongue

Coated tongue is not an oral manifestation of HIV but is often incorrectly diagnosed as thrush.

• A condition that occurs on the dorsal surface or top of the tongue.

• Most often just an overgrowth of the papillae on the tongue or bacteria; often confused with thrush.

• Treatment just involves brushing the tongue; medications are not necessary.⁹

Periodontal (Gum) Problems

Gingivitis and periodontitis can occur no matter what the patient's HIV status is, but there are some periodontal problems than are unique to HIV infection.

• Linear Gingival Erythema (LGE) or Red Band Gingivitis

  LGE is marked by profound red banding (erythema) along the necks of the teeth where the gingival tissue and teeth meet. Treatment involves a thorough dental cleaning and adjunctive rinse with a .12% chlorhexidine gluconate solution such as Periogard Oral Rinse7.¹⁰

  The patient should rinse two times a day for two weeks. If you are unable to get the patient scheduled for a dental cleaning within a few weeks, Periogard7, which is a prescription rinse, will reduce the symptoms until the patient can be seen by the dental professional.

• Necrotizing Ulcerative Periodontitis (NUP)

  NUP is a serious oral manifestation that causes pain, spontaneous gingival bleeding and rapid destruction of gum tissue and the supporting bone.¹¹ NUP is a marker of severe immune suppression.¹² Patients will often refer to their pain as "deep jaw pain". If you look closely, you may notice ulcerated tissues around the necks of the teeth. Teeth are often times loose. Treatment involves a thorough cleaning and debridement of the infected tissues with a .12% chlorhexidine lavage. Patients are then placed on antibiotic therapy (metronidazole 250 mg 3 - 4 times a day for 7 - 10 days or augmentin 500 mg 3 times a day for 7- 10 days) and a .12% chlorhexidine gluconate solution for two weeks. Pain management is very important and nutritional supplements should be considered, as with any other painful oral manifestation that interferes with eating. Prompt recognition and treatment are very important, but if you are unable to facilitate an emergency dental appointment, .12% chlorhexidine oral rinses, antibiotic therapy, pain management and nutritional supplements will benefit the patient until an appointment can be scheduled.

Kaposi's Sarcoma (KS)

• KS is the most common tumor associated with AIDS and has been reported in 15% of the AIDS population. Intraoral KS may be the initial presentation in as many as 60% of these reported cases.¹³ Biopsy is necessary for a definitive diagnosis.

• Appearance of these lesions can range from flat to raised and red to purple. Location is possible anywhere in the oral cavity.

• There is a correlation between a KS herpesvirus (HHV8) and Kaposi's sarcoma.¹⁴ HHV8 has been found in semen leading to the theory that KS may be sexual1y transmitted.¹⁵

• Treatment decisions are based on the extent of the disease. Small lesions confined to the mouth may be treated with intralesional injections of 0.2 mg/cc of vinblastine sulfate, cryotherapy, surgical excision or radiation therapy. Systemic therapy is reserved for patients with widespread disease or visceral involvement.¹³ (Please visit the HIVdent Picture Gallery for examples.)

• Communication between the primary care physician, dermatologist, oncologist and dentist are very important in the proper management of Kaposi's sarcoma.

• KS lesions around the gum line should be kept very clean as suprainfection is possible as plaque accumulates. It is very important to stress oral home care.

Oral Ulcerations

Oral ulcerations may occur in up to one half of HIV-infected people at some time during the course of infection. Differential diagnosis of ulcers presenting in the oral cavity include recurrent aphthous ulcers and those caused by herpesviruses.

• Recurrent Aphthous Ulcerations (RAU)

  RAU are of unknown etiology and tend to occur on non-keratinized tissues such as buccal mucosa (cheeks), posterior oropharynx and the sides of the tongue. Whereas RAU may not be more frequent in people with HIV disease, they are more severe and prolonged.¹⁶ Treatment involves the use of topical steroids such as Celestone7 syrup for most cases or systemic corticosteroid therapy for major lesions.¹³ In cases that are refractory to steroid therapy, thalidomide (100 mg - 200 mg per day) has proven to be effective.¹⁷

• Herpes Simplex Virus (HSV) Ulcerations

  Recurrent herpes simplex affects the lips and intraoral mucosa and affects approximately 10% to 25% of people with HIV infection when considering all outbreaks of cutaneous lesions.¹⁸ Inside the oral cavity HSV is usually confined to keratinized tissues such as the hard palate and gingival tissue. Treatment involves acyclovir 200 mg five times a day for ten days to two weeks. As with any other oral ulceration, care should be taken to insure the cleanliness of the lesion. Rinsing with hydrogen-peroxide based mouth rinses can be helpful.

Xerostomia (Dry Mouth)

Dry mouth is a common complaint among HIV+ people and should be aggressively managed to prevent dental decay and periodontal problems.⁶ This condition may be due to salivary gland involvement or medications used therapeutically in people with HIV. Several types of medication are known to cause dry mouth including antidepressive, antihypertensives, antianxiety and antihistamines. Candidiasis becomes more difficult to treat without adequate salivary flow.¹⁹ Patient comfort and protection are important issues that need to addressed by the health care team. Patients can chew sugarless gum and/or suck on sugarless candies to stimulate saliva production. Optimoist Oral MoisturizerJ is a pleasant tasting oral moisturizer than can provide relief for people suffering from dry mouth. Fluorides should be prescribed to patients to prevent cavities that occur as a result of decreased salivary flow. Prevident 5000 PlusJ is a l.1% neutral sodium fluoride prescription dental cream that can be used in place of regular toothpastes.

David A. Reznik, D.D.S., is the Director of Infectious Disease Oral Health Center at Grady Health System in Atlanta, Ga.

Resources

1. Greenspan D, Schiodt M, Greenspan JS, Pindborg JJ. AIDS and the Mouth, Diagnosis and Management of Oral Lesions. Copenhagen: Munksgaard; 1990

2. Closer D, Erridge P, Robinson P. HIV and Dentistry: A guide to dental treatment for patients with HIV and AIDS. BDA Occasional Paper. 1994; 4.F7

3. Glick M, Muzyka BD, Lurie O, Salkin LM. Oral Manifestations associated with HIV-related disease as markers for immune suppression and AIDS. Oral Surg Oral Med Oral Pathol 1994, vv:344-9

4. Silverman Jr S, Gallo JW, McKnight BS et al. Clinical characteristics and management responses in 85 HIV-infected patient with oral candidiasis. Oral Surg Oral Med Oral Pathol 1996; 82:402 -7

5. Greenspan D, Greenspan J. HIV-related oral disease. Lancet l996; 348 729-33

6. Greenspan D, Treatment of oral candidiasis in HIV infection. Oral Surg Oral Med Oral Pathol 1994; 78:211-15

7. De Wit S, Weets D, Goossens H, Clumeck N. Comparison of fluconazole and ketoconazole for oropharyngeal candidiasis in AIDS. Lancet 1989; 1:746-8

8. Greenspan JS, Greenspan D, Lennette ET, Abrams DL, Chant MA, Peterson V, et a1, Replication of Epstein-Barr virus within the epithelial cells of oral hairy leukoplakia, an AIDS associated lesion. N Engl J Med. 1985; 313.1564-71

9. Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. St. Louis; Mosby; 1997

10. Winkler JR, Herrera C, Westenhose J, et al. Periodontal disease in HIV-infected and uninfected homosexual and bisexual men. AIDS 1992; 6:1041-43.

11. Greenspan D, Greenspan JS. Oral manifestations of HIV infection. Dermatol Clin. 1991:9:517-22

12. Glick M, Muzyka BC, Salon LM, Luric D. Necrotizing ulcerative periodontitis: a marker for immune deterioration and a predictor for the diagnosis of AIDS. J Periodontol 11994; 65:393-97

13. Weinert M, Grimes RM, Lynch DP. Oral Manifestations of HIV Infection. Ann Intern Med. 1996;125:485-496

14. Moore PS, Chang Y. Detection of herpesvirus-like DNA sequences in Kaposi's sarcoma in patients with and without HIV infection. N Engl J Med. 1995;332:1181-5

15. Beral V, Peterman TA, Berkelmann RL, Jaffe HW. Kaposi's sarcoma among persons with AIDS: a sexually transmitted infection? Lancet 1990;335:123-8

16. Ficarra G. Oral ulcerations in patients with HIV infection; etiology, diagnosis and management. in: Greenspan JS, Greenspan D, eds. Oral Manifestations of HIV Infection Proceedings of the Second International Workshop on the Oral Manifestations of HIV Infections, 31 January-3 February, 1993, San Francisco, California. Chicago; Quintessence publishing; 1995

17. Thalidomide effective treatment for AIDS-related mouth ulcers. Bethesda, MD: National Institute of Allergy and Infectious Diseases; 31 October 1995

18. Bartlett JG. The Johns Hopkins Hospital Guide to Medical Care of Patients with HIV Infection. 4th ed Baltimore: Williams and Widens; 1994

19. Navazesh M, Wood GJ, Brightman V. Relationship between salivary flow rates and candida albicans counts. Oral Surg Oral Med Oral Pathol 1995, 80:284-8.

About David A. Reznik, D.D.S.