Periodontal

CHAPTER 3
C L I N I C A L M A N I F E S TAT I O N S A N D
M A N A G E M E N T O F H I V- R E L AT E D
P E R I O D O N TA L D I S E A S E
I. INTRODUCTION
RECOMMENDATION:
The most important components in the management of HIV-
associated gingival and periodontal disease should be the removal
of local irritants from the root surfaces, débridement of necrotic
tissues, and appropriate use of antibiotics.
Two types of gingival/periodontal disease associated with HIV infection
have been widely reported in the literature. In the past, these have been
called HIV-associated gingivitis (HIV-G) and HIV-associated periodontitis
(HIV-P). There is now evidence that these diseases also occur in HIV-
negative immunocompromised individuals and are not specific to HIV
infection, thus making the original terms inappropriate. Therefore, HIV-
associated gingivitis has been renamed linear gingival erythema (LGE)
and HIV-associated periodontitis has been renamed necrotizing ulcerative
periodontitis (NUP).
The prevalence of these two diseases remains unclear,1-3 with estimates of
occurrence among HIV-infected individuals ranging from 5% to 50%. It is
not yet clear where in the spectrum of HIV disease these conditions occur
or which patients are at greatest risk for developing them. There is some
evidence that NUP is associated with a low CD4 count (<200 cells/mm3).4
II. LINEAR GINGIVAL ERYTHEMA (LGE)
A. Presentation
LGE is limited to the soft tissue of the periodontium and characteris-
tically appears as an erythematous linear band that extends approxi-
mately 2 mm to 3 mm from the free gingival margin. There also may
be punctate erythema, which extends onto the alveolar mucosa. At
times, these areas coalesce, creating broadly diffuse erythematous
zones from the gingival margin into the vestibule. Unlike conven-
tional gingivitis, LGE is not significantly associated with plaque. In
most cases of LGE, bleeding is seen after gentle probing (see page
34 for photographic example).
B. Diagnosis
RECOMMENDATION:
The diagnosis of LGE is made on the basis of distinctive clinical
characteristics (see Presentation).
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C. Treatment
There is no known treatment for LGE.
III. NECROTIZING ULCERATIVE PERIODONTITIS (NUP)
A. Presentation
NUP affects the osseous structures of the periodontium. Clinical fea-
tures include pain, interproximal gingival necrosis, and cratered soft
tissues (see page 34 for photographic example). Patients frequently
complain of spontaneous bleeding and deep-seated pain in the
jaws. Destruction of the periodontal attachment and bone can be
extremely rapid and extensive and may result in as much as 90%
bone loss around isolated teeth in as few as 12 weeks. If left
untreated, NUP may extend into the contiguous tissues and expose
the alveolar or palatal bone. When this occurs, the condition has
been called necrotizing stomatitis.
B. Diagnosis
RECOMMENDATION:
The diagnosis of NUP is made on the basis of distinct clinical
characteristics (see Presentation).
C. Treatment
RECOMMENDATIONS:
Systemic antibiotics, such as metronidazole, tetracycline,
clindamycin, amoxicillin, and amoxicillin-clavulanate potassium,
should be combined with débridement of necrotic tissues.
As systemic antibiotics increase the patient’s risk of developing
candidiasis, concurrent, empiric administration of an antifun-
gal agent should be considered.
Frequent appointments are appropriate and recommended in
the acute and healing stages of NUP to perform the necessary
periodontal therapies, to assess tissue response, and to monitor
the patient’s oral hygiene performance.
A thorough periodontal examination should be performed at
each recall session for any patient with a history of NUP. Because
the periodontal maintenance program for patients with HIV
should be individualized, oral health care providers should con-
sider plaque control, past severity of disease, and evidence of
case stabilization when determining the frequency of recall visits.
Published reports, supported by clinical experience, suggest that an
antibiotic regimen of 250 mg metronidazole 3 times per day for 5 to 7
days, often combined with 250 mg amoxicillin-clavulanate potassium 3
times a day for 5 to 7 days, is effective for management of this disease.
32
Chlorhexidine oral rinse 15 cc twice daily has been reported to be
very useful in the management and control of NUP, and intrasulcular
lavage with povidone-iodine has been shown to have a palliative
effect for patients with NUP.
Oral health care providers report their most favorable treatment
responses when HIV-associated periodontal disease is addressed in
the earliest stages. Patients who have been treated for NUP may
develop repeated episodes, especially when oral hygiene levels are
unsatisfactory. NUP can be insidious, localized, and not necessarily
related to plaque. Once clinical stabilization has occurred, recall vis-
its are generally scheduled every 3 months to detect and prevent
disease recurrence at an incipient stage.
IV. NECROTIZING ULCERATIVE GINGIVITIS (NUG)
RECOMMENDATION:
Necrotizing ulcerative gingivitis should be treated similarly to NUP.
Necrotizing ulcerative gingivitis (NUG) has been associated with HIV infec-
tion. NUG and NUP may represent different stages of the same pathologic
process, with NUP being a later stage of NUG.5
REFERENCES
1. Friedman RB, Gunsolley J, Gentry A. Periodontal status of HIV-
seropositive and AIDS patients. J Periodontol 1991;62:623-627.
2. Klein RS, Quart AM, Small CB. Periodontal disease in heterosexuals with
acquired immunodeficiency syndrome. J Periodontol 1991;62:535-540.
3. Swango P, Kleinman DV, Konzelman JL. HIV and periodontal health:
A study of military personnel with HIV. J Am Dent Assoc 1991;122:49-52.
4. Glick M, Muzyka BD, Salkin LM, Lurie D. Necrotizing ulcerative
periodontitis: A marker for immune deterioration and a predictor of the
diagnosis of AIDS. J Periodontol 1994;65:393-397.
5. Novak MJ. Necrotizing ulcerative periodontitis. Ann Periodontal
1999;4:74-78.
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I L L U S T R AT I O N S O F P E R I O D O N TA L
D I S E A S E A S S O C I AT E D W I T H
HIV INFECTION
Linear gingival erythema (LGE) Necrotizing ulcerative

periodontitis (NUP)
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CHAPTER 3

Linear gingival erythema (LGE) Necrotizing ulcerative

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