ORAL MANIFESTATIONS OF HIV and the IMMUNOCOMPROMISED PATIENT Oral Manifestations of HIV • Candidiasis • Oral hairy leukoplakia • Kaposi’s sarcoma • Lymphoma • Squamous cellcarcinoma Oral Manifestations of HIV • Bacterial infections • Mycotic infections • Viral infections • Non-specific ulcerations • NOMA-like lesions 1 Oral Manifestations of HIV • Papilloma viral lesions • Autoimmune disease • Salivary gland disease • Idiopathic thrombocytopenia • Periodontal disease Candidiasis Yeast, C albicans, globrata • Pseudomembraneous • Atophic • Hyperplastic • Angular cheilitis Causes of Angular Cheilitis • Candidiasis • Decreased vertical dimension • Anemia • Malnutrition • Vitamin deficiency 2 Management of Mild/Moderate Candidiasis • Clotrimazole Troches • Nystatin Suspension • Gentian Violet • Dairy products with acidophilus Management of Angular Cheilitis • Clotrimazole Cream/Ointment • Nystatin-Triamcinolone Cream • Clotrimazole-Betamethasone Cream Management of Moderate/Severe Candidiasis • Itraconazole Solution/ Capsules • Fluconazole For resistant cases: • Add Amphotericin Suspension • Add Nystatin Suspension • Caspofungin acetate IV • Amphotericin IV 3 Oral Hairy Leukoplakia Treatment for Oral Hairy Leukoplakia • Podophyllin resin 25% • Podophyllotoxin • Retinoic acid • Acyclovir White lesions - Differential Diagnosis • Pseudomembraneous candidiasis • Hyperplastic candidiasis • Hairy leukoplakia • White hairy tongue • Leukoedema • Lichen planus • Hyperkeratosis • Leukoplakia 4 Kaposi’s Sarcoma Differential Diagnosis for Kaposi’s Sarcoma •Hematoma • Hemangioma • Bacillary angiomatosis • Lyphoma • Pyogenic granuloma • Hyperplastic gingivitis Lymphoma 5 Squamous Cell Carcinoma Bacterial Infections • Syphillis • Gonorrheae • Atypical tuberculosis • Bacillary angiomatosis Deep Mycotic Infections • Candidal ulcers • Invasive candidiasis • Histoplasmosis • Mucormycosis 6 Management of Deep Mycotic Infections • Itraconazole 200-400mg qd • Amphotericin B IV • Caspofungin acetate IV Oral Ulcerations • Aphthous major • Drug Induced • Herpes simplex • Cytomegalovirus Management of Aphthous Ulcers • Fluocinonide gel/ointment 0.05% • Clobetasol ointment 0.05% • Dexamethasone elixir 0.5mg/5ml • Prednisone 60mg qd for 10 days • Intralesional dexamethasone 4mg/ml 7 Viral Infections • Herpes simplex –labialis – folliculitis – intraoral • Cytomegalovirus – ulceration – intrabony Management of HSV and HZV • Acyclovir 1-4gm qd • Acyclovir ointment 5% • Penciclovir ointment • Valacyclovir 1gm tid • Famciclovir 0.5gm tid • Foscarnet IV Management of CMV • Acyclovir 4gm qd • Ganciclovir IV or PO • Foscarnet IV • may need concomitant steroid tx 8 NOMA-Like Lesions Necrotizing stomatitis Cancrum oris Management of NOMA-Like Lesions • Biopsy to exclude viral/fungal etiology • Antibiotic therapy – Metronidazole – Amoxicillin/clavulanate – Clindamycin – Tobramycin – Floxin Management of NOMA-Like Lesions • Prednisone • Intralesional steroid therapy – Dexamethasone 4mg/cc • Thalidomide • Surgical debridement • Nutrional supplementation 9 Papillomavirus Lesions • Condyloma acuminatum • Focal epithelial hyperplasia • Verruca vulgaris • Verruca plana • Molluscum contagiosum Management of Papillomavirus Infections • Podophyllin resin 25% • Laser ablation • Surgical excision • Intralesional interferon • Intraleisonal cidofovir • Cimetidine 400mg tid • Levamisole HIV-Associated Periodontitis • Linear Gingival Erythema (LGE) • Necrotizing Ulcerative Gingivitis (NUG) • Necrotizing Ulcerative Periodontitis (NUP) 10 Periodontal Treatments • Subgingival scaling and debridement • Antibiotic therapy – Metronidazole – Clindamycin • Oral hygiene instructions • Clorhexidine mouthrinse Periodontal Treatments • Root planing and scaling • Removal of sequestrae • Osseous recontouring • Gingival grafts Immune Dysfunction • Lichenoid reactions • Lichen planus •Psoriasis 11 Allergic of Drug Reactions • Erythema multiforme – Candidiasis – Herpes simplex • Chemical Burns Salivary Gland Disease • Diffuse infiltrative lymphocytosis • Obstructive salivary gland disease • Sialendenitis • Mucocele • Xerostomia 12.