1. Sachin RathodSachin Rathod Email:- drsachin.rathod@yahoo.comEmail:- drsachin.rathod@yahoo.com

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. Bangui (1985) definition Exclusion criteria Pronounced malnutrition Cancer Immunosuppressive treatment Inclusion criteria Important signs weight loss > 10% body weight 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. Group: Group VI (ssRNA-RT) Family: Retroviridae Genus: Lentivirus Species: Human immunodeficiency virus 1 Species: Human immunodeficiency virus 2 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. High genetic variability Fast replication High mutation rate Recombinogenic property Three groups M, N & O differ in ENV genes M most common 8. Heterosexual / Homosexual intercourse Exposure to infected body fluids/ tissues Intrauterine or perinatal 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. 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 Kaposis sarcoma; these diseases are indicators of AIDS 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. Category C full blown AIDS CD4 count < 200/mm3 Candidiasis-trachea, bronchi, lungs Cervical cancer invasive Toxoplasmosis brain Kaposis Sarcoma 13. Category Classification CD4 level 1 Asymptomatic >/ 500/ mm3 2 AIDS related complex 200-499 cell/ mm3 3 AIDS < 200/ mm3 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. Challecombe SJ, Greenspan J, Williams DM J Oral Path 1993; 22: 289-291 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. Kaposis Sarcoma Erythematous ,bluish , violaceous macules swellings Biopsy Non Hodgkins Lymphoma firm, elastic reddish purplish Biopsy 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. Diff diagnosis- lichen planus frictional keratosis geographic tongue cancer , dysplasia Treatment antiviral therapy but recurs after stoppage laser or conventional surgery , ART 20. 90% patients Psuedomembranous, Erythematous and Hyperplastic Esophageal candidiasis diagnostic sign Diagnosis smears Recurrence rate high. 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. Treatment broad spectrum antibiotics conservative periodontal therapy excision of lesion 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. Treatment intralesional; injections of vinblastine 0.1 mg/cm2 or 0.2mg/ml saline ART, interferon , If destruction of periodontium ,conventional periodontal therapy 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 (Gornisky91) CD4 count. Barr C 92 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. 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. 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. Severe pain. No deep pockets, deep interdental craters Bleeding on probing Borrelia spp, gram positive spp, hemolytic streptococci C. albicans oppurtunistic spp also seen Progression correlates with HIV disease and vice versa NP strong predictor of prognosisGlick 94 30. Treatment no improvement with conventional SRP Adjunctive Metronidazole Anti mycotic drugs 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. HIV strong indicator for developing periodontitis Lamster 98 Lucht E91 correlates more to the CD4 count than Plaque index Intensive oral care programs as soon as diagnosis of AIDS done. 33. Antibody tests Antigen tests Virus isolation Demonstration of viral NA HIV viral load CD4 counts Antiviral susceptibility assays 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. View/quantify the result using a spectrophotometer or other optical device Enzyme acts as an amplifier 36. Analysis qualitative or quantitative Other types sandwich competitive 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. 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. 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. 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. Fixed dose combinations Synergistic enhancers Combination therapy- Who should be treated??? 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. Value conflicts are visible most on the faces of those who suffer. 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. 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. AIDS-diagnosis, treatment andprevention Glickman- IX edition Periodontal medicine- Genco, Rose & Cohen J Oral Path Med;93 :29:289-294 Net references 47. Sachin RathodSachin Rathod Email:- drsachin.rathod@yahoo.comEmail:- drsachin.rathod@yahoo.com