Download Management of Periodontal Disease in HIV

Module 8
Management of Periodontal
Disease in HIV-Infected Patients
Management of Periodontal
Disease in HIV-Infected Patients
Mark A. Reynolds, D.D.S., Ph.D.
Niki M. Moutsopoulos, D.D.S.
Department of Periodontics
Dental School
University of Maryland Baltimore
and the
Pennsylvania/Mid-Atlantic AIDS ETC
Program Outline
• Classification of Periodontal Diseases
and Conditions
• Periodontal Diseases and Conditions
in HIV-Infected Patients
• Periodontal Management of HIVInfected Patients
Program Objectives
The objectives of this program are to:
(1) Outline the current classification of periodontal
diseases and conditions based on the 1999
international workshop for a classification of
periodontal diseases and conditions;
(2) Review selected periodontal diseases and
conditions in HIV-infected patients
(3) Provide an overview of considerations and
approaches in the periodontal management of
HIV-infected patients
International Workshop for the Classification of
Periodontal Diseases and Conditions, 1999
I.
II.
III.
IV.
Gingival Diseases
Chronic Periodontitis
Aggressive Periodontitis
Periodontitis as a Manifestation of
Systemic Diseases
Annals of Periodontology, 1999
Recent Changes in Classification
• 1989 World Workshop in Periodontics
provided a widely recognized classification
system
• Concerns included:
a.
b.
c.
Overlap in disease categories
Absence of gingival disease component
Inappropriate emphasis on age of onset of
disease
d. Inadequate or unclear classification criteria
Armitage, Annals of Periodontology, 1999
International Workshop for the Classification of
Periodontal Diseases and Conditions, 1999
V.
Necrotizing Periodontal Diseases
VI. Abscesses of the Periodontium
VII. Periodontitis Associated with
Endodontic Lesions
VIII. Developmental or Acquired
Deformities and Conditions
Annals of Periodontology, 1999
I. Gingival Diseases
A. Dental plaque-induced gingival diseases
1. Gingivitis associated with dental plaque only
a. With or without local contributing factors
2. Gingival diseases modified by systemic factors
a. Associated with the endocrine system
b. Associated with blood dyscrasias
3. Gingival diseases modified by medications
4. Gingival diseases modified by malnutrition
Annals of Periodontology, 1999
I. Gingival Diseases; Continued
B. Non-plaque-induced gingival lesions
1. Gingival diseases of specific bacterial origin
E.g., Bacillary (epithelioid) Angiomatosis
2. Gingival diseases of viral origin
E.g., Herpes simplex virus
3. Gingival diseases of fungal origin
E.g., Linear gingival erythema
4. Gingival lesions of genetic origin
Annals of Periodontology, 1999
I. Gingival Diseases
B. Non-plaque-induced gingival lesionsContinued
5. Gingival manifestations of systemic conditions
1. Mucocutaneous disorders
2. Allergic reactions
6. Traumatic lesions (factitious, iatrogenic,
accidental)
7. Foreign body reactions
8. Not otherwise specified
Annals of Periodontology, 1999
II. Chronic Periodontitis
A. Localized
B. Generalized
III. Aggressive Periodontitis
A. Localized
B. Generalized
Annals of Periodontology, 1999
IV. Periodontitis as a Manifestation
of Systemic Diseases
A. Associated with hematological disorders
B. Associated with genetic disorders
C. Not otherwise specified (NOS)
Annals of Periodontology, 1999
V. Necrotizing Periodontal Diseases
A. Necrotizing ulcerative gingivitis (NUG)
B. Necrotizing ulcerative periodontitis (NUP)
Annals of Periodontology, 1999
VI. Abscesses of the Periodontium
VII. Periodontitis Associated with
Endodontic Lesions
VIII. Developmental or Acquired
Deformities and Conditions
Annals of Periodontology, 1999
Periodontal Diseases and
Conditions in HIV-Infected Patients
• Unclear whether there are periodontal
lesions specific to HIV infection
• Exacerbation of periodontal conditions
and disease, such as chronic periodontitis,
may result from severe immunodeficiency
or immunosuppression
• Mixed infections
 Opportunistic
 Poly-microbial
Selected Gingival Diseases and
Conditions in HIV-Infected Patients
A. Dental plaque-induced gingival diseases
i.e., common gingivitis (not “HIV-gingivitis”)
B. Non-plaque-induced gingival lesions
1. Gingival diseases of specific bacterial origin
Gingival Diseases and Conditions
in HIV-Infected Patients
B. Non-plaque-induced gingival lesions
1. Gingival diseases of specific bacterial origin
1. Mycobacterium
2. Gingival diseases of viral origin
1.
2.
3.
4.
5.
Herpesvirus infections
Primary herpetic gingivostomatitis
Recurrent oral herpes
Varicella-zoster infections
Other
3. Gingival diseases of fungal origin
1. Linear gingival erythema
2. Histoplasmosis
3. Other
Factors that Predispose to
Oral Lesions
•
•
•
•
•
CD4+ counts < 200cells/mm3
Viral load > 3000copies/mm3
Xerostomia
Poor oral hygiene
Smoking
HIV PROGRESSION
1000
CD4 < 200 = AIDS
• Immune deterioration
• Opportunistic Infections
• Oral Manifestations
CD4
Virus
CD4 T cell concentration
800
600
400
200
0
M0
6
12
18
24
30
36
42
48
54
Time (months post infection)
60
66
72
78
Adapted from Fauci et al., 1983
Linear Gingival Erythema
• Linear erythematous band involving the free
marginal gingiva without demonstrable attachment
loss
 Erythema may extend to attached gingiva
 Possible precursor of necrotizing ulcerative
periodontal conditions
 Prevalence: 4% -50% (Holmstrup et al., 2002)
• Spontaneous hemorrhage
• Minimal plaque deposits
• Associated with Candida albicans
• Responds poorly to conventional treatment
Linear Gingival Erythema
Photograph courtesy of Dr. Louis DePaola, Baltimore, MD
Periodontal Diseases and
Conditions in HIV-Infected Patients
• Aggressive periodontitis

Severe localized forms reported in literature
• Chronic periodontitis modified by
immunosuppression

Recent interest in potential for accelerated rate of
chronic periodontitis occurring in HIV+ patients

Rate of progression may be dependent upon the
immunologic competency of the host as well as
local inflammatory response to typical and atypical
subgingival microorganisms (Lamster et al., 1997)
Chronic Periodontitis
• It is not clear whether HIV+ patients develop a more
progressive form of conventional periodontitis
• One study demonstrated a three fold increase in the
odds ratios of bone loss for males (Tomar et al., 1995)
• Chronic periodontitis modified by immunosuppression

Recent interest in potential for accelerated rate of
chronic periodontitis occurring in HIV+ patients

Rate of progression may be dependent upon the
immunologic competency of the host as well as
local inflammatory response to typical and atypical
subgingival microorganisms (Lamster et al., 1997)
Periodontal Diseases and
Conditions in HIV-Infected Patients
• Necrotizing Periodontal Diseases
 Necrotizing ulcerative gingivitis (NUG)
 Necrotizing ulcerative periodontitis (NUP)
Necrotizing Ulcerative Gingivitis
• Primarily affects the papillary and marginal
gingiva
• Gingival erythema and edema, with
spontaneous bleeding
• Yellowish-grayish (“pseudomembranous”)
areas of marginal and/or papillary necrosis
of gingiva
 Loss of interdental papillae
 Pain
 Rapid progression and extension possible
Necrotizing Ulcerative Gingivitis
Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MD
Necrotizing Ulcerative Gingivitis
Gingival tissues appear
erythematous and
edematous, with
evidence of papillary
necrosis and cratering
Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MD
Necrotizing Ulcerative Periodontitis
• Interproximal ulceration, necrosis and cratering
• Foetor is often present
• Pain (severe, deep, localized in jaw)
• Spontaneous bleeding
• Soft tissue necrosis and rapid periodontal
destruction
• Prevalence:
 1%-88% (Holmstrup et al., 2002).
 One large study found a rate of 6.3% (Glick et al., 1994)
Necrotizing Ulcerative Periodontitis
Prominent changes in
gingival contour are
associated with tissue
necrosis and loss of
periodontal attachment
and bone
Photograph courtesy of Dr. Valli I. Meeks, Baltimore, MD
General Considerations in the
Management of HIV+ Patients
•
Universal precautions
•
Medical consultation
a. Overall medical status
b. Current medications
c. Opportunistic infection(s)
d. Stage of HIV disease
a. CD4 lymphocyte count
b. Viral load
•
Management of oral infections
•
Comprehensive preventive and restorative
oral health care
General Considerations in the
Management of HIV+ Patients
•
In the absence of significant immunosuppression,
the periodontal treatment of HIV+ patients should
be guided by the same parameters of care
appropriate for HIV- individuals.
Management of Linear Gingival Erythema
• Scaling and debridement
• Topical and/or subgingival irrigation with
antimicrobial chemotherapeutic agent

Povidine iodine 10%, chlorhexidine gluconate
irrigation 0.12%-0.2%, or Listerine Antiseptic
• Prescribe daily microbial mouth rinse

Chlorhexidine gluconate mouth 0.12% (Rx)1

Listerine Antiseptic (OTC)2
• Recommendation for tobacco cessation
• Re-evaluate in 2-3 weeks.
1.
2.
Available only by Rx; Many State drug plans do not cover this agent
Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious
Management of Linear Gingival ErythemaContinued
• For nonresponsive lesions, evaluate for Candidal
infection, and consider antifungal agent
 Refer to module 6
• Selected narrow-spectrum antibiotics sparing
gram-positive organisms may be beneficial
 Metronidazole (250mg, tid 7-10 days)
 In the absence of resolution, consideration should be
given to other possible lesions, such as lymphomas,
including referral for appropriate diagnostic testing
(i.e., biopsy)
• Meticulous oral hygiene and frequent supportive
maintenance
Periodontal Diseases and
Conditions in HIV-infected Patients
• Necrotizing Periodontal Diseases
 Necrotizing ulcerative gingivitis
 Necrotizing ulcerative periodontitis
 Necrotizing stomatitis
Management of Necrotizing Ulcerative Gingivitis
• Local debridement, scaling and root planing, and
irrigation of affected areas with either povidine iodine
10% or chlorhexidine gluconate 0.12-0.2%.
 Povidine iodine provides some analgesic properties.
• Daily rinses with antimicrobial
 Chlorhexidine gluconate mouth 0.12% 1
 Listerine Antiseptic 2
• Frequent (daily or every-other-day) follow up for 7-10
days, repeating scaling and debridement as necessary
• Reevaluation 1 mo following resolution of acute
symptoms
1.
Available only by Rx; Many State drug plans do not cover this agent
2.
Pfizer, Morris Plains, NJ 07950; OTC, inexpensive and efficacious
Management of Necrotizing Ulcerative Gingivitis
• Systemic antibiotics
 Metronidazole (250mg tid, 7-10 days)
 When necessary, should administered concurrently with
topical (e.g, clotrimazole troches or nystatin vaginal tablets
and, in severe immunosuppression, systemic antifungal
medication (e.g, fluconazole)
• Reevaluation 1 mo following resolution of acute
symptoms
Management of Necrotizing Ulcerative
Periodontitis
• Local debridement, scaling and root planing, and
irrigation of affected areas with either povidine iodine
10% or chlorhexidine gluconate 0.12-0.2%.
 Povidine iodine provides some analgesic properties.
• Daily rinses with antimicrobial
 Chlorhexidine gluconate mouth 0.12%
 Listerine Antiseptic
• Frequent (daily or every-other-day) follow up for 7-10
days, repeating scaling and debridement as necessary
Management of Necrotizing Ulcerative
Periodontitis
• Systemic antibiotics
 Metronidazole (250mg tid, 7-10 days; Robinson et al.,1998)
 Consideration should also be given to the prophylactic
administration of topical (e.g, clotrimazole troches or nystatin
vaginal tablets) and, in severe immunosuppression, systemic
antifungal medication (e.g, fluconazole 100mg, 1 td, 7 to 10 days)
• Reevaluation 1 mo following resolution of acute
symptoms
• 3 mo supportive periodontal maintenance
 30% of patients experience recurrence in 2 years (Patton et al.,
2000)
 History of NUP predisposes to Necrotizing Ulcerative Stomatitis
(Robinson, 2002)
Management of Necrotizing Ulcerative
Stomatitis
• Debridement of affected areas
• Daily rinses with antimicrobial
 Chlorhexidine gluconate mouth rinse 0.12%
 Listerine Antiseptic
• Daily (or every-other-day) follow up for the first week,
repeating debridement at each visit
• Systemic antibiotics (e.g., metronidazole 250 tid, 7-10
days).
 Consideration should also be given to the prophylactic
administration of an antifungal medication (fluconazole 100mg,
1td or Itraconazole 200mg, 1td; for 7 to 10 days)
• Reevaluation 1 mo following resolution of acute
symptoms
Abscesses of the Periodontium
•
Rapid palatal enlargement, smooth and shiny
swelling associated with pain
•
Treatment:
 Establish drainage by debriding pocket and
removing plaque, calculus and irritants
 Monitor for resolution of symptoms –
failure to resolve may be due to incomplete
debridement
 In severely immunocompromized patients
(CD4<200) as well as non-resolving lesions
consider systemic antibiotics (e.g.,
Amoxicillin 1.0 gm loading dose and 500
mg tid for 3 days)
• Consideration should be given to prophylatic
administration antifungal agent(s)
• Culture and sensitivity testing is advisable
Photograph courtesy of Dr. Louis DePaola, Baltimore, MD
Periodontal Microflora in HIV+ Patients
• No major differences in the microbial composition
of periodontal lesions between HIV and non-HIV
infected patients
• Colonization includes:
 A.actinomycetemcomitans
 P.gingivalis
 P. intermedia
 F. nucleatum in LGE and NUP
• Recovery of human herpes virus types 6, 7, and 8,
found in 90% of HIV+ patients
 Over 2X higher than in HIV- controls (Mardirossian et al, 1999)
Considerations in the Use of Antibiotics
• Preferred use of narrow spectrum antibiotics
(e.g., Metronidazole) to minimize development
of antibiotic resistance
• Possibility of presence of antibiotic resistant
strains
 Culture and antibiotic sensitivity may be indicated
• Use of antibiotics may lead to overgrowth of
Candida albicans
 Antifungal treatment may be indicated in conjunction
with systemic antibiotics
• Local delivery antibiotics may be useful but
have not been evaluated
Antibiotic and Antifungal Regimens
Antibiotics
Rx
Metronidazole tabs 250 mg
Disp: 30 to 40 tabs
Sig: Two tablets as a loading dose
and thereafter 250 mg qid for
7-10 days
Antibiotic and Antifungal Regimens
Topical Antifungal Agents
Rx
Clotrimazole troche 10mg
Sig: Dissolve 3-5/day for 7-10 days
or
Nystatin vaginal tablets (100,000 U):
Sig: dissolve 1 tablet in mouth tid 7-10 days
Antibiotic and Antifungal Regimens
Systemic Antifungal Agents
Rx
Fluconazole tablets 100mg
Disp: 9 to 16 tabs
Sig: two tablets immediately and
then 1 tablet daily for 7-10 days
Antibiotic and Antifungal Regimens
Systemic Antifungal Agents
Rx
Itraconazole capsules 100mg
Disp: 14 capsules
Sig: 200mg once daily for 7days
Pediatric Patients
• Oral lesions have been reported in HIV+ pediatric
populations. The CDC revised the classification system
for HIV infection in children <13 years of age to include
oral lesions as markers of severity of HIV infection (1994)
• Linear gingival erythema has been reported in
approximately 10% of HIV+ children exhibit
• Periodontal conditions and diseases, such as necrotizing
ulcerative gingivitis and periodontitis, have been
infrequently described
Considerations in Periodontal
Therapy
• The effects of systemic bacteremia created
following Sc/RP have not been studied
• The response of HIV+ patients to periodontal
surgery has not been studied
• The presence of antibiotic resistant oral
bacteria has not been evaluated
Oral Manifestations in the HAART Era
• Overall prevalence of oral infections has changed since
introduction of highly active antiretroviral treatment
(HAART)
• Overall reductions in oral infections from 47.6% to
37.5% (Patton et al., 2000)
• Reductions in oral hairy leukoplakia and necrotizing
ulcerative periodontitis
• Increase in oral warts (Greenspan, 2002)
• No change noted for oral candidiasis, oral ulcers, or
Kaposi sarcoma
Web Resources
1. http://www.hivatis.org.
2. https://w3.ada.org/prof/prac/issues/topics/icon
trol/ic-recs/index.html.
3. http://www.hivdent.org/dtc.htm.
4. http://www.critpath.org/daac/standards.html
Resources and Contact Information
•
•
Mark A. Reynolds, D.D.S., Ph.D.
Niki M. Moutsopoulos, D.D.S.
University of Maryland
Dental School
Department of Periodontics
666 West Baltimore Street
Baltimore, Maryland 21201
(410) 706-7152
References
• Classification and diagnostic criteria for oral lesions in HIV infection. ECClearinghouse on Oral Problems Related to HIV Infection and WHO
Collaborating Centre on Oral Manifestations of the Immunodeficiency
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• Fauci, AS. The acquired immune deficiency syndrome. The everbroadening clinical spectrum. JAMA 1983 May 6;249:2375-6.
• Glick, M., et al. Necrotizing ulcerative periodontitis: a marker for immune
deterioration and a predictor for the diagnosis of AIDS. J Periodontol
1994; 65: 393-397.
• Greenspan, JS. Periodontal complications of HIV infection.
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• Greenspan D., Canchola A., MacPhail C, Cheikh B, Greenspan J. Effect
of Highly Active Antiretroviral Therapy on Frequency of Oral Warts.
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• Holmstrup, P. and Glick, M. Treatment of periodontal disease in the
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References
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immunodeficient patient. Periodontol 2000 2002;28:190-205.
• Lamster IB, Grbic JT, Bucklan RS, Mitchell-Lewis D, Reynolds HS,
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Periodontology 9th Edition, Chicago: W B Saunders, 2001.
References
• Robinson PG, Sheiham A, Challacombe SJ, Wren MW, Zakrzewska
JM. Gingival ulceration in HIV infection. A case series and case control.
study. J Clin Periodontol 1998 Mar;25:260-7.
• Robinson PG, Periodontal diseases and HIV infection. Oral Dis 2002;8
Suppl 2:144-50.
• Ryder, MI. Periodontal management of HIV-infected patients.
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Jun;66:421-8.
• Winkler JR, Murray PA, Grassi M, Hammerle C. Diagnosis and
management of HIV-associated periodontal lesions.
J Am Dent Assoc 1989;Suppl:25S-34S.
• Winkler JR, Robertson PB. Periodontal disease associated with HIV
infection. Oral Surg Oral Med Oral Pathol 1992;73:145-50.
• 1999 International Workshop for a Classification of Periodontal Diseases
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