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Oral Manifestations of HIV Infection Nicoleta Vaseliu, DDS, MS, OMFS Harrison Kamiru, BDS, MS, Drph Mark Kabue, BDS, MS, MPH, Drph

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Oral Manifestations of HIV Infection Nicoleta Vaseliu, DDS, MS, OMFS Harrison Kamiru, BDS, MS, Drph Mark Kabue, BDS, MS, MPH, Drph HIV Curriculum for the Health Professional Oral Manifestations of HIV Infection Nicoleta Vaseliu, DDS, MS, OMFS Harrison Kamiru, BDS, MS, DrPH Mark Kabue, BDS, MS, MPH, DrPH Objectives In developed countries, HIV disease progression is + 1. Discuss the importance of oral and dental care monitored by two key laboratory markers: CD4 lympho­ for patients with human immunodeficiency virus cyte count and HIV viral load. Unfortunately, these tests (HIV) infection. are not readily available in many developing countries. 2. Review the classification of orofacial lesions There, other important clinical findings guide clinicians associated with HIV infection in adults and in the evaluation and treatment of HIV disease. Because children. the oral cavity is easily accessible to clinical examination, 3. Describe the clinical presentation and orofacial lesions associated with HIV infection may be management of the most common oral used as clinical markers of HIV disease progression. manifestations of HIV infection. The advent of highly active antiretroviral therapy Key Points (HAART) in 1996 greatly reduced the mortality and morbidity of HIV­infected patients who have access to 1. Oral health care is an important part of HIV treatment. The incidence rates of many opportunistic primary care. infections associated with HIV disease have decreased, 2. Oral manifestations are common clinical findings including that of HIV­associated orofacial lesions. in children and adults with HIV infection. 3. Early diagnosis and management of oral mani­ Evaluation of oral health status is an important part festations is important to prevent compli cations of routine health care. A thorough oral examination is and improve quality of life. important at every stage in the management of HIV disease. It is also desirable to encourage collaboration Importance of Oral Manifes ta- among general medical practitioners, infectious­ tions of HIV Infection disease doctors, general and pediatric dentists, and oral pathologists to provide the best care possible for HIV­ Since human immunodeficiency virus (HIV) infection infected patients. was first described in 1981, a variety of oral conditions associated with HIV disease have been documented. Studies have shown that 70%­90% of HIV­infected Classification of Orofacial Lesions individuals will develop at least one oral manifestation Associated with HIV during the course of the disease. A review of the dental There are two main classification systems of oral lesions literature shows that HIV­associated orofacial lesions associated with HIV infection. The first is based on the have been considered etiology of the oral lesions. According to this system, • clinical indicators of HIV infection in otherwise orofacial lesions are classified as bacterial, viral, or fungal healthy, undiagnosed individuals; infections or as neoplastic lesions or other conditions. • early clinical features of HIV infection; The second, more widely used, system—recommended • clinical markers for the classification and staging of by the EC Clearinghouse on Oral Problems Related to HIV disease; and HIV Infection and WHO Collaborating Centre on Oral • predictors of HIV disease progression. Manifestations of the Human Immunodeficiency Virus— classifies orofacial lesions into three groups according to the degree of their association with HIV infection. 184 184 Oral Manifestations of HIV Infection Tables 1 and 2 show this classification of orofacial Clinical appearance. Oral candidiasis is often observed lesions associated with HIV/AIDS in adults and children, in one of the following four clinical forms: erythematous respectively. (atrophic) candidiasis, pseudomembranous candidiasis, hyperplastic candidiasis, and angular cheilitis. Clinical Presentation and 1. Erythematous (atrophic) candidiasis appears Management clinically as multiple small or large patches, most often localized on the tongue and/or palate Oral Candidiasis (Figure 1). Oral candidiasis is the most common orofacial manifes­ 2. Pseudomembranous candidiasis (oral thrush) tation of HIV infection. Its prevalence may depend on is characterized by the presence of multiple study population, diagnostic criteria, study design, and superficial, creamy white plaques that can be availability of antiretroviral therapy. Reported prevalence easily wiped off, revealing an erythematous base rates have varied widely, to as high as 72% in children (Figure 2). They are usually located on the buccal and 94% in adults. Oral candidiasis is also a significant mucosa, oropharynx, and/or dorsal face of the predictor of HIV disease progression in both adults and tongue. children. The median time of survival from its clinical 3. Hyperplastic candidiasis lesions appear white and diagnosis to death is 3.4 years among HIV­infected hyperplastic and cannot be removed by scraping. children. The main etiologic factor of oral candidiasis is This form of oral candidiasis is rare in HIV­ the fungus Candida albicans, although other species of infected individuals. Candida may be involved. Table 1. Orofacial lesions associated with HIV/AIDS in adults Lesions strongly associated with HIV infection • Candidiasis • Non­Hodgkin’s lymphoma – Erythematous • Periodontal disease – Pseudomembranous – Linear gingival erythema 1 • Hairy leukoplakia – Necrotizing (ulcerative) gingivitis • Kaposi’s sarcoma – Necrotizing (ulcerative) periodontitis Lesions less commonly associated with HIV infection • Bacterial infections • Viral infections – Mycobacterium avium­intracellulare – Herpes simplex virus – Mycobacterium tuberculosis – Human papillomavirus (wart­like lesions) • Melanotic hyperpigmentation – Condyloma acuminatum • Necrotizing (ulcerative) stomatitis – Focal epithelial hyperplasia 2 • Salivary gland disease – Verruca vulgaris – Dry mouth due to decreased salivary flow rate – Varicella zoster virus – Unilateral or bilateral swelling of the major – Herpes zoster salivary glands – Varicella • Thrombocytopenic purpura • Ulceration NOS (not otherwise specified) Lesions seen in HIV infection • Bacterial infections • Fungal infection other than candidiasis – Actinomyces Israel – Cryptococcus neoformans – Escherichia coli – Geotrichum candidum – Klebsiella pneumoniae – Histoplasma capsulatum • Cat­scratch disease – Mucoraceae (mucormycosis/ zygomycosis) • Drug reactions (ulcerative, erythema multiforme, – Aspergillus flavus 3 lichenoid, toxic epidermolysis • Recurrent aphthous stomatitis • Epithelioid (bacillary) angiomatosis • Viral infections • Neurologic disturbances – Cytomegalovirus – Facial palsy – Molluscum contagiosum – Trigeminal neuralgia 185 HIV Curriculum for the Health Professional Figure 1. Erythematous candidiasis in an HIV-infected child Figure 2. Pseudomembranous candidiasis in an HIV-infected child 4. Angular cheilitis is characterized by the presence presence of OHL is a sign of severe immunosuppression. of erythematous fissures at the corners of the OHL is a significant predictor of HIV disease progression mouth. It is usually accompanied by another form in adults. Although its etiology is not clear, OHL seems to of intraoral candidiasis. be caused by Epstein­Barr virus infection. Treatment. Treatment with topical and systemic Clinical appearance. OHL presents as white, thick antifungal agents is recommended (Table 3). patches that do not wipe away and that may exhibit vertical corrugations with a hairlike appearance (Figure Oral Hairy Leukoplakia 3). The lesions usually start on the lateral margins Oral hairy leukoplakia (OHL) is more common among of the tongue and sometimes inside the cheeks and HIV­infected adults than among HIV­infected children. lower lip. They may be unilateral or bilateral, and they The reported prevalence of OHL in adults is about 20%­ are asymptomatic. OHL is often associated with oral 25%, increasing as the CD4+ lymphocyte count decreases, candidiasis. whereas in children the prevalence is about 2%­3%. The Table 2. Orofacial lesions associated with pediatric HIV infection Lesions commonly associated with pediatric HIV infection • Oral candidiasis • Parotid enlargement (swelling of the major salivary glands) – Pseudomembranous • Recurrent aphthous ulcers – Erythematous – Minor 1 – Angular cheilitis – Major • Herpes simplex virus infection – Herpetiform • Linear gingival erythema Lesions less commonly associated with pediatric HIV infection • Bacterial infections of oral tissues • Viral infections • Periodontal diseases – Cytomegalovirus – Necrotizing ulcerative gingivitis – Human papillomavirus – Necrotizing ulcerative periodontitis – Molluscum contagiosum 2 – Necrotizing stomatitis – Varicella zoster virus • Xerostomia – Herpes zoster • Seborrheic dermatitis – Varicella Lesions strongly associated with HIV infection but rare in children • Neoplasms – Kaposi’s sarcoma and non­Hodgkin’s lymphoma 3 • Oral hairy leukoplakia • Tuberculosis­related ulcers 186 Oral Manifestations of HIV Infection Figure 3. Oral Hairy Leukoplakia in an HIV-infected adult Figure 4. Linear Gingival Erythema in an HIV-infected adult Treatment. OHL usually does not require any treatment, erythema on the attached gingiva and oral but in severe cases systemic antivirals are recommended mucosa (Figure 4). The degree of erythema is (Table 3). When OHL is associated with oral candidiasis, disproportionately intense compared with the therapeutic management of oral candidiasis is required. amount of plaque present on the teeth. 2. NUG is more common in adults than in HIV-Associated Periodontal Disease children. It is characterized
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