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The frequent occurrence of unusual and unexpected gingivitis and periodontitis in HIV-infected patients confirms an association between immunosuppression and these inflammatory/infectious conditions. This consequence of HIV disease is not surprising based on the loss of protective salivary enzymes, some changes in the subgingival microbial flora, suppressed responses of tissue immune components, and altered leukocyte functions. This involvement can be acute and often is progressive, causing pain and leading to exposed, necrotic bone and tooth mobility. In the chronic form, gingival inflammation and necrosis with subsequent destruction of alveolar bone can progress rather rapidly.
The diagnosis is based on history and radiographic and clinical findings. Spontaneous bleeding, or bleeding on probing, is not unusual. This finding can be exaggerated in some HIV patients who also may be suffering from thrombocytopenia (low platelet count). The gingiva may manifest an idiopathic marginal linear erythema or a generalized erythema. In the latter case, candidiasis must be considered in the differential diagnosis. ".
Treatment requires an aggressive program of home and office care, simultaneously recognizing the importance of long-term maintenance. When indicated, debridement should be instituted. Use of antiseptic mouth rinses, like 0.12% chlorhexidine (Peridex, PerioGard), is a must to supplement routine professional office management and conscientious home care. Antibiotics are frequently required. Suggestions include metronidazole (Flagyl, 1000 mg daily), combined, based on judgment, with a gram-positive antibiotic, such as amoxicillin (1500 mg daily); or a broad spectrum bactericidal antibiotic such as clindamycin (Clindacin, 900 to 1200 mg daily). Many times, extraction is the optimal therapeutic choice. Compliance is often a problem based on depression, forgetfulness, costs, social problems, and other HIV-associated sickness.
Bacteria not ordinarily found as part of the oral flora can cause opportunistic mouth infections in the immunodeficient patient. Fortunately, this condition is not commonly found, recognized, or reported. The most common causative agents arise from the respiratory and gastrointestinal tracts, as example, Klebsiella pneumoniae (respiratory) and Escherichia coli (gastrointestinal).
Management entails suspicion of an infectious source and performing a culture if there is no response to usual care.
TB very rarely will cause an oral lesion, but like hepatitis, it creates a risk to health care professional workers. In recent years, TB has increased in the United States, primarily in large cities, as well as throughout the world. The rise is mainly found in HIV-infected patients, in underrepresented ethnic groups, and in persons between the ages of 25 and 44. This risk to health is even more critical, since many of the infections involve mycobacteria that are resistant to some or all drugs that usually control TB.
Because infection is by exposure to contaminated aerosols, appropriate masks should be worn when one is exposed to a suspected coughing patient. Skin testing with PPD is suggested for health care workers to determine TB status, exposure, and seroconversion. Precautions and education are mandated by OSHA.