Introduction

AIDS

Most advanced stage of Human Immuno Deficiency Virus (HIV) infection.

Acquired not inherited

Immuno – attacks the immune system

Deficiency by destroying certain WBC’s

Syndrome – Group of symptoms that occur as a result of HIV infection

Epidemiology

1st case detected in Brazil in 1982

1st case in India in 1986 (Chennai)

5.2 million infections estimated (end 2005)

Max  : Transmission – Heterosexual contact

Male : Female= 3:1

HIV 1 subtype C most prevalent

14,000 new infections per day

3.6 million deaths in 2005

Sources of Infection

Infected Blood, Semen, Vaginal fluids

Infected Breast Milk …..?????

Saliva and tears – epidemiologically insignificant

Exposure to tears, sweat, urine, feaces and saliva of an infected person is normally NOT considered as an “EXPOSURE” unless these secretions contain visible blood. HIV enters the host cell and uses parts of the CD4 cells to make more viruses (Replication) thereby killing the CD4 cells in process.

Oral Disease

It is frequently associated with HIV. While nearly all oral disorders associated with HIV infection also occur in other conditions characterized by immunosuppression, no other condition is associated with as wide and significant a spectrum of oral disease as HIV infection. Many HIV associated oral disorders occur early in HIV infection, not frequently as presenting sign or symptom. Thus early detection of associated oral disease should, in many cases, result in earlier diagnosis of HIV infection. Likewise, awareness of variety of oral disorders which can develop throughout the course of HIV infection, and coordination of health care services between physician and dentist, should improve overall health and comfort of patient.

No particular oral lesion is uniquely associated with HIV infection. However, the presence of one or more lesions requires that HIV infection be considered as a possible underlying cause. Some oral lesions, such as oral Candidiasis and oral hairy lukoplakia are strongly associated with HIV infection. Indeed, the emergence of one or more oral lesions correlates highly with HIV progression. A CD₄ lymphocyte count of less than 200/mm₃ is a reliable prognosticator of active disease and probability of shortened lifespan.

Classification of the Most Common Oral Manifestations of Aids

Bacterial Infections

Linear erythematous gingivitis (LEG)

Necrotizing ulcerative periodontitis (NUP)

Bacillary Epithelioid Angiomatosis (BEA)

Fungal Infections

Candidiasis

Pseudomembranous

Hyperplastic

Erythematous

Angular cheilitis

Viral Infections

Epstein – Barr Virus (Oral Hairy lukoplakia)

Herpes Simplex Virus

Cytomegalovirus

Human Pailloma Virus

Neoplasms

Kaposi’s sarcoma

Non-Hodgkin’s lymphoma (NHL)

Other Oral Lesions

Major aphthous ulceration

Necrotizing stomatitis

Bacterial Infections

Linear Erythematous Gingivitis (Leg)

This entity, previously known as HIV associated gingivitis, is characterized by an erythematous band that follows that counter of the free gingival with a typical chevron appearance. The attached gingival is the site of an inflammatory reaction composed of petechia-like macules also having a reddish cue. Spontaneous bleeding is a frequent finding. The erythematous inflammatory band is a result of bacterial proliferation in the gingival sulcus.the most frequently found microorganisms in this lesion are: Bacteroides gingivalis, Bacteroides intermedius, Actinomyces viscous, Fusobacterium nucleatum and Actinobacillus actinomycetemcomitants, among others. LEG is seen in patients with increased immunosuppression and as a rule is not associated with pain but is considered a potential precursor of necrotizing ulcerative periodontitis. .LEG does not respond to the usual therapeutic methods utilized to treat other types of gingivitis not associated to HIV infection.This entity appears as a 1–3 mm band of marginal gingival erythema, often with petechiae (Fig. 1). It is typically associated with no symptoms or only mild gingival bleeding and mild pain. Histological examination fails to reveal any significant inflammatory response, suggesting that the lesions represent an incomplete (aborted) inflammatory response, principally with only hyperemia present. There is no evidence to suggest that this entity will proceed to the far more destructive necrotizing periodontitis. Unlike conventional gingivitis, the erythema often persists following simple dental prophylaxis.

Figure 1: Linear erythematous gingivitis.   Click here to View figure

Necrotizing Ulcerative Periodontitis (Nup)

This unique periodontal lesion is characterized by generalized deep osseous pain, significant erythema that is often associated with spontaneous bleeding, and rapidly progressive destruction of the periodontal attachment and bone (Fig. 2). The destruction is not self-limiting and can result in loss of the entire alveolar process in the involved area. This very painful associated lesion adversely affects oral intake of food, resulting in significant and rapid weight loss. Because the periodontal microflora is no different from that seen in healthy patients, the lesion probably results from the altered immune response in HIV infection. More than 95% of patients with NUP have a CD₄ lymphocyte count of less than 200/mm3 .

Figure 2: Necrotizing ulcerative periodontitis.   Click here to View figure

Bacillary Epithelioid Angiomatosis (Bea)

This recently described lesion appears to be unique to HIV infection and is often clinically indistinguishable from oral Kaposi’s sarcoma (KS). Since both may present as an erythematous, soft mass which may bleed upon gentle manipulation, biopsy and histological examination are required to distinguish BEA from KS. The presumed etiological pathogen, Rochalimaea henselae, can be identified using Warthin-Starry staining. Both KS and BEA are histologically characterized by atypical vascular channels, extravasated red blood cells, and inflammatory cells. However, prominent spindle cells and mitotic figures occur only in KS.

Viral Infections

Herpes virus accounts for the majority of HIV-related oral viral infections, most frequently as recurrent oral herpes due to herpes simplex virus (HSV) or Epstein-Barr virus (EBV)-induced oral hairy leukoplakia (OHL). Less commonly occurring viral infections involving the oral cavity include cytomegalovirus and human papilloma virus.

Oral Hairy Leukoplakia (Ohl)

Although originally postulated to be pathognomonic for HIV infection, this lesion has subsequently been reported in other immune deficiency states as well as in immunocompetent individuals. It appears as an asymptomatic adherent white patch with vertical corrugations, most commonly on the lateral borders of the tongue (Fig. 3). It may infrequently be confused with hypertrophic candidiasis and is predominantly found in homosexual males. Oral hairy leukoplakia has since been shown to be associated with a localized Epstein-Barr virus (EBV) infection and occurs most commonly in individuals whose CD₄ lymphocyte count is less than 200/mm3 . While the diagnosis is most often clinical, histological inspection will reveal typical epithelial hyperplasia suggestive of EBV infection. This asymptomatic lesion does not require treatment. However, for cosmetic purposes, some patients may request treatment.

Figure 3: Oral hairy leukoplakia.   Click here to View figure

Herpes Simplex Virus

Intraoral herpes in healthy individuals results in multiple, small, shallow ulcerations with irregular raised white borders. Small clusters of lesions usually coalesce to form a larger ulcer, which heals uneventfully in 7–10 days. While the prevalence of seropositive HSV and the rate of reactivation is similar among both HIV-infected and non-infected populations, estimated to be 60% for those older than 30 years of age, recurrent intraoral HSV in patients with HIV infection often results in ulceration and pain of longer duration . Recurrent intraoral HSV lesions occur more commonly on poorly keratinized tissue like the buccal and labial mucosa, an uncommon site in healthy individuals. The pain associated with persistent herpetic ulceration can result in reduced oral intake of food and significant weight loss. Clinical diagnosis can be assisted by culture and examination of a cytologic smear for the virus. Culture results should be interpreted with caution due to the high HSV seropositivity and the potential for false negative results due to silent shedding of HSV.

Cytomegalovirus (Cmv)

It is necessary to recognize oral CMV, which is an uncommon cause of intraoral ulceration in patients with HIV disease. Such a lesion may represent an early sign of disseminated CMV infection. Disseminated CMV infection must be diagnosed as early as possible because of the serious nature of its sequelae, including retinitis and meningitis. CMV has been detected postmortem in one or more organ systems in as many as 90% of patients with AIDS. Oral CMV infection typically appears as a solitary, chronic deep ulceration most often involving the buccal and labial mucosa. Clinically, it is indistinguishable from other nonspecific ulcerations such as chronic HSV and major aphthous ulceration.

Human Papilloma Virus (Hpv)

In some patients with HIV infection, HPV causes a focal epithelial and connective tissue hyperplasia, forming an oral wart. More than 50 strains of HPV exist. The most common genotypes found in the mouth of patients with HIV infection are 2, 6, 11, 13, 16 and 32.

Neoplasms

Kaposi’s Sarcoma  (Ks)

Kaposi’s sarcoma is the most common intraoral malignancy associated with HIV infection Recognition of the lesion is essential, since oral KS is often the first manifestation of the disease and is a diagnostic criterion for AIDS. The lesion may appear as a red-purple macule, an ulcer, or as a nodule or mass. Intraoral KS occurs on the heavily keratinized mucosa, the palate being the site in more than 90% of reported cases (Fig. 4). How ever, lesions have also been reported on the gingivene, tongue and buccal mucosa. The skin should also be examined for lesions whenever oral lesions are discovered. KS is especially common among homosexual and bisexual males and is rarely found in HIV-infected women.

Figure 4: Kaposi’s sarcoma.   Click here to View figure

Non-Hodgkin’s Lymphoma (Nhl)

NHL is the most common lymphoma associated with HIV infection and is usually seen in late stages with CD4 lymphocyte counts of less than 100/mm3. It appears as a rapidly enlarging mass, less commonly as an ulcer or plaque, and most commonly on the palate or gingivae. NHL may be indistinguishable from masses caused by KS or other diseases in HIV-infected patients. Histological examination is essential for diagnosis and staging. Prognosis is poor, with mean survival time of less than one year, despite treatment with multi-drug chemotherapy.

Fungal Infections

Candidiasis

The most common HIV-related oral lesion is candidiasis, predominantly due to Candida albicans. While Candida can be isolated from 30–50% of the oral cavities of healthy adults, making it a constituent of the normal oral flora, clinical oral candidiasis rarely occurs in healthy patients. In stark contrast, clinical oral candidiasis has been reported to occur in 17–43% of patients with HIV infection and in more than 90% of patients with AIDS. One report found that unexplained oral candidiasis in healthy adults with risk factors for HIV infection predicted the development of clinical signs of AIDS within 3 months. Based on clinical appearance, oral candidiasis can appear as one of four distinct clinical entities: erythematous or atrophic candidiasis, pseudomembranous candidiasis (Fig-5,5a), hyperplastic or chronic candidiasis, and angular cheilitis. (Fig. 6).

Figure 5: Pseudomembranous candidiasis.   Click here to View figure

Figure 5a: Pseudomembranous candidiasis.   Click here to View figure

Figure 6: Angular cheilitis.   Click here to View figure

Other Oral Lesions

Major Aphthous Ulceration

Major aphthous ulceration is the most common immune-mediated HIV-related oral disorder, with a prevalence of approximately 2–3% The large solitary or multiple, chronic, deep, painful ulcerations of major aphthae appear identical to those in non-infected patients, but they often last much longer and are less responsive to therapy

(Fig. 7, 8).

Figure 7: Aphthous ulceration.   Click here to View figure

Figure 8: Aphthous ulceration.   Click here to View figure

Necrotizing Stomatitis

Necrotizing stomatitis is an uncommon acute, painful ulceration which often exposes underlying bone and leads to considerable tissue destruction. This lesion may be a variant of major aphthous ulceration, but occurs in areas overlying bone and is associated with severe immune deterioration. Unlike necrotizing ulcerative periodontitis, the lesion may occur in edentulous areas.

Conclusion

Oral conditions seen in association with HIV disease are still quite prevalent and clinically significant. A thorough examination of the oral cavity can easily detect most of the common lesions. An understanding of the recognition, significance, and treatment of said lesions by primary health care providers is essential for the health and well-being of people living with HIV disease

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