New Classification of Dental Diseases

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New Classification of Dental Diseases Cesar Augusto Migliorati Cesar Augusto Migliorati DDS, MS, PhD DDS, MS, PhD

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New Classification of Dental Diseases. Cesar Augusto Migliorati DDS, MS, PhD. New Classification June 2004. Classification of oral diseases of HIV- associated immune suppression (ODHIS) - PowerPoint PPT Presentation

Transcript of New Classification of Dental Diseases

Page 1: New Classification of Dental Diseases

New Classificationof Dental DiseasesNew Classificationof Dental Diseases

Cesar Augusto Migliorati DDS, MS, PhDCesar Augusto Migliorati DDS, MS, PhD

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New ClassificationJune 2004

New ClassificationJune 2004

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

Glick M, Abel SN, Flaitz CM, Migliorati CA, Patton LL, Phelan JA, Reznik DA (ODHIS Workshop

Group-USA, Dental Alliance for AIDS/HIV CARE – DAAC)

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Classification of oral diseases of HIV – associated immune

suppression (ODHIS)

Classification of oral diseases of HIV – associated immune

suppression (ODHIS)• Present classification systems for HIV –

associated oral lesions developed in the early 1990’s

• HAART

• Changing pattern of oral conditions

• New system needed

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Classification of oral diseases of HIV – associated immune

suppression (ODHIS)

Classification of oral diseases of HIV – associated immune

suppression (ODHIS)• System should reflect:

• Changes in epidemiology of oral lesions

• Therapeutics

• Development of lesions and immune systems

• Oral lesions to oral disease

• 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

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New ClassificationNew Classification

• 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

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Classification of oral disease of HIV- associated immune

suppression (ODHIS)

Classification of oral disease of HIV- associated immune

suppression (ODHIS)• Oral diseases do not belong exclusively to

one classification Group

• Overlap may exist

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Use for the New Classification

Use for 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

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Group 1. ODHIS associated with severe immune

suppression (CD4<200 cells/mm3)

Group 1. ODHIS associated with severe immune

suppression (CD4<200 cells/mm3)• Major recurrent aphthous ulcer

• Neutropenia-induced ulcers• Necrotizing ulcerative periodontitis• Necrotizing stomatitis• Cytomegalovirus (CMV)• Chronic HSV• Histoplasmosis• Esophageal, pseudomembranous, and

hypertrophic candidiasis• Oral hairy leukoplakia• Kaposi’s sarcoma

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Pseudomembranous Candidiasis

Pseudomembranous Candidiasis

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Esophageal CandidiasisEsophageal Candidiasis

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Hyperplastic CandidiasisHyperplastic Candidiasis

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Pseudomembranous Candidiasis / KS

Pseudomembranous Candidiasis / KS

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Kaposi’s SarcomaKaposi’s Sarcoma

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Kaposi’s SarcomaKaposi’s Sarcoma

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HistoplasmosisHistoplasmosis

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PeriodontitisPeriodontitis

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Consider:•Bacterial•Viral•Fungal•Combination

Silverman, Eversole, Truelove. Essentials of Oral Medicine. London, B.C. Decker, 2001.

Idiopathic Necrotizing Stomatitis

Idiopathic Necrotizing Stomatitis

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Necrotizing StomatitisNecrotizing Stomatitis

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Chronic HSVChronic HSV

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• Major recurrent aphthous ulcer• Increased frequency, harder to treat, atypical location

• Erythematous candidiasis• Salivary gland disease

• Drug induced low salivation• Facial palsy• Neuropathies

• Hyposalivation• Human papilloma virus (HPV)• Linear gingival erythema• Non-Hodgkin’s lymphoma

Group 2. ODHIS associated with immune suppression

(CD4,500 cells/mm3)

Group 2. ODHIS associated with immune suppression

(CD4,500 cells/mm3)

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Aphthous UlcerAphthous Ulcer

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Erythemathous CandidiasisErythemathous Candidiasis

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Linear Gingival ErythemaLinear Gingival Erythema

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Lymphoepithelial CystLymphoepithelial Cyst

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Human Papilloma VirusHuman Papilloma Virus

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Group 3. ODHIS assumed associated with immune

suppression

Group 3. ODHIS assumed associated with immune

suppression• More commonly observed

• Angular candidiasis• Herpes labialis• Intra-oral herpes• Minor aphthous ulcers

• Rarely reported• Bacillary epithelioid angiomatosis• Tuberculosis• Deep-seated mycosis (except histoplasmosis)• Molluscum contagiosum• Varicella Zoster Virus (VZV)

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Angular CandidiasisAngular Candidiasis

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HSV LabialisHSV Labialis

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Intra-oral HerpesIntra-oral Herpes

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Silverman, Eversole, Truelove. Essentials of Oral Medicine. London, B.C. Decker, 2001.

Minor Aphthous UlcersMinor Aphthous Ulcers

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CoccidiomycosisCoccidiomycosis

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Group 4. Therapeutically-induced oral diseases

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

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• Adverse reactions• Oral ulcers

• Stevens Johnson’s

• Taste changes

• Dryness

• Perioral paresthesia

• Thrombocytopenia

Antiretrovirals and Adverse ReactionsAntiretrovirals and Adverse Reactions

• Drugs• Indinavir

• Saquinavir

• Amprenavir

• Nevirapine

• Delavirdine

• Efavirenz

• Stavudine

• Didanosine

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Silverman, Eversole, Truelove. Essentials of Oral Medicine. London, B.C. Decker, 2001.

Ulcers – Medication Induced

Ulcers – Medication Induced

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Recurrent HSVRecurrent HSV

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Group 5. Emerging oral diseases

Group 5. Emerging oral diseases

• Human papilloma virus, several HPV types (may be associated with immune reconstitution)

• Erythema migrans

• Variants of Non-Hodgkin’s Lymphoma (NHL B-cell types)

• Epithelial neoplasms

• Aggressive interproximal dental caries

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HPV Genotypes

6 & 11

Condyloma AccuminatumCondyloma Accuminatum

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Squamous Cell CarcinomaSquamous Cell Carcinoma

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Patel, P. et al. Incidence of non-AIDS defining malignancies in the HIV Outpatient Study. 11 th CROI, San Francisco, CA 2004. Abstract 81

Trends in Cancer and HIVTrends in Cancer and HIV

- Between 1996-2002, KS and cervical cancer declined, not NHL

- Among Chicago clinic patientslung (RR = 3.63),HD (RR = 77.43),anorectal (RR = 5.03),melanoma (RR = 4.10),head/neck (RR = 9.96)

- Compared to general population, incidence has notably increased in HIV-infected individuals

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Aggressive Interproximal Caries

Aggressive Interproximal Caries