Oral Problems in the Immunocompromised Patient

• Opportunistic infections:

  • Bacterial
  • Tuberculosis
  • Streptococcal pneumonia
  • Viral
  • Herpes infections
  • Influenza
  • COVID-19
  • Parasitic
  • Pneumocystis carinii - seen in HIV/AIDS pts
  • Fungal
  • Candida
  • Cryptococcus
• Erythematous candidiasis:

  • Oral candidosis secondary to immunodeficiency
  • May be an undiagnosed diabetic patient
  • May be taking antimicrobials for another infection somewhere else - alters intraoral flora balance, therefore opportunistic infection follows

  
• Pseudomembranous candidiasis - oral candida will act as a commensal organism - something happens that tips the scales and they develop an actual clinically relevant infection, like pseudomembranous candidiasis.

  
• Angular cheilitis can occur for many reasons eg poor vertical dimension in dentures (so patients constantly over-close), meaning there's constant moisture at the edges of the mouth, leading to staphylococcal superinfection. Can also occur because of vitamin deficiencies - eg iron deficiency. Could be because of immunodeficiency too - especially if you start to treat it and it doesn't respond in the way you'd expect it to.

  
• People are more likely to get herpetic infections if immunosuppressed.

  
• Lesions caused by Human Papilloma Virus (HPV):

  • Appearance: exophytic, papillary oral mucosal lesions
  • Several different types of HPV
  • May be multiple
  • Often difficult to treat due to high risk of recurrence
  • Implications in aetiology of oral/oro-pharyngeal cancer
• Squamous cell papilloma:

  • A benign problem in the palate
  • Usually treated by simple surgical excision

  
• Oral ulcers:

  • Proportion of oral ulcers will be secondary to some sort of immunomodulation, usually immunosuppression
  • Herpes Simplex
  • Cytomegalovirus
  • Aphthous ulcers
  • Histoplasmosis
  • HPV lesions
  • Lymphoma
  • Necrotising ulcerative gingivitis (NUG)
  • Necrotising ulcerative periodontitis (NUP)
  • Necrotising stomatitis (NS)
• Minor aphthous ulcers are painful, tend to last 7-10 days and heal without scarring.
• Major aphthous ulcers are painful, can last longer than minor apthous ulcers, and can sometimes scar when healing because they're so big.

  
• Kaposi's sarcoma:

  • Appearance: oral lesions appear as reddish purple, raised or flat
  • Size - from small to extensive
  • Unpredictable behaviour
  • Associated with human herpes virus 8
  • Diagnosis - biopsy
  • Incurable - antiretroviral therapy, radiation, chemotherapy, sclerosing agents
• Kaposi's sarcoma skin lesion - vascular, raised lesion

  
• Intraoral Kaposi's sarcoma lesion

  
• Palatal appearance of Kaposi's sarcoma lesion

  
• B cell lymphoma:

  • Lymph node swelling on patient with Hodgkin's lymphoma
  • Should examine facial nerve to see that he can raise his eyebrows, close eyes and show his teeth without problem - checks it's still working
  • If facial nerve doesn't work then makes malignancy a suspicion

  
• Oral hairy leukoplakia generally does not require treatment. Diagnosis is made by incision or biopsy - clinically better to do biopsy.
• In cases of oral hairy leukoplakia, look for underlying deficiency

  • General immunity problem - seen in AIDS patients before treatments became more refined
  • May also see it in patients with a localised effective immunodeficiency
  • Most common is someone who uses a steroid inhaler
  • Inhaler hits certain parts of the tongue (particularly lateral borders) and causes this localised problem
• Oral hairy leukoplakia is linked to EBV. It tends to wax and wane. It would always be wise to get a biopsy if hairy leukoplakia suspected to see if there's any dysplasia or disordered maturation of the epithelium.