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

Upper Limb Anatomy-MCQ

01.Regarding pronator teres which of the following statements is correct?

a)      It forms the lateral border of the cubital fossa

b)      It arises from the coronoid process and lateral epicondyle.

c)      The Median nerve passes deep to both heads

d)     It’s medial border forms the medial boundary of the cubital fossa

e)      It is the most lateral of the superficial flexors of the forearm

02.Regarding the radial nerve which statement is incorrect?

a)      It passes anterior to the lateral epicondyle of the humerus

b)      Injury to the radial nerve from fracture of the shaft of the humerus will result in wrist drop

c)      Injury to the deep radial nerve in the mid forearm will prevent extension only at the MCPJs

d)     Sensory loss from injury to the superficial radial nerve will usually result in loss of sensation over the entire thumb

e)      It is the larger terminal branch of the posterior cord of the brachial plexus

03.Regarding the blood supply of the forearm

a)      The radial artery is the larger of the terminal branches of the brachial artery

b)      The radial artery runs under brachialis as it leaves the cubital fossa

c)      The radial artery has just one named branch proximal to the carpal braches

d)     Ligation of the radial artery at its origin will significantly reduce blood flow through the posterior interosseous artery.

e)      The radial artery has no involvement in the elbow anastomotic network

04The median nerve

a)      Supplies flexor carpi ulnaris and half of flexor digitorum profundis

b)      Gives rise to most of its braches in the upper arm

c)      Gives rise to the common interosseous nerve which divides anterior to the radial head

d)     May be compressed between the two heads of pronator teres

e)      Enters cubital fossa lateral to the brachial artery

Answers

1) E

2) D

3) C

4) D

Anatomy MCQs (Thorax)-12 Questions

1-      Regarding the intercostal nerve all the following are True, EXCEPT:

a-      7^th Intercostal nerve is typical

b-      End by anterior cutanous nerve

c-       2^nd will supply the skin of axilla (lateral branch)

d-      Communicate with sympathetic trunk through rami communication

e-      Located below the arteries

Answer- a

2-      Regarding intercostal arteries:

a-      are superior to veins & nerves

b-      musculophrenic artery will supply 7^th to 9^th intercostals spaces

c-       all the posterior branches are from the aorta

d-      the collateral branch supply the lung

e-      all the anterior branches are from the internal thoracic

Answer- b

3-      All the following are in the Rt atrium, EXCEPT:

a-      azygos vein

b-      anterior cardiac vein

c-       coronary sinus

d-      SVC

e-      IVC

Answer- a

4-      Regarding Rt ventricle all the following are True, EXCEPT:

a-      have three papillary muscle

b-      the  septomarginal trabecula (moderator band) extend from the septum to the base of the anterior papillary muscle

c-       have a pectinate muscle which passes anteriorly

d-      The outflow portion of the champer inferior to the pulmonary  orifice called infandibulum

e-      The infandibulum is smooth and the remainder of the ventricle is rough

Answer- c

5-      X-ray of the Lt border of mediastinum show the following, EXCEPT:

a-      left auricle

b-      aortic arch

c-       pulmonary trunk

d-      left ventricle

e-      right atrium

Answer- e

6-      superior mediastinum shows all the following, EXCEPT:

a-      trachea

b-      ascending aorta

c-       arch of aorta

d-      left brachiocaphalic vein

e-      vagus nerve

Answer- b

7-      Regarding the Arch of the aorta, the incorrect statements is:

a-      Located in superior mediastinum

b-      Located below the brachiocaphalic vein

c-       Connected to the pulmonary trunk by ligamentum arteriosum

d-      It is arches over the Lt main bronchus

e-      The Rt recurrent laryngeal nerves hocks around it

Answer- e

8-      the correct statement about Thoracic duct is:

a-      it is enter to the thorax through caval opening

b-      it lies posterior to the esophagus in the superior mediastinum

c-       it lies in the superior & posterior mediastinum

d-      drain into Rt subclavian vein

e-      it receives the lymph from both lungs

Answer- c

9-      Regarding pericardium:

a-      visceral part supplied by phrenic nerve

b-      Fibrous pericardium consist of visceral & parietal parts

c-       serous pericardium down represent the attachment of central tendon of diaphragm

d-      Located laterally to the esophagus

e-      The oblique sinus is bounded anteriorly by the visceral layer of serous pericardium

Answer- e

10-   All the following are related posteriorly to the heart, EXCEPT:

a-      Oblique sinus

b-      Rt bronchus

c-       Thoracic aorta

d-      Lt vagus

e-      Esophagus

Answer- b

11-   Regarding Rt main bronchus all the following are True, EXCEPT:

a-      wider than the Lt

b-      longer than the Lt

c-       more vertical than the Lt

d-      bacteria pass through it easily

e-      gives off the Rt superior lobe bronchi before entering the hilum

Answer- b

12-   Regarding the pleura the incorrect statement is:

a-      cervical part is above the clavicle

b-      diaphragmatic pleura supplied by intercostal nerves ONLY

c-       cervical pleura is crossed by subclavian vessels

d-      pleural cavity is a potential space

e-      the visceral & parietal pleurae are continuous around the root of the lung

Answer- b