Oral manifestations of HIV infection and their management. I. More common lesions

The initial interplay between HIV and mucosal innate immunity

Human Immunodeficiency Virus (HIV) is still one of the major global health issues, and despite significant efforts that have been put into studying the pathogenesis of HIV infection, several aspects need to be clarified, including how innate immunity acts in different anatomical compartments. Given the nature of HIV as a sexually transmitted disease, one of the aspects that demands particular attention is the mucosal innate immune response. Given this scenario, we focused our attention on the interplay between HIV and mucosal innate response: the different mucosae act as a physical barrier, whose integrity can be compromised by the infection, and the virus-cell interaction induces the innate immune response. In addition, we explored the role of the mucosal microbiota in facilitating or preventing HIV infection and highlighted how its changes could influence the development of several opportunistic infections. Although recent progress, a proper characterization of mucosal innate immune response and microbiota is still missing, and further studies are needed to understand how they can be helpful for the formulation of an effective vaccine.

Oral Candidiasis: Aiding in the Diagnosis of HIV-A Case Report

Opportunistic fungal infections account for a significant amount of morbidity associated with HIV disease. Candidiasis is the most common oral opportunistic infection affecting people with HIV infection or AIDS. It is considered as an important marker of immune suppression and may be the initial manifestation of the disease in about 10% of HIV-infected adults. We report a case of an apparently healthy 45-year-old male with oral candidiasis which proved to be the first indicator of HIV infection.

Ulcerative lesions of the mouth: an update for the general medical practitioner

Oral ulceration is a common complaint of patients attending out-patient clinics. Because of the diversity in causes of oral ulceration, patients presenting with oral mucosal disease can be challenging to diagnose and manage. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics; however, in most instances the ulcers do not result from gastrointestinal disease. The aim of the present article is to review aspects of the etiology, diagnosis and management of common ulcerative disorders of the oral mucosa. A search in the National Library of Medicine computerized bibliographic database MEDLINE was performed. Selection of publications, extraction of data, and validity assessment were then performed by the authors. Based upon the searched literature, it is concluded that there are several systemic disorders that can present with similar clinical signs and symptoms, and knowledge of each disease is necessary for the clinician to provide proper management.

Oral lesions as indicators of HIV infection among routine dental patients in Lagos, Nigeria

OBJECTIVES

To document the incidental oral lesions of human immunodeficiency virus (HIV) infection, the pattern and frequency of the lesions based on clinical presentation and oral manifestations in routine dental patients who tested positive in Nigeria.

SUBJECTS AND METHODS

The study was conducted at the Oral Diagnosis/Oral Medicine clinic of the Lagos University Teaching Hospital, Lagos, Nigeria between May 2002 and April 2003. During this period, all patients with oral lesions suggestive of HIV/acquired immunodeficiency syndrome (AIDS) as described in the EEC-WHO Classification and diagnostic criteria of oral lesions of HIV were counseled and offered voluntary HIV testing. All the 35 patients who consented and tested positive were included in this study.

RESULTS

Of a total of 700 patients 53 patients with oral lesions suggestive of HIV/AIDS were seen, thirty-eight (72%) consented to HIV screening, 15 patients (28%) refused. Thirty-five patients (92%), mean age 36 +/- 13 years were confirmed positive for HIV. Oral candidiasis was the commonest lesion seen (43%) the second common being Herpes zoster (23%). Other lesions seen included erythema multiforme in two (6%), facial palsy in two (6%) and oral hairy leukoplakia in one (3%).

CONCLUSION

An oral mucosal lesion may be the presenting lesion of HIV/AIDS in routine patients attending the dental clinic. Oral health care workers should practice optimal infection control based on the Centers for Disease Control 'Standard Precautions' guidelines on infection control for all patients to minimize occupational transmission of HIV.

Enfermedad periodontal necrosante: una manifestación de trastornos sistémicos

Necrotizing periodontal disease (NPD) is an infection characterized by gingival necrosis presenting as "punched-out" papillae, with gingival bleeding, and pain. Prevotella intermedia and spirochetes have been associated with the gingival lesions. Predisposing factors may include emotional stress, immunosuppression, especially secondary to human immunodeficiency virus (HIV) infection, cigarette smoking, poor diet and pre-existing gingivitis. During the last few years, diagnosis of NPD has became more important not only because of its contribution to the appearance of clinical attachment loss and gingival sequelae, but also because it has been revealed as a marker for immune deterioration in HIV-seropositive patients.

Review article: oral ulcers and its relevance to systemic disorders

Oral ulceration is a common problem, and is sometimes a marker of gastroenterological disease. Patients with signs or symptoms of oral ulcers are sometimes referred to gastroenterology clinics, however, in most instances the ulcers does not reflect gastrointestinal disease. Indeed, a spectrum of disorders other than those of the gut can give rise to oral mucosal ulcers ranging from minor local trauma to significant local disease such as malignancy or systemic illness. This present article reviews aspects of the aetiology, diagnosis and management of common ulcerative disorders of the oral mucosa.

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 candidosis as a clinical marker of immune failure in patients with HIV/AIDS on HAART

Oral candidosis (OC) has been proposed as a clinical marker of highly active antiretroviral therapy (HAART) success or failure. The principal objective of this work was to assess whether the presence OC is associated with immunologic or virologic failure in patients with HIV/AIDS undergoing HAART. One hundred fifty-one patients with HIV/AIDS from Regional Hospital "Carlos Haya," Malaga, Spain, were examined orally. All patients had been undergoing HAART for a minimum of 6 months prior to oral examination. OC diagnosis was in accordance with World Health Organization-Centers for Disease Control (WHO-CDC) criteria. Age, gender, route of HIV infection, CD4 lymphocyte counts, and viral load were taken from the medical records. In regard to HAART response the patients were classified as: virologic- responders (viral load < 50 copies per milliliter), virologic nonresponders (viral load >50 copies per milliliter); immunologic responders (CD4 cells counts > 500 per milliliter), and immunologic nonresponders (CD4 cells counts < 500 per milliliter). Prevalence of OC was determined for each group. The presence of OC was closely related to immune failure (p 0.006; odds ratio [OR] 3.38 95% confidence interval [CI] 1.262-12.046) in patients with HIV/AIDS undergoing HAART. The probability of immune failure in the presence of OC was 91% for men who have sex with men, 95.5% for heterosexuals, and 96% for intravenous drug users. In conclusion, OC should be considered a clinical marker of immune failure in patients with HIV/AIDS undergoing HAART.

Cutaneous markers of HIV infection

Despite the development of laboratory methods, dermatological symptoms are a basic index of the presence and physical course of HIV infection. HIV infection usually undergoes a long latent period, proceeds to a period of immunodeficiency-related symptoms, and ends in an advanced immunodeficiency state characterized by opportunistic infections and neoplasms. Occasionally, dermatological manifestations can be the first signs of asymptomatic disease, indices of advanced immunodeficiency, or symptoms of opportunistic infections or neoplasms. The variety of symptoms and signs for the skin during the course of HIV infection is a consequence of the progressing immunodeficiency and therefore indicates the underlying disorder. The use of these manifestations is a challenge for clinical praxis.

The role of apoptosis in oral disease: mechanisms; aberrations in neoplastic, autoimmune, infectious, hematologic, and developmental diseases; and therapeutic opportunities

Apoptosis is a genetically programmed form of cell death, which primarily functions to eliminate senescent or altered cells that are useless or harmful for the multicellular organism. Contrary to necrosis, apoptosis represents a physiologic cellular mechanism, normal function and control of which are critical for the development and homeostasis of multicellular organisms. In contrast, aberrations of the apoptotic mechanisms that cause excessive or deficient programmed cell death have been linked to a wide array of pathologic conditions. This review briefly summarizes the major apoptotic pathways and molecules and presents the most important oral diseases that are related to dysregulation of apoptosis. Knowledge of the association between aberrations in apoptotic mechanisms and human pathology hopefully will be implemented for the design of improved diagnostic and prognostic assays and the development of novel, more efficient, therapeutic strategies.

The pathology of oral cancer

Oral cancer is a serious public health problem, with over 200,000 new cases reported annually worldwide, two-thirds of which occur in developing countries. The overall mortality rate for intra-oral cancer remains high at approximately 50%, even with modern medical services, probably due to the advanced stage of the disease at presentation. This review outlines recent advances in our understanding of the roles and interactions of major risk factors for oral cancer worldwide, notably tobacco, alcohol and betel quid and the genetic polymorphisms determining their metabolism that may predispose patients to oral carcinoma. Oral epithelial lesions with malignant potential are described. We discuss the histopathology of oral cancer, its grading and the staging of the disease at clinical, microscopic, immunohistological and molecular levels. A recommended minimum dataset for pathology reports is described. The available strategies and current prospects for controlling oral cancer in the community are summarised.

Oral Kaposi Sarcoma Associated with Severe Alveolar Bone Loss: Case Report and Review of the Literature

BACKGROUND

In AIDS patients who present with an oral neoplasm, Kaposi sarcoma is the tumor most frequently encountered, comprising 50% to 80% of all tumor occurrences. However, oral Kaposi sarcoma associated with erosion of underlying bone is a relatively rare finding. This report and review of the literature documents a case of AIDS-related oral Kaposi sarcoma exhibiting severe bilateral erosion of the maxillary alveolar ridges.

METHODS

An HIV-seropositive male with extensive maxillary Kaposi sarcoma and associated bilateral alveolar bone erosion presented for dental evaluation subsequent to radiation therapy. Clinical and radiographic examinations were performed. Medical and dental histories were procured and supplemented with consultations from the patient's primary physician and radiation oncologist. Maxillary edentulation with surgical revision for primary closure was the treatment of choice for management of the dentoalveolar pathology. A maxillary immediate treatment denture was designed to obturate anticipated antral communications with the maxillary sinus.

RESULTS

Surgical and prosthetic treatments were completed, but complicated by an oral-antral perforation that subsequently healed without complication. Soft tissue biopsies obtained during surgery revealed no evidence of residual Kaposi sarcoma.

CONCLUSIONS

Although AIDS-related oral Kaposi sarcoma is a relatively common finding, erosion of subjacent alveolar bone is uncommon. Treatment of the tumor with subsequent dental reconstruction can be complicated by the severe lack of bone, surgical perforation of the maxillary sinus, and lack of stable teeth to serve as abutments. Significant advances in understanding the pathogenesis of AIDS-related Kaposi sarcoma have occurred in the last decade. HHV-8 and various inflammatory cytokines have been implicated in the pathogenesis and are likely to become the primary targets for therapeutic intervention.

Periodontal pathogens in subgingival plaque of HIV-positive subjects with chronic periodontitis

Many putative periodontal pathogens associated with periodontal disease in human immunodeficiency virus (HIV)-infected patients also occur in non-HIV-infected individuals. This study examined the prevalence of eight periodontal pathogens in HIV-positive and HIV-negative patients with chronic periodontitis using the 16s RNA polymerase chain reaction technique. The results showed a significant prevalence of Porphyromonas gingivalis and Treponema denticola among HIV-negative patients compared to HIV-positive patients. Sixty percent of the patients in both groups were colonized by five to six species. Odds ratio analysis revealed a statistically significant positive association between three of the 28 possible combinations in the HIV-positive group. They included Prevotella nigrescens/Campylobacter rectus, P. nigrescens/P. gingivalis and P. nigrescens/T. denticola. Although the prevalence of periodontal pathogens is similar in both the groups, the combination of certain periodontal pathogens may be responsible for chronic periodontitis seen in HIV-infected adults.

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.

The cutaneous manifestations of HIV infection

Dermatologic disease is extremely common and varied in HIV-infected patients. While some cutaneous findings are nearly exclusive to HIV-seropositive individuals, many are found in the general population. However, HIV-infected individuals often have an increased prevalence or severity, atypical presentations, or difficulty with treatment of the disease. Immune reconstitution with HAART significantly reduces the prevalence of many dermatologic diseases, but also has associated cutaneous side effects. Correct and early diagnosis of skin disease in HIV-infected individuals allows for early management and improved quality of life. Because dermatologic manifestations may be the first clue of HIV infection, offering HIV testing to affected individuals can lead to early diagnosis and treatment of HIV infection and, ideally, a decrease in disease progression and transmission.

Oral leishmaniasis in a HIV-positive patient. Report of a case involving the palate

Leishmaniasis is a parasitic disease caused by a protozoon (Leishmania), with different clinical forms that are endemic in certain countries. The association of this disease in patients who are seropositive to human immunodeficiency virus (HIV) has recently been described. Leishmaniasis can develop in any stage of HIV infection, although the clinical manifestations - and hence the diagnosis - tend to coincide with the periods of maximum immune depression. We present the case of a HIV-positive, ex-intravenous drug abuser (in stage B2 of the CDC, 1992) with concomitant hepatitis C infection who presented with palatinal pain and bleeding for the past 2 months. Exploration revealed a vegetating tumoration of the hard palate. Hematoxylin-eosin and Giemsa staining of the biopsy confirmed the diagnosis of leishmaniasis. The definitive diagnosis was mucocutaneous leishmaniasis (MCL), for a bone marrow aspirate proved negative, and no further lesions could be established. The patient was treated with meglumine antimoniate (Glucantime), followed by improvement of the lesions.

Oral candidiasis as a clinical marker related to viral load, CD4 lymphocyte count and CD4 lymphocyte percentage in HIV-infected patients

BACKGROUND

High viral load is currently considered to be one of the main indicators of the progression of HIV-induced immunodepression, but few studies have analysed its relationship to the presence of oral candidiasis (OC). The aim of this cross-sectional study is to analyse the relationship between viral load, total CD4 lymphocyte count, and percentage of CD4 lymphocytes to the occurrence of OC.

METHODS

The present cross-sectional study included 156 HIV-infected patients seen at a clinic for sexually transmitted diseases and HIV. We assessed the presence or absence of OC, and microbiological samples were obtained from the palatine mucosa and dorsal tongue for a smear stained with KOH (potassium hydroxide) and culture on Sabouraud's dextrose agar in all patients. Viral load was determined by quantification of viral RNA in peripheral blood with a minimum detectable level of 500 RNA copies/ml. CD4+ counts/CD4+ percentage were categorized as <200/<14%, 200-499/14-28%, and >500/>29%, and HIV viral loads were categorized as <500, 500-10,000, >10,000 copies/ml.

RESULTS

Thirty-eight percent (37.8%) of the patients had OC. Patients with CD4+ lymphocyte counts below 200 x 10(6)/l and CD4+ percentages below 14% showed a significantly higher frequency of OC (57.9% and 48.0%, respectively). Patients with a viral load over 10,000 copies/ml also had OC more frequently (44.8%). In the multiple logistic regression analysis, OC showed a statistically significant association with high viral load [>10,000 vs <500, odds ratio (OR)=11.4], low percentage of CD4+ lymphocytes (<14% vs >28%, OR=5), and injection drug use (IDU vs heterosexual transmission, OR=10.2). In HIV-infected patients, high viral load was associated with more frequent OC, regardless of CD4+ lymphocyte level.

CONCLUSIONS

These findings suggest that oral candidiasis could be a useful clinical marker of patients with high viral load. In view of these results, emphasis should be placed on the importance of systematic examination of the oral cavity in all medical follow-up examinations of HIV-infected patients.

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 lesions in HIV/AIDS patients undergoing highly active antiretroviral treatment including protease inhibitors: a new face of oral AIDS?

The objective of this work was to assess the prevalence of human immunodeficiency virus-related oral lesions (HIV-ROL) in HIV-positive/acquired immunodeficiency syndrome (AIDS) patients receiving highly active antiretroviral therapy (HAART) including HIV-protease inhibitors. One hundred fifty-five (154) AIDS patients (69 intravenous drug users [IDU], 53 heterosexuals, 29 males who have sex with males, 1 transfused, and 2 of unknown contagious source) receiving HAART, were examined. We found the following prevalences: HIV-ROL 53.2%; oral candidiasis 34.4%; hairy leucoplakia 26.6%; xerostomia 15.5%; herpes simplex labialis 1.9%; HIV/periodontitis-gingivitis 0.6%. No cases of Kaposi's sarcoma were observed. The highest prevalence of HIV-ROL was found in the IDU group, and in patients with viral load more than 10,000 copies and CD4(+) cell count less than 200. Using our historical controls, this suggests that the prevalence of all oral lesions, particularly oral candidiasis, herpes simplex labiali, Kaposi's sarcoma, and periodontal disease has decreased more than 30% after the institution of HAART.

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.

Necrotizing ulcerative periodontitis

In patients with no known systemic disease or immune dysfunction, necrotizing periodontitis (NUP) appears to share many of the clinical and etiologic characteristics of necrotizing ulcerative gingivitis (NUG) except that patients with NUP demonstrate loss of clinical attachment and alveolar bone at affected sites. In these patients, NUP may be a sequela of a single or multiple episodes of NUG or may be the result of the occurrence of necrotizing disease at a previously periodontitis-affected site. The existence of immune dysfunction may predispose patients to NUG and NUP, especially when associated with an infection of microorganisms frequently associated with periodontal disease such as Treponema and Selenomonas species, Fuscobacterium nucleatum, Prevotella intermedia, and Porphyromonas gingivalis. The role of immune dysfunction is exemplified by the occasionally aggressive nature of necrotic forms of periodontal disease seen in patients with HIV infection or malnutrition, both of which may impact host defenses. Clinical studies of HIV-infected patients have shown that patients with NUP are 20.8 times more likely to have CD4+ cell counts below 200 cells/mm3. However, these same studies have demonstrated that most patients with CD4+ cell counts below 200 cells/mm do not have NUP, suggesting that other factors, in addition to immunocompromisation, are involved. Further studies are needed to define the complex interactions between the microbial, or viral, etiology of necrotic lesions and the immunocompromised host. It is, therefore, recommended that NUG and NUP be classified together under the grouping of necrotizing periodontal diseases based on their clinical characteristics.

Periodontopathic bacteria in English HIV-seropositive persons

Selected periodontopathic bacteria were sought in 20 HIV-infected English patients and eight noninfected control subjects with similar periodontal status, using highly specific DNA probes. Actinobacillus actinomycetemcomitans (A. a), Porphyromonas gingivalis, Campylobacter rectus, Prevotella intermedia, and Fusobacterium nucleatum were more frequently detected and were found at higher levels in HIV-infected individuals than in controls. Significantly increased levels of Treponema denticola but, in contrast, lower levels of Eikenella corrodens were found in nonbleeding sites of HIV-infected patients compared with controls. The results of the present investigation on English patients suggest a periodontopathogenic role for A. a, P. gingivalis and C. rectus, and possibly P. intermedia and are in general accord with most previously reported data from the United States. Longitudinal studies are now required to determine more precisely the association between periodontopathic microflora, immune competence and periodontal health and disease in HIV-infected persons.

Immunohistochemical analysis of the oncoprotein c-erbB-2 expression in oral benign and malignant lesions

Thirty-seven samples of oral mucosa were analysed and divided histologically into groups of normal mucosa (6), hyperplastic lesions (6), dysplastic lesions (14), and squamous cell carcinoma (11). All lesions displayed some expression of c-erbB-2 but the distribution and intensity of expression varied strongly according to the differentiation. The lower the epithelial differentiation of the sample, the higher the expression of c-erbB-2 oncoprotein showing very strong staining in carcinoma samples. This suggests that in oral carcinoma, transformation might be related to c-erbB-2 interaction.

Oral manifestations of HIV infection in 600 South African patients

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

Chronic osteomyelitis of the mandible following tooth extraction in HIV infection

A case is presented of refractory chronic osteomyelitis of the left mandible arising after a tooth extraction in HIV infection. The challenges of prompt diagnosis and the dilemma of satisfactory management are highlighted. It is imperative that dental and oral health providers have a particularly high index of suspicion of conditions that occur in HIV infection so that early identification and appropriate management may be instituted.

HIV-associated oral pleomorphic B-cell malignant lymphoma

A 48-year-old HIV-seropositive homosexual patient presented with an ulcerative lesion in the left side of the soft palate, extensively involving local soft tissue structures. On histologic evaluation the lesions appeared to be a large-cell high-grade B-cell pleomorphic lymphoma with anaplastic and plasmacytoid features harboring Epstein-Barr virus genome in the tumor cells. Although known to be associated with HIV infection, this is a rare subtype of a malignant lymphoma arising in a patient positive for HIV. Its meaning is yet unknown in biologic and prognostic terms.

Orofacial manifestations and seroprevalence of HIV infection in Namibian dental patients

SUBJECTS AND METHODS

In an anonymous study of HIV-I sero-reactivity in dental patients in a Government clinic in Namibia, 29 (7%) out of 405 patients (10 female and 19 male) were confirmed as HIV-infected. HIV-antibody testing was done cheaply and conveniently by collecting and storing finger-prick blood on absorbent paper, and eluting the samples 7 weeks later. Testing was done by GACPAT, a simple, inexpensive temperature independent assay which requires no specialised equipment.

RESULTS AND CONCLUSIONS

Six patients had orofacial lesions, including Kaposi's sarcoma, leukoplakia (bilateral on buccal mucosa), cervical lymphadenopathy, hairy leukoplakia, circum-oral herpes simplex, HIV-gingivitis and necrotising ulcerative gingivitis. This sampling and testing system is well suited for use in epidemiological surveys in developing countries.

Matrix metalloproteinases-1, -3 and -8 and myeloperoxidase in saliva of patients with human immunodeficiency virus infection

OBJECTIVE

Human immunodeficiency virus (HIV)-seropositive patients have frequently severe gingival inflammation and/or attachment loss. In addition many infectious diseases affect their periodontium with varying clinical manifestations. Matrix metalloproteinases seem to play a key role in physiological periodontal remodelling and pathological tissue destruction. The aim of the present study was to characterize the presence, molecular forms, cellular sources, activities, and relative amounts of fibroblast-type (matrix metalloproteinase [MMP]-1) and neutrophil (MMP-8) collagenases, as well as their potential activator stromelysin-I (MMP-3) and myeloperoxidase in saliva of HIV-seropositive patients at different phases of HIV-infection. HIV-seronegative, healthy, age-matched patients served as controls.

PATIENTS AND METHODS

Saliva samples were characterized by Western blotting using antibodies specific for MMP-1, MMP-3 and MMP-8. Interstitial collagenase activities were measured using quantitative sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis/laser densitometry assay. Myeloperoxidase was analysed using quantitative dot blotting.

RESULTS

Clinical and microbiological evaluation of HIV-seropositive patients' periodontium showed the presence of putative periodontopathogens ie Actinobacillus actinomycetemcomitans (Aa), Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), Peptostreptococcus micros (Psm) and Campylobacter rectus (Cr) in their periodontal pockets. The amount of Candida increased with the severity of HIV-infection. Clinical and microbiological findings of HIV-seropositive patients suggested that they have a tendency to develop periodontal disease. Interstitial collagenase activities were found to be increased in saliva of different phases of HIV-infected patients compared to the controls. Independent of the phase of HIV-infection saliva samples contained pro- and active forms of MMP-1, -3 and -8 using Western blotting. Saliva samples from healthy controls were found to contain hardly any immunoreactivities for MMP-1 or MMP-8, but considerable amounts of MMP-3 were detected. Quantitative dot blotting demonstrated increased amounts of myeloperoxidase in HIV-patients' saliva relative to controls.

CONCLUSION

The present results showed increased amounts of MMP-1, -3, -8 and myeloperoxidase in HIV-patients' saliva. MMP-1 and -8 may have been activated by MMP-3 and/or oxidants generated by myeloperoxidase. The increased amounts of MMPs and myeloperoxidase may reflect and directly participate in HIV-infection associated periodontitis.

Periodontal implications: medically compromised patients

The presence of systemic disease in patients requiring periodontal therapy creates challenges for management. Alteration of treatment plans, with emphasis on physician consultation and preventive periodontal care, is frequently needed to minimize the impact of periodontal disease on the systemic condition. Conversely, detection and treatment of systemic disorders may impact upon the status of the periodontium and the success of periodontal therapy. The goal of holistic patient management is facilitated by a free flow of information between the patients and their medical and dental health care providers.

Immunoglobulin G subclass measurements in recurrent aphthous stomatitis

We have measured serum levels of IgG subclasses and total IgG, IgA and IgM in a group of 34 recurrent aphthous stomatitis (RAS) patients. At the time of blood collection, 23 of the 34 patients had active oral lesions. The remaining 11 patients were at an inactive stage. All measurement were performed in the Beckmann 360 Array Protein System. Serum levels of IgG2 subclass were significantly lower (P < 0.05) in the whole group of patients (34) when compared to the control group. This relationship was still significant (P < 0.05) when only the 11 patients without active oral lesions were considered but disappeared in patients at an active stage. We conclude that low serum levels of IgG2 may play a role in the pathogenesis of RAS, just as in other recurrent infectious diseases, and that serum levels of this immunoglobulin subclass, as well as total IgA, may undergo transient changes, depending on the different periods of activity and quiescence of the disease.

Pathogenesis of oral Kaposi's Sarcoma in HIV-infection: relevance of endogenous glucocorticoid excess in blood and saliva

Endogenous glucocorticoid excess with concomitant hypercortisolaemia and increased saliva levels of the free active hormone, is a common feature of HIV-infected/AIDS patients. Exposure of the oral tissues to virtually uninterrupted high burden of glucocorticoids through saliva may contribute to the high frequency of oral Kaposi's sarcoma (KS) in these patients. AIDS-KS cells contain unusually high levels of glucocorticoid receptor protein and recent studies indicate that growth of these cells in culture is significantly stimulated by glucocorticoids, particularly in the presence of growth factors, such as oncostatin-M. The suggestion that glucocorticoid excess may be important in the pathogenesis of KS in AIDS is not in conflict with the suspected aetiological role of newly reported KS-associated herpesviruses (KSHV), since steroid hormones may upregulate the expression of the viral gene. The latter is consistent with the observation that infection by specific oncogenic viruses does not necessarily result in cancers in the human, and does require the presence of other cellular factors or events.

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.

Oral manifestations of HIV infection in homosexual men and intravenous drug users. Study design and relationship of epidemiologic, clinical, and immunologic parameters to oral lesions

This article describes the baseline findings from a study designed to compare the oral manifestations of HIV infection in homosexual men and intravenous drug users. Both seropositive and seronegative persons were studied. A standard examination instrument was developed to record indexes of oral disease as well as to record the presence of oral lesions. The two groups differed in terms of education, race, socioeconomic status, employment status, housing, and smoking experience. The prevalence and type of oral lesions differed in the two seropositive groups. In seropositive homosexual men, white lesions on the tongue (28.4%) predominated; whereas for the seropositive intravenous drug users, oral candidiasis (43.0%) and gingival marginal erythema (33.3%) were most often detected. We also observed that seronegative intravenous drug users displayed a greater number of oral lesions than seronegative homosexual men. For seropositive homosexual men, lesion presence was significantly associated with decreased levels of CD4; positive associations were seen with current smoking, antiviral drug use, and antibiotic use, and a negative association was observed with current employment. In contrast, only exposure to antiviral drugs was significantly correlated with lesion presence for seropositive intravenous drug users. This baseline analysis from our longitudinal study suggests clear differences in oral manifestations of HIV infection between seropositive homosexual men and intravenous drug users and between seronegative homosexual men and intravenous drug users. Among other parameters, it is apparent that lifestyle, access to health care, and the condition of the oral cavity before infection influence the development of oral lesions in persons with HIV infection.

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.

Periodontal diseases in HIV-infected patients

Periodontal diseases may be the first clinical sign of human immunodeficiency virus (HIV)-infection. Since the immunosuppression and subsequent susceptibility may alter the responses of the oral tissues as well as the microflora, both periodontal treatment and result of therapy may be modified. The periodontal diseases in HIV-seropositive patients include common as well as less conventional forms of gingivitis and periodontitis, and bacterial, mycotic and viral infections are seen. Neoplasias may also involve the periodontium; most common are Kaposi's sarcoma and non-Hodgkin's lymphoma. Recent studies of unselected groups of patients indicate that periodontal health in at least some groups of HIV-seropositive patients is better than previously reported.

Major aphthous ulcers in patients with HIV disease

Major aphthous ulcers are associated with a high degree of morbidity in patients infected with human immunodeficiency virus. A large representative cohort infected with human immunodeficiency virus was examined to evaluate the prevalence of major aphthous ulcers, demographic data of patients with major aphthous ulcers, and the usage of major aphthous ulcers as a marker for immune deterioration. The effects of tobacco smoking and the use of specific antibiotics, trimethoprim/sulfamethoxazole or dapsone, on the development of major aphthous ulcers was also investigated. In a population of 767 persons infected with human immunodeficiency virus, major aphthous ulcers were found at a prevalence rate of 3.1% (24 patients). This type of lesion did not show any predilection for human immunodeficiency virus transmission category, ethnic group, or gender. Persons who received trimethoprim/sulfamethoxazole or dapsone or had a history of tobacco smoking showed a decreased prevalence of major aphthous ulcers. All patients (100%) with major aphthous ulcers had CD4+ cell counts below 100 cells/mm3, but only 50% had a previous acquired immunodeficiency syndrome defining illness. Major aphthous ulcers in persons infected with human immunodeficiency virus are suggestive of severe immune suppression and may serve as a marker for human immunodeficiency virus disease progression.

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.

Concurrent oral cytomegalovirus and herpes simplex virus infection in association with HIV infection. A case report

Recurrent oral herpes simplex virus lesions are common in both immunocompetent and immunocompromised persons. In contrast, cytomegalovirus-associated intraoral lesions are rarely seen, even in the immunocompromised host. We report a case of concurrent oral herpes simplex virus and cytomegalovirus infection, appearing as an ulcerative lesion of the labial mucosa in a patient with acquired immunodeficiency syndrome. Herpes simplex virus type 1 was shown to be present in the lesion by culture tests, histopathologic examination, immunohistochemistry findings and a direct immunofluorescence assay, and cytomegalovirus by histopathologic examination and immunohistochemistry findings. We deduce that the lesion was due to concurrent herpes simplex virus-1 and cytomegalovirus infection. The patient responded well to 2 weeks of treatment with a high dose of acyclovir.

Oral CMV lesions and the HIV infected. Early recognition can help prevent morbidity

Although they are rare, oral ulcers caused by cytomegalovirus infection can occur in immunocompromised people, including those infected with HIV. Once recognized, however, oral CMV lesions can be successfully treated in most cases. Moreover, early recognition permits prompt evaluation for CMV retinitis or disseminated CMV infection, and may help prevent morbidity caused by CMV.

Complications of dental surgery in persons with HIV disease

Post tooth extraction infective complications have occasionally been described in HIV-infected persons. However, there is little objective data as to the frequency of this and the need for antibiotic prophylaxis. Similarly the frequency of postextraction bleeding in patients infected with HIV, who may have thrombocytopenia, is unknown. In the present study the frequency of postextraction complications has been investigated in a group of 38 persons at stages 2 to 4 of HIV infection and 26 matched subjects from patients groups commonly at risk of HIV infection but not seropositive. During 40 clinical procedures in HIV-infected patients, 100 (range 1 to 23, median 1) teeth were extracted. Three episodes of delayed postextraction healing were recorded. During 30 procedures in the non-HIV-infected persons, 68 (range 1 to 5, median, 2) teeth were extracted, and two episodes of delayed postextraction healing were recorded. These differences were not significant. Only one HIV-infected patient had an episode of severe postextraction bleeding: this was a hemophiliac who bled despite receiving factor VIII prophylaxis. The bleeding occurred 7 days after the extraction and ceased with tranexamic acid and additional factor VIII. No control subject had severe postextraction hemorrhage. It is concluded that postextraction complications are uncommon in HIV-infected patients and that routine antibiotic prophylaxis is not indicated.