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Case report
a r t i c l e i n f o a b s t r a c t
Article history: There are a multitude of oral manifestations of human immunodeficiency virus (HIV), many of which
Received 7 April 2017 have decreased in frequency following the introduction of combination antiretroviral therapy (cART) in
Received in revised form 5 July 2017 1996. Atypical periodontal disease is an example of an oral manifestation that is infrequently seen yet
Accepted 12 July 2017
strongly associated with HIV infection. HIV-associated periodontal disease can be classified into three
Available online xxx
categories, linear gingival erythema, necrotizing ulcerative gingivitis (NUG), and necrotizing ulcerative
periodontitis (NUP), which vary based on disease severity. When this disease process extends beyond
Keywords:
the alveolar ridges and causes massive tissue destruction, it is termed necrotizing ulcerative stomatitis
HIV
Necrotizing ulcerative stomatitis (NUS). Herein, we report a case of a 20-year-old male patient with undiagnosed HIV in whom necrotizing
Periodontal disease ulcerative stomatitis was the first presenting sign of underlying disease.
© 2017 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
http://dx.doi.org/10.1016/j.ajoms.2017.07.005
2212-5558/© 2017 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.夽
Please cite this article in press as: Peters SM, et al. Necrotizing ulcerative stomatitis as initial presentation of undiagnosed HIV infection:
A case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.07.005
G Model
JOMSMP-658; No. of Pages 5 ARTICLE IN PRESS
2 S.M. Peters et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2017) xxx–xxx
Fig. 1. Initial presentation (July 2015). (a) Anterior maxilla with erythematous and edematous gingiva and blunting of papilla. (b) Ulcerative lesion of the palate.
Fig. 3. Periapical radiographs (July 2015). Anterior maxilla with bone loss.
Please cite this article in press as: Peters SM, et al. Necrotizing ulcerative stomatitis as initial presentation of undiagnosed HIV infection:
A case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.07.005
G Model
JOMSMP-658; No. of Pages 5 ARTICLE IN PRESS
S.M. Peters et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2017) xxx–xxx 3
Table 1
Patient Laboratory Values Pre and Post cART.
Initial Presentation (Pre-cART) One month post initiation of cART One year post initiation of cART Normal Value
bleeding bone. A small perforation into the nasal cavity was noted
but the nasal mucosa remained intact. A rim of nasal aperture,
out tension and the maxillary obturator was delivered (Fig. 6b). A
as well as the anterior nasal spine, was maintained for structural
slight anterior open bite was maintained to alleviate pressure on
support (Fig. 6a). Primary closure of the mucosa was attained with-
the mucosa (Fig. 7).
Fig. 5. (August 2015): (a) CT scan (axial view). Anterior maxilla with bony erosion. (b) CT scan (coronal view). Destruction of the anterior nasal floor.
Please cite this article in press as: Peters SM, et al. Necrotizing ulcerative stomatitis as initial presentation of undiagnosed HIV infection:
A case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.07.005
G Model
JOMSMP-658; No. of Pages 5 ARTICLE IN PRESS
4 S.M. Peters et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2017) xxx–xxx
Fig. 6. (October 2015): (a) Intra-operative photograph following extraction of teeth #5–11 and peripheral ostectomy. (b) Intra-operative insertion of obturator.
Please cite this article in press as: Peters SM, et al. Necrotizing ulcerative stomatitis as initial presentation of undiagnosed HIV infection:
A case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.07.005
G Model
JOMSMP-658; No. of Pages 5 ARTICLE IN PRESS
S.M. Peters et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (2017) xxx–xxx 5
dental plaque and calculus and debridement of hard and soft tissue Conflict of interest
[13]. Chlorhexidine gluconate 0.12% rinse administered twice daily
and antibiotics are recommended to reduce the bacterial burden, The authors have no conflicts of interest to declare.
and typically a course of metronidazole or clindamycin in combi-
Ethical approval
nation with amoxicillin is prescribed [13,14]. Pain management,
nutritional supplementation, counseling, and frequent follow-ups Not needed.
are important factors to consider when treating a patient with
NUP/NUS. In cases of NUS where gingival involvement is absent, Funding
clinical findings are non-specific and biopsy is required.
Following the advent of cART, there has been a decline in The study received no commercial funding.
the number of reported cases of HIV associated periodontitis and
NUS [12]. That being said, the literature base from the 1990s References
and early 2000s provides documentation of the clinical and his-
tologic features of the disease. Patton and McKaig report a case [1] Grbic JT, Lamster IB. Oral manifestations of HIV infection. AIDS Patient Care
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in 1992 with complaints of right upper quadrant pain and fetid human immunodeficiency virus infection in patients with periodontal
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involved teeth [13]. A retrospective study by Jones et al. in 2000 1999;4(1):65–73, discussion 78.
[5] Classification and diagnostic criteria for oral lesions in HIV infection.
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patients in this study ranged from 20 to 52 years of age, were collaborating centre on oral manifestations of the immunodeficiency virus. J
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that in all patients the NUS, lesions possessed reproducible micro- [7] Jones AC, Gulley ML, Freedman PD. Necrotizing ulcerative stomatitis in
scopic and immunohistochemical features which also resembled human immunodeficiency virus-seropositive individuals: a review of the
histopathologic, immunohistochemical, and virologic characteristics of 18
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[7]. p. 1991.
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treatment of systemic diseases. Consideration of and access to HIV
testing is important in the clinical setting.
Please cite this article in press as: Peters SM, et al. Necrotizing ulcerative stomatitis as initial presentation of undiagnosed HIV infection:
A case report and review of literature. J Oral Maxillofac Surg Med Pathol (2017), http://dx.doi.org/10.1016/j.ajoms.2017.07.005