The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 8: Oral ProblemsPERIODONTAL DISEASE■ Periodontal disease, the chronic inflammatory process that affects the ligaments and bonethat support the teeth, is a condition that can occur in all patients irrespective of HIV status.26 picasHowever, there are several conditions that appear to be unique to individuals with a compromisedimmune system.Periodontal disease—like gingivitis, which is not associated with HIV status but can be presentin individuals who are HIV-positive—is treated by the same methods as with HIV-negative patients.The success rate does not appear to depend upon HIV status.The gingival condition originally known as HIV-gingivitis and now called linear gingival erythemaconsists of a red lesion on the attached gingiva, which can be very painful and can lead toperiodontal disease. (Color Plate 8-7) Ordinary gingivitis is not painful and does not lead toperiodontal disease. Palliative care until the patient can get to a dentist consists of antimicrobialmouth rinses, such as chlorhexidine, and in severe cases, systemic antibiotics. Treatmentshould be limited to a short duration, days, or at most, one week, until the patient can be seen bya dentist.Necrotizing ulcerative periodontitis, which previously was called HIV-periodontitis, is a painfulcondition that causes rapid bone loss, including the exposure of the bone, and rapid loss ofattachment. This condition can result in the premature loss of teeth. (Color Plate 8-8) Treatmentincludes antimicrobial mouth rinses, systemic antibiotics Metronidazole or Augmentin,and when necessary, pain medication. Again, the patient should be referred to a dentist as soonas is feasible.Palliative care does not definitively treat the underlying periodontal disease. However, frequentdental examinations and care can either prevent periodontal disease from occurring or limit theextent of the disease.OPPORTUNISTIC TUMORS■ There are several opportunistic tumors that can occur in the mouth which are associatedwith a patient being HIV-positive. The two most frequently occurring neoplasms are Kaposi’ssarcoma and non-Hodgkin’s lymphoma.Kaposi’s sarcoma is the most common neoplasm in HIV-positive patients. It is a malignancy ofthe endothelial lining of blood vessels and appears clinically as a flat or raised, asymptomatic,purplish lesion that does not blanch with pressure. (Color Plate 8-9) Lesions often enlargerapidly and can become exophytic. Treatment may be necessary, especially if the lesion interfereswith function. Various chemotherapeutic regimens (e.g., vincristine, doxorubicin) as wellas alpha-interferon may be somewhat effective, as well as radiation therapy. In many cases HAARTitself can be associated with regression of KS lesions.Non-Hodgkin’s lymphoma when seen in the oral cavity is most often an exophytic soft, tumorlikemass that can enlarge rapidly. (Color Plate 8-10) Biopsy is required for diagnosis and treatmentconsists of radiation and/or chemotherapy. Until treatment can be implemented, palliative careis usually not required.Neither of these conditions is seen until immune suppression is severe and patients have endstageHIV disease.172U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau