Classifications of oral lesions in HIV infection

Severe periodontitis is more common in HIV- infected patients

OBJECTIVE

To assess periodontitis prevalence and severity in HIV infected patients as compared to controls. Furthermore, to assess whether HIV infection characteristics are associated with periodontitis.

DESIGN

cross-sectional controlled study.

METHODS

We assessed prevalence and severity of periodontitis in 258 HIV-infected patients and 539 historical controls with the Dutch Periodontal Screening Index (DPSI). HIV characteristics were collected from medical charts. Age-related diseases and oral care were assessed with questionnaires.

RESULTS

Severe periodontitis (DPSI 4) was more prevalent in HIV-infected patients than in controls (66% vs. 36%, p = 0.002). HIV-infection, increasing age and male sex were significant risk factors for severe periodontitis. In particular, older male HIV patients have a higher risk of severe periodontitis. Clinical, immunological and virologic characteristics, and antiretroviral therapy were not associated with periodontitis prevalence or severity. HIV-infected patients rate the importance of their oral health as high, although many do not disclose their HIV infection to their dentists.

CONCLUSIONS

Prevalence and severity of periodontitis are higher in HIV-infected patients compared to controls, particularly in older males. Awareness of the increased prevalence of periodontitis associated with HIV-infection among patients and health-care professionals could significantly improve oral health and quality of life of HIV-infected patients.

Xerostomia related to HIV infection /AIDS: a critical review

Introduction: The presence of oral manifestations in HIV positive individuals is quite common. Xerostomia appears as one of the most frequent problems and may lead to a reduction in the quality of life of this population. Objective: This study was a critical review of the relationship between xerostomia and HIV infection, to attract the attention of dentists on the importance of dental care to these patients. Material and method: We included articles published between 2000 and 2009, indexed in PUBMED database. The descriptors used were "HIV" and "xerostomia", the exclusion criteria adopted were: the absence of these descriptors associated, non-location of the full-text, articles based on case studies or case series and the absence of the abstract in the database. Result: Based on studies in the review, it can be said that the xerostomia is a common manifestation of HIV infection, predisposing the patient to several other oral problems. Among the risk factors for its occurrence it was reported: low counts of CD4+ T cells, high plasma viral load, the use of some medications and antiretroviral therapy. Conclusion: The HIV/AIDS can change the salivary glands, and were considered important risk factors for the occurrence of xerostomia the presence of didanosine and the drug class which corresponds to protease inhibitors in antiretroviral therapy.

Oral epithelial changes in HIV-positive individuals

HIV infections frequently affect the oral cavity, and local changes may be utilized as indicators of immunosuppression in HIV-positive patients. Morphometric and morphological features of the lining, masticatory, and specialized epithelium of the oral mucosa were studied in 12 HIV-positive and 12 HIV-negative patients autopsied from 2007 to 2010. Mucosal samples from the cheek, gingival, and tongue of 24 individuals were fixed in Carnoy solution and stained with hematoxylin-eosin. Various morphometric characteristics (epithelial thickness, number of cell layers, mean cell diameter) and morphological parameters (basal layer hyperplasia, exocytosis of inflammatory cells, glycogenic acanthosis, cell ballooning degeneration) were then measured. The HIV-positive group had a greater epithelial thickness (mean: 304.4μm) and a higher mean cell diameter (11.84μm), whereas the HIV-negative group had more epithelial layers (26.7). Basal layer hyperplasia did not differ significantly between the two groups, but exocytosis of inflammatory cells, glycogenic acanthosis, cell ballooning, and spongiosis were more prevalent in the HIV-positive group. Our findings demonstrate that HIV infection causes diverse epithelial changes in the oral cavity, including thickening, increased cell diameter, increased migration of inflammatory cells, and inter- and intra-cellular edema.

Ranulas: possible signs for HIV/AIDS? 1 year Ugandan descriptive study

INTRODUCTION

Certain oral manifestations signal progression of HIV disease among HAART naïve patients or an increase in the plasma HIV-1 RNA levels for those on treatment. Ranulas may be one of those manifestations. Therefore, this study describes the clinical features of patients who presented with ranulas including their demographics, HIV sero-status and the CD4 CD8 cell counts for those who were HIV positive.

METHODS

A prospective study on ranulas was undertaken at Mulago national referral hospital and St Mary's hospital Lacor covering the period December 2008 to November 2009.

RESULTS

Fifty-seven cases participated in the study: 38.6% male and 61.4% female. Out of the study group, 73.7% were HIV positive. This was statistically significant (Chi = 12.789, df = 1, p = 0.001). In relation, to CD4 cell count, 23.8% had <200 cells/mm(3), 35.7% between 200-500 cells/mm(3) and 40.5% more than 500 cells/mm(3). The CD4-to-CD8 ratio ranged from 0.02-0.98 with an average of 0.31 ± 0.23, median and mode of 0.27 and 0.32, respectively.

CONCLUSIONS

It is felt that ranulas may be one of the oral manifestations of worsening immunity in HIV/AIDS disease. Therefore, more research is needed to establish if it should be included among known oral manifestations of the disease.

Oral complications of HIV disease

Oral lesions are among the early signs of HIV infection and can predict its progression to acquired immunodeficiency syndrome (AIDS). A better understanding of the oral manifestations of AIDS in both adults and children has implications for all health care professionals. The knowledge of such alterations would allow for early recognition of HIV-infected patients. The present paper reviews epidemiology, relevant aspects of HIV infection related to the mouth in both adults and children, as well as current trends in antiretroviral therapy and its connection with orofacial manifestations related to AIDS.

Occurrence of yeasts, enterococci and other enteric bacteria in subgingival biofilm of HIV-positive patients with chronic gingivitis and necrotizing periodontitis

The purpose of this study was to determine the prevalence of enteric bacteria and yeasts in biofilm of 80 HIV-positive patients with plaque-associated gingivitis or necrotizing periodontitis. Patients were subjected to extra, intra oral and radiographic examinations. The oral hygiene, bleeding on probing, gingival conditions, and attachment loss were evaluated. Clinical specimens were collected from gingival crevices or periodontal pockets, transferred to VMGA III, diluted and transferred to Sabouraud Dextrose agar with 100 μg/ml of chloramphenicol, peptone water, EVA broth, EMB agar, SS agar, Bile esculin agar and Brilliant green agar. Isolation of yeasts was carried out at room temperature, for 3-7 days; and for the isolation of enteric microorganisms plates were incubated at 37°C, for 24-48 h. The yeasts identification was performed according to the carbon and nitrogen assimilation, fermentation of carbohydrates and germ tube formation. Bacteria were identified according to their colonial and cellular morphologies and biochemical tests. Yeasts were identified as Candida albicans and its occurrence was more common in patients with CD4+ below 200/mm³ and was affected by the extension of periodontal involvement (P = 0.0345). Enteric bacteria recovered from clinical specimens were identified as Enterobacter sakazakii, Enterobacter cloacae, Serratia liquefaciens, Klebsiella oxytoca and Enterococcus sp. Enterobacteriaceae and enterococci were detected in 32.5% of clinical samples from patients with necrotizing periodontitis. In conclusion, non-oral pathogenic bacteria and C. albicans were more prevalent in periodontal sites of HIV-positive patients with necrotizing periodontitis and chronic gingivitis.

Bisphosphonates and osteomyelitis of the jaw: a pathogenic puzzle

The maxillary and mandibular bones undergo high-turnover remodeling to maintain mechanical competence. Common dental or periodontal diseases can increase local bone turnover. Bisphosphonates (BPs) accumulate almost exclusively in skeletal sites that have active bone remodeling. The maxillary and mandibular bones are preferential sites for accumulation of BPs, which become buried under new layers of bone and remain biologically inactive for a long time. Surgical odontostomatological procedures create open bony wounds that heal quickly and without infection, as a result of activation of osteoclasts and subsequently osteoblasts. Once BPs are removed from the bone via activation of osteoclasts after a tooth extraction or a periodontal procedure, they induce osteoclast apoptosis. This inhibition of osteoclast bone resorption impairs bone wound healing because of decreased production of cytokines derived from the bone matrix, and the bone is exposed to the risk of osteomyelitis and necrosis. The pathogenic relationship between BPs and osteonecrosis of the jaw is unclear, but there is evidence to indicate an association between high-dose BP treatment and exposure to dental infections or oral surgical procedures. A better knowledge of the interactions between BPs and jaw and maxillary bone biology will improve clinical and therapeutic approaches.

Gingival Involvement in a Case Series of Patients With Acquired Immunodeficiency Syndrome-Related Kaposi Sarcoma

BACKGROUND

This case series presents the polymorphic clinical characteristics of gingival acquired immunodeficieny syndrome (AIDS)-related Kaposi sarcoma (KS), a malignancy that is gradually becoming uncommon in developed nations. An up-to-date overview of the related epidemiology, etiopathogenesis, histopathology, and treatment is provided, along with a pictorial guide to ease clinical diagnosis.

METHODS

The oral/maxillofacial pathology records at Aristotle University and the University of Geneva were retrospectively reviewed. Thirty-two cases diagnosed with oral AIDS-related KS were retrieved between 1991 and 2004. KS diagnosis was established histologically by incisional biopsies from intraoral lesions. All charts contained clinical oral examination data, radiological images, and detailed photographic records.

RESULTS

Thirteen patients (12 males and one female) presented with KS gingival involvement (40.6%). Eleven of the male patients were homosexual/bisexual men. The mean age of the patients at the time of intraoral KS diagnosis was 42.1 years, and the mean CD4 cell count was 103 (0 to 481). Gingival epidemic KS presented with various degrees of pigmentation and a wide range of clinical patterns, from relatively flat macules (early stage) to tumors with variable nodular morphology (advanced disease). Solitary or multiple gingival involvement may appear concomitantly with palatal and/or cutaneous lesions.

CONCLUSIONS

Even though the incidence of intraoral KS had fallen precipitously in developed countries after the mid-1990s, gingival KS should be considered in the differential diagnosis of every pigmented gingival lesion. Periodontists are in a unique position to identify gingival involvement of intraoral KS and facilitate early diagnosis.

Oral Disease Prevalence Among HIV-Positive American Indians in an Urban Clinic

Abstract-According to Centers for Disease Control and Prevention (CDC) estimates, there have been almost 930,000 AIDS cases diagnosed at the end of 2003 in the United States. About 3,000 of those infected were American Indian and Alaska Natives (AI/ANs). Persons with HIV and AIDS have been shown to have increased risk of dental and periodontal disease. Unfortunately, there are no publications on dental disease and AI/ANs with HIV/AIDS. This study addresses this shortcoming by examining the relationship between dental health, drug use, and HIV among AI/AN patients in an urban setting. The study included a consecutive chart review of 51 AI/AN HIV-positive dental patients seen from 2001 to 2004 at the Native American Health Center in San Francisco. Results showed that 55% had moderate or severe periodontal disease, 80.4% had tooth decay, and 88.2% had missing teeth. Substance users had more dental caries or decayed teeth than non-substance users (88% versus 73%). The average rate for decayed, missing or filled teeth (DMFT) among the total sample was 18.73%. This chart review study suggests that dental disease is more prevalent in AI/ANs with HIV/AIDS when compared to the general population and AI/AN data from the Indian Health Service.

Bacterial diversity in necrotizing ulcerative periodontitis in HIV-positive subjects

BACKGROUND

Necrotizing ulcerative periodontitis (NUP) is a painful and potentially debilitating affliction that affects about 2% to 6% of HIV-positive subjects. NUP may be caused by specific microorganisms that are presently unknown or by microbial species not usually thought to cause periodontal infections. The purpose of this study was to define the bacterial species associated with NUP in HIV-positive patients.

METHODS

16S rRNA bacterial genes of DNA isolated from subgingival plaque of 8 HIV-positive subjects with NUP were amplified by polymerase chain reaction (PCR) and cloned into Escherichia coli. The sequences of cloned inserts were used to determine species identity or closest relatives by comparison with known sequences. The microbial profiles in subgingival plaque of subjects with NUP, chronic periodontitis, and periodontal health were compared using a battery of over 200 oligonucleotide probes in a PCR-based, reverse-capture, checkerboard DNA-DNA hybridization assay.

RESULTS

Sequence analysis of over 400 clones revealed 108 species; 65 were "uncultivable" phylotypes, of which 26 were novel to NUP subjects. Species or phylotypes most commonly detected were Bulleidia extructa, Dialister, Fusobacterium, Selenomonas, Peptostreptococcus, Veillonella, and the phylum TM7. Based on sequence analysis and checkerboard analysis, NUP did not possess the classical periodontal pathogens such as Porphyromonas gingivalis. Otherwise, the microbial profiles of NUP and periodontitis had many similarities. The microbial profiles of subgingival plaque from periodontally healthy subjects were different and less complex in comparison to the profiles of both disease groups.

CONCLUSIONS

Certain species appear to be associated with health and periodontal diseases. The putative pathogens associated with periodontal disease in HIV-negative subjects are not associated with NUP in HIV-positive subjects.

Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult population in Oyo State, Nigeria

OBJECTIVE

The objective of this study was to define the oro-facial lesions associated with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) in an adult population in Oyo state, Nigeria and to relate these with the level of immune suppression as measured by the CD4 counts.

MATERIALS AND METHOD

The study population consisted of 679 consecutive subjects who were seen at the state-owned blood bank. Information on demography, medical and medication histories were obtained. Oro-facial examinations were carried out according to Greenspan et al [Oral Surg Oral Med Oral Pathol (1992)73:142-144]. HIV sero-prevalence status was determined for all patients. CD4+ T-lymphocyte count was carried out for those sero-positive for HIV and 31 randomly selected HIV-negative subjects. Data were analyzed using the chi-square test, Fisher's exact test, Student's t-test and odds ratio where appropriate.

RESULTS

Eighty-one (11.9%) of the entire study sample were confirmed HIV positive. The prevalence of specific oral lesions by HIV sero-status revealed that pseudomembranous oral candidiasis and angular cheilitis occurred significantly and more frequently in HIV-positive subjects (33.3 and 21% respectively) than those who were HIV negative (4.3 and 1.8% respectively, P < 0.05). The mean CD4 count of the HIV-positive subjects was 452 cells mm(-3), s.d. 137, while it was 602 cells mm(-3), s.d. 251, for the HIV negatives. The difference was statistically significant (P = 0.000). Forty-four (66.7%) subjects with CD4 counts <500 cells mm(-3) had oro-facial lesions whereas among those with CD4 counts >500 cells mm(-3) only 22 (33.3%) had oro-facial lesions (OR = 4.57).

CONCLUSION

The type of oro-facial lesions most commonly associated with HIV/AIDS in Oyo state, Nigeria, has been shown to be pseudomembranous oral candidiasis. This was followed by angular cheilitis. These lesions, although found in HIV-negative subjects, were in a lower proportion as compared with HIV-positive subjects. Mean CD4 counts were lower in HIV-positive subjects and this was associated with greater prevalence of oro-facial candidiasis and angular cheilitis.

Baseline characteristics of participants in the oral health component of the Women's Interagency HIV Study

OBJECTIVES

This study described baseline sociodemographic and oral health characteristics of a subset of HIV sero-positive and sero-negative women who participated in the oral health component of the Women's Interagency HIV Study (WIHS).

METHODS

In 1995-96, 584 HIV sero-positive and 151 sero-negative women from five WIHS core sites were enrolled in the oral study. Data on oral mucosa, salivary glands, dentition and periodontium, along with demographics, socioeconomics, and behavioral characteristics, were used to characterize this population.

RESULTS

Mean (SD) age was 37 (8) years for HIV sero-positive and 36 (8) years for sero-negative women; 27% of sero-positive women had CD4 counts < or =200 and 34% had viral loads >50,000 copies/ml. Sero-positive and sero-negative women were similar demographically, as well as on plaque index, gingival bleeding, linear gingival banding, and numbers of DMF teeth and surfaces, but sero-positive women had more abnormal gingival papilla (P = 0.004) and fewer teeth (P = 0.01). Among sero-positive women, those with <200 CD4 counts had more DMF teeth (P = 0.007), and the number of DMF surfaces increased with decreasing CD4 counts (P = 0.04). Sero-positive women who fit the Center for Disease Control (CDC) AIDS criteria were also more likely to have more DMF teeth (P = 0.004), DMF surfaces (P = 0.003), and decayed and/or filled (DF) root surfaces (P = 0.0002) compared to sero-positive women without AIDS.

CONCLUSIONS

Dental and periodontal variables showed little difference between HIV sero-positive and sero-negative women. Among sero-positive women, there were significant differences in coronal and root caries by AIDS diagnostic criteria, but no periodontal indicators by either AIDS diagnostic criteria or CD4 status, were observed.

Tumor necrosis factor-alpha expression and detection of apoptosis at the site of chronic periodontitis in AIDS patients

BACKGROUND

Apoptosis, or programmed cell death, is associated with the regulation of the life cell cycle of leukocytes in healthy and diseased states.

OBJECTIVES

In the present study, we investigated the presence of apoptosis of mononuclear inflammatory cells in the periodontal lesion from adult periodontitis in healthy control patients and AIDS patients.

MATERIALS AND METHODS

Tissue samples adjacent to a 5-6 mm gingival sulcus, measured with a periodontal probe, were obtained during routine periodontal surgical procedures. The direct immuno-peroxidase of digoxigenin-labeled genomic DNA method was used for in situ detection of apoptosis in gingival tissues.

RESULTS

Many tumor necrosis factor-alpha (TNFalpha)-positive cells, detected by immunohistochemistry method, were observed in gingival samples of both groups of patients. In addition, a significant lower number ( p < 0.05) of mononuclear apoptotic cells were observed in AIDS patients when compared with healthy control patients.

CONCLUSION

These data suggested an important role of the apoptosis of mononuclear cells in the pathogenesis of chronic adult periodontitis in AIDS patients.

Oral Kaposi Sarcoma Associated with Severe Alveolar Bone Loss: Case Report and Review of the Literature

BACKGROUND

In AIDS patients who present with an oral neoplasm, Kaposi sarcoma is the tumor most frequently encountered, comprising 50% to 80% of all tumor occurrences. However, oral Kaposi sarcoma associated with erosion of underlying bone is a relatively rare finding. This report and review of the literature documents a case of AIDS-related oral Kaposi sarcoma exhibiting severe bilateral erosion of the maxillary alveolar ridges.

METHODS

An HIV-seropositive male with extensive maxillary Kaposi sarcoma and associated bilateral alveolar bone erosion presented for dental evaluation subsequent to radiation therapy. Clinical and radiographic examinations were performed. Medical and dental histories were procured and supplemented with consultations from the patient's primary physician and radiation oncologist. Maxillary edentulation with surgical revision for primary closure was the treatment of choice for management of the dentoalveolar pathology. A maxillary immediate treatment denture was designed to obturate anticipated antral communications with the maxillary sinus.

RESULTS

Surgical and prosthetic treatments were completed, but complicated by an oral-antral perforation that subsequently healed without complication. Soft tissue biopsies obtained during surgery revealed no evidence of residual Kaposi sarcoma.

CONCLUSIONS

Although AIDS-related oral Kaposi sarcoma is a relatively common finding, erosion of subjacent alveolar bone is uncommon. Treatment of the tumor with subsequent dental reconstruction can be complicated by the severe lack of bone, surgical perforation of the maxillary sinus, and lack of stable teeth to serve as abutments. Significant advances in understanding the pathogenesis of AIDS-related Kaposi sarcoma have occurred in the last decade. HHV-8 and various inflammatory cytokines have been implicated in the pathogenesis and are likely to become the primary targets for therapeutic intervention.

[Oral manifestations of HIV infection]

Oral manifestations of HIV infection are sometimes the first sign of the disease and often indicate its progression to acquired immune deficiency syndrome (AIDS), thus it is important for health professionals (physicians and dentist) to possess adequate knowledge of these lesions. Improvements in antiretroviral treatments, especially with the incorporation of HAART therapy, have produced a gradual reduction in the prevalence of HIV-associated oral lesions. On the other hand, the increased life expectancy of HIV-positive patients has led to their greater presence at our clinics, implying the need for continuous updating in the diagnosis and treatment of these processes. Using the consensus classification (EEC-Clearinghouse, 1993) we reviewed the diagnostic criteria and current treatment protocols for the different HIV infection related oral lesions in both adults and children.

Candidíase oral como marcador de prognóstico em pacientes portadores do HIV

Introdução: A candidíase oral é uma das doenças oportunistas mais fortemente associadas à infecção pelo Vírus da Imunodeficiência Humana (HIV). Vários relatos epidemiológicos enfatizam a prevalência da candidíase em pacientes HIV positivos e ressaltam a sua importância como marcador da progressão da doença e preditivo para o aumento da imunodepressão. Objetivo: Verificar as alterações estomatológicas em pacientes portadores do HIV tratados no Hospital Heliópolis - São Paulo, Brasil e comparar com a literatura. Forma de Estudo: Retrospectivo clínico não-randomizado. Casuística e Método: Foram analisados 431 pacientes HIV+/AIDS (298 homens e 133 mulheres) no Hospital Heliópolis - São Paulo, Brasil, no período de 1995 a 2001. Resultados: A idade média mais comum foi dos 31 aos 40 anos (47,10%); a via de contágio mais comum foi a sexual (71,26%). Dentre as patologias, a candidíase apresentou maior prevalência (29,69%), seguida pela gengivite (16,70%) e queilite angular (14,15%). Conclusões: Concluímos que o exame oral e o diagnóstico precoce da candidíase em pacientes infectados pelo HIV são fundamentais para o tratamento imediato, melhorando a sua qualidade de vida, uma vez que a candidíase é uma lesão bucal muito freqüente nesta população.

Long-term results of supportive periodontal therapy (SPT) in HIV-seropositive and HIV-seronegative patients

AIM

The aim of the present study was to investigate the long-term results of periodontal supportive therapy in HIV-seropositive and HIV-seronegative patients.

MATERIAL AND METHODS

Baseline examination of 18 HIV-seropositive patients (14 males and four females, median age of 29.7 years) revealed the following periodontal diagnoses: eight patients with linear gingival erythema, four patients with necrotizing periodontitis, five patients with conventional gingivitis and one patient with chronic periodontitis. In the HIV-seronegative group, out of 16 patients (12 males and four females, median age 35.5 years), one patient presented with conventional gingivitis and 15 patients with chronic periodontitis. Periodontal therapy and maintenance care consisted of supra- and subgingival removal of plaque and calculus and instruction in oral hygiene. Based on the individual patient's needs, the mechanical therapy was repeated.

RESULTS

In the test group, the mean maintenance period was 22.7 +/- 9.4 months (range 11.0-37.4) and in the control group, 48.9 +/- 32.0 months (range 9.3-110.8). In the test group, the mean PlI (1.1 +/- 0.8) remained at the same level (1.1 +/- 0.5; p = 0.73, Wilcoxon sign rank test, p < 0.05) throughout the observation period, the mean GI was reduced from 1.6 +/- 0.5 to 1.4 +/- 0.4 (p = 0.18), the mean PPD was reduced from 2.9 +/- 0.3 to 2.8 +/- 0.2 (p = 0.15) and the mean PAL (3.1 +/- 0.5) remained unaltered as well (3.1 +/- 0.4; p = 0.83). None of these differences was statistically significant. In the control group, PPD (3.0 +/- 0.4) and PAL (3.0 +/- 0.5) were significantly reduced: PPD = 2.7 +/- 0.2 (p = 0.0003) and PAL = 2.9 +/- 0.5 (p = 0.0034).

CONCLUSION

In HIV-seropositive patients, attachment level can be maintained. However, oral hygiene and compliance are the key factors for this.