opic 150: AIDS.

The etiology, pathogenesis, clinical manifestations on the oral

mucous membrane, diagnosis. Treatment and prevention. The tactics of dentist.

Questions for the control of students' knowledge.
1. Etiology and pathogenesis of AIDS.
2. General clinical manifestations of AIDS. Classification of clinical stages of HIV infection.
3. Manifestations in the oral cavity of HIV-infection. Groups of manifestations.
4. The clinic, diagnosis, differential diagnosis, treatment appearances on the oral mucosa, which
occur most often: candidiasis, hairy leukoplakia, HIV gingivitis, periodontitis HIV, herpes lesions of
Kaposi's sarcoma, lymphoma non - Godzhkin.
5. The tactics of dentist. Dental aspects of HIV infection.
1.Quantity of hours - 2 hours.
2. Substantiation of topic:
HIV infection is a quite common, serious and insidious human disease. The disease is highly
contagious and spreads exponentially, dramatically reducing the immune function of the body (hence its
name - AIDS - Acquired Immune Deficiency Syndrome). Transmission is carried out by contact and
sexual way, through blood and blood products, including donated blood, through damaged skin and oral
mucosa membrane, through breast milk, tears and saliva of HIV-infected patients. The high concentration
of HIV is the causative agent in the blood, semen, cerebrospinal fluid and less in milk, saliva and tears.
Dentist in his professional work is constant contact with the blood and oral liquid of patient and
should clearly demonstrated safety by using hand gloves and face masks, working in the mouth only by
dental tools.
In the absence of these measures of protection the risk of self-infection of medical staff and
patients with disorders of the oral cavity can be very significant.
Therefore, dentists should know well the route of infection, the mechanism of formation and
development of AIDS in humans, as well as general and local manifestations of the disease on OMM and
periodontal tissues. This will prevent possible HIV - infection and immediate action to clarify the
diagnosis.
The contingents of the increased social risk are drug addicts, homosexuals, people conducting chaotic
sexual life.
3. Purpose of theme:
General: to deepen the students' knowledge about HIV transmission, the mechanism of development of
the symptomatology and course of HIV infection, lesions of OMM. Know the clinical manifestations of
AIDS. Focus on how to prevent HIV infection at work in dental offices with protection of dental patients
and medical staff.
The specific objectives are:
- Distinguish the characteristics of the psychological state of the patient with AIDS, which requires
special tactics behavior of dentist;
- substantiate and prescribe appropriate methods of examination in AIDS;
- To do a differential diagnosis;
- Peculiarities of the local manifestations of AIDS treatment in the mouth.
a) to know:
- Etiology and pathogenesis of AIDS;
- linic of all forms of gingivitis,
- linic of all forms of periodontitis,
- linic of herpetic diseases, ulcerative, candidose stomatitis;
- What is the symptomatic treatment;
- What is the general treatment;
- Arsenal of drugs that is used for a variety of disease states and their mechanism of action and
pharmacodynamics,
- Where to refer a patient with suspected HIV infection and AIDS.
b) to be able to:
- Conduct a examination of patients with manifestations of AIDS in the mouth,
- To analyze the obtained results,

- A diagnosis on the basis of the data obtained,

- To determine the behavior of the doctor tactics HIV infected, and AIDS,
- To prescribe drugs for symptomatic treatment of AIDS manifestations in the oral cavity,
- Identify ways of AIDS preventing.
4. Graf of logical structure.

HIV / AIDS
etiology

The group of retroviruses

(human immunodeficiency
virus)

The source of infection

Clinical manifestations
(classification by V.I.
Pokrovsky 1989)

HIV - infected person

Ways of transmission

pathogenesis
The defeat of T4
lymphocytes and their death
Violation of cellular
immunity, loss of body
resistance to pathogenic
microflora

The organism is sensitive to

a number of non-specific
infections and tumors

Sexual, parenteral, and

perinatal

1. Incubation stage
2. Stage of primary
manifestations
3. Stage of secondary
manifestations
4. The terminal stages

Manifestations in the oral cavity

Group 1 - directly connected

with HIV
1. Candidiasis (erythematous,
hyperplastic,
psevdamembranose).
2. Hairy leukoplakia.
3. HIV gingivitis.
4. Necrotizing ulcerative
gingivitis.
5. HIV-periodontitis.
6. Kaposi's sarcoma.
7. Non-Hodgkin's lymphoma.

Group 3 - lesions probably associated with HIV infection:

1. Bacterial infections (excluding gingivitis, periodontitis) actinomycosis, tuberculosis.
2. Cat scratch disease.
3. Exacerbation of apical periodontitis.
4. Fungal infection non-candidose etiology (cryptococcosis,
geotrichosis, histoplasmosis, mucormycosis).
5. Melanin hyperpigmentation.
6. Neurological disorders (trigeminal neuralgia, facial paralysis).
7. Osteomyelitis.
8. Sinusitis.
9. Inflammation of the submandibular fat (abscess, cellulitis).
10. Squamous cell carcinoma.
11. Toxic epidermal necrolysis.

Group 2 - rarely connected

with HIV
1. Atypical ulceration
(oropharyngeal).
2. Idiopathic
thrombocytopenic purpura.
3. Diseases of the salivary
glands (xerostomia, single or
bilateral enlargement of the
salivary glands).
4. Viral infections (other than
caused by the Epstein-Barr
virus) cytomegalovirus
infection, caused by the herpes
simplex virus, human
papillomavirus, varicella
zoster virus (herpes zoster,
varicella).

Deferential diagnosis

Diagnosis

infectious diseases that are manifested in

the mouth

Data of questioning, physical

examination

Examination at the AIDS Centre

HIV / AIDS
Treatment

Antiretroviral therapy

Inhibition of opportunistic,
parasitic, viral, fungal or
protozoal infections, available
to the individual patient and
defining clinic disease

Possible
cancer treatment

Correction of drugs immunodeficiency

Dental aspects of
AIDS
prevention

Compliance with safety regulations when working with

patients - carriers of infection

If possible, to work by materials and tools one-time use

Disinfection and sterilization of reusable materials to

conduct according to the sanitary requirements

At the end of the working day to process the surface of

tables and dental devices according to the sanitary
requirements

5. The material and methodological support topics: tools, out-patient medical history, medications,
Atlas of OMM diseases, computer support, workbooks, tests, case-patients.
6. Materials to provide practical training.

Human immunodeficiency virus (HIV) is the causative agent of an infectious disease that
bears the name of HIV infection and acquired immunodeficiency syndrome manifests itself
(AIDS), which is expressed in the reduction of the total resistance of patients to opportunistic
pathogens and increased susceptibility to cancer. Human immunodeficiency virus belongs to the
retroviruses. HIV infects T4 lymphocytes and causes their death. As a result, impaired cellular
immune system and the body lose resistance to pathogenic microflora, becomes susceptible to a
number of non-specific infections and tumors.
The source of infection is HIV-positive person. At virus carriers pathogen is found in
various biological fluids (blood, semen, vaginal secretions, breast milk, saliva, tears, sweat, etc.).
However, transmission of infection is only through blood, semen, vaginal secretions and breast
milk.
Three ways of HIV transmission are known: sexual, parenteral, and perinatal. When
parenteral transmission of HIV infected persons are the source of infection in the first days after
infection. And from which moment after infection, the infected becomes a source of infection in
the sexual transmission of HIV - is unknown.
History of HIV infection is characterized by a number of features. First, until now no
reliable cases sanation registered persons infected by HIV. Second, HIV infection is
characterized by a long-term period of relative prosperity, well-being when the patient has no
effect on his social or biological activity. It not only keeps the disabled, but can be a source of
active infection. The third feature of HIV infection - a high, close to 100% mortality.
Of the large number of classifications of HIV infection for clinical dispensary observation
and the most convenient classification VI Intercession (1989)
1. Stage of incubation.
2. Stage of primary manifestations.
A. Acute infection.
B. Asymptomatic infection.
C. Persistent generalized lymphadenopathy.
1. Stage of secondary diseases.
A. The decrease in body weight less than 10%, fungal, viral, bacterial skin and mucous
membranes, shingles, repeated pharyngitis, sinusitis.
B. The decrease in body weight of more than 10%, unexplained fever or diarrhea persisting
more than 1 month., Pulmonary tuberculosis, recurrent or persistent viral, bacterial, fungal,
protozoan internal organ, hairy leukoplakia, or re-disseminated herpes zoster, recurrent or
persistent (at least 2 mo.) skin ulceration, localized Kaposi's sarcoma.
C. Generalized bacterial, viral, fungal, protozoal and parasitic diseases; pnevmotsite
pneumonia, esophageal candidosis, generalized tuberculosis, atypical mycobacterioses,
cachexia, disseminated Kaposi's sarcoma, CNS disease of various etiologies.
2. Terminal stage.
Incubation stage (stage I) - from the time of infection until the reaction of the body in
the form of clinical manifestations of the "acute infection" or antibody production. Duration it is
usually from 3 weeks to 3 months, but in rare cases may increase to 1 year.

Acute infection (stage 2A) accompanied by a fever of varying severity, events

pharyngitis, lymphadenopathy, enlarged liver and spleen disorders chairs, and a variety of nonpersistent (urticaria, papular, petechial) skin rash. Possible meningeal phenomena. The duration
of this stage varies from a few days to several months. However, usually acute infection stage
duration is about 2-3 weeks, after which disease into one of the following phases: asymptomatic infection (2B) or persistent generalized lymphadenopathy (2B).
Possible recurrence of clinical signs of acute infection. In rare cases, acute infection can,
passing the phase of asymptomatic infection or persistent generalized lymphadenopathy, enter
the phase of secondary diseases.
Phase asymptomatic infection (2B) is characterized by the absence of any clinical signs
of the disease, there may be a moderate increase of the lymph nodes.
A characteristic feature of phase 2C is a "persistent generalized lymphadenopathy"
(increase of no less than two lymph nodes in two different groups, except inguinal, in adults up
to the size of more than 1 cm, the children of more than 0.5 cm in diameter, persisting for at least
3 months ). Persistent generalized lymphadenopathy may occur in the later stages of HIV
infection, but in the stage 2B, it is the only clinical symptom.
Asymptomatic infection and persistent generalized lymphadenopathy occur after the
acute stage of infection or immediately after the incubation step. Phases 2B and 2C can be
interleaved. In general, the stage of the primary manifestations characterized by a relative
equilibrium between the host immune response and the action of the virus. Its length can vary
from 2-3 to 10-15 years. At that time, HIV-infected fully active as his sources.
With progression of the disease in patients clinical symptoms begin to appear, indicating
a deepening deterioration of the immune system, which characterizes the transition of HIV
infection to secondary disease (stage 3). Stage 3A usually begins after 3-5 years after infection.
It is characterized by bacterial, fungal and viral lesions of the mucous membranes and skin,
inflammatory disease of the upper respiratory tract.
On stage 3B (5-7 years after infection) skin lesions deeper and more prone to prolonged
duration, progressing to the internal organs. May experience localized Kaposi's sarcoma,
moderately expressed constitutional symptoms, disorders of the peripheral nervous system.
stage 3B (7-10 years) is characterized by the development of severe, life-threatening
secondary diseases, their generalized, lesions of the central nervous system.
In the terminal stage (stage 4) of HIV occurred in patients with lesions of the internal
organs and systems are irreversible, one replaces the other disease. Even the adequacy of
treatment of secondary diseases is ineffective, and the patient dies within a few months.
These terms of development stages of the disease are the average character. In a number
of cases the disease develops rapidly and in 2-3 years passes in terminal stage.
In addition to the general symptoms is quite common in HIV-infected and AIDS patients
observed various lesions of the oral cavity. They have considerable diagnostic value, as it allows
easier and more likely to identify the manifestation of AIDS patients and the medical staff to
avoid infection. The manifestation of AIDS in the mouth are quite varied, making it difficult to
systematize them.
In August 1990, in Amsterdam, the working group of leading Europen dentists have
proposed a classification of oral manifestations of HIV infection. Proposed distinguish three
groups of symptoms based on the likelihood connection with HIV infection.
The first group - the defeat of OMM directly associated with HIV:
1. Candidosis (erythematous, hyperplastic, psevdamembranose).
2. Hairy leukoplakia.
3. HIV gingivitis.
4. Necrotizing ulcerative gingivitis.
5. HIV-periodontitis.
6. Kaposi's sarcoma.
7. Non-Hodgkin's lymphoma.

The second group - the defeat, rarely associated with HIV infection:
1. Atypical ulceration (oropharyngeal).
2. Idiopathic thrombocytopenic purpura.
3. Diseases of the salivary glands (xerostomia, single or bilateral enlargement of the
salivary glands).
4. Viral infections (other than caused by the Epstein-Barr virus) cytomegalovirus
infection, caused by the herpes simplex virus, human papillomavirus, varicella zoster virus
(herpes zoster, varicella).
The third group - loses, probably associated with HIV infection:
1. Bacterial infections (excluding gingivitis, periodontitis) - actinomycosis, tuberculosis.
2. Cat scratch disease.
3. Exacerbation of apical periodontitis.
4. Fungal infection non-candidose etiology (cryptococcosis, geotrichosis, histoplasmosis,
mucormycosis).
5. Melanin hyperpigmentation.
6. Neurological disorders (trigeminal neuralgia, facial paralysis).
7. Osteomyelitis.
8. Sinusitis.
9. Inflammation of the submandibular adipose tissue (abscess, cellulitis).
10. Squamous cell carcinoma.
11. Toxic epidermolysis.
Most authors think that the first manifestation of HIV infection are hitting the mouth. For
others, the oral cavity is affected in the terminal stage (AIDS) when the number of T4
lymphocytes in 1 mm3 of blood is decreased to 200. According to the frequency of occurrence of
oral lesions as follows: candidosis (88%), herpetic lesions (11-17%), dry mouth (19-28%),
exfoliative cheilitis (9%), ulceration (7%), desquamative glossitis (6 %), hairy leukoplakia (5%),
Kaposi sarcoma (4-50), hemorrhage.
Then the teacher expands on the clinical manifestations of the above oral lesions in HIV
infection and their differential diagnosis.
Treatment. To combat AIDS are new approaches based on new technologies (gene
therapy, intracellular immunity). And among the drugs that are used in the world for AIDS, the
most common is azidothymidine. Except the last one, are widely used suramin, acyclovir,
proofreaders immunity (interleukin, gamma globulin, izoprinozin).
The tactics of dentist. For a dentist in the treatment of these patients is to provide them
basic symptomatic relief and sanation of the mouth.
Dental aspects of AIDS prevention.
Considering the clinical features of AIDS dentist may be first doctor, suspecting the
disease. Moreover, the dentist should take an active role in identifying HIV-infected patients.
Although in the saliva of HIV-infected people and AIDS virus is found in small quantities, a
dentist must be aware that he belongs to the group of the highest professional risk.
For dentists there is a risk of getting HIV from casual bites AIDS patients or carriers of
the virus, getting their saliva on broken skin or mucous membranes of the doctor when injured
tool that has been used for the treatment of patients. Besides, the use of the turbine drill can
cause hospital infections, such as AIDS and hepatitis B.
Dentists recommend these preventive measures:
- Obtain information on possible risk factors in a patient;
- Antiseptic skin of hands and work gloves;
- The use (if possible) tools, materials, burs, endodontic instruments one-off;
- Perfect sterilization and disinfection materials used repeatedly;
- Mandatory use of safety goggles and masks;
- Regularly with chair, dental equipment and other equipment appropriate disinfectants;

- When droplets of blood or saliva on the skin, face to wash them with water and then
treated with an alcohol, 3% hydrogen peroxide, 0.57% sodium hypochlorite or other means.
Adequate prevention techniques make it possible to avoid HIV infection, even in the case
of working with a group of risk. Therefore, personal protective equipment must be all the
medical personnel (use of gloves, protective glasses, masks, special gowns and caps).
Need to avoid injuries by instruments that contact with the patient's blood and saliva. To
significantly reduce spray is not recommended to use a turbine dental drill. Significantly reduces the
aerosol pollution workplace air koferdama use.
Gloves and masks should to change after each patient. Hands should be washed under running
water and process 4% solution of chlorhexidine. Gowns should have less seams and tightly close the
chest. Desirable to use disposable gowns with synthetic fabric.
Sterilization of instruments. HIV is rapidly inactivated by using a wet or dry sterilization.
Dental tools reusable (including impression trays) previously soaked in a solution of sodium hypochlorite,
and then use a cool way - processed with 1% solution of glutaraldehyde or sterilized in autoclave with
ethylene oxide.
Before sending impressions to a laboratory them should be placed for 15 minutes in a 1% solution of
glutaraldehyde or 0.5% sodium hypochlorite. For disinfection using 1% solution of glutaraldehyde, 25%
solution of ethyl alcohol with propionolactone in a ratio of 1:400, 0.2% sodium hypochlorite solution
with 0.35% formalin solution. At a temperature of 56 C virus inactivated for 30 min. Careful
compliance with the conditions guarantee the complete inactivation of the virus. Improves the
presterilizing preparation is use of ultrasonic cleaning machine.
7. Practical skills on the topic:
1. Conducting a clinical examination of the patient with AIDS: trustee contact with patients,
2. special attention to the complaints, not only from the mouth, but also from the organs and systems;
determine anamnesis of disease, personal history to determine possible exposure routes, with an objective
study, pay attention to the body temperature, blood pressure, pulse, state of the lymph nodes, skin color
and the presence of lesions on the skin. In the mouth to reveal the presence of elements of defeat, paying
particular attention to the changes associated with tumor-like growths, hyperkeratosis.
3.Material capture for cytologic and bacteriological researches
4 . Analysis of results of cytologic and bacteriological research, clinical analysis of blood.
5 . Medical record registration, scheduling of inspection and treatment of the patient by AIDS;
6 . Direction invoicing in the AIDS center;
7 . Carrying out application anesthesia.
8 . Conducting irrigation, applications of drugs.
8. Terminology (in Latin script).
Acquired immunodeficiency syndrome (AIDS, eng. AIDS - Acquired immune dificiecy syndrome) (syndromum immunodefectionis aguisitae).
9. Questions for the control of students' knowledge.
1. Etiology and pathogenesis of AIDS.
2. General clinical manifestations of AIDS. Classification of clinical stages of HIV infection.
3. Manifestations in the oral cavity of HIV-infection. Groups of manifestations.
4. The clinic, diagnosis, differential diagnosis, treatment appearances on the oral mucosa, which
occur most often: candidiasis, hairy leukoplakia, HIV gingivitis, periodontitis HIV, herpes lesions of
Kaposi's sarcoma, lymphoma non - Godzhkin.
5. The tactics of dentist. Dental aspects of HIV infection.
10. Tasks "CROK 2".
1. Doctor, treated patient with HIV. A mixture of liquid from the mouth to the patient accidentally
get in the eye. What are the priority actions of the doctor?
A. Eye drip solution of 1% atropine.
B. Rinse the eye with isotonic solution.
C. Rinse the eye with a weak solution of alkali.
D. Rinse the eye with plenty of water.
E. Rinse the eye with 2% solution of boric acid.
2. At 25 years old patient was identifed foci of necrosis along the gingival margin in both jaws.
Leads chaotic lifestyles, using drugs. In the last month, noted the weakness, the constant increase
of body temperature up to 37,3-37,5 C, diarrhea, weight loss of 15 kg. The facial skin with an

3.

4.

5.

6.

7.

8.

earthy shade. Looks older than his years. Submandibular, chin, neck and axillary lymph nodes
were enlarged, painless, mobile. What is the most likely initial diagnosis?
A. Vitamin deficiencies.
B. Acute leukemia.
C. Agranulocytosis.
D. Vincent gingivitis.
E. AIDS.
The patient 21 years old has manifestations of necrotizing stomatitis. During 3 months noted
weakness, fever up to 37,5 C, drastic weight loss. On examination: pale face, lymph nodes are
enlarged, painless. What is the most likely diagnosis?
A. Vincent's stomatitis
B. agranulocytosis
C. acute leukemia
D. AIDS
E. hypovitaminosis
At the dispensary examination of 20 year old student 20 was found chronic oral candidiasis,
generalized lymphadenopathy. In the history for a year frequent herpes simplex disease. Body
temperature constantly increased to 37,4-37,5 C, weight loss during the last month to 8 kg.
What disease can indicate this symptom?
A. Chronic leukemia.
B. Acquired immunodeficiency syndrome (AIDS).
C. Acute leukemia.
D. Hodgkin's disease.
E. infectious mononucleosis
A patient 36 years complains of discomfort when eating, fever, malaise, enlarged lymph nodes.
Smoke, consume alcohol in moderation. Three years ago was on business trip in Africa.
OBJECTIVE: submandibular, cervical, axillary lymph node palpation increased, mobile, painless.
On the first lateral surface portions whitish filiform papillae 3-4 mm long. What research is
needed to confirm the diagnosis? A. General blood test.
B. A blood test for RW.
C. A blood test for HIV.
D. A blood test for sugar.
E. Rheumatic sample.
6. On examination of the 23 years old patient was founded chronic candidiasis on the oral mucous
membrane, generalized lymphadenopathy. In history: during the year is sick of herpes. Body
temperature constantly rises to 37,4 - 37,5 C, the weight of the body for the last month
decreased by 8 kg. What disease can indicate this symptom?
A. chronic leukemia
B. infectious mononucleosis.
C. Candidiasis of the oral mucosa
D. AIDS
E. acute leukemia
The disease caused by a retrovirus, with a selective involving T-cell immunity (T-lymphocytes, X
-macrophages,) and nerve cells:
A. infectious mononucleosis
B. leukosis
C. murrain
D. AIDS
E. Chronic recurrent herpes
8. Symptom complex - swollen lymph nodes, prolonged fever, chronic diarrhea, progressive
weight loss, chronic inflammatory and pustular skin lesions and mucous membranes, pneumonia,
resistant to conventional therapy are are typical for:
A. leukemia
B. diabetes
C. Ulcerative colitis
D. hyperchromic anemia
E. AIDS

The appearance on the mucous membrane of the mouth of Kaposi's sarcoma is characteristic for :
A. syphilis
B. Wegener's granuloma
C. AIDS
D. tuberculosis
E. Gonorrhea
10. On examination, the patient was suspected on AIDS disease, what should be done:
A. Submit to the AIDS Center
B. Observe patient ambulatory
C. Call for consultation infectionist
D. A blood lead test
E. Urgently hospitalized patient in the infectious disease clinic or hospital
11. For the AIDS diagnosis in oral cavity not carry information:
A. medical history
B. General clinical signs
C. The results of immunological studies
D. These microscopic lesions
E. General blood test
9.