Oral and Perioral Manifestations of the Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome (AIDS)

Medicine and Health

Background

Acquired Immunodeficiency Syndrome (AIDS) is a disease caused by retroviruses—the Human Immunodeficiency Virus (HIV). It’s mainly characterized by extreme immunosuppression associated with opportunistic infections, malignancies, wasting, and central nervous system (CNS) degeneration. “The Human Immunodeficiency Virus directly infects lymphocytes and, in particular, depresses the number of T-helper (CD4+) cells and reverses the ratio of helper to suppressor (CD8) lymphocytes” (Cawson, Binnie & Eveson, 1988). There are approximately 36.9 million people currently living with HIV/AIDS. Two forms of the virus have been identified: HIV type 1 (HIV-1) and HIV type 2 (HIV-2). HIV-1 is responsible for most of the infections worldwide and HIV-2 is endemic to many countries primarily in West Africa. The morbidity rates of AIDS-related deaths have been on the decline since the 1990’s, largely in part to the continual improvement of drug therapies and education. In fact, it is now considered a chronic illness.

Route of Transmission

There are various possible routes for transmission including sexual transmission, transmission via needles or from mother to fetus/child. HIV can reside in semen and vaginal fluids, and these fluids can transmit the virus onto mucous membranes of another person. Needles, syringes, and other drug injection paraphernalia are common because they increase the risk for blood-to-blood contacts. Blood donations are now screened for the virus, so blood transfusion recipients are no longer at risk. For children infected with HIV, the mode of transmission is most often directly from the mother to the infant. The virus can be transmitted during pregnancy, birth or while breastfeeding. HIV, however, is not spread via saliva or casual contact.

It’s important to consider that a patient infected with HIV is infectious even in the absence of symptoms. Seroconversion is the term used when an infected person’s blood converts from being negative for HIV antibodies to being positive. Seroconversion usually occurs within 1 to 3 months after exposure but can take up to 6 months. The time between infection and seroconversion is called the window period. Consequently, blood collection centers must screen potential donors to identify those with high risk behaviors who are potentially within this particular window period.

The Phases of HIV Progression

There are three distinct phases in the progression of HIV which occur over a 5-14 year period; the primary infection phase, the chronic asymptomatic (latent) phase and the overt phase. The primary phase is an acute illness stage similar to acute mononucleosis. This phase includes signs and symptoms such as fever, fatigue, headache, pharyngitis, night sweats, oral or genital ulcers and gastrointestinal problems. The latent phase is characterized by a period in which there are few signs or symptoms of the illness. Some patients may present with swollen or sore lymph nodes in two or more locations, not including the groin. The length of the latent phase is averaged at ~10 years. Patients who have entered the overt phase develop AIDS and the risk for opportunistic infections increase significantly.

Manifestations and Features of HIV/AIDS

Other manifestations include, but are not limited to rapidly progressive periodontitis, Addisonian pigmentation, angular cheilitis, herpes simplex or zoster, parotitis, myobacterial ulcers, facial palsy, trigeminal neuropathy and major aphthae.

Treatment

Candidosis: The Centers for Disease Control and Prevention has published guidelines for treatment of oropharyngeal candidosis (OPC) in patient with HIV (December 2004). Their guidelines are divided by age group; adults and adolescents vs. children and infants.

Recommended treatment of OPC in adults and adolescents:

  1. Fluconazole 100 mg PO QD for 7-14 days
  2. Itaconazole oral solution 200 mg PO QD for 7-14 days
  3. Clotrimazole troches 10 mg PO 5x/d for 7-14 days
  4. Nystatin suspension 4-6 mL QID or 1-2 flavored pastilles PO 4-5x/d for 7-14 days
  5. Itraconazole oral solution 200 mg (or more) PO QD
  6. Amphotericin B deoxycholate 0.3 mg/kg IV QD

Recommended treatment of OPC in children and infants:

  1. Fluconazole 3-6 mg/kg body weight (max 400 mg/dose) PO for 7-14 days
  2. Itraconazole cyclodextrin oral solution 2.5 mg/kg body weight (max 200-400 mg/d) for 7-14 days)
  3. Clotrimazole troches 10 mg PO QID for 14 days
  4. Nystatin suspension 4-6 mL PO QID or 1-2 flavored pastilles PO 4-5x/day for 7-14 days
  5. Itraconazole cyclodextrin oral solution 2.5 mg/kg body weight PO BID (max 200-400 mg/day) for 7-14 days
  6. Amphotericin B oral suspension 1 mL (100 mg/mL) PO QID for 14 days or less

Hairy Leukoplakia: There are both local and systemic treatment options for Oral Hairy Leukoplakia (OHL). Local treatments often include the use of topical podophyllum resin (POD) and/or surgery. POD is made from different plants such as American mandrake and Indian apple. POD must be used with caution to limit toxicity. Large amounts of POD may result in serious system adverse effects and fatalities (Baccaglini et al., 2007). Topical treatment is ideal for small, contained lesions and is impractical for very large lesions. Systemic antiviral treatments may include antivirals such as desciclovir, valacyclovir and acyclovir but recent studies show that they are not as effective as local treatments with topical drug application and/or surgical removal of the lesion.

Osteomyelitis of the Jaw: Osteomyelitis is most commonly affects the mandible compared to the maxilla. Treatment is dependent on various factors such as which stage in the Cierny-Mader Classification system it’s in, which pathogen is involved and what other comorbidities the patient may have. Treatment may involve sequestrectomy (removal of dead bone that is separated from the rest of the jaw), hyperbaric oxygen therapy, resection and reconstruction of the jaw, drainage of the infection, specific antibiotic prescription based on pathogen cultured, and debridement of the area.

Ulcerative Gingivitis: Treatment for ulcerative gingivitis includes debridement, antiseptic mouth rinse such as chlorhexidine or hydrogen peroxide, improved hygiene and antibiotics. Treatment should be divided into 4 stages:

  1. Stage 1: Stop the disease process and control patient discomfort and pain
  2. Stage 2: Treat the preexisting chronic gingivitis through professional prophylaxis and/or scaling and root planning
  3. Stage 3: Corrective treatment of disease sequelae with procedures such as gingivoplasty and/or gigivectomy
  4. Stage 4: Maintenance through compliance with oral hygiene practices and controlling predisposing factors

References

Baccaglini et al. (2007). Management of oral lesions in HIV-positive patients. Oral surgery, oral medicine, oral pathology, oral radiology, and endodontology, v.103, S50.e1-S50.e23. https://doi.org/10.1016/j.tripleo.2006.11.002

Campbell-Yesufu, O. T., & Gandhi, R. T. (2011). Update on human immunodeficiency virus (HIV)-2 infection. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America52(6), 780–787. https://doi.org/10.1093/cid/ciq248

Cawson, R., Bonnie, W. & Eveson, J. (1994). Color atlas of oral disease: Clinical and pathological correlations. Wolfe Publishing.

Hanley M., Hendriksen,S. & Cooper, J. (2020). Hyperbaric treatment of chronic refractory osteomyelitis. Treasure Island (FL): StatPearls Publishing. PMID: 28613536

Malek,R., Gharibi, A., Khlil, N. & Kissa, J. (2017). Necrotizing ulcerative gingivitis. Contemporary Clinical Dentistry, 8(3), 496-500. https://doi.org/10.4103/ccd.ccd_1181_16

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