Transcript KAPOSI'S SARCOMA PATHOGENESIS

ORAL HEALTH IN
WOMEN
ORAL MANIFESTATIONS OF HIV
INFECTION
DENTAL HEALTH CARE
PROVIDER
TEAM APPROACH
EPIDEMIOLOGY OF
HIV-RELATED ORAL
MANIFESTATIONS IN
WOMEN
Epidemiology of HIV-Related Oral
Manifestations in Women: A Review
 Oral
Lesions in 15% of HIV-Infected
Women
 Most Common Oral Lesion - Candidiasis
 Prevalence of Hairy Leukoplakia and
Kaposi's Sarcoma Significantly Less
Common in Women
Oral Dis 1997 Sep;3(3):206.
Many Manifestations of HIV Disease
are Similar in Men & Women
 Other
Conditions Differ In Frequency:
– HIV-Infected Men 8 X’s More Likely to
Develop Kaposi's Sarcoma
– Women Have Higher Rates of
Esophageal Candidiasis & Herpes
Simplex Infections
CHANGING
PREVALENCE OF
ORAL
MANIFESATIONS
Overall
Prevalence of Oral
Lesions Has Decreased
(47.6%-37.5%)
Hairy Leukoplakia (25.8%11.4%) & Necrotizing
Periodontal Diseases
(4.8%-1.7%) Decreased
HIV
Salivary Gland Disease
Increased (1.8%-5.0%)
Candidiasis (20.3%-16.7%),
Aphthae (3.7%-3.0%), Oral
Warts (2.2%-4.0%), Herpes
Simplex Virus Lesions (1.8%2.0%) and Kaposi’s Sarcoma
(1.1%-0.3%) Unchanged
HIV/AIDS Women's Health: Oral
Lesions in HIV-Positive Women
Reduced in HAART Therapy
 503
HIV+ women over 6 years
 Incidence of EC fell to 2.99 percent
from 5.48 percent
 PC fell to 2.85 percent from 6.70
percent
 No changes were seen in HL or
warts
Women's Health Weekly (03.25.04)
CANDIDIASIS
Reported in 7-93%
of HIV+ /AIDS
Patients
FOUR MAJOR
TYPES
Pseudomembranous
Hyperplastic
Erythematous
(Atrophic)
Angular Cheilitis
PSEUDOMEMBRANOUS
White
or Yellow Patches
Easily Removed w/ Scraping
Yielding Bleeding Surface
Any Mucosal Surface (Palate,
Buccal or Labial Mucosa,
Tongue)
HYPERPLASTIC
CANDIDIASIS
White
Plaques Can’t Be
Removed w/ Scraping
Buccal Mucosa Most
Common Site in HIV+
Patients
ERYTHEMATOUS
(ATROPHIC)
Fiery
Red Surfaces to Hardly
Discernible Pink Spots
Most Common Location Palate & Dorsum of Tongue
Spotty Areas in Buccal
Mucosa
ANGULAR
CHEILITIS
Common
in Elderly
Fissures Radiating From
Angles of Mouth
PREDISPOSING
FACTORS
SYSTEMIC
FACTORS
Age
Use
of Antibiotics
Xerostomia
Nutritional Deficiencies
Immunosuppression
Gastric Reflux
LOCAL FACTORS
Ill-Fitting
Dentures
Poor Prosthesis Hygiene
Heavy Smoking
Topical Medications
CANDIDIASIS
TREATMENT
Nystatin
Oral Susp
– 480 ml
– Rinse w/ One Tablespoonful QID
Clotrimazole
(Mycelex) Troches
– 10 mg Troches
– 3-5 Times a Day for 7-14 Days
Ketoconazole
(Nizoral)
– 200 mg
– 200-400 mg Daily for 7-14 Days
Fluconazole
(Diflucan)
– 100 mg Tabs
– 2 Tabs First Day, Then 1 Tab
Daily for 14 Days
Itraconazole (Sporanox)
– 100 mg Tablets
– 1 tablet B.I.D. for 14 days
OROFACIAL VIRAL
INFECTIONS IN
IMMUNOCOMPROMISED
HOST
HAIRY LEUKOPLAKIA
First
Identified Among HIV+
Individuals
Never Described Before AIDS
Epidemic
CLINICAL
PRESENTATION
Painless
White Patches
Do Not Rub Off
Lateral Borders of the Tongue
Surface May Be Smooth,
Corrugated or Markedly Folded
Thick, Hair-Like Projections
DIFFERENTIAL
DIAGNOSIS
Hyperplastic
Candidiasis
Geographic Tongue
Lichen Planus
Frictional Keratosis
Leukoplakia
HAIRY LEUKOPLAKIA
- PATHOGENESIS
Epstein-Barr
Virus
HAIRY LEUKOPLAKIA
TREATMENT
Appears
to Be Little
Advantage in Treating
Surgical Removal
–Laser
Acyclovir
Topical
Vitamin A
HUMAN
PAPILLOMA VIRUS
LESIONS
HUMAN PAPILLOMA
VIRUSES
More
Than 100 Human
Papilloma Virus (HPV)
Types
24 Associated with Oral
Lesions
HPV ORAL LESIONS
Warts,
Papillomas
Condyloma Acuminatum
Verruca Vulgaris
Focal Epithelial Hyperplasia
Dysplasia / Carcinoma
HUMAN PAPILLOMA VIRUS
LESIONS
CONDYLOMA
ACUMINATUM
Sexually
Transmitted
Appears 1-3 Months After
Exposure
Multiple Wart-Like Lesions
Lips, Lingual Frenum & Tongue
TREATMENT
CONDYLOMA ACUMINATUM
Surgical
Removal
Cryotherapy
Laser Therapy
Medications
KAPOSI’S
SARCOMA
Originally Described
in 1872 - Idiopathic
Multiple Sarcomas of
the Skin
Previously
Uncommon in USA
Elderly
Jewish Men of Eastern
European or Mediterranean Descent
Usually Involved Lower Extremities
Indolent Course
1981 - Fulminant, Aggressive Form
Occurring in Young Homosexual Men
w/ AIDS
>50%
of AIDS Patients w/ KS
Display Oral Lesions
Remains Significant Cause of
Morbidity & Mortality in HIV
Infected Patients
CLINICAL PRESENTATION
Angiomatous
Malignancy of Skin,
Mucosa, and Internal Organs
Most Common Intraoral Locations
– Palate
– Gingiva
Non-Elevated
Macules, Nodules or
Papules
Brown, Blue, Purple
KAPOSI’S SARCOMA
PATHOGENESIS
Sexually
Transmitted Cofactor
Human Herpes Virus 8 (HHV 8)
TREATMENT
Treatment
Reserved for Lesions
Which Interfere w/ Function or
Esthetics
Laser Excision
Cryotherapy
Radiation
Intralesional Injection w/ Vinblastine
CANCER IN
PATIENTS WITH
AIDS
AIDS AND CANCER
 Roche
et al, NJ Med 2001,Jan;98(1);27-36
 2460 Persons w/ AIDS and Cancer
 2159 Males, 301 Females
 50% Kaposi’s Sarcoma
 33% Non-Hodgkins Lymphoma
 Lung, Oral, Cervical, Hodgkins Lymphoma,
Other Digestive
RECURRENT
ORAL
ULCERATIONS
RECURRENT
APHTHOUS
STOMATITIS
EPIDEMIOLOGY
Prevalence
in General
Population 10-20%
67-85% Develop Prior
to Age 30
Familial Disposition
MINOR APHTHAE
Superficial
Erosion with Fibrinous
Coating & Red Halo
Single or Multiple Lesions
2-3 mm’s to Over 10 mm’s in
Diameter
Persists for 7-10 Days
Painful
MAJOR APHTHAE
Large
Painful Ulcerations
Single or Multiple
Lesions
Persists Up to 6 Weeks
Heal w/ Scarring
GENERAL RULE
Aphthae
Occur on Mobile
Mucosa
Herpetic Lesions Occur
on Tissue That is Firmly
Bound Down
FACTORS ASSOCIATED
WITH APHTHAE
 Psychological
(Stress)
 Socio-Economic
 Endocrine
 Immunosuppression
 Hereditary
 Hypersensitivity
 Chemicals in Food
Trauma
S. sanguis
TREATMENT
Chlorhexidine
Topical
Steroids
–Lidex Gel .05%
Aphthasol
Cream 5%
HERPES SIMPLEX
INFECTIONS
RECURRENT HERPETIC
STOMATITIS
 Attenuated
Form of Primary
Infection
 Tissue Firmly Bound Down
 Vesicles Burst to Form Ulcers
 Coalesce
 Heals in 7-10 Days
HERPES LABIALIS
SYSTEMIC ANTIVIRALS
 Acyclovir
(Zovirax) 200 mg Capsules
One Capsule 5 Times a Day
 Valacyclovir (Valtrex) 1 gm Caplets
Two Caplets Twice a Day
 Famciclovir (Famvir) 125 mg Tablets
One Tablet Twice Daily
TOPICAL ANTIVIRALS
 Zovirax
(Acyclovir) Ointment 5%
– 15 Gram Tube
– Apply TID
 Denavir
(Penciclovir) Cream 1%
– 2 Gram Tube
– Apply Every Two Hours
AIDS RELATED
PERIODONTAL DISEASE
 Linear
Gingival Erythema
 Necrotizing Ulcerative Gingivitis
 Necrotizing Ulcerative Periodontitis
 Necrotizing Ulcerative Stomatitis
LINEAR GINGIVAL
ERYTHEMA
 A Persistent,
Linear Erythematous
Gingivitis Which Bleeds Easily
 Resistant to Treatment
 Spontaneous Remission
NECROTIZING
ULCERATIVE GINGIVITIS
 Also
Known as ANUG
 Acute Gingivitis Characterized by
Ulceration & Necrosis of the
Gingival Margin & Destruction of
the Interdental Papilla
 Gingival Pain
NECROTIZING
ULCERATIVE GINGIVITIS
 Profuse
Gingival Bleeding
 Fetid Odor
 No Involvement of Osseous Tissues
 Associated w/ Stress, Anxiety,
Malnutrition & Smoking
NECROTIZING ULCERATIVE
PERIODONTITIS
 Severe
Deep Pain
 Spontaneous Gingival Bleeding
 Extensive Soft Tissue Necrosis
 Severe Loss of Periodontal
Attachment
NECROTIZING ULCERATIVE
PERIODONTITIS
 Rapid
Onset & Progression
 Bone May Be Exposed
 Associated with Low CD4 Counts
NECROTIZING ULCERATIVE
STOMATITIS
 Necrosis
of Significant Areas of the
Oral Soft Tissue & Underlying
Bone
INTRAORAL
PIGMENTATION
Racial Pigmentation
Amalgam Tattoo
Heavy Metal Poisoning
Medications
Birth Control Pills
Minocycline
AZT
Smoking
Addison’s Disease
Puetz-Jeger Syndrome
SALIVARY GLAND
DISEASE
 Xerostomia
 Bilateral
Parotid Gland Enlargement
Occurs in HIV Infected Individuals
 Histology Has Been Described as
Resembling Autoimmune Salivary
Gland Disease w/ Cystic Changes
Thanks for Coming!
Jacqueline M. Plemons DDS, MS
6031 Sherry Lane
Dallas, TX 75225
(214)369-8585
[email protected]