Oral Manifestations and Dental Treatment Considerations

By Dr. Stuart L. Fischman, D.M.D.

Oral signs and symptoms

Oral signs and symptoms are common in HIV disease. The healthcare proffesional should be aware of these lesions and their management.

Oral Kaposi's sarcoma

The most common malignancy seen in HIV infected individuals is Kaposi's Sarcoma. It has been stated that this condition occurs in 1520 percent of AIDS patient. The most common presentation of Kaposi's Sarcoma is on the skin, although more than half the patients have been reported to have oral lesions. It has been described as a psuedo malignancy related to an HIV-induced lymphocyte-macrophage growth factor, which stimulates angiogenesis and proliferation of vascular endothelium. The disease is more prominent in homosexual men, and it may be due to a sexually transmitted agent, as well as to HIV infection. Silverman and others have noted that the first sign of Kaposi's sarcoma occurs in the mouth in approximately 22 percent of the patients. In another 45 percent, Kaposi's sarcoma occured in the mouth and skin simultaneously. The oral lesions vary in appearance from asymptomatic flat purple-red discolorations to large multiple nodular growths. The differential diagnosis includes hemangioma, coagulation defects, and infection. Diagnosis is generally made by biopsy. Management requires chemotherapy and radiation therapy and is most often provided by the patient's primary care physician.

Candidiasis

Candidiasis is a another common oral finding in HIV-positive individuals. In general, oral candidiasis is seen only in unhealthy individuals. This includes persons with poorly controlled diabetes mellitus and those receiving broad-spectrum antibiotic therapy and long-term steroid treatment. HIV-positive persons frequently demonstrate intraoral lesions of candidiasis in addition to esophageal candidiasis. The oral lesions may be erythematous, pseudomembranous, erosive, or hyperplastic. Angular cheilitis may also be present. Persistent candidiasis in HIV positive patients usually requires systemic therapy. The drug of choice is fluconazole. Topical therapy with nystatin or clotrimazole may also be effective. The treatment duration is at least two weeks.

Hairy leukoplakia

Hairy leukoplakia is a common manifestation of AIDS. It appears as bilaterally symmetrical corrugated white lesions on the lateral borders of the tongue. It is usually asymptomatic and may be the first sign of HIV infection. Biopsy confirmation should be considered if the diagnosis is in doubt or if other diseases (e.g., carcinoma) are significant in the differential diagnosis. Evidence suggests that the EpsteinBarr virus may play a causative role in hairy leukoplakia. The condition requires no treatment.

Premature and advanced periodontal disease

Oral ulcerations and HIV-associated periodontal disease have also been reported. HIV-associated periodontal disease is often rapidly progressive and unusually painful. The most likely cause is alteration in the bacterial flora and immunosuppression. Control requires professional treatment and conscientious oral hygiene. Povidone iodine irrigation may help manage the acute disease state. Because of the severity of the periodontal complications and the immunosuppression of the patient, antibiotics are often required for successful management. Metronidazole has been the most effective antibiotic. In severe cases, intravenous medication may be required. Patients with gingival disease may develop acute necrotizing ulcerative gingivitis. In some HIV+ patients, this may progress to large ulcerations of the palate and gingival mucosa, termed necrotizing stomatitis or NS. These extensions can be managed by aggressive systemic antibiotic therapy, usually requiring intravenous administration of metronidazole. Biopsy should be considered to rule out lymphoma. These large ulcers are most frequently seen when the patient's CD4 count drops below 200. Once the acute infection is stabilized, conscientious oral hygiene is essential to prevent recurrence.