Progress in understanding oral health and HIV/AIDS

Follicular lymphoma manifests as multiple erosive and proliferative lesions of the oral mucosa: case report and brief literature review

Background

Erosion is one of the most common and basic lesions of oral mucosal diseases. Long-term refractory oral erosions, induced by autoimmune blistering diseases, infectious diseases, malignant diseases, and some rare conditions, may substantially reduce the quality of life of patients or even constitute a life-threatening condition, resulting in a clinical dilemma regarding the accurate diagnosis and precise management of these diseases. As a special type of malignant lymphoma, most lesions of follicular lymphoma (FL) in the oral mucosa present as masses or swelling of the oral mucosa, while emerging novel presentations lead to intractable diagnoses. Hence, diagnostic algorithms for such diseases are clinically required. 

Case presentation

A 55-year-old female patient presented to the clinic with long-lasting oral mucosal erosions and proliferative lesions. Blood tests, pathological examinations of oral lesions including haematoxylin–eosin (HE) staining, and direct immunofluorescence precluded all of the potential diagnoses described previously. Unexpectedly, positron emission tomography/computed tomography (PET/CT) and abdominal CT of the patient revealed a dense mass in the retroperitoneal area, and the final diagnosis of the retroperitoneal mass was FL. After three courses of chemotherapy conducted by the haematologist, the erosion and proliferative lesions in the patient's oral mucosa had significantly improved. HE and immunohistochemical staining results of intraoral lesions also confirmed it as oral FL. The successful diagnosis of FL in this case is of great clinical significance, as the oral and abdominal FL were treated in a timely manner to avoid unfavourable outcomes.

Conclusions

To the best of our knowledge, this is the first case of FL that exhibited widespread erosions interspersed with proliferative lesions. Clinicians should be aware of oral FL or seek systemic factors in the presence of similar refractory oral erosions when treatment is non-responsive and the diagnosis is intractable.

HIV Infection and Oral Manifestations: An Update

Human immunodeficiency virus (HIV) causes a complete depletion of the immune system; it has been a major health issue around the world since the 1980s, and due to the reduction of CD4+ T lymphocytes levels, it can trigger various opportunistic infections. Oral lesions are usually accurate indicators of immunosuppression because these oral manifestations may occur as a result of the compromised immune system caused by HIV infection; therefore, oral lesions might be initial and common clinical features in people living with HIV. So, it is necessary to evaluate and understand the mechanism, prevalence, and risk factors of oral lesions to avoid the increase morbidity among those with oral diseases.

Stage II and stage III periodontitis clinical burdens of HIV-1 undergoing antiretroviral therapy

Objectives

The aim of this retrospective cross-sectional study was to estimate the association of HIV-1 infection under highly active antiretroviral treatment (HAART) on the clinical parameters of periodontitis.

Materials and methods

A total of 205 patients were divided in two groups: 74 HIV + and 131 HIV − . Periodontal probing depth (PPD), clinical attachment loss (CAL), bleeding on probing (BOP), and visible supragingival biofilm (VSB) were recorded. The association of HIV-1 infection with the presence of at least 3 sites with PPD ≥ 5 mm and/or CAL ≥ 4 mm in non-adjacent teeth was estimated using binary logistic regression models.

Results

The variables HIV-1 infection (OR = 5.53, p < 0.0001, 95% CI: 2.45–13.64), age [range 35–50 years old (OR = 5.73, p < 0.0001, 95% CI: 2.49–13.20); > 50 years old (OR = 6.29, p = 0.002, 95% CI: 1.94–20.42)], and VSB (OR = 23.68, p < 0.0001, 95% CI: 8.07–69.53) showed a significant direct association with BOP outcome.

Conclusions

HIV-1 infection under HAART did not have association with the presence of at least 3 sites with PPD ≥ 5 mm and/or CAL ≥ 4 mm. However, HIV patients on HAART had direct association of HIV-1 infection with BOP and an inverse association with PPD.

Clinical relevance

These results support that monitoring gingival bleeding associated with oral prophylaxis would be beneficial in the prevention and management of periodontitis in HIV-1 patients on HAART.

Expression of Inflammatory Markers RANK, MMP-9 and PTHrP in Chronic Apical Periodontitis from People Living with HIV Undergoing Antiretroviral Therapy

To compare the expression of the receptor activator of nuclear factor-kappa B (RANK), matrix metalloproteinase 9 (MMP-9) and parathyroid hormone-related protein (PTHrP) in primary chronic apical periodontitis lesions (CAPLs) between people living with HIV (PLWHIV) undergoing antiretroviral therapy (ART) and HIV- individuals, 32 CAPLs (16 lesions from each group) were submitted to histopathological and immunohistochemical analyses and compared between groups. The majority of the PLWHIV group had undetectable plasma viral loads (n = 13; 81.3%). The means of TCD4+ lymphocytes, exposure to HIV-1 and the time of the use of ART were 542.1 cells/mm³ (SD = 256.4), 6.3 years (SD = 2.9) and 5.0 years (SD = 2.5), respectively. Of all variables studied, only histopathological diagnosis showed a significant difference between groups (LWHIV: granuloma n = 11 (68.0%); cyst n = 5 (31.2%); HIV-: granuloma n = 15 (93.8%); cyst n = 1 (6.2%); p = 0.015). When comparing the expressions of the three inflammatory markers between the groups, no significant differences were seen. There was no difference in the expression of RANK, PTHrP and MMP-9 in primary chronic apical periodontitis lesions between PLWHIV under ART and HIV- individuals.

Recognition of Candida albicans and Role of Innate Type 17 Immunity in Oral Candidiasis

Candida albicans is an opportunistic pathogenic fungus considered to be a common member of the human microflora. Similar to some other opportunistic microbes, C. albicans can invade and benefit from its host when the immune status of that host is weakened. Most often this happens to immunocompromised individuals, leading to the infection of oral and vaginal mucosae or the systemic spread of the pathogen throughout the entire body. Oropharyngeal candidiasis (OPC) occurs in up to 90 percent of patients with acquired immunodeficiency syndrome (AIDS), making it the most frequent opportunistic infection for this group. Upon first signs of fungal invasion, a range of host signaling activates in order to eliminate the threat. Epithelial and myeloid type cells detect C. albicans mainly through receptor tyrosine kinases and pattern-recognition receptors. This review provides an overview of downstream signaling resulting in an adequate immune response through the activation of various transcription factors. The study discusses recent advances in research of the interleukin-17 (IL-17) producing innate cells, including natural T helper 17 (nTh17) cells, γδ T cells, invariant natural killer T (iNKT) cells and type 3 innate lymphoid cells (ILC3) that are involved in response to oral C. albicans infections.

Dynamic study of oral Candida infection and immune status in HIV infected patients during HAART

OBJECTIVE

To dynamically monitor oral Candida infection, CD4⁺ T lymphocyte counts, CD8⁺ T lymphocyte counts and CD4/CD8 ratios in HIV/AIDS patients during their first year of HAART and to preliminarily explore the relationships between them.

DESIGN

Forty-six patients with HIV/AIDS receiving HAART at the Infection Department of Chongqing Red Cross Hospital were followed for one year. At baseline and 3, 6, and 12 months after HAART initiation, oral rinses were collected and cultured to identify Candida species. Further, blood samples were collected to detect CD4⁺ T lymphocyte counts, CD8⁺ T lymphocyte counts and CD4/CD8 ratios.

RESULTS

The prevalence of OC decreased after HAART initiation (P ＜ 0.05), and Candida albicans was the dominant species isolated from the oral cavity (66/93). At 3, 6 and 12 months after HAART initiation, CD4⁺ T lymphocyte counts were 327.91 ± 138.82, 329.65 ± 142.66 and 319.98 ± 97.90 cells/mm³, respectively, which were significantly higher than the level at baseline (263.39 ± 126.01 cells/mm³) (P = 0.016, P = 0.014, and P = 0.035, respectively). During the first year of HAART, CD4/CD8 ratios increased gradually, and CD8⁺ T lymphocyte counts decreased continually. OC was associated with low CD4⁺ T lymphocyte counts and a low CD4/CD8 ratio. CD4⁺ T lymphocyte counts <200 cells/mm³ and Candida load ≥300 CFU/mL were risk factors for OC (P ＜ 0.05), and oral Candida load was negatively correlated with CD4⁺ T lymphocyte counts and the CD4/CD8 ratio.

CONCLUSION

OC might be a useful marker for the evaluation of immune status in patients with HIV/AIDS.

Oral Manifestations in HIV-Positive Children: A Systematic Review

Background: The number of pediatric patients affected by HIV still remains high, mainly in developing countries, where the main cause of infection is vertical transmission from the mother. Even today, a large number of these children do not have access to treatment, and, without proper care, they die in the first few years of life. Objective: The aim of our review was to assess the prevalence of oral hard and soft tissue lesions in HIV-positive pediatric patients by identifying the most common manifestations and the overall impact that they may have on the children’s quality of life. Study design: A systematic review of the articles in the English language in PubMed and Scopus was conducted in March 2019 in order to identify the main epidemiological and cross-sectional studies on the topic. Results: Oral diseases are still one of the most common manifestations in HIV-positive pediatric patients, and they often represent the first form in which immunosuppression shows itself. An analysis of the literature shows that candidiasis is the most common oral lesion found in HIV-positive children. A significant incidence of gingivitis and gingival disease is also evident, though not strictly correlated to HIV infection. However, thanks to the introduction of new antiretroviral therapies, the incidence of HIV-related oral lesions is decreasing. Conclusions: An HIV-positive children care program should also include dental protocols, as oral disease negatively influences the quality of life, affecting both functional and social aspects.

Oral lesions associated with human immunodeficiency virus in 75 adult patients: a clinical study

OBJECTIVES

The objective of this study was to investigate the presence of oral lesions in human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients in a descriptive cross-sectional study, and to establish their presence according to levels of CD4+ cells (including the CD4+/CD8+ cell ratio).

MATERIALS AND METHODS

A total of 75 patients infected with HIV were included. Oral lesions were observed and classified using World Health Organization classification guidelines. Potential correlations between the presence and severity of oral lesions and CD4+ cells, including the CD4+/CD8+ cell ratio, were studied.

RESULTS

The most frequent oral lesion detected was oral pseudomembranous candidiasis (80.0%), followed by periodontal disease (40.0%), herpetic lesions (16.0%), hairy leukoplakia (16.0%), gingivitis (20.0%), oral ulceration (12.0%), Kaposi's sarcoma (8.0%), and non-Hodgkin's lymphoma (4.0%). The CD4+ count was <200 cells/mm3 in 45 cases (60.0%), between 200-500 cells/mm3 in 18 cases (24.0%), and >500 cells/mm3 in 12 cases (16.0%). The mean CD4+ count was 182.18 cells/mm3. The mean ratio of CD4+/CD8+ cells was 0.26. All patients showed at least one oral manifestation.

CONCLUSION

There was no correlation between the CD4+/CD8+ cell ratio and the presence of oral lesions. The severity of the lesions was more pronounced when the CD4+ cell count was less than 200 cells/mm3.

A Literature Review on Women's Oral Health Across the Life Span

The importance of women's oral health and its association with overall systemic health cannot be overemphasized. Poor oral health can have several detrimental effects on a woman's health across her life span. This article reviews the literature and describes how nurses, nurse practitioners, and nurse-midwives can incorporate oral cavity examinations into their care of women.

Potential gingival crevicular fluid and serum biomarkers by stage of HIV infection

OBJECTIVE

This study evaluates the potential of gingival crevicular fluid and serum cytokines as HIV stage biomarkers.

METHODS

Gingival crevicular fluid (GCF) and serum samples from 78 HIV-positive adult male subjects (cases) and 39 HIV-negative male subjects (controls) from Mexico were examined for 17 cytokines using multiplex ELISA. Participants were divided into five subgroups by HIV stage of infection on age-specific CD4+ T-lymphocyte count and antiretroviral therapy (ART), and further correlated to the cytokine levels.

RESULTS

GCF concentrations of IL-6, IL-7, IL-10, IL-12, G-CSF and MCP-1, as well as serum concentrations of IL-1β, IL-2 and IL-6 showed a statistically significant difference among subgroups. We found a significant effect size correlation on cytokines expression levels. Subjects who were not in ART showed significantly higher levels of some of the analyzed cytokines compared to the rest. We found that GCF IL-8 was a significant predictor for the Non-ART HIV status (p<0.05). We observed the same result for GCF G-CSF in the ART Short-term group and serum GM-CSF in the ART Long-term subgroup.

CONCLUSION

Results indicate a high variability of GCF and serum cytokines concentrations and low frequency of their detection in different HIV/ART stages. However, within the limits of the present study, some GCF and serum cytokine concentrations correlate positively. Oral and periodontal innate immunity is affected by HIV viremia and ART. GCF IL-8, G-CSF, as well as serum IL-8, MCP-1 and GM-CSF may be useful biomarkers for the detection of disease presence and/or its severity due to HIV infection and ART use.