Free Online CME: HIV and Oral Health Care

Updated December 2001

I. INTRODUCTION

Recommendation:

The most important components in the management of HIV-associated gingival and periodontal disease should be the removal of local irritants from the root surfaces, débridement of necrotic tissues, and appropriate use of antibiotics.

Two types of gingival/periodontal disease associated with HIV infection have been widely reported in the literature. In the past, these have been called HIV-associated gingivitis (HIV-G) and HIV-associated periodontitis (HIV-P). There is now evidence that these diseases also occur in HIV-negative immunocompromised individuals and are not specific to HIV infection, thus making the original terms inappropriate. Therefore, HIV-associated gingivitis has been renamed linear gingival erythema (LGE) and HIV-associated periodontitis has been renamed necrotizing ulcerative periodontitis (NUP).

The prevalence of these two diseases remains unclear,^1-3 with estimates of occurrence among HIV-infected individuals ranging from 5% to 50%. It is not yet clear where in the spectrum of HIV disease these conditions occur or which patients are at greatest risk for developing them. There is some evidence that NUP is associated with a low CD4 count (<200 cells/mm³).⁴

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II. LINEAR GINGIVAL ERYTHEMA (LGE)

A. Presentation

LGE is limited to the soft tissue of the periodontium and characteristically appears as an erythematous linear band that extends approximately 2 mm to 3 mm from the free gingival margin. There also may be punctate erythema, which extends onto the alveolar mucosa. At times, these areas coalesce, creating broadly diffuse erythematous zones from the gingival margin into the vestibule. Unlike conventional gingivitis, LGE is not significantly associated with plaque. In most cases of LGE, bleeding is seen after gentle probing (see Appendix 3-A for photographic example).

B. Diagnosis

Recommendation:

The diagnosis of LGE is made on the basis of distinctive clinical characteristics (see Section II. A. Presentation).

C. Treatment

There is no known treatment for LGE.

III. NECROTIZING ULCERATIVE PERIODONTITIS (NUP)

A. Presentation

NUP affects the osseous structures of the periodontium. Clinical features include pain, interproximal gingival necrosis, and cratered soft tissues (see Appendix 3-A for photographic example). Patients frequently complain of spontaneous bleeding and deep-seated pain in the jaws. Destruction of the periodontal attachment and bone can be extremely rapid and extensive and may result in as much as 90% bone loss around isolated teeth in as few as 12 weeks. If left untreated, NUP may extend into the contiguous tissues and expose the alveolar or palatal bone. When this occurs, the condition has been called necrotizing stomatitis.

B. Diagnosis

Recommendation:

The diagnosis of NUP is made on the basis of distinct clinical characteristics (see Section III. A. Presentation).

C. Treatment

Recommendations:

Systemic antibiotics, such as metronidazole, tetracycline, clindamycin, amoxicillin, and amoxicillin-clavulanate potassium, should be combined with débridement of necrotic tissues.

As systemic antibiotics increase the patient’s risk of developing candidiasis, concurrent, empiric administration of an antifungal agent should be considered.

Frequent appointments are appropriate and recommended in the acute and healing stages of NUP to perform the necessary periodontal therapies, to assess tissue response, and to monitor the patient’s oral hygiene performance.

A thorough periodontal examination should be performed at each recall session for any patient with a history of NUP. Because the periodontal maintenance program for patients with HIV should be individualized, oral health care providers should consider plaque control, past severity of disease, and evidence of case stabilization when determining the frequency of recall visits.

Published reports, supported by clinical experience, suggest that an antibiotic regimen of 250 mg metronidazole 3 times per day for 5 to 7 days, often combined with 250 mg amoxicillin-clavulanate potassium 3 times a day for 5 to 7 days, is effective for management of this disease.

Chlorhexidine oral rinse 15 cc twice daily has been reported to be very useful in the management and control of NUP, and intrasulcular lavage with povidone-iodine has been shown to have a palliative effect for patients with NUP.

Oral health care providers report their most favorable treatment responses when HIV-associated periodontal disease is addressed in the earliest stages. Patients who have been treated for NUP may develop repeated episodes, especially when oral hygiene levels are unsatisfactory. NUP can be insidious, localized, and not necessarily related to plaque. Once clinical stabilization has occurred, recall visits are generally scheduled every 3 months to detect and prevent disease recurrence at an incipient stage.

IV. NECROTIZING ULCERATIVE GINGIVITIS (NUG)

Recommendation:

Necrotizing ulcerative gingivitis should be treated similarly to NUP.

Necrotizing ulcerative gingivitis (NUG) has been associated with HIV infection. NUG and NUP may represent different stages of the same pathologic process, with NUP being a later stage of NUG.⁵

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REFERENCES

1. Friedman RB, Gunsolley J, Gentry A. Periodontal status of HIV-seropositive and AIDS patients. J Periodontol 1991;62:623-627.

2. Klein RS, Quart AM, Small CB. Periodontal disease in heterosexuals with acquired immunodeficiency syndrome. J Periodontol 1991;62:535-540.

3. Swango P, Kleinman DV, Konzelman JL. HIV and periodontal health: A study of military personnel with HIV. J Am Dent Assoc 1991;122:49-52.

4. Glick M, Muzyka BD, Salkin LM, Lurie D. Necrotizing ulcerative periodontitis: A marker for immune deterioration and a predictor of the diagnosis of AIDS. J Periodontol 1994;65:393-397.

5. Novak MJ. Necrotizing ulcerative periodontitis. Ann Periodontal 1999;4:74-78.

APPENDIX 3-A

CLINICAL MANIFESTATIONS AND MANAGEMENT OF HIV-RELATED PERIODONTAL DISEASE

Figure 3A-1: Illustrations of Periodontal Disease Associated With HIV Infection