Antiretroviral therapy: effects on orofacial health and health care

Management and Diagnosis of Empagliflozin-Induced Burning Mouth Syndrome: A Case Report

Burning mouth syndrome (BMS) poses a significant clinical challenge. Patients often present with symptoms that can severely affect their quality of life, leading to anxiety, depression, and social withdrawal. The etiology of BMS remains poorly understood, which complicates its diagnosis and treatment. This case report describes an 80-year-old woman who presented with BMS following the administration of empagliflozin, a sodium-glucose cotransporter-2 (SGLT2) inhibitor used for glycemic control, along with its benefits in the progression and prognosis of cardiac insufficiency and chronic renal disease. Despite multiple treatments, her symptoms persisted until empagliflozin withdrawal, resulting in significant improvement at the six-month follow-up. This report suggests a potential association between empagliflozin and BMS, underscoring the need for clinicians to be vigilant regarding drug-related etiologies in the diagnosis and management of oral symptoms.

Current oral hygiene and recreational behavioral trends in HIV disease

OBJECTIVE

HIV disease is evolving with more HIV+ persons experiencing a high quality of life with well-controlled viremia. We recently enrolled a large cohort of HIV+ and clinically relevant HIV- persons for oral microbiome analyses that included a questionnaire related to oral hygiene and recreational behaviors. Here, the questionnaire responses were analyzed for behavioral trends within the cohort, together with trends over time by comparison to a previous geographically centered HIV+ cohort.

METHODS

Data were collected by questionnaire at baseline visits as cross-sectional assessments. Multivariable analyses were conducted for associations of HIV status as well as age, race, and sex, on oral hygiene/recreational behaviors.

RESULTS

HIV+ subjects had reduced brushing frequency, but increased incidence of past cleanings and frequency of dry mouth, compared to the HIV- subjects. Within the entire cohort, positive associations were identified between age and several oral hygiene practices, and between age, race, and sex for several recreational behaviors. In comparison to the historical cohort, the contemporary HIV+ cohort participated in fewer high-risk behaviors, but with similar trends for smoking and oral hygiene practices.

CONCLUSION

HIV status had little association with oral hygiene and recreational behaviors despite several differences in age, race, and sex. Behavioral trends over time support a higher quality of life in people currently living with HIV.

Inflammatory cytologic alterations in the oral epithelium associated with HIV pre-exposure prophylaxis: a preliminary study

OBJECTIVE

The objective of this study was to assess inflammatory cytologic alterations in the oral epithelium of patients on human immunodeficiency virus pre-exposure prophylaxis (PrEP).

MATERIAL AND METHODS

Epithelial cells from the buccal mucosa of 30 patients were collected by exfoliative cytology and were evaluated according to inflammatory cellular alterations: karyomegaly, bi- or multinucleation, karyopyknosis, karyorrhexis, perinuclear halo formation, metachromasia, cytoplasmic vacuolization, indistinct cytoplasmic border, keratinization, and atrophy. Epithelial cells were collected initially before PrEP onset (T1) and then after 30 days of PrEP use (T2). Two experienced cytopathologists independently analyzed the slides.

RESULTS

The nonparametric Wilcoxon test showed that there was a statistically significant increase in the number of cells with karyomegaly at T2 compared to T1 (P = .033). The other cellular alterations did not present with statistically significant differences between the 2 moments of evaluation (P > .05).

CONCLUSION

The increased number of oral epithelial cells with karyomegaly after 30 days of using PrEP suggests the presence of inflammatory alterations at this site.

Current trends and new developments in HIV research and periodontal diseases

With the advent of combined antiretroviral therapies, the face of HIV infection has changed dramatically from a disease with almost certain mortality from serious comorbidities, to a manageable chronic condition with an extended lifespan. In this paper we present the more recent investigations into the epidemiology, microbiology, and pathogenesis of periodontal diseases in patients with HIV, and the effects of combined antiretroviral therapies on the incidence and progression of these diseases both in adults and perinatally infected children. In addition, comparisons and potential interactions between the HIV-associated microbiome, host responses, and pathogenesis in the oral cavity with the gastrointestinal tract and other areas of the body are presented. Also, the effects of HIV and combined antiretroviral therapies on comorbidities such as hyposalivation, dementia, and osteoporosis on periodontal disease progression are discussed.

The burden of oral conditions among adolescents living with HIV at a clinic in Johannesburg, South Africa

Background

There are inconsistent reports on the prevalence of oral conditions and their associated factors among adolescents living with HIV (ALHIV). The current inconsistencies may hinder the development of clear guidelines on the prevention and treatment of oral conditions among ALHIV. This study provides an update on oral conditions and their associated factors in a cohort of South African ALHIV and receiving routine HIV treatment services at a Johannesburg HIV wellness clinic.

Methods

Decayed Teeth (DT), Decayed Missing and Filled Teeth (DMFT) and Oral HIV/AIDS Research Alliance case definitions were used for caries examination and reporting of the Oral Mucosal Lesions (OML) respectively. Data analyses were stratified by the study main outcomes; chi-squared tests were performed to determine the associations; and multiple logistic regressions were also used to identify associated factors after adjusting for other exposure variables. In addition to fitting logistic regressions, we explored the data for potential confounders and effect modifiers.

Results

A total of 407 ALHIV were assessed, of which 51.0% were females. The mean age of the ALHIV was 14.75 years (SD 2.43) while the median age of their parents was 43 years (IQR 37–48 years). Regardless of sex, age group and other socio-demographic characteristics, participants had high count of dental caries (DMFT>0). The overall prevalence of dental caries was 56.76% (n = 231) with mean DT score of 2.0 (SD 2.48) and mean DMFT score of 2.65 (SD 3.01). Dental caries prevalence (DT>0) was significantly associated with the HIV clinical markers. HIV RNA viral loads more than 1000 copies/ml and CD4 cell counts less than 200 count cells/mm³, increased the likelihood of having dental decay among ALHIV (p<0.05). ALHIV at WHO staging III, IV had higher caries prevalence ranging from 70% to 75% (p<0.05). The prevalence of dental caries was directly related to the presence of oral mucosal lesions (p<0.05). The prevalence of OML was 22%, with linear gingival erythema (13.8%) accounting for most of the OML. Multiple logistic regression modelling suggested that dental caries experience (DMFT>0), age category 13–15 years, WHO staging of IV and viral load of more than 1000 copies/ml significantly predicted the outcome of oral lesions as assessed using the OHARA case definitions (p<0.05). The odds of developing dental caries was also 1.5 times more among ALHIV who brush their teeth less frequently and those who reported more frequent eating of sugar sweetened diets (p<0.05).

Conclusions

There is high prevalence of dental caries and OML among ALHIV in Johannesburg. The reported prevalence was associated with high HIV RNA viral loads, shorter duration on antiretroviral treatment and high WHO staging of HIV disease on crude analysis. Additionally, caries experience contributed to the prevalence of OML. Our study acknowledges the protective effect of HIV treatment and positive oral health practices on the presence of oral conditions among ALHIV in Johannesburg.

Evaluation of salivary flow rate and gustatory function in HIV-positive patients with or without highly active antiretroviral therapy

Objectives:

The aim of this study is to evaluate the salivary flow rate and gustatory changes in HIV-positive patients on highly active anti-retroviral therapy (HAART) and without HAART. We also correlated CD4 count and salivary flow rate and gustatory function in both groups.

Methods:

Sample size for each group was thirty. After obtaining informed consent, we measured salivary flow rate using Schimer's method and gustatory function using four tastants (sweet, sour, bitter, and salty) of different concentrations. The readings were recorded at 0 month, 2^nd, 4^th, and 6^th month interval. The data obtained was statistically analyzed.

Results:

The mean salivary flow rate was decreased more in Group I as compared to Group II. The mean identification score for sweet, salty, sour, and bitter was significantly higher in Group II than Group I. The mean detection threshold score for sweet, salty, sour and bitter taste was comparatively higher in Group I than Group II. The Pearson's correlation analysis showed inverse relation between age and salivary flow rate in Group II. No significant correlation was observed in CD4 count and salivary flow rate.

Conclusion:

Along with routine oral health appraisal in seropositive patients, evaluation of salivary flow rate, and taste abnormalities should also be considered an integral part of patient assessment.

Oral manifestations, salivary flow rates and Candida species in Thai HIV-infected patients

Background

Effects of various Highly Active Antiretroviral Therapy (HAART) regimens on oral heath are unclear. Objectives: We aimed to evaluate effects of HAART on oral manifestations, salivary flow rates (SFR) and Candida species in HIV-infected patients who took mostly non-protease inhibitor-based HAART regimens.

Material and Methods

A cross-sectional study was performed on HIV-infected patients taking and never taken HAART who attended Thai Red Cross AIDS Research Centre (n = 48). Non-HIV subjects were recruited as control (n = 20). Oral conditions and salivary flow rates were evaluated using oral examination and measurement of unstimulated and stimulated saliva. In addition, Candida colonization counts (colony forming units; CFUs) and Candida species from the collected saliva were evaluated using CHROMagar.

Results

The most common oral manifestation in HIV-infected subjects taking HAART was hyperpigmentation. Unstimulated and stimulated SFR among the three groups were not statistically significant. Candida colonization was detected in 64%, 65% and 35% of HIV-infected subjects taking HAART, HAART-naïve, and non-HIV subjects, respectively. While 20% and 35% of HIV-infected subjects with and without HAART, respectively, had Candida CFUs higher than 500/ml, all non-HIV carriers had Candida CFUs lower than 500/ml. The most common Candida colonization species was C. albicans in HAART and non-HIV groups. Interestingly, HAART-naïve group was colonized more by non-albicans species.

Conclusions

HAART has minimal effects on oral health. While HAART may not prevent Candida colonization, it might lead to reduction of non-albicans species. Because maintaining low Candida counts is important, HAART administration and antifungal sensitivity test should be considered in HIV-infected patients. Key words:HIV, Candida, HAART, Oral manifestation, Salivary flow rates.

The application of L-PRP in AIDS patients with crural chronic ulcers: A pilot study

PURPOSE

Nonhealing wounds or skin ulcerations are the result of insufficient repair and destruction of a local healing potential. Opportunistic infections which cause a lot of ulcer complications influence the worsening general condition of patients with AIDS, ultimately leading to death. The chronicity of the condition and poor results of conventional therapy have prompted the search for new methods of treatment.

MATERIALS AND METHODS

We have examined venous or arteriovenous insufficiency-related extensive crural ulcers in AIDS patients. Crural ulcer healing processes were evaluated with clinical observations and histopathological, immunohistochemical and molecular examinations of tissue samples harvested from the wound edges before and on day 10 after L-PRP cover dressing.

RESULTS

Clinical observations showed positive effects of L-PRP in all patients. However, complete wound closure was noted in 60% of cases. Statistical analysis of histological examination showed increased epidermal processes between samples, but the difference was nonsignificant. However, immunohistochemical investigations showed an increased healing process with strong statistical significance. The mean VEGF level before L-PRP usage was 114.3 vessels/mm² and on day 10 118.9 (p=0.001523). The mean FLK level was 103.2 and 109.9 respectively (p=0.008241). The biggest differences were observed for CD34, with values of 68.2 on day 0 and 100.8 on day 10 (p=0.006982). Molecular analysis generally showed decreased gene expression and confirmed vascular formation and reepithelialization processes.

CONCLUSIONS

In our opinion, L-PRP may be used to eradicate microorganisms from wounds, to induce neovascularization, and in unhealed cases prepare the base and edge of the ulcer for skin grafting and tissue expansion procedures.

"It was pain. That's it. It was pain." Lack of oral health care among otherwise healthy young adults living with HIV in South Africa: A qualitative study

INTRODUCTION

The purpose of this study is to understand engagement with and availability of dental services among people living with HIV in a low-income community of South Africa.

METHODS

In depth qualitative interviewing was used to collect data, which was analyzed using an inductive content analytical approach. The study was conducted in Gugulethu, a township community located outside of Cape Town, South Africa. Local public sector health services provided free of charge are the main source of primary health and dental care for this population. Participants included South African adults (age 18-35) recently diagnosed with HIV who had a CD4 count >350 cells/mm3.

RESULTS

Many participants had little to no experience with dental care, did not know which health care providers are appropriate to address oral health concerns, were not aware of available dental services, utilized home remedies to treat oral health problems, harbored many misperceptions of dental care, avoided dental services due to fear, and experienced poverty as a barrier to dental services.

CONCLUSIONS

Our findings suggest that integration of oral healthcare into medical care may increase patient knowledge about oral health and access to care. Leveraging the relatively robust HIV infrastructure to address oral disease may also be an effective approach to reaching these participants and those living in resource poor communities generally.

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.

A Guide to Medications Inducing Salivary Gland Dysfunction, Xerostomia, and Subjective Sialorrhea: A Systematic Review Sponsored by the World Workshop on Oral Medicine VI

BACKGROUND

Medication-induced salivary gland dysfunction (MISGD), xerostomia (sensation of oral dryness), and subjective sialorrhea cause significant morbidity and impair quality of life. However, no evidence-based lists of the medications that cause these disorders exist.

OBJECTIVE

Our objective was to compile a list of medications affecting salivary gland function and inducing xerostomia or subjective sialorrhea.

DATA SOURCES

Electronic databases were searched for relevant articles published until June 2013. Of 3867 screened records, 269 had an acceptable degree of relevance, quality of methodology, and strength of evidence. We found 56 chemical substances with a higher level of evidence and 50 with a moderate level of evidence of causing the above-mentioned disorders. At the first level of the Anatomical Therapeutic Chemical (ATC) classification system, 9 of 14 anatomical groups were represented, mainly the alimentary, cardiovascular, genitourinary, nervous, and respiratory systems. Management strategies include substitution or discontinuation of medications whenever possible, oral or systemic therapy with sialogogues, administration of saliva substitutes, and use of electro-stimulating devices.

LIMITATIONS

While xerostomia was a commonly reported outcome, objectively measured salivary flow rate was rarely reported. Moreover, xerostomia was mostly assessed as an adverse effect rather than the primary outcome of medication use. This study may not include some medications that could cause xerostomia when administered in conjunction with others or for which xerostomia as an adverse reaction has not been reported in the literature or was not detected in our search.

CONCLUSIONS

We compiled a comprehensive list of medications with documented effects on salivary gland function or symptoms that may assist practitioners in assessing patients who complain of dry mouth while taking medications. The list may also prove useful in helping practitioners anticipate adverse effects and consider alternative medications.

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.

Comorbidities associated with HIV and antiretroviral therapy (clinical sciences): a workshop report

In the era of combination antiretroviral therapy (ART), parsing out the effects of HIV vs ART on health outcomes is challenging. Nadir CD4 count, a marker of the extent of immunosuppression, has significant long-term impact on an array of disease states in HIV+ persons; however, in the dental literature, reporting of pre-ART exposure to immunosuppression has largely been ignored and this limits the validity of previous studies. In Workshop A1, we explain fully the importance of nadir CD4, pre-ART immunosuppression, and identify a need to include specific variables in future research. The questions posed herein are challenging, typically not neatly addressed by any one study and require integration of the latest evidence from the wider medical literature. We consider topics beyond the confines of the oral cavity and examine oral health in the complex context of ART era HIV immunopathophysiology. We depict how variability in geographic setting and time period (pre- and post-ART era) can impact oral conditions - influencing when HIV infection was detected (at what CD4 count), the type and timing of ART as well as social determinants such as strong stigma and limited access to care. We hope our Workshop will stir debate and energize a rigorous focus on relevant areas of future research in HIV/AIDS.

Oral health associated with quality of life of people living with HIV/AIDS in Brazil

Background

The epidemic of HIV/AIDS enters into its fourth decade and is still considered an important public health problem in developed and developing countries. The purpose is verify the oral health and other factors that influence the quality of life of people living with HIV/AIDS attending a public service reference in Brazil.

Methods

The participants answered the questionnaire on socio-demographic conditions, issues related to HIV and daily habits. The quality of life was analyzed by the HIV/AIDS Targeted Quality of Life (HAT-QoL) instrument with 42 items divided into nine domains: General Activity, Sexual Activity, Confidentiality concerns, Health Concerns, Financial Concern, HIV Awareness, Satisfaction with Life Issues related to medication and Trust in the physician. The oral health data were collected by means of the DMFT index, use and need of dentures and the Community Periodontal Index, according to the criteria proposed by the World Health Organization, by a calibrated researcher. Bivariate and multiple linear regressions were performed.

Results

Of the participants, 53.1% were women and had a mean age of 42 years, 53.1% had eight years or less of schooling and 20.3% were not employed. In analyzing the quality of life domain of the HAT-QoL, with a lower average there was: Financial concern (39.4), followed by Confidentiality concern (43.2), Sexual activities (55.2) and Health concerns (62. 88). There was an association between the variables: do not have link to employment (p <0.001), is brown or black (p = 0.045), alcohol consumption (p = 0.041), did not make use of antiretroviral therapy (p = 0.006), high levels of viral load (p = 0.035) and need for dentures (p = 0.025), with the worse quality of life scores.

Conclusion

Socioeconomic and inadequate health conditions had a negative impact on the quality of life of people with HIV/AIDS.