Aids And The Periodontium ..

1. Sachin RathodSachin Rathod
Email:- drsachin.rathod@yahoo.comEmail:- drsachin.rathod@yahoo.com

3. • Definition
• Epidemiology
• Virus
• Structure
• Pathogenesis
• Transmission & Prevention
• Classification & Grading
• Manifestations
• General
• Oral
• Periodontal
• Management of oral diseases
• Diagnosis
• Treatment of AIDS
• The AIDS patient & the
dental office

4. • Bangui (1985) definition
• Exclusion criteria
• Pronounced malnutrition
• Cancer
• Immunosuppressive treatment
• Inclusion criteria
• Important signs
• weight loss > 10% body weight 4

5. • Very frequent signs
• continuous attack / repeated bouts of fever 3
• Diarrhoea > 1 month 3
• Other signs
• relapsing Herpes 4
• oropharyngeal candidiasis 4
• Nuerological signs 2
• Generalised Kaposi s sarcoma 12
• The diagnosis of AIDS established when the score is equal or
more than 12
• 1994 modification…

7. Group: Group VI (ssRNA-RT)
Family: Retroviridae
Genus: Lentivirus
Species: Human immunodeficiency virus
1
Species: Human immunodeficiency virus
2

8. • Previous names ….
• 120 nm in diameter , roughly spherical in shape
• two copies of positive single-stranded RNA that
codes for the virus's nine genes enclosed by a
conical capsid composed of 2,000 copies of the viral
protein p24
• matrix composed of the viral protein p17 surrounds
the capsid
• viral envelope which is composed of two layers of
fatty molecules phospholipids

9. • High genetic variability
• Fast replication
• High mutation rate
• Recombinogenic property
• Three groups – M, N & O –
differ in ENV genes
• M most common

10. • Heterosexual / Homosexual intercourse
• Exposure to infected body fluids/ tissues
• Intrauterine or perinatal

11. • Some people show resistance to getting infected by HIV 1 or if
infected in developing full blown AIDS…???
• Genetic mutation slows / stops progression
• CCR5 affects the major coreceptor CKR5 which affects the
entry of the virus into the cell
• Vaccine for HIV ???

12. • WHO classification (1990) modified September 2005
• Stage I: HIV disease is asymptomatic and not categorized as AIDS
• Stage II: includes minor mucocutaneous manifestations and recurrent
upper resp tract infections
• Stage III: includes unexplained chronic diarrhoea for longer than a
month, severe bacterial infections and pulmonary tuberculosis
• Stage IV: includes toxoplasmosis of the brain candidiasis of the
esophagus, trachea bronchi or lungs and Kaposi’s sarcoma; these
diseases are indicators of AIDS

13. • CDC (1993)
• Category A – acute symptoms / asymptomatic
conditions
individuals with PGL
without malaise , fever (low grade),
fatigue
• Category B – Symptomatic conditions
oropharyngeal candidiasis, Herpes
Zoster
oral hairy leukoplakia, ITP
Constitutional symptoms
fever ,weight loss ,diarrhoea

14. • Category C – full blown AIDS
CD4 count < 200/mm3
Candidiasis-trachea,
bronchi, lungs
Cervical cancer –invasive
Toxoplasmosis brain
Kaposis Sarcoma

15. Category Classification CD4 level
1 Asymptomatic >/ 500/ mm3
2 AIDS related complex 200-499 cell/ mm3
3 AIDS < 200/ mm3

16. • General
• Acute – fever, myalgia, arthralgia , pharyngitis
diarrhoea, thrush,
persistent generalized lymphadenopathy
• ARC – Candidiasis mucosal, constitutional symptoms, Herpes
Zoster, ITP, oral hairy leukoplakia,
peripheral neuropathy
• AIDS defining conditions-
• Candidiasis ( pulmonary , esophageal)
cervical cancer, coccidiomycosis, CMV infection,
Kaposi Sarcoma

17. • Challecombe SJ, Greenspan J, Williams DM
J Oral Path 1993; 22: 289-291

20. • Erythematous Candidiasis –
• presumptive – red areas on the palate / dorsum
• No definitive criteria-detection of candida organisms
• Psuedomembranous Candidiasis-
• White /yellow spots plaques, any part of the oral cavity
• Response to anti fungal
• Hairy Luekoplakia-
• Bilateral whitish grey lesions (lateral margins), non
scrapable
• Demonstration of EBV

21. • Kaposi’s Sarcoma
• Erythematous ,bluish ,
violaceous macules
swellings
• Biopsy
• Non Hodgkins Lymphoma
• firm, elastic reddish
purplish
• Biopsy

22. • Oral hairy luekoplakia-
lat borders of tongue ,extends to ventral surface
asymptomatic, keratotic areas
vertical striae, corrugated appearance
non scrapable, candidial superinfection
strong indicator
psuedo hairy luekoplakia in HIV –ve pts
H/P…

23. • Diff diagnosis- lichen planus
frictional keratosis
geographic tongue
cancer , dysplasia
• Treatment – antiviral therapy but
recurs after stoppage laser or
conventional surgery , ART

24. • 90% patients
• Psuedomembranous,
• Erythematous and
• Hyperplastic
• Esophageal candidiasis – diagnostic sign
• Diagnosis – smears
• Recurrence rate high….

27. • Vascular proliferative disorder
• Rickettsiae like organisms ,
• Gingival – red, purplish edematous soft tissue
destruction of pdl & bone
• lesion seen , CD4 levels dip
• Biopsy –
epitheloid proliferation of angiogenic cells
acute inflammatory cell infiltrate
organism stains with Warthen starry silver stain

28. • Treatment – broad spectrum antibiotics
conservative periodontal therapy
excision of lesion

29. • Multifocal ,vascular neoplasm
• HHV-8 –decreased immunocompetence activates the latent
virus
• Palate & Gingiva most common sites
• Painless red macules, progress to nodular lesions
• H/P….
• Diff diagnosis- hemangioma, varicosity bacillary
angiomatosis , pyogenic granuloma

30. • Treatment – intralesional; injections of
vinblastine
0.1 mg/cm2
or 0.2mg/ml saline
• ART, interferon ,
• If destruction of periodontium ,conventional
periodontal therapy

32. • Linear gingival erythema
• HIV ass gingivitis
• Persistent linear, easily bleeding, erythematous gingiva
• Disproportionate to amount of plaque, increased chances ofsmokers
• No ulcerations , no pockets
• No response to plaque control
• Localised / generalised
• Candida spp…. Candida dubliniensis
• Periodontal pathogens seen in periodontitis (Gornisky’91)
• CD4 count…. Barr C ’92

33. • no inflammatory infiltrate and increased blood vessels
• Diff diagnosis – lichen planus
pemphigoid
plasma cell gingivitis
• Treatment -
Step 1: Instruct the patient in performance of meticulous oral
hygiene.
Step 2: Scale and polish affected areas, and perform subgingival
irrigation with chlorhexidine.

34. Step 3: Prescribe chlorhexidine gluconate mouthrinse.
Step 4: Reevaluate the patient in 2 to 3 weeks. If lesions
persist, evaluate for possible candidiasis. Consider empiric
administration of a systemic antifungal agent such as
fluconazole for 7 to 10 days.
Step 5: Re-treat if necessary.
Step 6: Place the patient on 2- to 3-month recall.

36. • Necrotizing gingivitis . No attachment loss
• Rapidly progressing into NUP
• Difference b/w necrotizing periodontitis and necrotizing
stomatitis
• Initial – interdental papilla, moderate- att gingiva,
tooth mobility , sequestration of crestal bone, extensive bone
loss and necrosis of soft tissue
• Fetor oris….

37. • Severe pain….
• No deep pockets, deep interdental craters
• Bleeding on probing
• Borrelia spp, gram positive spp,
ß hemolytic streptococci
C. albicans
oppurtunistic spp also seen
• Progression correlates with HIV disease and vice versa
• NP strong predictor of prognosis…Glick ‘94

38. • Treatment – no improvement
with conventional SRP
• Adjunctive Metronidazole
• Anti mycotic drugs

40. • Acute ulceronecrotic disorder, extremely painful
• Extends from NUP
• Exposes underlying bone
• More severe but less common
• Similar to NOMA
• Life threatening strongly related to immune depletion

41. • HIV – strong indicator for developing periodontitis
Lamster ‘98
• Lucht E’91 –correlates more to the CD4 count than
Plaque index
• Intensive oral care programs as soon as diagnosis of
AIDS done….

43. • Antibody tests
• Antigen tests
• Virus isolation
• Demonstration of viral NA
• HIV viral load
• CD4 counts
• Antiviral
susceptibility assays

44. • ELISA – biochemical technique
• detects the presence of an antibody or an antigen in
a sample. It uses two antibodies
• One antibody is specific to the antigen. The other
reacts to Ag-Ab complexes , and is coupled to an
enzyme. chromogenic or fluorogenic substrate.

45. • View/quantify the result using a spectrophotometer or other
optical device
• Enzyme acts as an amplifier …

46. • Analysis – qualitative or
quantitative
• Other types – sandwich
competitive

47. • Western Blot Assay-
individual proteins of HIV-1 lysate
are separated using polyacrylamide
gel electrophoresis.
↓
nitrocellulose paper and reacted
with patients serum
↓
colored bands are produced

48. • Earliest detection –GAG, p24
• All HIV pts- ENV, gp120, gp41
• Positive- p24, p31, gp41,
gp120
• All other patterns-indeterminate
• Negative – no bands detected ,
not only viral bands

49. • Other criteria – presence of any two foll bands gp41,
p24, gp120/gp 160
• Red cross – positive test – more than one –GAG,
POL & ENV
• TRI DOT- rapid HIV testing
flow through device with an inbuilt internal control
& two separate antigen dots for HIV -1 & 2

50. • HAART – Different classes of drugs target different
stages
• Reverse trancriptase inhibitors-
• Nucleoside analogues
• Non nucleoside analogues
• Protease inhibitors –
• Fusion inhibitors
• Integrase inhibitors
• Entry inhibitors-

51. • Fixed dose combinations
• Synergistic enhancers
• Combination therapy-
• Who should be treated???

52. • Limitations …. Mega HAART / salvage therapy
• To reduce resistance
• drug resistance –FOTO, WOWO
• ADVERSE EFFECTS –
Alopecia, diarrhoea, Fanconi syndrome, Hepatitis
,hyperbilirubinemia, hyperpigmentation, mental confusion
peripheral neuropathy , Steven Johnsons syndrome

53. “ Value conflicts are visible most
on the faces of
those who suffer….
”

54. • Risk of transmission – low
• Trace amounts of HIV in saliva-
• Saliva inhibits infectivity of free virus & to a lesser
extent ,virus within cells

55. • Principles of infection control -
• take action to stay healthy
• Avoid contact with blood
• Limit the spread of blood
• Make objects safe for use
• Instruments – Critical, semi critical and non critical

56. • AIDS-diagnosis, treatment andprevention
• Glickman- IX edition
• Periodontal medicine- Genco, Rose & Cohen
• J Oral Path Med;93 :29:289-294
• Net references

57. Sachin RathodSachin Rathod
Email:- drsachin.rathod@yahoo.comEmail:- drsachin.rathod@yahoo.com