PROCAARE: CLINICAL SCIENCE--ORAL MANIFESTATIONS--PART II

[Albert Shaw <ashaw@usa.healthnet.org>]

KEYWORDS: ORAL MANIFESTATIONS/ ULCERS/ HERPES SIMPLEX/ VARICELLA ZOSTER/ 
CYTOMEGALOVIRUS/ GINGIVITIS/ PERIODONTAL DISEASE/ SALIVARY GLAND
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PART II:

Reference: Weinert, M., Grimes, R.M., Lynch, D.P. (1996).  Oral 
manifestations of HIV infection.  Ann. Intern. Med. 125: 485-96.

This review divides oral manifestations of AIDS into classes based upon 
clinical appearance. White or yellow-white nonulcerative lesions and red 
or reddish-purple nonulcerative lesions were discussed in Part I.

Ulcerative lesions:

1. Herpes simplex virus (HSV) infection--often seen on the hard palate 
and gingiva, as well as on nonkeratinized areas such as the vermilion 
border of the lips and adjacent skin on the face.  Solitary and multiple 
lesions are usually painful and in the setting of HIV infection may 
progress to erosive ulcerations.

2. Varicella-zoster virus (VZV) infection--erosive vesicular lesions, 
usually unilateral, involving both skin and oral mucosa along trigeminal 
nerve distribution.  

3. Cytomegalovirus (CMV) infection--painful, punched out lesions with 
nonindurated margins involving oral mucosa.

Diagnosis of these herpesvirus infections may be made on clinical 
grounds, but biopsy may be required for definitive diagnosis.  Oral 
acyclovir in a 10-14 day course is the first line of therapy for HSV and 
VZV ulcers, but intravenous therapy may be necessary for severe 
infection.  Acyclovir-resistant viral strains may respond to foscarnet.

CMV oral ulcers usually require biopsy confirmation for diagnosis, and 
should be considered a manifestation of disseminated infection; thus, an 
ophthalmological examination should be carried out for the suspicion of 
CMV retinitis.  Ganciclovir and foscarnet are effective for the treatment 
of CMV retinitis, and should be similarly efficacious for CMV ulcers, though 
this has not been definitively addressed.

4. Aphthous ulcers--Painful, well-demarcated, shallow lesions involving 
nonkeratinized mucosa (cheeks, lips, soft palate, floor of mouth, ventral 
tongue).

Aphthous ulcers less than 1 cm in diameter are usually self-limiting; 
however, major recurrent aphthous ulcers (greater than 1 cm) may be 
progressive and associated with dysphagia or odynophagia.  Because the 
clinical appearance may mimic other causes of oral ulcers, biopsy may be 
required for diagnosis.  Histological examination reveals nonspecific 
ulceration with diffuse inflammation.  Therapy of aphthous ulcers 
includes topical steroids (though oral candidiasis may be exacerbated) 
and anesthetics, as well as adherent dressings to protect inflamed 
mucosal surfaces.  Recent data suggests that thalidomide may also be 
effective for recurrent aphthous ulcers; however, thalidomide cannot be 
used in pregnant women or in women who may become pregnant because of its 
high teratogenic potential.

5. Drug-induced ulcers have been associated with foscarnet, zalcitabine 
and interferon as well.

Periodontal disease:

Periodontal disease may be severe and rapidly progressive in the setting 
of HIV infection.  Mixed aerobic and anaerobic bacteria are usually 
responsible for disease, though gram negative bacilli (Klebsiella and 
Enterobacter species) may also be involved.  There are four stages of 
infection:

1. Linear gingival erythema--painless, marked erythema of the free 
gingival margin.
2. Necrotizing gingivitis--painful, reddened gingiva with diffuse 
petechiae and interdental papillae ulceration and destruction.
3. Necrotizing periodontitis--involving both gingiva and underlying bone; 
severe pain, halitosis, loosened teeth, reddened gingiva.
4. Necrotizing stomatitis--involving gingiva, underlying bone including 
nonalveolar bone and soft tissue; teeth easily removable; halitosis; 
severe pain.

Prevention with meticulous oral care is essential for all HIV-infected 
patients.  Therapy for severe periodontal disease requires dental 
curettage and debridement of involved tissues, treatment with topical 
antiseptics (e.g. Peridex) and systemic antibiotics (including anaerobic 
coverage).

Salivary gland disorders:

One or both parotid glands are the most common sites for involvement, and 
HIV-positive children are more frequently affected than adults.  There is 
nontender glandular enlargement, thought to result from lymphoid 
proliferation in the setting of HIV disease.  Infectious and neoplastic 
processes may involve the salivary glands, as well, so that biopsy and 
culture of tissue samples may be helpful.  Nonspecific parotid gland 
disease in the HIV-positive patient is treated supportively, using 
artificial saliva as needed, and sugarless chewing gum to stimulate 
salivary output and minimize the consequences of xerostomia (mucositis, 
periodontal disease, dental caries).