Classification of oral diseases of HIV- associated immune suppression (ODHIS)


         Present classification systems for HIV – associated oral lesions developed in the early 1990’s which was named as HAART. Patterns of oral conditions keep on changing very frequently. This highlights the need of new system.

Classification of oral diseases of HIV – associated immune suppression (ODHIS)

System should consider:
·         Changes in epidemiology of oral lesions
·         Therapeutics
·         Development of lesions and immune systems
·         Oral lesions to oral disease

Definition of Oral disease:  abnormality characterized by a defined set of signs and symptoms in the oral cavity, extending from the vermilion border of the lip to the oropharynx, with the exception of salivary gland disease

New Classification- Classification of oral diseases of HIV – associated immune suppression (ODHIS)
Group 1 – ODHIS associated with severe immune suppression (CD4<200 cells/mm3)
Group 2 – ODHIS associated with immune suppression (CD4<500 cells/mm3)
Group 3 – ODHIS assumed associated with immune suppression
A) More commonly observed
B) Rarely reported
Group 4 – Therapeutically-induced oral diseases
Group 5 – Emerging oral diseases
Oral diseases do not belong exclusively to one classification Group
Overlap may exist

Use of the New Classification
·         Identifying undiagnosed individuals
·         Provides additional rationale for HIV testing
·         Affects access and type of HIV-related healthcare
·         Provides clinical markers for therapeutic interventions and efficacy

Group 1. ODHIS associated with severe immune suppression (CD4<200 cells/mm3)
1.      Major recurrent aphthous ulcer
2.      Neutropenia-induced ulcers
3.      Necrotizing ulcerative periodontitis
4.      Necrotizing stomatitis
5.      Cytomegalovirus (CMV)
6.      Chronic HSV
7.      Histoplasmosis
8.      Esophageal, pseudomembranous, and hypertrophic candidiasis
9.      Oral hairy leukoplakia
10.   Kaposi’s sarcoma
11.   Idiopathic Necrotizing Stomatitis    

Hyperplastic candidosis

Oesophageal candidosis

Pseudomembranous Candidosis

Kaposi's Sarcoma

Histoplasmosis
Periodontitis
Neccotizing Sialometaplasia
Chronic HSV

Group 2. ODHIS associated with immune suppression (CD4,500 cells/mm3)
1.       Major recurrent aphthous ulcer
2.       Increased frequency, harder to treat, atypical location
3.       Erythematous candidiasis
4.       Salivary gland disease
5.       Drug induced low salivation
6.       Facial palsy
7.       Neuropathies
8.       Hyposalivation
9.       Human papilloma virus (HPV)
10.   Linear gingival erythema
11.   Non-Hodgkin’s lymphoma
12.   Linear Gingival Erythema

Aptheous Ulcer
HPV

Group 3. ODHIS assumed associated with immune suppression
More commonly observed
1.       Angular candidiasis
2.       Herpes labialis
3.       Intra-oral herpes
4.       Minor aphthous ulcers
Rarely reported
1.       Bacillary epithelioid angiomatosis
2.       Tuberculosis
3.       Deep-seated mycosis (except histoplasmosis)
4.       Molluscum contagiosum
5.       Varicella Zoster Virus (VZV)
6.       HSV Labialis
7.       Intra-oral Herpes
8.       Minor Aphthous Ulcers
Angular Chelitis with candidosis

Group 4. Therapeutically-induced oral diseases

Side-effect
·         Melanotic hyperpigmentation
·         Ulcers
·         Hyposalivation
·         Lichenoid drug reaction
·         Neutropenia-induced ulcers
·         Thrombocytopenia
·         Lypodystrophy-associated oral changes
·         Perioral paresthesia
·         Steven Johnson’s?
·         Exfoliative cheilitis?

Resistance-induced disease
·         Different Candida spp and strains
·         HSV

Antiretrovirals and Adverse Reactions

Antiretroviral Drugs
Indinavir
Saquinavir
Amprenavir
Nevirapine
Delavirdine
Efavirenz
Stavudine
Didanosine

Recurrent HSV
Adverse reactions of antiretroviral drugs
Oral ulcers
Stevens Johnson’s
Taste changes
Dryness
Perioral paresthesia
Thrombocytopenia
Ulcers – Medication Induced
Recurrent HSV

Group 5. Emerging oral diseases
1.       Human papilloma virus, several HPV types (may be associated with immune reconstitution)
2.       Erythema migrans
3.       Variants of Non-Hodgkin’s Lymphoma (NHL B-cell types)
4.       Epithelial neoplasms
5.       Aggressive interproximal dental caries
6.       Condyloma Accuminatum
7.       Squamous Cell Carcinoma

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