Clinical evaluation in treatment of oral lichen planus with topical fluocinolone acetonide: a 2-year follow-up

BACKGROUND

Oral lichen planus (OLP) is a chronic inflammatory disease which is recalcitrant to medical treatment. The purpose of this study was to compare the effectiveness of various forms of the topical steroid fluocinolone acetonide applications in patients with OLP.

METHODS

Data of OLP patients were collected retrospectively from the chart record and the 97 OLP patients were divided into three groups. The first group (n = 28) was treated with a 0.1% solution of fluocinolone acetonide (FAS), the second group (n = 22) with 0.1% fluocinolone acetonide in orabase (FAO), and the third group (n = 47) with both FAS and FAO (FAS/FAO) throughout the study. Each group was clinically evaluated as complete remission (CR), partial remission (PR), or no response (NR), following the treatment. Also, the side-effect of oral candidiasis was recorded in each group.

RESULTS

Two years of treatment resulted in complete remission of 77.3, 21.4, and 17.0% of patients in the FAO, FAS, and FAS/FAO groups, respectively. There was a statistically significant difference in disease remission (P < 0.05), but not in oral candidiasis appearance (P > 0.05) among various forms of topical steroid application.

CONCLUSION

The study concluded that FAO or FAS can produce improved results in the management of OLP by long-term follow-up.

Prognosis of oral pre-malignant lesions: significance of clinical, histopathological, and molecular biological characteristics

The concept of a two-step process of cancer development in the oral mucosa, i.e., the initial presence of a precursor subsequently developing into cancer, is well-established. Oral leukoplakia is the best-known precursor lesion. The evidence that oral leukoplakias are pre-malignant is mainly derived from follow-up studies showing that between < 1 and 18% of oral pre-malignant lesions will develop into oral cancer; it has been shown that certain clinical sub-types of leukoplakia are at a higher risk for malignant transformation than others. The presence of epithelial dysplasia may be even more important in predicting malignant development than the clinical characteristics. Three major problems, however, are attached to the importance of epithelial dysplasia in predicting malignant development: (1) The diagnosis is essentially subjective, (2) it seems that not all lesions exhibiting dysplasia will eventually become malignant and some may even regress, and (3) carcinoma can develop from lesions in which epithelial dysplasia was not diagnosed in previous biopsies. There is, therefore, a substantial need to improve the histologic assessment of epithelial dysplasia or, since epithelial dysplasia does not seem to be invariably associated with or even a necessary prerequisite for malignant development, it may be necessary to develop other methods for predicting the malignant potential of pre-malignant lesions. As a consequence of these problems, numerous attempts have been made to relate biological characteristics to the malignant potential of leukoplakias. Molecular biological markers have been suggested to be of value in the diagnosis and prognostic evaluation of leukoplakias. Markers of epithelial differentiation and, more recently, genomic markers could potentially be good candidates for improving the prognostic evaluation of precursors of oral cancer. As yet, one or a panel of molecular markers has not been determined that allows for a prognostic prediction of oral pre-cancer which is any more reliable than dysplasia recording. However, these new markers could be considered complementary to conventional prognostic evaluation.

Oral candidiasis in head and neck cancer patients receiving radiotherapy with amifostine cytoprotection

This controlled study assessed the incidence of oral candidiasis, a xerostomia-related complication, in head and neck cancer patients receiving radiotherapy, with amifostine cytoprotection. Thirty-eight patients received 500 mg amifostine i.v., prior to each radiotherapy fraction, while 16 patients received radiotherapy alone. Oral candidiasis was diagnosed according to the criteria described before. Subjective xerostomia scales were completed by all patients. Mucositis was evaluated using the RTOG criteria. Oral candidiasis was diagnosed in 11/38 amifostine patients and in 9/16 controls (P = 0.07). Severe xerostomia was reported by 4/38 amifostine patients and by 7/16 controls. Oral candidiasis was reduced with amifostine cytoprotection. Oral candidiasis is suggested as an objective, early, though indirect, endpoint for amifostine's radioprotective effect on salivary glands.

Use of Punica granatum as an antifungal agent against candidosis associated with denture stomatitis

The aim of this study was to evaluate the use of a gel containing the extract of Punica granatum as an antifungal agent against candidosis associated with denture stomatitis. Sixty patients with denture stomatitis confirmed by clinical and mycologic examination were selected. The patients were randomly allocated in two groups of 30 individuals each according to the medication prescribed: group A used miconazole (Daktarin(R) gel oral) and group B used a gel of P. granatum Linné (pomegranate). Both groups used the medicines three times per day for 15 days. Forty-eight hours after finishing the treatment the patients were re-examined and a second set of samples was collected for mycologic examination. The medicines were evaluated for their clinical response and negativity for Candida. The clinical results showed a satisfactory and regular response in 27 and 21 subjects of groups A and B, respectively. Negativity of yeasts was observed in 25 subjects of group A and 23 of group B. It can be concluded that the extract of P. granatum may be used as a topical antifungal agent for the treatment of candidosis associated with denture stomatitis.

Persistence of oropharyngeal Candida albicans strains with reduced susceptibilities to fluconazole among human immunodeficiency virus-seropositive children and adults in a long-term care facility

Nineteen oropharyngeal Candida albicans isolates from six children and seven adults living with AIDS at the Russia AIDS Centre, Moscow, from 1990 to 1998 were selected for molecular typing. Two fluconazole-resistant C. albicans genotypes were identified from a child who contracted human immunodeficiency virus infection during the Elista Hospital outbreak in the Kalmyk Republic in 1989. Highly related strains were observed 4 years later in the oral lesions and colonization of two patients and a health care worker. There may be a tendency for persons who are living with AIDS in a long-term care facility and who receive fluconazole therapy for oropharyngeal candidiasis to harbor and spread fluconazole-resistant C. albicans strains.

Racial distribution of Candida dubliniensis colonization among South Africans

Candida dubliniensis is a yeast species that has only recently been differentiated from Candida albicans. C. dubliniensis colonization was initially associated with human immunodeficiency virus (HIV)-positive individuals. Because of the large proportion of AIDS patients in South Africa, we tested the generality of this association by assessing the prevalence of C. dubliniensis colonization among 253 black HIV-positive individuals, 66 healthy black individuals, 22 white HIV-positive individuals, and 55 healthy white individuals in South Africa carrying germ tube-positive yeasts in their oral cavities. Molecular fingerprinting with Ca3, a complex DNA fingerprinting probe specific for C. albicans, and Cd25, a complex DNA fingerprinting probe specific for C. dubliniensis, provides the first conclusive evidence of the existence of C. dubliniensis among South African clinical yeast isolates and reveals a higher relative prevalence of this species among white healthy individuals (16%) than among HIV-positive white individuals (9%), black healthy individuals (0%), and black HIV-positive individuals (1.5%). A cluster analysis separated South African C. dubliniensis isolates into two previously described groups, groups I and II, with the majority of isolates clustering in group I. Isolates from white healthy individuals exhibited a higher level of relatedness. A comparison of the C. dubliniensis isolates from South Africa with a general collection of C. dubliniensis isolates collected worldwide revealed no South Africa-specific clade, as has been demonstrated for C. albicans. These results suggest that in South Africa, C. dubliniensis carriage is influenced more by race than by HIV infection status.

'Genotypic shuffling' of sequential clones of Candida albicans in HIV-infected individuals with and without symptomatic oral candidiasis

Although HIV-infected individuals harbour multiple strains of oral Candida albicans, little is known of their micro-evolution over time. Therefore, a prospective study was conducted with 16 HIV-infected ethnic Chinese individuals with and without symptoms of oropharyngeal candidiasis to evaluate the genotype distribution of oral C. albicans isolates during HIV disease progression. Oral-rinse samples were obtained from all individuals and up to five C. albicans colonies were selected for each visit, over a 12 month period of multiple visits. After identification of isolates using standard mycological criteria, the genetic similarities of yeast isolates within and between sequential clones of C. albicans were assessed by DNA fingerprinting through random amplification of polymorphic DNA (RAPD). The results of RAPD gel profiles and the lineage of each isolate were further analysed using commercially available software. RAPD studies revealed the prevalence of up to 14 different genotypes per individual during the study period, with multiple genotypes isolated simultaneously from a single oral rinse. Computer analysis of RAPD profiles revealed that yeasts isolated over sequential visits from symptomatic individuals demonstrated a striking level of relatedness compared with isolates from asymptomatic individuals. Genetically identical C. albicans strains also formed 'loosely' connected subclusters that overlapped multiple visits, implying genetic 'shuffling' in these isolates during disease progression. These data point to varying evolutionary genetic trends in C. albicans associated with symptomatic oral candidiasis and asymptomatic carriage in HIV disease.

Colonization of the oral cavity by Candida species: risk factors in long-term geriatric care

The population of elderly people in hospitals for long-term geriatric care presents many risk factors for nosocomial infection by Candida species. The aim of this work was to reduce the risk of C. albicans nosocomial infections starting from colonization of the oral cavity. The population of concern was the patients in long-stay geriatrics units; a sample of 110 people was selected by drawing lots. The clinical and biological parameters of each patient included in the study were recorded. The oral cavity was colonized by Candida spp in 67% of cases. The distribution of the strains showed that C. albicans was the most frequently identified strain, followed by C. glabrata; of the 73 patients with at least one strain of Candida spp., 47 had a clinically diagnosed candidiasis (64.4%). The wearing of dentures was not statistically linked with the development of oral candidiasis. Detecting which patients have been colonized, identifying the risk factors and applying preventive measures should reduce the probability of elderly people falling into the vicious circle of infection-malnutrition-immune-depression.

Thermal sensation and pain in oral lichen planus and lichenoid reaction

BACKGROUND

Our previous findings in oral lichen planus (OLP) and lichenoid reactions (LR) raised the question whether the histopathological changes observed in sensory and autonomic innervation produce oral sensory disorders.

METHODS

Spontaneous pain was assessed using the Visual Analogue Scale (VAS). Thermal pain thresholds were measured with a contact thermostimulator and mechanical pain thresholds with an electronic algometer.

RESULTS

Patients with OLP reported a higher intensity of spontaneous pain than LR patients (P = 0.001). Even erosive LRs were relatively painless. No thermal or mechanical hyperalgesia was detected in oral lesions. Highest separate cold pain threshold was measured in lesions affected by intense Candida growth.

CONCLUSION

Together with previous histological findings, the present data suggest that increased somatic innervation and sympathetic denervation do not promote clinical pain sensitivity or hyperalgesia in oral mucosa and that these sensory functions are not affected by OLP and LR. Candida growth may function as secondary irritant modulating the pain responses.

Reassessing the presence of Candida albicans in denture-related stomatitis

OBJECTIVE

The aim of this study was to reevaluate the link between Candida albicans and denture-related stomatitis according to a modified Newton classification, which reflects the classic types of inflammation as well as the extent to which the tissue is affected.

STUDY DESIGN

Two groups of denture wearers were evaluated for denture-related stomatitis. The presence and number of yeasts on the dentures, the identification of the Candida species present, and the amount of plaque coverage were determined. Putative risk factors were included in the study. Relations between these variables and stomatitis were analyzed statistically.

RESULTS

According to Newton's classification, the presence of yeast on the denture was not linked to whether subjects had stomatitis. But with our classification, higher prevalence of yeast carriers, yeast colony number, and plaque coverage were found on the dentures of individuals with the most extensive inflammation, regardless of Newton type. Among risk factors evaluated, wearing dentures at night and smoking were associated with the most extensive inflammation. We also demonstrated that the presence of C albicans as well as the cohabitation of different Candida species was more frequent in denture-related stomatitis. The differences were statistically significant.

CONCLUSIONS

Statistical analysis of microbiologic data from different denture-related stomatitis categories according to our modified classification showed that the presence of yeast on dentures was significantly associated with the extent of the inflammation, rather than with the Newton type. Our findings suggest that the inflammatory process of stomatitis favors the colonization of Candida. These results could have new implications for diagnosis and management of the condition.

Candida-induced stomatopyrosis and its relation to diabetes mellitus

BACKGROUND

Glycaemic disorders and oral candidosis can be accompanied by burning mouth sensations. However, no clear relation between all three disorders is known.

METHODS

Seventy-two native Upper-Austrians with burning mouth sensations were examined and smears for Candida estimation were taken from the spots where the sensations were felt. All patients with previously unknown diabetes mellitus (DM) were subjected to an oral glucose tolerance test (OGTT). Use of glucocorticoid-containing anti-asthmatic sprays and the body mass index (BMI) were determined.

RESULTS

Of the examined non-inhalers of sprays, 52% had increased candidal density. A correlation between that increase and type 2 DM was found. The burning sensations in all patients with increased candidal density subsided completely after anti-mycotic therapy.

CONCLUSION

The perception of burning sensations was hypothesised to occur via stimulation of the capsaicin (vanilloid) receptor by Candida metabolites. The Candida-induced stomatopyrosis should be regarded as a single symptom indicating (predisposition to or established) type 2 DM in non-inhalers of the concerned population.

High oral prevalence of Candida krusei in leprosy patients in northern Thailand

Although Candida albicans is the most common human yeast pathogen, other Candida species such as C. krusei are now recognized as emerging agents, especially in patients with human immunodeficiency virus (HIV) disease. C. krusei is inherently resistant to the widely used triazole antifungal fluconazole and poses therapeutic problems, especially in systemic candidiasis. In a surveillance study of leprosy patients (with arrested or burnt-out disease) in a leprosarium in northern Thailand, we found a rate of oral carriage of C. krusei (36%) significantly (P < 0.05) higher than that for a healthy control group (10%). Among the Candida-positive patients, 16 of 35 (46%) carried C. krusei, while C. albicans was the second most common isolate (12 of 35 patients; 34%). The corresponding figures for the control group were 2 of 13 (15%) and 6 of 13 (46%), respectively. Studies of the antifungal resistance of the C. krusei isolates from patients indicated that all except one of the isolates were resistant to fluconazole, two isolates were resistant to ketoconazole, and all isolates were sensitive to amphotericin B. Evaluation of their genetic profiles by randomly amplified polymorphic DNA analysis with three different primers and subsequent analysis of the gel profiles by computerized cluster-derived dendrograms revealed that the C. krusei isolates from patients belonged to 10 disparate clusters, despite the origin from a single locale. These nascent findings indicate an alarmingly high prevalence of a Candida species resistant to a widely used antifungal in a part of the world where HIV disease is endemic.

An update on HIV and periodontal disease

With the advent of newer pharmacological approaches to the treatment of human immunodeficiency virus (HIV) infection, the incidence and progression of both atypical and conventional periodontal diseases are changing. The incidence of necrotizing periodontitis and gingival diseases of fungal origin appears to be on the decline as a result of these therapies that have led to increased life spans for HIV patients. However, in cases where these therapies lose their effectiveness and HIV patients relapse into an immunosuppressed state, these conditions may recur. Recent evidence has shown that HIV patients with more conventional periodontal diseases such as chronic periodontitis may have increased attachment loss and gingival recession when compared to their HIV-negative counterparts. This pattern of loss of periodontal support may be due in part to a diffuse invasion of opportunistic bacterial infections, viruses, and fungi into the gingival tissue, leading to a more elevated and more diffuse destructive inflammatory response in the periodontal soft and hard tissues. While the accepted approaches to treating the spectrum of periodontal diseases in HIV patients remain essentially unchanged over the past 15 years, the impact of newer systemic therapies on patient immunocompetence may influence treatment decisions.

Fungal infections associated with HIV infection

Oral candidiasis is perhaps the commonest infection seen in HIV disease. The aim of this workshop was to provide a sketch of the multifarious aspects of the disease from a global perspective. To this end the panellists addressed issues such as the virulence of Candida, emergence of antifungal resistance, management of candidiasis and other exotic, oral mycotic diseases. An all-pervasive theme was the dramatic differences in the management of fungal infections consequential to the availability (or the lack) of anti-HIV drugs in the developed and the developing world. Further, the social stigmata associated with the HIV disease in many developing regions in Africa and Asia appears to modify the therapeutic strategies. Additionally, the lesser-known regional variations in the disease manifestations and therapeutic approaches were stark. Further work is direly needed to address these issues.

The significance and management of periodontal lesions in HIV infection

It is now almost 20 years since we reported the existence of a previously unknown lesion, oral hairy leukoplakia, and its unexpected nature as the only human disease in which there is prolific replication of the gamma-herpesvirus, Epstein-Barr virus (EBV). Since then, it has become clear that, in the HIV-infected population, oral lesions are of particular significance. Their presence in individuals of unknown HIV serostatus is highly suggestive of HIV infection, while in people who are known to be HIV-infected, the development of oral candidiasis or hairy leukoplakia--often the very first lesions to occur--indicates that the battle between HIV virion production and destruction of immunologically important cells on, versus replacement of those cells has shifted in favour of HIV. These observations have led to the almost universal inclusion of oral lesions in staging and classification schemes for HIV infection. Recently, lower frequencies of oral disease have been seen in those on HIV therapy, except that oral warts may become more common as the viral load falls and CD4 count rises.

OBJECTIVES

To review the significance and management of periodontal lesions seen in HIV infection.

DESIGN

Traditional review.

RESULTS

HIV-associated periodontal lesions may be categorized as unusual forms of gingivitis, necrotizing periodontal diseases and exacerbated periodontitis. These lesions are significant in the extent to which they mark the underlying HIV disease and have service planning implications. Only limited data are available to inform guidelines for the management of individual patients.

CONCLUSIONS

Research of the effectiveness of interventions for HIV-associated periodontal lesions is needed.

Periodontal diseases and HIV infection

The workshop considered six related questions about periodontal changes seen in HIV infection. 1) To what extent are specific periodontal changes associated with HIV? 2) Are conventional periodontal diseases modified by HIV infection? The changes associated with HIV appear to be modified presentations of conventional diseases. Research should identify initiation and progression factors for necrotizing diseases. 3) What is the role of geography and transmission groups? These questions cannot be answered without greater standardisation of research methods. 4) Has the epidemiology of these changes changed with the advent of new therapies? The data required to answer this question should be available soon but this question is irrelevant to the vast majority of people with HIV. 5) What pathogens are involved in periodontal changes seen in HIV infection? The role of Candida spp. and other potential pathogens requires further investigation. 6) What management protocols are suitable for the periodontal diseases? The significance of periodontal diseases among people with HIV in developing countries is not known. Further research is needed of the effectiveness of interventions especially necrotizing disease in developing countries. The quality of research of these diseases would be enhanced by standardized approaches. A list of relevant variables might prevent their omission from studies.

[Non plaque-related gingivitis]

Gingivitis is a symptom revealing an underlying pathology, mostly due to a bacterial accumulation. This explains why for dentists gingivitis is often synonymous of a plaque-related gingivitis. This is a dangerous simplification since it can be due to very different etiologies, which evidently imply very different treatments. This paper illustrates the most frequent causes, not only encountered by the periodontologist, but also by the general practitioner, such as erosive lichen planus, herpes, Candida and radiotherapy.

Nonspecific secretory immunity in HIV-infected patients with oral candidiasis

Buccal and digestive tract opportunistic infections occur frequently in patients infected by HIV. In this study, we measured lysozyme (Lz), lactoferrin (Lf), total IgA (T-IgA), and secretory IgA (S-IgA) levels to investigate nonspecific secretory immunity in HIV-infected patients with oral candidiasis. Serum, saliva, and stool samples were analyzed by time-resolved immunofluorometric assay for Lz and Lf levels and by enzyme-linked immunosorbent assay for T-IgA and S-IgA levels. Mean salivary Lf and T-IgA levels (66.50 mg/L and 0.10 g/L, respectively) and mean fecal Lf, T-IgA, and S-IgA outputs (0.87, 54.0, and 43.6 mg/d, respectively) were significantly higher in HIV-infected patients with oropharyngeal candidiasis than in HIV-infected patients without oropharyngeal candidiasis and healthy subjects. There was a modification in the molecular form rate, with a high increase in S-IgA and monomeric IgA transudation from the plasmatic compartment into salivary and digestive fluids and an increase in salivary Lf local synthesis by polymorphonuclear neutrophils. HIV infection appears to be associated with dysregulation of some of the nonspecific immune factors at the mucosal surface. Despite high saliva concentrations and high intestinal output, innate immunity was not able to stop yeast expansion in HIV-infected patients.

Efficacy of alcohol-based and alcohol-free melaleuca oral solution for the treatment of fluconazole-refractory oropharyngeal candidiasis in patients with AIDS

PURPOSE

To evaluate the efficacy of alcohol-based and alcohol-free melaleuca oral solution in patients with AIDS and fluconazole-refractory oropharyngeal candidiasis.

METHOD

We performed a prospective, single-center, open-label study in a university-based inner city HIV/AIDS clinic. The study included 27 patients with AIDS and oral candidiasis clinically refractory to fluconazole. Patients were randomized 1:1 to receive either alcohol-based or alcohol-free melaleuca oral solution four times daily for 2-4 weeks. Thirteen patients were enrolled into cohort 1, and 14 patients were enrolled into cohort 2. The main outcome measure was resolution of clinical lesions of oral candidiasis. Evaluations were performed at 2 and 4 weeks for clinical signs and symptoms of oral candidiasis and quantitative yeast cultures.

RESULTS

All C. albicans isolates showed some degree of in vitro resistance to fluconazole. Overall, using a modified intent-to-treat analysis, 60% of patients demonstrated a clinical response to the melaleuca oral solution (7 patients cured and 8 patients clinically improved) at the 4-week evaluation.

CONCLUSION

Both formulations of the melaleuca oral solution appear to be effective alternative regimens for patients with AIDS suffering from oropharyngeal candidiasis refractory to fluconazole.

Treatment of azole-resistant oropharyngeal candidiasis with topical amphotericin B

OBJECTIVE

To report a case of successful treatment of azole-refractory oropharyngeal candidiasis with topical amphotericin B.

CASE SUMMARY

A 30-year-old white woman presented with recurrent oral thrush. The patient had been exposed to azole antifungals for >20 years, and in vitro susceptibility tests revealed class resistance. The patient started taking amphotericin B 100 mg oral suspension swish-and-spit 4 times daily. After 4 weeks of topical amphotericin B treatment, the patient reported significant symptomatic improvement. The oral candidiasis worsened following a course of oral antibiotics, but improved once the antibiotic was discontinued and after receiving amphotericin B swish-and-swallow for 4 additional weeks.

DISCUSSION

Current Infectious Diseases Society of America guidelines include topical amphotericin B as a potentially effective option for the treatment of oropharyngeal candidiasis. There is limited evidence to support this recommendation. Besides lack of data, an appropriate dosing regimen and consistent means of product formulation need to be determined.

CONCLUSIONS

This report demonstrates the potential role for topical amphotericin B in the treatment of azole-refractory oral candidiasis. Double-blind, randomized, controlled trials are needed to define dosing, efficacy, administration, and long-term safety of oral amphotericin B.

Oropharyngeal candidiasis in HIV(+) patients may influence the selection of HIV-1 protease variants

Approximately 500 HIV-1 protease gene (pro) sequences were obtained from oral tissues (gingival cuff, buccal mucosa, tongue, palate) as well as saliva and peripheral blood mononuclear cells (PBMC) of 80 HIV-1 positive patients by nested amplification and manual sequencing of PCR products. By visual inspection each patient in this study exhibited a unique sequence profile. HIV-1 pro sequences obtained from patients with oropharyngeal candidiasis (OPC(+) patients) had significantly higher numbers of mutations than sequences from OPC(-) patients, but OPC(+) patients were no more likely to accumulate protease inhibitor resistance mutations than OPC(-) patients. Although the sequences for each patient were predominantly consistent between PBMC and oral tissues, approximately 10% of the patients demonstrated tissue specificity, and patients that demonstrated tissue specificity tended to be OPC(+). Furthermore, HIV-1 pro sequences derived from OPC lesions demonstrated unique mutations in approximately 30% of the patients who provided paired OPC(+/-) samples of the same tissue type. These data provide evidence for minimal compartmentalization of HIV-1 in oral tissues, yet some patients demonstrate minor variation between the HIV-1 pro sequences obtained from an OPC lesion and those obtained from a non-lesion site of similar tissue.

Itraconazole solution: summary of pharmacokinetic features and review of activity in the treatment of fluconazole-resistant oral candidosis in HIV-infected persons

The clinical pharmacology of itraconazole is presented in relation to its use in the treatment of fluconazole-resistant oropharyngeal candidosis. The oral solution is a new formulation of itraconazole in which itraconazole is solubilised with the use of cyclodextrin. This formulation has a higher bioavailability and leads to higher local concentrations in the oral cavity which are advantages over the solid capsule formulation. Literature, in which the use of itraconazole oral solution was described to treat fluconazole-resistant oral candidosis, is reviewed. In about 55% of the patients signs and symptoms of oral candidosis were resolved after treatment with itraconazole oral solution. Although all the reviewed studies lack data to objectively qualify all the included patients as having a fluconazole-resistant candidosis, the authors conclude, that based on the available information itraconazole oral solution 100 or 200mg twice daily can be effective for fluconazole-resistant oropharyngeal candidosis (OPC) and should be considered prior to salvage therapy with intravenous amphotericin B. The use of itraconazole, however, requires careful monitoring of the patients co-medication for potential serious drug-drug interactions.

[Incidence of candidiasis of the buccal mucosa and efficiency of its treatment in diabetics]

A total of 102 patients with diabetes mellitus (types 1 and 2) were examined. Local immunity of the oral cavity and infection of the buccal mucosa with Candida fungi was evaluated. The incidence of true candidiasis of the buccal mucosa in diabetics was 35.3% and of latent candidiasis 43.1%. The adsorption activity of epithelial cells of the buccal mucosa was decreased in diabetics. Treatment was prescribed for all patients with both true and latent infection. Basic therapy did not essentially modify the course of candidal infection of the buccal mucosa, while therapy with Varzi-Yatchi mineral water 4.5 times decreased the contamination of the buccal mucosa and increased the adsorption activity of epithelial cells of the buccal mucosa.

Pneumococcal disease in HIV-infected Malawian adults: acute mortality and long-term survival

OBJECTIVE

HIV-infected patients in Africa are vulnerable to severe recurrent infection with Streptococcus pneumoniae, but no effective preventive strategy has been developed. We set out to determine which factors influence in-hospital mortality and long-term survival of Malawians with invasive pneumococcal disease.

DESIGN, SETTING AND PATIENTS

Acute clinical features, inpatient mortality and long-term survival were described among consecutively admitted hospital patients with S. pneumoniae in the blood or cerebrospinal fluid. Factors associated with inpatient mortality were determined, and patients surviving to discharge were followed to determine their long-term outcome.

RESULTS

A total of 217 patients with pneumococcal disease were studied over an 18-month period. Among these, 158 out of 167 consenting to testing (95%) were HIV positive. Inpatient mortality was 65% for pneumococcal meningitis (n = 64), 20% for pneumococcaemic pneumonia (n = 92), 26% for patients with pneumococcaemia without localizing signs (n = 43), and 76% in patients with probable meningitis (n = 17). Lowered consciousness level, hypotension, and age exceeding 55 years at presentation were associated with inpatient death, but not long-term outcome in survivors. Hospital survivors were followed for a median of 414 days; 39% died in the community during the study period. Outpatient death was associated with multilobar chest signs, oral candidiasis, and severe anaemia as an inpatient.

CONCLUSION

Most patients with pneumococcal disease in Malawi have HIV co-infection. They have severe disease with a high mortality rate. At discharge, all HIV-infected adults have a poor prognosis but patients with multilobar chest signs or anaemia are at particular risk.

[Infections and coronary heart diseases]

The role of inflammatory mechanisms in the initiation, progression and clinically expression of atherosclerosis is increasingly appreciated, and a large number of review have been published on associations between of coronary heart disease and various bacterial and viral agents. This review provides a systematic overview of the available the epidemiological and clinical studies on coronary heart disease and Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus and dental disease as well as possible mechanisms. These published prospective studies provide no good evidence to support the existence of strong epidemiological associations between coronary heart disease and Chlamydia pneumoniae, Helicobacter pylori, cytomegalovirus and dental disease but because the available evidence is still sparse, further studies of these agents are needed that can reliably investigate the possibility of associations with coronary heart disease.

Oral yeast carriage correlates with presence of oral epithelial dysplasia

Previous studies have suggested a link between the presence of Candida albicans and the development of oral squamous cell carcinoma (OSCC). The aim of the present study was to assess the presence and level of colonisation of oral yeast in patients undergoing an incisional oral mucosal biopsy in order to assess whether the amount of oral yeast present correlated with the presence and degree of oral epithelial dysplastic or neoplastic change. Two hundred and twenty-three patients who were undergoing an incisional biopsy for the diagnosis of an oral mucosal lesion were enrolled in this study. Mouth swills were obtained from each patient for the presence and amount of oral yeast present. Some of the patients (44.6%) had a histopathological diagnosis of either oral epithelial dysplasia (OED) or OSCC and the frequency of oral yeast carriage was significantly greater (P<0.001) in these patients than those without histopathologically detected dysplastic or neoplastic oral lesions. Furthermore, significantly (P<0.001) more patients with OED or OSCC had a higher number of yeast (over 1000 cfu/ml) in their oral cavity than patients without any evidence of epithelial dysplasia or neoplasia histopathologically. The degree of epithelial dysplasia present in these patients also correlated with higher amounts of yeast in the oral cavity (P=0.017). The results of the present study reveal that there is an interaction between oral carriage of yeast and oral epithelial dysplasia, however it remains unclear how yeast infection influences the development and progression of dysplasia.

[Case of acute deep neck infection in a patient with aplastic anemia]

Aplastic anemia often causes a life-threatening infection. We report a case of deep neck infection in a 30-year-old man with aplastic anemia treated with intensive antibiotics after admission, who rapidly recovered without surgery. The infection was caused by dental caries with an immunocompromised host via hemodyscrasia. He remains free from inflammation recurrence 5 months after treatment. We discuss the importance of early, appropriate treatment of deep neck infection associated with aplastic anemia occurring in immunocompromised patients.

Plasma and salivary IgA subclasses and IgM in HIV-1-infected individuals

We examined IgA and IgM responses in parotid saliva from human immunodeficiency virus-1 (HIV-1)-infected individuals. Compared to the uninfected controls, levels of salivary secretory IgA2 were significantly increased in HIV-1-infected subjects, with higher levels in those who displayed oral manifestations of HIV- I infection. Assessed by enzyme immunoassay, about two thirds of the HIV-1-infected individuals tested positive for salivary HIV-1-specific IgA antibodies but not for salivary IgM. No clear correlations between the amount of HIV-1-specific IgA and CD4 counts or plasma viral loads were found. The proportions of HIV-1-specific IgA did not correlate with the levels of total IgA. Determined by Western blot, IgA1 accounted for the majority of anti-HIV-1 IgA antibodies in saliva. Comparisons between the specificities of plasma and salivary IgA directed to HIV-1 proteins revealed the absence of salivary anti-gp41 IgA antibodies, and lower HIV-1-specific reactivity of IgA and IgM were determined in saliva than in plasma.

Candidal carriage in the oral cavity of human immunodeficiency virus-infected subjects

OBJECTIVES

We sought to assess asymptomatic oral carriage of Candida species and relative density in human immunodeficiency virus-infected (HIV+) subjects, as well as to determine whether yeast carriage is associated with CD4+ cell count, HIV-1 RNA quantity, gender, route of HIV transmission, antiretroviral therapy, or smoking.

STUDY DESIGN

A cross-sectional analysis of oral rinses from HIV+ and healthy subjects was undertaken. Oral candidal carriage and relative species were investigated in 42 HIV+ and 41 healthy individuals, all of whom were seen at the Palermo University Department of Oral Sciences, Italy. Data were managed and analyzed by means of the computer software package StatView 5.0.1.

RESULTS

Carriage rate was 61.9% and 29.3% (P =.003) among HIV+ and healthy subjects, respectively. Similarly, density carriage in the HIV+ group was found to be significantly higher than in the control group (P = .0002). Among HIV+ subjects, Candida carriage was significantly associated with smoking, whereas density was not. Oral candidal carriage and relative density were not significantly associated with the other 4 parameters evaluated. Candida albicans was the most frequently recovered species.

CONCLUSIONS

Asymptomatic candidal carriage and relative density were found to be significantly higher in the oral cavity of HIV+ subjects-but not associated with CD4+ counts or HIV-1 RNA quantities.

Th1/Th2 cytokine profiles in saliva of HIV-positive smokers with oropharyngeal candidiasis

Oropharyngeal candidiasis (OPC) is a common opportunistic infection among HIV-positive individuals and often correlates with a CD4 cell number < 200 cells/microl. This study further examined the association of smoking and OPC in HIV-positive persons. A strong association between smoking and OPC was seen in HIV-positive individuals with > or =200 CD4 cells/microl. In HIV-positive persons with > or =200 CD4 cells/microl, OPC+ smokers had lower gamma-interferon (IFN-gamma) concentrations and a trend toward higher interleukin (IL)-4 concentrations in whole saliva compared to OPC- persons with > or =200 CD4 cells/microl, a cytokine profile consistent with that observed in HIV+OPC+ persons with < 200 CD4 cells/microl. These results suggest that premature OPC in HIV-positive smokers is associated with altered oral host defence mechanisms that cannot be overcome by levels of systemic CD4 cells that are otherwise sufficient to protect against OPC.

Recovery of Candida dubliniensis from sputum of cystic fibrosis patients

Yeasts have been cultivated in a high percentage of sputum samples from patients with cystic fibrosis (CF). In cases of Candida dubliniensis a high recovery rate (15-25%) has so far only been reported from the oral cavity of HIV-infected persons. When studying sputum samples of patients suffering from cystic fibrosis (n = 54) we could repeatedly observe C. dubliniensis in 6 patients (11.1%) by using a complex isolation procedure involving the use of Staib agar. This revealed that the prevalence rate was significantly higher than the estimated overall prevalence for all non-HIV infected patients (0.8%) currently reported.

Clinical and pathological characteristics of oral lichen planus in hepatitis C-positive and -negative patients

The reported prevalence rate of anti-hepatitis C virus (HCV) antibodies in patients with oral lichen planus shows wide geographical variation and ranges from 0 to 65%. Certain characteristic clinical features have been attributed to oral lichen planus associated to HCV infection. The purpose of this investigation has been to assess hypothetical clinical differences, as well as differences in the intensity of the subepithelial inflammatory infiltrate between oral lichen planus-HCV +ve patients and oral lichen planus-HCV -ve patients. A total of sixty-two patients entered the study. Their mean age was 63.5 +/- 14.49 years, and 48.4% of them were men and 51.6% women. Patients were classified according to their serum HCV positivity. Age, sex, clinical presentation (reticular or atrophic-erosive), extension of the lesions, location of the lesions, number of locations affected, intensity of the inflammatory infiltrate and Candida albicans colonization were recorded for each patient. Reticular lichen planus was the most frequent clinical presentation in both HCV +ve (57.1%) and HCV -ve patients (63.6%). C. albicans colonization ranged from 42.8% in HCV +ve and 41.7% in HCV -ve patients. HCV + ve patients showed certain oral locations more frequently affected than HCV -ve ones: lip mucosa, 28.6% versus 7.3%; tongue, 57.1% versus 29.1%; and gingiva, 71.4% versus 23.6%. The number of affected intraoral locations was higher in HCV +ve patients (71.4%) than among HCV -ve ones (20.4%; chi2 = 8.34; P < 0.011). No statistically significant differences could be established in terms of density of subepithelial inflammatory infiltrate between the groups. Our results reinforce the need for liver examination in all patients with oral lichen planus, particularly those showing lesions on the gingiva with multiple intraoral locations affected, as no pathological differences could be identified between HCV + ve and HCV -ve patients.

Detection of anti-Candida antibodies by the indirect immunofluorescence assay in patients with cancer in the orofacial region

An indirect immunofluorescence assay was performed to detect antibodies to Candida albicans blastospores and germ tubes. Serum specimens were obtained from 82 patients with neoplastic diseases in the orofacial region and thrush of the oral mucosa. C. albicans was identified in the oral cavity of 63 patients investigated but serum anti-Candida antibodies were detected in only 23 of them. Serological examination showed that titers of antibodies to C. albicans blastospores ranged from 1:20 to 1:1280. High titers from 1:640 to 1:1280 were detected in patients without antibiotic, cytostatic, or radiotherapeutic treatment. The titers of antibodies to C. albicans germ tubes ranged from 1:20 to 1:640. Our results indicate that titers of antibodies to the C. albicans germ tubes were lower and were detected in a smaller number of patients.

Differences in risk factors among clinical types of oral candidiasis in the Women's Interagency HIV Study

OBJECTIVES

The purpose of this study was to determine the prevalence and concurrence/associations of oral candidiasis types and multiple risk factors in women.

STUDY DESIGN

A cross-sectional analysis of baseline data for 577 human immunodeficiency virus (HIV)-seropositive and 152 HIV-seronegative women from the Women's Interagency HIV Study was conducted. Pseudomembranous candidiasis (PC) and erythematous (EC) candidiasis, angular cheilitis (AC), and denture stomatitis (DS) were studied, and bivariate and multivariate regression analyses were performed.

RESULTS

Prevalences were 8% for PC, 7% for EC, 18% for DS, and 3% for AC; all except AC usually occurred alone. HIV seropositivity was associated with PC, EC, and DS, but not AC. Among HIV-seropositive women, low CD4 cell counts were associated with PC, but not with EC or DS. Heroin/methadone use was associated with PC and EC; salivary hypofunction was associated with PC; high viral load was associated with EC, and poor oral hygiene, with EC and DS.

CONCLUSIONS

Risk factors varied among candidiasis types, suggesting differences in pathogenic mechanisms and usefulness as markers of HIV infection/progression.

Revisiting the source of candidemia: skin or gut?

The source of candidemia has been the subject of considerable debate, with some suggesting a origin in the gastrointestinal tract and others suggesting a skin origin. To evaluate the potential sources of candidemia, we performed a computerized search of the MEDLINE database for studies published from January 1966 through September 2000 and we identified relevant abstracts presented at national meetings. We reviewed the literature with special emphasis on studies that used appropriate definitions, evaluated both gut and skin as sources, and conducted molecular-relatedness studies. Among 203 candidemia studies published, we identified 21 that evaluated a specific source for candidemia and only 5 that performed molecular typing. Those studies and additional experimental, epidemiologic, and molecular-relatedness studies strongly suggested that the gut is an important source of candidemia, and studies that supported the skin as a source for this infection were surprisingly incomplete.

Strain persistence of invasive Candida albicans in chronic hyperplastic candidosis that underwent malignant change

OBJECTIVES

The aim of this study was to assess persistence and tissue invasion of Candida albicans strains isolated from a 65 year-old patient with chronic hyperplastic candidosis (CHC), that subsequently developed into squamous cell carcinoma (SCC).

MATERIALS AND METHODS

C. albicans (n=7) were recovered from the oral cavity of the patient over seven years. Confirmation of CHC and SCC in this patient was achieved by histopathological examination of incisional biopsy tissue. DNA fingerprinting was performed on the seven isolates from the CHC patient together with a further eight isolates from patients with normal oral mucosa (n=2), chronic atrophic candidosis (n=1), SCC (n=1) and CHC (n=4). Genotyping involved the use of inter-repeat PCR using the eukaryotic repeat primer 1251. Characterisation of the tissue invasive abilities of the isolates was achieved by infecting a commercially available reconstituted human oral epithelium (RHE; SkinEthic, Nice, France). After 24 h, C. albicans tissue invasion was assessed by histopathological examination.

RESULTS

DNA fingerprinting demonstrated strain persistence of C. albicans in the CHC patient over a seven year period despite provision of systemic antifungal therapy. The strain of C. albicans isolated from this patient was categorised as a high invader within the RHE compared to other isolates.

CONCLUSIONS

Candidal strain persistence was evident in a patient with CHC over seven years. This persistence may be due to incomplete eradication from the oral cavity following antifungal therapy or subsequent recolonisation from other body sites or separate exogenous sources. The demonstration of enhanced in vitro tissue invasion by this particular strain may, in part, explain the progression to carcinoma.

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.

Salivary anticandidal activity and saliva composition in an HIV-infected cohort

This study investigated salivary anticandidal activity and salivary composition in stimulated whole saliva of 18 advanced HIV-infected patients and compared these values to healthy controls. Stimulated whole saliva from HIV-infected patients showed decreased anticandidal activity. The flow rate was reduced by 40% as compared with controls. The saliva flow rate for HIV-infected patients who had recoverable yeast in their saliva was reduced as compared to HIV-infected patients without recoverable yeast. For HIV-infected patients, the saliva concentrations of lactoferrin, secretory IgA and Cl- were increased while the secretion rate of lysozyme, total protein and K+ were reduced. There was no difference in any parameter as a function of taking the antifungal drug fluconazole. There was no association between salivary anticandidal activity and any salivary component. This study shows reduced anticandidal activity and salivary flow rate in HIV-infected patients. These alterations may contribute to their increased incidence of oral candidal infections.

Oral manifestations in 45 HIV-positive children from Northern Thailand

Forty-five Northern Thai children with HIV infection or AIDS were examined for oral manifestations. Of these children, 51.1% (n=23) were asymptomatic (category N), 48.9% were mildly, moderately or severely symptomatic (category A, B, C) and 48.9% (n=22) revealed oral lesions. Eleven patients (24.4%) showed one oral lesion, eight (17.8%) had two and three (6.6%) had three oral lesions. Erythematous candidiasis was the most common lesion (17.8%). Oral hairy leukoplakia was seen in 6.7% (n=3). Geographic tongue, not usually considered to be associated with HIV infection, was seen in 6.7% (n=3). Only 15 patients (33.3%) received antiretroviral therapy (ART). Comparison of patients with or without ART did not show differences in the prevalence of oral lesions. More studies in Thai HIV-infected children are needed to reveal the prevalence of oral manifestations, as well as for the predictive value of the most common or specific oral manifestations.

Accuracy of diagnoses of HIV-related oral lesions by medical clinicians. Findings from the Women's Interagency HIV Study

OBJECTIVE

To determine if medical clinicians are as accurate as dental clinicians in recognizing diagnostic characteristics of HIV-related oral lesions.

METHODS

In 355 HIV-infected participants at five Women's Interagency HIV Study sites, we paired oral examinations conducted within 7 days of each other by dental and medical clinicians. We used the former as a gold standard against which to evaluate the accuracy of the latter. We assessed the accuracy of the medical clinicians' findings based both on their observations of abnormalities and on their descriptions of these abnormalities.

RESULTS

Dental clinicians diagnosed some oral abnormality in 38% of participants. When "abnormality" was used as the medical clinicians' outcome, sensitivities were 75% for pseudomembranous candidiasis and 58% for erythematous candidiasis, but only 40% for hairy leukoplakia. When a precise description of the abnormality was used as their outcome, sensitivities were 19%, 12% and 20%, respectively.

CONCLUSIONS

Medical clinicians recognize that HIV-related oral abnormalities are present in 40-75% of cases, but less often describe them accurately. Low sensitivity implies that the true associations of specific oral lesions with other HIV phenomena, such as time until AIDS, must be stronger than the literature suggests.

Do intraoral radial forearm free flaps re-mucosalise and is candida infection relevant?

Eleven patients, with a mean age of 57 years, who had undergone radial forearm flap reconstruction following the excision of intraoral carcinoma, underwent flap biopsy at a mean of 45 months postoperatively. Seven of the patients had received postoperative radiotherapy. In eight patients the clinical appearance of the flap was similar in colour to that of adjacent normal oral mucosa; the remaining flaps retained the appearance of normal volar forearm skin. Histological examination of the flaps showed varying degrees of telangiectasia and mild chronic inflammation. In only two patients was superficial infection by candida hyphae identified. Intraoral free flaps, although clinically resembling oral mucosa, retain histological features of skin, at least within the period under study. The erythematous clinical appearance was not correlated with the presence of chronic fungal infection, but reflected the presence of vascular repair tissue, telangiectasia and mild residual chronic inflammation.

Oral manifestations of HIV positive children

Oral manifestations in HIV positive children were observed in thirty-eight HIV infected children that have received care at the Special Care Dentistry Center (SCDC) of the School of Dentistry, University of Sao Paulo. Results have shown that 52.63% of the children presented at least one oral manifestation related with HIV/AIDS. Angular cheilitis occurred in 28.94%, parotid gland bilateral enlargement, pseudomembranous candidiasis and erythematous candidiasis in 18.42%, conventional gingivitis in 13.15%, herpes simplex in 5.26%, hairy leukoplakia, recurrent aphthous ulcer and condyloma acuminatum in 2.63%. Although enamel hypoplasia occurred in 23.68%, this could not be attributed specifically to HIV infection.

Increased serum and salivary immunoglobulins against Candida albicans in HIV-infected patients with oral candidiasis

The aim of this study was to explore anti-Candida albicans systemic and mucosal humoral responses against Candida virulence antigens such as somatic antigen and secreted aspartic proteases (Saps) in HIV-infected patients with oral candidiasis. Twenty-eight subjects were included in the study: 11 HIV-positive patients without oral candidiasis (group A), 6 HIV-positive patients with oral candidiasis (group B) and 11 HIV-negative healthy controls (group C). Total IgA, IgG and IgM concentrations and antibodies to C. albicans (somatic antigen, Sap1, Sap6) were measured in serum and saliva. We developed a time-resolved immunofluorometric assay with biotin and europium-labeled streptavidin for this purpose. Salivary total IgA, IgG and IgM concentrations were higher in group B. IgA, IgG and IgM anti-C. albicans antibodies (against somatic antigen, Sap1, Sap6) were higher in saliva and serum from patients from group B compared with patients from group A and controls. Our results suggest that, in oral candidiasis, HIV-infected patients have a high mucosal response, specifically directed against C. albicans virulence antigens, such as somatic antigen, Sap1 and Sap6.

Oral candidosis

Oral candidoses are frequently encountered in the practice of dentistry. Although most oral candidoses are symptomless, the can indicate the presence of an underlying systemic disease, and the persistence of oral candidosis following appropriate conventional management may be one of the first signs of undiagnosed immunosuppression. The opportunistic pathogen Candida albicans is the most commonly isolated species from oral candidal lesions; however, the non-albicans Candida spp. are also implicated in the aetiology of oral candidoses. The effective management of oral candidosis is dependent on an accurate diagnosis, identification and elimination of any predisposing factors (where possible), and the prescription of either topical or systemic antifungal agents. Oral candidosis may have significant implications for the general health of immunosuppressed patients, particularly when caused by the non-albicans spp. and, in cases of severe immunosuppression, systemic candidosis can be life-threatening. This article outlines the clinical presentation and appropriate management for the commonly presenting oral candidal conditions.