Braz Dent J (1998) 9(1): 47-51 ISSN 0103-6440
| Introduction | Oral manifestations | Rapid progressive periodontitis | Prevention and treatment | Discussion | References |
The aim of this study is to analyze periodontal diseases in AIDS patients. Although AIDS was first detected in Brazil in 1982, it is growing steadily and is more frequent in the Southeast. Oral manifestations are common and may represent early signs of the disease. These lesions often precede systemic symptoms. The development of periodontal lesions in AIDS patients differs from that in non-infected patients. This is due to its chronic nature and lack of full recovery in AIDS patients. Characteristically, these lesions are not related to local irritants and progress quickly. Because these lesions do not respond properly to conventional treatment used in non-infected patients, the use of preventive methods is extremely important. These methods must include patient education and periodical professional scaling. It is important to reinforce the use of preventive measures in AIDS patients mainly in those presenting severe manifestations of the disease. The aim of treatment must be to preserve the teeth and periodontal tissues and allow more comfort to the patient during the progression of the disease.
Key Words: HIV-gingivitis, HIV-necrotizing ulcerative gingivitis,
HIV, AIDS, HIV-periodontitis, HIV-prophylactics.
Acquired immunodeficiency syndrome (AIDS) is an infectious syndrome
caused by a lymphoneurotropic virus already cloned in blood, cerebrospinal
fluid, saliva, bronchial and vaginal secretions, tears, and semen (Lacaz
et al., 1990). Although early reports of AIDS cases in Brazil date back
to 1982, the epidemic is increasing throughout the country. The epidemiological
pattern of the disease in Brazil shows that most cases occur in homosexuals,
bisexuals and endovenous drug users, respectively. Amongst women, the more
affected group is that of heterosexuals, endovenous drug users and those
who had blood transfusion. The disease is more frequent in the Southeast,
followed by the South, Northeast and Central regions of Brazil.
Systemic manifestations of AIDS are frequently reported in the literature (Melo, 1989; De Vita et al., 1991; Duffy et al., 1992, Ministério da Saúde, 1994). Oral manifestations are also common and may represent early clinical signs of the disease, often preceding systemic manifestations. This aspect is particularly important because it shows the importance of the dental profession as a primary healthcare worker as Dentists may be responsible for early detection of oral lesions which may indicate HIV infection (Pindborg, 1992).
Lesions associated with HIV infection are variable and are widely described
in the literature. The majority of these lesions can be detected early
or appear during the progression of the disease. This is the case of a
peculiar and uncommon aggressive type of periodontal disease found in AIDS
patients (Swango et al., 1991.
Although oral manifestations of bacterial origin can be less evident these must be considered and may lead to periodontal disease, bone pockets and delayed wound healing (Correa et al., 1994). Gingival lesions and alveolar bone loss are clinical features found frequently in HIV patients, and these lesions often do not respond properly to treatment (Winkler and Robertson, 1992). This may be a direct result of changes in the microbial flora and colonization which reflect a breakdown of the immunologic system. The appearance of stomatitis in AIDS patients differs from that seen in non-infected patients because in AIDS sufferers the lesion is chronic and does not obtain complete remission (Melo, 1989).
Gingivitis associated to HIV (G-HIV) is characterized by the lack of local irritants, severe erythema of the gum and oral mucosa, and bleeding. It is highly resistant to conventional local treatments (Winkler and Robertson, 1992; Langford, 1994; Murray, 1995; Serb, 1995).
The disease is aggravated by acute necrotizing ulcerative gingivitis or ANUG (HIV-ANUG), when it assumes a chronic or sub-acute course. It may initially appear as ulcerations covered by fibrinous exudate which precedes the disruption of the gingival crest and the formation of craters. The lesion may also progress quickly to necrotizing periodontitis (Langford, 1994; Murray, 1995; Serb, 1995).
Periodontitis associated to HIV (P-HIV) is a very peculiar feature because HIV-infected patients frequently show a severe increase in the manifestation of this atypical periodontal disease (Glick et al., 1990). Clinically, severe edema, gingival erythema, pain, spontaneous bleeding, interproximal necrosis, ulcerations, and rapid loss of periodontal tissue can be observed. This is often followed by severe necrosis, with the progression of this disease extremely fast not responding to conventional treatment used in non-infected patients (Friedman et al., 1991; Klein et al., 1991; Winkler and Robertson, 1992; Serb, 1995).
Rapid progressive periodontitis is another periodontal disease which must be differentiated from the above-mentioned diseases. This disease was described a century ago and has bimodal peaks (puberty and around 35 years of age) affecting all teeth without limits of destruction. Some patients may have a previous history of juvenile periodontites. Initially there is quick and severe bone destruction which may stop spontaneously. After this acute phase the gum presents signs of inflammation and marginal hyperplasia and may be extensively covered by residues. In approximately 83% of the patients modification in the function of neutrophils and/or monocytes, weight loss, malaise and depression are observed. Some patients respond to treatment (Page et al., 1983).
The natural history of periodontal diseases includes long-term chronic
irritation of the periodontal tissue followed by circumscribed areas of
inflammation of both surface and deep tissues resulting in the migration
of the junction epithelium. Later, there is loss of alveolar bone and formation
of deep pockets and consequent pathologic tooth mobility which results
in loss of function and finally exfoliation of the tooth.
Early preventive measures must be taken to prevent progression of the disease. Initially, improved conditions for increased resistance of the periodontal tissues must be sought. Specific and direct protection of periodontal health and early diagnosis and treatment of any disease must be provided. Limitation of damage through rehabilitation must be carried out .
Generally the treatment of periodontal lesions requires debridement, antibiotics and long-term follow-up. Professional oral prophylaxis, plaque control and debridement of necrotic tissues are essential for the success of treatment. There are other procedures which may be used to improve the results of the control of plaque and post-surgical treatments must be used according to the needs of each patient. Fundamentally, the prevention of periodontal disease must be precocious due to the accumulative characteristic of these pathologies.
Up to now there is no treatment for AIDS. Therefore, treatments available are used to minimize symptoms of associated diseases. However, many times these treatments may result in severe side effects which may need multiple medical consultations and frequent stays in the hospital (De Vita et al., 1991; Winkler and Robertson, 1992).
Because periodontal diseases associated with AIDS do not respond well to conventional treatment, the lost of teeth is very common. Literature has shown that these patients need rigorous and frequent follow-up in order to assess the use of preventive measures and to verify the progression of the disease. Dental health education and rigid plaque control are essential and must be associated with the use of antibiotics and chlorhexidine-based oral mouthrinses (Glick et al., 1990; De Vita et al., 1991; Winkler and Robertson, 1992).
Oral hygiene of areas of difficult access must be associated with the use of interproximal cleaning devices and interproximal brushes. Long-term need of periodontal treatment varies from patient to patient and appears to depend on the general conditions of the patient. Monthly visits to the Dentist for the assessment of oral hygiene and professional scaling and tooth polishing are strongly recommended and must be carried out until the condition is stabilized. When the situation is controlled, visits may be at 3-month intervals. Relapses of HIV-associated lesions are common in patients who are not able to keep an excellent level of oral hygiene and do not follow a regular program of visits to their Dentists (Winkler and Robertson, 1992).
AIDS is a very peculiar syndrome because its progression leads invariably
to death. It is a disease which occurs indiscriminately in women, men and
children and results in severe disturbances in behavior (Lacaz et al.,
1990). In addition to systemic manifestations AIDS sufferers also present
oral lesions, amongst them G-HIV and P-HIV (Melo, 1989; Lacaz et al., 1990;
De Vita et al., 1991; Duffy et al., 1992; Pindborg, 1992). Characteristically
there is lack of local irritants and extremely rapid progression. These
lesions, because of their clinical evolution, result in serious disturbances
in most patients and tooth loss is, in many cases, the final result. Tooth
loss occurs mainly because these diseases do not respond properly to conventional
treatment used in periodontal disease in non-infected patients (Glick et
al., 1990; Winkler and Robertson, 1992; Ministério da Saúde,
1994; Correa et al., 1994; Langford, 1994; Murray, 1995; Serb, 1995). Because
AIDS has no treatment, health care workers must work multidisciplinarly
to provide mainly relief of local symptoms which are progressive following
the evolution of the disease (Winkler and Robertson, 1992). Because G-HIV
and P-HIV do not respond to most conventional treatments routinely used
in other forms of periodontal diseases observed in non-infected patients
the implementation and use of preventive measures is necessary which must
include education and periodic plaque control. Surgical treatment is not
recommended in AIDS patients not only because of the higher risk of such
procedures in HIV-infected patients but also because of the immunodeficiency
and other systemic disturbances which may further complicate treatment
(Glick et al., 1994).
Routine visits to the Dentist must be made at least every three months when periodontal status and oral hygiene should be assessed. During the visits the patient must be stimulated to recognize their fundamental importance in maintaining oral health. Patients must also be stimulated to use additional auxiliary procedures such as antiseptic mouthwashes (Winkler and Robertson, 1992). However, if the patient does not respond to treatment and fails to follow the scheduled periodic visits to the dental office every three months, he must return to the monthly routine of visits and professional prophylaxis until his condition is again stabilized when he can return to the three month program. In some cases, the use of antibiotics such as penicillin, tetracycline and metronidazole are recommended. We also recommend the use of antifungal drugs due to the high incidence of candidal infections in AIDS patients.
It is extremely important to consider the value of preventive measures in AIDS patients, especially in those who already show severe systemic manifestations of the disease. We must also consider that the number of infected patients is growing continuously worldwide and the frequency of visits to Dentists will also increase. Besides the preservation of the teeth and periodontal tissues, the objective of treatment must be to provide a more comfortable life for patients during the progression of AIDS.
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Correspondence: Dr. Tatiana Irla Tavares Nunes Rêgo, Universidade Federal de Pernambuco, Mestrado em Odontologia, Cidade Universitária, 50670-901 Recife, PE, Brasil.
Accepted May 15, 1996
Electronic publication: October, 1998