oral manifestations of hiv...oral hairy leukoplakia •virtually diagnostic of hiv (but not always)...
TRANSCRIPT
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.