Classification of oral lesions associated with HIV infection

Systematic review of the changing pattern of the oral manifestations of HIV

The purpose of the present study paper was to review the reported prevalence of the oral manifestations of HIV (OM-HIV) worldwide since 1980, and to determine the global variation in its prevalence over time. PubMed, Scopus, Embase and Google Scholar were searched. The filter "English" was used. The timeframe searched was 1980- 2015. The PRISMA flow chart was used. Data were extracted using the Joanna Briggs Institute standardized data extraction form and transferred to SPSS version 22 for analysis. The systematic review of 97 studies (70 low bias risk) showed that the prevalence of OM-HIV continue to be significant in developing countries. Globally and through all the decades, oral candidiasis remained the most commonly encountered OM-HIV, including among patients on antiretroviral therapy (ART) (26.2%). Hairy leukoplakia was more prevalent in Europe and America compared with Africa and Asia. Oral warts were reported more often in studies on patients receiving ART. Interestingly, salivary gland disease decreased in the developed world and increased in developing countries over time. Despite the changing pattern of these conditions over time, there is no evidence that the OM-HIV have become of less significance globally. Maintaining the drive for high-quality research in the subject will have an impact on less developed countries to help address oral health inequalities.

Relationship between human immunodeficiency virus (HIV-1) infection and chronic periodontitis

INTRODUCTION

Current studies show that, even in the era of antiretroviral therapies, HIV-1 infection is associated with more severe and frequent refractory chronic periodontitis. Areas covered: This review, based on a systematic analysis of the literature, intends to provide an update on factors that may be involved in the pathogenesis of periodontal disease in HIV-1-infected patients, including local immunosuppression, oral microbial factors, systemic inflammation, salivary markers, and the role of gingival tissue as a possible reservoir of HIV-1. Expert commentary: The therapeutic revolution of ART made HIV-1 infection a chronic controllable disease, reduced HIV-1 mortality rate, restored at least partially the immune response and dramatically increased life expectancy of HIV-1-infected patients. Despite all these positive aspects, chronic periodontitis assumes an important role in the HIV-1 infection status for activating systemic inflammation favoring viral replication and influencing HIV-1 status, and also acting as a possible reservoir of HIV-1. All these issues still need to be clarified and validated, but have important clinical implications that certainly will benefit the diagnosis and management of chronic periodontitis in HIV-1-infected patients, and also contributes to HIV-1 eradication.

Relationships between CD4+ Counts and the Presence of Oral Lesions in Human Immunodeficiency Virus Positive Women in Nigeria

Background:

Oral lesions are common findings in human immunodeficiency virus (HIV) infection. The main factor associated with the development of oral lesions is damage to the immune system, specifically loss of CD4+ lymphocytes, which are involved in cell-mediated immunity.

Aim:

This study was aimed to determine the association of oral lesions in HIV/acquired immune deficiency syndrome women patients with the level of immune suppression as measured by the CD4+ counts.

Subjects and Methods:

This was a prospective cross-sectional study with a study population of 191 consecutive female patients seen at the University of Benin Teaching Hospital, Nigeria. Ethical clearance was obtained from the institution of study and informed consent was given by every participant. HIV sero-status was determined for all patients. CD4+ count was analyzed for both the HIV+ and HIV– women with oral lesions. The relationships between oral lesions and CD4+ cell count were investigated.

Result:

About 56.0% (107/191) of the 191 women studied were HIV positive. Age range for the HIV positive women was 18-50 years with a mean age (standard deviation) of 36 (9.2) years. The most common oral lesion observed in the HIV positive women was pseudomembranous candidiasis accounting for 34.6% (37/107). About 68.4% (67/98) of the oral lesions occurred at CD4+ count < 200 cells/ml. Chi-square revealed statistically significant association between the presence of oral lesions and CD4+ count in HIV infected women (P = 0.03).

Conclusion:

As the CD4+ count was decreasing the presence of oral lesions was increasing in the study. The presence of pseudomembranous candidiasis was found to be significantly associated with CD4+ count level < 200 cells/ml. This association of oral candidiasis with CD4+ cell counts could be used as additional markers of immunosuppression and progression of HIV infection, particularly in a developing country like Nigeria where CD4+ count cannot be determined routinely.

Comparative study on the microbiological features of angular cheilitis in HIV seropositive and HIV seronegative patients from South India

Objective:

This study was designed to compare the microbiological features of angular cheilitis (AC) in human immunodeficiency virus (HIV) seropositive and HIV seronegative individuals, in a group of south Indians.

Materials and Methods:

Swabs from oral commissures of 46 patients were obtained and inoculated on to Sabouraud's dextrose agar (SDA) supplemented with chloramphenicol, blood agar (BA) and MacConkey's agar (MCA) plates and cultured. α-hemolytic Streptococci, Staphylococcus albus, Staphylococcus aureus, Candida species, Klebsiella species and Pseudomonas species were cultured. Candidal colonies were further speciated by the conventional biotyping technique.

Results:

In AC of HIV seropositive patients Candida albicans and Staphylococcus aureus were more prevalent than that in HIV seronegative patients. Incidentally in patients with CD4 cell count less than 200 there was an increase in the incidence of Candidal and Staphylococcus aureus colonization when compared to patients with CD4 cell count higher than 200.

Conclusion:

The present study suggests a definite difference in the microbial flora of AC in HIV seropositive patients than that of HIV seronegative population.

Increased risk of mortality and loss to follow-up among HIV-positive patients with oropharyngeal candidiasis and malnutrition before antiretroviral therapy initiation: a retrospective analysis from a large urban cohort in Johannesburg, South Africa

OBJECTIVE

We investigated the effect of oropharyngeal candidiasis (OC) and body mass index (BMI) before antiretroviral therapy (ART) initiation on treatment outcomes of human immunodeficiency virus (HIV)-positive patients.

STUDY DESIGN

Treatment outcomes included failure to increase CD4 count by ≥50 or ≥100 cells/μL or failure to suppress viral load (<400 copies/mL) at 6 or 12 months in addition to loss to follow-up (LTFU) and mortality by 12 months. Risk and hazard ratios (HRs) were estimated with the use of log-binomial regression and Cox proportional hazards models, respectively.

RESULTS

Baseline CD4 <100 cells/μL, low BMI (<18.5 kg/m(2)), low hemoglobin, and elevated aspartate transaminase were associated with OC at ART initiation. Patients with low BMI with and without, respectively, OC were at risk of mortality (HR 2.42, 95% CI 1.88-3.12; HR 1.87, 95% CI 1.54-2.28) and LTFU (HR 1.36, 95% CI 1.02-1.82; HR 1.55, 95% CI 1.30-1.85).

CONCLUSIONS

Low BMI (with/without OC) at ART initiation was associated with poor treatment outcomes. Conversely, normal BMI with OC was associated with adequate CD4 response and reduced LTFU compared with without OC.

Plasmablastic lymphoma of gingiva mimicking a reactive lesion: a case report

Oral plasmablastic lymphoma (PBL) is a rare malignancy, associated with HIV or other immunocompromised conditions. The lesion constituted a new subtype of diffuse large B-cell lymphoma and proposed a distinct entity based on its basic morphology, its clinical behaviour involving predominantly extramedullary sites (particularly oral cavity), and its limited antigenic phenotype data suggesting plasmacytic differentiation. Authors here report a case of apparently healthy individual aged 35 years, presenting one-month history of swelling associated with loosened teeth around upper anteriors. Following incisional biopsy, routine histopathologic and immunohistochemical studies, the diagnosis of plasmablastic lymphoma was given.

Oro-facial lesions and CD4 counts associated with HIV/AIDS in an adult population in Oyo State, Nigeria

OBJECTIVE

The objective of this study was to define the oro-facial lesions associated with Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) in an adult population in Oyo state, Nigeria and to relate these with the level of immune suppression as measured by the CD4 counts.

MATERIALS AND METHOD

The study population consisted of 679 consecutive subjects who were seen at the state-owned blood bank. Information on demography, medical and medication histories were obtained. Oro-facial examinations were carried out according to Greenspan et al [Oral Surg Oral Med Oral Pathol (1992)73:142-144]. HIV sero-prevalence status was determined for all patients. CD4+ T-lymphocyte count was carried out for those sero-positive for HIV and 31 randomly selected HIV-negative subjects. Data were analyzed using the chi-square test, Fisher's exact test, Student's t-test and odds ratio where appropriate.

RESULTS

Eighty-one (11.9%) of the entire study sample were confirmed HIV positive. The prevalence of specific oral lesions by HIV sero-status revealed that pseudomembranous oral candidiasis and angular cheilitis occurred significantly and more frequently in HIV-positive subjects (33.3 and 21% respectively) than those who were HIV negative (4.3 and 1.8% respectively, P < 0.05). The mean CD4 count of the HIV-positive subjects was 452 cells mm(-3), s.d. 137, while it was 602 cells mm(-3), s.d. 251, for the HIV negatives. The difference was statistically significant (P = 0.000). Forty-four (66.7%) subjects with CD4 counts <500 cells mm(-3) had oro-facial lesions whereas among those with CD4 counts >500 cells mm(-3) only 22 (33.3%) had oro-facial lesions (OR = 4.57).

CONCLUSION

The type of oro-facial lesions most commonly associated with HIV/AIDS in Oyo state, Nigeria, has been shown to be pseudomembranous oral candidiasis. This was followed by angular cheilitis. These lesions, although found in HIV-negative subjects, were in a lower proportion as compared with HIV-positive subjects. Mean CD4 counts were lower in HIV-positive subjects and this was associated with greater prevalence of oro-facial candidiasis and angular cheilitis.

[Oral manifestations of HIV infection]

Oral manifestations of HIV infection are sometimes the first sign of the disease and often indicate its progression to acquired immune deficiency syndrome (AIDS), thus it is important for health professionals (physicians and dentist) to possess adequate knowledge of these lesions. Improvements in antiretroviral treatments, especially with the incorporation of HAART therapy, have produced a gradual reduction in the prevalence of HIV-associated oral lesions. On the other hand, the increased life expectancy of HIV-positive patients has led to their greater presence at our clinics, implying the need for continuous updating in the diagnosis and treatment of these processes. Using the consensus classification (EEC-Clearinghouse, 1993) we reviewed the diagnostic criteria and current treatment protocols for the different HIV infection related oral lesions in both adults and children.

Oral fungal and bacterial infections in HIV-infected individuals: an overview in Africa

Oral opportunistic infections developing secondary to human immunodeficiency virus (HIV) infection have been reported from the early days of the epidemic and have been classified by both the EC-Clearinghouse and the World Health Organisation (WHO). Among the fungal infections, oral candidiasis, presenting in African HIV-infected patients has been sporadically documented. We review the literature with respect to candidal carriage, oral candidiasis prevalence and the predictive value of oral candidiasis for a diagnosis of underlying HIV disease in African HIV-infected patients. The use of oral candidiasis as a marker of disease progression, the species of yeasts isolated from the oral cavity in Africa and the resistance of the yeasts to antifungal agents and treatment regimens are discussed. Orofacial lesions as manifestations of the systemic mycoses are rarely seen in isolation and few cases are reported in the literature from Africa. In spite of the high incidence of noma, tuberculosis, chronic osteomyelitis and syphilis in Africa, surprisingly there have been very few reported cases of the oral manifestations of these diseases in HIV-positive individuals. Orofacial disease in HIV-infected patients is associated with marked morbidity, which is compounded by malnutrition. The authors indicate specific research areas, initially directed at the most effective management strategies, which would complete data in this important area.

Diagnosis and Management of Candida and Other Fungal Infections of the Head and Neck

Fungi are common inhabitants of the oral and nasal mucosa, and therefore the differentiation between colonization and pathogenicity in the setting of upper respiratory tract infection symptoms can be difficult. Fungal head and neck infections occur in both immunocompetent and immunocompromised persons, and patients with neutropenia, diabetes mellitus, corticosteroid use, and HIV infection are particularly susceptible to serious and potentially life-threatening infections. Invasive fungal head and neck infections generally require extensive surgical debridement and prolonged systemic antifungal therapy, and frequently carry a poor prognosis when the underlying immunosuppression cannot be corrected. In contrast, noninvasive fungal head and neck infections often respond to short courses of systemic or topical antifungal therapy, or require limited surgical debridement alone.

Classifications of oral lesions in HIV infection

BACKGROUND

Manifestations of immunosuppression may take the form of opportunistic infection, and neoplasia. While this paper has focused on gingival and periodontal manifestations. these tissues cannot be evaluated in isolation. The presence of involvement of other oral tissues such as the cheek or tongue with manifestations associated with HIV such as hairy leukoplakia, Kaposi's sarcoma at these sites, and candidiasis in addition to periodontal manifestations may further increase the clincal suspicion of underlying immunosuppression and/or progression of the immunosuppressive state.

DISCUSSION

The periodontist plays an essential r le in identifying the periodontal status of an individual and has an important r le to play in early recognition of signs and symptoms of HIV disease or progression of the medical condition.

CONCLUSION

Only through such recognition can appropriate definitive diagnostic testing be conducted, and appropriate therapeutic intervention for the oral condition and the systemic condition be considered.

Oral manifestations of systemic disease

Many systemic diseases have associated oral symptoms. Occasionally, patients with these diseases present with lesions that occur primarily in the mouth. Although few systemic diseases have strictly pathognomonic lesions of the oral mucosa, a careful examination of the oral cavity can often lend important clues to making a diagnosis.

Viral and fungal infections of the oral cavity in immunocompetent patients

Oral lesions are easily visualized and often are signs of systemic diseases. Clinical diagnosis of viral and fungal infections can sometimes be confusing because many lesions will have similar clinical presentations. This article reviews the more common viral- and fungal-associated lesions found in the oral cavity in immunocompetent individuals. Differential diagnoses for the oral lesions are discussed and treatment options are proposed.

Pseudotumour of the tongue caused by herpes simplex virus type 2 in an HIV-1 infected immunosuppressed patient

An HIV-1 infected immunosuppressed patient (CD4+ cell counts: 382 cells/microL; viral load 94,000 copies/mL) with recurrent perianal herpes simplex virus type 2 (HSV-2) infections is described, showing an unusual exophytic tumour resembling a squamous cell carcinoma in the lateral part of the tongue. He also had persistent facial herpes infection, oral candidosis, oral hairy leukoplakia and lymphadenopathy. The presence of HSV-2 was detected by polymerase chain reaction both in smears and in a tissue biopsy taken from the involved tongue area. Treatment with brivudin, a new oral virustatic drug, led to rapid regression of the tumour.

Gingival ulceration in HIV infection. A case series and case control study

All cases of HIV-associated gingival ulceration seen at a dedicated dental clinic in a 5-year period were reviewed and compared against other patients attending the clinic. 94 (7.1%) of 1308 patients had 146 episodes of gingival ulceration. 89 patients had 140 episodes similar to acute necrotising ulcerative gingivitis (ANUG) and responded well to conventional treatment for ANUG. The cases were compared with 269 controls in logistic regression. Gingival ulceration was associated with oral candidiasis, lower age and lack of AIDS diagnosis possibly due to a protective effect of co-trimoxazole medication. 5 patients with neutropenia had extensive ulceration without the microflora of ANUG. Histopathology, viral and bacterial culture revealed non-specific changes. The ulcers did not respond to the treatment regimen for ANUG but responded to treatment of their neutropenia. Gingival ulceration is not common in HIV infection. Most cases resemble severe ANUG. It is more frequent in younger people, those with oral candidiasis and without AIDS. Co-trimoxazole may be protective. A minority of cases with ulceration and associated neutropenia resembled the non-specific oral ulceration associated with HIV.

Salivary IgA responses to bacteria in dental plaque as related to periodontal and HIV infection status

Levels of total IgA and specific IgA reactive with Streptococcus mutans, Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Prevotella nigrescens and Fusobacterium nucleatum were measured by ELISA in parotid saliva from HIV+ and HIV- persons with healthy gingiva (HG), chronic gingivitis, chronic marginal periodontitis (CMP), or necrotizing ulcerative periodontitis (NUP). When the HIV+ group was compared with the HIV- group regardless of periodontal status, total salivary IgA concentration was higher in HIV+ patients, but no such difference was observed for total IgA output. HIV+ CMP displayed higher total IgA concentration as compared with HIV- CMP. No significant differences in specific IgA outputs and ratios were detected between HIV+ and HIV- subgroups with similar periodontal status. HIV+ NUP displayed increased specific IgA output towards S. mutans and increased specific IgA ratio values towards S. mutans, P. gingivalis and P. nigrescens as compared with HIV+ CMP, and increased specific IgA ratio values towards S. mutans and P. nigrescens as compared with HIV+ HG. No such differences were observed between the HIV- subgroups. In sum, salivary IgA responses to bacteria in dental plaque seem not to be related to chronic periodontal disease and HIV infection, but are possibly influenced by acute periodontal infection.

Predictors of postextraction complications in HIV-positive patients

OBJECTIVE

The purpose of this study was to identify factors associated with an increased risk for post-tooth-extraction complications in a sample of HIV-positive patients.

STUDY DESIGN

A cohort of HIV-positive patients who required the extraction of one or more teeth was enrolled. The predictor variables were grouped into the following sets: demographics; medical and social history; preoperative clinical findings; preoperative laboratory measures (hematologic, immunologic, and nutritional); and treatment. The outcome variable was defined as the presence or absence of a complication following tooth extraction. Logistic regression techniques were used to identify variables associated with an increased risk for complications following tooth extraction.

RESULTS

During the enrollment period, 76 HIV-positive patients were enrolled into the study cohort. Seventeen patients (22.4%) had postoperative complications. Based on the bivariate statistical analyses, variables associated with the presence of postoperative complications were red blood cell count, CD8 count, total number of positive sites tested using cell-mediated immunity skin tests, and extraction technique (p < or = 0.05). Using a stepwise logistic regression technique, the variable identified as being predictive of postoperative complications was the CD8 count (p = 0.02). The post-tooth-extraction complication rate of the HIV-positive patients in this study sample was greater than the rate reported in most other studies (22% vs. 3%-5%). The complications, however, were minor and easily treated. The variable consistently identified with an increased risk for complications was the CD8 count: the lower the CD8 count, the higher the risk for complications. The CD8 count, however, had poor predictive value.

CONCLUSION

In acute clinical situations--for example, in cases of patients with significant dental pain--the results suggest that delaying treatment to obtain laboratory studies may be of little clinical value. It may be appropriate to proceed with suitable, definitive procedure(s) to alleviate symptoms.

HIV status and the risk of post-extraction complications

Tooth extraction is commonly performed for patients infected with the human immunodeficiency virus (HIV). We undertook a prospective study to determine if HIV-positive patients had an increased risk for complications following tooth extraction. The study sample was composed of patients who presented for tooth extraction to the outpatient oral/maxillofacial surgery clinic at Grady Memorial Hospital, Atlanta, GA. The predictor variable was HIV status (positive or negative). The outcome variable was the presence or absence of a post-extraction complication. Other study variables were grouped into the following sets: (1) demographic, (2) past medical and social history, (3) clinical, (4) laboratory values, and (5) treatment. Between 11/93 and 4/96, 166 patients were enrolled. The study sample was composed of the 151 patients who completed the study protocol and consisted of 76 HIV-positive and 75 HIV-negative patients. The post-extraction complication rates were 22.3 and 13.3% for the HIV-positive and -negative groups, respectively (relative risk = 1.68, 95% confidence interval = 0.82 to 3.42, p = 0.15). The types of complications that occurred were similar in both groups. While the data suggest an increased rate of post-extraction complications in the HIV-positive group, the difference in complication rates between the two groups was not statistically significant. In addition, the complications were minor, self-limiting, and readily treated. Based on these findings, we believe that tooth extraction is a low-risk procedure in HIV-positive patients. Treatment may be rendered routinely to patients who present on an outpatient basis without the need for an extensive pre-operative work-up, unless otherwise indicated by relevant history.

Less common oral lesions associated with HIV infection: prevalence and classification

This paper deals with a number of group II and III lesions, ie lesions definitely but less commonly, and lesions possibly associated with HIV infection, respectively. Salivary gland disease includes dry mouth and/or swelling of major salivary glands, often as a part of CD8-lymphocytosis syndrome. Xerostomia occurs commonly (2-10%) in HIV-infected individuals. Enlargement of the major salivary glands occurs frequently (19%) among HIV-infected children, but rarely among adults (0.8%). The major salivary glands show lymphoepithelial lesions or cysts histopathologically. Hyperpigmentation of the oral mucosa was found in 2.2% of 1710 HIV+ individuals in seven studies. The hyperpigmentation has been ascribed to a number of medicaments, and possibly to HIV. The prevalence of pigmentation is not significantly higher among HIV+ than HIV- individuals. Thrombocytopenia frequently occurs in HIV infection. Oral petechiae were reported in 2% of 1121 HIV+ in five studies. Human papilloma virus (HPV) infection occurred in 1.1% of 989 HIV+ in seven studies. Drug reactions (white lichenoid lesions, ulceration, toxic epidermal necrolysis) have been reported in a number of cases, not allowing prevalence figures. However certain drugs, notably Foscarnet, Interferon and 2,3-dideoxycytidine, may frequently cause oral ulcerations. Oral neurologic manifestations such as peripheral facial paralysis and sensory neuropathy have been reported in a few cases or series only.

Human immunodeficiency virus infection: a review of the mode of infection, pathogenesis, disease course, and the general and clinical manifestations

Acquired immunodeficiency syndrome (AIDS) was first recognized in 1981 and in 1983 the virus responsible for this syndrome, the human immunodeficiency virus, was first isolated. There has been an increasing understanding of the many aspects related to infection with this virus and this review discusses the historical as well as the more recent findings related to infection with this virus. In particular, the pathogenesis, mode and course of infection are discussed followed by an overview of the general and oral manifestations of infection with this virus.

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.

Noma (cancrum oris) in human immunodeficiency virus/acquired immune deficiency syndrome patients: report of eight cases

PURPOSE

This article describes the clinical features and management of noma (cancrum oris) in HIV/AIDS patients.

PATIENTS AND METHODS

Eight HIV/AIDS patients were studied. Clinical presentation was different in all of the cases. Conservative debridement under local anesthesia with an antibiotic was performed.

RESULTS

Satisfactory resolution of the acute phase of this dangerous infection was achieved.

CONCLUSION

Minimal but thorough debridement of necrotic tissue along with lavage with povidone-iodine is effective in controlling this infective process. However, long-term sequelae of noma are not possible because of the underlying HIV infection from which the patients inevitably soon succumbs.

Intralesional vinblastine injections for the treatment of oral Kaposi's sarcoma: report of 10 patients with 2-year follow-up

PURPOSE

This study evaluated the use of intralesional vinblastine injections for the treatment of the intraoral lesions of Kaposi's sarcoma.

PATIENTS AND METHODS

Eighteen patients were treated with up to three intralesional injections of 0.1 mg/cc vinblastine.

RESULTS

All lesions responded to the local injections; 40% required one injection; 31%, two injections; and 29%, three injections. Large, exophytic lesions usually required the multiple injections. No complications were encountered, and the patients tolerated the protocol well. Ten patients were followed for 24 months. Eight died of their general disease during this period. Four patients developed new intraoral lesions, which were treated with, and responded favorably to, the three-injection protocol.

CONCLUSION

Intralesional vinblastine injections are an effective and useful treatment alternative for human immunodeficiency virus (HIV)-associated intraoral Kaposi's sarcoma.

Treatment of neutropenic oral ulceration in human immunodeficiency virus infection with G-CSF

We report the novel use of granulocyte colony-stimulating factor in the treatment of severe oral ulceration in human immunodeficiency virus-associated neutropenia. A 38-year-old man with acquired immunodeficiency syndrome developed severe refractory oral aphthous ulceration that persisted for 6 months despite a range of empirical treatments including corticosteroid. Rapid resolution of the ulceration occurred once the neutrophil count was restored to normal with granulocyte colony-stimulating factor.

Clinical, microbiological and ultrastructural features of angular cheilitis lesions in Southern Chinese

OBJECTIVE

To obtain baseline data on angular cheilitis in Southern Chinese.

DESIGN

A cross-sectional investigation of the clinical, microbiological and ultrastructural features of the condition.

SUBJECTS AND METHOD

Thirty six Chinese adults with angular cheilitis; 28 controls matched for age and sex, with no inflammation. Clinical examination, swabs of lesions for microbiology, impressions of lesions for ultrastructure, using replica technique.

MAIN OUTCOME MEASURES

Severity of lesions, associated signs and symptoms, incidence and type of microorganisms, ultrastructural features.

RESULTS

Of a total 68 lesions 32 were bilateral and four unilateral. Forty four (65%) were mild (Type I) and the remaining 24 (35%) moderate (Type II). Infective agents were isolated from 37 (54%) lesions; pure growth of Candida spp and Staph. aureus was noted in nine lesions each; a mixed growth of the two in II, beta-haemolytic streptococci in three and a mixed flora including coliforms in the other five. Candida spp were present in one control, beta-haemolytic streptococci in two and coliforms in four others. Scanning electron microscopy revealed natural topography of the angular skin with sparse colonisation by bacteria and yeasts.

CONCLUSIONS

Angular cheilitis in Southern Chinese seems to be characterised by a milder clinical presentation and classic infective agents of the disease: Candida spp and Staph. aureus.

Median rhomboid glossitis. An oral manifestation in patients infected with HIV

A follow-up study included the oral examination of 39 persons known to be infected with the human immunodeficiency virus. In addition to the other human immunodeficiency virus-associated oral lesions, lesions clinically similar to the smooth form of median rhomboid glossitis, which is now believed to be erythematous candidiasis located in the dorsum of the tongue, were found in seven patients (18%). Patients with median rhomboid glossitis were classified in different stages of the Centers for Disease Control 1986 classification system and showed an average of CD+4 cell counts 397.5/mm3. Also the presence or the absence of anti-p24 antibodies in the serum and stimulated whole saliva of the patients with median rhomboid glossitis did not correlate with the stage of the disease or with low levels of CD+4 cell counts as in other forms of oral candidiasis. Therefore our results suggest that median rhomboid glossitis should be included as a distinct form of oral candidiasis in the classification of the oral manifestations of infection with the human immunodeficiency virus.

Immunologic status in patients infected with HIV with oral candidiasis and hairy leukoplakia

Although numerous studies of oral manifestations associated with HIV have been reported, only a few refer to the correlation of these lesions with laboratory parameters. In this study we investigated the relationships between the two most common HIV-associated oral lesions, oral candidiasis and hairy leukoplakia, with the stage of the disease, circulating CD4+ cell counts, and the presence of anti-p24 antibodies in serum and stimulated whole saliva in 43 known HIV-1-infected persons. Although oral candidiasis and hairy leukoplakia were exclusively observed in subjects who were classified as Centers for Disease Control and Prevention group IV, only the prevalence of oral candidiasis is strongly associated with circulating CD4+ counts less than 200/mm3 (p < 0.02). The prevalence of oral candidiasis and hairy leukoplakia was significantly related to the absence of anti-p24 antibodies in serum (p < 0.01 and p < 0.01, respectively), but was only statistically significant for hairy leukoplakia in stimulated whole saliva (p < 0.02). The results suggest that oral candidiasis and hairy leukoplakia in correlation with immunologic status as indicated by low circulating CD4+ cell counts and the absence of anti-p24 antibodies in serum and the loss of secretory anti-p24 antibodies in subjects with hairy leukoplakia, may constitute prognostic markers for the progression of HIV-infection to AIDS. Our results also indicate that the absence of anti-p24 antibodies is not only influenced by the low levels of circulating CD4+ cells but probably by the presence of oral candidiasis or hairy leukoplakia as well.

The oral prevalence of aerobic and facultatively anaerobic gram-negative rods and yeasts in Hong Kong Chinese

Saline oral rinse samples were obtained from 300 community-dwelling Hong Kong Chinese attending an outpatient dental clinic to determine the oral prevalence of aerobic and facultatively anaerobic Gram-negative rods (AGNR) and yeasts. The oral prevalence of AGNR was 41.7%. Enterobacteriaceae species comprised 73% of all AGNR isolated, with an overall prevalence of 32%. There was no difference in prevalence between females (n = 190) and males (n = 110). Morning samples (n = 154) yielded a significantly higher prevalence of AGNR (54.5%) and Enterobacteriaceae (42.2%) than afternoon samples (n = 146) (28.1 and 21.2%, respectively; p < 0.01, p < 0.01). Subjects over 50 yr had a significantly higher prevalence of AGNR than those aged 30-49 yr (p < 0.01). The most commonly isolated AGNR species were Enterobacter cloacae and Klebsiella pneumoniae pneumoniae. The oral prevalence of yeasts was 24%, with Candida albicans forming 77% of all yeasts isolated. Subjects taking medication (n = 38) or wearing dentures (n = 38) had a significantly higher oral yeast prevalence of 36.8 (p < 0.05) and 44.7% (p < 0.01), respectively. Yeast prevalence was significantly higher in subjects over 50 yr than those aged 30-49 yr (p < 0.05) and 15-29 yr (p < 0.05). Comparisons with previous studies suggest that the oral prevalence of AGNR in Chinese may be higher in Hong Kong than in other parts of the world.

Prophylactic application of an intra-alveolar socket medicament to reduce postextraction complications in HIV-seropositive patients

A prospective, controlled trial was performed to investigate the effect of a prophylactic socket medicament containing chlortetracycline, aspirin, and local anesthetics, in reducing the incidence of postextraction pain and infection in patients who are HIV-seropositive. Fifty patients were in the study; 25 received the experimental dressing and 25 had no dressing. Patients were asked to complete a questionnaire rating the pain at 24 hours and 48 hours after surgery. Seven days after extraction, socket healing was scored, and sockets with delayed healing sampled for culture. Four of 25 (16%) patients who received the experimental dressing and 8 of 25 (32%) controls experienced pain during the 48 hours after extraction (p = not significant). None of the group who received the experimental dressing and 7 of 25 (28%) in the control group had delayed healing, of these 4 had alveolar osteitis and three had infected sockets (p = 0.0096). We conclude that the experimental agent is useful as a prophylactic agent to reduce delayed healing in HIV-positive patients who undergo exodontia.

Oral and oropharyngeal prevalence of Enterobacteriaceae in humans: a review

Members of the Enterobacteriaceae family are widely distributed in nature and exhibit substantial diversity in ecology, host range and pathogenic potential for man. While wide discrepancies in methodology exist between epidemiological studies, the available data indicate an increased prevalence of oral and/or oropharyngeal Enterobacteriaceae carriage in patients with illnesses of varying severity compared with healthy subjects. This paper reviews the prevalence of Enterobacteriaceae in the oral and oropharyngeal region of healthy human subjects and those affected by different disease entities, and discusses the complexities associated with collating and interpreting such data. The effect of antimicrobials and antiseptics on oral and oropharyngeal Enterobacteriaceae has also been reviewed, while highlighting the gaps in knowledge and future research directions.

Oral manifestations in HIV-infected patients: diagnosis and management

Oral lesions have been observed since the beginning of the AIDS epidemic. The number of HIV-infected patients is still increasing, especially in the heterosexual population. Oral diseases in HIV-infected patients are often more difficult to diagnose because the clinical presentations may differ from the same diseases in HIV-negative patients. HIV-associated oral lesions have diagnostic, prognostic, and therapeutic impact. Approximately 10% of the HIV-infected population will have oral manifestations as a first sign of their disease. In HIV-infected men oral hairy leukoplakia and oral candidiasis are useful markers for disease progression. This article summarizes the oral manifestations and the management of oral health in persons with HIV infection.

Cytomegalovirus infection presenting as acute periodontal infection in a patient infected with the human immunodeficiency virus

During childhood, many people acquire primary infection with cytomegalovirus (CMV), one of the herpes viruses. If they later become immunosuppressed, such as occurs with human immunodeficiency virus (HIV) infection, CMV is likely to become reactivated. Severe disease caused by CMV is life-threatening in the HIV-infected population. CMV retinitis, gastritis, colitis, pneumonia, encephalitis and hepatitis have all been reported, but oral lesions due to infection with CMV are rarely reported. We report a case of oral CMV infection which at first was clinically indistinguishable from HIV-associated periodontal disease.

Head and neck manifestations during HIV infection

The ENT manifestations of HIV infection are well known and the findings in AIDS patients have been described, nevertheless there are no reports of the frequency of head and neck involvement during the various stages of the disease. From 1987 to 1991, 210 HIV positive patients had ENT evaluation without symptoms-related selection. The majority of them were men and intravenous drug users. The frequency of enlarged neck nodes, neck mass, nasopharyngeal lymphatic tissue hypertrophy, extranodal localization of non-Hodgkin's lymphomas, Kaposi's sarcoma, oral hairy leukoplakia, candidiasis and other less common findings is reported, in relation to the stage of the disease. Overall 84 per cent of the observed patients had head and neck manifestations. An ENT evaluation in every HIV infected patient is suggested.

Healing after dental extractions in men with HIV infection

To determine the incidence of delayed healing after dental extractions in men with HIV infection, a retrospective audit was conducted of all extractions performed in a dedicated dental clinic over a 26-month period. The incidence of delayed healing in patients with HIV was compared with the incidence in those patients without HIV. Eighty men with HIV had 163 teeth extracted, which resulted in five dry sockets (3.01%). Thirty-six men thought not to have HIV had 70 extractions and three dry sockets (4.28%). All three dry sockets in the control group occurred in men who had tested negative for HIV antibodies in the year before their extraction. There were no other incidents of delayed healing. These findings contrast with other reports since they reveal no increase in delayed healing after extractions in men with HIV and do not support recommendations that prophylactic antimicrobials are required for extractions in this group of patients.

Periodontal diseases and HIV infection. A review of the literature

There have been many references in the literature to HIV-related periodontal diseases, which although poorly substantiated, seem to have established them as part of the expected range of HIV-associated conditions. The original studies have produced conflicting reports which may stem from shortcomings in design. Consequently, the picture remains confused with respect to the classification, epidemiology, microbiology, natural history and management of HIV-related periodontal diseases. Future studies should give greater attention to sampling methods, the use of control groups and defining criteria. This will allow comparison of data between centres and facilitate study of what may be an uncommon disease.

The simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected patient

Numerous publications have reviewed the oral manifestations of HIV infection and AIDS. Although uncommon, herpetic infections and histoplasmosis are among the diseases reported. The case that follows presents the first description of the simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected person. These infections appeared as extensive oral ulcerations and were the only clinical manifestation of HIV infection. Eleven months after the initial presentation, the patient died of complications of AIDS.

Oral diseases in HIV-1 infection

HIV-associated oral lesions have been reported since the beginning of the AIDS epidemic, be they fungal, viral, bacterial, neoplastic, or non-specific in origin. The most common lesions are oral candidiasis (OC; noted in several forms) and oral hairy leukoplakia (OHL). OC appears to be directly related to levels of immunosuppression while OHL, a newly described lesion, is associated with the Epstein-Barr virus. Although prevalence data for all types of oral lesions are scarce, this review identifies and describes those reported most often. Lesions associated with HIV may appear on most oral mucosal surfaces and may differ from those seen on other body areas. The role of saliva in reducing the potential for transmission of the HIV virus appears to be significant. Physicians and dentists should cooperate in the management of the HIV patient who has oral disease.

Evaluation of prognosis and survival of the HIV-infected patient

HIV disease, once considered an acute disease with a 100% mortality rate but a very short symptomatic stage, has begun to emerge as a preventable, treatable, chronic disease. Interactions between patients, dentists, and physicians are essential to gain the information necessary to provide appropriate dental care for both short-term and long-term survivors. The prognosis and survival time of the dental patient may influence treatment protocols and necessitate modified dental procedures. Certain clinical and laboratory parameters, which may be useful indicators of disease progression, need to be recognized by the dental clinician. These parameters include systemic signs, symptoms, and serologic data as well as intraoral manifestations associated with HIV disease. Although a perfect classification system for progression of HIV disease does not exist, trends among larger cohorts may enable health care providers to estimate the prognosis and survival of HIV-infected patients on an individual basis. This article presents clinical and laboratory parameters that indicate HIV disease progression. Providers who care for HIV-infected patients need to consider these parameters to establish an appropriate and flexible treatment plan based on changes in the patient's medical status.

HIV-associated oral lesions; immunologic, virologic and salivary parameters

There are numerous reports of oral lesions in HIV-infected individuals. However, few correlate the oral lesions with laboratory parameters. This study examined oral candidiasis and hairy leukoplakia, the two most common HIV-associated oral lesions, in relation to T-cell counts, p24 core antigen levels and salivary flow rates. Oral mucosal examinations, immunologic and virologic studies and stimulated whole and parotid saliva flow rates were conducted on 135 (HIV+ = 102, HIV- = 33) homosexual or bisexual men. Results indicate that, among HIV-infected subjects, the odds of having oral candidiasis is 6 times (95% CI = 0.6-56.6) greater for subjects with T4 counts between 200-399 per mm3, and 23 times (95% CI = 2.8-193.0) greater for subjects with T4 counts less than 200/mm3 compared to subjects with T4 counts of 400/mm3 or greater. Subjects had an equal likelihood of having hairy leukoplakia at different levels of immunocompetence. The prevalence of oral candidiasis and hairy leukoplakia was higher among subjects with infectious virus in their serum, but was only statistically significant for hairy leukoplakia (p = 0.01).

Gingival lesions of HIV infection in 178 Greek patients

One hundred seventy-eight HIV-infected Greek patients were examined and the gingival lesions were recorded. At the time of oral examination, 77 patients were HIV positive, 53 had ARC, and 48 had AIDS. The mean age of the patients was 36.6 years; 158 were men and 20 were women. Fifteen different gingival lesions were recorded. Necrotizing gingivitis (10.1%), gingivitis (5.0%), periodontitis (18.5%), candidiasis (5.8%), and Kaposi's sarcoma (5.0%) were the most common lesions observed. Oral lymphomas and other lesions were recorded in low numbers. Our findings show that dentists should be aware of gingival lesions of HIV disease because some of them are common and diagnostically important.