48: Therapeutic Management of Oral Lesions in the Immune-Competent and the Immune-Compromised Patient in the Dental Setting

48

Therapeutic Management of Oral Lesions in the Immune-Competent and the Immune-Compromised Patient in the Dental Setting

OVERVIEW

The common oral lesions seen in the immune-competent and the immune-compromised patient will be collectively discussed because many of the lesions in the two populations overlap. However, the severity and duration often differ.

Immunity can be compromised because of many factors including HIV/AIDS, chemotherapy, radiotherapy, leukemias, lymphomas, connective tissue disorders, and poorly controlled diabetes. Stress, chronic corticosteroid therapy, severe sun exposure, and broad-spectrum antibiotic use are often the cause of oral lesions in the immune-competent patient. Thus, presence of oral lesions by themselves is not diagnostic of HIV infection or other causes of decreased immunity.

With the presence of oral lesions, the clinician must assess the medical history and decide if appropriate laboratory tests need evaluation to confirm the presence or absence of all causes of decreased immunity, including HIV infection. However, once confirmed, the underlying cause or disease state should be addressed and appropriately managed along with the care of the oral lesions.

When treating an HIV patient, the dentist must refer a formerly asymptomatic, untreated, known HIV patient to the physician upon discovery of new oral lesions. The physician will evaluate the patient’s current health status, including the CD4 count and the viral load, to determine if antiretroviral treatment is necessary. The oral lesions can resolve with improvement of the patient’s immunity following antiretroviral treatment. Recurrence of oral lesions following resolution in the HIV/AIDS patient can indicate failure of oral lesion therapy or worsening of the HIV infection. In spite of tremendous advances in antiretroviral therapy, oral lesions do occur and they must be appropriately managed.

The oral lesions have a tendency to recur more often with reduction of immunity, and in the HIV patient it can herald the start of the symptomatic phase. Oral herpes simplex or zoster, oral and/or esophageal candidiasis, angular chilities, xerostomia, and aphthous ulcers can affect the immune-competent or the immune-compromised patient.

Oral viral leukoplakia (OVL) or hairy leukoplakia (HL), HIV-gingivitis, HIV-periodontitis, HIV necrotizing stomatitis, Kaposi’s sarcoma, cytomegalovirus, or papilloma virus infections are found only in the HIV/AIDS patient. Oral lesions occur in 30–80% of the affected patient population and highly active antiretroviral therapy (HAART) has decreased the incidence, frequency, and severity of most, but not all, HIV-associated oral lesions.

Table 48.1 Prescriptions Management of Oral Lesions in the Immune-Competent and the Immune-Compromised Patient

Infection/Lesion; Medication(s);
Drug Category
Prescription/Treatment Guidelines
HERPES SIMPLEX:
Valacyclovir (Valtrex):
Prganancy Category B
1. Rx: Valtrex caplet, 1g/caplet
Disp: 4 caplets
Sig: Take 2g q12h for 1 day only
2. Therapy for first herpes infection:
Rx: Valtrex 1g bid x 10 days
3. Therapy for recurrent herpes infection:
Rx: 500mg bid x 5 days
Acyclovir (Zovirax):
Pregnancy Category B
1. 5-day Rx:
Zovirax capsules, 200mg/cap
Disp: 25 capsules
Sig: 1 capsule q4h while awake or take 5 capsules per day. Start when symptoms begin.
2. 5-day therapy with kidney disease: GFR <10mL/minute or dialysis: 200mg q12h for 5 days

Acyclovir (Zovirax) capsules:
Pregnancy Category B

1. 14-day Rx:
Zovirax capsules, 200mg/capsule
Disp: 70 capsules
Sig: 1 cap. 5 times/day x 2 weeks
2. 14-day Rx with kidney disease:
GFR <10mL/minute or dialysis: Dose 200mg q12h

Famciclovir (Famvir):
Pregnancy Category B

Recurrent cold sores in immune-competent patient: 1,500mg as a single dose.

HIV-infected patients (cold sores or genital herpes): 500mg 3 times/day x 7 days.

Acyclovir (Zovirax) ointment:
Pregnancy Category B

Rx: 5% Zovirax ointment for recurrent herpes:

Disp: 15g tube
Sig: Apply to sores 5-6/day. Zovirax ointment is most effective when used with Zovirax capsules.

HERPES ZOSTER:

Valacyclovir (Valtrex):
Pregnancy Category B

1. Rx: Valtex caplet, 1g/caplet
Disp: 21 caplets
Sig: Take 1g tid for 7 days
2. Kidney disease dose: GFR <30mL/minute or s.creatinine >3mg/dL to predialysis: 1g q24h

Acyclovir (Zovirax):
Pregnancy Category B

1. Rx: Zovirax capsules, 200mg/capsule
Disp: 140 capsules
Sig: 800mg 5 times/day x 7 days
2. Kidney disease dose:
a. GFR 10-25mL/minute or s.creatinine >3mg/dL to predialysis:
Rx: Dose 800mg q8h
b. GFR <10mL/minute or dialysis:
Rx: Dose 800mg q12h
Famciclovir (Famvir): 1. Famciclovir Herpes Zoster Rx: 500mg every 8 hours x 7 days.
2. Famciclovir dosing for Herpes Zoster with GFR [40–59mL/min/1.73m2]: 500mg q12h.
3. Famciclovir dosing for Herpes Zoster with GFR [20–39mL/min/1.73m2]: 500mg q24h.
4. Famciclovir dosing for Herpes Zoster with GFR [<20mL/min/1.73m2]: 250mg q24h.
5. Famciclovir dosing for patients on dialysis: 250mg after each dialysis.
HERPES CHRONIC
SUPPRESSIVE THERAPY:
Valacyclovir (Valtrex):
Pregnancy Category B
Rx: Valtrex caplet, 500mg/caplet
Disp: Dispensed for 6 months to 1 year according to the patient’s immunity
Sig: 500mg OD (once a day) or bid
Acyclovir (Zovirax):
Pregnancy Category B
1. Rx: Zovirax capsules, 200mg/capsule
Disp: Variable
Sig: 200mg tid for up to 6 months or 400mg bid/tid, for up to 3 years
2. Chronic suppressive Rx with kidney disease: GFR <10mL/minute or dialysis: Dose 400mg q12h or 200mg q12h
HIV-GINGIVITIS:
0.12% nonalcoholic Chlorhexidine Gluconate (Peridex): – Oral hygiene and scaling with Betadine irrigation Rx: Chlorhexidine (Peridex):
Disp: 3 x 16 oz bottles
Sig: Rinse with 1/2 oz. for 30 seconds bid after oral hygiene
HIV-PERIODOTITIS:

Treat with 0.12% nonalcoholic
Chlorhexidine Gluconate (Peridex) AND

Antibiotics:

First Choice:

Metronidazole

Second Choice:

Clindamycin, Cephalexin (Keflex) or Amoxicillin with Clavulanate potassium or Ciprofloxacin

–Oral hygiene and scaling with Betadine irrigation

Rx: Chlorhexidine (Peridex)

Disp: 3 x 16 oz bottles
Sig: Rinse with 1/2 oz for 30 seconds bid after oral hygiene

Rx: Metronidazole (Flagyl):

250mg/tablet
Disp: 20 tablets x 5 days
Sig: 1 tab qid

Clindamycin:

150/300mg tid/qid x 5 days

Cephalexin (Keflex):

250/500mg bid/tid x 5 days

Amoxicillin with Clavulanate potassium (Augmentin):

250/500mg tid x 5 days

Ciprofloxacin (Cipro):

500mg bid x 5 days

ORAL CANDIDIASIS:
PSEUDOMEMBRANOUS
or HYPERTROPHIC or
ERYTHEMATOUS
As first choice: Use Topicals
Refractory/severe cases: Use systemic antifungals.
Clotrimazole (Mycelex) Troche:
Pregnancy Category B/C
Topical Azole antifungal
Rx: Clotrimazole (Mycelex) Troches, 10mg/Troche
Disp: 70 troches
Sig: Use 1 troche 5x/day, swallow saliva. No eating/drinking for 30 minutes after use. Also dispense: Chlorhexidine to all patients.
In patients with removable appliances, re-infection can be avoided by dropping a clotrimazole (Mycelex) troche into water and soaking the appliance over night for 14 days. Clotrimazole is not an ideal drug to dispense in the presence of xerostomia.
Nystatin (Mycostatin) Prescriptions:
Pregnancy Category B
Topical Polyene antifungal
a. Rx: Nystatin (Mycostatin) Lozenge 200,000 units/Lozenge
a. Disp: 70 Lozenges (14 day supply)
a. Sig: Dissolve 1 Lozenge in the mouth 5 times daily. There should be no eating or drinking for 30 minutes after use.
b. Rx: Nystatin Oral Suspension 100,000 units/mL
Disp: 473mL (1 pint) bottle (14 day supply)
Sig: Use 1 teaspoonful or 5mL, qid. Rinse and hold in the mouth as long as possible before swallowing. There should be no eating or drinking for 30 minutes after use.
c. Rx: Nystatin Oral Suspension 100,000 units/mL for dentures
Disp: 473mL (1 pint) bottle
Sig: Add 5–10mL of 1:100,000 units Nystatin to half cup of water and soak the dentures overnight daily, for 14 days. Rinse the dentures before use.
d. Rx: Nystatin Pastille 200,000 units/pastille
Disp: 70 pastilles
Sig: Dissolve 1 pastille in the mouth 4–5 times/day for 14 days.

e. Nystatin (Mycostatin) Cream:
e. The cream can be applied to dentures before insertion or can be used for angular chielitis.
Rx: 100,000 units/g
Disp: 15/30g tube
Sig: Apply to the affected area 4–5 times/day. Do not eat or drink for 30 minutes after use.
f. Re-infection can be avoided in patients with removable appliances by dropping a Nystatin lozenge/troche into a 1/4 cup of water and soaking the appliance overnight for 14 days. Also, Nystatin powder or Nystatin ointment can be applied to appliances prior to insertion.

Amphotericin B:
Topical Polyene antifungal;
Pregnancy Category B
a. Rx: 3% Topical Amphoteric B Cream
Disp: 20g tube
Sig: Apply to the affected area 3–4 times/day for 2–4 weeks
b. Oral Amphotericin B: Oral Amphotericin B is dispensed as a capsule or a suspension. The oral forms are poorly absorbed.
i Rx: Amphotericin B 500mg/capsule
Disp: 56 capsules
Sig: Take 500mg capsule PO qid for 2 weeks.
ii Rx: Amphotericin B suspension: 500mg/mL
Disp: 56mL suspension
Sig: Use 1mL of the suspension, swish and swallow qid for 2 weeks.
REFRACTORY
ORAL/SYSTEMIC
CANDIDIASIS:
Fluconazole (Diflucan):
Systemic Azole antifungal;
Pregnancy Category C
Rx: Fluconazole (Diflucan) 100mg/capsule
Disp: 15 capsules
Sig: Day 1: Take 2 capsules.
Days 2–14: Take 1 capsule daily.
ESOPHAGEAL
CANDIDIASIS:
Fluconazole (Diflucan):
Systemic Azole antifungal;
Pregnancy Category C
Rx: Fluconazole (Diflucan) 100mg/capsule
Disp: Variable
Sig: 100mg qd (maximum 400mg qd) for 14–21 days
Itraconazole (Sporanox):
Triazole antifungal;
Pregnancy Category C
Rx: Itraconazole Oral Suspension
Sig: 200mg qd PO x 10–21 days
ANGULAR CHEILITIS:
Clotrimazole (Mycelex) Cream:
Pregnancy Category B/C
Rx: Clotrimazole (Mycelex) Cream
Disp: 15g tube
Sig: Rub on lesions 2–3 times daily
Nystatin (Mycolog) Ointment:
Pregnancy Category B
Rx: Mycolog cream (Nystatin)
Disp: 15g tube
Sig: Rub on lesions 2–3 times daily
Clioquinol and Hydrocortisone (Corque Topical):
Pregnancy Category C
Rx: Clioquinol and Hydrocortisone (Corque Topical)
Disp: 15g tube
Sig: Rub into affected area 2–3 times daily
RECURRENT APHTHOUS ULCERS:
Tetracycline Capsules
Pregnancy Category D
Tetracycline Capsules: Dissolve a 250mg Tetracycline capsule in 180mL water. Swish and spit qid for several days until ulcers heal. Do not eat or drink for 30 minutes.
Tetracycline suspension:
Pregnancy Category D
Tetracycline suspension: Dispense 250mg
Tetracycline/5ml. Swish and expectorate qid until ulcers heal. Do not eat or drink for 30 minutes.
Avoid in children and pregnant women.
Triamcinolone 0.1% (Kenalog in Orabase):
Topical steroid; use sparingly for pain relief.
Triamcinolone 0.1% (Kenalog in Orabase): Apply the paste to ulcers bid/qid until the ulcers heal.
Disp: 5g tube
Sig: Apply a thin film without rubbing, on affected areas up to 3 times daily
0.05% Flucinonide (Lidex) ointment mixed 50/50 with Orabsase: Rx: 0.05% Lidex ointment mixed 50/50 with Orabsase
Disp: 30g total
Sig: Apply a thin layer on the lesions 4–6 times daily
Dexamethasone Elixir Rx: Dexamethasone Elixir, 0.5mg/5mL
Disp: 250mL
Sig: Rinse with 1 teaspoon solution in the mouth for 1 minute 4–5 times daily and expectorate
Thalidomide (Thalomid):
Pregnancy Category X
Thalidomide (Thalomid), 200mg OD/bid x 3–8 weeks is reserved for HIV/AIDS or refractory patients.
Xylocaine 2% Viscous: Rx: Xylocaine 2% Viscous
Disp: 100mL or 450mL
Sig: Use 2tsp to rinse the oral cavity, as needed and expectorate.
Diphenhydramine (Benadryl) Syrup with Liquid Bismuth Subsalicylate (Kaopectate): Rx: Diphenhydramine (Benadryl) Syrup (5mg/mL) with Liquid Bismuth Subsalicylate (Kaopectate), mix 50/50
Disp: 8oz total
Sig: Rinse with 2tsp, as needed for pain relief; expectorate
Diphenhydramine (Benadryl) Syrup with Magnesium Hydroxide antacid: Rx: Diphenhydramine (Benadryl) Syrup (5mg/mL) with Magnesium Hydroxide antacid, mixed 50–50
Disp: 8oz total
Sig: Rinse with 2tsp, as needed for pain relief; expectorate
Topical 0.15 Benzydamine (Difflam or Tantum) oral rinse: Rx: Topical 0.15 Benzydamine (Difflam/Tantum) oral rinse:
Apply to the ulcers 4x/day for 2 weeks or until the ulcers heal. Treats mild disease.
Topical Carellose: (Orabase: Pectin plus Gelatin) Rx: Topical Carellose (Orabase: Pectin plus Gelatin):
Apply to the ulcers qid for 2 weeks or until the ulcers heal. A protective bio-adhesive preparation for mild disease.
Topical Corticosteroids:
Spray/cream/pellet
For mild disease
a. Rx: 1% triamcinalone dental paste (Adrortyl or Kenolog in Orabase):
b. Rx: Hydrocortisone, 2.5mg pellets (Corlan)
c. Rx: 0.12% or 0.2% chlorhexidine gluconate aqueous mouthwash (Peridex) or 1% chlorhexidine gluconate gel. Apply to the ulcers qid with any one of the 3 preparations for 2 weeks/ until the ulcers heal.
Rx: Systemic Corticosteroids: For severe disease. Rx: 30–60mg prednisone PO daily for 1 week, followed by a 1 week dose taper.
XEROSTOMIA:
Xerostomia Treatment Options:
Daily oral hygiene; 3–6 month recall; nonalcoholic Peridex mouth rinse; topical Fluorides; saliva substitutes; saliva stimulants.
A calcium-containing remineralizing oral rinse such as Caphsol (Eusa Pharma) is also recommended as calcium has a remineralizing effect on dental enamel.
Use fluoride therapy in the form of professionally applied concentrated sodium fluoride varnishes and daily use of 1.1% sodium fluoride prescription strength fluoride toothpaste (PreviDent 5000 Dry Mouth), all to prevent tooth decay.
Saliva Substitutes: The combined use of Biotene and Oralbalance is very effective in the management of xerostomia.
Biotene Products Biotene available as sugar-free gum, alcohol-free mouthwash, and toothpaste.
Biotene mouthwash: Use one tablespoon PRN, swish, and expectorate. It works best when used with Biotene toothpaste.
Biotene toothpaste: This toothpaste is non-irritating and it contains the protective enzyme systems needed for optimal oral health. The toothpaste should be used post meals and at bedtime.
Oralbalance Oralbalance is available as a moisturizing gel.
Saliva Stimulants:
1. Pilocarpine HCL (Salagen)
Increases saliva secretion
by systemic cholinergic
stimulation
2. Cevimeline (Evoxac)
Pilocarpine HCL (Salagen), Strength: 5mg/tab
Disp: Variable
Sig: 1–2 tablets tid/qid per day taken 30 minutes prior to meals
Cevimeline (Evoxac)
Strength: 30mg/capsule
Disp: Variable
Sig: 30mg three times a day, taken with meals.
CHEMOTHERAPY/ RADIOTHERAPY ASSOCIATED SIDE EFFECTS: Refer to Table 51.2 for chemotherapy or radiotherapy associated oral lesions or side-effects and suggested management guidelines

The treatment guidelines for oral herpes, oral candidiasis, xerostomia, and aphthous ulcers in the HIV/AIDS and the non-HIV/AIDS patient are the same. The viral infections in the HIV/AIDS patient are generally treated for a longer duration when compared with the non-HIV/AIDS patient. The HIV/AIDS patient also often needs chronic suppressive therapy.

COMMON ORAL LESIONS

The following are common oral lesions that are encountered in dentistry:

1. Viral infections: Herpes simplex and herpes zoster are the viral infections encountered in the immune-competent or immune-compromised patient. Cytomegalovirus infection occurs in only the immune-compromised patient.
2. Oral viral leukoplakia (OVL) or hairy leukoplakia (HL): OVL or HL is specific for HIV/AIDS.
3. Fungal infections: Oral and/or esophageal candidiasis and angular cheilitis are seen in both populations.
4. HIV-gingivitis (HIV-G): HIV-G is specific for HIV/AIDS.
5. HIV-periodontitis (HIV-P): HIV-P is specific for HIV/AIDS.
6. HIV necrotizing stomatitis: This lesion is also specific for HIV/AIDS.
7. Kaposi’s sarcoma: Kaposi’s sarcoma is specific for HIV/AIDS.
8. Oral warts: Oral warts are caused by the papilloma virus and occur specifically in the HIV/AIDS patient.
9. Aphthous ulcers: These ulcers occur in both populations.
10. Xerostomia: This occurs in both populations.
11. Petechiae and ecchymosis: These occur in both populations.

DETAILED DISCUSSION OF COMMON VIRAL INFECTIONS

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 48: Therapeutic Management of Oral Lesions in the Immune-Competent and the Immune-Compromised Patient in the Dental Setting
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