Dental PBL

A 23-year-old female came with her male companion and was seen in the dental school’s emergency clinic for extreme pain in the oral cavity. You are on rotation in the emergency clinic and are assigned the patient to conduct a work-up of the case. Oral examination presented a number of findings. White legions were noticed on the lateral regions of the tongue. There were large ulcerations of the palate and gingival mucosa. The patient was also found to have large purple discolorations (possibly due to Kapossi’s sarcoma) in the oral cavity. On the medical history, the patient reports that she has been feeling tired and run down lately. She also reports getting “colds” more frequently, and that they last longer before resolving. The patient was suspected of having contracted the AIDS virus.

1. What is the significance of white lesions on the tongue of this patient?

2. What factors, disease(s) might cause ulcerations of the palate and gingival mucosa?

3. The patient was tested for hemangioma and coagulation defects. What would the rationale for these tests?

4. The patients had lesions that were identified as Kaposi’s sarcoma. What is Kaposi’s sarcoma and is it related to AIDS infection?

5. Please describe the life cycle AIDS virus.

6. What blood tests can be done to confirm AIDS infection in this patient?

7. What drugs are currently prescribed for controlling AIDS infection and what is the mode of their of action?

8. If the patient had AIDS, why would she get “colds” frequently?

9. What course of treatment would you suggest to improve oral health in this patient?

10. How would you handle the oral health of this patient over the long-term?

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Faculty Handout

1. White lesions: Like most healthy people, you probably have small amounts of the fungus Candida albicans in your mouth and digestive tract and on your skin. You can't see the fungus and normally won't know it's there — Candida usually doesn't cause problems because normal bacteria (flora) in your body keep its growth in check. But when this balance is disturbed — by medications, stress or illness — Candida can grow out of control, leading to problems such as diaper rash, vaginal yeast infections and a mouth infection called oral thrush. Oral thrush causes creamy white lesions, usually on your tongue or inner cheeks. The lesions can be painful and may bleed slightly when you scrape them or brush your teeth. Sometimes the infection may spread to the roof of your mouth, your gums, tonsils or the back of your throat. Although signs and symptoms often develop suddenly, they may become chronic, persisting over a long period of time.

Although oral thrush can affect anyone, it occurs most often in babies and toddlers, older adults, and people whose immune systems have been compromised by illness or medications. It's usually a minor problem for healthy children and adults and can be effectively treated with natural remedies or antifungal medications. But for people with weakened immune systems, symptoms may be more severe, widespread and difficult to control. In severe cases, the lesions may spread downward into your esophagus — the long, muscular tube stretching from the back of your mouth to your stomach (Candida esophagitis (inflammation of the esophagus)).

Oral candidiasis is often the first presenting sign of HIV infection, and it may occur in as many as 90% of patients with HIV. HIV infection should be considered in patients presenting with repeated oral candidiasis and in those who have no other associated risk factors, such as being on steroids or taking oral antibiotics.

The 4 common classifications of candidal infections are as follows: pseudomembranous candidiasis (ie, thrush), erythematous candidiasis, angular cheilitis, and hyperplastic candidiasis. Pseudomembranous candidiasis is the most common AIDS-related presentation. Removable white plaques on the soft and hard palates, buccal (cheek) mucosa (most commonly), and tongue that leave a reddened area when scraped characterize pseudomembranous candidiasis. The frequency of candidal infection increases as HIV disease progresses. Antifungal treatment is effective, but the effectiveness may decrease over time with repeated infections due to increased resistance. Mouth rinses with chlorhexidine gluconate, Listerine, or hydrogen peroxide in sodium chloride solution may serve as adjunctive therapy.

2. Ulceration of the palate and gingival mucosa: Ulcerative colitis is an inflammatory condition with some similarities to Crohn disease. However, it is restricted to the colon and is limited to the mucosa and submucosa, sparing the muscularis (tubular structure). Lesions in the colon consist of areas of hemorrhage and ulcerations along with abscesses. Similar lesions may present in the oral cavity as aphthous (small white spots on the mucous membrane) ulcerations or superficial hemorrhagic ulcers. Generally, the oral lesions coincide with exacerbations of the colonic disease. Similar ulcerations may arise on the buttocks, abdomen, thighs, and face. Aphthous ulcers or angular stomatitis (inflammation of the mucous membrane of the mouth) occurs in as many as 5-10% of patients.

Oral ulcerations are not very common (~2-4%) in HIV infected patients. These generally consist of red or white-bordered erosions or ulcerations varying in size from 1 mm to 2 cm on buccal mucosa, oropharynx, tongue, lips, gingiva, hard or soft palate. In general gingival and palate ulcerations represent necrotic or eroded oral mucosa, including tongue. Most such lesions are idiopathic (apthous) or of viral etiology, although they also may be due to fungal, parasitic, or bacteriologic pathogens. Herpetic ulcerations tend to appear on keratinized tissues such as the hard palate or gingiva. Aphthous ulcerations tend to manifest on non-keratinized tissues such as the floor of the mouth, soft palate and lingual (bottom) surface of the tongue. Inquire about other ulcerative gastrointestinal diseases, including HSV, CMV or histoplasmosis; trauma, burn. Inquire about ETOH and smoking history, which can also cause ulcerations.

3. Hemangioma and coagulation defects: The discoloration in the oral cavity may reflect hemangioma and coagulation defects. That would be the rationale for testing it. Hemangiomas are abnormally dense collections of dilated small blood vessels (capillaries) that may occur in the skin or internal organs.

Hemangioma: Purple compressible lesion of the left soft palate. The lesion blanches upon pressure

The classically recognized hemangioma is a visible red skin lesion that may be in the top skin layers deeper in the skin (cavernous hemangioma), or a mixture of both. Hemangiomas are usually present at birth, although they may appear within a few months after birth, often beginning at a site that has appeared slightly dusky or differently colored than the surrounding tissue.
Hemangiomas, both deep and superficial, undergo a rapid growth phase in which the volume and size increase rapidly. This phase is followed by a rest phase, in which the hemangioma changes very little, and an involutional phase in which the hemangioma begins to disappear.

During the involutional phase, hemangiomas may disappear completely. Large cavernous hemangiomas distort the skin around them and will ultimately leave visible changes in the skin. A superficial capillary hemangioma may involute completely, leaving no evidence of its past presence.
Hemangiomas may be present anywhere on the body. However, they are most disturbing to parents when they are on the infant's face or head. Hemangiomas of the eyelid may interfere with the development of normal vision and must be treated in the first few months of life. On rare occasions, the size and location of hemangiomas may interfere with breathing, feeding, or other vital functions. These lesions also require early treatment. Large cavernous hemangiomas may develop secondary infections and ulcerate. Bleeding is common and may be significant following injury to the hemangioma.

Treatment: Superficial or "strawberry" hemangiomas often are not treated. When they are allowed to disappear on their own, the result is usuaully normal-appearing skin. In some cases, a laser may be used to eradicate the small vessels. Cavernous hemangiomas that involve the eyelid and obstruct vision are generally treated with injections of steroids or laser treatments that rapidly reduce the size of the lesions, allowing normal vision to develop. Large cavernous hemangiomas or mixed hemangiomas are treated, when appropriate, with oral steroids and injections of steroids directly into the hemangioma. Recently, lasers have been used to reduce the bulk of the hemangiomas. Lasers emitting yellow light selectively damage the vessels in the hemangioma without damaging the overlying skin. Some physicians are using a combination of steroid injection and laser therapy together.

Fibrin clot: This patient has multiple ulcers associated with primary herpes. Each ulcer is covered by a white to yellow fibrin clot.

Coagulation Defects in Oral Cavity: The Rendu-Osler-Weber disease, also known as hereditary hemorrhagic telangiectasia (HHT), is transmitted as an autosomal dominant disorder characterized by hemorrhages, which can potentially affect any organ and by vascular anomalies (venous and capillary dilatations and arteriovenous malformations) caused by the loss of supporting tissues, which normally surround the vascular walls. Cutaneous (fingertips) and mucosal (lips, oral cavity, conjunctivae, nasal mucosa) telangiectases usually begin around the age of 30 to 50 years. These are small reddish raised lesions, composed of dilated and convoluted capillaries which are extremely fragile and thus easily subject to bleeding with only slight blood loss.

4. Kaposi’s sarcoma: A sarcoma is a cancer that develops in connective tissues such as cartilage, bone, fat, muscle, blood vessels, or fibrous tissues (related to tendons or ligaments). Kaposi sarcoma (KS) was named for Dr. Moritz Kaposi who first described it in 1872.

For decades KS was considered a rare disease that mostly affected elderly men of Mediterranean or Jewish heritage, organ transplant patients, or young adult African men. In the last 20 years, however, the vast majority of KS cases have developed in association with human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS), especially among homosexual men. With the use of new treatments for AIDS, this is turning around, and the number of KS cases due to HIV infection is decreasing. This disease typically causes tumors to develop in the tissues below the skin surface, or in the mucous membranes of the mouth, nose, or anus. These lesions (abnormal tissue areas) appear as raised blotches or nodules that may be purple, brown, or red. Sometimes the disease causes painful swelling, especially in the legs, groin area, or skin around the eyes.

AIDS-related (or epidemic) Kaposi sarcoma arises in people who are infected with HIV. It was in part the unusual and sudden appearance of this form of KS in so many young men at the start of the AIDS epidemic that led doctors to realize that a new disease had emerged.

Acquired immune deficiency syndrome (AIDS) results from infection by the human immunodeficiency virus (HIV). This virus destroys certain cells of the immune system, making the body unable to fight infections caused by certain other viruses, bacteria, and parasites. Certain forms of cancer are also more likely to develop in people whose immune systems have been damaged.

A person infected with HIV (that is, being HIV-positive) does not necessarily have AIDS. The virus can be present in the body for a long time, typically many years, before causing any major illness. The disease known as AIDS begins when the virus has caused serious damage to the immune system, which results in certain types of infections and other medical complications.

Certain diseases occur so often in people with AIDS that they are considered "AIDS-defining conditions" -- that is, their presence in a person infected with HIV is a clear sign that full-blown AIDS has developed. The Centers for Disease Control and Prevention has identified certain cancers as AIDS-defining diseases: Kaposi sarcoma, lymphoma (especially non-Hodgkin lymphoma and primary central nervous system lymphoma), anal cancer, and cancer of the cervix that has spread to neighboring tissue (called invasive cervical cancer). Many other kinds of cancer may be more likely to develop in people with HIV infection. Of course, people without HIV or AIDS can also have these types of cancer.

In most cases, epidemic KS causes widespread lesions that erupt at many places on the body soon after AIDS develops. Lesions of epidemic KS may arise on the skin and the mouth and may affect the lymph nodes and other organs, usually the gastrointestinal tract, lung, liver, and spleen. In contrast, classic KS usually involves only one or a few areas of skin, most often the lower legs. At the time of diagnosis, some people with epidemic KS experience no symptoms, especially if their only lesions develop on the skin. However, many -- even those with no skin lesions -- will have swollen lymph nodes, unexplained fever, or weight loss. Eventually, in almost all cases, epidemic KS spreads throughout the body. Extensive lung involvement by KS can be fatal. More often, however, patients die of other AIDS-related complications such as infections. This is rare because modern treatment of the HIV infection usually prevents the development of advanced Kaposi sarcoma.

A sarcoma is a cancer that develops in connective tissues such as cartilage, bone, fat, muscle, blood vessels, or fibrous tissues (related to tendons or ligaments). Kaposi sarcoma (KS) was named for Dr. Moritz Kaposi who first described it in 1872.