James R. Winkler

Oral manifestations of HIV infection. Definitions, diagnostic criteria, and principles of therapy. The U.S.A. Oral AIDS Collaborative Group.

A set of definitions and diagnostic criteria for the more common oral features of human immunodeficiency virus infection were prepared as the result of a consensus reached by a group of dental and medical clinicians, epidemiologists, and other experts. These are intended for use in epidemiologic surveys, where the presumptive diagnoses are recommended, and in clinical care, pathogenesis and therapy studies, where the definitive diagnoses are appropriate.

Periodontal disease associated with HIV infection

Patients with severe immunosuppression as a consequence of infection by human immunodeficiency virus (HIV) are at risk for a number of severe periodontal diseases. HIV-associated gingivitis and HIV-associated periodontitis (HIV-P) are seen exclusively in HIV-infected persons. In some cases HIV-P may extend into adjacent soft tissue and bone, resulting in necrotizing stomatitis of periodontal origin. In addition, acute necrotizing ulcerative gingivitis has also been reported to have an increased prevalence in HIV-infected patients. The clinical and microbiologic features of HIV-associated gingivitis and HIV-P suggest that these diseases are early and later stages of the same lesion, that results in severe gingival erythema, extensive soft tissue necrosis, and destruction of alveolar bone. Although acute necrotizing gingivitis and the initial stages of HIV-P share a number of clinical signs current evidence indicates that they are distinct pathologic processes. Treatment of these lesions requires debridement, local antimicrobial therapy, immediate follow-up care, and long-term maintenance. In addition, patients with systemic involvement or extensive and rapidly progressing lesions may require systemic antibiotics appropriate to the organisms that dominate the lesion.

HIV-associated periodontitis complicated by necrotizing stomatitis

This report describes a case of HIV-associated periodontitis complicated by necrotizing stomatitis in a homosexual male patient with AIDS. Necrotizing stomatitis is a rapidly progressive ulcerative and necrotic infection that causes massive destruction of the oral tissues and underlying bone. Like HIV periodontitis, it appears to be related to the immune suppression caused by human immunodeficiency virus (HIV) infection; importantly, it may be life threatening. In this case, initial resolution resulted from local debridement in association with metronidazole therapy. Long-term clinical management consisted of monthly professional prophylaxis, good oral hygiene, and daily rinses with chlorhexidine. This case suggests that progressive oral necrotizing infection should be recognized as one element in the spectrum of oral manifestations of HIV infection.

Prevalence of Hiv-associated Periodontitis and Gingivitis in Hiv-infected Patients Attending an Aids Clinic

We investigated the prevalence of HIV-associated periodontal disease in an AIDS clinic in San Francisco. Patient recruitment occurred over 6 months with 90% patient participation. In 136 patients, three forms of periodontal disease were recorded: HIV-associated gingivitis (HIV-G), HIV-associated periodontitis (HIV-P), and conventional non-HIV-associated periodontal disease. Diagnosis was based on defined clinical criteria established before the study began. For the HIV-associated diseases, two sets of diagnostic criteria were used. One consisted of clinical signs that included bleeding on probing, pocket depth, and attachment loss; and the other consisted of the same signs but did not require probing (the measurement of the depth of the gingival sulcus). Using the first set of these criteria, HIV-G was diagnosed in 42 patients [31%; 95% confidence interval (CI) 23 to 39%] and HIV-P in 5 (4%; 95% CI 1 to 7%). Using the second set, 68 patients were diagnosed with HIV-G (50%; 95% CI 42 to 58%) and 8 with HIV-P (6%; 95% CI 2 to 10%). All other categories of periodontal disease that were non-HIV-associated were diagnosed in 60 (44%) of patients. These results indicate that while the prevalence of HIV-P is low, the prevalence of HIV-G and conventional periodontal disease among HIV-infected individuals is high and should be considered in the dental care of these patients.

Immediate Dental Implant Placement in HIV-Positive Patients Receiving Highly Active Antiretroviral Therapy: A Report of Two Cases and a Review of the Literature of Implants Placed in HIV-Positive Individuals

BACKGROUND There are numerous reports of oral surgical procedures in patients undergoing highly active antiretroviral therapy. In the general population, the success of immediate implant placement for replacing teeth is well documented. The number of human immunodeficiency virus (HIV)-positive patients seeking comprehensive dental care, including implant therapy, continues to increase. Aside from a solitary case report published 12 years ago, there is very limited evidence describing immediate implant placement in the HIV-positive population. The two cases described herein demonstrate successful immediate implant placement in this population. METHODS Two white male patients aged 48 and 55 were scheduled to undergo extraction of a mandibular premolar. Both patients were HIV-positive, receiving highly active antiretroviral therapy, and were closely monitored by their physicians. On the day of the surgical procedure, atraumatic extractions were completed, osteotomies prepared in the ideal orientation, and implants placed. The bone-to-implant gap was >1.5 mm in Case 2, which required particulate bone graft placement. Case 1 did not need additional bone grafting. In Case 1, the healing abutment was placed at the time of implant placement, whereas a second-stage surgical procedure was performed for Case 2. RESULTS Patients were seen at 2 and 4 weeks for postoperative assessment. No adverse postoperative sequelae were observed, and both implants integrated and were successfully restored. CONCLUSIONS Immediate implant placement in HIV-positive patients is a viable and successful treatment option. To our knowledge, only one other similar report exists. It is hoped that this case report adds to the body of evidence supporting immediate implant placement in the HIV-positive population.

Gingival Kaposi's sarcoma and periodontitis: A case report and suggested treatment approach to the combined lesions

Kaposis sarcoma is frequently observed in patients with the acquired immunodeficiency syndrome, and the mouth is a common site for these lesions. Gingival Kaposis sarcoma lesions can often be exacerbated by coexisting periodontal disease. To obtain the best treatment results, it is important to recognize and treat the gingival Kaposis sarcoma lesion and the associated periodontitis concomitantly. In this report we describe a case of oral Kaposis sarcoma in which gingival debridement, root planning and scaling, and monitored oral hygiene were used in conjunction with intralesional and systemic chemotherapy. These combined therapies significantly reduced the size of the lesions and dramatically improved the symptoms.

Surgical crown lengthening in a population with human immunodeficiency virus: a retrospective analysis).

BACKGROUND Individuals with human immunodeficiency virus (HIV) have an increased risk of developing health problems, including some that are life threatening. Today, dental treatment for the population with a positive HIV diagnosis (HIV+) is comprehensive. There are limited reports on the outcomes of intraoral surgical therapy in patients with HIV, such as crown lengthening surgery (CLS) with osseous recontouring. This report investigates the outcome of CLS procedures performed at an urban dental school in a population of individuals with HIV. Specifically, this retrospective clinical analysis evaluates the healing response after CLS. METHODS Paper and electronic records were examined from the year 2000 to the present. Twenty-one individuals with HIV and immunosuppression, ranging from insignificant to severe, underwent CLS. Pertinent details, including laboratory values, medications, smoking history/status, and postoperative outcomes, were recorded. One such surgery is described in detail with radiographs, photographs, and a videoclip. RESULTS Of the 21 patients with HIV examined after CLS, none had postoperative complications, such as delayed healing, infection, or prolonged bleeding. Variations in viral load (<48 to 40,000 copies/mL), CD4 cell count (126 to 1,260 cells/mm(3)), smoking (6 of 21 patients), platelets (130,000 to 369,000 cells/mm(3)), and neutrophils (1.1 to 4.5 × 103 /mm(3)) did not impact surgical healing. In addition, variations in medication regimens (highly active anti-retroviral therapy [18]; on protease inhibitors [1]; no medications [2]) did not have an impact. CONCLUSIONS The results of this retrospective analysis show the absence of postoperative complications after CLS in this population with HIV. Additional investigation into this area will help health care practitioners increase the range of surgical services provided to this group of patients.