Idiopathic Thrombocytopenic Purpura

• Oral lesions may be first manifestation of this condition
• Petechiae, ecchymosis & hematoma can occur anywhere on the oral mucosa. Spontaneous bleeding from the gingiva can occur & patients may report finding blood in their mouth on walking

Atypical periodontal disease

Periodontal disease is a common problem in both asymptomatic & symptomatic HIV infected patients.

Classification of periodontal disease associated with HIV infection:-

1. HIV- associated gingivitis- now it is called linear gingivitis
2. HIV associated periodontitis, now called necronizing ulcerative periodontistis
3. HIV- necrotising gingivitis now called Necronizing ulcerative gingivitis
4. Necrotizing stomatitis

Clinical features

• It often occurs in clean mouth where there is very little plaque or calculus to account for the gingivitis.
• The onset is often sudden, with rapid loss of bone & soft tissue. In linear gingival erythema, the gingival may be reddened & edematous.
• Patients sometimes complain of spontaneous bleeding.In acute onset ulcerative gingivitis, ulcers occurs at the tip of the interdental paipilla & along the gingival margin & often elicit complaints of severe pain .The ulcers heal, leaving the gingival papillae with characteristic cratered appearance.
• Necrotizing ulcerative periodontitis may present as rapid loss of supporting bone & soft tissue. Typically, these losses occur simultaneously with no formation of gingival pocket,sometimes involving only isolated areas of the mouth.Teeth may loosen & eventually fall out, but uninvolved sites can appear healthy.
• Necrotising stomatitis may develop and areas of necrotic bone nmay appear along the gingival margin.The bone may eventually sequestrate. Patients with necrotizing ulcerative  periodontitis & necrotizing stomatitis frequently complain  of extreme pain & spontaneous bleeding.
• It will produce severe pain.

Differential Diagnosis

It is some times difficult to distinguish this type of periodontal disease from non-HIV related periodontal problems.However, the complaints of severe pain, rapid onset & rapid destruction in an often extremely clean mouth are unusual for non-HIV related periodontal disease.

Management

Following protocol has achieved reasonable success:-

• Plaque removal,Irrigation with povidine iodine, scaling & root planning & maintenance with a chlorhexidine mouth rinse(0.12 %) once or  twice daily
• In case of necrotizing ulcerative periodontistis Metronidazole (250mg tablet four times daily), amoxicillin/clavulanate (augmentin 250 mg TDS), or clindamycin (300mg tablet TDS) should be added to the treatment regimen.
• Systemic analgesics can be prescribes in the case of necrotizing ulcerative periodontitis

Kaposi’s sarcoma

Kaposi’s sarcoma is also called as angioreticuloendothelioma. It is most common tumour associated with AIDS & occurs in 1/3 rd of AIDS patients.

Etiology

• Higher incidence of Kaposi’s sarcoma is in homosexual men with AIDS as compared to heterosexuals with AIDS
• It has been suggested that there is transmissible agent prevalence in homosexual population, which stimulate certain factor such as angiogenesis protein that may be critical in the pathogenesis of neoplasm.
• The patient with AIDS often shows clustered lesion in the oral cavity which suggests direct inoculation of mucosa with sexually transmitted agent.
• Some theories suggests role of cytomegalovirus in the pathogenesis of Kaposi’s sarcoma, but studies on prevalence of antibodies to cytomegalovirus in patient with classic & epidemic Kaposi’s sarcoma have failed to demonstrate role of cytomegalovirus.

Epidemiology & Form

• Kaposi’s sarcoma appear in various forms like

1. Classic
2. African(cutaneous variant)
3. African(lymphadenopathy variant)
4. Kaposi’s sarcoma associated with AIDS.

1. Classic type is rare neoplasm and occurs in older man.  Usually it appears as blue-black macule on the lower extremities. It is slow growing & rarely involves the lymph nodes & visceral organs.
2. African Kaposi’s sarcoma is considered an endemic disease & affects children, 10 year old or younger patients, more common in men than women. It appears as exophytic  growth located in legs & arms.This form is locally aggressive & lymph nodes involvement is rare.The lymphadenopathic form occurs in children of 10  years age & younger with same frequency in men & women.The visceral & massive nodal involvement is common.
3. Kaposi’s sarcoma is observed in patients with kidney transplantation and in patients who receive the immunosuppressive drugs for variety of diseases. Drugs such as prednisolone ,cyclosporine and cyclophosphamide have been associated with development  of Kaposi’s  sarcoma.It usually affects legs, arms, lymph nodes & visceral organs.
4. Kaposi’s sarcoma with AIDS is common in homosexual but can occur in all risk groups. Male to female ratio is 20:1. Generally affects skin, oral & visceral organs.

Clinical features

• Site-it occurs commonly in head & neck region. Tip of nose is peculiar & frequent location of it.It can involve lymph nodes, soft tissues, extremities, GIT, lung,liver, pancreas, spleen & adrenal gland.
• Age-It can occur at any age but most common in 5^th to 7^th decades except in Africa where it occurs in children.It occurs  mostly in men but also had been observed in women.
• Appearance-it begins as multinucleated neoplastic process that manifests as multiple red or purple macules & in more advanced stage, a nodule occurring on the skin or mucosal surface.
• Size-size of it ranges from a few millimetres  to a centimetres or more in diameter & are usually tender on palpation.It is slow growing but can behave as a very aggressive lesion with rapid visceral involvement.

Oral manifestations

• Site-it had tendency to involve the oral cavity, with hard palate as the most common site.But lesions may occur on any part of the oral mucosa including the gingival, soft palate, buccal mucosa & in the oropharynx.It can involve either alone or in association with skin & disseminated lesions.It may be the first symptom of AIDS.
• Appearance-It can appear as a red, blue or purplish lesion. It may be flat or raised solitary or multiple.Occasionally , yellowish mucosa surrounds the lesion. The lesions may enlarge, ulcerate& become infected. Good oral hygiene is essential to minimize these complications.
• Size-it may vary in size from few mm to a centimetre or more in diameter and are tender & painful.

Histopathological features

• It consists of interweaving band of spindle shaped and or pulp endothelial cells and atypical vascular channels, enmeshed in reticular  or collagen fibres.
• It consists of numerous, small capillary type blood vessels which may or may not contain blood
• Inflammatory cells infiltration is common
• In late stage, lesion consists of well defined nodules or lesions with diffuse involvement of the lamina propria

Management

• Treatment is determined according to the number, size & location of lesion..The choice of therapy depends on the effect of treatment on the adjacent mucosa, pain associated with treatment,interference with eating & speaking & the patients preference .It is important to perform through dental prophylaxis before initialising treatment for lesions involving gingival.Local application of sclerosing agents may reduce size of oral lesions.
• Local treatment is appropriate for large oral lesions that interfere with eating & talking.Oral lesions can be treated surgically or with localised intralesional chemotherapy.
• Surgial removal is suitable for small, well-circumscribed lesions such as gingival or tongue lesions.Surgical removal can be performed  under L.A with a blade or with carbondioxide laser.
• Intralesional  vinblastine(0.1 to 0.2 mg per ml solution) is useful in treating small lesions on palate or gingival.
• Radiation therapy may be indicated for large multiple lesions.
• Intravenously interferon alpha & sclerotherapy with 3 % sodium tetradecyl sulphate.

Prognosis

Poor with mean survival time 6-14 months.

Hairy Leukoplakia

Oral hairy Leukoplakia , which presents as a non-movable, corrugated or "hairy" white lesion on the lateral margins of the tongue occurs in all risk groups for HIV infections, although less commonly in children than in adult.
It occurs in about 20% of persons with asymptomatic HIV infection & becomes more common as the CD4+ T cell count falls.
Etiology

• Exact etiology is not known but Epstein-Barr virus has identified in these lesions.
• One hypothesis is that basal epithelial cells of lateral margin of tongue normally harbors EBV in majority of adult population,who are EBV sero-positive  & carrier of that disease. It is found primarily in homosexual male.
• Direct infection of Langerhans' cell due to HIV induced loss of factor essential for their integrity & function,permit reactivation of EBL with frequent epithelial hyperplasia.

Clinical Features

• Site-Unique & significant lesion which primarily occurs unilaterally or bilaterally on the lateral border of tongue. It can also occur on dorsum of the tongue, buccal mucosa, floor of mouth, retromolar areas & soft palate.
• Appearance-there is characteristic corrugated and white appearance. It does not rub off and may resemble the keratotic lesion.
• Surface- the surface is irregular and may have resembling hairs. occasionally, however, some areas may be smooth and flat. Lesions occur most commonly on the lateral margins of the tongue and may spread to cover the entire dorsal surface.
• Spread-they may spread downward on to the ventral surface of the tongue ,where they usually appear flat.
• sometimes white lesion satisfies many criteria for diagnosis of hairy Leukoplakia, but if EBV not present this is called pseudohairy Leukoplakia .
• Presence of hairy Leukoplakia is fairly indicator of HIV prosensitivity and is predictor of deficiency immunocompetence.

Histopathological features

• histologically lesion shows hyperkeratosis,acanthosis,ballooning cells,epithelial cells contain Epstein-Barr virus & no or minimum inflammation.
• Immunochemistry tissue in situ  hybridization, non-invasive tissue in situ hybridization , or electron microscopy does demonstrate of Epstein-Barr virus.
• The lesion of Leukoplakia consists of Langerhans cells.

Management

• Hairy Leukoplakia is usually asymptomatic & does not require treatment.hairy Leukoplakia is almost always a manifestation of HIV infection & clinicians should arrange evaluation of HIV disease & appropriate treatment  for patients with hairy leukoplakia Doses of acyclovir-2.5 to 3 mg per day for 2-3 weeks usually eliminates hairy leukoplakia but the lesion usually recurs with cessation of treatment.
• Desciclovir,phosphonoformate, Retin A & podophyllin resin have also been found effective in oral hairy leukoplakia, although lesion tend to reoccur with in few months.
• Occasionally Candida albicans may be found in hairy leukoplakia .treatment consists of antifungal medications like:-

1. Topical agent- clotrimazole 10 mg 5 times a day
2. Nystatin 10000 units/gm 5 times a day
3. Systemically:-Ketoconazole 200mg BD aday.acyclovir,azidothymidine & retinoic acid, podophyllin resin.

Exfoliative cheilitis

These is chronic exfoliation of superficial layer of epithelium on the vermillion border of lip.

Salivary Gland disease & xerostomia

• Salivary gland disease associated with HIV infection (HIV-SGD) can present as xerostomia with or with out salivary gland enlargement. Reports describe salivary gland enlargement in children and adults with HIV infection usually involving the parotid gland.
• The enlarged salivary gland are soft but not fluctuant. In some cases, enlarged salivary gland may be due tolymphoepithelial cyst.
• The etiology of HIV- salivary gland disease is as yet unknown but the enlarged parotid glands can be source of annoyance & discomfort.
• Xerostomia is sometimes seen in individuals with HIV-salivary gland disease. HIV-infected patients may also experience dry mouth in association with taking certain medications that can hamper salivary secretion, such as antidepressants, antihistamines & anti anxiety drugs.

Management

Removal of enlarged parotid gland is rarely recommended.For individuals with xerostomia, the use of salivary stimulants such as sugarless gum or sugarless candies may provide relief.

Candies that are acidic should be avoided, as frequent use may lead to loss of tooth enamel. The use of salivary substitute may also be helpful. an increase in caries can occur, so fluoride rinses should be used daily & visits to the dentist should occur two to three times per year.With this treatment salivary gland disease can be managed.

Vesicular- erosive lesions

• Other conditions like recurrent apthous stomatitis, erythema multiforme & lichenoid reactions may occur in HIV patients
• They are reflections of immune dysfunction. Report says pituitary suppresses the reduced host cortisone production, might account for this lesion

Treatment

• Short-term dosage of corticosteroids
• Topical corticosteroid cream or gel, dexamethasone rinse
• Short term topical tetracycline.
• Rarely systemic antibody or metronidazole.
• Thalidomide for chronic resistance ulcer.

Cytomegalo virus infection

• Cytomegalo virus had got predilection for salivary glands because many HIV infected patients have xerostromia. It is a hypothesis that in such patients salivary glands, cytomegalovirus infection produce inflammation causing reduced salivary production
• Treatment-Systemic ganciclovir or foscarnet is drug of choice for cytomegalo virus

Herpes Zoster

• Occurs more frequently in hIV infected patients & carries poor prognosis
• THe occurance of unilateral vesicles that break & scab is charecteristic of this infection.
• They are self limiting
• Main complication is neuropathy after inflammation
• Diagnosis is made by cytological smear & finding of multinucleated giant cells.
• Treatment - Systemic acyclovir 800 mg orally or 15-30 mg/kg/day IV 8 hrly for 10-15 days

Oral Human Papilloma Virus Lesions

It is caused by human papilloma virus. Oral warts, papillomas, skin Warts & genital warts are associated with the human papilloma virus lesions(HPV). lesions caused by HPV are common on the skin & mucous menbrane of person with HIV disease. Anal warts have frequency been reported among homesexual men. because of the HPV types found in oral lesions in HIV infected persons are diffrent from the HPV types associated with anogenital warts, clinicians should probably not use the term condyloma acuminatum to describe oral HPV lesions.
Clinical features

• Appearance- HPV lesions in the oral cavity may appear as solitary or multiple nodules.They may be sessile or pedunculated & appear as multiple,smooth- surfaced raised masses resembling focal epithelial hyperplasia or as multiple, small papilliferous or cauliflower like projections.
• Site-it can be found on any mucosal surface & are contagious to both host & sex partner.

Management

Simultaneous irradiation of all lesions & care of infected partner. Local excision & cauterization of base.

Recurrent Herpes Labialis

• Mainly appear as herpes labialis & recurrent intraoral herpes
• Appearance-it occurs as characteristic lip lesion containg vesicles on an erythematous base that heals with in 7-10 days
• Site-RHL are small,shallow,irregular & errosive like lesion that may coalesce and seen to occur only on keratinized epithelium like that of gingiva, hard palate or dorsal surface of tongue.
• Diagnosis-it is made by isolation of virus from ulcer
• Treatment-antiviral drugs & symptomatic systemic Acyclovir 30 mg/kg/day.Acylovir resistance foscarnet

Candidiasis

Oral candidiasis is most commonly associated with Candida albicans , although other species such as C.glabrata & C. tropicalis are frequently part of the normal flora.Anumber of factors predispose patients to develop candidiasis: infacy, old age, antibiotic therapy, storoid & other immunosuppresive drugs, xerostromia, anemia, endocrine disorders & primary & acquired immunodeficiency.Candiddiasis is a common finding in people with HIV infection. Reports describe oral candidiasis during the acute stage of HIV infection, but it occurs most commonly with falling CD4+T cell count in middle & latter stages of HIV disease.Several reports indicate that most persons with HIV infection carry a single strain of Candida during clinically apparent candidiasis & when Candidiasis is quiescent.
Clinical Features

• Site- patient with HIV usually has lesion of hard palate & soft palate
• Appearance-the clinical appearances of oral candidiasis vary. The most common presentations include pseudomembranous & erythematous candidiasis, which are equally predictive of the development of AIDS & angular cheilitis.
• Symptoms-these lesions may be associated with a variety of symptoms, including a burning mouth, problems in eating spicy food & changes in taste.

All three of these common forms may appear in one individual.

• Pseudomembranous candidiasis (Thrush)-Characteristic creamy white, removable plaques on the oral mucosa are caused by overgrowth of fungal hyphae mixed with desquamated epithelium & inflammatory cells. the mucosa may appear red when the plaque is removed. this type of candidiasis may involve any part of the mouth or pharynx.
• Erythematous candidiasis- It appears cas flat, red patches of varying size. It is commonly occurs on the palate & the dorsal surface of the tongue. It is frequently subtle in appearance & clinicians may easily overlook lesions, which may persist for several weeks if untreated.
• Angular cheilitis-It appears clinically as redness, ulceration, & fissuring, either unilaterally or bilaterally at the corners of the mouth.It can appear alone or in conjunction with another form of candidiasis

Diagnosis

Candida is a commensal organism in the oral cavity.

acndidiasis is diagnosed by its clinical appearance & by detection of organisms on smears. smears taken from clinical lesions are examined, using potassium hydroxide(KOH), PAS, or gram's stain

Management

Oral candidiasis may be treated either topically or systematically.Treatment should me maintained for 7 days. response to treatment if often good.

• Topical treatment- it is preferred because they limit systemic absorption, but the effectiveness depends entirely on patients compliance.some of the agents rae. Clotrimazole, 1% gentian violet, Nystatin 
• Systemic-Nystatin 250mg TDS for 2 weeks, Ketokonazole, Fluconazole, Itraconazole

Oral Manifestations of AIDS

Oral disorders in HIV Disease Includes:-

1)      Fungal

·         Candidiasis

·         Aspergillosis

·         Histoplasmosis

·         Cryptococcus neoformans

·         Geotrichosis

2)      Bacterial

·         HIV gingivitis

·         HIV periodontitis

·         Necrotizing gingivitis

·         Mycobacterium avium intracellulare

·         Klebsiella pneumonia

·         Enterobacterium cloacae

·         E.coli

·         Salmonella enteritidis

·         Sinusitis

·         Exacerbation of apical periodontistis

·         Submandibular cellulitis

3)      Viral

·         Varicella zoster

·         Epstein-Barr including hairy leukoplakia

·         HPV virus

·         CMV virus

4)      Neoplasm

·         Kaposi’s sarcoma

·         Non-Hodgkin lymphoma

·         Squamous cell carcinoma

5)      Lymphadenopathy

6)      Neurologic disorders

·         Paresthesia

·         Facial palsy

·         Hyperesthesia

·         Dysphagia

7)      Miscellaneous

·         Recurrent apthous ulceration

·         Progressive necrotizing ulceration

·         Toxic epidermolysis

·         Delayed wound healing

·         Thrombocytopenia

     Xerostomia & sicca type syndrome

     Herpes Simplex

·         HIV embryopathy

·         Hyperpigmentation

·         Granuloma annulare

·         Exfoliative cheilitis

·         Lichenoid & other drug Reaction