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Strive-the Student View The Oral Manifestations of AIDS A Worldwide Epidemic AIDS has become one of the largest threats to our world. Once termed "Gay Cancer," this disease has proven to be unbound to sexual preference or lifestyle.1 It is indiscriminate of sin or religious preference, preying on each and every host it enters. According to "AIDS in the Modern World" by I. Edward Alcamo, "The face of AIDS is seen in women and men, children, youth, and adults. It is our sons and daughters, brothers and sisters, husbands and wives, mothers and fathers. Sometimes the face of AIDS is seen in the homeless or the imprisoned. Other times, it is a pregnant mother, fearing the disease will reach her unborn child. At times, the face of AIDS is a child with no care giver, the orphaned with little hope for adoption. The faces of AIDS are seen in all walks of life; present in every ethnic group, cultural group, social group, religious group, and country of the world."2 According to recent statistics, AIDS has claimed the lives of 21 million people since its emergence in 1980.3 In the year 2000, it was recorded that 35 million people worldwide were living with HIV or AIDS, and by 2004, over 40 million were infected.4 According to current projections from the U.S. Centers for Disease Control and Prevention (CDC), it is estimated that these numbers will double every 10 years, unless measures of prevention and/or disease elimination are greatly increased.4,5 Oral Manifestations In 1980, Michael Gottlieb, MD, was the first physician to identify the symptoms of AIDS. Among his observations were two prominent oral manifestations: candidiasis and oral Kaposi's sarcoma.3 These two conditions, along with the patient's decreased immune function, were critical in the discovery of AIDS. Current research supports Gottlieb's observations, revealing that 90 percent of people with HIV will present with at least one oral manifestation at some time during the course of their infection.6 As dental hygienists, we are able to offer a great service to the public by identifying the oral manifestations associated with AIDS. By performing routine and thorough extra-/intraoral exams, we may assist in the early detection and treatment of HIV-which places us on the front lines of this worldwide epidemic. The intention of this article is to help dental hygienists recognize some of the common oral manifestations of AIDS. The manifestations listed are divided into four categories: fungal, viral, bacterial and malignancies. Because HIV/AIDS is an extremely complex disease, this article will focus on the most commonly seen oral manifestations. Fungal Infections Candidal fungi are commonly found within healthy oral flora.7,8 However, oral candidiasis is caused primarily by an overgrowth of Candida albicans; presenting a variety of fungal manifestations named on the basis of their unique characteristics. Fungal infections are often the initial signs and symptoms of HIV infection.7,9 Recent statistics have shown that oral candidiasis is the most common oral manifestation of HIV, but there are a multitude of other causes for these infections: chemotherapy, corticosteroid therapy, long-term antibiotic therapy, xerostomia, diabetes mellitus and dentures among many. Patients affected by oral candidiasis often present with oral discomfort or pain, halitosis and/or altered taste sensation (dysgeusia).7,9 Studies have shown that esophageal candidiasis often indicates a patient developing full-blown AIDS, a condition wherein the number of helper T cells has fallen below 200 per microliter of blood.8,10,11 While recognition and treatment of these manifestations is important, it can be somewhat difficult. Pseudomembranous candidiasis, or thrush, commonly appears as white curd-like plaque, easily removed by wiping or scraping the affected oral mucosa to expose a reddened area.12,13 Patients may experience a mild burning sensation and metallic taste during the onset of this condition.9 Pseudomembranous candidiasis has been known to affect all areas of the oral cavity, including the pharynx.8 This condition may be initiated and/or exacerbated in patients with decreased immune response or long-term antibiotic usage, both situations are characteristic of the average HIV patient.9 In fact, this is the one of the most frequently observed fungal manifestations of HIV.8,9,14 Treatment of this condition includes topical and/or systemic antifungal medications, typically clotrimazole, nystatin, fluconazole and itraconazole prescribed for 5-7 days.8,9 Studies have shown these medications to be successful despite the extremely low T cell counts of some AIDS patients.15 However, recurrence and long-term persistence is common with immunosuppressed patients.15 Erythematous candidiasis commonly appears as flat red patches of varying size on the palate or dorsal surface of the tongue.8,12 It frequently appears as a hard-to-distinguish, painful lesion occurring both locally and generally in the oral cavity-often concomitant with pseudomembranous infections.8,12,16 In fact, statistical studies show that erythematous candidiasis occurs as frequently as pseudomembranous candidiasis in HIV-positive patients, suggesting that these infections are potential indicators of or precursors to the progression of HIV to AIDS.8,9 Treatment of this condition is similar to that for pseudomembranous candidiasis and includes the same topical and/or systemic antifungal medications.8,9 Recurrence and long-term persistence is likewise common with immunosuppressed patients.8,9 Angular cheilitis commonly appears as sore red ulcerations or fissures, occurring either unilaterally or bilaterally at the corners of the mouth.8,9,12,13 This condition is caused primarily by a candida infection, most often Candida albicans.8 However, if the lesions appear crusted, a secondary infection with Staphylococcus aureus is likely.13 Recent studies link nutritional deficiencies (vitamin B and iron) with the initial onset of angular cheilitis, along with decreased immune function.8,9 This condition generally develops in the early stages of HIV infection and occurs in conjunction with another form of candidiasis.8 Treatment includes the application of antifungal ointments, such as cream formulations of clotrimazole, nystatin, Vioform-HC and ketoconazole 2%.8,9,13 Once again, reccurrence and long-term persistence is common with immunosuppressed patients. Viral Infections Patients with HIV are much more susceptible to viral infections than healthy people because they lack the natural ability to repel foreign invaders, including many types of viruses.17,18 Herpes simplex virus has been associated with numerous manifestations, affecting 10 percent to 25 percent of HIV positive individuals.19 Commonly, these lesions reoccur in the presence of excessive sunlight, fatigue and emotional stress.8,12,13,20 Oral lesions often begin as small painful vesicles that rapidly erupt, leaving shallow yellow ulcers bordered by a red halo.8,12,13,20 This virus can persist within the trigeminal ganglion in a latent state, allowing for frequent reccurrence of oral lesions.12,14 Primary herpetic gingivostomatitis occurs in children between the ages of 6 months to 6 years. This condition often results in extremely painful erythematous, swollen gingiva and numerous vesicles on the lips and oral mucosa.8,12,13,21 In adults, herpes simplex type 1 is primarily named according to location in the oral cavity. Recurrent intraoral herpes simplex occurs on keratinized mucosa fixed to bone; for example, the hard palate and attached gingiva.8,13,19 Herpes labialis occurs on the vermilion border of the lips and is often called cold sores or fever blisters.8,13,19 In addition to the oral manifestations, herpetic whitlow is a painful infection of the fingers that often occurs as a secondary infection.8,12,19 Unfortunately, all forms of the herpes simplex virus are known to recur. Vesicles often form in clusters, erupting to create lesions that coalesce to form larger lesions.12,13 Currently, no treatment exists to completely eradicate this viral infection. However, antiviral drugs such as acyclovir and phosponoformate have been known to shorten healing time.8,19 Most often, these lesions resolve in 7-10 days without treatment, but they may persist longer in patients with HIV.8,19 Cytomegalovirus has been known to affect 99 percent of HIV-positive homosexual men who remain sexually active.22 Most often, this virus is asymptomatic. However, studies have shown that it may remain dormant in the body for life, transmitting to other hosts through body fluids such as blood, saliva, semen, cervical secretions and breast milk.8,13,22,23 This virus has been know to present serious, potentially life-threatening manifestations in immunosuppressed patients, causing bilateral parotid gland swelling (tumefaction), xerostomia, gingival ulcerations, fevers, pneumonia, liver dysfunction, anemia, retinal damage, blindness and death.8,12,13 Currently, there is no specific treatment for this infection; although antiviral medications are often administered to immunosuppressed patients who have it.8,22,23 Epstein-Barr virus has been associated with multiple diseases including mononucleosis, nasopharyngeal carcinoma and hairy leukoplakia.8,12,13,24,25 Hairy leukoplakia was first diagnosed on the tongue of a homosexual man in 1984.3,26 However, this condition may also present on the buccal mucosa, soft palate and floor of mouth as a white corrugated lesion that cannot be removed.8,13,24,25 These lesions are typically asymptomatic and do not require treatment, although, studies have shown antiviral medications and podophyllin/retinoic acid gels (anti-wart medicines) to be successful in symptomatic patients.8,13,24,25 Bacterial Infections Bacterial infections, similar to viral infections, present as a progressive problem for immunocompromised individuals. Unfortunately, without a strong presence of leukocytes or antibodies, most bacterial infections progress quickly. Many of these infections begin as acute minor conditions and quickly develop into chronic necrotic situations.17,27 Linear gingival erythema is caused by bacterially induced inflammation, resulting in a red linear band that follows the gingival margin of the affected area.6,28,29 The condition is equally likely to occur on both the maxillary and mandibular margins.13,29 Affected areas are prone to spontaneous bleeding.29 Treatment often involves mechanical debridement of bacteria and may incorporate bactericidal chemotherapies.6,8,29 Necrotizing Ulcerative Gingivitis (NUG) is found commonly among patients with HIV, due to immunosuppression caused by an abundance of fusiform and spirochetal organisms.8,13,30,31 This condition is characterized by blunted gingival papilla, swollen, fiery red gingiva, bleeding ulcerations and localized necrosis.8,12,13,31 This condition is often extremely painful, inhibiting the patient's ability to eat or speak comfortably. Initially, NUG is treated with broad-spectrum antibiotic therapy to reduce bacterial load and inflammation.8,13 Consequently, full-mouth debridement is also required for gingival restoration. This condition is known to recur often in patients with HIV.12,31 Necrotizing Ulcerative Periodontitis (NUP) is similar to NUG, however, this condition is associated with rapid destruction of bone as well as gingival tissues, resulting in mobility or loss of teeth.8,12,28,32 An abundance of spirochetal bacteria, primarily Treponema denticola, have been associated with this condition.6,31 Treatment involves full-mouth debridement (including necrosed tissues), .12% chlorhexidine sulcular lavage, and 7-10 days of antibiotic therapy (augmentin and metronidazole are commonly used).22,31 It may also be necessary to prescribe nutritional supplements, if the patient is unable to eat due to associated pain.10,31 Malignancies "Malignant" simply means threatening to life. However, this term often relates to a state of neoplasia, which means uncontrolled proliferation of cells or uncontrolled/unorganized cell growth. Research has shown that patients with HIV have an elevated risk of developing cancer.17,33 Kaposi's sarcoma is a rare skin cancer found primarily in older Mediterranean men with impaired immune function.3,34 Twenty percent of patients worldwide with HIV/AIDS have Kaposi's sarcoma, which presents as red or purple macules, papules, nodules or swellings.8,13,31,34 These lesions can be painful when irritation or ulceration persists. At this time, there is no effective treatment for this type of cancer,31,34 although, experts have recommended radiation, chemotherapy and surgical removal.22,31,34 Non-Hodgkin's B-cell Lymphoma is a malignant, cancerous growth of B or T cells in the lymph system. The associated oral lesions may be the first presentation of lymphoma in HIV infected patients.8,14,31,33 The lesions present as firm masses and persistent ulcers,8,14,31 which studies have shown to occur more frequently in adult males.31 The treatment of these tumors include chemotherapy, radiation and surgical removal.8,31,33 Clinical Considerations Regarding AIDS As this article shows, there are many things to look for during an extra-/intraoral exam. Current research suggests that HIV may not express clinical manifestations for a period of eight to ten years, suggesting that many infected people may be unaware of their condition. Researchers estimate that there are two to four undiagnosed cases of HIV for every diagnosed case.4,11 As clinicians, dental hygienists have the knowledge, ability and responsibility to recognize the related oral manifestations of AIDS. While it is not possible to diagnose a patient by oral manifestations alone, we may recommend further testing if these manifestations persist. Opportunistic infections are the primary cause of mortality in patients with HIV, not the virus itself.2,37 By using universal precautions and astute observations, we are able to detect and limit these potentially lethal infections. Due to its methods of transmission, AIDS is unique in its ability to stir controversy. Because there is no cure, it remains one of the most feared infectious diseases of our time. Since some of the earliest signs of infection appear in the mouth, dental hygienists need to transcend both controversy and fear and continuously update their knowledge about HIV and AIDS in order serve and protect the overall health of their patients and the community at large. James P. Starkey is in his final year of dental hygiene studies at Columbus State Community College, in Columbus, Ohio. He is currently serving his fellow classmates as class president and was recently chosen as a representative for the ADHA Student Advisory Board. James was also honored this year by receiving the Christopher Simmons' Student Scholarship, recognizing his academic merit and student leadership. In the future, he plans to pursue a bachelor's degree and EFDA license through The Ohio State University. See a printed copy of Access for a chart including photographs of the conditions described. These appear by kind permission of David Reznik, DDS, president of HIVdent, a not-for-profit coalition of concerned health care professionals committed to assuring access to high-quality oral health care services for adults, adolescents and children living with HIV disease. For additional information on the oral manifestations of AIDS, visit HIVdent at www.hivdent.org
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By James P. Starkey
