Oral hyperpigmentation in HIV-infected patients

Oral Health Status of Children and Adolescents Living with HIV Undergoing Antiretroviral Therapy: A Systematic Review and Meta-Analysis

Antiretroviral therapy (ART) increases the survival of HIV-infected children, but might also bring in oral health-related side effects and increase their risks of oral diseases. The review compared the oral health status of children living with HIV (CLWH) undergoing ART with healthy controls. Dual independent screening and study selection from four electronic databases and manual searches, data extraction, risk of bias assessment, and quality-of-evidence evaluation with Grading of Recommendations Assessment Development and Evaluation were performed. Twelve studies were included in qualitative and quantitative analysis. CLWH taking ART had a significantly higher prevalence of periodontal diseases (OR = 3.11, 95% CI 1.62-5.97), mucosal hyperpigmentation (OR = 20.35, 95% CI 3.86-107.39), and orofacial-related opportunistic infections than healthy controls. No significant differences regarding caries prevalence and tooth development were identified. Those with CD4+ T-cell counts below 250 cells/mm³ were more likely to manifest opportunistic infections, while medication duration had minimal influence on the prevalence of orofacial opportunistic infections. The current findings did not identify HIV and antiretroviral status as predisposing factors to dental caries, but affirmed the associated increased risk of periodontal diseases, mucosal hyperpigmentation and candidiasis.

Impact of Antiretroviral Therapy on Oral Health among Children Living with HIV: A Systematic Review and Meta-Analysis

Oral health is an integral component of general health and well-being but might be undermined among children living with HIV (CLWH) due to the condition itself or the antiretroviral therapy (ART) received. This review summarises the current evidence and compares the oral health status of the CLWH who were treatment-naïve with those undergoing different ART medications. Fourteen studies were included in the final qualitative and quantitative analyses. This review identified no significant difference in the prevalence of caries, periodontal conditions, and tooth development between both groups. Orofacial opportunistic infections were more prevalent in the CLWH without ART. Children undergoing ART with a duration longer than 3 years had a significantly lower prevalence of oral candidiasis and CD4+ T-cell counts. However, due to the insufficient number of well-administered case-control studies with adequate sample size, the quality of the evidence in all outcomes was of very low certainty.

Reviewing the oral pigmented lesions of human immunodeficiency virus with emphasis on the effect of highly active antiretroviral therapy

Acquired immunodeficiency syndrome a disease with high mortality rates is caused by the well-known human immunodeficiency virus. The disease is characterized by several opportunistic infections owing to the decreased CD4 lymphocyte counts. Oral manifestations of human immunodeficiency virus are vital as they are one of the early manifestations of the disease. Also, they serve as prognostic markers as they correlate with the CD4 lymphocyte counts of the affected individuals. Human immunodeficiency virus is not only common in the adult population but also can affect pediatric patients through vertical transmission. The initial therapeutic strategy for the management of the virus was only the prevention of opportunistic infections. Later in the mid-1990s, antiretroviral therapy was introduced but there was no significant improvement in prognosis. After the advent of combination therapy or the use of three antiretroviral drugs also known as highly active antiretroviral therapy, there has been a marked reduction in human immunodeficiency virus-associated mortality rates. The highly active antiretroviral therapy has several effects on the oral manifestations of the human immunodeficiency virus. The present paper aims to review the oral pigmented lesions associated with human immunodeficiency virus with an emphasis on the effect of highly active antiretroviral therapy.

The global changing pattern of the oral manifestations of HIV

The significance of the oral manifestations of HIV has been widely recognised since the start of the epidemic. It is estimated that more than 38 million people are living with HIV currently, with more than a third presenting with oral manifestations. Access to optimum clinical management and effective treatment in resource-rich countries has led to a remarkable decrease in some of the oral manifestations in the HIV population but this is not mirrored in developing countries, where most HIV-positive patients reside. In this paper, a review of the literature since the start of the HIV infection in different parts of the world is presented to highlight the current significance of the oral conditions in this population. Oral candidiasis was repeatedly reported as the most encountered oral manifestation of HIV in different countries, including in studies on groups on anti-retroviral therapy. Over time salivary gland disease was reported less in developed countries but was encountered more in developing countries. There is evidence to show that the prevalence of oral warts increased with the establishment of anti-retroviral therapy. A review of the worldwide prevalence of HIV-related oral conditions indicates that except for oral hairy leucoplakia, the prevalence of all other nine commonly reported oral conditions remained the same or increased over time. Oral opportunistic infections in HIV-infected patients are an ongoing clinical burden mainly in developing countries. Maintaining research in the subject and improving access to HIV treatment will help address the oral health inequalities around the world.

Medication-Induced Oral Hyperpigmentation: A Systematic Review

BACKGROUND

Medication-induced oral hyperpigmentation is an oral condition that impacts patients' quality of life and has been linked to many systemic therapeutic agents. The exact pathogenesis of tissue pigmentation varies greatly and is not completely known. This systematic review aimed to present data on the causal association between medications and the development of oral/mucosal pigmentation as an adverse drug reaction.

METHODS

A systematic review and analysis of literature were conducted using the following databases: PubMed, Science Direct, ProQuest, Web of Science, and Scopus. The systematic review included original articles written in English and published between January 1982 and June 2020. Following the PRISMA statement, eligible articles were systematically reviewed, and data were extracted from eligible studies and analyzed.

RESULTS

A total of 235 articles were identified, of which 57 met the inclusion criteria and were included in this review. The mean age of included patients was 46.2±16.38 years (range: 10-90 years) with a male to female ratio of 1:1.45. Oral mucosal hyperpigmentation was reported following the use of several classes of medications such as antiviral (eg, zidovudine), antibiotic (eg, minocycline), antimalarial (eg, chloroquine), anti-fungal (eg, ketoconazole), antileprotic (eg, clofazimine), antihypertensive (eg, amlodipine), chemotherapeutic, and antineoplastic drugs. The risk of developing oral pigmentation was significantly higher with antimalarial medications, antibiotics, antineoplastic and chemotherapeutic agents. Medication-induced oral hyperpigmentation was most frequent among women and in the hard palate.

CONCLUSION

Future research is warranted to better understand the pathogenesis and risk factors for medication-induced oral hyperpigmentation in order to reassure patients during prescription and management.

Oral Manifestations in HIV-TB Co- infected Patients and Their Correlation with CD4 Count in Telangana State, India

AIMS AND OBJECTIVES

Human immunodeficiency virus (HIV)-related oral lesions are often an early finding, and they reflect the underlying immunosuppression, and tuberculosis (TB) coinfection can have further deteriorating effect. Hence, a cross-sectional study was conducted to evaluate clinical and oral presentations of patients coinfected with HIV-TB, correlating with various parameters such as the type of TB with CD4 cell count, the type of TB with oral manifestations, site of the lesion, oral manifestations with CD4 cell counts, age, and gender.

MATERIALS AND METHODS

A cross-sectional study was conducted among selected 200 patients coinfected with HIV-TB, registered at Gandhi Medical College, Hyderabad, Telangana, India, and demographic data, CD4 count, diagnosis of TB, and clinical presentation of TB were correlated with site, age, gender, and the type of lesions in the oral cavity. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software, (IBM SPSS), version 20 (Chicago, IL, USA), with the chi-square test, and the significant P value for all the parameters was considered as <0.05.

RESULTS

A total of 200 patients with HIV-TB coinfection, who presented with oral lesions of 258 coinfected cases, were examined. Among which, 129 patients were with pulmonary tuberculosis (PTB), 61 patients with extrapulmonary TB, 2 patients with disseminated TB, and 8 patients with PTB and pneumonia. There were multiple oral manifestations involving different sites of oral cavity, oral candidiasis (28.5%), angular cheilitis (24.5%), linear gingival erythema (21.5%), oral hairy leukoplakia (1.5%), melanotic pigmentation (29.0%), ulcers (20.0%), depapillation of tongue (26.5%), lobulated tongue (12.0%), hairy tongue (11.5%), and papules (10.0%). The correlation of the type of TB with CD4 cell count, oral lesions with the type of TB in tongue, labial mucosa, and palate was significant.

CONCLUSION

A total of 77.5% patients coinfected with HIV-TB had shown oral manifestations emphasizing that the presence of oral lesions can be considered as a strong indicator of coinfection. The oral lesions might be used as a clinical indicator or screening mechanism in patients who were HIV seropositive for TB coinfection and should be necessarily evaluated for TB.

Mucocutaneous Disorders of Pediatric HIV in South West Nigeria

Objectives:

Nigeria has the world’s highest burden of pediatric HIV. In the face of paucity of monitoring tests in Nigeria, we studied the spectrum of pediatric mucocutaneous manifestations and evaluated their clinical utility as surrogate markers for immunodeficiency and plasma viral load levels.

Methods:

Cross-sectional study comparing mucocutaneous manifestations in 155 HIV-positive children aged 12 weeks to 14 years with 155 HIV-negative children. Relationships between mucocutaneous manifestations in HIV-infected patients and their immunologic and virologic indices were analyzed.

Results:

Mucocutaneous lesions were seen in 53.5% of HIV-infected children compared with 18.1% of the controls. Prevalence of lesions increased with worsening levels of immunodeficiency and increasing viral loads ( P < .01). Oral candidiasis, angular stomatitis, and fluffy hair were associated with more severe degrees of immunodeficiency.

Conclusion:

Mucocutaneous disorders are common in HIV-infected children. Oral candidiasis and nutritional dermatoses can be used as surrogates for advanced or severe immunodeficiency.

HIV-Associated Oral Mucosal Melanin Hyperpigmentation: A Clinical Study in a South African Population Sample

Objective. The aim of the study was to determine the prevalence of HIV-associated oral mucosal melanin hyperpigmentation (HIV-OMH) in a specific population of HIV-seropositive South Africans and to analyse the associations between HIV-OMH clinical features and the demographic and immunological characteristics of the study cohort. Material and Methods. This cross-sectional study included 200 HIV-seropositive Black subjects. The collected data comprised age, gender, CD4+ T cell count, viral load, systemic disease, medications, oral site affected by HIV-OMH, extent (localized or generalized), intensity of the pigmentation (dark or light), and smoking and snuff use. Results. Overall, 18.5% of the study cohort had HIV-OMH. Twenty-two and a half percent had OMH that could not with confidence be attributed to HIV infection, and 59% did not have any OMH. There was a significant but weak association between smoking and the presence of HIV-OMH. Conclusions. The prevalence of HIV-OMH in the study population was 18.5%, the gingiva being the most commonly affected site. It appears that the CD4+ T cell count does not play any role in the biopathology of HIV-OMH.

Melanocyte biology and function with reference to oral melanin hyperpigmentation in HIV-seropositive subjects

The color of normal skin and of oral mucosa is not determined by the number of melanocytes in the epithelium but rather by their melanogenic activity. Pigmented biopolymers or melanins are synthesized in melanosomes. Tyrosinase is the critical enzyme in the biosynthesis of both brown/black eumelanin and yellow/red pheomelanin. The number of the melanosomes within the melanocytes, the type of melanin within the melanosomes, and the efficacy of the transfer of melanosomes from the melanocytes to the neighboring keratinocytes all play an important role in tissue pigmentation. Melanin production is regulated by locally produced factors including proopiomelanocortin and its derivative peptides, particularly alpha-melanocyte-stimulating hormone (α-MSH), melanocortin 1 receptor (MC1R), adrenergic and cholinergic agents, growth factors, cytokines, and nitric oxide. Both eumelanin and pheomelanin can be produced by the same melanocytes, and the proportion of the two melanin types is influenced by the degree of functional activity of the α-MSH/MC1R intracellular pathway. The cause of HIV oral melanosis is not fully understood but may be associated with HIV-induced cytokine dysregulation, with the medications commonly prescribed to HIV-seropositive persons, and with adrenocortical dysfunction, which is not uncommon in HIV-seropositive subjects with AIDS. The purpose of this article is to discuss some aspects of melanocyte biology and HIV-associated oral melanin hyperpigmentation.

Oral manifestations of HIV infection in children and adults receiving highly active anti-retroviral therapy [HAART] in Dar es Salaam, Tanzania

BACKGROUND

The aim of the study was to compare the prevalence and types of HIV-related oral lesions between children and adult Tanzanian patients on HAART with those not on HAART and to relate the occurrence of the lesions with anti-HIV drug regimen, clinical stage of HIV disease and CD4+ cell count.

METHODS

Participants were 532 HIV infected patients, 51 children and 481 adults, 165 males and 367 females. Children were aged 2-17 years and adults 18 and 67 years. Participants were recruited consecutively at the Muhimbili National Hospital (MNH) HIV clinic from October 2004 to September 2005. Investigations included; interviews, physical examinations, HIV testing and enumeration of CD4+ T cells.

RESULTS

A total of 237 HIV-associated oral lesions were observed in 210 (39.5%) patients. Oral candidiasis was the commonest (23.5%), followed by mucosal hyperpigmentation (4.7%). There was a significant difference in the occurrence of oral candidiasis (chi2 = 4.31; df = 1; p = 0.03) and parotid enlargement (chi2 = 36.5; df = 1; p = 0.04) between children and adults. Adult patients who were on HAART had a significantly lower risk of; oral lesions (OR = 0.32; 95% CI = 0.22-0.47; p = 0.005), oral candidiasis (OR = 0.28; 95% CI = 0.18-0.44; p = 0.003) and oral hairy leukoplakia (OR = 0.18; 95% CI = 0.04-0.85; p = 0.03). There was no significant reduction in occurrence of oral lesions in children on HAART (OR = 0.35; 95% CI = 0.11-1.14; p = 0.15). There was also a significant association between the presence of oral lesions and CD4+ cell count < 200 cell/mm3 (chi2 = 52.4; df = 2; p = 0.006) and with WHO clinical stage (chi2 = 121; df = 3; p = 0.008). Oral lesions were also associated with tobacco smoking (chi2 = 8.17; df = 2; p = 0.04).

CONCLUSION

Adult patients receiving HAART had a significantly lower prevalence of oral lesions, particularly oral candidiasis and oral hairy leukoplakia. There was no significant change in occurrence of oral lesions in children receiving HAART. The occurrence of oral lesions, in both HAART and non-HAART patients, correlated with WHO clinical staging and CD4+ less than 200 cells/mm3.

(A3) HIV Phenotypes, oral lesions, and management of HIV-related disease

Workshop participants discussed: the role of HIV subtypes in disease; the treatment of oral candidiasis; the relationship between and among viral load, CD4+ counts, oral candidiasis and oral hairy leukoplakia, pigmentation; and the development of a reliable oral index to predict disease progression. Regarding HIV, the literature revealed that Type I (HIV-I), in particular group M, is involved in the majority (90%) of documented infections, and groups N and O to a lesser extent. Viral envelope diversity led to the subclassification of the virus into nine subtypes, or clades-A-D, F-H, J, and K-each dominating in different geographical areas. HIV-2, currently occurring mostly in West Africa, appears to be less virulent. No evidence could be produced of any direct impact of type, subtype, or clade on oral lesions, and participants believed that further research is not feasible. Oral candidiasis in patients from resource-poor countries should be prevented. When the condition does occur, it should be treated until all clinical symptoms disappear. Oral rinsing with an antimicrobial agent was suggested to prevent recurrence of the condition, to reduce cost, and to prevent the development of antifungal resistance. Lawsone methyl ether, isolated from a plant (Rhinacanthus nasutus leaves) in Thailand, is a cost-effective mouthrinse with potent antifungal activity. Evidence from a carefully designed prospective longitudinal study on a Mexican cohort of HIV/AIDS patients, not receiving anti-retroviral treatment, revealed that the onset of oral candidiasis and oral hairy leukoplakia was heralded by a sustained reduction of CD4+, with an associated sharp increase in viral load. Analysis of the data obtained from a large cohort of HIV/AIDS patients in India could not establish a systemic or local cause of oral melanin pigmentation. A possible explanation was a dysfunctional immune system that increased melanin production. However, longitudinal studies may contribute to a better understanding of this phenomenon. Finally, a development plan was presented that could provide a reliable prediction of disease progression. To be useful in developing countries, the index should be independent of costly blood counts and viral load.

Tongue disease in advanced AIDS

OBJECTIVE

This study describes the involvement and the histological alterations found in the tongues of 92 autopsied patients who died with AIDS.

MATERIALS AND METHODS

Sex, age, CD4 cell count and clinical history were obtained from the files of 92 patients who died with AIDS. All the tongues were examined for macroscopical alterations and stained using H&E, Gomori-Grocott, Ziehl-Neelsen, PAS, Brow-Hopps and Mucicarmine. Histological autopsy findings were grouped based on a protocol that was designed following the World Health Organization recommendations.

RESULTS

The mean age of the patients who died of AIDS and CD4 cell count were 36 years and 82 cells microL(-1), respectively. Histological alterations of the tongues were found in 75% of the cadavers. The most common lesions were hairy leukoplakia (HL) (42 cases), candidosis (31 cases) and non-specific chronic glossitis (29 cases), followed by concomitant lesions (28 cases), non-specific chronic ulceration (17 cases), melanotic pigmentation (13 cases), herpes simplex (10 cases), lymphoepithelial cysts (two cases), cryptococcosis (two cases), mycobacteriosis (one case), histoplasmosis (one case), cytomegalovirus infection (one case) and non-Hodgkin Lymphoma (one case). HL with oral candidosis (n = 13) were the most common concomitant lesions.

CONCLUSION

These findings indicate that the tongue is a favorite site to occurrence of reactive, infectious and concurrent lesions in the end-stage of AIDS patients.

Pigmentation: a potential cutaneous marker for AIDS?

Pigmentation of skin, nails and mucosae has frequently been described in HIV positive patients. Various causes for this phenomenon have been ascribed, which include intake of various drugs like zidovudine, opportunistic infections like toxoplasmosis and adrenocortical suppression. However, there has been no uniform explanation. We describe three AIDS patients with different personal and disease profiles but essentially the same pattern of pigmentation. This pattern of pigmentation is thereby discussed. We also propose that this pigmentation could be a result of late stage HIV disease per se and thus could serve as a useful cutaneous marker for the same.

Oral mucosal pigmentation secondary to minocycline therapy: report of two cases and a review of the literature

Minocycline is a semisynthetic broad-spectrum antimicrobial agent that was first introduced into clinical practice in 1967. The most common use of minocycline is for the long-term treatment of acne vulgaris. A well-recognized side effect of minocycline treatment is pigmentation, which has been reported in multiple tissues and fluids including thyroid, skin, nail beds, sclera, bone, and teeth. While there have been several reports of oral pigmentation following minocycline therapy, these have been, for the most part, pigmentation of the underlying bone with the overlying oral mucosa only appearing pigmented. We report two cases of actual pigmented oral mucosal lesions on the hard palate secondary to minocycline therapy with the accompanying histopathology, followed by a discussion of minocycline-induced oral pigmentation and a differential diagnosis of these lesions.

Oral mucosal hyperpigmentation secondary to antimalarial drug therapy

A case of oral mucosal hyperpigmentation resulting from antimalarial drug therapy is presented. The patient reported a history of long-term quinacrine therapy and exhibited diffuse blue-gray pigmentation of the nail beds and the skin of the nasal ala. Microscopic examination of the involved mucosa showed macrophages, containing both melanin and ferric iron, scattered within the connective tissue adjacent to the epithelium. The clinical, historical, and microscopic features of antimalarial-induced pigmentation are discussed. Other causes of diffuse or multifocal oral pigmentation are also addressed.

Drugs and oral disorders

This chapter affirms that drugs and medicaments may have a profound effect on the periodontal structures. In some instances, such as drug-induced melanosis, the effect may be insignificant to the health of the patient. In other circumstances, drug-induced disorders may initiate painful, destructive disease processes that will not be successfully managed unless the causal role of drugs is recognized and altered. Finally, the clinician must remain aware of the contribution of drug-induced xerostomia and smoking to increased susceptibility to dental and periodontal diseases.

Oral manifestations of HIV disease: an update

More than 40 different oral diseases and conditions have been described in patients infected with human immunodeficiency virus (HIV). The recognition of the oral manifestations of HIV disease is of great significance because they may represent the first signs of the disease and have been shown to be highly predictive markers of severe immune deterioration and disease progression. Although some oral diseases and conditions have a weak association with HIV disease, others are strongly linked with the disorder, and a few are acquired immune deficiency syndrome (AIDS)-defining in nature. The spectrum of oral manifestations of HIV disease is reviewed with emphasis on clinical recognition, diagnosis, and treatment.

Gastrointestinal pathology in HIV-infected patients

Specific pathologic processes, particularly oral, esophageal, and intestinal infections, are common in the alimentary tract of AIDS patients. Many of these diseases are adequately assessed only by biopsy with histologic examination. Most are rare or unreported in immunocompetent hosts and are easily missed by those not familiar with them. This article describes the gross or endoscopic and histologic appearances and the diagnostic criteria for enteric pathologic processes seen in HIV-infected individuals.

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.

Lingual hyperpigmentation associated with minocycline therapy

Minocycline can cause hyperpigmentation of the conjunctiva, oral mucosa, and skin. Pigmentation of the oral mucosa may also be associated with a variety of endogenous or exogenous factors. Lingual pigmentation may be seen in Addison's disease, amalgam tatoo, malignant melanoma, Peutz-Jegher's syndrome, and other diseases. Two women who had isolated pigmentation of the tongue while taking minocycline are described; no other drug-induced pigmentation of their oral mucosa or skin occurred. Minocycline-induced pigmentation should be added to the differential diagnosis of isolated lingual hyperpigmentation.

Oral melanotic macules that develop after radiation therapy

External beam radiotherapy treatment of malignant conditions in the head and neck can give rise to several adverse oral effects if the oral or salivary tissues are within the field of beam. We report on a patient with widespread oral melanotic hyperpigmentation that developed after a course of radiotherapy for metastatic carcinoma in the cervical lymph nodes. As no other local or systemic cause was evident it is possible this abnormal hyperpigmentation was a result of the radiotherapy. The development of oral melanotic macules as a consequence of radiotherapy has not been previously described.

Human oral mucosal melanocytes: a review

Despite the complex role of melanocytes in skin physiology, the function of oral mucosal melanocytes has attracted little research interest and remains largely unclear. This article reviews what is known about oral mucosal melanocytes and identifies areas of research that may shed further light on their role in oral biology.

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.

Acral hyperpigmented macules and longitudinal melanonychia in AIDS patients

Two patients with AIDS are described who developed acral hyperpigmented macules of the fingers, palms and soles, buccal mucosa and genitalia, associated with longitudinal melanonychia. These pigmentary changes seemed to be independent of zidovudine and were associated in one with diffuse melanoderma and elevated levels of alpha-MSH. Histological and ultrastructural studies showed an increase of the dendrites and pigmentation of the melanocytes and few melanosomes in the keratinocytes.

Oral lesions of iatrogenic and undefined etiology and neurologic disorders associated with HIV infection

A review of a miscellaneous group of oral mucosal disorders in the setting of infection with the human immunodeficiency virus is presented. Included is a discussion of oral lesions of iatrogenic and undefined etiology and neurologic disorders. Mechanisms of pathogenesis, including possible common pathways and relationships to underlying immunosuppression, are emphasized.

Smoker's melanosis. A case report

Smoker's melanosis is a benign pigmentation of the oral mucosa, predominantly observed on the attached anterior mandibular gingiva and interdental papillae. These macular lesions are independent of genetic factors, therapeutic medication usage, and various systemic disorders. As a group they are often seen after the third decade of life. Due to the onset in adulthood and the progressive darkening, malignant melanoma must be ruled out. A review of the literature and a case report of this interesting and unique entity is presented.

Oral manifestations of HIV infection and their management. II. Less common lesions

This second of two articles reviews the many uncommon and rare oral lesions that have arisen in persons infected with human immunodeficiency virus (HIV). The various drug-related oral disorders of HIV disease are also considered.

Oral melanotic macules in patients infected with human immunodeficiency virus

A group of 217 patients seropositive for human immunodeficiency virus (HIV) were studied for 2 years, during which time pigmented lesions of the oral mucosa developed in 14 (6.4%) of them. The lesions were well circumscribed in some cases and diffuse in others. In some patients the macules enlarged or recurred after surgical excision. In two patients the macules appeared during the administration of zidovudine. Clinical and laboratory evidence of adrenal insufficiency was not detected in any of the patients examined. The histologic appearances were those of melanotic macules. No ultrastructural alterations of the melanocytes were observed. Two of these macules also contained Epstein-Barr virus, and in one case normal oral mucosa was examined and also contained Epstein-Barr virus in the epithelial cells. As a control group we examined 180 health care workers who did not belong to any risk category, and 30 intravenous drug abusers who tested seronegative to HIV. Oral melanotic pigmentation was found in eight of the control subjects (3.6%). The difference was not statistically significant (p = 0.3097). Our study shows that oral macules do not occur more frequently in HIV-infected patients. However, the clinical behavior of these lesions appears to be different during the course of HIV infection. In some HIV-infected patients the cause of the macules might relate to the administration of zidovudine and antifungal or antibacterial drugs. In others the cause remains unknown and could be due to multiple factors.

Oral lesions in Mexican HIV-infected patients

One hundred and twenty-five HIV-infected patients, of whom 49 (39%) were at early stages of the infection (CDC-II & III) and 76 (61%) in CDC IV, were prospectively examined. In 100 (80%) one or more oral mucosal lesions were observed; candidiasis (51%) and hairy leukoplakia (43%) were the commonest. Erythematous candidiasis was more often seen (35%) than the pseudomembranous type (16%), and appeared with the higher values at early than later stages. The prevalence of hairy leukoplakia, oral hyperpigmentation and xerostomia were incremented in groups CDC-IV. Pseudomembranous candidiasis and exfoliative cheilitis increased significantly with severity of disease. Our study demonstrates that oral alterations associated to HIV are a frequent finding, both at early (76%) and late (83%) stages of the infection in Mexican patients.

Ultrastructural findings in oral hyperpigmentation of HIV-infected patients

Oral hyperpigmentation has been observed in six HIV-infected patients, in two of whom systemic medication (ketokonazole, clofazimine) was supposed to be etiologically involved. Histologically, pigment was found in epithelial basal cells and particularly in subepithelial connective tissue. Ultrastructurally, the presence of premature melanosomes in subepithelial keratinocytes was of interest. Stimulation of melanocytes during HIV infection may occur in association with immunopathologic changes in the oral mucosa.