Use of dental care services among adolescents living with HIV on antiretroviral treatment in Kampala, Uganda: a cross-sectional study

OBJECTIVE

The primary purpose of this study was to assess the prevalence and socio-behavioral determinants of ever-use of dental care services among adolescents aged 10-18 years, living with HIV, on Antiretroviral treatment (ART), and attending selected HIV clinics in Kampala, Uganda.

METHODS

A cross-sectional study was carried out between March and September 2020. The study conveniently recruited 154 adolescents between 10 and 18 years old from 4 specific HIV clinics in Kampala. Andersen's behavioral model guided the selection of variables, with the ever-use of dental care services as the outcome and predisposing, enabling, need-related factors and personal dental health practices as exposure variables. Data were analyzed using Fischer's exact test for cross-tabulation and modified Poisson regression for multivariate analysis.

RESULTS

The prevalence of ever-use of dental care services was 12.3%. The adolescents aged 14-18 had higher odds of using dental care services (Prevalence ratio (PR) of 3.35 than those aged 10-13 years. Fear of the spread of HIV was negatively associated with ever-use of dental care services (PR of 0.06). Participants who were afraid of going to the dentist had higher odds of using dental care services (PR of 2.98) than those not afraid. Failure to receive dental treatment because it was not part of the medical appointment had a positive association with the ever-use of dental care services (PR of 4.50). Those who were satisfied with their dental condition had lower odds of using dental care services. The bad oral odor was positively associated with the ever-use of dental care services (PR of 2.80). The use of soap for toothbrushing was positively associated with the ever-use of dental care services (PR of 2.51).

CONCLUSION

The study found a low frequency of dental care use among HIV-infected adolescents in Kampala, Uganda, with age being a predisposing factor. Enabling factors included fear of HIV spread, medical-dental appointment incoordination, and satisfaction with the dental condition and bad oral odor while under personal dental health practices. The use of soap for toothbrushing was an important association with dental care. Nevertheless, these study results cannot be generalized to the entire HIV adolescent population in Uganda.

Use of dental care services among adolescents living with HIV on Antiretroviral Treatment in Kampala, Uganda: a cross-sectional study

Objective

The main purpose of this study to assess the prevalence and socio-behavioural determinants of ever-use of dental care services among the adolescents aged 10-18 years, living with HIV on Antiretroviral treatment (ART), attending selected HIV clinics in Kampala, Uganda.

Methods

A cross-sectional study was carried out between March and September 2020. The study conveniently recruited 154 adolescents between 10-18 years from 4 specific HIV clinics in Kampala. The Andersen's behavioral model guided the selection of variables in terms of ever use of dental care services as the outcome- and predisposing, enabling, need related factors and dental health related behavior as exposure variables. Data was analyzed using Fischer's exact test for cross-tabulation and modified Poisson regression for multivariate analysis.

Results

The prevalence of ever-use of dental care services was 12.3%. The adolescents aged 14-18 years were more likely to have used dental care services (Prevalence ratio (PR) of 3.35 (Confidence Interval (CI) 1.48-7.59) than those aged 10-13 years. Fear of spread of HIV was negatively associated with ever-use of dental care services (PR of 0.06 and CI of (0.01-0.44). Participants who were afraid of going to the dentist were more likely to have ever used dental care services (PR of 2.98 and CI of 1.41-6.30) than those not afraid. Failure to receive dental treatment because it was not part of the medical appointment had a positive association with ever-use of dental care services (PR of 4.50 (CI: 1.14-17.80). Those who were satisfied with their dental condition were less likely to have ever-used dental care services (PR of 0.21 and CI of (0.05-0.94). Bad oral odor was positively associated with ever-use of dental care services with a PR of 2.80 and CI of 1.19-6.60. Use of soap for toothbrushing was positively associated with ever-use of dental care services (PR of 2.51, CI of 1.47-4.28).

Conclusion

The study found low frequency of dental care use among HIV infected adolescents in Kampala, Uganda, with age being a predisposing factor. Enabling factors included fear of HIV spread, dental appointment failure, and satisfaction with dental condition and bad oral odor while under personal oral hygiene and dental practices, use of soap for toothbrushing was an important association of use of dental care.

The effect of antiretroviral therapy initiation on vitamin D levels and four oral diseases among Kenyan children and adolescents living with HIV

OBJECTIVES

The impact of antiretroviral treatment (ART) on the occurrence of oral diseases among children and adolescents living with HIV (CALHIV) is poorly understood. The aim of this study was to determine the effect of ART timing on vitamin D levels and the prevalence of four oral diseases (dry mouth, dental caries, enamel hypoplasia, and non-herpes oral ulcer) among Kenyan CALHIV from two pediatric HIV cohorts.

METHODS

This nested cross-sectional study was conducted at the Kenyatta National Hospital, Nairobi, Kenya. CALHIV, 51 with early-ART initiated at <12 months of age and 27 with late-ART initiated between 18 months-12 years of age, were included. Demographics, HIV diagnosis, baseline CD4 and HIV RNA viral load data were extracted from the primary study databases. Community Oral Health Officers performed oral health examinations following standardized training.

RESULTS

Among 78 CALHIV in the study, median age at the time of the oral examination was 11.4 years old and median ART duration at the time of oral examination was 11 years (IQR: 10.1, 13.4). Mean serum vitamin D level was significantly higher among the early-ART group than the late-ART group (29.5 versus 22.4 ng/mL, p = 0.0002). Children who received early-ART had a 70% reduction in risk of inadequate vitamin D level (<20 ng/mL), compared to those who received late-ART (p = 0.02). Although both groups had similar prevalence of oral diseases overall (early-ART 82.4%; late-ART 85.2%; p = 0.2), there was a trend for higher prevalence of dry mouth (p = 0.1) and dental caries (p = 0.1) in the early versus late ART groups. The prevalence of the four oral diseases was not associated with vitamin D levels (p = 0.583).

CONCLUSIONS

After >10 years of ART, CALHIV with early-ART initiation had higher serum vitamin D levels compared to the late-ART group. The four oral diseases were not significantly associated with timing of ART initiation or serum vitamin D concentrations in this cohort. There was a trend for higher prevalence of dry mouth and dental caries in the early-ART group, probably as side-effects of ART.

Impact of Antiretroviral Therapy on Oral Health among Children Living with HIV: A Systematic Review and Meta-Analysis

Oral health is an integral component of general health and well-being but might be undermined among children living with HIV (CLWH) due to the condition itself or the antiretroviral therapy (ART) received. This review summarises the current evidence and compares the oral health status of the CLWH who were treatment-naïve with those undergoing different ART medications. Fourteen studies were included in the final qualitative and quantitative analyses. This review identified no significant difference in the prevalence of caries, periodontal conditions, and tooth development between both groups. Orofacial opportunistic infections were more prevalent in the CLWH without ART. Children undergoing ART with a duration longer than 3 years had a significantly lower prevalence of oral candidiasis and CD4+ T-cell counts. However, due to the insufficient number of well-administered case-control studies with adequate sample size, the quality of the evidence in all outcomes was of very low certainty.

Oral Lesions Associated with COVID-19 and the Participation of the Buccal Cavity as a Key Player for Establishment of Immunity against SARS-CoV-2

BACKGROUND

Some oral lesions have been described in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); the possibility has been raised that the buccal lesions observed in patients with the coronavirus disease 2019 (COVID-19) are due to this virus and the patient's systemic condition. The aim of this review was to integrate the knowledge related to the oral lesions associated with COVID-19 and the participation of the buccal cavity in the establishment of immunity against SARS-CoV-2.

METHODS

A literature search on the manifestations of buccal lesions from the beginning of the pandemic until October 2021 was carried out by using the PubMed database. A total of 157 scientific articles were selected from the library, which included case reports and reports of lesions appearing in patients with COVID-19.

RESULTS

Oral lesions included erosions, ulcers, vesicles, pustules, plaques, depapillated tongue, and pigmentations, among others. The oral cavity is a conducive environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, immunodeficiencies, and autoimmunity primarily.

CONCLUSIONS

The oral cavity is an accessible and privileged environment for the interaction of SARS-CoV-2 with the mucosal immune system and target cells; the direct effects of the virus in this cavity worsen the antiviral inflammatory response of underlying oral disorders, in particular those related to immunodeficiencies and autoimmunity.

The influence of antiretroviral therapy on HIV-related oral manifestations

PURPOSE

This review aims to provide primary medical and dental healthcare professionals with the current state of information on the oral manifestations of HIV infection in the era of antiretroviral therapy (ART) advancements.

RESULTS

Infection with the human immunodeficiency virus (HIV) is associated with an increased risk of infectious, neoplastic, and immune-mediated oral complications that are regarded as a major constituent of this global epidemic. HIV-related oral manifestations have been subject to changes in their prevalence with the employment of ART, particularly in this period of enhanced patient accessibility to ART. Available antiretroviral medications (ARVs), the clinical presentation of common HIV-related oral manifestations, and patients and healthcare providers' perceptions are also discussed.

CONCLUSIONS

Screening, diagnosing, and treating patients with HIV/Acquired immunodeficiency syndrome (AIDS) has improved drastically since the isolation and characterization of HIV. Oral manifestations have been acknowledged to correlate with treatment responses and disease progression. Healthcare providers should be familiar with HIV-related oral manifestations and comfortable in managing and referring patients with HIV/AIDS, they are also key stakeholders in facilitating the elimination of the stigma associated with the infection.

Frequent and Persistent Salivary Gland Ectasia and Oral Disease After COVID-19

The clinical picture of coronavirus disease 2019 (COVID-19) in various target organs has been extensively studied and described. However, relatively little is known about the characteristics of oral cavity involvement. This is surprising, considering that oral mucosal and salivary gland cells are known targets for the direct replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and that the presence of the virus in saliva is a source of transmission of the infection. The aim of our study was to investigate the presence and prevalence of oral manifestations in COVID-19 survivors. We profiled the oral involvement in 122 COVID-19 survivors that were hospitalized and followed up at a single-referral university hospital in Milan, Italy, between July 23, 2020 and September 7, 2020, after a median (interquartile range) time from hospital discharge of 104 (95 to 132) d. We found that oral manifestations, specifically salivary gland ectasia, were unexpectedly common, with oral manifestations being detected in 83.9% while salivary gland ectasia in 43% of COVID-19 survivors. Salivary gland ectasia reflected the hyperinflammatory response to SARS-CoV-2, as demonstrated by the significant relationship with C-reactive protein (CRP) and lactate dehydrogenase (LDH) levels at hospital admission, and with the use of antibiotics during acute disease. Both LDH levels and antibiotic administration survived as independent predictors of salivary gland ectasia at multivariable analysis. Temporomandibular joint abnormalities, facial pain, and masticatory muscle weakness were also common. Overall, this retrospective and prospective cohort study of COVID-19 survivors revealed that residual damage of the oral cavity persists in the vast majority of patients far beyond clinical recovery, and suggests that the oral cavity represents a preferential target for SARS-CoV-2 infection. Further studies are needed to clarify the connection between SARS-CoV-2 infection and oral disorders.

Review of adverse cutaneous reactions of pharmacologic interventions for COVID-19: A guide for the dermatologist

The new coronavirus, severe acute respiratory syndrome coronavirus 2, is associated with a wide variety of cutaneous manifestations. Although new skin manifestations caused by COVID-19 are continuously being described, other cutaneous entities should also be considered in the differential diagnosis, including adverse cutaneous reactions to drugs used in the treatment of COVID-19 infections. The aim of this review is to provide dermatologists with an overview of the cutaneous adverse effects associated with the most frequently prescribed drugs in patients with COVID-19. The skin reactions of antimalarials (chloroquine and hydroxychloroquine), antivirals (lopinavir/ritonavir, ribavirin with or without interferon, oseltamivir, remdesivir, favipiravir, and darunavir), and treatments for complications (imatinib, tocilizumab, anakinra, immunoglobulins, corticosteroids, colchicine and low molecular weight heparins) are analyzed. Information regarding possible skin reactions, their frequency, management, and key points for differential diagnosis are presented.

Oral environment and taste function of Japanese HIV-infected patients treated with antiretroviral therapy

The aim of the study was to evaluate the oral environment and the taste function of Japanese HIV-infected patients treated with antiretroviral therapy. Their median age of 73 patients taking anti-HIV drugs was 46 years. The median period of taking anti-HIV drugs was 30 months. The oral condition was evaluated by measurement of oral moisture, amount of saliva secretion, the number of oral bacteria, presence of oral candida, a taste test, and the number of missing teeth. The levels of oral moisture and secreted saliva were significantly lower in the HIV-infected group than in the healthy volunteer (control) group. The HIV-infected group showed a more robust decrease in taste sensation than the control group. The number of missing teeth was significantly higher in the HIV-infected group than in the control group. Furthermore, all of the evaluated oral conditions were worse in the HIV-infected patients whose CD4+ T lymphocyte counts were less than 500/mm³ than in the control group. It became clear that the patients taking anti-HIV drugs, especially the CD4+ count < 500/mm3 group, had a deteriorated oral environment and dysgeusia, suggesting that the management of oral hygiene is necessary to maintain oral health, which leads to systemic health.

Access and management of HIV-related diseases in resource-constrained settings: a workshop report

With advancement of medical interventions, the lifespan of people living with HIV has increased globally. However, low- and middle-income countries (LMICs) which bear the greatest burden of the HIV pandemic face a constant challenge in addressing the treatment needs of immune-suppressed patients. An analysis of the current management protocols and access to medication in resource-poor settings was conducted at this workshop, with emphasis on the situation in resource-poor settings. The participants developed a consensus document based on the need to respond to the constantly changing HIV pandemic. Provision of oral health care must be guided by interconnecting principles based on population based strategies that address upstream determinants of health. Basic oral health coverage in developing countries can only be realized with a strong foundation at the primary health level. Early diagnosis of HIV-related comorbidities including the adverse effects of ARVs is essential for the improvement of treatment outcomes. Standardization of oral health care delivery mechanisms will facilitate evaluation at national and regional levels. Oral health care workers have a moral obligation to participate in sustained campaigns to reduce the social stigma associated with HIV/AIDS in their work places at every stage of the referral chain. Future research also needs to realign itself towards prevention using the common risk factor approach, which has a broader impact on non-communicable diseases, which are increasingly affecting patients with HIV/AIDS as their life expectancies increase.

Sore or Swollen Lips Part 2: Systemic Causes

This series of three papers reviews the causes, diagnosis and differential diagnosis, and outlines the management of sore and/or swollen lips. Clinical relevance: Sore and/or swollen lips are not uncommon, often have a local cause, but may reflect a systemic disease. The previous article reviewed important causes, from actinic to contact cheilitis, while this paper starts with drug-induced cheilitis and completes that alphabetical list.

Adverse Drug Reactions in the Orofacial Region

A wide spectrum of drugs can sometimes give rise to numerous adverse orofacial manifestations, particularly dry mouth, taste disturbances, oral mucosal ulceration, and/or gingival swelling. There are few relevant randomized double-blind controlled studies in this field, and therefore this paper reviews the data from case reports, small series, and non-peer-reviewed reports of adverse drug reactions affecting the orofacial region (available from a MEDLINE search to April, 2003). The more common and significant adverse orofacial consequences of drug therapy are discussed.

(B3) Markers of Immunodeficiency and Mechanisms of HAART Therapy on Oral Lesions

Highly active anti-retroviral therapy (HAART) has revolutionized the treatment and prognosis of HIV disease and AIDS in those who can take advantage of the treatment. There are currently 20 different anti-retroviral drugs in 4 different classes that are used in specific combinations. Suppression of HIV replication and immune reconstitution are goals of therapy. Since the prevalence of some easily detectable oral manifestations of HIV/AIDS (OMHIV/AIDS) decreases with HAART, it has been suggested that they might be clinically useful surrogate markers of HAART efficacy and immune status. This might be particularly useful if their recurrence presaged or accompanied HAART failure. To date, there has been little work in this area, but its potential value to the clinical management of HIV/AIDS is apparent, especially if frequent measures of viral load and CD4 cell counts are not readily available. However, the usefulness of OMHIV/AIDS as signals for HAART failure is complicated by three phenomena: the immune reconstitution syndrome, the similarity of some adverse reactions of HAART to OMHIV/AIDS, and the direct inhibitory effect of HAART medications on some OMHIV/AIDS ( e.g., inhibition of oral candidosis by protease inhibitors). This workshop considered the current evidence and proposed pertinent research questions.

Oral Lesions of HIV Disease and HAART in Industrialized Countries

The epidemiology of HIV-related oral disease in industrialized nations has evolved following the initial manifestations described in 1982. Studies from both the Americas and Europe report a decreased frequency of HIV-related oral manifestations of 10–50% following the introduction of HAART (highly active antiretroviral therapy). Evidence suggests that HAART plays an important role in controlling the occurrence of oral candidosis. The effect of HAART on reducing the incidence of oral lesions, other than oral candidosis, does not appear as significant, possibly as a result of low lesion prevalence in industrialized countries. In contrast to other oral manifestations of HIV, an increased prevalence of oral warts in patients on HAART has been reported from the USA and the UK. HIV-related salivary gland disease may show a trend of rising prevalence in the USA and Europe. The re-emergence of HIV-related oral disease may be indicative of failing therapy. A range of orofacial iatrogenic consequences of HAART has been reported, and it is often difficult to distinguish between true HIV-related oral disease manifestations and the adverse effects of HAART. A possible association between an increased risk of oral squamous cell carcinoma and HIV infection has been suggested by at least three epidemiological studies, with reference to the lip and tongue. These substantial and intensive research efforts directed toward enhancing knowledge regarding the orofacial consequences of HIV infection in the industrialized nations require dissemination in the wider health care environment.

Oral lichen planus: a literature review and update

Lichen planus (LP) is a common chronic inflammatory condition that can affect skin and mucous membranes, including the oral mucosa. Because of the anatomic, physiologic and functional peculiarities of the oral cavity, the oral variant of LP (OLP) requires specific evaluations in terms of diagnosis and management. In this comprehensive review, we discuss the current developments in the understanding of the etiopathogenesis, clinical-pathologic presentation, and treatment of OLP, and provide follow-up recommendations informed by recent data on the malignant potential of the disease as well as health economics evaluations.

Perception of taste in HIV-positive individuals in treatment antiretroviral: results of a case-control study

OBJECTIVE

The aim of this study was to evaluate the perception of taste in HIV-infected patients.

METHOD

One hundred males and females (11 to 60 years old) were divided into two groups (50 patients infected by HIV and 50 controls) and evaluated for gustatory function.

RESULTS

The results revealed that the mean score in the evaluation of taste was significantly lower in individuals with HIV when compared to controls for both sides of the tongue (p < 0.05). Patients with HIV infection had difficulty recognizing the bitter taste, followed by salty and sweet. When each side of the tongue was evaluated separately and compared, the Wilcoxon test showed that there was no significant difference on the tongue of individuals with HIV. The prevalence of hypogeusia was 20% in individuals with this disease.

CONCLUSIONS

Individuals with HIV infection may have a deficit in taste that can affect your general and oral health.

HIV nucleoside reverse transcriptase inhibitors efavirenz and tenofovir change the growth and differentiation of primary gingival epithelium

OBJECTIVES

An increasing number of HIV-infected patients are combating HIV infection through the use of antiretroviral drugs, including reverse transcriptase inhibitors. Oral complications associated with these drugs are becoming a mounting cause for concern. In our previous studies, both protease inhibitors and reverse transcriptase inhibitors have been shown to change the proliferation and differentiation state of oral tissues. This study examined the effect of a nonnucleoside and a nucleoside reverse transcriptase inhibitor on the growth and differentiation of gingival epithelium.

METHODS

Organotypic (raft) cultures of gingival keratinocytes were treated with a range of efavirenz and tenofovir concentrations. Raft cultures were immunohistochemically analysed to determine the effect of these drugs on the expression of key differentiation and proliferation markers, including cytokeratins and proliferating cell nuclear antigen (PCNA).

RESULTS

These drugs dramatically changed the proliferation and differentiation state of gingival tissues when they were present throughout the growth period of the raft tissue as well as when drugs were added to established tissue on day 8. Treatment with the drugs increased the expression of cytokeratin 10 and PCNA and, conversely, decreased expression of cytokeratin 5, involucrin and cytokeratin 6. Gingival tissue exhibited increased proliferation in the suprabasal layers, increased fragility, and an inability to heal itself.

CONCLUSIONS

Our results suggest that efavirenz and tenofovir treatments, even when applied in low concentrations for short periods of time, deregulated the cell cycle/proliferation and differentiation pathways, resulting in abnormal epithelial repair and proliferation. Our system could be developed as a potential model for studying the effects of HIV and highly active antiretroviral therapy (HAART) in vitro.

Oral health considerations in HIV-infected children

Children with the human immunodeficiency virus (HIV) have a higher probability of hard and soft oral tissue diseases because of their compromised immune systems and socioeconomic factors such as poor access to medical and dental care and limited availability of fluoridated water or toothpaste. To improve health outcomes and help monitor the progression of HIV, a preventive, child-specific oral health protocol for children with HIV that is easy to use and appropriate for all different resource settings should be established. Further, both medical and dental health practitioners should incorporate such a protocol into their care routine for HIV-infected children. Using proactive oral health risk assessments complemented by scheduled follow-up visits based on individual risk determination can prevent opportunistic infection, track the HIV disease trajectory, and monitor the effectiveness of highly active antiretroviral therapy (HAART) while improving the quality of life and longevity of children living with HIV.

Oral lesions associated with human immunodeficiency virus disease

Human immunodeficiency virus (HIV)-associated oral disease among people living with HIV infection includes oral candidiasis, oral hairy leukoplakia, Kaposi sarcoma, oral warts, herpes simplex virus ulcers, major aphthous ulcers or ulcers not otherwise specified, HIV salivary gland disease, and atypical gingival and periodontal diseases. Diagnosis of some oral lesions is based on clinical appearance and behavior, whereas others require biopsy, culture, or imaging for definitive diagnosis. Management strategies including pharmacologic and nonpharmacologic approaches are discussed in this article. Dentists also need to be cognizant of the potential oral side effects of HIV antiretroviral medications.

Comparison of epigenetic profiles of human oral epithelial cells from HIV-positive (on HAART) and HIV-negative subjects

HIV-infected subjects on highly active antiretroviral therapy (HAART) are susceptible to comorbid microbial infections in the oral cavity. We observed that primary oral epithelial cells (POECs) isolated from HIV+ subjects on HAART grow more slowly and are less innate immune responsive to microbial challenge when compared with POECs from normal subjects. These aberrant cells also demonstrate epigenetic differences that include reduction in histone deacetylase 1 (HDAC-1) levels and reduced total DNA methyltransferase (DNMT) activity specific to enzymes DNMT1 and DNMT3A. The DNMT activity correlates well with global DNA methylation, indicating that aberrant DNMT activity in HIV+ (on HAART) POECs leads to an aberrantly methylated epithelial cell phenotype. Overall, our results lead us to hypothesize that, in patients with chronic HIV infection on HAART, epigenetic changes in key genes result in increased vulnerability to microbial infection in the oral cavity.

Oral lichen planus: focus on etiopathogenesis

Lichen planus is a chronic mucocutaneous inflammatory disease, which frequently affects the oral mucosa of white females over 40 years old. Its aetiology remains uncertain and the pathogenesis is still the object of much speculation. The present paper presents the most well known antigens, and describes the action of different cells and proteins associated with the development of that disease, as well as the possible agents involved with its malignant transformation. Different external agents, especially virus, and internal agents, like stress, and the heat shock protein antigen expression, associated or not, can alter the basal keratinocytes of the oral mucosa making them susceptible to apoptosis by CD8(+) cytotoxic T cell as well as activate matrix metalloproteinase and mast cell degranulation, which produce a great range of inflammatory mediators and cytokines determining the clinical onset of the disease. Regarding carcinogenesis, since it is a complex process and presents multifactorial origin, it is believed that there may be a synergism between intrinsic, such as inflammation mediators, and extrinsic agents (tobacco, alcohol, viral infections) for the OLP malignant transformation to occur. However, further studies are needed to better understand the origin, pathogenesis and process of malignant transformation of OLP.

Oxidation of 2-hydroxynevirapine, a phenolic metabolite of the anti-HIV drug nevirapine: evidence for an unusual pyridine ring contraction

Nevirapine (NVP) is an anti-HIV drug associated with severe hepatotoxicity and skin rashes, which raises concerns about its chronic administration. There is increasing evidence that metabolic activation to reactive electrophiles capable of reacting with bionucleophiles is likely to be involved in the initiation of these toxic responses. Phase I NVP metabolism involves oxidation of the 4-methyl substituent and the formation of phenolic derivatives that are conceivably capable of undergoing further metabolic oxidation to electrophilic quinoid species prone to react with bionucleophiles. The covalent adducts thus formed might be at the genesis of toxic responses. As part of a program aimed at evaluating the possible contribution of quinoid derivatives of Phase I phenolic NVP metabolites to the toxic responses elicited by the parent drug, we have investigated the oxidation of 2-hydroxy-NVP with dipotassium nitroso-disulfonate (Frémy's salt), mimicking the one-electron oxidation involved in enzyme-mediated metabolic oxidations. We report herein the isolation and full structural characterization of a 1H-pyrrole-2,5-dione derivative as a major product, stemming from an unusual pyridine ring contraction.

Effect of the HIV nucleoside reverse transcriptase inhibitor zidovudine on the growth and differentiation of primary gingival epithelium

OBJECTIVES

Oral complications associated with HIV infection and with the antiretroviral drugs used to treat it are of increasing concern in HIV-infected patients. Protease inhibitors have been shown to change the proliferation and differentiation state of oral tissues but the effect of nucleoside reverse transcriptase inhibitors is currently unknown. This study examined the effect of zidovudine on the growth and differentiation of the gingival epithelium.

METHODS

Gingival keratinocyte organotypic (raft) cultures were established. The raft cultures were treated with a range of zidovudine concentrations. Haematoxylin and eosin staining was performed to examine the effect of zidovudine on gingival epithelium growth and stratification. Raft cultures were immunohistochemically analysed to determine the effect of this drug on the expression of key differentiation and proliferation markers, including cytokeratins and proliferating cell nuclear antigen (PCNA).

RESULTS

Zidovudine dramatically changed the proliferation and differentiation state of gingival tissues both when it was present throughout the growth period of the tissue and when it was added to established tissue at day 8. Zidovudine treatment increased the expression of cytokeratin 10, PCNA and cyclin A. Conversely, cytokeratin 5, involucrin and cytokeratin 6 expression was decreased. The tissue exhibited characteristics of increased proliferation in the suprabasal layers as well as an increased fragility and an inability to heal itself.

CONCLUSIONS

Zidovudine treatment, even when applied at low concentrations for short periods of time, deregulated the cell cycle/proliferation and differentiation pathways, resulting in abnormal epithelial repair and proliferation. Our system could potentially be developed as a model for studying the effects of HIV and highly active antiretroviral therapy in vitro.

The HIV protease inhibitor lopinavir/ritonavir (Kaletra) alters the growth, differentiation and proliferation of primary gingival epithelium

OBJECTIVE

This study was designed to evaluate the effects of the HIV protease inhibitor lopinavir/ritonavir on gingival epithelium growth, integrity and differentiation.

METHODS

Organotypic (raft) cultures of gingival keratinocytes were established and treated with a range of lopinavir/ritonavir concentrations. To examine the effect of lopinavir/ritonavir on gingival epithelium growth and stratification, haematoxylin and eosin staining was performed. To investigate the effect of this drug on tissue integrity, transmission electron microscopy (TEM) was performed on untreated and drug-treated tissues. Further, immunohistochemical analysis of raft cultures was performed to assess the effect of lopinavir/ritonavir on the expression of key differentiation and proliferation markers including cytokeratins, proliferating cell nuclear antigen (PCNA) and cyclin A.

RESULTS

Lopinavir/ritonavir treatments drastically inhibited the growth of gingival epithelium when the drug was present throughout the growth period of the tissue. When the drug was added on day 8 of tissue growth, lopinavir/ritonavir treatments compromised tissue integrity over time and altered the proliferation and differentiation of gingival keratinocytes. Expression of cytokeratins 5, 14, 10 and 6, PCNA and cyclin A was induced, and their expression patterns were also altered over time in treated rafts.

CONCLUSIONS

The findings of our studies suggest that lopinavir/ritonavir treatments compromised tissue integrity over time and deregulated the cell cycle/proliferation and differentiation pathways, resulting in abnormal epithelial repair and proliferation. Our study provides a model of potential utility in studying the effects of antiretroviral drugs in vitro.

Effect of the HIV protease inhibitor amprenavir on the growth and differentiation of primary gingival epithelium

BACKGROUND

HIV-positive patients taking antiretroviral drugs, including protease inhibitors, have shown a significant increase in the development of oral complications; these complications are a major health issue for affected patients. The effect of these drugs on oral epithelium growth and differentiation is presently unknown. In this study, we explore for the first time the effect of the HIV protease inhibitor amprenavir on gingival epithelium growth and differentiation.

METHODS

Organotypic (raft) cultures of gingival keratinocytes were established and the raft cultures treated with a range of amprenavir concentrations. Haematoxylin and eosin staining was performed to examine the effect of amprenavir on gingival epithelium growth and stratification. The raft cultures were also immunohistochemically analysed to determine the effect of amprenavir on the expression of key differentiation and proliferation markers, including cytokeratins, proliferating cell nuclear antigen (PCNA) and cyclin A.

RESULTS

Amprenavir severely inhibited the growth of gingival epithelium when the drug was present throughout the growth period of the tissue. When the drug was added at day 8, amprenavir treatment altered the proliferation and differentiation of gingival keratinocytes. Expression of the cytokeratins 5, 14, 6 and 10, PCNA and cyclin A was increased; their expression pattern was also altered over time in treated rafts. Biochemically, the tissue exhibited characteristics of increased proliferation in the suprabasal layers of amprenavir-treated tissue.

CONCLUSIONS

Our results suggest that amprenavir treatment deregulates the cell cycle/proliferation and differentiation pathways, resulting in abnormal epithelial repair and proliferation. Our system could be developed as a potential model for studying the effects of highly active antiretroviral therapy in vitro.

Effects of long-term use of HAART on oral health status of HIV-infected subjects

BACKGROUND

The aim of this study was to determine the effects of long-term use of highly active antiretroviral therapy (HAART) on oral health status of HIV-infected subjects.

METHODS

Oral examination and measurement of saliva flow rate of both unstimulated and wax-stimulated whole saliva were performed in HIV-infected subjects with and without HAART, and in non-HIV individuals. The following data were recorded; duration and risk of HIV infection, type and duration of HAART, CD4 cell count, viral load, presence of orofacial pain, oral dryness, oral burning sensation, oral lesions, cervical caries, and periodontal pocket. Multiple logistic regression analysis was performed to determine the effects of long-term use of HAART on oral health status of HIV-infected subjects.

RESULTS

One hundred and fifty-seven HIV-infected subjects - 99 on HAART (age range 23-57 years, mean 39 years) and 58 not on HAART (age range 20-59 years, mean 34 years) - and 50 non-HIV controls (age range 19-59 years, mean 36 years) were enrolled. The most common HAART regimen was 2 NRTI + 2 NNRTI. HIV-infected subjects without HAART showed greater risks of having orofacial pain, oral dryness, oral lesions, and periodontal pockets than those with short-term HAART (P < 0.01). The subjects with long-term HAART were found to have a greater risk of having oral lesions than those with short-term HAART (P < 0.05). The unstimulated and stimulated salivary flow rates of the subjects with HAART were significantly lower than in those without HAART (P < 0.05).

CONCLUSION

We conclude that long-term HAART has adverse effects on oral health status of HIV-infected subjects.

HIV protease inhibitors block oral epithelial cell DNA synthesis

OBJECTIVES

Anti-retroviral therapy regimens that include HIV protease inhibitors (PIs) are associated with diverse adverse effects including increased prevalence of oral warts, oral sensorial deficits and gastrointestinal toxicities suggesting that PIs may perturb epithelial cell biology. To test the hypothesis that PIs could affect specific biological processes of oral epithelium, the effects of these agents were evaluated in several oral epithelial cell-lines.

DESIGN

Primary and immortalized oral keratinocytes and squamous carcinoma cells of oropharyngeal origin were cultured in the presence of pharmacologically relevant concentrations of PIs. Their affects on cell viability, cytotoxicity and DNA synthesis were assessed by enzymatic assays and incorporation of 5-bromo-2'-deoxyuridine (BrdU) into DNA.

RESULTS

Viability of primary and immortalized oral keratinocytes as well as squamous carcinoma cells of oropharyngeal origin was significantly reduced by select PIs at concentrations found in plasma. Of the seven PIs evaluated, nelfinavir was the most potent with a mean 50% inhibitory concentration [IC(50)] of 4.1 microM. Lopinavir and saquinavir also reduced epithelial cell viability (IC(50) of 10-20 microM). Atazanavir and ritonovir caused minor reductions in viability, while amprenavir and indinavir were not significant inhibitors. The reduced cell viability, as shown by BrdU incorporation assays, was due to inhibition of DNA synthesis rather than cell death due to cytotoxicity.

CONCLUSION

Select PIs retard oral epithelial cell proliferation in a drug and dose-dependent manner by blocking DNA synthesis. This could account for some of their adverse effects on oral health.

Oral lichenoid drug eruption: a report of a pediatric case and review of the literature

Lichenoid drug eruptions are seen most frequently on the skin and seldomly affect the mucosal surfaces. Oral involvement-known as oral lichenoid drug eruption-is more common in the adult population and has been associated with numerous medications. Pediatric-onset oral lichenoid drug eruption is an exceptionally rare finding with only isolated cases published in the literature. The nonspecific appearance and latent presentation of pediatric oral lichenoid drug eruption can cause confusion in diagnosis and treatment. We report a case of oral lichenoid drug eruption occurring in a 15-year-old and explore challenges in the clinical and histologic recognition of this condition.

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.

Long-standing oral ulcers: proposal for a new 'S-C-D classification system'

Persistent oral ulcers and erosions can be the final common manifestation, sometimes clinically indistinguishable, of a diverse spectrum of conditions ranging from traumatic lesions, infectious diseases, systemic and local immune-mediated lesions up to neoplasms. The process of making correct diagnosis for persistent oral ulcers still represents a challenge to clinicians. Major diagnostic criteria should include the clinical appearance of both ulcer and surrounding non-ulcerated mucosa, together with the evaluation of associated signs and symptoms, such as: number (single or multiple), shape, severity of the ulcer(s), conditions of remaining mucosa (white, red or with vesiculo-bullous lesions) and systemic involvement (e.g. fever, lymphadenopathy or evaluation of haematological changes). The aim of this paper was to review the literature relating to persistent oral ulcers and provide a helpful, clinical-based diagnostic tool for recognising long-standing ulcers in clinical dental practice. The authors, therefore, suggest distinguishing simple, complex and destroying (S-C-D system) ulcerations, as each requires different diagnostic evaluations and management. This classification has arisen from studying the current English literature relating to this topic, performed using MEDLINE / PubMed / Ovid databases.

Oral lichenoid lesions in HIV-HCV-coinfected subjects during antiviral therapy: 2 cases and review of the literature

Some dental materials and certain drugs may induce epithelial alterations, which clinically resemble oral lichen planus (OLP), on oral mucosa. But these alterations do not have all the clinical and/or the histological features of OLP; these lesions are known as oral lichenoid lesions (OLLs). Some researchers describe the onset and/or the worsening of OLL/OLP after the administration of anti-hepatitis C virus (HCV) therapy. In this article, we describe the development of symptomatic OLLs, as a consequence of anti-HCV therapy (interferon-alpha and ribavirine), in 2 human immunodeficiency virus-HCV-coinfected subjects. An immunological cause related to coinfection and administration of different medications could be responsible for the onset of OLLs. These new cases, together with the previous reports of a possible association between OLP and/or OLL and anti-HCV therapy, highlight the absolute need to monitor carefully the human immunodeficiency virus-HCV-coinfected subjects who are about to start the anti-HCV therapy and to define better the clinical and histopathological criteria to distinguish OLP from OLL.

Effect of HAART on salivary gland function in the Women's Interagency HIV Study (WIHS)

OBJECTIVE

To determine the impact of highly active antiretroviral therapy (HAART) on salivary gland function in human immunodeficiency virus (HIV) positive women from the Women's Interagency HIV Study (WIHS).

DESIGN

Longitudinal cohort study.

SUBJECTS AND METHODS

A total of 668 HIV positive women from the WIHS cohort with an initial and at least one follow-up oral sub-study visit contributed 5358 visits. Salivary gland function was assessed based on a dry mouth questionnaire, whole unstimulated and stimulated salivary flow rates, salivary gland enlargement or tenderness and lack of saliva on palpation of the major salivary glands.

MAIN OUTCOME MEASURES

Changes in unstimulated and stimulated flow rates at any given visit from that of the immediate prior visit (continuous variables). The development of self-reported dry mouth (present/absent), enlargement or tenderness of salivary glands (present/absent), and absence of secretion on palpation of the salivary glands were binary outcomes (yes/no).

RESULTS

Protease Inhibitor (PI) based HAART was a significant risk factor for developing decreased unstimulated (P = 0.01) and stimulated (P = 0.0004) salivary flow rates as well as salivary gland enlargement (P = 0.006) as compared with non-PI based HAART.

CONCLUSIONS

PI-based HAART therapy is a significant risk factor for developing reduced salivary flow rates and salivary gland enlargement in HIV positive patients.

Oral manifestations after immune reconstitution in HIV patients on HAART

In order to verify possible association between immune reconstitution inflammatory syndrome (IRIS) and oral manifestations (OMs), we selected AIDS patients who had low CD4 count before the initiation of highly active antiretroviral therapy (HAART) and who returned three months later for therapy evaluation. The oral lesions observed three months after the initiation of HAART were evaluated and associated with the type of antiretroviral therapy (ART), CD4 count and HIV-RNA load levels (before and three months after HAART initiation). A total of 105 patients matched the selected criteria. Immune reconstitution (IR) was identified in 35.2%. Among these patients, the mean CD4 cell count rose from 105.97 to 330.29 and the mean viral load dropped from 168.005 (log 5.22) to 21.852 (log 4.33). There was no significant difference in age (P = 0.78), sex (P = 0.41) or previous history of ART (P = 0.55) between IR and non-IR patients. In the IR group, the most common OM was parotid enlargement (57.14%) (P = 0.019), whereas in the non-IR group candidiasis (46.15%) was the most common OM. The results of our study suggest that the parotid gland enlargement found in the studied population might be an IRIS event, as it was found in patients with IR three months after the initiation of HAART.

Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation

Lichen planus, a chronic autoimmune, mucocutaneous disease affects the oral mucosa (oral lichen planus or OLP) besides the skin, genital mucosa, scalp and nails. An immune mediated pathogenesis is recognized in lichen planus although the exact etiology is unknown. The disease most commonly affects middle-aged females. Oral lichenoid reactions (OLR) which are considered variants of OLP, may be regarded as a disease by itself or as an exacerbation of an existing OLP, by the presence of medication (lichenoid drug reactions) or dental materials (contact hypersensitivity). OLP usually presents as white striations (Wickham's striae), white papules, white plaque, erythema, erosions or blisters. Diagnosis of OLP is established either by clinical examination only or by clinical examination with histopathologic confirmation. Direct immunofluorescence examination is only used as an adjunct to the above method of diagnosis and to rule out specific autoimmune diseases such as pemphigus and pemphigoid. Histopathologic features of OLP and OLR are similar with suggestions of certain discriminatory features by some authors. Topical corticosteroids are the treatment of choice for OLP although several other medications have been studied including retinoids, tacrolimus, cyclosporine and photodynamic therapy. Certain OLP undergo malignant transformation and the exact incidence and mechanisms are still controversial. In this paper, etiopathogenesis, diagnosis, management and malignant transformation of OLP and OLR have been reviewed.

Oral adverse effects due to the use of Nevirapine

AIM

The aim of this article is to present the clinical characteristics and management of an oral adverse effect stemming from the use of the antiretroviral medication Nevirapine (NVP).

BACKGROUND

NVP is a non-nucleoside reverse transcriptase inhibitor used in the treatment of Human Immunodeficiency Virus (HIV) infection.

CASE REPORT

A 29-year-old black man, HIV-infected since 1996, began highly active antiretroviral therapy (HAART) with zidovudine, lamivudine, and indinavir. From 1996 to 2002 several medications were changed due to their adverse effects: indinavir (renal colic and fever), nelfinavir (cutaneous rash), and efavirenz (nausea and temporary memory loss). When the patient presented to our service he was taking NVP, zidovudine, and lamivudine. A whitish plaque in the lips and bilateral buccal mucosa, burning, taste disturbance, and xerostomia were observed. The discontinuation of HAART led to the complete resolution of signs and symptoms. The patient has received follow-up treatment for three years and five months without local or systemic effects observed.

SUMMARY

Unfortunately, the clinical features of the oral adverse effect from NVP are not well known. This paper contributed to the identification of possible reactions in the oral cavity due to antiretroviral medication. Although HAART is very important in the treatment of HIV, its side effects are responsible for patients' non-adherence to medications. While more studies are needed to better understand the mechanism of action after suspending HAART, the complete resolution of the signs and symptoms was observed. Therefore, physicians and dentists alike must understand how to identify and prevent these adverse effects in order to further improve HIV patient treatments.

Current trends of HIV disease of the mouth

HIV infection affects residents of all countries of the world, but the greater majority of affected individuals reside in the developing world. In the past decade there have been substantial changes in the management of HIV disease, particularly the introduction of highly active antiretroviral therapy (HAART). Such agents have reduced significantly the morbidity and mortality associated with HIV disease, however, they are not available for most HIV-infected individuals in the developing world. There is now considerable understanding of the molecular epidemiology, transmission and therapy of the common opportunistic oral infections of HIV disease, and as a consequence of improved anti-HIV strategies, the frequency and severity of oral disease associated with HIV infection have reduced considerably, although HAART may predispose to human papilloma virus infection of the mouth and potentially increase the risk of later oral squamous cell carcinoma. Despite advances in clinical care the majority of individuals with HIV disease worldwide will continue to develop oral disease, as they are resident in the developing world and do not have ready access to even simple therapies.

Oral lichen planus, hepatitis C virus, and HIV: no association in a cohort study from an area of high hepatitis C virus endemicity

OBJECTIVES

We sought to assess the age-specific prevalence of oral lichen planus (OLP) in Mediterranean patients with chronic hepatitis C virus (HCV) and to evaluate the features of OLP in relation to sex, smoking, HCV genotype, HIV-1 coinfection, and antiviral treatments.

METHODS

In all, 178 anti-HCV-positive adults (60 women and 118 men; age range 20-66 years) recruited from two cohorts (104 HIV-negative patients and 74 patients with HIV coinfection) underwent oral examination.

RESULTS

Overall prevalence of OLP was 2.8% (5 of 178) (male/female ratio 0.2; odds ratio=0.119; 95% confidence interval=0.013-1.106), only among HIV-negative participants, always in the reticular pattern, and in the adult age. HCV genotype, tobacco smoking, and treatment (interferon alfa/ribavirin) were not significantly associated to OLP.

CONCLUSIONS

Among HCV-infected patients, we found a low prevalence of OLP. The absence of OLP in HIV-coinfected patients suggests immunosuppression secondary to defective CD4 functions.

An update of the etiology and management of xerostomia

Salivary gland disease gives rise to salivary gland enlargement, pain, and prolonged xerostomia (dry mouth). Xerostomia is the most common long-standing problem for the majority of affected patients. There are many causes of dry mouth, with long-standing xerostomia being a particular problem in Sjögren's syndrome and after radiation to the head and neck region. Xerostomia is usually managed with saliva substitutes, but a large number of potential systemic therapies of long-standing xerostomia now exist. Some-particularly immunosuppressants-are of fundamental interest for the potential reduction of gland damage in Sjögren's syndrome but as yet are of limited clinical usefulness. Others, particularly pilocarpine and cevimeline, are, or have the potential to be, clinically useful in stimulating salivation by virtue of their action on cholinergic receptors.

Gastrointestinal side effects of drugs

Drugs can have adverse effects on any part of the gastrointestinal (GI) tract from mouth to colon. It is essential that a detailed and accurate drug history is taken in patients presenting with GI complaints. Many drug-induced effects will regress or heal on cessation of treatment. NSAIDs are usually associated with gastric and duodenal ulcers but are also recognised to cause lichen planus in the mouth, oesophageal inflammation and strictures, and small bowel and colonic ulcers and strictures. A newer class of anti-inflammatory drugs, the cyclooxygenase-2 (COX-2)-selective inhibitors, have been developed and have a more favourable GI safety profile than standard NSAIDs. Acute diarrhoea, relapse of inflammatory bowel disease (IBD), microscopic colitis and acute pancreatitis are also induced by ingestion of standard NSAIDs. The calcium antagonists, phenytoin and cyclosporin, induce gum hyperplasia, particularly in patients with poor oral hygiene. Alendronate, a bisphosphonate, has been associated with development of oesophageal ulcers, and specific recommendations are now given to reduce this complication. Of the many different forms of colitis associated with drug ingestion, the most frequent is pseudomembranous colitis. This is a complication of antibiotics and is caused by the toxin produced by Clostridium difficile. Many drugs have been associated with the development of acute pancreatitis, although a definite cause and effect relationship has been shown for only a few drugs. These include didanosine, furosomide, corticosteroids, azathioprine and sodium valproate.

Adverse effects of antiretroviral therapy: focus on orofacial effects

The optimum anti-HIV drug has yet to be found. This paper will summarise some of the oral adverse effects associated with antiretroviral agents against HIV. The development of antiretroviral drugs for the treatment of HIV infection has been aimed at the inactivation of two HIV enzymes: reverse transcriptase and proteases. Erythema multiforme, ulcers and xerostomia are the main oral side effects associated with reverse transcriptase inhibitors. Parotid lipomatosis, taste disturbance, xerostomia and perioral paraesthesia are oral adverse effects, which are mainly related to protease inhibitor therapy. The search for new antiretrovirals with different active mechanisms and patterns of resistance constitutes a key question in HIV treatment. The use of new drugs and drug combinations will lead to the appearance of oral lesions, which will be difficult to identify and treat and which cannot be ignored by the practitioner.