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Dental and oral health problems are commonly seen in those with HIV and AIDS owing to the suppressed immune system characteristic of the condition. They vary in severity and require a variety of interventions to address the specific conditions.

What's the link between HIV/AIDS and oral issues?

AIDS is diagnosed when the HIV infection has compromised the immune system to the extent that it no longer works efficiently and is unable to fight certain illnesses and infections. Dental problems such as gums that are sore and bleed frequently, a dry mouth, herpes sores, and fungal and candida (yeast) infections are often experienced; indeed they may be one of the first signs that alert someone to the possibility that they may have AIDS. However, it should not be assumed that you have HIV if you have any of these symptoms, as these often occur in the general population, as well as in other conditions that compromise the immune system.

HIV and AIDS Patients and Periodontal Disease

Periodontal disease is a longstanding inflammatory condition affecting the tissue and supporting bone involving specific bacteria. While it may occur in anyone, a suppressed immune system (immunosuppression) is the primary reason that oral and periodontal lesions develop in patients with HIV infection. Those with compromised immune systems seem to display two particularly severe forms of periodontal lesions:

  • linear gingival erythema

  • necrotizing periodontal diseases

    • necrotizing ulcerative gingivitis

    • necrotizing ulcerative periodontitis

    • necrotizing ulcerative stomatitis

Furthermore, in an ageing HIV population, patients may develop chronic conditions that can increase the likelihood of chronic adult periodontitis progressing more severely.

Linear gingival erythema

Linear gingival erythema is classified as a fungal gum disease owing to candida being the primary cause. The gingival (gum) condition (initially termed HIV-gingivitis, and now known as linear gingival erythema), is characterized by a red band-like lesion along the gum line, which usually abates with topical and/or systemic antifungal treatment. Linear gingival erythema is often painful and bleeds, and may later become periodontal disease. Unfortunately, it can be confused with ordinary gingivitis (inflammation of the gums), although a distinguishing factor would be level of discomfort as ordinary gingivitis is not usually painful.

People diagnosed with this condition should be given an antimicrobial mouth rinse such as chlorhexidine (Peridex), pending a visit to a dental practitioner; in serious cases, an oral antibiotic may be used for a short period of time such as a week.

Necrotizing ulcerative gingivitis and periodontitis

Necrotizing ulcerative periodontitis is the more advanced presentation of necrotizing ulcerative gingivitis. Because they present very similarly and require the same treatment, these conditions are considered together herein. Of note is that like linear gingival erythema, Candida organisms may also be present in necrotizing ulcerative periodontitis.

Signs of necrotizing ulcerative gingivitis are:

  • Ulcerations that appear suddenly in the mouth, in the small bit of gum tissue between the teeth known as the interdental papilla

  • Inside the mouth there may be a fibrinous pseudomembrane or presence of tissue-like formation.

  • Gums that bleed.

  • Extreme discomfort.

Signs of necrotizing ulcerative periodontitis (formerly termed HIV-periodontitis) are:

  • Bleeding.

  • Severe pain deep in the jaw.

  • Considerable death of soft tissue in the mouth.

  • Foul mouth odor.

  • Loss of bone and/or exposure of the bone.

  • Teeth that become loose over a short period.

  • Premature tooth loss.

Other signs and symptoms of necrotizing ulcerative gingivitis and periodontitis include:

  • swelling glands or lymph nodes in the nearby area,

  • high fever

  • general feeling of being unwell or ill.

Treatment and follow up

Often people don't realize they have periodontitis until the teeth-supporting tissues are so damaged that the integrity of the teeth is irrevocably impaired. X-rays are used to determine the severity of the periodontal bone loss and, once diagnosed, oral health care providers should commence treatment to reduce the extent of the bacteria by manually removing debris and plaque through:

  • removing dead tissue

  • root planing and scaling

  • intrasulcular lavage/irrigation (irrigation around the teeth) with 0.12% chlorhexidine gluconate or, as an alternative, 10% povidone iodine.

Because the use of prophylactic antibiotic therapy (the use of antibiotics before surgery to prevent subsequent infection) is likely to increase the risk of oral candidiasis, oral health care providers are advised to use antibacterial mouthwashes rinses and antibiotics and fungal medications (metronidazole, clindamycin or amoxicillin-clavulanate) to address infection, as well as the use of analgesics when necessary to relieve pain and discomfort.

Your health care provider should also perform the following evaluations and interventions:

  • After seven days of treatment and follow with additional removal of damaged tissue/bacteria as required.

  • After two months to determine the need for further intervention.

  • Then three-monthly following stabilization of the condition.

When the disease is addressed in the early stages, this yields the most favorable treatment responses in HIV-associated periodontal disease. 

Individual good dental hygiene practices, such as ensuring the mouth, gums, and teeth are all clean, as well as ceasing smoking are also hugely influential in treatment success.

Necrotizing ulcerative stomatitis

Necrotizing ulcerative periodontitis and necrotizing ulcerative stomatitis represent different stages of the same disease process - stomatitis (considerable tissue and bone destruction) could be where the periodontitis has expanded into the surrounding bone, thus leading to loss of blood to the bone, causing it to die and become separated from healthy bone. This process is diagnosed through a biopsy or examination of the suspected tissue/bone and the patient is then referred to an oral surgeon, clinical pathologist, or oral medicine specialist.

Treatment should be provided as soon as possible after the diagnosis in the following forms:

  • Use of antibacterial mouthwash prior to any procedure

  • Localized removal of bacteria and subsequent disinfection using a 0.12% chlorhexidine gluconate or 10% povidone iodine

  • Removal of dead tissue and bone, along with scaling and root planing, using local anesthesia as required

  • Reiteration of the importance of good oral hygiene practices to include daily use of antimicrobial rinse for 30 days, antibacterial therapy, nutritional supplementation/advice, periodontal prescriptions (Metronidazole, Augmentin, or Clindamycin) and suggestions for pain management such as rinsing with 2 teaspoons of xylocaine 2% viscous solution.

When the soft tissue damage no longer only affects the soft tissue and bone of the oral cavity, it can present clinically very similarly to another condition known as cancrum oris; although cancrum oris tends to be more often seen in children and particularly those who have been subjected to severe or life-threatening malnourishment.

  • Photo courtesy of SteadyHealth.com

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