Frequent Oral Diseases in HIV Positive and AIDS Patients

Dr. Heddie O. Sedano, DDS

At the end of this lecture, you will be asked if you would like to take this course for continuing education units.
California Continuing Education Credits: 2 units

Kaposi Sarcoma

Moritz Kaposi in 1972 first described, in older individuals, what became know as Kaposi sarcoma (KS). This rare vascular tumor was further identified as being prevalent in older males of Italian or Jewish ancestry. With the advent of AIDS, KS became prevalent, especially in homosexual men infected with HIV. Kaposi sarcoma, when present in HIV positive patients, is considered one of the marker diseases which indicates the transition from positivism to AIDS. Today KS is divided in four different categories:

• Classic
• Endemic (Africa)
• Iatrogenic immuno-suppression-associated
• AlDS-related

KS in any of these varieties can manifest clinically as a single lesion or as a multicentric neoplasm. Recently DNA of a virus of the herpes family, herpesvirus 8 (Kaposi's sarcoma-associated) has been identified in saliva of HIV infected men. This virus also has been identified in tissue samples of the classical, endemic and immuno-suppressed KS. These findings speak in favor of a possible causative or participating role of this virus in the etiology of KS. Here only the AlDS-related KS will be presented.

Over 50% of AIDS patients with skin KS also have oral KS, while 10 to 20% of AIDS patients have only oral KS. The favorite location of KS in the oral cavity is the hard and soft palates, where it is initially characterized by one or more generally flat areas, with a reddish brown or deep purple discoloration which do not blanch upon pressure. Multiple lesions can be seen throughout the palate. With progression of the disease the color tends to change to a darker reddish brown and eventually to a violet color. KS can also develop on the gingiva, the anterior palate, the tongue and the buccal mucosa. A hyperplastic (nodular) variety of KS can also be seen, mostly on the gingiva and tongue. Large lesions may interfere with speech and mastication. Bleeding is a frequent finding especially in the hyperplastic variety of KS. The differential diagnosis of intraoral KS includes pyogenic granuloma, hematoma and bacillary angiomatosis.

KS of the skin develops also in multiple sites especially arms, trunk, face, head and neck. Internal organs can be affected as well, especially if KS is multicentric, the most frequent sites are Gl tract, lymph nodes and lungs.

KS is a neoplasm which histologically is characterized by proliferation of large numbers of small capillaries and spindle cells most likely of endothelial origin.

TREATMENT

HIV positive man with rapid growing lesion on the left mandibular gingiva. Note the deep blue-magenta color. A biopsy proved this lesion to be Kaposi sarcoma. The clinical differential diagnosis of this mass should include: pyogenic granuloma, peripheral giant cell granuloma and lymphoma among the most frequent diagnostic possibilities.	This HIV infected male presented this large Kaposi sarcoma affecting the maxillary gingiva as well as the palate. (Courtesy Dr. S. Silverman)
Kaposi sarcoma of the palate, which is the most frequent intraoral location for this neoplasia. Note the typical dark-bluish color. This early lesion is easily treated with intralesional injections of sodium tetradecyl sulfate. (Courtesy Dr. F. Lucatorto)	30 year-old HIV infected man with multiple Kaposi sarcoma in the skin of chest, arms, neck and upper back. The color of these lesions is rusty-brown to dark purple and they do not blanch upon pressure.

Large intraoral lesions of KS can be treated with systemic chemotherapeutic single-agents such as vinblastine and vincristine. Multiple chemotherapeutic agents are used to treat patients with multicentric KS. Radiation therapy is also used in large lesions. Prior to radiation chlorhexidine gluconate should be prescribed. This antimicrobial rinse will diminish the severity of glossitis and mucositis which are radiation side-effects.

Small intraoral KS can be treated with surgical and laser excision. Nonsurgical treatment are also effective and they consist of intralesional injections of vinblastine sulfate, 0.1 mg per square centimeter of lesion.

Another effective method consists of intralesional injections with a 3% solution of the sclerosing agent sodium tetradecyl sulfate (Sotradecol). The injections consists of 0.1-0.2 ml. per square centimeter of lesion. Both these intralesional injectable methods are recomended for lesions of not more than 2.6 cm in diameter.

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