Infections in Immunocompromised Patients

 

·  Gingivitis normally has a slow progression toward periodontal disease with increasingly obvious symptoms as the disease worsens. However, people with immune system impairments have more rapid development of periodontal disease.

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Causes of Periodontal Disease

  • The microbial causes of periodontal disease in immunocompromised patients are the same as in individuals with normal immune systems (Tyring, 2006).

 

In individuals infected with HIV, if the level of T-helper cells falls too low and AIDS develops, the likelihood of infection from even normally benign microorganisms increases (Prevention, 2017).

  • Effects of Periodontal Disease

·         Gingival tissues specifically are likely targets for opportunistic infections due to the diverse population of bacteria, fungi, and viral particles normally in their environment. In these patients an infection can take root quickly, resulting in significant destruction of gingival tissue and neighboring alveolar bone.

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·         These infections can penetrate into deep tissue and cause systemic, life-threatening infections in a short amount of time. This should prompt greater vigilance of oral infections on the part of healthcare providers who treat immunocompromised patients.

·  Linear Gingival Erythema

·  Linear gingival erythema is a condition that occurs in immunocompromised individuals and most frequently in people infected with HIV. This disease presents with an erythematous band, meaning a reddened line of tissue in the marginal gingival tissue.

  • ·  Causes of Linear Gingival Erythema

This can occur in the absence of plaques or calculus and can be confined to a specific location throughout the oral cavity. In contrast to gingivitis in immunocompetent individuals, linear gingival erythema is resistant to normal periodontal treatment and is not improved by even the strictest personal oral hygiene regimen. 

 

Affected tissues can be tender and bleed easily although these symptoms are usually minor. 

The American Academy of Periodontology has categorized linear gingival erythema as a fungal disease caused by Candida spp (Armitage, 1999).

Recommended Treatment for Linear Ginigical Erythema

The currently recommended treatment for this disease is an antimicrobial mouthwash, typically a two-week course of 0.12% chlorhexidine. Alternatively, antifungal medication applied to the site of infection using dental trays is also effective (Rutgers, 2017). 

 

Infections that do not respond to this treatment may require the use of systemic antifungal treatment including ketoconazole, fluconazole, or itraconazole, although care should be taken in prescribing these medications as they can interact with other drugs.

Further Treatment Approaches

It is important to note that following cessation of antimicrobial mouthwash or antifungal dental trays, the linear gingival erythema will return. More invasive treatment can be performed; however, a complete blood count should be performed for any HIV-positive patients to establish their fitness for surgical intervention.

·  2. Necrotizing Ulcerative Periodontitis

·  Necrotizing ulcerative periodontitis involves ulceration of the interdental gingivalis (Zia, Mukhtar-Un-Nisar Andrabi, Qadri, & Bey, 2015). This ulcer rapidly spreads along the gingiva, causing the destruction of periodontal tissue and severe halitosis.

  • ·  Cases of Necrotizing Uverative Periodontitis

This disease is extremely serious, with a 2-year survival rate of 27% following initial diagnosis (Atout & Todescan, 2013). Necrotizing gingivitis is a separate, but similar disease, with the key difference being that necrotizing gingivalis does not include loss of alveolar bone, whereas this does occur in necrotizing periodontitis. In both cases, these diseases are associated with microbial pathogens commonly found in other less severe periodontitis etiologies, including spirochetes and Fuscobacterium species.

Factors in the development of necrotizing ulcerative periodontitis in undeveloped countries

This disease is relatively rare in developed countries as key factors in the development of necrotizing ulcerative periodontitis include poor oral hygiene and extreme nutritional deficits, and extensive use of chewing tobacco may damage the gingival and periodontal tissues and increase the risk of developing these ulcers. 

Factors in the development of necrotizing ulcerative periodontitis in developed countries

In modernized countries, necrotizing ulcerative periodontitis occurs most often in individuals with HIV or other immune-compromising conditions (Novak, 1999). A study of HIV patients with necrotizing periodontitis revealed that these individuals were 20 times as likely to have severely compromised immune systems; however, the presence of similarly impaired immune systems was not highly indicative of the development of the necrotizing ulcers, suggesting that additional unknown factors contribute to the pathology.

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