Racial differences in dermatologic conditions associated with HIV: A cross-sectional study of 4679 patients in an urban tertiary care center

BACKGROUND

Because of reduced mortality, patients with HIV are living longer and presenting with chronic diseases. Little is known about racial differences in dermatologic conditions associated with HIV infection.

OBJECTIVE

This study examines associated dermatologic conditions in a large population of patients with HIV at a tertiary care center with a diverse patient population.

METHODS

Cross-sectional study of patients with HIV seen between July 14, 2013, and July 14, 2018, in a tertiary health care system. The burden of HIV-related dermatologic conditions was collected by using medical records. Patients with HIV were compared with control individuals of the same race, and significance was assessed using the chi-square test. A Bonferroni correction was performed to control for multiple hypothesis testing.

RESULTS

The study population (N = 4679) was 64.7% male and 69% African American, with 88.7% of patients receiving antiretroviral therapy. African American patients with HIV had a greater risk of oral hairy leukoplakia (odds ratio [OR], 64.49), herpes zoster (OR, 9.27), prurigo nodularis (OR, 8.80), and squamous cell carcinoma (OR, 5.72).

LIMITATIONS

Our data describe patients seen by 1 health care system.

CONCLUSIONS

African American patients with HIV may be at increased risk for pruritic disorders compared with race-matched control individuals and white patients with HIV.

Oral Lesions in HIV Infection in Developing Countries: an Overview

HIV infection is a major global health problem affecting developing and developed countries alike. Oral lesions that are associated with this disease are important, since they affect the quality of life of the patient and are useful markers of disease progression and immunosuppression. Oral lesions in HIV infection have been well-documented in developed countries, but there are fewer reports on oral lesions from developing countries. Oral candidiasis is the most common opportunistic infection seen in all continents. Kaposi’s sarcoma has been reported only from Africa and Latin America, while histoplasmosis and penicilliosis were reported in patients with advanced disease from Thailand. HIV-associated salivary gland disease has a high prevalence in Africa and Latin America, especially in the pediatric group. It is clear that there are considerable regional variations in the oral manifestations of HIV infection, depending both on the populations studied and on the clinical expertise available, among other factors. Well-designed and -documented studies are necessary for the correct assessment of the nature and magnitude of the problem in developing countries, if oral health measures are to be effectively formulated for the HIV-infected.

Oral manifestations of HIV/AIDS in China: a review

PURPOSE

The purpose of this study is to review the Chinese-language medical and dental literature from 1982 to 2008 on oral manifestations (OMs) of patients with HIV/AIDS for introducing the spectrum of OMs of the patients in China.

MATERIALS AND METHODS

All data were extracted from 18 references which had used diagnostic criteria for HIV/AIDS. Four of the references had used the EC-Clearinghouse classification for oral lesions in HIV infection. The feasible overall rate and 95% confidence interval (95%CI) of the data on OMs were calculated.

RESULTS

Risk group analysis revealed that, of 203 patients, 64.3% were men and 35.7% were women (age range, 5 months to 64 years; mean age in three studies, 34.0, 34.3, and 36.1 years). Of these patients, 22.2% were infected by sexual contacts, 11.8% by intravenous drug use (IDU), 59.6% by blood or its products, 2.9% by mother to child transmission, and 3.4% were unclear. In 203 patients, oral candidiasis (OC) was the most common lesion (66%, 95%CI = 59.48-72.52%), followed by herpes simplex (HS) (22.2%, 95%CI = 16.48-27.92%), ulcerative stomatitis (14.8%, 95%CI = 9.92-19.68%), salivary gland disease (11.3%, 95%CI = 6.94-15.66%), oral hairy leukoplakia (OHL) (9.8%, 95%CI = 5.71-13.89%), necrotizing gingivitis (5.9%, 95%CI = 2.66-9.14%), Kaposi's sarcoma (2.9%, 95%CI = 0.59-5.21%), other malignant tumors (2.9%, 95%CI = 0.59-5.21%), and linear gingival erythema (2.0%, 95%CI = 0.07-3.93%).

CONCLUSIONS

The spectrum of OMs reported from China is similar to that described in the international literature. Present data are useful to supplement international resources of HIV/AIDS research.

Prevalence of oral and perioral manifestations in HIV positive adults at Tikur Anbessa Teaching Hospital Addis Ababa, Ethiopia

BACKGROUND

Oral lesions are often characteristic in HIV patients and in the majority of cases can be diagnosed by their clinical features alone. To date there is no study addressing the prevalence of oral and perioral lesions in HIV patients in Ethiopia.

OBJECTIVES

To assess prevalence of oral and perioral manifestations, the clinical symptoms of oral disease, and to assess the association of oral and perioral lesions to the socio- demographic status and CD4 count of ART naive HIV patients.

METHODS

A cross-sectional study on 384 consecutive HIV patients before initiation of ARV treatment was conducted. Oral and perioral lesions were diagnosed according to the EC-clearinghouse's classification and diagnostic criteria for oral lesions in HIV infection and WHO collaborating centre on oral manifestations of HIV, 1992.

RESULTS

One hundred and twenty six (32.8%) of the study subjects were males and 258 (67.2%) were females and mean age was 35.4 +/- 9.94 years (range of 14-84 years). Overall prevalence of oral lesions was 64.3%, and perioral lesions was 15.4%. Nearly half (44%) had dental caries. Pseudomembraneous candidiasis (20.1%), linear gingival erythema (11.7%), and erythematous candidiasis (9.1%) were the three most common HIV associated oral lesions. Angular cheilitis (8%) and molluscum contagiosum (4%) were the two most common perioral conditions. The most common oral symptoms reported were dry mouth (34.4%), difficulty eating (27.9%), and oral pain (27.3%). Oral symptoms and a CD4 count < 200 mm(-3) were significantly (X2 = 22.4, P = 0.0001) associated with presence of oral and perioral lesions. Age above 40 years (31%) was significantly associated with oral lesions (P = 0.016), but not with perioral lesions (P = 0.26).

CONCLUSION

Oral and perioral lesions were common in HIV positive adults at Tikur Anbessa Specialized hospital and represent a treatable morbidity associated with this disease. Thus, a comprehensive oral examination is important in the clinical evaluation, management, and follow up of patients with HIV.

Prevalence of oral hairy leukoplakia and epithelial infection by Epstein-Barr virus in pregnant women and diabetes mellitus patients--cytopathologic and molecular study

Oral hairy leukoplakia (OHL) is generally reported in patients with severe immunosuppression, except for a few cases in individuals with moderate degree of immunodeficiency. It is a white lesion that appears mainly in the lateral border of the tongue, caused by Epstein-Barr virus (EBV). The nuclear changes caused by EBV (Cowdry A inclusion, ground glass and nuclear beading), observed in cytopathology, are specific and enough for the definitive diagnosis of OHL, independent of the identification of the virus. Here we investigated the prevalence of OHL and the presence of EBV-DNA in the lateral borders of the tongue from 90 pregnant women, 90 diabetes mellitus (DM) patients, 30 healthy individuals (negative group) and 30 HIV+ with OHL (positive group). Smears were analyzed by cytopathology and polymerase chain reaction (PCR). A case of subclinical OHL and candidiasis was identificated in a DM patient by cytopathologic analysis. PCR results demonstrated EBV-DNA in 65% of the pregnant women, in 35% of DM patients, and in 20% of the healthy individuals. We concluded that DM patients can develop OHL with a low prevalence. Furthermore, the prevalence of the EBV in lateral border of the tongue is larger in pregnant women than in healthy individuals.

Oral manifestations of HIV/AIDS in clients attending TASO clinics in Uganda

The objective of the study is to establish the prevalence of oral manifestations and their influence on oral functions. A total of 514 subjects aged 18 to 58 years (mean 42 years) were randomly recruited from five The AIDS Support Organization (TASO) clinics in Uganda. They were clinically examined for oral lesions under field conditions by four trained dentists based on World Health Organization criteria. Women constituted 74.5% of the study population. Oral manifestations were recorded in 72% of the subjects, out of which 70% had candidiasis of pseudomembranous, erythematous, and angular cheilitis variants. Non-Hodgkin's lymphoma, atypical ulcers, necrotizing periodontitis, and hairy leucoplakia were least frequently observed in the subjects. Of those who had oral lesions (n = 370), 68.4% had some form of discomfort in the mouth. Tooth brushing, chewing, and swallowing were frequently associated with discomfort. Reported forms of discomfort were dry mouth, increased salivation, and burning sensation especially on taking salty and spicy foods or acidic drinks. Only 8.5% (n = 44) of the subjects were taking medications specifically for oral lesions, which included antifungal, antiviral, and antibacterial agents. None of the subjects were on antiretroviral therapy. Oral lesions associated with human immunodeficiency virus/acquired immunodeficiency syndrome in TASO clients is a major public health problem requiring education in recognition and appropriate management.

HIV-Related Oral Lesions, Demographic Factors, Clinical Staging and Anti-Retroviral Use

BACKGROUND

The aim of the present study was to compare the prevalence of HIV-related oral lesions (HIV-OL) between two health centers for HIV in Mexico City and to analyze the factors that, in addition to combined antiretroviral therapy (CART) and low CD4(+), may be associated with possible differences in prevalence.

METHODS

A cross-sectional observational study was performed between January 2000 and February 2003 at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), a specialized referral center for HIV/AIDS patients and the Clínica Especializada Condesa (CEC), a primary care center for HIV-infected individuals without social security insurance. A consecutive sample of HIV-infected individuals had an oral examination based on established clinical criteria. Demographic, clinical and laboratory data were obtained. Independent association of each factor with specific HIV-OL was assessed by logistic regression modeling.

RESULTS

Eight hundred fifty individuals were examined (INCMNSZ: 479; CEC: 371). Hairy leukoplakia (HL), periodontal disease (PD) and Kaposi's sarcoma (KS) were independently associated with the study site [odds ratio (OR) = 1.7 (95% confidence interval (CI): 1.1-2.4), OR = 4.2 (95% CI: 1.3-13), OR = 10.1 (95% CI: 2.7-38.2), respectively], being more frequent in CEC patients. HL was independently associated with men having sex with men OR = 1.7 (95% CI: 1.1-2.8). All HIV-OL were independently associated with CD4(+) counts and, with the exception of PD and KS, with time under CART.

CONCLUSIONS

The present comparative study showed that several factors were associated with a difference in prevalence of oral lesions found in two AIDS clinics located in Mexico City. Severe immune suppression, CART duration and the study site were associated with HIV-OL. Further investigation into factors such as socioeconomic determinants associated with HIV-OL is warranted.

Risk factors for oral hairy leukoplakia in HIV-infected adults of Brazil

BACKGROUND

Oral hairy leukoplakia (OHL) may be an indicator of the progression of Human Immunodeficiency Virus (HIV)-induced immuno-depression, and the evaluation of risk factors leading to OHL is important in the management of these HIV-infected patients. However, there are few studies that analyze risk factors leading to OHL in the Brazilian population. The aim of this case-control study is to present data about prevalence rates and risk factors leading to OHL in a sample of HIV-infected adults in Brazil.

METHODS

This case-control study included 111 HIV-infected patients treated at a clinic for sexually transmitted diseases and HIV. In the initial examinations with dentists, variables were collected from all patients. Diagnosis of OHL was performed in accordance with the International Classification System and cytological features. The Fisher and the chi-squared tests were used for statistical analysis. The proportional prevalence and odds ratio were estimated.

RESULTS

Outcome presented a positive, statistically significant association among the presence of OHL and viral load of 3000 copies/mul or greater (P = 0.0001; odds ratio (OR) = 5.8), presence of oral candidiasis (P = 0.0000; OR = 11.1), previous use of fluconazole (P = 0.0000; OR = 24.6), and use of systemic acyclovir (P = 0.032; OR = 4.3). Antiretroviral medication presented a negative, statistically significant association with the presence of OHL (P = 0.002; OR = 8.4).

CONCLUSIONS

Prevalence of OHL was 28.8%. Viral load, oral candidiasis, previous use of fluconazole, and systemic acyclovir were determined to be risk factors for OHL. Antiretroviral medication proved to be protective against the development of OHL.

Prevalence of oral hairy leukoplakia in 120 pediatric patients infected with HIV-1

Oral hairy leukoplakia (OHL) is an EBV (Epstein-Barr virus) opportunistic infection found in HIV-infected patients. It is an asymptomatic lesion that has an important prognostic value in AIDS. Differently from what takes place with HIV adult patients, OHL has been described in the literature as having a very small prevalence in pediatric patients. Therefore, the aim of this study was to investigate the prevalence of OHL in HIV pediatric patients using cytopathology. The sample consisted of 120 patients who were submitted to oral examination and had material scraped from both sides of their tongues. The diagnostic criterion was based on the identification of nuclear alterations. Clinical OHL was identified in two (1.67%) patients. The cytopathology revealed twenty (16.7%) cases of subclinical OHL. Our results show that in pediatric patients the prevalence of OHL may be larger than that described in the literature.

Longitudinal study of the prevalence and prognostic implications of oral manifestations in romanian children infected with human immunodeficiency virus type 1

OBJECTIVE

We evaluated the prevalence and predictive value for human immunodeficiency virus (HIV) disease progression of oral manifestations in Romanian children.

METHODS

A nonrandom sample of 238 HIV-infected children was followed prospectively between 1998 and 2001 at the Romanian-American Children's Center in Constanta, Romania. Study subjects underwent comprehensive annual oral examinations. Oral manifestations of interest, demographic data and other selected medical information were recorded at baseline and at each subsequent visit. Descriptive statistics and survival analysis methods were used in the study. A level of statistical significance of alpha = 0.05 was used.

RESULTS

The study subjects' mean age was 9.9 +/- 1.2 (SD) years. The most common oral lesions were gingivitis (49%), parotid enlargement (13%) and oral candidiasis (11%). Oral candidiasis was associated with progression to acquired immunodeficiency syndrome or death (whichever occurred first) (log rank P = 0.03) and with death (log rank P < 0.001). Oral hairy leukoplakia also was associated with progression to death (log rank P = 0.001). The risk of dying was 3.43 (95% confidence interval, 1.86-6.34; P < 0.001) for children who had oral candidiasis at baseline and 4.62 (95% confidence interval, 1.67-12.77; P = 0.003) for those who had oral hairy leukoplakia.

CONCLUSIONS

Oral manifestations occur commonly among HIV-infected Romanian children. Oral candidiasis and oral hairy leukoplakia were positive predictors of HIV disease progression.

Oral and constitutional manifestations of HIV-infected hospital patients in Northern Vietnam

This study reports clinical features, with emphasis on oral lesions and constitutional signs, of 170 patients in a regional hospital in northern Vietnam, of whom 56 were HIV positive. The purpose of the study was to investigate the relationship of oral hairy leukoplakia (OHL) and oropharyngeal candidiasis (OPC) with HIV infection and late stage HIV disease. Late stage HIV disease was defined as WHO stage III or IV and/or a total lymphocyte count below 1200 cells/mm3. The 56 HIV positive patients included all patients with a positive HIV test between July 7th and September 9th 2002. A total of 114 HIV negative controls were included as well. All patients had a detailed medical history and examination as well as a thorough oral examination, which were all done without prior knowledge of the patient's HIV serostatus. HIV positive patients were then grouped according to WHO clinical stage and total lymphocyte count. Thirty-six patients (64.3%) out of 56 HIV positives were in WHO stage III+IV and 28 patients (50.0%) had a total lymphocyte count below 1200 cells/mm3. The presence of OPC, weight loss of more than 10% of body weight and/or chronic fever of more than one month's duration showed a significant association and high positive prediction with HIV infection, especially late stage HIV disease [all with odds ratio (OR) and 95% confidence interval (CI > 1)]. The presence of OHL only showed a significant association with positive HIV serostatus and WHO stage III+IV. It can be concluded that in North Vietnam, HIV positive patients and patients suspected of having HIV infection would benefit from initial and repeat oral examinations. OPC, together with other signs of progressive infection (constitutional signs, such as weight loss and chronic fever) may serve as indicators for institution of prophylactic drugs against opportunistic infections and even antiretroviral (ARV) therapy, when available. However, further research is needed to demonstrate the role of OHL in HIV patients in North Vietnam.

Oral white patches in a national sample of medical HIV patients in the era of HAART

OBJECTIVES

Several types of HIV-related oral mucosal conditions have been reported to occur during the course of HIV disease progression. Of these, few may be manifested as 'white' lesions and many are noticeable to the patient. This paper examines the relationships between social, behavioral and medical aspects of HIV infection and reporting an occurrence of oral white patches (OWP) by HIV-infected patients.

METHODS

The subjects are participants in all three interviews in the HIV Cost and Services Utilization Study (HCSUS). The subjects were selected using a three-stage probability sampling design. The multivariate analysis is based on 2109 subjects with nonmissing binary outcome variable for all three waves representing a national sample of 214 000 individuals. The multivariate model was fitted using generalized estimating equations (GEE) by implementing the XTGEE command in STATA.

RESULTS

We estimate that 75 000 persons (35%) reported at least one incident of OWP, of these 14 000 reported having OWP during all three interviews, and that the rate of reporting declined over the three HCSUS waves. The multivariate analysis showed seven variables that were significant predictors of at least one report of OWP.

CONCLUSIONS

Compared with persons on HAART therapy, patients on other regimens or taking no antiviral medications were 23-46% more likely to report an incident of OWP. Compared with whites, African Americans were 32% less likely to report OWP, while current smokers were 62% more likely than nonsmokers. Being diagnosed with AIDS and having CD4 counts less than 500 significantly increased the likelihood of reporting OWP.

Risk indicators for oral candidiasis and oral hairy leukoplakia in HIV-infected adults

OBJECTIVES

Oral candidiasis (OC) and oral hairy leukoplakia (OHL) are the most common oral mucosal diseases associated with HIV infection. Independent risk indicators associated with these sentinel opportunistic diseases have not been established in mixed race and gender adult populations in the southeast USA. The purposes of this study were 1) to estimate prevalence of OC and OHL among an HIV-1 positive adult population, and 2) to develop explanatory multivariable models for each disease outcome.

METHODS

This cross-sectional study evaluated 631 adult dentate HIV-1 seropositive persons examined for HIV-associated oral mucosal diseases between 1995 and 2000 at University of North Carolina Hospitals in Chapel Hill, North Carolina using data collected from medical record review, interview questionnaire and clinical examination. We analyzed the data using t-tests, anova, and unconditional logistic regression.

RESULTS

Prevalent OC was associated with low CD4+ cell count [<200 cells/microl, adj. OR = 12.7 (95%CI: 4.9-32.9)], antiretroviral combination therapy [OR = 0.6 (0.3-0.9)], and current smoking [OR = 2.5 (1.3-4.8)]. Prevalent OHL was associated with low CD4+ cell count [<200 cells/microl, OR = 7.2 (2.7-18.9)], antifungal medication use [OR = 1.8 (1.1-2.9)], current recreational drug use [OR = 2.5 (1.3-4.9)], and male gender [OR = 2.5 (1.3-4.8)].

CONCLUSIONS

While CD4+ cell count, and antiretroviral medication were important risk indicators for OC, and OHL, cigarette smoking appears to be an important risk indicator for OC in HIV-1-infected populations.

Incidence of oral candidiasis and oral hairy leukoplakia in HIV-infected adults in North Carolina

OBJECTIVES

To establish incidence rates and risk factors for HIV-associated oral candidiasis (OC), oral hairy leukoplakia (OHL), and any HIV-associated oral diseases (HIV-OD).

DESIGN

This prospective, cumulative case-control study followed 283 initially oral disease-free HIV-1-infected men and women for 2 years. Incidence rate ratios (IRR) and incidence proportions for OC, OHL, and HIV-OD were estimated. Multivariable analyses using Poisson regression determined the most parsimonious best-fitting model explaining the outcomes.

RESULTS

Incidence rate (per 1000 person-months) was 9.3 for OC, 6.8 for OHL, and 13.5 for HIV-OD. Incidence of OC was associated with low CD4 count (adjusted IRR = 3.0 (95% CI = 1.7, 5.1)), smoking (IRR = 1.9 (1.0, 3.8)) and combination antiretroviral therapy (IRR = 0.3 (0.1, 0.8)). Incidence of OHL was associated with low CD4 count, conditional upon smoking status. Conclusions Low CD4 count and smoking are important risk factors for HIV-associated OC and OHL. Antiretroviral medications are protective for OC but not for OHL.

Oral opportunistic infections in HIV-positive individuals: review and role of mucosal immunity

Oral opportunistic infections in the HIV-positive individual have been documented since the first reports of the epidemic, with many lesions associated with reduced CD4(+) T lymphocyte cell count. The most common oral lesions seen in HIV disease prior to the advent of highly active antiretroviral therapy (HAART) were oropharyngeal candidiasis and oral hairy leukoplakia. However, since the advent of HAART while many oral lesions have decreased significantly the incidence of oral warts has surprisingly increased. Despite the correlation of diminished CD4(+) T lymphocyte count to the occurrence of these lesions, it is rare for the lesions to occur concurrently suggesting that each pathologic lesion type is associated with distinct host immune dysfunctions. To date, the oral opportunistic infection most frequently investigated is oropharyngeal candidiasis, where data suggests that both systemic and local immunity is important for protection against infection. In contrast, recent investigations into the host responses associated with oral hairy leukoplakia and oral warts show little to no evidence of systemic or mucosal immune responsiveness despite the presumed competence of several types of leukocytes other than CD4(+) T cells. Together these data are suggesting that susceptibility to oropharyngeal candidasis in HIV-positive persons is predominantly immune-based, whereas protection or susceptibility to oral hairy leukoplakia and oral warts may be more associated with factors other than mucosal immune function.

Oral manifestations of HIV infection in relation to clinical and CD4 immunological status in northern and southern Thai patients

OBJECTIVES

To assess prevalence and variations in the oral manifestations of HIV in HIV-infected subjects in southern Thailand (a new HIV epidemic) and northern Thailand (a mature epidemic), and the association with age, sex, risk behaviours, CD4 count and medication used.

SUBJECTS AND METHODS

A total of 102 and 135 HIV-infected individuals were enrolled in northern and southern hospitals, respectively. Oral and haematological examination was performed after sociodemographic interview of the patients. Clinical history was retrieved from patients' medical records.

RESULTS

Oral candidiasis (OC, 55%), oral hairy leucoplakia (OHL, 21%) and HIV-associated-periodontal disease (14%) were among the most common oral lesions in southern Thailand. OHL (38%), OC (25%), HIV-associated-periodontal disease (15%) were the three most common lesions in the north. A significant association was found between any oral lesion, OC, particularly the pseudomembranous type (PC), and CD4 < 200 cells mm(-3) at both sites. A negative relationship was found between systemic antifungal treatment and OC including PC and erythematous candidiasis (EC) in the southern data. OHL showed a positive relationship with male sex and a negative relationship with antiretroviral treatment in the northern site. Younger age and being a current smoker were positively associated with oral lesions in the southern group.

CONCLUSION

OC, particularly PC, could be useful as a marker for immunosuppression, particularly where CD4 count cannot be determined routinely. Antifungal treatment is of benefit in the subjects who cannot afford highly active antiretroviral therapy (HAART).

Oral manifestations in HIV-infected individuals from Thailand and Cambodia

Oral manifestations were studied in 87 HIV-positive Thai adults (study 1), 45 HIV-positive children (study 2) and 101 HIV-positive (study 3). In study 1, 48% of patients had oral lesions; 23% had one and 13.8% two oral manifestations. Oral pseudomembranous candidiasis was found in 10.3%, erythematous candidiasis in 6.9%, and hairy leukoplakia (HL) in 11.5% of the patients. In study 2, 24.4% of children revealed one, 17.8% two and 6.6% three oral lesions; erythematous candidiasis was seen in 17.8%, and HL in 6.7% of the children. Fifteen patients (33.3%) received antiretroviral therapy. In study 3, pseudomembranous candidiasis was found in 52.5%, HL in 35.6% and necrotizing gingivo-periodontitis in 27.7%. Only 10% of patients were without oral lesions. The present three studies among HIV-infected Thai and Cambodians indicated a high prevalence of oral lesions, particularly variants of oral candidiasis such as pseudomembranous and erythematous candidiasis. Also, oral HL was a common finding, more so in patients with AIDS-associated diseases as represented by patients of study 3. Oral candidiasis and oral HL also seem to be quite prevalent in pediatric HIV-infected patients. In the absence of parameters indicating the degree of immunosuppression (CD4(+) cell counts and viral load) these oral lesions may be considered strong indicators of HIV-associated immunodeficiency.

Oral lesions and dental caries status in perinatally HIV-infected children in Northern Thailand

To describe the prevalence of oral lesions and dental caries status in perinatally HIV-infected children.

DESIGN

A cross-sectional study.

SETTING

Paediatric HIV outpatient department at the Nakornping Provincial Hospital, Chiang Mai, Thailand.

PATIENTS AND METHODS

Forty children with perinatal HIV infection, from early infancy to 12 years of age, were included in the study. These children were examined for oral lesions and dental caries. A number of children receiving antifungal and antiretroviral (ART) therapy were recorded.

RESULTS

The mean DMFT and DMFS scores were both 2.1 (SD = 2.3). The dft and dfs scores were 4.1 (SD = 5.0) and 10.9 (SD = 14.8), respectively. A total of 57.5% of the children had one or more oral lesions. Oral candidiasis and hairy leukoplakia were the most common oral lesions. Only 12.5% of children had received ART. A total of 22.5% of the children had a history of receiving antifungal therapy.

CONCLUSIONS

Oral lesions and dental caries were relatively high in this study. Consequently, treatment and prevention for oral lesions and dental caries are inevitably required for children with HIV infection in Northern Thailand. Furthermore, ART should be made available for all HIV-infected children to decrease the prevalence of HIV-associated oral lesions.

Oral mucosal lesions in a UK HIV/AIDS oral medicine clinic. a nine year, cross-sectional, prospective study

PURPOSE

To investigate changes in presentation of oral mucosal lesions in patients with HIV/AIDS attending a dedicated oral medicine clinic over a nine year period.

MATERIALS AND METHODS

358 Patients with HIV/AIDS attending a dedicated oral medicine clinic, contained within a genitourinary medicine clinic. Data was collected prospectively for all patients attending the oral medicine clinic, and entered into a database. Lesions were recorded according to the EEC-WHO diagnostic criteria 1991/1993.

RESULTS

In 358 patients with 542 lesions, over 54% of the lesions belong within one of the five categories of ulcers, warts, candidiasis, OHL and Kaposi's sarcoma. The major differences in the presentation of the lesions over time were between the ulcers and the warts, but in this series the introduction of HAART did not make a statistical difference.

CONCLUSIONS

There has been a large reduction in the presentation of oral ulcers, and there appears to be a relative increase in viral papillomata, and a decrease of other mucosal diseases over the period of study. Many of the warts biopsied showed dysplastic changes, and continued follow-up of these patients will be important to determine whether these patients are at increased risk for developing oral squamous carcinoma. Also, proposals are put forward suggesting a need for alteration of the three groups of HIV/AIDS lesions classification suggested by the EEC-WHO consensus.

Prevalence and classification of HIV-associated oral lesions

OBJECTIVES

An International Workshop addressed the prevalence and classification of HIV/ AIDS associated oral lesions.

DESIGN

Five questions provided the framework for discussion and literature review. What is the prevalence of oral lesions in children and adults? Should the accepted classification of HIV-related oral lesions be modified in the light of recent findings? Why is there a gender difference in the prevalence of oral lesions in developed and developing countries? Are there unusual lesions present in developing countries? Is there any association between modes of transmission and the prevalence of oral lesions?

RESULTS

Workshop discussion emphasized the urgent need for assistance in the development of expertise to obtain accurate global prevalence data for HIV-associated oral lesions. Oral candidiasis has been consistently reported as the most prevalent HIV-associated oral lesion in all ages. Penicilliosis marneffei, a newly described fungal infection, has emerged in South-east Asia. Oral hairy leukoplakia and Kaposi's sarcoma appear to be associated with male gender and male-to-male HIV transmission risk behaviours. These lesions occur only rarely in children.

CONCLUSIONS

Additional prevalence data are needed from developing countries prior to substantially altering the 1993 ECC/WHO Classification of oral lesions associated with adult HIV infection. The workshop confirmed current oral disease diagnostic criteria.

Oral lesions of HIV infection in developing countries

HIV infection has spread rapidly within developing countries since it was first recognized in the early 1980s. The purpose of this paper is to review the prevalence of oral lesions associated with HIV infection (oral HIV) in the developing world, and to identify additional factors that may complicate the presentation of these lesions. Direct comparison of regional and local prevalence studies within Africa, India and Thailand is speculative because there are few reports available. Furthermore, inherent differences in study design, data collection, standardization and calibration of health workers make any inferences inconclusive. Additional prevalence studies of oral HIV lesions associated with systemic disease or social conditions, such as poverty or malnutrition, are needed. In order to provide a basis for the diagnosis and treatment of HIV-associated oral lesions in the developing world, it is important to recognize any confounding factors that may impact on their presentation and management. Elucidation of these various factors may provide a basis for treatment within the developing and developed world.

Co-existence between oral lesions and opportunistic systemic diseases among HIV-infected subjects in Thailand

BACKGROUND

The purpose of this study was to determine whether any relationship exists between the occurrence of oral lesions and opportunistic systemic diseases among HIV-infected subjects.

METHODS

A cross-sectional analytical study was performed in two hundred and seventy-eight HIV-infected heterosexual persons and intravenous drug users (IVDUs)(230 males and 48 females, aged 16-65 years, mean 31.9 years). Eighty-six HIV-free subjects from the same population were included as controls (61 males and 25 females, aged 17-63 years, mean age 33.1 years). The following information was recorded for each patient: age, gender, risk group and stage of HIV infection, immune status, medication, systemic disease and presence of oral lesions.

RESULTS

Oral candidiasis was the most common oral lesion among HIV-infected individuals (40%), followed by hairy leukoplakia (HL)(26%). The three most common systemic diseases among the subjects were tuberculosis (TB)(53%), cryptococcosis (14%) and Pneumocystis carinii pneumonia (PCP)(11%). Logistic regression analysis revealed a significant association between the occurrence of TB and the presence of oral candidiasis (OR 2.8; 95% CI 1.6-4.8; P < 0.001), and the occurrence of PCP and the presence of HL (OR 2.2; 95% CI 1.1-4.3; P < 0.001). Positive predictive values of any oral lesions and oral candidiasis in predicting TB were 87% (95% CI 73.0-94.6) and 67% (95% CI 51.9-80.0), respectively.

CONCLUSIONS

We concluded that oral candidiasis might be used as a clinical marker for TB, and HL for PCP. Recognition of the lesions by health-care providers may indicate the need for more intensive clinical and laboratory monitoring and possibly initiation of prophylaxis against these opportunistic systemic infections.

Changes in the prevalence of HIV-associated mucosal disease at a dedicated clinic over 7 years

OBJECTIVE

To investigate changes in the prevalence of mucosal disease in patients with HIV/AIDS.

DESIGN

Retrospective analysis of clinic database.

SETTING

An open-access dental clinic dedicated to the dental treatment of patients infected with HIV in London, UK.

SUBJECTS

Dental patients attending for routine assessment (check-up).

MAIN OUTCOME MEASURES

Prevalence of HIV associated oral lesions, diagnosed in accordance with EC classification criteria, in patients taking and not taking antiretroviral therapies (ARTs).

RESULTS

Data were collected at 2789 dental examinations for 1590 patients between 1992 and 1998. More patients taking ART had one or more oral manifestations in the years up to 1996, after which the prevalence fell to a similar level to those not taking medications. The prevalence of mucosal disease in patients not taking ART was relatively constant over time. These trends were observed for oral hairy leukoplakia, pseudomembranous and erythematous candidiasis and Kaposi's sarcoma but not for oral papillomata.

CONCLUSIONS

These data provide evidence that decreases in the prevalence of oral disease in people with HIV infection can be attributed to the effectiveness of ART.

Oral manifestations in 101 Cambodians with HIV and AIDS

BACKGROUND

The HIV/AIDS epidemic in Cambodia has become a major problem in the last 7-8 years, mainly because in this formerly war-stricken country the socioeconomic situation is only slowly improving. Since only very few studies have been published to date on the oral health status of Cambodian HIV/AIDS patients, it was the purpose of the present investigation to study oral manifestations in Cambodian patients with HIV disease.

METHODS

One hundred one Cambodian patients with HIV infection or AIDS were examined for the presence of oral manifestations in one medical center in Phomh Penh, Cambodia.

RESULTS

Sixty-three men and 38 women with a median age of 32 years were examined (age range 7.5-63.5 years). Of these patients, 42.6% were smokers, 46.5% of men were heavy drinkers and 90.5% of men were promiscuous compared with 5.3% of women. The most frequent AIDS-defining diseases were wasting syndrome (54.5%), Pneumocystis carinii pneumonia (PcP) (19.8%) and tuberculosis (18.8%). Puritic papular eruption, a common cutaneous manifestation in HIV-infected patients, was seen in 17.8% of patients. Candida-associated infections of the oral cavity were most common. Among the patients, 52.5% revealed pseudomembranous candidiasis and 35.6% had bilateral hairy leukoplakia. Only 10% of patients had no oral lesions. Also common were necrotising ulcerative gingivo-periodontal diseases (27.7%).

CONCLUSION

The general health status of 101 Cambodian patients with HIV infection and AIDS was poor, and they demonstrated a large number of oral manifestations. Antiretroviral therapy is presently not available and only a fraction of patients receives antimycotic treatment (25.7%). HIV infection and the AIDS epidemic in Cambodia have become a serious problem and patients urgently need adequate diagnosis and antiretroviral therapies.

The effect of antiretroviral therapy on the prevalence of oral manifestations in HIV-infected patients: a UK study

OBJECTIVE

The purpose of this study was to compare the prevalence of oral manifestations in human immunodeficiency virus (HIV)-infected patients on monotherapy, dual therapy, or triple therapy with the prevalence of those not on antiretroviral therapy (ART).

STUDY DESIGN

A cross-sectional study of the oral manifestations of HIV was carried out on 284 HIV-infected patients, 89 of whom were undergoing ART (12 on monotherapy, 41 on dual therapy, and 36 on triple therapy) and 195 who were not undergoing ART. Oral manifestations were recorded by using established presumptive clinical criteria. Chi-square statistical tests and separate bivariate analyses were conducted by using the Spearman rank correlation to describe the relationship between the prevalence of oral lesions and ART.

RESULTS

The detection of oral manifestations was significantly decreased in subjects on dual therapy and subjects on triple therapy in comparison with patients on monotherapy (P <.05) and those on no ART regimen (P =.014). Oral manifestations were also significantly increased, with CD4 counts <200 cells/mm(3) and a viral load >3000 copies/mL (P <.001).

CONCLUSIONS

Compared with the non-ART group, subjects on combination ART had significantly fewer HIV-related oral manifestations-probably as a result of an expression of their reconstituted immune system.

Oral manifestations of human immunodeficiency virus (HIV)-infected patients in Singapore

INTRODUCTION

Oral lesions have been recognised as prominent features of acquired immune deficiency syndrome (AIDS) and human immunodeficiency virus (HIV) infection since the beginning of the epidemic.

OBJECTIVE

This descriptive study was conducted to study the types of oral lesions among HIV-infected patients in Singapore.

MATERIALS AND METHODS

Oral examination was done on 81 randomly selected HIV-infected patients attending the specialist outpatient clinic at the Communicable Disease Centre.

RESULTS

A total of 9 different lesions were observed in 45 (56%) patients. The lesions observed were oral candidosis (35%), periodontal disease (16%), aphthous-like ulcers (5%), oral hairy leukoplakia (5%) and lymphoma (1%).

CONCLUSION

The oral manifestations of HIV-infected patients in Singapore appear to be less frequent in comparison with those patients from Africa and Europe. Similarities in oral findings among the HIV-infected patients in Asia are evident with a notable lack of oral Kaposi's sarcoma (KS) and a low prevalence of non-Hodgkin's lymphoma and oral hairy leukoplakia.

Prevalence of HIV-1 and oral lesions in pregnant women in rural Malawi

OBJECTIVE

Whether oral lesions were associated with human immunodeficiency virus-type 1 (HIV-1) status in a cohort of pregnant Malawian women was studied.

STUDY DESIGN

Six hundred thirty-eight women participated in a randomized prospective study at 3 prenatal clinics in a rural area of southern Malawi. Oral examinations, followed by collection of oral fluid specimens with an HIV-1 oral specimen collection device, were performed. The specimens were tested for antibodies against HIV-1.

RESULTS

Sixty-one oral lesions were found in 60 participants. While traditional HIV-1 associated lesions were rare, benign migratory glossitis was unexpectedly common (6%). Oral hairy leukoplakia was significantly more common among women who were HIV-1 positive than among women who were HIV-1 negative. An HIV-1 prevalence rate of 21.8% was estimated among the women, with the highest rate of HIV-1 infection (34.1%) among women aged 25 to 29 years.

CONCLUSION

Stratifying lesions showed a small number of oral hairy leukoplakia to be markers for HIV-1. A high seroprevalence was found in this rural cohort, but there were unexpectedly few oral lesions. The relatively few oral lesions diagnosed may indicate a recent infection with HIV.

A retrospective analysis of oral hairy leukoplakia in South Australia

BACKGROUND

The features of oral hairy leukoplakia (OHL) have been widely reported in the literature. However, no studies have described this lesion in the Australian setting. This study retrospectively examines, with respect to specific clinical factors, the prevalence of OHL in a South Australian HIV-infected population.

METHODS

Clinical data were collected from the records of 197 HIV-infected patients who had attended the Adelaide Dental Hospital between January 1986 and February 1995. Data were analysed using the chi-square test.

RESULTS

The prevalence of OHL in South Australian HIV-infected patients was 45.2 per cent. The study found the presence of OHL was not related to CD4+ T-lymphocyte count or AIDS-defining illness nor did the length of time a patient had been infected with HIV relate to the presence of OHL. An association was observed between a reduced prevalence of OHL in patients who were taking antiviral medication.

CONCLUSION

The prevalence of OHL in South Australia is comparable with results of other studies. This study supports the notion that OHL is not an indicator of immunosuppression in South Australian HIV-infected patients. Further longitudinal studies are required to ascertain the relationship of OHL to HIV disease progression.

Prevalence of orodental findings in HIV-infected Romanian children

BACKGROUND

Romania, the pediatric AIDS capital of the world, has tremendous unmet dental care needs for children and adolescents with HIV infection. The purpose of this study was to assess the prevalence of orodental conditions in symptomatic HIV-positive children from Constanta, Romania.

METHODS

The children underwent dental examinations and treatment at Constanta Municipal Hospital by a volunteer team of dental healthcare professionals from the United States. Oral lesions and dental caries were recorded during an 8-day period prior to initiating comprehensive dental care.

RESULTS

The study population consisted of 173 children (88 males; 85 females) with a mean age of 8.8 years (range 6 to 12 years). The primary HIV risk factor was contaminated needle reuse and/or blood products (88%). The most common oral and perioral lesions included: candidiasis (29%), ulcers (15%), salivary gland disease (9%), necrotizing ulcerative gingivitis/periodontitis (5%), linear gingival erythema (4%), labial molluscum contagiosum (3%), oral warts (2%), hairy leukoplakia (2%), and herpes zoster (1%). One or more oral/perioral lesions occurred in 55% of the children. Severe dental caries was noted in the majority of children (dfs/dft 16.9/3.7 and DMFS/DMFT 8.1/3.1). Over-retention of primary teeth (25%) and delayed eruption (42%) were common. Postoperative complications included delayed clotting (common) and thrombocytopenia-induced bleeding disorders (4%).

CONCLUSIONS

The oral healthcare needs of Romanian HIV-infected children are considerable, with the majority living with persistent, symptomatic oral disease.

Oral mucosal lesions and HIV viral load in the Women's Interagency HIV Study (WIHS)

The prevalence of oral lesions was assessed in a five-center subset of the Women's Interagency HIV Study (WIHS) and correlated with other features of HIV disease. Oral examinations were performed by dental examiners on 729 women (577 HIV-positive and 152 HIV-negative) during baseline examination. Significant differences between the groups were found for the following oral lesions: pseudomembranous candidiasis, 6.1% and 2.0%, respectively; erythematous candidiasis, 6.41% and 0.7%, respectively; all oral candidiasis, pseudomembranous and/or erythematous, 13.7% and 3.3%, respectively. Hairy leukoplakia was observed in 6.1% of HIV-positive women. No significant differences were found for recurrent aphthous ulcers, herpes simplex lesions, or papillomas. Kaposi's sarcoma was seen in 0.5% of HIV-positive and 0% of HIV-negative women. Using multiple logistic regression models controlling for use of antiretrovirals and antifungals, in HIV-positive women the presence of oral candidiasis was associated with a CD4 count <200 cells/microl, cigarette smoking, and heroin/methadone use; the presence of hairy leukoplakia was not related to CD4 count but was associated with high viral load. Oral candidiasis and hairy leukoplakia are confirmed as being common features of HIV infection in women and appear to be associated with HIV viral load, immunosuppression, and various other behaviorally determined variables.

Changing prevalence of oral manifestations of human immuno-deficiency virus in the era of protease inhibitor therapy

OBJECTIVE

The purpose of this study was to determine temporal trends in the prevalence of oral manifestations of human immunodeficiency virus (HIV).

STUDY DESIGN

Five hundred seventy HIV-infected adults recruited consecutively were examined by using established presumptive clinical criteria for HIV-associated oral lesions. Prevalence of oral lesions before the widespread use of HIV protease inhibitors (February 1995 through August 1996, 8% of the early sample, n = 271) was compared with lesion prevalence in a more recent period of greater protease inhibitor use (December 1996 through February 1999, 42% of the late sample, n = 299).

RESULTS

Overall prevalence of oral lesions significantly decreased from early to late periods, 47.6% to 37.5%, respectively (P =.01), with some variation by lesion type. Prevalence of hairy leukoplakia (25. 8% to 11.4%; P <.01) and necrotizing periodontal diseases (4.8% to 1. 7%; P =.03) decreased, whereas HIV salivary gland disease increased (1.8% to 5.0%; P =.04). Changes in prevalence of oral candidiasis (20.3% to 16.7%), aphthous ulcers (3.7% to 3.0%), oral warts (2.2% to 4.0%), herpes simplex virus lesions (1.8% to 2.0%), and Kaposi's sarcoma (1.1% to 0.3%) were not statistically significant (P >.20 for all comparisons).

CONCLUSION

The pattern of oral opportunistic infections is changing in the era of protease inhibitor use.

Effect of receptive oral sex and smoking on the incidence of hairy leukoplakia in HIV-positive gay men

We sought to determine whether hairy leukoplakia (HL), an Epstein-Barr virus-related oral lesion, is associated with receptive oral sex activity and cigarette smoking among HIV-positive gay men. Oral examinations were conducted every 6 months among San Francisco Men's Health Study participants over a 6-year period. We fitted time-to-lesion regression models to compare the incidence of HL among men who had mouth-to-penis contact with various numbers of partners, while controlling for cigarette smoking and CD4 count. The 6-year incidence of HL was 32% among 291 HIV-positive men. We found no significant increase in the hazard of developing HL for each additional insertive-oral-sex male partner in the past 6 months (relative hazard = 1.01; 95% confidence interval [CI], 0.99, 1.02), and a similar lack of association when number of sex partners was categorized. However, the hazard of developing HL doubled with any 300-unit decrease in CD4 count (95% CI, 1.4, 2.7), or if men smoked > or =20 cigarettes/day compared with nonsmokers (95% CI, 1.2, 3.9). This finding, which may suggest one effect that smoking produces on the oral mucosa's local immune response, merits further investigation.

HIV infection: oral lesions, CD4+ cell count and viral load in an Italian study population

The aims of this study were to assess types and prevalence of HIV-related oral lesions and to correlate these lesions to the main laboratory parameters such as CD4+ cell count and plasma HIV-RNA. The study population consisted of 104 consecutive HIV+ patients living in Sicily (M=67, 64.4%; F=37, 35.6%; median age=35 years). CD4+ cell count and viral load were measured within 24 h of oral examination. Data were managed and analysed by Epi-Info 6.0. HIV-related oral lesions, as classified by the EC-Clearinghouse, were diagnosed in 35.6% of patients: these were of the Strongly Associated (SA) type in 22.1%, the Less Common Associated (LCA) type in 12.5%, and the Lesions Seen in HIV Infection (LS) type in 3.8%. CD4+ cell counts <200 x 10(6)/l were significantly associated only with SA lesions (P=0.03); median values of CD4+ cell count were also significantly correlated (P=0.02). Viral load, expressed both by median values of copies/ml (P=0.0001) and log10 copies/ml (P=0.0003), was significantly associated only with SA lesions. Treatment failure was significantly correlated to SA lesions (P=0.04). Besides the confirmed correlation with CD4 depletion, the strong association with a high level of viral load could make SA oral lesions a useful tool for identifying progression of HIV infection and could be of value in monitoring antiretroviral therapy.

Oral manifestations of HIV in a southeast USA population

OBJECTIVES

Examine variations in oral manifestations of HIV by gender, race, risk behaviors, substance use and immune status in a previously unstudied population in the southeast region of the USA.

DESIGN

Cross-sectional analytic study.

SETTING

Academic medical center, North Carolina, USA.

SUBJECTS

First 238 HIV-infected adults (76% male; 59% Black) enrolled in an ongoing longitudinal study.

METHODS

Oral examination, medical chart review, sociodemographic and behavioral interview. Descriptive, bivariate, and multivariable analyses.

OUTCOMES

Presence of oral manifestations of HIV.

RESULTS

50% had recent CD4 counts < 200 cells microliters-1, 48% had one or more oral lesion. Specific lesion prevalence: hairy leukoplakia (OHL) 26.5%; candidiasis (OC) 20%; HIV-associated periodontal diseases (HIV-PD) 8.8%; aphthae 4.2%; papillomas 2.5%; herpes simplex 2.1%; HIV salivary gland disease 2.1%; Kaposi's sarcoma (KS) 1.7%; other 1.3%. In bivariate analyses, OHL was associated with being male, White, having a CD4 < 200, and men who have sex with men (MSM); OC was associated with CD4 < 200 and current smoking; HIV-PD was associated with consumption of more than seven alcohol-containing drinks per week; KS was associated with being male and MSM. Significant variables in multivariable analysis for presence of any oral lesion were White, CD4 < 200, and more than seven drinks/week; for OHL were male and CD4 < 200; and for OC were White, CD4 < 200, current smoking, and not MSM.

CONCLUSIONS

MSM were at increased risk for KS and OHL, not OC, while smokers were at increased risk of OC. OC, OHL, and any oral lesion were associated with immune suppression. OHL was more likely in males independent of CD4 count.

Oral manifestations of HIV infection in 600 South African patients

Oral lesions associated with HIV infection, as classified by the EC-Clearinghouse on Oral Problems related to HIV infection and the WHO Collaborating Centre on Oral manifestations of the immunodeficiency virus, were studied in 600 consecutive HIV-infected patients in Cape Town, South Africa. One or more lesions were seen in 60.4% of cases. Combined candidal lesions were evident in 37.8%, hairy leukoplakia in 19.7% and combined gingival/periodontal lesions in 8.5% of patients seen. Lesions less commonly recorded include oral ulceration (2.9%) and Kaposi's sarcoma (1.5%). The clinical range of lesions seen is similar to those reported elsewhere, but socio-cultural differences allowed no reliable comparison. More than a quarter of our patients had oral soft tissue discomfort necessitating treatment; in 3.3% these were the presenting symptom. This indicates a potential major public health concern requiring education in recognition and appropriate referral and management.

Oral manifestations of HIV infection by gender and transmission category in Mexico City

A cross-sectional analysis was conducted in Mexico City from September 1989 to March 1996, to determine the prevalence of HIV-related oral manifestations by gender and route of HIV transmission. The diagnosis of HIV-associated oral lesions was based on preestablished criteria. For the statistical analysis chi-squared and Fisher's exact tests were used where appropriate. Odds ratios were calculated as estimates of the relative risks. Control of confounding factors was performed by logistic regression models. Oral lesions were present in 75% of 436 HIV+ patients. Hairy leukoplakia, erythematous and pseudomembranous candidosis, angular cheilitis and oral ulcers were frequently found. Patients who contracted HIV through blood transfusion were more likely to present erythematous candidosis (P=0.005) than subjects who acquired HIV through sexual transmission. Oral ulcers were seen only in men (P=0.02) and in individuals who contracted HIV through sexual transmission (P=0.02). This study brings valuable data in regard to differences in the type and prevalence of HIV-related oral lesions by gender and the risk categories analysed, particularly blood transfusion.

Oral manifestations in 70 German HIV-infected women

OBJECTIVE

To describe the prevalence of oral lesions in HIV-infected women, and to determine the association of oral lesions with the level of immunosuppression and the route of transmission.

PATIENTS

In a retrospective, cross-sectional study, a cohort of 70 HIV-infected women (median age: 32.5 y; median CD4(+)-cell count 262 per microliter) comprising 18% of all HIV-infected individuals (n = 389) was selected in an outpatient clinic. Oral lesions strongly associated with HIV-infection were evaluated.

RESULTS

The overall prevalence of oral lesions was 27/70 (39%). Among HIV-infected women with CD4(+)-cell counts < 200 per microliter, the prevalence was 65% (19/29); and with counts > 200 per microliter, the prevalence was 27% (11/41). The prevalence of candidiasis and hairy leukoplakia was similar among those infected heterosexually or by intravenous drug use.

CONCLUSIONS

As reported in men, these findings demonstrate that oral lesions are common in HIV-infected women. Candidiasis is more likely to occur at low CD4(+)-cell counts, whereas no difference was seen regarding the level of immunosuppression and hairy leukoplakia. Interestingly, the route of transmission does not play a role regarding the presence of oral lesions among HIV-infected women.

Epidemiology of HIV-related oral manifestations in women: a review

OBJECTIVE

(1) To assess the extent of knowledge acquired since 1981 on the epidemiology of HIV-related oral manifestations in women; (2) to determine if these findings differ by gender; and (3) to assess the needs and direction for future epidemiologic research on oral disease and HIV infection in women in relation to men.

DATA IDENTIFICATION

A computer-assisted search was conducted to identify epidemiologic studies reporting the frequency of various oral conditions in HIV-infected women. Studies on periodontal disease as manifestation of HIV infection were not included.

DATA EXTRACTION

Methods used in the retrieved articles were reviewed with respect to target population, study design, sampling scheme, outcomes, measurements and statistical issues. Results were summarized in relation to oral findings in HIV-infected men.

RESULTS OF DATA SYNTHESIS

Most studies were prospective, and sample selection was non-random. Studies differed with respect to geographic location, risk category for HIV transmission, and stage of HIV disease. Despite these differences, oral lesions were found in at least 15% of HIV-infected women, and the most common oral lesion in all studies was candidiasis. Women differed from men with respect to the prevalence of hairy leukoplakia and Kaposi's sarcoma (KS) both of which were significantly less common in women.

CONCLUSION

Future epidemiologic studies should be directed at identifying cofactors involved in addition to Epstein-Barr virus (EBV) in the development of hairy leukoplakia, and in addition to KS herpes virus (KSHV) in the occurrence of KS.

Intergroup comparisons of oral lesions in HIV-positive South Africans

OBJECTIVE

To determine whether there are any differences in the oral manifestations of sub-groups of persons with HIV. These data could provide information for planning of oral health promotion and prevention programmes.

DESIGN

A comparative inter-group cross-sectional investigation of the oral manifestations of HIV. Ethnic, gender and sexual orientation differences were taken into consideration.

SETTING

Three large general hospitals that offer comprehensive medical investigations and care to persons with HIV.

SUBJECTS AND METHODS

A total of 485 HIV-positive adults participated. Clinical examination and, where necessary, swabs or smears of lesions for microbiology, biopsies for histology.

MAIN OUTCOME MEASURES

Presence of lesions, associated signs, incidence and type of micro-organisms.

RESULTS

A total of 485 HIV-positive persons were examined over a period of 3 years consisting of 225 Blacks, 191 Coloureds (persons of 'mixed' descent) and 69 Whites. Data were analysed using, where relevant, the chi 2 test or Fisher's exact test. Heterosexual males revealed a higher prevalence of all oral lesions combined when compared with heterosexual females. A similar finding was evident when HIV-associated periodontal diseases was compared in these two groups. Homosexual males had a higher prevalence of candidal infections than heterosexual males. Coloured heterosexuals had a higher prevalence of oral lesions combined than black heterosexuals. All these results showed statistical significance.

CONCLUSIONS

The study tends to show that different patterns of prevalence emerge when inter-group comparisons are made of oral soft tissue diseases evident in HIV-infected South Africans.

Sentinels and signposts: the epidemiology and significance of the oral manifestations of HIV disease

A large number of studies attest to the frequency of oral disease in those with HIV infection. Most show that hairy leukoplakia and pseudomembranous candidiasis are the commonest lesions in those with HIV infection and AIDS, with higher prevalence and incidence rates correlating with falling CD4 counts and disease progression. HIV-infected individuals with oral candidiasis or hairy leukoplakia progress to AIDS more rapidly than matched controls without these lesions. Oral candidiasis and hairy leukoplakia increase with time since seroconversion. On the other hand, parotid enlargement in children appears to be associated with slower progression to AIDS. As a consequence of these and other observations, oral lesions are widely included in natural history studies, staging and classification schemes for HIV infection. In addition to their role in the diagnosis of HIV infection and as indicators of the progression of HIV disease, oral lesions are used as clinical correlates of CD4 counts and as criteria for entry into clinical trials.

Oral manifestations associated with human immunodeficiency virus infection in a Spanish population

A study was made of the oral manifestations in 396 patients with human immunodeficiency virus (HIV) infection. The following risk groups were established: intravenous drug users (79.5%), homosexuals (7.8%), homosexual intravenous drug users (3.3%), heterosexuals (8.1%) and hemophiliacs/transfusion patients (1.3%). The oral lesions, in decreasing order of frequency, were: periodontal disease (78.28%), candidiasis (65.65%), hairy leukoplakia (16.16%), herpes simplex virus lesions (5.30%). Kaposi's sarcoma (2.27%), recurrent aphthous ulceration (RAS) (1.01%), lichen planus (0.5%), non-Hodgkin's lymphoma (0.25%), tuberculous lesion of the tongue (0.25%) and ulcerations of uncertain etiology (0.25%). Attention is drawn to the greater predominance of these lesions in patients with CD4 values of less than 200/ mm3, compared with those who have higher lymphocyte counts.

Prevalence of skin disease in patients infected with human immunodeficiency virus in Bangkok, Thailand

A detailed study of the skin lesions of 248 patients infected with the human immunodeficiency virus (HIV) in Bangkok, Thailand, is reported. The study population consisted of 140 patients with asymptomatic disease (stage I), 27 patients with symptomatic disease (stage II), and 81 patients with advanced stage of the disease (stage III). Ninety-five percent of all patients were observed to have one or more skin disorders. Conditions with prevalence higher than 5% included oral candidiasis (34.3%), pruritic papular eruption (32.7%), seborrhoeic dermatitis (21.0%), herpes zoster (16.1%), oral hairy leucoplakia (14.9%), herpes simplex (10.9%), onychomycosis (9.3%), cutaneous ringworm (7.7%), psoriasis (6.5%), and folliculitis (5.6%). Patients in the stage II and III subgroups were found to have a significantly more number of skin disorders than patients in stage I. The prevalence pattern of skin disorders in this study are generally similar to previous studies in the literature. Three notable differences, however, emerge from this study: (1) the high prevalence of pruritic papular eruption in all subgroups, (2) the high prevalence of Penicillium maneffei infection in patients with advanced disease, and (3) the absence of Kaposi's sarcoma in the study population. Knowledge about the cutaneous disease pattern in the locals will be more clinically relevant for proper care of the patients.

Changing patterns of HIV infection in otolaryngology

To identify how the spectrum of head and neck complications of HIV disease has altered over the 7-year period between 1984 and 1991, a prospective collection of data on 429 HIV-positive subjects referred since 1984 was undertaken. Information was grouped into three study periods by date of presentation for analysis of trends. There has been a trend towards increased heterosexual acquisition (P < 0.02) and a decrease over time in the proportion of patients presenting with AIDS, as a proportion of HIV-positive patients (20/31 1983-1984; 90/179 1989-1991: P < 0.001). While the occurrence of mucosal candidiasis (P < 0.0001) and Kaposi's sarcoma (P < 0.05) has decreased that of rhinosinusitis (P < 0.0001) and non-Hodgkin's lymphoma (P < 0.05) has increased. Cervical lymphadenopathy has shown a significant decline (P < 0.05), but other conditions have been relatively constant. Otolaryngologists should be aware of current emphasis in the head and neck manifestations of HIV infection, which have important implications for diagnosis and management.

HIV-related oral manifestations in two cohorts of women in San Francisco

The goals of this study were to compare the prevalence of oral lesions in women infected with human immunodeficiency virus (HIV) and HIV-negative women, and to determine the association of oral lesions with route of HIV transmission and with level of immunosuppression in infected women. As part of a prospective 4-year study, oral examinations and blood tests were performed, at 6-month intervals, on 176 HIV-infected women and on 117 HIV-negative women at risk for HIV infection. We evaluated participants for the following oral conditions: hairy leukoplakia, candidiasis, ulcers, warts, non-Hodgkin's lymphoma, Kaposi's sarcoma, and parotid enlargement. As previously reported in men, the prevalence of oral lesions was significantly higher among HIV-infected (22%) than HIV-negative women (3%) [odds ratio (OR) = 8.2; 95% confidence interval (CI) 2.8, 23.5], particularly candidiasis (14%) and hairy leukoplakia (10%). Among HIV-infected women with CD4 cell count nadir > or = 200 cells/microliters, the prevalence of hairy leukoplakia was higher among those infected heterosexually than among injection drug users (OR = 5.5; 95% CI: 1.5; 19). The OR for the association between oral lesions and CD4 cell count nadir (< 200 vs. > 500 cells/microliters) was 8.9 (95% CI: 2.6, 30), indicating a strong positive association with level of immunosuppression.

[The recent data on the viral origin of hairy leukoplakia of the oral cavity (OHL)]

Buccal hairy leukoplakia is associated with Epstein-Barr and HIV virus infections. The main symptom is the characteristic hairy lesion on side parts of the tongue without any other clinical signs. Histologically, there are hyperkeratosis, vacuolar degeneration, and presence of Candida, but no inflammatory infiltration. Antiviral drugs led to the regression of lesions, but there is a trend to relapse when treatment is interrupted.

[Recent data on the viral origin of hairy leukoplakia of the oral cavity]

Buccal hairy leucoplakia is associated with Epstein-Barr and HIV virus infections. The main symptom is the characteristic hairy lesion on side parts of the tongue without any other clinical sign. Histologically, there are hyperkeratosis, vacuolar degeneration, and presence of Candida, but no inflammatory infiltration. Antiviral drugs led to the regression of lesions, but there is a trend to relapse when treatment is interrupted.