Periodontal status of individuals in early stages of human immunodeficiency virus infection

Relationship between human immunodeficiency virus (HIV-1) infection and chronic periodontitis

INTRODUCTION

Current studies show that, even in the era of antiretroviral therapies, HIV-1 infection is associated with more severe and frequent refractory chronic periodontitis. Areas covered: This review, based on a systematic analysis of the literature, intends to provide an update on factors that may be involved in the pathogenesis of periodontal disease in HIV-1-infected patients, including local immunosuppression, oral microbial factors, systemic inflammation, salivary markers, and the role of gingival tissue as a possible reservoir of HIV-1. Expert commentary: The therapeutic revolution of ART made HIV-1 infection a chronic controllable disease, reduced HIV-1 mortality rate, restored at least partially the immune response and dramatically increased life expectancy of HIV-1-infected patients. Despite all these positive aspects, chronic periodontitis assumes an important role in the HIV-1 infection status for activating systemic inflammation favoring viral replication and influencing HIV-1 status, and also acting as a possible reservoir of HIV-1. All these issues still need to be clarified and validated, but have important clinical implications that certainly will benefit the diagnosis and management of chronic periodontitis in HIV-1-infected patients, and also contributes to HIV-1 eradication.

Effect of Nadir CD4+ T cell count on clinical measures of periodontal disease in HIV+ adults before and during immune reconstitution on HAART

Background

The contribution of HIV-infection to periodontal disease (PD) is poorly understood.  We proposed that immunological markers would be associated with improved clinical measures of PD.

Methods

We performed a longitudinal cohort study of HIV-infected adults who had started highly active antiretroviral therapy (HAART) <2 years. PD was characterized clinically as the percent of teeth with ≥1 site with periodontal probing depth (PPD) ≥5.0mm, recession (REC) >0mm, clinical attachment level (CAL) ≥4.0mm, and bleeding on probing (BOP) at ≥4 sites/tooth and microbiologically as specific periodontopathogen concentration. Linear mixed-effects models were used to assess the associations between immune function and PD.

Results

Forty (40) subjects with median 2.7 months on HAART and median nadir CD4+ T-cell count of 212 cells/μl completed a median 3 visits. Over 24 months, CD4+ T-cell count increased by a mean 173 cells/µl (p<0.001) and HIV RNA decreased by 0.5 log₁₀ copies/ml (p<0.001); concurrently, PPD, CAL and BOP decreased by a mean 11.7%, 12.1%, and 14.7% respectively (all p<0.001). Lower nadir CD4+ T-cell count was associated with worse baseline REC (-6.72%; p=0.04) and CAL (9.06%; p<0.001). Further, lower nadir CD4+ T-cell count was associated with a greater relative longitudinal improvement in PPD in subjects with higher baseline levels of Porphyromonas gingivalis (p=0.027), and BOP in subjects with higher baseline levels of Porphyromonas gingivalis or Treponema denticola (p=0.001 and p=0.006 respectively). Longitudinal changes from baseline in CD4+ T-cell count and level of HIV RNA were not independently associated with longitudinal changes in any clinical markers of PD.

Conclusion

Degree of immunosuppression was associated with baseline gingival recession. After HAART initiation, measures of active PD improved most in those with lower nadir CD4+ T-cell counts and higher baseline levels of specific periodontopathogens. Nadir CD4+ T-cell count differentially influences periodontal disease both before and after HAART in HIV-infected adults.

Characterizing traditionally defined periodontal disease in HIV+ adults

BACKGROUND

Results have varied from previous studies examining the level and extent of periodontal disease (PD) in HIV-1 infected (HIV+) adults. These studies used different methodologies to measure and define PD and examined cohorts with divergent characteristics. Inconsistent methodological approaches may have resulted in the underestimation of traditionally-defined PD in HIV+ individuals.

OBJECTIVES

To characterize the level, extent and predictors (i.e. immunologic, microbiologic, metabolic and behavioral) of PD in an HIV+ cohort during the era of highly active antiretroviral therapy (HAART).

STUDY DESIGN

Cross-sectional study.

SETTING

HIV+ adults receiving outpatient care at three major medical clinics in Cleveland, OH. Subjects were seen from May, 2005 to January, 2008.

MEASUREMENTS

Full-mouth periodontal examinations included periodontal probing depth (PPD), recession (REC) and clinical attachment level (CAL). Subgingival plaque was assessed for DNA levels of Porphyromonas gingivalis (Pg), Tannerella forsythia, and Treponema denticola by real-time DNA PCR assays developed for each pathogen. Rather than using categories, we evaluated PD as three continuous variables based on the percent of teeth with >or=1 site per tooth with PPD >or= 5mm, REC > 0 mm and CAL >or= 4mm.

RESULTS

Participants included 112 HIV+ adults. Each subject had an average 38% (+/-24%) of their teeth with at least one site of PD >or= 5 mm, 55% (+/-31%) of their teeth with at least one site of REC > 0 mm, and 50% (+/-32%) of their teeth with at least one site of CAL >or= 4 mm. CD4+ T-cell count <200 cells/mm(3) was significantly associated with higher levels of REC and CAL, but not PPD. Greater levels of Pg DNA were associated with PPD, REC and CAL.By regression analysis, CD4+ T-cell count <200 cells /mm3 had approximately twice thedeleterious effect on CAL as did smoking (standardized beta coefficient 0.306 versus 0.164) [corrected]. Annual dental visit compliance remained an independent predictor for lower levels of PD.

CONCLUSIONS

The level and extent of PD were high in this cohort even though most patients were being treated with HAART. The definition of periodontal disease used and cohort characteristics examined can influence the level of periodontal disease reported in studies of persons with HIV. Traditional periodontal pathogens are associated with PD in this cohort. Those with CD4+ T-cell counts <200 cells/mm(3) are at greater risk for PD. Therefore, earlier HAART initiation may decrease exposure to immunosuppression and reduce PD morbidity. Continuity of dental care remains important for HIV+ patients even when they are being treated with HAART.

Enfermedad periodontal necrosante: una manifestación de trastornos sistémicos

Necrotizing periodontal disease (NPD) is an infection characterized by gingival necrosis presenting as "punched-out" papillae, with gingival bleeding, and pain. Prevotella intermedia and spirochetes have been associated with the gingival lesions. Predisposing factors may include emotional stress, immunosuppression, especially secondary to human immunodeficiency virus (HIV) infection, cigarette smoking, poor diet and pre-existing gingivitis. During the last few years, diagnosis of NPD has became more important not only because of its contribution to the appearance of clinical attachment loss and gingival sequelae, but also because it has been revealed as a marker for immune deterioration in HIV-seropositive patients.

Association of T CD4 Lymphocyte Levels and Chronic Periodontitis in HIV-Infected Brazilian Patients Undergoing Highly Active Anti-Retroviral Therapy: Clinical Results

BACKGROUND

Controversial data regarding the association between immunosuppression and prevalence/ severity of periodontal diseases in HIV infection have been reported. Thus, the aim of this study was to test the hypothesis that lower T CD4 lymphocyte levels are not related to a higher prevalence of chronic periodontitis in HIV-infected Brazilians undergoing highly active anti-retroviral therapy (HAART).

METHODS

Sixty-four HIV-infected patients under HAART were classified as having chronic periodontitis; i.e., > or = three sites with probing depth (PD) and/or clinical attachment level (CAL) > or = 5 mm or periodontal healthy (no sites with PD > 3 mm and/or CAL > 4 mm). All subjects received conventional periodontal therapy. Bleeding on probing, plaque accumulation, PD, and CAL were registered at six sites/tooth at baseline and 4 months after therapy. Epidemiological features and levels of T CD4 lymphocytes were obtained from medical records. Significance of differences in periodontal clinical parameters within and between groups were determined using Wilcoxon signed-rank and Mann-Whitney or independent sample t tests. Associations between T CD4 levels and clinical parameters were determined using the chi square test.

RESULTS

Sixty-one percent of the HIV-infected patients represented AIDS cases, although 69% of them were periodontally healthy. The overall T CD4 lymphocyte mean levels was 333 +/- 254 cells/mm3 and viral load was 12,815 +/- 24,607 copies/mm3. Yet the prevalence of chronic periodontitis was relatively low (36%). In addition, patients with periodontitis presented a moderate disease (mean PD = 2.2 +/- 0.10; mean CAL = 2.6 +/- 0.13) and responded successfully to periodontal therapy. These subjects showed higher levels of T CD4 cells, but lower counts of neutrophils than periodontally healthy patients. Among periodontally healthy and chronic periodontitis patients, 41.7% and 22.9%, respectively, had low levels of T CD4 lymphocytes. No significant differences between periodontal status and epidemiological and immunological parameters were observed.

CONCLUSION

Based on these results, the hypothesis that lower T CD4 lymphocyte levels are not associated with higher prevalence of chronic periodontitis in HIV-infected Brazilians under HAART cannot be rejected.

Periodontal Disease in HIV-Positive Individuals: Association of Periodontal Indices with Stages of HIV Disease

BACKGROUND

Periodontal disease has been previously associated with human immunodeficiency virus (HIV) infection, and HIV infection has been considered a modifier of periodontal disease. The aim of this study was to report the prevalence and severity of periodontal disease in a population of HIV-positive individuals and to investigate the association between clinical periodontal indices and the stage of HIV disease, as expressed by CD4 cell counts.

METHODS

Thirty-nine male HIV-positive patients were recruited and a medical history was taken. To evaluate periodontal disease, probing depth (PD), attachment level loss (AL), bleeding index (BI), and modified gingival index (MGI) were recorded. Associations between the above indices and CD4 counts were examined.

RESULTS

Immunocompromised patients (with CD4 cell counts < 200 cells/microl) showed significantly lower BI and fewer sites with PD and AL > 4 mm compared to patients with CD4 cell counts > 200 cells/microl. When patients with CD4 counts < 500 cells/microl were considered alone, a correlation was observed between CD4 cell counts and BI (r2 = 0.1617, P = 0.0463), MGI (r2 = 0.2123, P = 0.0204), and number of sites with AL > 4 mm (r2 = 0.1469, P = 0.056).

CONCLUSIONS

Severely immunocompromised HIV-positive patients showed less severe gingival inflammation than expected. Patients with CD4 cell counts > 500 cells/microl showed no association between CD4 cell count and periodontal indices.

Clinical implications of the oral manifestations of HIV infection in children

The authors hypothesized that patients infected with HIV at birth would be more vulnerable to oral diseases such as periodontal disease and caries because of their compromised immune system. As a result, they designed a 3-year, longitudinal, case-controlled study that examined HIV-infected children as compared with their normal noninfected household peers. Over 100 HIV-infected participants ages 2 to 15 years were examined at 6-month intervals; no differences were found with respect to caries or periodontal disease prevalence and incidence when the two groups were compared. Although the level of oral disease was similar in the two groups, both groups had more caries than the national norm. Thus, failure to use a control group would have led to the erroneous conclusion that children with HIV infection had a high level of caries. In addition, the authors discovered that tooth eruption was delayed in the HIV-infected group, suggesting some developmental impediment. The HIV-infected group also showed more oral lesions that included candidiasis, linear gingival erythema, and medial rhomboid glossitis. Overall, oral lesions were not valid predictors of the serious consequences of AIDS. The authors speculated, however, that examinations at intervals more frequent than every 6 months might be required to determine whether oral lesions can predict frank AIDS and lowered CD4 cell counts.

Fungal infections associated with HIV infection

Oral candidiasis is perhaps the commonest infection seen in HIV disease. The aim of this workshop was to provide a sketch of the multifarious aspects of the disease from a global perspective. To this end the panellists addressed issues such as the virulence of Candida, emergence of antifungal resistance, management of candidiasis and other exotic, oral mycotic diseases. An all-pervasive theme was the dramatic differences in the management of fungal infections consequential to the availability (or the lack) of anti-HIV drugs in the developed and the developing world. Further, the social stigmata associated with the HIV disease in many developing regions in Africa and Asia appears to modify the therapeutic strategies. Additionally, the lesser-known regional variations in the disease manifestations and therapeutic approaches were stark. Further work is direly needed to address these issues.

Do regular dental visits affect the oral health care provided to people with HIV?

BACKGROUND

Financial factors related to income and insurance coverage have been found to limit access to, and influence use of, oral health care services by people with human immunodeficiency virus, or HIV.

METHODS

The authors determined if visiting a dentist regularly affected the oral health services provided to people with HIV when financial barriers were eliminated as an impediment to access. They analyzed dental claims data for services submitted for payment to the Minnesota Access to Dental Care Program. The analyses focused on comparisons of dental utilization patterns among 273 people classified as regular patients, or RPs, and 222 people classified as nonregular patients, or NRPs.

RESULTS

RPs were found to have been provided more diagnostic and preventive care, and less restorative, endodontic, periodontic, removable prosthodontic and oral surgical treatment than were NRPs. Although the mean submitted cost per patient visit was much higher for NRPs, total mean submitted costs per patient for RPs and NRPs were not significantly different. Even though NRPs underwent fewer procedures and had fewer clinic visits than did RPs, the procedures provided to NRPs were more complex and costly. As indicated by differences in the mix of dental care services provided to RPs vs. NRPs, continuity of primary oral health care for RPs led to a better oral health result at no increase in cost over that for NRPs.

CONCLUSIONS

The study findings provide substantial evidence regarding the value of regular oral health care for people with HIV.

CLINICAL IMPLICATIONS

This study reinforces the need for dentists to educate and encourage people with HIV to integrate regular oral health care into the ongoing maintenance of their overall health and well-being.

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.

Treatment of plaque-induced gingivitis, chronic periodontitis, and other clinical conditions

The inflammatory components of plaque induced gingivitis and chronic periodontitis can be managed effectively for the majority of patients with a plaque control program and non-surgical and/or surgical root debridement coupled with continued periodontal maintenance procedures. Some patients may need additional therapeutic procedures. All of the therapeutic modalities reviewed in this position paper may be utilized by the clinician at various times over the long-term management of the patient's periodontal condition.

Isolation and genotyping of black-pigmented anaerobes from periodontal sites of HIV-positive and non-infected subjects in Thailand

BACKGROUND, AIMS

The aims of this study were to investigate the prevalence of periodontitis, the prevalence of black-pigmented anaerobes and the genotypes of Porphyromonas gingivalis and Prevotella intermedia present in HIV-infected and control subjects in a heterosexual Thai population.

METHOD

50 AIDS patients and 50 control subjects were included in the study. Their periodontal condition was examined by assessment of bleeding on probing, attachment loss and probing depth, and presence of erythema around 6 teeth (16, 21, 24, 36, 41, 44). Subgingival plaque was collected from the mesiobuccal sites of these teeth and was cultured anaerobically for black-pigmented bacteria. Species were characterised using biochemical profiles and total protein profiles. Genotyping of each isolate was performed using PCR techniques.

RESULTS

There was little clinical evidence of HIV-associated periodontitis in the HIV-positive subjects and no difference was found in the prevalence or genotype distribution of black-pigmented anaerobes between HIV-infected and control subjects.

CONCLUSIONS

These data suggest lack of severe periodontal destruction due to HIV-infection in Thailand and that these subjects are not colonised by more numerous or characteristic clones of certain putative periodontal pathogens.

Factors associated with periodontitis in an HIV-infected southeast USA study

OBJECTIVES

To determine the relationship of immunosuppression with measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL) in an HIV-infected population from North Carolina (NC), a state in the southeastern United States (USA).

DESIGN

Cross-sectional study of HIV-infected adults (n = 326) treated at the University of North Carolina Hospitals. Clinical medical record review and sociodemographic interview data were collected. Median age of study participants was 37 years (range 19-67). Males comprised 78% and Blacks 60%. Analyses were limited to those who were dentate (n = 316).

MAIN OUTCOME MEASURES

Main outcomes were cases vs non-cases of notable PPD, REC, and CAL. Immunosuppression measured by CD4+ cell count microL was the exposure of interest.

RESULTS

Defined cases of PPD (n = 148) were 2.6 (95% CI = 1.3, 5.3) times less likely to occur at CD4+ cells < 200 than non-cases, whereas, cases of REC (n = 94) were 2.8 (95% CI = 1.2, 6.6) times more likely to occur at that level of severe immunosuppression, controlling for confounders.

CONCLUSION

Sub-groups of persons with HIV experience a high burden of periodontitis where notable severity and extent of PPD, CAL, and REC were clearly evident at different stages of immunosuppression.

Immunologic and viral markers of HIV-1 disease progression: implications for dentistry

BACKGROUND

Current medical care for patients infected with the human immunodeficiency virus type 1, or HIV-1, involves monitoring laboratory assays for CD4+ lymphocyte cell count and plasma viral load.

TYPES OF STUDIES REVIEWED

The authors reviewed recent medical and dental studies that contribute to our current understanding of these immunologic and viral markers and their relevance to systemic and oral health.

RESULTS

Dramatic reduction in plasma viral load resulting from more potent antiretroviral drug combinations is the goal of medical management for HIV. These protease inhibitor-containing regimens, although complex, expensive and associated with substantial side effects, have decreased the morbidity and mortality associated with HIV in the United States. Although reduction in viral load can result in increases in CD4+ counts, which restores some level of immune competence, a cure for AIDS has not yet been found.

CLINICAL IMPLICATIONS

Patients with low CD4+ cell counts (and often high viral loads) are more likely to develop destructive periodontal infections and other oral manifestations of HIV. Partial recovery of the immune system after viral load reduction may affect both the prognosis and oral disease experience of these patients.

Alveolar bone levels in AIDS and HIV seropositive patients and in control subjects

Alveolar bone levels were studied from intraoral radiographs of 24 non-hospitalized patients with AIDS, 17 HIV seropositive subjects, and 39 matched control subjects. The AIDS/HIV subjects were seeking dental care in a faculty practice. The matched control subjects came from those non-HIV-infected patients seeking dental care at the University of Washington. Magnified intraoral radiographs were used to assess the distance between the cemento-enamel junction (CEJ) and the alveolar bone level (BL). The extent of vertical defects and furcation invasions was also assessed. The mean age of the AIDS, HIV, and control subjects was 38.9 +/- 6.6 years, 37.1 +/- 7.6, and 39.9 +/- 5.6, respectively, and was not statistically different. Among the AIDS patients, 75% were smokers, while 88.2% of the HIV subjects were cigarette smokers. Therefore, the matched control subjects were also smokers to the same extent. The mean difference in distance CEJ-BL was 0.1 mm (mesial) and 0.3 mm (distal) and greater in the HIV/AIDS group than in the control group, but not statistically different. No vertical defects > or = 3.0 mm were found in 69.2% of the control subjects and in 58.5% of the combined HIV/AIDS group. None of the HIV/AIDS subjects had more than 5 defects > 3.0 mm, while 7.6% of the control subjects had such defects. Significant associations were found between smoking and extent of alveolar bone loss (distance) (P < 0.001) as well as the number and extent of vertical defects (P < 0.01), but were not associated with HIV status. The extent of furcation invasions, as read radiographically, did not differ between groups. In conclusion, smoking but not HIV status was the primary factor for alveolar bone loss.

New concepts regarding the pathogenesis of periodontal disease in HIV infection

Periodontal manifestations of human immunodeficiency virus (HIV) infection were first described in 1987. Initially, the lesions receiving attention were HIV-associated gingivitis (now known as linear gingival erythema [LGE]) and HIV-associated periodontitis (now known as necrotizing ulcerative periodontitis [NUP]). The true prevalence of LGE was difficult to determine due to variable diagnostic criteria. Recently, LGE has been associated with intraoral Candida infection. The prevalence of NUP is low (< or = 5%), and this lesion is associated with pronounced immunosuppression. Current focus on the periodontal manifestations of HIV infection centers on rapid progression of chronic adult periodontitis in HIV+ patients. Attempts to identify the pathogenesis of the increased progression of periodontitis have not proven successful. For example, analysis of subgingival plaque for the presence of bacterial pathogens has failed to detect differences between HIV+ and HIV- patients. Recently our laboratory has identified alterations in the host response in the gingival crevice of HIV+ patients. Comparing HIV+ and HIV- injecting drug users (IDU), levels of the proinflammatory cytokine interleukin-1 beta (IL-1 beta) in gingival crevicular fluid (GCF) were slightly elevated at sites with a probing depth of 1 to 3 mm. At deeper sites (> or = 4 mm), total IL-1 beta in GCF was significantly greater in HIV+ individuals. Using the lysosomal acid glycohydrolase beta-glucuronidase (beta G) as a measure of the influx of polymorphonuclear leukocytes (PMN) into the gingival crevice, our data indicated a significant correlation of total beta G in GCF and probing depth in the HIV-IDU (r = 76; P = .02). This result was similar to what we have observed in other studies. In contrast, for HIV+ subjects, total beta G was not associated with probing depth (r = .20; NS). These data suggest that HIV+ patients have altered regulation of PMN recruitment into the gingival crevice. We have begun to investigate the conditions under which subgingival Candida may contribute total periodontal lesions in HIV+ individuals. Candida from subgingival sites has been cultured in HIV+ individuals. Subgingival Candida was distinct from Candida isolated from tongue and buccal mucosal surfaces (as indicated by genomic fingerprinting). We hypothesize the absence of adequate priming of PMN by HIV+ patients. This may be due to a reduced Th1 lymphocyte response. The inability of HIV+ individuals to adequately prime PMN may allow Candida to colonize the subgingival environment. In that milieu, it may act directly or in concert with subgingival bacterial pathogens, or as a cofactor (by inducing production of proinflammatory cytokines) to increase the occurrence of periodontal attachment loss.

Reduced serum IgG reactivities with bacteria from dental plaque in HIV-infected persons with periodontitis

Serum samples were obtained from 44 HIV-seropositive (HIV+) and 37 HIV-seronegative (HIV-) persons that were grouped according to periodontal status. Serum IgG and IgA reactivities towards Streptococcus mutans, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis. Prevotella intermedia, Prevotella nigrescens and Fusobacterium nucleatum were measured by means of ELISA. HIV+ persons with chronic marginal periodontitis showed significantly lower IgG reactivities to the periodontal pathogens A. actinomycetemcomitans, P. gingivalis, P. intermedia and F. nucleatum as compared with their HIV- counterparts (p < 0.05). Specific serum IgA reactivities were similar in the two periodontitis groups, except for P. nigrescens where the HIV+ group with chronic marginal periodontitis had lower values than their systemically healthy counterparts (p < 0.05). The results indicate that HIV infection affects the humoral serum immune responses against bacteria in dental plaque; the depressed antibody responses may contribute to the increased susceptibility for periodontal infections in HIV-infected patients.

Is there an association between periodontal condition and HIV infection?

Individuals in Tanzania who have limited access to medical and dental treatment provide an opportunity to study the natural association between periodontal condition and HIV infection and the stage of infection. 119 HIV-infected adult individuals and 73 individuals with AIDS from the AIDS Clinical Trial Clinic at Muhimbili Medical Centre (MMC) in Dar-es-Salaam participated as cases. Mean age was 35.3 and 35.1 years, respectively. 156 individuals with a mean age of 28.3 years, confirmed as HIV-seronegative, served as controls. There were no significant differences in bleeding on probing, pocket formation or attachment loss among the HIV-seronegative individuals, HIV-seropositive and AIDS patients. We applied multiple logistic regression to calculate odds ratios for presence of periodontal conditions adjusting for age, gender and DMFT. Our odds ratios did not reveal any significant associations between bleeding on probing, pocket formation or attachment loss with regard to lymphocyte and CD4+ T-cell counts among the HIV-infected individuals and AIDS patients. When associations were investigated with regard to HIV-serostatus (HIV-seronegative, HIV-seropositive or AIDS), our adjusted odds ratios were insignificant, too. In fact, most odds ratios were close to 1. Thus, our study supports recent views that the presence, extent and severity of periodontal disease among HIV-infected individuals, may be less that hitherto thought.

Epidemiology and diagnosis of HIV-associated periodontal diseases

A review of periodontal disease as a manifestation of HIV infection suggests a shift in emphasis over the past 5 years. Initially the focus was on newly described forms of periodontal disease (i.e., HIV-associated gingivitis or linear gingival erythema (LGE); HIV-associated periodontitis or necrotizing ulcerative periodontitis (NUP). While the clinical definition of LGE varies from study to study, an association between LGE and Candida infection has been described. Furthermore, the prevalence of NUP is quite low and this disorder is associated with severe immunosuppression. In contrast, the focus today is on the accelerated rate of chronic adult periodontitis occurring in seropositive patients. While the organisms that characterize adult periodontitis in seronegative individuals are present in subgingival plaque from seropositive individuals, reports suggest that atypical pathogens are also present (i.e., Mycoplasma salivarium, Enterobacter cloacae). Recent studies from our laboratory have identified a novel strain of Clostridium isolated from the subgingival plaque of injecting drug users that has pathologic potential. This organism, however, was found in both seropositive and seronegative individuals in this cohort, suggesting an association with lifestyle rather than serostatus. In addition, data has been published examining the local host response in periodontitis in seropositive individuals. Distinctly elevated levels of IgG in gingival crevicular fluid (GCF) have been observed in seropositive patients. Furthermore, data from our laboratory examining inflammatory mediators in GCF (polymorphonuclear leukocyte lysosomal enzyme beta-glucuronidase and the pro-inflammatory cytokine interleukin-1 beta) suggests an altered response in patients with HIV infection. The alteration manifests as the absence of the expected strong correlation between polymorphonuclear leukocyte activity in the gingival crevice and clinical measures of existing periodontal disease, as well as elevated levels of interleukin-1 beta in sites with deeper probing depths. Therefore, it can be concluded that the progression of periodontal disease in the presence of HIV infection is dependent upon the immunologic competency of the host as well as the local inflammatory response to typical and atypical subgingival microorganisms.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

The effect of a single mechanical treatment on the subgingival microflora in patients with HIV-associated gingivitis

The purpose of the present study was to investigate the effect of a single episode of scaling and root planing on clinical periodontal parameters and on the subgingival microflora in human immunodeficiency virus (HIV)-positive and HIV-negative subjects. 13 subjects participated and were clinically scored at days -7, 7, 30 and 90. 7 subjects were infected with HIV and presented an HIV-associated gingivitis. 6 subjects were HIV-negative with at least 12 teeth affected by conventional gingivitis. No significant differences were seen between both groups regarding the presence of P. gingivalis, P. intermedia and A. actinomycetemcomitans. The mean plaque index (PlI) was 1.79 in the HIV-negative and 1.29 in the HIV-positive group. The mean gingival index (GI) was higher in the HIV-positive group (HIV-positive: 1.55; HIV-negative: 1.47). Whereas, the PlI decreased significantly in the HIV-negative group during the course of the study, no change was observed in the HIV-positive group. GI as well as bleeding upon sampling decreased significantly in both patient groups during the same period. The bacterial counts decreased from day -7 to day 7 and generally remained on a lower level until day 90. Small differences were seen in the microbiological flora of the HIV-positive and the HIV-negative subjects following mechanical treatment.

Periodontal disease in HIV seropositive patients and its relation to lymphocyte subsets

This study was performed to determine the type of periodontal pathology found in a group of HIV+ patients and its relation to serum levels of CD4. The sample consisted of 101 individuals: intravenous drug users (84%), homosexuals (7%), and heterosexuals (10%). Each patient was examined clinically and radiographically. Periodontal clinical parameters included gingival index and probing depth and loss of attachment on four sites per tooth. Severity of disease was defined as the most severe lesion found: gingivitis, or early, moderate, or advanced periodontitis. CD4 counts were determined on 64 of these patients. Associations between severity of the disease and gender and CD4 counts were analyzed using the Mantel Haenszel chi square test, while associations between severity and age and CD4/CD8 ratio were analyzed using the Kruskal-Wallis test. No disease was found in 14.8% of the sample, gingivitis was found in 21.8%, early periodontitis in 43.6%, moderate periodontitis in 10.9%, and advanced periodontitis in 8.9%. Linear gingival erythema (LGE) was seen in 17.8% of all patients and necrotizing periodontitis (NUP) in 4.9%. No statistically significant differences were observed between the severity of the disease and CD4 counts.

Loss of periodontal attachment in HIV-seropositive military personnel

The cross-sectional relationship between severe loss of periodontal attachment (LPA) and worsening immune status due to HIV infection was evaluated in 474 HIV-infected subjects (416 men, 58 women) aged 18 to 49 years who had been classified at stages 1 through 6 of the Walter Reed Army Institute of Research (WR) Staging Classification System. LPA was measured at four sites per tooth using a manual probe; severe LPA was defined as > or = 1 site/subject exhibiting > or = 5 mm LPA. Severe LPA was found in 94 (20%) of the subjects. Modeling with multiple logistic regression analysis revealed that WR stage and peripheral CD4+ lymphocyte cell counts were not significant independent predictors of severe LPA. Severe LPA was more common in subjects at WR stage 5 or 6 who exhibited oral candidiasis (OC), a marker of immune system damage, than in persons at those WR stages without OC (odds ratio = 7.85; 95% confidence interval (CI) = 1.94-31.81). After the analysis controlled for WR stage, younger subjects receiving AZT had greater odds of severe LPA than same-age subjects not taking the drug (e.g., odds ratio for subjects aged 30 years = 2.59; 95% CI = 1.22, 5.49). Other significant predictors in the model included male sex; retired military status; cigarette smoking; and presence of cratered, ulcerated, or necrotic interdental papillae. HIV-associated immune deficiency may be associated with localized severe LPA, but this may be an indirect association due to medication use, opportunistic infection, or other factors not captured by the WR staging system or peripheral CD4+ cell counts.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of candidiasis to linear gingival erythema in HIV-infected homosexual men and parenteral drug users

Periodontal status was evaluated in two cohorts participating in a study of the natural history of human immunodeficiency virus (HIV) infection. One cohort consisted of 77 seropositive and 44 seronegative homosexual men, and the other cohort was comprised of 44 seropositive and 39 seronegative parenteral drug users (PDU). No differences were observed between seropositive and seronegative individuals within a cohort in terms of clinical periodontal parameters (percent of sites with > or = 4 mm probing depth, percent of sites exhibiting bleeding on probing, mean oral hygiene index). The PDU displayed more existing periodontal disease than the homosexual men. Periodontal disease in the seropositive individuals in both cohorts was not strictly related to the number of CD4+ lymphocytes. Linear gingival erythema (LGE), defined as an erythematous band of at least 2 mm extending between adjacent papilla, was observed in all 4 groups. Seropositive homosexual men displayed more LGE than seronegative homosexual men (16.6% vs. 11.4%) and seronegative PDU displayed more LGE than seropositive PDU (38.5% vs. 29.5%), but neither difference was significant. LGE tended to be related to reduced numbers of CD4+ lymphocytes, but this relationship did not reach statistical significance. A statistically-significant relationship was found between the presence of intraoral candidiasis and LGE in seropositive homosexual men: 42.9% of these subjects with candidiasis had LGE, while only 12.7% of the subjects without candidiasis had LGE (P < .05). For the seropositive PDU, 35.3% of the individuals with candidiasis had LGE and 25.9% of the subjects without candidiasis displayed LGE, but the difference was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodontal diseases in HIV-infected patients

Periodontal diseases may be the first clinical sign of human immunodeficiency virus (HIV)-infection. Since the immunosuppression and subsequent susceptibility may alter the responses of the oral tissues as well as the microflora, both periodontal treatment and result of therapy may be modified. The periodontal diseases in HIV-seropositive patients include common as well as less conventional forms of gingivitis and periodontitis, and bacterial, mycotic and viral infections are seen. Neoplasias may also involve the periodontium; most common are Kaposi's sarcoma and non-Hodgkin's lymphoma. Recent studies of unselected groups of patients indicate that periodontal health in at least some groups of HIV-seropositive patients is better than previously reported.

The diagnosis of periodontal conditions associated with HIV infection

Objective, reliable, and valid diagnostic criteria are required for studies of HIV-associated periodontal conditions. A set of diagnostic criteria were devised based on a literature review and the clinical experience of the authors. Validity was assessed by comparison with clinical photographs and the criteria were evaluated and refined for ease of use and objectivity. To assess the reliability of the criteria, 9 experienced examiners were shown 20 clinical photographs accompanied by brief vignettes of clinical information. Each examiner was asked to identify signs evident in a particular area of the photograph and to record a diagnosis. Five examiners were then trained and calibrated in the use of the criteria. Finally, all 9 examiners were shown the original 20 photographs and asked to identify signs and record diagnoses. The examiners showed only fair reliability in the recognition of clinical signs, made diagnoses intuitively, and had only fair agreement on the diagnosis of periodontal diseases. The inter-examiner reliability of examiners trained and calibrated in the use of the criteria increased and was greater than among untrained examiners. Rigid diagnostic criteria are essential in epidemiologic studies. Inter-examiner reliability will be increased if examiners are trained in their use and calibrated in the recognition of clinical signs. Diagnostic criteria should be modified as understanding of the diseases they classify increases. The proposed criteria will enhance the value of studies of HIV-associated periodontal changes and will contribute to that understanding.

HIV-associated periodontal disease: new oral spirochete found

This study examines plaque for the presence of a recently described oral spirochete, tentatively called pathogen-related oral spirochete. This investigation found PROS in plaque of patients with HIV-associated periodontal disease.