Oral Manifestations of HIV...Oral Hairy Leukoplakia •Virtually diagnostic of HIV (but not always)...
Transcript of Oral Manifestations of HIV...Oral Hairy Leukoplakia •Virtually diagnostic of HIV (but not always)...
Oral Manifestations of HIV
Dr Claire McGoldrickConsultant Infectious Diseases Physician
Monklands Hospital
Objectives
• To have a basic understanding of HIV
• To recognise some of the oral clues to an HIV diagnosis and promote referral/signposting for testing
• To recognise oral lesions that can occur in known HIV positive individuals
www.hps.scot.nhs.uk
http://hivinsite.ucsf.edu/InSite-KB-ref.jsp?page=kb-03-01-01&ref=kb-03-01-01-fg-02&no=2
http://www.aidsmap.com/v635494203890000000/file/1187469/drug_chart_october_2014_web.pdf
Transmission
• Graph showing HIV with time and exposure groups in the UK
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf
Oral Manifestations
• Infections
- Reactivation of latent infections normally kept in check by immune
system
- Normally non-pathogenic organisms
- More severe forms of ordinary infections
- Higher exposure to certain pathogens
• Neoplasms
• Other
Why should you know this?
• Unique position to recognise some clues to the presence of HIV – although they are not necessarily pathognomonic of HIV
• You may be responsible for the dental health of a person living with HIV
Oral Candidiasis
Oral Candidiasis
• Pseudomembranous Candidiasis
• Erythematous Candidiasis
• Angular Cheilitis
• Chronic Hyperplastic Candidiasis
Pseudomembranous Candidiasis
• Creamy white or yellow plaques
• Can be scraped off to leave erythematous or bleeding mucosa
• On any intra-oral surface
• No symptoms or mild-moderate pain/burning
• Clinical diagnosis, but can swab
Image courtesy of Dr Rob Laing, Aberdeen Royal Infirmary
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Erythematous Candidiasis
• Patchy red areas – may become diffuse and atrophic
• Mainly hard palate and dorsum of tongue, occasionally buccal mucosa
• No symptoms or mild-moderate pain/burning
• Clinical diagnosis, but can swab
Image courtesy of: AIDS Images Library www.aids-images.ch
Angular Cheilitis
• Erythema an fissures /ulcers at corners of mouth
• No symptoms or mild-moderate pain/burning
• Clinical diagnosis, but can swab
http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf
Chronic Hyperplastic Candidiasis
• Rough and irregular, speckled or homogenous white patches that cannot be wiped off
• Mainly buccal mucosa near labial commisures– less frequent involvement of palate or tongue
• Usually no symptoms, but speckled lesions may cause discomfort
• Clinical diagnosis, but can swab
• May demonstrate dysplasia
Oral Candidiasis
• Early HIV disease associated with mild oral candida
• Late HIV disease leads to extensive oral and oesophageal candidiasis
• Other causes of oral candida– Diabetes– Steroids (inhaled and oral)– Antibiotics
• Treatment: Miconazole Gel, Nystatin, Fluconazole etc
Oral Hairy Leukoplakia
Oral Hairy Leukoplakia
• Virtually diagnostic of HIV (but not always)• Induced and maintained by repeated direct EBV infection of
epithelial cells• More prevalent with lower CD4 counts• Whitish, elevated, non-removable - surface
characteristically has vertical ridges but can be smooth• Located at lateral borders of tongue, but may extend onto
ventral/dorsal surface of tongue and occasionally onto buccal mucosa
• Usually asymptomatic• Clinical diagnosis• No specific treatment
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Oral Ulceration
Oral Ulceration
• Primary HIV Infection (Remember “Window Period”)• Major/Minor/Herpetiform Aphthous Ulcers• Syphilis• HSV• VZV• CMV• Periodontal Infections• Ulcerated Neoplasms• Other
• Consider need for HIV test / swabs / biopsy
Recurrent Aphthous Ulcers
• Unknown cause
• Well circumscribed , erythematous margin
• Usually non-keratinized mucosae
• Minor – solitary and 0.5-1cm
• Herpetiform – clusters of small ulcers – 1-2mm(usually soft palate or oropharynx)
• Major – 2-4cm, necrotic (very painful)
• May require biopsy (especially major)
• Topical vs Systemic Treatment
HSV
• Herpes Labialis – multiple small vesicles/ulcers on lips and sometimes surrounding skin
• Intra-oral HSV = small, round vesicles that rupture leaving shallow ulcers that may coalesce
• Lesions are superimposed on an erythematous base
VZV
• Reactivation of VZV
• Intra-orally, it presents as roughly linear eruption of herpetiform vesicles or bullae that ulcerate (may coalesce)
• Mild-severe pain
• Clinical diagnosis, swab for PCR
• Aciclovir/Famciclovir/Valaciclovir
CMV
• Punched out ulcers (from mm to several cm)
• Can erode into deep tissues
• Mainly palate or gingiva, but occasionally buccal mucosa, tongue and pharynx
• Mild-severe pain and xerostomia
• May be treated with ganciclovir/valganciclovir
Human Papilloma Virus
HPV
• Warts
• HPV-induced condyloma may be pearly, filiform, fungating, cauliflower, or plaque-like
• Not exclusive to HIV, but severe or extensive warts are suggestive
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Kaposi’s Sarcoma
Kaposi’s Sarcoma
• Tumour arising from the endothelium
• Preponderance for the skin, palate, bronchi & gut
• Associated with HHV8
• In mouth, most commonly hard palate involved, followed by gingiva and buccal mucosa
• Usually painless
• Biopsy (but may need platelet count first)
• Treatment: cART, Systemic Chemo, Intra-lesionalChemo, Radiotherapy
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Image courtesy of: AIDS Images Library www.aids-images.ch
Non-Hodgkin’s Lymphoma
NHL
• EBV association
• Lymphoma often occurs in unusual sites in the context of HIV
• Diffuse, rapidly proliferating, slightly purplish mass
• B-symptoms
• Biopsy, CT
• Treatment: Resection, Chemo, Radiotherapy
Image courtesy of: AIDS Images Library www.aids-images.ch
Periodontal Disease
Periodontal disease in HIV-infectedindividuals
• Linear Gingival Erythema
• Necrotising Periodontal Diseases
- Necrotising Ulcerative Gingivitis
- Necrotising Ulcerative Periodontitis
- Necrotising Stomatitis
• Chronic Periodontitis
Linear Gingival Erythema
• HIV Gingivitis, Red-Band Gingivitis
• Erythematous band on gingival margin (extends 2-3mm from gingival margin)
• Erythema is disproportionate to local factors such as plaque and calculus
• Lack of response to oral hygiene measures
• May be tender and bleed easily
http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf
Necrotising Ulcerative Gingivitis
• Characteristic Lesion = punched out, ulcerated and erythematous interdental papilla covered by a greyish necrotic slough
• Moderate-severe pain, bleeding, fetor oris
• Systemic symptoms eg fever, malaise, lymphadenopathy may be present
• Sudden onset and rapid deteropration
• Clinical Diagnosis
Necrotising Ulcerative Gingivitis
http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf
Necrotising Ulcerative Periodontitis
• Ulcerated erythematous gingival tissues, particularly interdental papilla, covered by a greyish necrotic slough
• May be exposed bone, gingival recession and tooth mobility
• Moderate-severe pain, bleeding and fetor oris. May be systemic symptoms eg fever, malaise, lymphadenopathy
• Sudden onset and rapid worsening• Clinical Diagnosis
Necrotising Ulcerative Periodontitis
http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf
Necrotising Ulcerative Stomatitis
• Extensive are of ulceration, tissue necrosis and erythema that extends from gingival into adjacent mucosa
• May involve bone leading to osteonecrosis and sequestration
• Moderate-severe pain, bleeding, fetor oris. Usually associated with systemic symptoms of fever, malaise and lymphadenopathy
• Sudden onset and rapid worsening• Clinical Diagnosis
Necrotising Ulcerative Stomatitis
http://www.ashm.org.au/images/Publications/Booklets/DENTISTS_and_HIV_May2011.pdf
Treatment of HIV-Associated Periodontal Disease
• Treat as would in HIV-negative
• Encourage home oral hygiene
• Irrigation and rinsing with povidone iodine or chlorhexidine
• Systemic antibiotics eg metronidazole
Other Conditions
• Other conditions
– Xerostomia
– Bleeding secondary to thrombocytopenia
Effect of cART
• Generally less oral manifestations due to improved immune system
• Some may persist eg aphthous ulceration
• Some may recur even in context of adequate viral control eg periodontal disease
Accessing an HIV Test
• Refer to GP
• THT – Fastest Clinics, Postal Tests
• Sexual Health Clinic (Tel: 0845 6187191)
Conclusions
• Think about the possibility of HIV
• Signpost for testing
• Consider investigations/ treatments that may be needed
Acknowledgments
• Dr Rob Laing, Consultant Infectious Diseases Physician, Aberdeen Royal Infirmary
• Images courtesy of: AIDS Images Library www.aids-images.ch
Information and Images also from: http://www.ashm.org.au
www.hps.scot.nhs.uk
http://hivinsite.ucsf.edu
http://www.aidsmap.com/v635494203890000000/file/1187469/drug_chart_october_2014_web.pdf
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PHE_HIV_annual_report_19_11_2014.pdf
www.hivdent.org
Reznik DA. Perspective – Oral Manifestations. Topics in HIV Medicine. 2005; 13:143-148.