Oral Manifestations of HIV Patient

Case Report

Supervisor :

dr. A. Yudho S. Akp, Sp. PD, FINASIM

By :

Yas’a Nuruuha 131611101009

Melisa Novitasari 131611101036
Narita Ajeng Loviana 141611101031

Faculty of Dentistry of Jember University

Departement of Internal Medicine
Balung General Hospital
Jember
October 11, 2018
Yas’a Nuruuha Melisa Novitasari
131611101009 131611101036

Narita Ajeng Loviana

141611101031
 Name Mrs. N
Age 31 y.o
Sex Female
Chief Complaint (S) Patient came to the RSD Balung after
breathless since a month ago, diarrhea for a
week, has seizure once, mouth ulcer (+),
and poor intake nutrition
Clinical observation Fatigue and breathless
Temporary diagnosis HIV

a. Introduction
Acquired Immunodeficiency Syndrome (AIDS) is characterized by a severe
depletion of the immune system as a result of Human Immunodeficiency Virus (HIV)
infection, which causes a reduced number of CD4+ T lymphocytes. In humans, these
cells are responsible for the immunologic defense, and their reduced count results in the
onset of various infirmities, including opportunistic infections and malignant tumors;
accordingly, these are considered indicators of AIDS (Tatiany et al, 2014).
The HIV/AIDS pandemic has become a human and social disaster, particularly
in resource limited settings. Oral health is an important component of the overall health
status in HIV infection and essential component of quality of life. HIV related oral
abnormalities occur in 30% to 80% of the affected patient population. Policies for
strengthening oral health promotion and the care of HIV-infected patients have been
issued by WHO. Oral health services and professionals can contribute effectively to the
control of HIV/AIDS through health education, patient care, infection control and
surveillance (Askynite et al, 2015).
Studies have shown that the oral manifestations most commonly result from
fungal, bacterial, and viral infections. Among the fungal infections, oral candidiasis
caused by Candida albicans is one of the most common opportunistic diseases
associated with HIV infection, of which the erythematous and pseudomembranous
forms have a greater incidence, followed by angular cheilitis. It is believed that these
manifestations are related to the immunosuppression caused by the reduced CD4+ T
lymphocyte count, as well as local factors such as xerostomia (Sharma et al, 2009).
 In addition to the oral manifestations in HIV patients, there are several
systemic manifestations associated with the virus, and these can severely worsen the
individual's prognosis. Diseases commonly found in these patients include tuberculosis
(TB), hypertension, and hepatitis B and C. Another noteworthy manifestation is
atypical ulcers of unknown etiology, which can present with different levels of severity
(Tatiany et al, 2014).
 b. Oral and Dental Manifestation of HIV

Fact Reference Solution

Oral candidiasis remains the most The treatment of oral candidiasis
common HIV-oral lesion. Being includes topical and systemic
strongly associated with a low CD4 antifungal medication. Topical
count, oral candidiasis occurred in therapies include topical
as many as 90% of patients before antifungal oral suspension or
introduction of highly active tablets. These formulations
antiretroviral therapy (HAART). should be used concomitantly
The prevalence of oral candidiasis with systemic drugs, especially
among patients who receive in cases of esophageal
antiretroviral treatment is 50% candidiasis.
lower compared to the prevalence Topical treatments are nystatin
before HAART era. However oral oral suspension (100,000
1. Oral Candidiasis
candidiasis remains common in units/mL), nystatin tablets, or
HIV-infected patients without oral gel (Hitomi and Hirata,
access to HAART or those for 2015).
whom antiviral therapy is started Another topical treatment is D-
late. Candida albicans is the most Cateslytin (D-Ctl) (Pauline et al,
prominent pathogen. Other 2018)
Candida species (particularly C. Systemic antifungal agents are
krusei, C. glabrata, C. dublinensis) fluconazole and itraconazole.
are also associated with oral Resistance to fluconazole was
candidiasis in HIV patients. Oral reported as occurring in patients
candidiasis presents commonly in with severe immune deficiency.
three forms: erythematous Treatments of fluconazole-
candidiasis, pseudomembranous resistant patients with a
candidiasis, and angular cheilitis. combination of fluconazole and
This patient shows the form of terbinafine have been successful
pseudomembranous candidiasis that (Hitomi and Hirata, 2015).
presents as painless creamy white
plaque-like lesions on the tongue,
palate, buccal mucosa, or
oropharynx and is frequently
 asymptomatic (Askynite et al,
2015).
Linear gingival erythema is Basic periodontal therapy

2. Linear Gingival Erythema characterized by a distinct fiery red provided at regular periodic
band along the margin of the intervals can effectively reduce
gingiva, most frequently found in periodontal inflammation in HIV
anterior teeth, accompanied in patients. Removal of local
some cases by bleeding and irritants from the root surfaces
discomfort (Askynite et al, 2015). by scalling, mechanical
This condition may lead to tooth debridement of necrotic tissues
mobility due to the rapid loss of by curetase, and appropriate use
bone and soft tissue, consequently of local and systemic antibiotics
resulting in bleeding, an unpleasant remain important components in
smell, and intense pain over the the management of HIV-
entire maxilla and jaw area. associated gingival and
Individu with TCD4+ levels below periodontal diseases. Multiple
200 cells/mm3 present with a more factors affect response to
severe loss of insertion in chronic treatment, including immune
periodontitis, which suggests that status and personal oral hygiene
preexisting periodontitis may be practices of keeping the mouth,
exacerbated in HIV positive gums, and teeth clean (Valentine
individuals. Immunodeficiency et al, 2016).
caused by HIV infection directly To increase and mantain
affects the pathogenesis of personal oral hygiene, the
periodontal disease, given that patient should brush her teeth
individuals affected by the virus twice a day (morning after
commonly present with oral lesions breakfast and night before
associated with immunosuppression sleep), floss once a day, and
(Tatiany et al, 2014). have regular dental visit (Kumar
et al, 2011).
 Cheilitis is a term that refers to Medication of cheilitis such as

3. Cheilitis inflammation of the lips. This may topical steroid are sometimes
comprise inflammation of the skin used to decrease inflammation
around the mouth, the vermilion (such as hidrokortison). For
border and/or labial mucosa, but idiopatic causes of cheilitis
vermilion border is more treatment can be as simple as
commonly involved. Cheilitis is a applying petroleum jelly to the
chronic localized inflammatory affected area (Darby and Walsh,
condition of the vermillion border, 2010).
which is characterized by the
regular shedding of surface keratin
layer. Vermilion is the junctional
zone between the skin and mucosa,
where has a thick squamous
epithelium and rich capillary
network. (Barakian et al., 2015).

Recurrent aphthous ulcer (RAU) is Mouthwash can effectively

4. Mouth ulcer
a common pathological changes provide symptomatic relief of
found in the oral mucosa, ulcers. Chlorhexidine
characterized by painful single or mouthwash (corsodyl or
multiple ulcers. This is a result of chlorohex) and aloeclair
oral ephitelium lesion, which mouthwash can be used to
typically exposed nerve endings, reduce and ease the pain.
resulting in pain or soreness. HIV is Steroid are used as rinses only if
also considered as a predisposing the patient is unable to apply
factor for RAU due to immune topical agents (such as
deficiency. HIV-associated RAU triamcinolone) directly to ulcer
lesions tend to be more severe and or if lesions cover a large area.
longer lastingand may cause An aqueous preparation of 0.1%
debiliating pain with associated or 0.2% triamcinolone, 0.3%
alteration of important oral hydrocortisone mouth rinse, and
functions such as speaking, dexamethasone elixir 0.5/5.0 mL
 chewing, and swallowing, which were all effective when used
ultimately lead to malnutrition, and three or four times per day
weight loss, compromise the ability (Caputo et al, 2012).
to take medication and seriously
interfere with the quality of life
(Caputo et al, 2012).
5. Xerostomia Xerostomia or dry mouth is a The treatment for xerostomia
symptom frequently observed focuses on symptomatic relief
in HIV-infected patients. It has through hydration, minimizing
been reported that reduced salivary the consumption of alcohol and
flow occurs in 2---30% of subjects. caffeine, and using artificial
The most common cause of saliva. The use of pilocarpine to
reduced salivary flow is due to the stimulate saliva flow may be a
side effects of medication, for useful option.
example, anti-retroviral agents. Pilocarpine is a parasympathetic
Furthermore, xerostomia can result agonist of acetylcholine
from a salivary gland disease muscarinic M3 receptors and
associated with HIV. The thus stimulates secretion by
parathyroid glands are more exocrine glands such as the
frequently affected; however, minor salivary, sweat, lacrimal, and
salivary glands may also be respiratory mucous glands; the
affected by a viral infection (Hitomi contraction of smooth muscle;
and Hirata, 2015). and the motility of the
gastrointestinal and urinary
tracts, gall bladder, biliary ducts,
and bronchi (Hitomi and Hirata,
2015).
What should i do for this patient?

Oral manifestation in this patient with HIV are cheilitis, reccurent aphthous ulcer,
linear gingiva erythema (gingival disease), and oral candidiasis. The treatments we can
give to her are dietary changes and supplements are used to treat nutritional deficiency.
Cheilitis medication can used topical steroid to decrease inflammation of the lession or
can be as simple as applying petroleum jelly to the affected area. Dentists should also
correct the predisposing factors and underlying diseases and try to promote the use of oral
antiseptic and antibacterial rinses such as Chlorhexidine which also can be used to ease
the pain in mouth ulcer. In oral candidiasis and linear gingiva erythema cases, we can
used a conservative measures before starting drug or dental treatment by promoting good
oral hygiene (tooth brush twice a day and using floss). Topical drugs for oral candidiasis
is used to treat superficial infection, however, systemic drugs is used on widespread
infection that has not been enough with topical therapy.
HIV can cause malnutrition for the patient. Doctor can give some recommendation to
increase the nutrition. The recommendations are
1. Eat plenty of fruits and vegetables, they are high in nutrients wich protect immune
system. Eat a lot of different product to get most vitamins and minerals.
2. Eat protein, the body uses it to build muscle and a strong immune system.
3. Limit sugar and salt.
4. Drinks plenty of fluids, make sure to have at least 8 to 10 cups of waterduring each
day.
Reference
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and Systemic Manifestations in HIV-1 Patients. Revista da Sociedade Brasileira de
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