Frequent Oral Diseases in HIV Positive and AIDS Patients

Dr. Heddie O. Sedano, DDS

Necrotizing Ulcerative Periodontitis (NUP)

This particular type of gingivitis is generally seen in AIDS patients with advanced immune suppression, that is with CD4+ cell counts below 100 cell per mm3. NUP may involve only a few teeth but in severe cases it may affect all teeth. Generally it is preceded by intense pain, patients complain of severe bone pain as if the teeth were hitting the bone. Clinically there is marked necrosis of soft tissue with rapid periodontal ligament and bone destruction. Pocket formation is usually absent. Spontaneous gingival bleeding is also part of the clinical findings. NUP is very similar to the type of ANUG seen in patients which are not immuno compromised but it is much more severe and produces marked pain. Non-AIDS associated ANUG as a rule does not produce bone resorption unless it recurs periodically. The soft tissue involvement of NUP may resemble the appearance of intraoral lymphomas.

NUP Case #1 - This 26 year old HIV+ man had this marked retraction and necrosis of the anterior mandibular gingiva. According to the patient the lesion started three days before consultation with a dull ache in the area. There is no history of trauma or any previous episode of periodontal disease. No other areas of the oral cavity were affected. The diagnosis of NUP was established.

NUP Case #2 - Another example of NUP in a 46 year old HIV+ male. Note the marked gingival erythema and necrosis with root exposure. The patient had a constant deep seated pain and increased body temperature.

• Gentle debridement of affected areas to minimize bleeding and pain.
• Irrigation with 10% Betadine (providone-iodine) to aid debridement.
• If possible root planning and scaling under local anesthesia again with 10% Betadine as irrigant.
• Instruct patient to maintain a methodical and careful oral hygiene regimen.

• Rx: Metronidazole (Flagyl) 250 mg tablets
• Disp: 24 Tablets
• Sig: 1 Tab. 4 times a day
  NOTE: Refill if needed for one more week

If the patient presents with severe pain, necrosis and fever, then penicillin need to be prescribed (either of the two prescriptions below):

• Rx: Amoxicillin (Amoxil) 500 mg Tablets
• Disp: 24 Tablets
• Sig: 1 Tab. 4 times a day

• Rx: Clindamycin (Cleocin) 300 mg capsules
• Disp: 24 Capsules
• Sig: 1 Cap. 4 times a day

If the patient is allergic to penicillin, then prescribe:

• Rx: Erythromycin enteric coated 500 mg Tablets
• Disp: 24 Tablets
• Sig: 1 Tab. 4 times a day

The patient should be reevaluated after one week of treatment and the medication should be reinstated if the response is not satisfactory. Recalls every four weeks are recommended until total stabilization, then control check-ups every three to four months.

• Rx: Chlorexidine gluconate (Peridex), 0.12%
• Disp: 2 x 16 oz bottle
• Sig: 15 or 20 ml, 30 seconds oral rinse 2 times per day
  The patient should be warned that Chlorexidine gluconate will stain the teeth and also the tongue.