Oral
Manifestations of Immunocompromised Conditions
Human immunodeficiency virus (HIV) infection, bone
marrow transplantation, solid-organ transplants, irradiation, and chemotherapy
account for most immunosuppressive conditions. Typically the oral
manifestations associated with HIV and other immunosuppressive conditions can
be attributed to one of five etiologic categories: fungal, as in oral
candidiasis; bacterial, as in gingivitis; viral, as in leukoplakia (see Plate
2-41); neoplastic, as in Kaposi sarcoma; and miscellaneous.
It has been reported that up to 50% of patients with HIV develop oral lesions during the course of the illness; however, in the era of highly active retroviral therapy (HAART), the incidence of oral candidiasis, hairy leukoplakia, and Kaposi sarcoma has decreased significantly. The effect of HAART on periodontal disease remains less clear. Linear gingival erythema, formally called HIV-associated gingivitis, is typically found in the gingiva along the anterior teeth line in immunosuppressed individuals. When seen in HIV-infected patients, there is an increase in polymorphonuclear lymphocytes compared with nonimmunosuppressed patients. Oral candidiasis is often associated with this lesion. Although typically associated with the formation of plaque, improvements in oral hygiene and gingival debridement do not improve this condition. The sublingual plaques are associated with increased amounts of bacteria; therefore, therapy includes professional plaque removal and supplementation with antimicro- bial oral rinses. Necrotizing ulcerative gingivitis (NUG) is limited to the gingival tissue without loss of periodontal clinical attachment. In contrast, necrotizing ulcerative periodontal (NUP) disease, also seen in the immunosuppressed population, involves the periodontal ligament and destruction of the alveolar bone. In these cases, therefore, the disease may include constitutional symptoms of fever, malaise, malodorous breath, and local lymphadenopathy. In patients with HIV, NUG is typically not seen until the CD4 count falls below 500 cells/ mm3 whereas NUP is most often seen in those with CD4 counts below 200 cells/mm3. Although HAART therapy should decrease the incidence of these conditions, progression of quiescent disease to symptomatic disease has been reported with the initiation of HAART.
It has been reported that up to 50% of patients with HIV develop oral lesions during the course of the illness; however, in the era of highly active retroviral therapy (HAART), the incidence of oral candidiasis, hairy leukoplakia, and Kaposi sarcoma has decreased significantly. The effect of HAART on periodontal disease remains less clear. Linear gingival erythema, formally called HIV-associated gingivitis, is typically found in the gingiva along the anterior teeth line in immunosuppressed individuals. When seen in HIV-infected patients, there is an increase in polymorphonuclear lymphocytes compared with nonimmunosuppressed patients. Oral candidiasis is often associated with this lesion. Although typically associated with the formation of plaque, improvements in oral hygiene and gingival debridement do not improve this condition. The sublingual plaques are associated with increased amounts of bacteria; therefore, therapy includes professional plaque removal and supplementation with antimicro- bial oral rinses. Necrotizing ulcerative gingivitis (NUG) is limited to the gingival tissue without loss of periodontal clinical attachment. In contrast, necrotizing ulcerative periodontal (NUP) disease, also seen in the immunosuppressed population, involves the periodontal ligament and destruction of the alveolar bone. In these cases, therefore, the disease may include constitutional symptoms of fever, malaise, malodorous breath, and local lymphadenopathy. In patients with HIV, NUG is typically not seen until the CD4 count falls below 500 cells/ mm3 whereas NUP is most often seen in those with CD4 counts below 200 cells/mm3. Although HAART therapy should decrease the incidence of these conditions, progression of quiescent disease to symptomatic disease has been reported with the initiation of HAART.
Recurrent labial and intraoral
herpes simplex infection is more common in HIV-infected than
non–HIV-infected individuals. These oral lesions begin with the formation of a
vesicle that ulcerates and crusts over in extraoral locations. Herpetic lesions
typically affect the keratinized mucosa of the gingiva, beginning as very small
(1 to 2-mm) rounded ulcerations that can increase in size and coalesce to form
a single larger ulceration. Although the gingiva is most often the site of
origin, they can occur less often on the palate and tongue.
Cytomegalovirus infection is less often seen in HIV patients and
more often seen in immunosuppressed individuals following bone marrow or organ
transplantation. The infection can cause painful oral mucosal ulcerations
characterized by a punched-out appearance with nonindurated borders without any
surrounding edema. These are typically seen on the lips, gingiva, tongue,
buccal mucosa, and pharynx.
Oral warts (condyloma
acuminatum) are caused by
the human papillomavirus and appear as either verruca vulgaris with single or
multiple pink cauliflower-like nodules, papillomas with white spikelike
projections, or focal epithelial hyperplasia with flat pink papules. The warts
are asymptomatic, variable in size, and primarily seen in the lips, gingiva,
and buccal, labial, and palatal mucosa. Oral warts occur in 1.2% of
HIV-infected individuals. Malignant transformation may occur in this
population.
Oral candidiasis is most often a result of infection by Candida
albicans; less often by C. glabrata, C. krusei, or C. tropicalis;
and even less often by other Candida species. It is the most common
infection in patients with immunocompromised conditions or who are receiving
immunosuppressive therapeutic regimens. Pseudomembranous candidiasis (thrush)
is characterized by single to multiple white, creamy, curdlike plaques
located on any oral mucosal surface. When they are wiped off, superficial
bleeding may be revealed, and in rare instances, invasive ulcerations can
develop.
Oral Kaposi sarcoma is the most common neoplastic lesion seen
with HIV infection. Its development is correlated with the degree of
immunosuppression and the CD4 T-cell count. Human herpesvirus type 8 may be the
agent responsible for the development of this vascular mucocutaneous neoplasm.
The lesions are typically asymptomatic, reddish purple, macular or
papulonodular lesions that do not blanch. The most common location in the oral
cavity is the palate, followed by the gingiva and tongue. Infrequently the
lesions can extend into the alveolar bone of the jaw, resulting in bone
destruction and tooth mobility. The lesions can remain localized and qu et, or
they can coalesce and cause pain and bleeding.
