HIV infection and periodontal diseases

Cohort study of HIV-positive and -negative methamphetamine users

BACKGROUND

The effects of methamphetamine (MA) on caries have been well documented. Little, however, is known about its effects on the periodontium. The authors conducted this study to determine the prevalence and severity of periodontal disease in an urban population of HIV-positive MA users.

METHODS

This cross-sectional survey was conducted in one of the most populous urban areas of Los Angeles County, California, beset with high rates of MA use. Participants were recruited by a combination of street outreach methods, referral from drug treatment centers, and word of mouth. Participants were eligible if they were older than 18 years, spoke English or Spanish, used MA in the past 30 days, were willing to undergo a dental examination and psychosocial assessments, and were willing to provide a urine sample. Periodontal assessments were completed for 541 participants by 3 trained and calibrated dentists.

RESULTS

The prevalence and severity of periodontal disease were high in this population of HIV-positive and -negative MA users. Cigarette smoking and age were identified as risk factors.

CONCLUSIONS

The HIV-positive and -negative cohorts were remarkably similar, suggesting that their lifestyles contributed more to their destructive periodontal disease than their MA use.

PRACTICAL IMPLICATIONS

MA users are at high risk of developing destructive periodontal disease and badly broken-down teeth. Clinicians should plan accordingly for timely management of the patients' care, knowing that MA users have extensive periodontal and restorative treatment needs.

Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre-existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre-existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re-evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre-existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.

Viruses in periodontal disease - a review

The purpose of this review was to evaluate the evidence supporting the hypothesis that viral infection plays a role in the development of periodontitis. An involvement in periodontal diseases has been suspected specifically for human immunodeficiency virus (HIV) and herpes viruses. An association has been demonstrated between HIV infection and some distinct forms of periodontal infection, i.e. necrotizing lesions. Furthermore, reports of increased prevalence and severity of chronic periodontitis in HIV-positive subjects suggests that HIV infection predispose to chronic periodontitis. Several studies, most of them from the same research group, have demonstrated an association of herpesviruses with periodontal disease. Viral DNA have been detected in gingival tissue, gingival cervicular fluid (GCF) and subgingival plaque from periodontaly diseased sites. In addition markers of herpesviral activation have been demonstrated in the GCF from periodontal lesions. Active human cytomegalovirus (HCMV) replication in periodontal sites may suggest that HCMV re-activation triggers periodontal disease activity. Concerns regarding sampling, methods and interpretation cast doubts on the role of viruses as causes of periodontal disease.

Differential recovery of Candida species from subgingival sites in human immunodeficiency virus-positive and healthy children from Rio de Janeiro, Brazil

The prevalence of subgingival Candida species was studied in 52 human immunodeficiency virus (HIV)-positive and 42 HIV-negative children. Candida was cultured from 22 (42.3%) and 3 (7.1%) HIV-infected and control children, respectively. C. albicans was the most common Candida species isolated from HIV-infected children, followed by C. dubliniensis, C. glabrata, and C. tropicalis. In the HIV-positive group, the prevalence of Candida isolation was significantly higher in children who presented with low CD4(+)-T-lymphocyte counts, elevated viral loads, and gingivitis.

Update on general health risk of periodontal disease

OBJECTIVES

To review the potential of periodontal infections to cause nonoral diseases. Therapeutic recommendations are provided to help patients and dental practitioners prevent systemic complications from periodontal infections.

FINDINGS

Systemic diseases from oral bacteria are mostly caused by transient bacteraemias, which can occur spontaneously from dental foci of infection, from mastication, brushing, flossing or other daily manipulations, or from dental treatments. Examples of systemic infections that may involve oral microorganisms include infective endocarditis, aspiration pneumonia, HIV-related disseminated candidiasis and cancrum oris, septicaemia associated with cancer chemotherapy and radiotherapy, necrotising faciitis and various other life-threatening infections. Inflamed gingiva constitutes a significant reservoir for herpes viruses, which have the potential to cause serious systemic diseases in immunocompromised patients. Periodontal disease may also aggravate chronic insulin insensitivity and thus interfere with glycaemic control in diabetic patients. Controversy surrounds the involvement of periodontal infections in coronary heart disease.

CONCLUSIONS

Cumulative evidence suggests that periodontal disease can be an important cause of morbidity and mortality of various systemic diseases, especially in individuals exhibiting compromised host defence. Maintaining a healthy dentition and periodontium by means of daily oral hygiene practice and regular professional care is the most effective way of preventing systemic diseases from oral infections.

Oral infections and systemic diseases

An association between periodontal infection and CVD has been revealed in some epidemiologic studies, whereas other studies were unable to demonstrate such an association. A link between the two diseases may be explained by shared established or nonestablished risk factors. Future studies with extended control of confounding factors and intervention studies may add to the understanding of a possible relationship between the diseases. In some cases, IE is caused by dental plaque bacteria. Several studies are suggestive of oral bacteria causing respiratory infection. The pathogenesis and course of a number of other diseases including DM and rheumatoid arthritis have been associated wish periodontitis, but more research is necessary to elucidate possible pathogenic interactions.

Periodontal pathogens in subgingival plaque of HIV-positive subjects with chronic periodontitis

Many putative periodontal pathogens associated with periodontal disease in human immunodeficiency virus (HIV)-infected patients also occur in non-HIV-infected individuals. This study examined the prevalence of eight periodontal pathogens in HIV-positive and HIV-negative patients with chronic periodontitis using the 16s RNA polymerase chain reaction technique. The results showed a significant prevalence of Porphyromonas gingivalis and Treponema denticola among HIV-negative patients compared to HIV-positive patients. Sixty percent of the patients in both groups were colonized by five to six species. Odds ratio analysis revealed a statistically significant positive association between three of the 28 possible combinations in the HIV-positive group. They included Prevotella nigrescens/Campylobacter rectus, P. nigrescens/P. gingivalis and P. nigrescens/T. denticola. Although the prevalence of periodontal pathogens is similar in both the groups, the combination of certain periodontal pathogens may be responsible for chronic periodontitis seen in HIV-infected adults.

Recovery of Candida dubliniensis and other yeasts from human immunodeficiency virus-associated periodontal lesions

Oral and subgingival samples from periodontal lesions were collected from 54 human immunodeficiency virus (HIV)-positive and 20 HIV-negative patients and cultured for yeast species. Of the 54 samples cultured from HIV-positive patients, 44 (82%) were positive for yeast species, of which 29 (66%) were subgingival. A total of 19 (48%) patients were positive for Candida dubliniensis, of which 15 (79%) were colonized in subgingival sites. Seven isolates of Candida glabrata, two isolates of Candida parapsilosis, and one isolate of Saccharomyces cerevisiae were recovered. This study reports for the first time the recovery of C. dubliniensis from subgingival intraoral sites and confirms the presence of Candida species in sites of periodontal disease associated with HIV.

Osteoclastogenesis is enhanced by activated B cells but suppressed by activated CD8(+) T cells

Host immune response is known to contribute to the progression of periodontitis, and alveolar bone destruction in periodontitis is associated with enhanced osteoclast activity. Therefore, we evaluated the roles of activated lymphocyte subsets in osteoclastogenesis. Osteoclast precursors were co-cultured with activated lymphocytes (B, CD4(+) T, CD8(+) T) in the presence of either macrophage colony-stimulating factor (M-CSF) alone or M-CSF plus soluble receptor activator of NF-kappaB ligand (sRANKL), and subsequent differentiation into active osteoclasts was evaluated by a resorption assay. The activated B and CD4(+) cells, but not CD8(+) T cells, induced osteoclast differentiation in the presence of M-CSF alone. In the presence of M-CSF and sRANKL, B cells induced the formation of small but highly active osteoclasts and increased resorption, while CD8(+) T cells profoundly suppressed osteoclastogenesis. Co-culture using an insert well or supernatant suggested that both B and CD8(+) T cells acted on osteoclasts mostly via soluble proteins. Activated B cells expressed many osteoclastogenic factors including RANKL, TNF-alpha, IL-6, MIP-1alpha, and MCP-3. CD8(+) T cells expressed a substantial amount of osteoprotegerin (OPG) along with RANKL. However, blocking antibody to OPG did not reverse the suppression by CD8(+) T cells, suggesting that other factor(s) are involved. Taken together, activated B cells promoted osteoclastogenesis, while CD8(+) T cells inhibited the osteoclast formation via direct interaction. The results imply the importance of lymphocyte subpopulations in the development of periodontitis.

Avoiding malpractice for nondental conditions. The example of human immunodeficiency virus

BACKGROUND

Dentists are legally liable for failing to recognize medical conditions that they identify while providing dental care and for failing to refer patients for follow-up care and testing. This article suggests ways to avoid liability using human immunodeficiency virus, or HIV, infection as an example. TYPES OF LITERATURE REVIEWED: The authors conducted a review of the legal literature to determine circumstances that would cause dentists to have legal liability for failing to recognize a medical problem. The authors also conducted a review of the dental literature to identify the most common signs of HIV infection that dentists might see in practice.

RESULTS

The legal literature indicates that dentists can be held liable for failing to recognize medical problems, including HIV and acquired immunodeficiency syndrome. The dental literature shows that there are multiple signs and symptoms that indicate the potential for HIV infection to be the underlying cause of many oral diseases.

PRACTICE IMPLICATIONS

Dentists should be familiar with the most common oral manifestations of medical conditions that are likely to be identified in the dental office, including those associated with HIV infection. They must recognize medical conditions and arrange for appropriate referral to avoid liability.

Herpesviruses in HIV-periodontitis

BACKGROUND/AIMS

Human herpesvirus-associated diseases exhibit elevated morbidity and mortality in patients infected with human immunodeficiency virus (HIV). This study aimed to investigate the occurrence of herpesviruses in HIV-periodontitis.

METHOD

Gingival biopsies from periodontitis lesions of 21 HIV-patients and 14 non HIV-patients were studied. Nested-polymerase chain reaction methods were employed to detect human cytomegalovirus, Epstein-Barr virus type 1 and 2 (EBV-1, EBV-2), herpes simplex virus, human herpes virus (HHV)-6, HHV-7 and HHV-8.

RESULTS

Gingival biopsies from HIV-periodontitis lesions showed on average 4.0 herpesvirus species and gingival biopsies from HIV periodontitis lesions of non-HIV patients revealed an average of 1.9 herpesvirus species (p<0.001). Occurrence of 4 to 6 different herpesviruses was more common in HIV- than in non HIV-gingival biopsies (71% vs. 7%) (p<0.001). EVB-2 was detected in 12 (57%) biopsies from HIV-periodontitis but was absent in non HIV-periodontitis biopsies (p= 0.002). HHV-6 also occurred in significantly higher frequency in HIV-periodontitis (71%) than in non HIV-periodontitis (21%) (p=0.01). HHV-8 was detected only in biopsies from HIV-periodontitis lesions..

CONCLUSION

HIV-periodontitis seems to be associated with elevated occurrence of EBV-2, HHV-6 and herpesvirus co-infections compared to periodontitis in non-HIV-patients. The periodontopathic significance of herpesviruses in HIV-periodontitis constitutes a research topic of considerable interest.

Herpesviruses: a unifying causative factor in periodontitis?

Human cytomegalovirus and Epstein-Barr virus type 1 are discussed in this review as they relate to destructive periodontal disease in humans. Genomes of the two herpesviruses occur frequently in severe adult periodontitis, localized and generalized juvenile periodontitis, Papillon-Lefèvre syndrome periodontitis, Down's syndrome periodontitis, HIV-associated periodontitis and acute necrotizing ulcerative gingivitis. Herpesvirus infections generally involve a mild or asymptomatic primary phase followed by an asymptomatic latent phase interrupted sporadically by periods of activation, where viral replication and possibly clinical disease become manifest. Herpesvirus reactivation is triggered by a number of immunosuppressing factors, some of which have also been shown to be risk indicators of periodontal disease. Available evidence argues for the involvement of active cytomegalovirus infection in the initiation and progression of localized juvenile periodontitis and possibly other types of periodontal disease. In periodontal disease, herpesviruses may cause release of tissue-destructive cytokines, overgrowth of pathogenic periodontal bacteria, and initiation of cytotoxic or immunopathogenic events. Understanding the significance of herpesviruses in the causation and pathogenesis of destructive periodontal diseases may have important implications in future prevention and treatment of the diseases.

Non-plaque-induced gingival lesions

The origin of gingival inflammation is occasionally different from that of routine plaque-associated gingivitis, and such non-plaque-associated types of gingivitis often present characteristic clinical features. Examples of such forms of gingivitis are specific bacterial, viral, and fungal infections. Specific bacterial infections of gingiva may be due to Neisseria gonorrhea, Treponema pallidum, streptococci, and other organisms. The most important viral infections of gingiva are herpes simplex virus type 1 and 2 and varicella-zoster virus. Fungal infections may be caused by several fungi, the most important of these being Candida species including C. albicans, C. glabrata, C. krusei, C. tropicalis, C. parapsilosis, and C. guillermondii. Gingival histoplasmosis is a granulomatous disease caused by the fungus Histoplasma capsulatum and, as for the other specific infections of gingiva, a confirmed diagnosis may require histopathologic examination and/or culture. Atypical gingivitis may also occur as gingival manifestations of dermatological diseases, the most relevant of these being lichen planus, pemphigoid, pemphigus vulgaris, erythema multiforme, and lupus erythematosus. Non-plaque induced gingival inflammation can be caused by allergic reactions to dental restorative materials, toothpastes, mouthwashes, and foods. In addition, gingival inflammation may result from toxic reactions, foreign body reactions, or mechanical and thermal trauma.