Nutrition and Oral Medicine (Nutrition and Health)

Chapter 13 / HIV 233gressive type of conventional chronic periodontal disease, but this is not a consistentfeature. Acute, rapidly progressive periodontal conditions may be early signs of immunesuppression and HIV infection (22). Studies have demonstrated an association betweenaggressive periodontal conditions in HIV-infected individuals and a progressive deteriorationof individuals’ immune status (44,45). Even though different periodontal conditionsin the HIV-infected individual are linked to the person’s immune status, they are notassociated with a change in the microflora (22). There are three types of periodontalconditions that have been associated with HIV disease: linear gingival erythema (LGE),necrotizing ulcerative gingivitis (NUG), and necrotizing ulcerative periodontitis (NUP)(11,46).3.3.1.1. Linear Gingival ErythemaAn erythematous 2–3 mm red band at the gingival margin, disproportional to plaqueaccretion, characterizes LGE with an equal distribution around the teeth. There is noulceration, no increase in pocket depth with periodontal attachment loss, and minimalbleeding on probing (22). Occasionally, punctuated or diffuse erythema is noted on theattached gingiva near the alveolar mucosa. The condition may be asymptomatic. Thispresentation does not have a strong correlation with HIV disease (22). The differentialdiagnosis can be quite extensive and include localized effect secondary to dry mucosaassociated with open-mouth breathing, localized candidiasis, oral lichen planus, mucousmembrane pemphigoid, hypersensitivity reaction presenting as plasma cell gingivitis,Geotrichum candidum infection, and thrombocytopenia. The presentation of LGE maybe caused by a subgingival candida infection (22).LGE will typically not respond to routine dental scaling and root planing. However,concomitant use of chlorhexidine gluconate (0.12%) mouth rinse twice a day for up to3 mo generally produces a notable improvement. The patient should be advised to swishwith 15 mL of the solution for 30 s and then expectorate. Addition of a topical antifungalagent may be advantageous. Meticulous oral hygiene is essential for both the treatmentand maintenance.3.3.1.2. NUG and NUPBoth NUG and NUP may represent different stages in a spectrum of the same severeperiodontal condition. NUG is classically limited to the gingiva without related periodontalattachment loss, whereas NUP is recognized by the loss of periodontal attachmentand ulceration of the adjacent alveolar mucosa. Both lesions manifest in the acutephase and may vary from initial lesions with restricted necrosis at the top of the papillaeto involvement of the complete attached gingiva, accompanied by tooth mobility andbone sequestering (44). Individuals with NUP generally complain of severe deep-seatedjaw pain, spontaneous bleeding from the gingiva, and, in chronic cases, tooth movement(47–49). Characteristically, foeter ex oris, or halitosis, is also present. Left untreated,NUP may progress with 1–2 mm of soft and hard tissue destruction per week. NUP hasbeen linked with severe immune suppression and CD4 cell counts below 100 cells permm 3 (44). During the acute stage of these lesions, patient’s oral intake may be severelylimited.Several conditions should be included in a differential diagnoses: benign mucousmembrane pemphigoid, erythema multiforme, and acute forms of leukemia (22).