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Oral Manifestations of HIV

Dr Claire McGoldrick Consultant 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/3771 94/2014_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

• Pseudomembranous Candidiasis

• Erythematous Candidiasis

• Angular

• 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 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

• 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/DENTI STS_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 Oral

• 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

• – multiple small vesicles/ulcers on 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

•

• 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-lesional Chemo, 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 in HIV-infected individuals • Linear Gingival Erythema • Necrotising Periodontal Diseases - Necrotising Ulcerative - Necrotising Ulcerative Periodontitis - Necrotising • Linear Gingival Erythema

• HIV Gingivitis, Red-Band Gingivitis • Erythematous band on (extends 2-3mm from gingival margin) • Erythema is disproportionate to local factors such as plaque and • Lack of response to 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, and • 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 • 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.p df

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/377194/2014_PH E_HIV_annual_report_19_11_2014.pdf

www.hivdent.org

Reznik DA. Perspective – Oral Manifestations. Topics in HIV Medicine. 2005; 13:143-148.