Oral manifestations of HIV infection

The oral manifestations of HIV infection are reviewed along with evidence supporting the need for training of health-care professionals in the recognition of oral lesions. The diagnosis, prevalence, pathogenesis, and management of the most common oral lesions observed in HIV infection are described. Oral candidiasis and hairy leukoplakia are two oral lesions that have been demonstrated to have important prognostic significance. The diagnosis and management of periodontal disease in seropositive patients is emphasized, and a preventive protocol for patients at risk for periodontal pathology is recommended.

Non-insulin-dependent diabetes mellitus as a risk factor for denture stomatitis

The prevalence of denture stomatitis as well as the frequency of isolation of Candida species and their density on the palatal mucosa have been compared in 70 acrylic denture-wearers suffering from non-insulin-dependent diabetes mellitus (NIDDM) versus 58 acrylic denture-wearers with normal glucose metabolism. The adherence of C. albicans to palatal epithelial cells in vitro was also assessed in both groups. The patients with NIDDM had a significantly higher prevalence of denture stomatitis compared with the controls. The frequency of Candida colonization was increased in diabetics, but not significantly. According to the imprint culture technique, the density of Candida species was significantly higher in patients with NIDDM compared with the controls. The adherence of C. albicans to palatal epithelial cells from patients with NIDDM showed a significant increase compared with that observed in cells collected from the controls. This study supports the view that NIDDM predisposes to Candida-associated denture stomatitis.

Oral leukoplakia

Leukoplakia has evolved as a clinico-pathologic concept over many years, with the current clinical designation being accepted worldwide. Reflective of the biology of leukoplakia is the concept of cellular atypia and epithelial dysplasia. Adding to a better understanding of leukoplakia in general has been the definition of relevant clinical subsets which, in some cases, includes etiology (snuff), while in other cases a verrucous clinical appearance will suggest a more aggressive anticipated behavior pattern. Tobacco usage, in many of its forms, remains the prime etiologic factor; however, other considerations also apply. More recently, the potential etiologic role of Candida albicans has been stressed, as well as its possible role in carcinogenesis. So-called oral hairy leukoplakia has been defined in relation to a possible Epstein-Barr viral infection, usually in the immunosuppressed patient. Other viruses, human papilloma virus in particular, have been implicated in leukoplakia, while genetic alterations involving tumor suppressor elements (p53) have also been investigated. Finally, the management of this common condition remains a variable and includes local, topical, and systemic therapies such as anti-oxidants, carotenoids, and retinoids.

[The usefulness of different markers in the diagnosis of advanced HIV infection]

BACKGROUND

The aim of this study was to evaluate the usefulness of different markers to diagnose advanced infection by the human immunodeficiency virus (HIV) (AIDS or CD4 lymphocyte < 0.2 x 10(9)/L), establish the degree of correlation and define markers of advanced infection in primary health care.

METHODS

Clinical, hematological, biochemical, cellular, serological and immunological variables were analyzed in 146 patients diagnosed for the first time with HIV infection. The patients were classified into three stages: A (II, III, CDC-1987), B (IV-A, IV-C2) and C or advanced (IV-C1, IV-D). The following data were compared: the results in the three stages, the degree of correlation, the specificity and sensitivity to the diagnosis of AIDS. Two multiple logistic regression models were established: the first for all the variables and the second for only those available in primary health care.

RESULTS

All the markers except the triglycerides, IgG, IgM, and beta 2-microglobulin presented significant differences in the stages (p < 0.05). With the exception of the CD3+, CD4+ and CD8+ lymphocytes (r > or = 0.6 or -0.6) the remaining variables were independent. The decrease in CD4+ and the increase in neopterin were very sensitive markers (> 95%) but only hyperamylasemia demonstrated a specificity greater than 95% for the diagnosis of advanced infection. Oropharyngeal candidiasis (OR = 4.80) and the CD4+ lymphocyte (OR = 0.99) had the greatest weight in the first model. In the second model the most significant markers were weight loss (OR = 4.41), a decrease in lymphocytes (OR = 7.65) and an increase in IgA (OR = 5.82) with p < 0.01 and a predictive value of 85.16%.

CONCLUSIONS

The presence of weight loss, lymphocyte count < 1 x 10(9)/L and an increase in IgA may be used in primary health care to diagnose advanced infection by the human immunodeficiency virus. Asymptomatic hyperamylasemia with no apparent cause suggests advanced infection.

[Effect of candidal infection on the hyperplastic oral epithelium]

DMBA was used to produce oral epithelial changes, from benign hyperplasia to epithelial dysplasia of different severity in golden hamsters. Thereafter, they were inoculated with candida albicans. The result shows that candidal infection can induce epithelial dysplasia in benign hyperplasia; and in epithelial dysplasia, candidal infection will promote malignant transformation. It implies that candidal infection of the oral leukoplasia should be detected and treated.

Effect of sialoadenectomy on the carriage of Candida albicans in the mouths of rats

Xerostomia provoked in rats by surgical removal of the major salivary glands significantly increased oral carriage of Candida albicans. Five weeks after 3 oral inoculations of 10(8) CFU, C. albicans were found in the mouths in 50% of normal animals but after 8 weeks in none. In xerostomic rats, 100% had oral C. albicans after 5 weeks and after 18 weeks, 66.6% still harboured yeasts. Over the whole experimental period the amount of C. albicans was greater in the mouths of sialoadenectomized than in normal rats.

Orofacial manifestations of the systemic mycoses

Aspergillosis, cryptococcosis and zygomycosis (mucormycosis) are overall the most common systemic mycoses but histoplasmosis is particularly endemic in parts of central USA and other areas worldwide. Orofacial lesions caused by systemic mycoses have rarely been reported in the past though they have been recorded particularly in outdoor workers from geographic areas with a high prevalence of infection and occasionally in immunocompromised individuals. Increasing world-wide travel, and the dramatic increase in numbers of immunocompromised persons, especially those with human immunodeficiency virus (HIV) disease, have been responsible for an increase in reports and other studies of orofacial disease in systemic mycoses and new opportunists are now being recognized. Those in Oral Medicine and Pathology must now be aware of the possibility of a systemic mycosis as the cause of chronic oral ulceration, chronic maxillary sinus infection, or bizarre mouth lesions, especially in patients with HIV disease, lymphoproliferative disorders, or diabetes mellitus, or in those who have been in endemic areas. Diagnosis and management should be undertaken in consultation with a physician with appropriate expertise, as pulmonary and other systemic infection may well be present. This paper reviews the eight main systemic mycoses.

Dental management of HIV-infected individuals

In 1981, a group of male homosexuals was found to have an immunological defect resulting in opportunistic infections. The pattern of symptoms became known as acquired immune deficiency syndrome (AIDS). Much time and expense have been invested to study the human immunodeficiency virus (HIV), prevent its spread, and find a cure for HIV infection. Fear of HIV infection has resulted in implementation of stricter infection control practices. Intervention by the Occupational Safety and Health Administration (OSHA) and Environmental Protection Agency (EPA) has mandated procedures for infection control and waste disposal. Ethical questions and social problems have surfaced concerning the treatment of HIV-infected patients. Despite reports on infection control, literature concerning management of HIV-infected dental patients is limited. Misinformation has prevented the application of reliable information about the care of HIV-infected individuals. An accurate general knowledge of HIV infection is essential for optimal care of these patients.

[Chronic candidosis]

The paper deals with the problem of mucocutaneous candidosis, because the incidence of the disease is increasing steadily in recent years. The author draws attention to various already known causes of the development of candidosis and submits also some hypothese reported in the literature. The classification of candidosis should facilitate diagnostic work of the attending physician. In therapy in particularly refractory candidoses are emphasized and the author present on the example of one patient an account of recent therapeutic possibilities.

[Stomatitis from dentures: etiopathological and therapeutic considerations]

Infection of the oral mucous membrane is frequent in patients with removable prostheses, either totally of partially, and particularly when the prostheses is palatal. The principal etiological factor causing the infection is accepted to be "Candidas" aided by the presence of plaque bacteria (in patients with poor oral hygiene care), and a poor fit of the prostheses to the soft tissues. Treatment of the infection must proceed in the following order: a) use of effective medication against oral fungus such as Nystatin or Ketoconazole. b) Meticulous oral hygiene care in the mucous membrane as well as in the prostheses, but using the prostheses as little as possible during the treatment period. c) A total cure of the infection (denture stomatitis) before proceeding to the next phase of the treatment. d) Determination of the adjustment and occlusion of the prostheses in order to determine those areas of the prostheses which need to be refilled because of maladjustment of the prostheses to the soft tissues of the patient.

Candida esophagitis following cardiac operation and short-term antibiotic prophylaxis

Dysphagia and retrosternal pain are common complaints in patients after cardiac operations, and most often they result from the median sternotomy and/or endotracheal intubation. Although Candida esophagitis is a recognized cause of similar symptoms, it is usually not suspected except in immunologically compromised hosts. This report describes the case histories of five patients, not immunosuppressed or cachectic, who developed persistent dysphagia during recovery from cardiac operations; four patients received only 4 days of preoperative and postoperative prophylactic antibiotic treatment with cefazolin (Kefzol) and cephalexin (Keflex). A nasogastric tube had been used for less than 24 hours in the postoperative period. The fifth patient developed symptoms following prolonged and varied antibiotic therapy. Candida esophagitis was diagnosed by a combination of coexisting oral candidiasis (5/5), roentgenographic appearance on barium swallow (5/5), endoscopy (4/4), and biopsy or culture (2/4). Initial therapy consisted of antireflux measures and antacids (4/5), cimetidine (4/5), oral nystatin in methylcellulose base (1,000,000 units every 4 hours) (4/5), and termination of other antibiotic therapy (1/5). These measures were effective in clearing the infection in only two patients. A third patient required prolonged massive oral nystatin therapy, and in two patients intravenous Amphotericin B was necessary to control infection. Two patients subsequently developed strictures which necessitated multiple esophageal dilatations. One of these patients developed endocarditis during home dilatation therapy. All patients are currently free of disease. Current measures utilized to recognize and treat the disease are discussed.

[Fungal infection after antibiotic therapy (author's transl)]

The increasing use of antibacterial chemotherapy in the last four decades encourages the commensal colonization of man by candida yeasts. The sites of particular commensal colonization are the oropharyngeal cavity and the intestinal tract. They are the principal reservoirs from which candida infections can settle into other regions and organs. The metastasis of candida yeasts from the commensal reservoir into regions which are free of microorganisms in healthy persons, usually needs a stimulant noxa: an eliciting bacterial infection, a consumptive primary disease, immunosuppressive therapy among other factors. In the event of candida infection being superimposed on a bacterial infection, successful antibacterial chemotherapy may lead to a remission of the mycosis by removal of the primary noxa.