AIDS and the oral cavity. The HIV-infection: virology, etiology, origin, immunology, precautions and clinical observations in 110 patients

Gingival crevicular fluid: As a diagnostic marker in HIV positive patients

Objective:

To determine the utility of gingival crevicular fluid (GCF) for the detection of anti-HIV antibodies in human immunodeficiency virus (HIV)-infected individuals using enzyme linked immunosorbent assay (ELISA) with respect to their CD4 counts.

Materials and Methods:

The study was carried out between 37 seropositive (37GCF, 10 saliva) and 37 seronegative (GCF) individuals for a period of 7-8 months in GDC Nagpur. Thirty-seven GCF and 10 whole saliva samples were collected from the same patient. GCF samples were collected from gingival crevice with the help of Kimble disposable microcapillary. Saliva was collected by asking the patient to bend forward. The drooling saliva was collected in a sterile bottle and stored at Minus 20°C (-20°C). After the clinical observations the data were collected and tabulated for statistical analysis.

Results:

When compared with serum, the sensitivity, specificity, and positive and negative predictive values of GCF were 100% respectively.

Conclusion:

All the above findings are suggestive of GCF being a better diagnostic medium than saliva.

Anti-infective periodontal therapy promoting improvement in systemic markers of HIV infection

Research supports the theory that the chronic infectious response occurring in periodontal disease may have a role as a risk modifier of systemic diseases. This study assessed the impact of HIV-associated chronic periodontitis treatment on systemic HIV-related markers (CD4 T lymphocytes cell counts and HIV viral load). Fifteen HIV patients presenting chronic periodontitis [at least eight sites presenting a probing depth (PD) >4 mm and bleeding] were included in this study. Patients received full mouth periodontal treatment with an ultrasonic device and supragingival plaque control. Medical (CD4 cell counts and HIV load) as well as periodontal clinical parameters [probing pocket depth (PPD), clinical attachment level (CAL)] were assessed at baseline and 3 and 6 months after treatment. ANOVA/Tukey and Pearson's correlation tests were used for statistical analysis (α=5%). The results showed that PPD reduction and CAL gain were statistically significant at 3 and 6 months after periodontal therapy (p<0.05). At 6 months, CAL gain was 0.6±0.5 mm and PPD reduction was 0.7±0.5 mm. At the same time, a statistically significant increase in CD4 cell counts could be seen after the third month (p<0.05) and sixth month (p<0.05). Moreover, at 6 months, the relationship between the improvement in clinical parameters, i.e., PPD reduction, and the number of TCD4 lymphocytes could be highlighted. This was shown as the greater the PPD reduction, the greater the increase in TCD4 cells (r=0.68, p=0.02). These data suggest that periodontitis treatment could be associated with an improvement in medical conditions in HIV subjects.

Acquired immunodeficiency syndrome related Kaposi's sarcoma eroding the maxillary bone

BACKGROUND

Oral involvement is a common manifestation of acquired immunodeficiency syndrome related Kaposi's sarcoma, and it occurs in approximately one-third of afflicted patients.

METHODS

We report an unusual case of Kaposi's sarcoma of the hard palate which invaded the underlying maxillary bone.

RESULTS

The patient underwent excisional biopsy and was subsequently treated with localised radiation and systemic chemotherapy including liposomal doxorubicin.

CONCLUSIONS

The presentation, differential diagnosis, radiographic appearance and management of this serious complication are discussed. Our case highlights the need for a multidisciplinary approach, consisting of ENT, oncology and infectious disease consultation, to ensure appropriate management of maxillofacial, intraosseous, acquired immunodeficiency syndrome related Kaposi's sarcoma.

Periodontal microflora of HIV infected patients with periodontitis

The aim of this study was to determine the microbial profile of periodontal lesions in HIV seropositive patients and to compare it with rapidly progressing periodontal lesions in systemically healthy patients. The subgingival microflora of 20 CDC II, 20 CDC III, 20 CDC IV/V and 20 systemically healthy patients with rapidly progressing periodontitis was examined. Four sites with greatest probing depth in each patient were selected for microbiological sampling. The samples were cultured aerobically and anaerobically for bacterial isolation using selective and non-selective media. Isolates were characterized to species level by conventional biochemical tests and various identification kits. The microflora of periodontitis lesions within the three stages of the HIV infection was similar to that of progressing periodontitis in systemically healthy adults including Campylobacter rectus, Capnocytophaga spp., Fusobacterium nucleatum, Porphyromonas gingivalis, Prevotella intermedia, Selenomonas spp. and Peptostreptococcus micros. However, HIV seropositive periodontitis lesions harboured a range of exogenous pathogens rarely associated with common types of periodontitis including Staphylococcus aureus, Enterobacter cloaca, Pseudomonas aeruginosa, Candida albicans, Enterococcus faecalis, Enterococcus avium, Clostridium difficile, Aspergillus fumigatus, Klebsiella pneumoniae and Mycoplasma incognitum. The lack of immune effector and regulatory cells in HIV infected patients could in fact explain the increase of some opportunistic pathogens and the characteristic and rapidly progressing nature of the periodontal disease in these patients.

Subgingival plaque microbiota in HIV positive patients

AIM

To describe and compare the predominant bacterial and fungal species associated with gingivitis, periodontitis, and linear gingival erythema (LGE), in HIV positive subjects with different immune status.

METHODS

Viral loads and CD4 levels determined HIV disease status. From pooled subgingival plaque, 16S and 18S rDNA were cloned and sequenced to determine species identity.

RESULTS

One hundred and nine bacterial species were identified from 14 subjects. Nearly half of the species were not cultivable. Notably, the classical putative periodontal pathogens, Treponema denticola, Porphyromonas gingivalis and Tannerella forsythia were below the limit of detection and were not detected. Species of Gemella, Dialister, Streptococcus and Veillonella were predominant. In one HIV positive subject with periodontitis and low viral load, Gemella morbillorum, a known opportunistic pathogen, constituted 84% of the clones. Saccharomyces cerevisiae was the only fungal species detected in an LGE subject and in periodontitis subjects with high viral loads. In periodontitis patients with low viral loads, Candida albicans was predominant, while S. cerevisiae was only a minor component.

CONCLUSION

These case studies suggest that other bacterial species, rather than the classical periodontal pathogens, may be involved in periodontal diseases of subjects with HIV. These data are indicative of opportunistic infections in a highly susceptible immunocompromised host.

Dental and oral lesions in HIV infected patients: a study in Brazil

AIM

To determine the prevalence of dental and oral lesions, as well as treatment need, in a group of HIV sero-positive Brazilians. In addition, to test the association between oral manifestation of HIV infection and age, sex, mode of transmission and drug therapy.

METHOD

All HIV seropositive patients attending a dedicated dental clinic in Recife were invited to participate in the study. They were all examined by one trained and calibrated examiner and interviewed by one trained interviewer.

RESULTS

161 of 204 patients (78.9%) agreed to participate in this study. Most of the participants were male (76%), had acquired HIV sexually (74.5%), and were taking some form of antiretroviral therapy (70.8%). 33.5% had one or more oral manifestation of HIV. Candidiasis was the most common (28.6%), followed by hairy leukoplakia (9.3%), Kaposi sarcoma (2.5%), ulceration (2.5%), herpes simplex (1.2%), papiloma (0.6%), and 4.4% had periodontal disease. Only 1.2% reported xerostomia. There were no differences in the prevalence of oral manifestations of HIV infection between age groups, sexes, modes of transmission and types of drug therapy (P>0.05). The mean DMF-T score was 19 (SD 8) and 78.9% needed some form of dental treatment.

CONCLUSIONS

While the prevalence of oral manifestations of HIV/AIDS was low in this sample of HIV seropositive Brazilians, dental status was poor and need for dental treatment was high.

Oral manifestations in selective IgA deficiency

Selective immunoglobulin A (IgA) deficiency is the most common of the primary immunodeficiencies with a frequency of 1/300-1/3000, depending on the screened population. As secretory IgA (SIgA) has a protective role in mucosal surfaces from invasion of microorganisms, it is thought that IgA-deficient subjects are susceptible to periodontal diseases and oral manifestations. Previous studies show contradictory results, concerning the involvement of the individuals' periodontium with IgA deficiency. The aim of this study was to investigate and compare the oral manifestations in IgA-deficient subjects with controls. Eleven selective IgA-deficient subjects aged 3-18 years with serum IgA levels <10 mg dl(-1) and 11 age-sex-matched healthy children as the controls entered the study. Oral mucosal investigation, dental caries, plaque accumulation and periodontal status were assessed. Serum immunoglobulin levels were measured by single radial immunodiffusion (SRID) method. Saliva immunoglobulins and secretory component levels were measured by enzyme linked immunosorbent assay (ELISA) methods. IgA-deficient patients had serum and saliva IgA levels less than 10 mg dl(-1) and 10 microg ml(-1), respectively, but other serum immunoglobulin levels were normal and saliva immunoglobulin M (IgM) levels were increased, compared with controls. There were no significant differences in oral manifestations between IgA-deficient subjects and controls, which may be a result of compensatory increase of saliva IgM or other non-immunological defence factors in saliva. Thus, it is not necessary to evaluate IgA and SIgA in all the patients with oral and dental lesions and it is thought that it is better to investigate other factors.

HIV/AIDS orofacial lesions in 156 Zimbabwean patients at referral oral and maxillofacial surgical clinics

OBJECTIVE

To document the prevalence, age and gender distribution and clinical features of HIV/AIDS orofacial lesions in patients referred to the two largest Oral and Maxillofacial specialist centers in Harare, Zimbabwe, and compare the findings with those from other parts of the world.

DESIGN

Descriptive study.

SETTING

Oral and Maxillofacial Surgical Clinics at specialist referral hospitals; Harare Central Hospital and Parirenyatwa Government Hospital, Harare, Zimbabwe.

SUBJECTS

A total of 7800 consecutive patients referred for various orofacial conditions were examined. From this group, 156 patients with orofacial lesions of or suggestive of HIV/AIDS were further interviewed and examined by the oral and maxillofacial surgeon in charge of the clinics.

METHODS

Head, neck and oral examinations were carried out. Oral examination was carried out using mouth mirror and dental light in a dental chair. HIV/AIDS orofacial lesions were recorded and diagnosed using the EC Clearing House Criteria on Oral Problems related to HIV Infection (1993).

RESULTS

There were 79 males and 77 females. Male:female ratio 1:1; age range 1-56 years; candidiasis (55.1%) was the most common lesion with the pseudomembranous type (55.8%) predominating. High prevalences of Kaposi's sarcoma (18.6%), salivary gland disease (12.2%) and cancrum oris (3.8%) were noted. Heterosexual contact and mother to child transmissions appear to be the mode of transmission.

CONCLUSION

The spectrum of orofacial lesions is similar to that in other countries. This study shows a high prevalence of candidiasis, Kaposi's sarcoma, salivary gland disease, non-Hodgkin's lymphoma, cancrum oris and rampant caries.

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.

Long-term results of supportive periodontal therapy (SPT) in HIV-seropositive and HIV-seronegative patients

AIM

The aim of the present study was to investigate the long-term results of periodontal supportive therapy in HIV-seropositive and HIV-seronegative patients.

MATERIAL AND METHODS

Baseline examination of 18 HIV-seropositive patients (14 males and four females, median age of 29.7 years) revealed the following periodontal diagnoses: eight patients with linear gingival erythema, four patients with necrotizing periodontitis, five patients with conventional gingivitis and one patient with chronic periodontitis. In the HIV-seronegative group, out of 16 patients (12 males and four females, median age 35.5 years), one patient presented with conventional gingivitis and 15 patients with chronic periodontitis. Periodontal therapy and maintenance care consisted of supra- and subgingival removal of plaque and calculus and instruction in oral hygiene. Based on the individual patient's needs, the mechanical therapy was repeated.

RESULTS

In the test group, the mean maintenance period was 22.7 +/- 9.4 months (range 11.0-37.4) and in the control group, 48.9 +/- 32.0 months (range 9.3-110.8). In the test group, the mean PlI (1.1 +/- 0.8) remained at the same level (1.1 +/- 0.5; p = 0.73, Wilcoxon sign rank test, p < 0.05) throughout the observation period, the mean GI was reduced from 1.6 +/- 0.5 to 1.4 +/- 0.4 (p = 0.18), the mean PPD was reduced from 2.9 +/- 0.3 to 2.8 +/- 0.2 (p = 0.15) and the mean PAL (3.1 +/- 0.5) remained unaltered as well (3.1 +/- 0.4; p = 0.83). None of these differences was statistically significant. In the control group, PPD (3.0 +/- 0.4) and PAL (3.0 +/- 0.5) were significantly reduced: PPD = 2.7 +/- 0.2 (p = 0.0003) and PAL = 2.9 +/- 0.5 (p = 0.0034).

CONCLUSION

In HIV-seropositive patients, attachment level can be maintained. However, oral hygiene and compliance are the key factors for this.

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.

Prevalence and incidence of oral lesions--the changing scene

A range of oral mucosal and periodontal lesions is associated with HIV infection and HIV disease progression. These are often symptomatic and require treatment in themselves, and also have a diagnostic and prognostic role in the management of the underlying HIV disease. These lesions have been broadly divided into: (a) those strongly associated with HIV such as oral candidoses, oral hairy leukoplakia and Kaposi's sarcoma; (b) those less strongly associated such as swellings of the major salivary glands; and (c) those least commonly associated such as recurrent aphthous ulcers. Overall the prevalence and severity of these lesions inversely correlate with the level of immunosuppression. With the passage of time, there has been improved understanding of the disease pathogenesis resulting in the development of new drugs to combat this infection. Medication has changed from monotherapy to current triple combination therapy (Highly Active Anti-Retroviral Therapy). This review looks at the impact of changing therapy on the prevalence of the various oral lesions associated with HIV. It finds a decrease in the prevalence of the oral lesions in the era of combination therapy as compared to earlier periods. It also shows a change in the types of lesions which predominate with those previously placed amongst the strongly associated lesions no longer being predominant in the era of combination therapy where such treatment is available.

Specific microbial colonizations in the periodontal sites of HIV-infected subjects

The purpose of this study was to examine colonization by specific organisms at periodontal sites in HIV-seropositive [HIV(+)] subjects. A total of 67 HIV(+) and 32 HIV(--) subjects were investigated. The specific pathogens included black-pigmented anaerobic rods (BPAR), Porphyromonas gingivalis, Actinobacillus actinomycetemcomitans, Candida albicans and mycoplasma species. P. gingivalis was present in the HIV(+) subjects more frequently than in the HIV(--) periodontitis patients (P < 0.01). The cell numbers of BPAR and P. gingivalis and percentages as the total of CFUs on blood agar cultured in an anaerobic chamber were statistically higher in periodontal pocket samples from HIV(+) than from HIV(--). A. actinomycetemcomitans was also detected at a high rate (41.8%) in HIV(+) patients. The average cell numbers of C. albicans were higher in samples from the HIV(+) group (P < 0.05). The detection rate of mycoplasma species in the HIV(+) patients was significantly lower than that in HIV(--) subjects (P < 0.05), and most isolated mycoplasma strains were Mycoplasma salivarium.

Hematologic abnormalities among HIV-infected patients: associations of significance for dentistry

OBJECTIVE

The purpose of this study was to determine the prevalence and severity of and the factors associated with peripheral blood cytopenias among HIV-infected patients.

STUDY DESIGN

The investigation involved 516 HIV-infected adults in a longitudinal study of oral disease. Prevalence of hemoglobin, hematocrit, white blood cell, neutrophil, lymphocyte, and platelet values below the lower limit of normal and certain hematologic "critical values" were determined. Demographic, clinical/immunologic/viral stage, medications, and oral lesions were assessed for association with cytopenias by chi(2) and bivariate analyses.

RESULTS

Findings with respect to prevalence were as follows: anemia, 51%; leukopenia, 43. 4%; neutropenia, 27.5%; lymphopenia, 20.7%; thrombocytopenia, 15.5%. Severe cytopenias were detected in fewer than 1% of the patients. Severity of HIV clinical disease and CD4 cell count depletion were significantly associated with all cytopenias. High viral load was associated only with the leukopenias. Black race, antiparasitic therapy, and some oral lesions were associated with certain cytopenias.

CONCLUSIONS

In HIV-infected patients, mild cytopenias are common; however, severe anemia, neutropenia, and thrombocytopenia that may predispose to certain oral manifestations and dental surgical complications are rare.

Oral manifestations of toxic epidermal necrolysis (TEN) in patients with AIDS: report of five cases

OBJECTIVE

To describe oral findings in HIV-infected individuals with toxic epidermal necrolysis (TEN).

PATIENTS

In a retrospective study over a 10 year period the medical histories of 931 hospitalised HIV-infected patients were reviewed for the occurrence of TEN.

RESULTS

Five cases of TEN were diagnosed (three men, two women; median age: 41 years; median CD4+ T lymphocyte count: 20/microliter). Four patients had been treated with biweekly pyrimethamine/sulfadoxine for prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis. In one patient flucloxacillin was administered. Signs of TEN with cutaneous epidermolysis occurred and patients showed oral lesions characterized as oropharyngeal blisters and bullae on the palate, buccal mucosa, tongue and floor of the mouth initially. Antibiotics and corticosteroids were administered; none of the patients died.

CONCLUSION

Longacting sulfonamides and antibiotics have been implicated as the cause of severe mucocutaneous reactions. Since rash and oral blisters may be the first signs of TEN in patients receiving these it is mandatory to follow up these patients closely to detect oral or cutaneous changes indicating the development of TEN.

Prevalence of HIV-associated periodontitis and chronic periodontitis in a southeastern US study group

OBJECTIVES

This study estimates factors associated with the prevalence of HIV-associated periodontal diseases (HIV-P) and the severity and extent of periodontitis in HIV-infected adults from North Carolina (NC).

METHODS

Data are derived from a cross-sectional study of HIV-infected adults (total n = 326, dentate n = 316) treated at the University of North Carolina Hospitals. Outcomes were a diagnosis of HIV-P and measures of probing pocket depth (PPD), recession (REC), and clinical attachment level (CAL). Immunosuppression was measured by peripheral blood CD4+ cells/mm3.

RESULTS

In addition to persons with HIV (non-AIDS), this study included 10 percent of the AIDS cases in North Carolina. Median age was 37 years (range = 19-67); 78 percent were male and 60 percent were black. Sixty-two percent of persons had a probing pocket depth > or = 5 mm; 46% had recession > or = 3 mm, and 66 percent had attachment level > or = 5 mm in one or more sites. Cases of HIV-P (n = 15) were rare. Persons taking HIV-antiretroviral medication were one-fifth (OR = 0.20; 95% CI = 0.07, 0.63) as likely to have HIV-P as those not taking those medications, controlling for CD4+ cell counts.

CONCLUSIONS

HIV-infected persons in this study group from North Carolina exhibited severe and extensive measures of adult periodontitis. A small proportion experienced a severe form of HIV-P, which was attenuated by antiretroviral therapy.

Is there an association between periodontal condition and HIV infection?

Individuals in Tanzania who have limited access to medical and dental treatment provide an opportunity to study the natural association between periodontal condition and HIV infection and the stage of infection. 119 HIV-infected adult individuals and 73 individuals with AIDS from the AIDS Clinical Trial Clinic at Muhimbili Medical Centre (MMC) in Dar-es-Salaam participated as cases. Mean age was 35.3 and 35.1 years, respectively. 156 individuals with a mean age of 28.3 years, confirmed as HIV-seronegative, served as controls. There were no significant differences in bleeding on probing, pocket formation or attachment loss among the HIV-seronegative individuals, HIV-seropositive and AIDS patients. We applied multiple logistic regression to calculate odds ratios for presence of periodontal conditions adjusting for age, gender and DMFT. Our odds ratios did not reveal any significant associations between bleeding on probing, pocket formation or attachment loss with regard to lymphocyte and CD4+ T-cell counts among the HIV-infected individuals and AIDS patients. When associations were investigated with regard to HIV-serostatus (HIV-seronegative, HIV-seropositive or AIDS), our adjusted odds ratios were insignificant, too. In fact, most odds ratios were close to 1. Thus, our study supports recent views that the presence, extent and severity of periodontal disease among HIV-infected individuals, may be less that hitherto thought.

Oral ulcerations in HIV infection

Oral ulceration in HIV infection may be due to: (1) mycotic; (2) bacterial, protozoan; (3) and viral infections; (4) oral neoplasia; (5) aphthous ulceration/ulceration not otherwise specified (NOS); or (6) ulceration of iatrogenic origin. Of particular significance are oral ulcerations caused by viruses of the herpes virus group (HSV 1/2, CMV, VZV) and ulcerations of the aphthous type. It was shown recently that coinfection of viral ulcers occurs. The aetiopathogenesis of the aphthous type of ulcerations including the still debated ulceration NOS is not clear. Further basic and clinical research is necessary in order to better understand ulceration particularly in relation to immunoregulation, tissue breakdown and repair.

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.

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.

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.

The effect of a single mechanical treatment on the subgingival microflora in patients with HIV-associated gingivitis

The purpose of the present study was to investigate the effect of a single episode of scaling and root planing on clinical periodontal parameters and on the subgingival microflora in human immunodeficiency virus (HIV)-positive and HIV-negative subjects. 13 subjects participated and were clinically scored at days -7, 7, 30 and 90. 7 subjects were infected with HIV and presented an HIV-associated gingivitis. 6 subjects were HIV-negative with at least 12 teeth affected by conventional gingivitis. No significant differences were seen between both groups regarding the presence of P. gingivalis, P. intermedia and A. actinomycetemcomitans. The mean plaque index (PlI) was 1.79 in the HIV-negative and 1.29 in the HIV-positive group. The mean gingival index (GI) was higher in the HIV-positive group (HIV-positive: 1.55; HIV-negative: 1.47). Whereas, the PlI decreased significantly in the HIV-negative group during the course of the study, no change was observed in the HIV-positive group. GI as well as bleeding upon sampling decreased significantly in both patient groups during the same period. The bacterial counts decreased from day -7 to day 7 and generally remained on a lower level until day 90. Small differences were seen in the microbiological flora of the HIV-positive and the HIV-negative subjects following mechanical treatment.

Periodontal disease in HIV seropositive patients and its relation to lymphocyte subsets

This study was performed to determine the type of periodontal pathology found in a group of HIV+ patients and its relation to serum levels of CD4. The sample consisted of 101 individuals: intravenous drug users (84%), homosexuals (7%), and heterosexuals (10%). Each patient was examined clinically and radiographically. Periodontal clinical parameters included gingival index and probing depth and loss of attachment on four sites per tooth. Severity of disease was defined as the most severe lesion found: gingivitis, or early, moderate, or advanced periodontitis. CD4 counts were determined on 64 of these patients. Associations between severity of the disease and gender and CD4 counts were analyzed using the Mantel Haenszel chi square test, while associations between severity and age and CD4/CD8 ratio were analyzed using the Kruskal-Wallis test. No disease was found in 14.8% of the sample, gingivitis was found in 21.8%, early periodontitis in 43.6%, moderate periodontitis in 10.9%, and advanced periodontitis in 8.9%. Linear gingival erythema (LGE) was seen in 17.8% of all patients and necrotizing periodontitis (NUP) in 4.9%. No statistically significant differences were observed between the severity of the disease and CD4 counts.

Infection following treatment of mandibular fractures in human immunodeficiency virus seropositive patients

PURPOSE

There are little data available on the prevalence of human immunodeficiency virus (HIV) disease and its relationship to postoperative infection in patients presenting with mandibular fractures. This retrospective study assesses these parameters.

PATIENTS

The study population consisted of 251 patients treated for mandibular fractures at San Francisco General Hospital (SFGH) between January 1990 and December 1993. Group 1 (n = 20) was composed of patients with documented HIV infection and group 2 (n = 231) served as controls. The groups were comparable with regard to age, sex, etiology, and number and types of fractures.

RESULTS

HIV prevalence for this population was 7.9%, and was consistent with previously documented prevalence studies in SFGH surgical patients. In the HIV-positive group, 6 of 20 patients (30%) developed postoperative infection: 2 soft tissue (10%) and 4 bone-related (20%). In the control group, 22 of 231 patients (9.5%) developed postoperative infections: 16 soft tissue (6.9%) and 6 bone-related (2.6%). Statistical analysis showed a significant difference between the two groups with regard to overall (P = .016) and to bone-related (P = .001) infection rates. There was no statistically significant difference in soft tissue infections between the two groups (P = .953). The rate of postoperative infection was significantly higher in those patients (both HIV-positive and controls) who had open reduction and internal fixation (ORIF; 25/155; 16%) versus those who had closed reduction and maxillomandibular fixation (3/96; 3.1%; P = .003). The postoperative infection rate after ORIF was significantly higher in the HIV-positive (5/11; 45%) compared with the control group (20/144; 13.9%; P = .02).

CONCLUSIONS

The results of this study indicate that the overall rate of postoperative infection after treatment of mandibular fractures is significantly higher in HIV-positive than in HIV-negative patients. Specifically, the use of ORIF in HIV-positive patients represents a significant risk.

Role of intralesional vinblastine administration in treatment of intraoral Kaposi's sarcoma in AIDS

The purpose of this clinical study was to determine the effect of intralesional vinblastine administration on intraoral Kaposi's sarcoma (KS) in AIDS patients. One hundred and forty-four KS lesions in 50 HIV-positive homosexual males (mean CD4 count 64/mm3) were treated periodically with intralesional vinblastine injection (0.1 mg/cm2) until lesion resolution or no further reduction in lesional area. The most common lesion sites were: palate 56% (hard palate 42%, soft palate 14%); gingiva 22% (maxillary 15%, mandibular 7%); and maxillary tuberosity 6%. The mean lesion area was 4.6 cm2 (range = 0.1-35 cm2). Complete resolution occurred in 74%. The mean reduction in lesional area was 93% for all lesions. Lesions with only a partial response (26%) to vinblastine had a mean reduction in the lesional area of 69%. The mean number of treatments was 2.4 (range = 1-6). The recurrence rate was 26% with a mean disease-free period of 12.9 weeks. Recurrence rates were highest for nodular (40%) and purple macular lesions with focal nodularity (36%). The most frequent complications were transient pain (72%), superficial mucosal ulceration (22%) and transient paresthesia (12%). Intralesional vinblastine administration produced complete resolution in a substantial number of intraoral KS lesions and represents a well-tolerated treatment regimen for localised control of intraoral KS lesions. Owing to a 25% recurrence rate, re-evaluation is necessary for treatment of recurrent and new Kaposi's sarcoma lesions.

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.

Impaired bactericidal activity of PMN from two brothers with necrotizing ulcerative gingivo-periodontitis

The purpose of this study was to investigate the pathogenesis of necrotizing ulcerative gingivo-periodontitis (ANUP) diagnosed in two brothers, age 9 (ANUP1) and 14 (ANUP2) from rural Egypt. Complete blood count, differential and blood chemistry were within normal limits for both brothers and they were not malnourished. The phagocytosis and killing function of their polymorphonuclear leukocytes (PMN) towards four bacterial species were assessed using a fluorochrome microassay. The selection of bacterial species was based on preliminary microbiological results in early onset periodontitis in Egypt. Fluorochrome-labeled Prevotella intermedia, Peptostreptococcus micros, Campylobacter rectus, and Porphyromonas gingivalis were pre-opsonized with ANUP serum and added to PMN from both ANUP patients, as well as PMN from three sex-matched and two sex- and age-matched healthy Egyptian control (CTL) subjects. We found significant depressions (P < 0.05) in PMN phagocytosis and killing of C. rectus and P. intermedia by ANUP1 and ANUP2, when compared to all CTL PMN. An assessment of the Gram-negative subgingival microflora present in both ANUP patients (in colony forming unit percent of total CFU recovered) (CFU %) revealed the presence of P. intermedia (ANUP1, 41.7 CFU %; ANUP2, 14.8 CFU %), Fusobacterium nucleatum (ANUP1, 3.6 CFU %; ANUP2, 48.1 CFU %), and Veillonella spp. (ANUP1, 18.2 CFU %; ANUP2, 18.5 CFU %). Spirochetes were also observed in cytocentrifuged, Gram-stained plaque from both ANUP patients. The predominant Gram-positive bacterial species recovered from both NUG1 and NUG2 was Streptococcus morbillorum.

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.

Treating Kaposi's lesions in the HIV-infected patient

Kaposi's sarcoma is the most frequent malignant neoplasm in AIDS, occurring in about 10 percent of all risk groups. This study evaluates the effect of intralesional vinblastine on intraoral Kaposi's sarcoma in 24 HIV-positive, homosexual males with 82 lesions. Complete resolution occurred in nearly 70 percent of the cases.

Epidemic oro-facial Kaposi's sarcoma (eKS)--report on 124 cases

Oro-facial epidemic Kaposi's sarcoma (eKS) was observed in 124 patients (123 homo-/bisexual men, average age 37.9 years, and one 35-year-old transsexual patient). Average survival time was 1 year 9 months (range: 3 months 4 years 6 months). 57.3% of the patients had died. The hard and/or soft palate, gingiva and tongue were most frequently affected, with falling frequency within these locations. Oral manifestations of eKS appear to be common; treatment modalities must be optimised.

Human immunodeficiency virus type 1 and cytomegalovirus in saliva

The aim of this study was to evaluate whether HIV-1 or cytomegalovirus (CMV) may contribute to oral lesions frequently found in patients with the acquired immunodeficiency syndrome (AIDS). Saliva samples from 63 HIV-1 positive patients and 21 healthy controls were tested for the presence of HIV-1 and CMV using the polymerase chain reaction (PCR) and virus isolation. CMV IgG titres in serum were also compared in the different groups. HIV-1 RNA, but not DNA, was detected in saliva from 15% (9 out of 59) of the HIV-infected patients. There was no correlation between the presence of HIV-1 RNA and oral symptoms in the patients. CMV DNA was detected significantly more frequently in samples from HIV-1 seropositive than from seronegative patients. CMV was detected in saliva from AIDS patients more often than in saliva from patients with mild or no symptoms. CMV IgG titres were also significantly higher in symptomatic than in asymptomatic patients. There was a significant correlation between the presence of CMV DNA and necrotizing gingivitis, and oral Kaposi's sarcoma in the patients, and also between these lesions and the stage of disease. This does not prove that CMV causes these oral lesions, but a direct or indirect role for CMV cannot be excluded.

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.

Oral conditions in individuals with selective immunoglobulin A deficiency and common variable immunodeficiency

Saliva and serum samples were collected from 36 individuals with selective immunoglobulin A deficiency (IgAd) and 23 patients with common variable immunodeficiency (CVI). The oral examination included registration of the teeth, Russell's periodontal index (PI), pocket formation, and salivary flow rate in both unstimulated and stimulated saliva. No differences were found in salivary flow rate, number of teeth, or pocket depth when donors with IgAd or CVI were compared to age and sex matched controls. However, mucosal manifestations of lichenoid type were more frequent in both types of immunoglobulin deficient individuals. An increased PI was also seen in CVI patients. Increased serum IgG and salivary IgM levels were found in the IgAd population.

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.

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.

Oral signs and symptoms in 160 Greek HIV-infected patients

One hundred and sixty HIV-infected Greek patients were prospectively examined and the oral signs and symptoms were recorded. At the time of oral examination, 76 patients were asymptomatic seropositive, 47 were in ARC stage and 37 had AIDS. One or more oral findings were recorded in 90.6% of the patients while a total of 33 different lesions were observed. The more common oral lesions (highly suspicious) were candidiasis (61%), hairy leukoplakia (24%), periodontitis (19%), necrotizing gingivitis (11%) and Kaposi's sarcoma (12%). In addition some unclassified lesions or symptoms (xerostomia 26%, burning mouth syndrome 19%, patchy depapillated tongue 16%, hairy tongue 10%, exfoliative cheilitis 4%), were common while submandibular and cervical lymph node enlargement were found in 49% of the patients. Interestingly in 16 patients (10%) the suspicion of HIV infection was exclusively based on oral lesions. Our findings show that oral signs and symptoms are common and some times early manifestations of HIV infection and it is in association to those reported in previous studies.

Management of oral health in persons with HIV infection

Prevention and treatment of oral disease is required to maintain quality of life and to improve prognosis of patients infected with the human immunodeficiency virus (HIV). Management requires a team approach, and close collaboration with the appropriate responsible physicians and other health care workers is necessary. Oral infection is frequent and usually opportunistic, and management is based on certain principles. Infections may disseminate and can be persistent and severe; multiple concurrent or consecutive infections with different microorganisms are frequent; fungal, viral, and parasitic infections are rarely curable; and long-term antimicrobial therapy may be required. This article reviews the management of oral candidiasis, hairy leukoplakia, and infections with herpes simplex virus, varicella-zoster virus, and cytomegalovirus. The management of Kaposi's sarcoma, lymphomas, aphthous ulceration, gangrenous stomatitis, bleeding, xerostomia, and adverse drug reactions is also described. Treatment should avoid further immunosuppression and inducement of xerostomia or caries, and should be designed to avoid adverse drug reactions and possible drug interactions.

Immunocytochemical detection of herpes viruses in oral smears of HIV-infected patients

Cytologic smears (CS) were taken from the lateral border of the tongue of HIV-seropositive patients (HIV+) (n = 39) and of seronegative controls (HIV-) (n = 19) and examined by immunocytochemistry (APAAP) and in situ hybridization (ISH) (biotinylated DNA probes) for the presence of viral antigens/DNA of EBV and CMV. While none of the HIV controls showed positive results for EBV antigen, 61% (APAAP) resp. 79% (ISH) of oral epithelial cells in the group of HIV+ patients were EBV-positive. While all CS taken from areas with the clinical diagnosis of hairy leukoplakia (HL) were EBV positive (APAAP and/or ISH), the detection of EBV in CS from uninvolved oral mucosa seemed to be associated with the later development of HL. In the group of HIV+ patients the detection rate for CMV was about five times (APAAP) resp. three times (ISH) higher than in HIV- persons. This non-invasive technique seems to be a valuable tool to screen for viral antigens/genomes.

Oral mycoses in HIV infection

Oral mycoses in human immunodeficiency virus (HIV) infection are becoming increasingly common. Of these, oral candidiasis is by far the most prevalent; fewer than 10 cases of cryptococcosis, histoplasmosis, and geotrichosis have thus far been reported. Oral candidiasis is one of the earliest premonitory signs of HIV infection and may present as erythematous, pseudomembranous, hyperplastic, or papillary variants, or as angular cheilitis. Cumulative data from 23 surveys (incorporating 3387 adults) suggest that in general, oral candidiasis may develop in one third to half of HIV-seropositive persons. Almost equal numbers of cases manifest with either erythematous or pseudomembranous variants. These and related concepts pertaining to oral mycoses in HIV infection are reviewed.

Distribution of cytokeratins in oral cytological smears of HIV-infected patients

Cytological smears (CS), taken from the lateral border of the tongue of HIV-seropositive patients (HIV+) (n = 34) and of seronegative controls (HIV-) (n = 16), were examined by means of immunocytochemistry (APAAP) for the distribution patterns of different cytokeratins and MHC class II antigens. Compared with HIV- patients in CS of HIV-infected patients cornification associated cytokeratins 10/11 were increased, while the number of keratinocytes positive for cytokeratins 13/16 was comparable in both groups. Expression of simple epithelial cytokeratins 19, rarely observed in CS of HIV- patients, was a frequent findings in CS of HIV+ patients. Keratinocytes positive for MHC class II antigens were observed in CS of 12/34 HIV+, while all control CS were negative. In the group of HIV+ patients no correlation was found between the clinical presence of HL and the expression of cytokeratins or class II antigens. The altered distribution of cytokeratins may reflect local responses to proliferative stimuli or local inflammation due to the presence of microbial antigens or may occur as a general unspecific reaction in the setting of systemic viral infection. This non-invasive technique seems to be a valuable tool to determine the proliferation rate of oral epithelial cells.

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.

Oral ulceration and iatrogenic disease in HIV infection

Ulcerative lesions of oropharyngeal mucous membranes are less commonly seen than other lesions in HIV infection and may be associated with mycotic, bacterial, and viral infection, as well as neoplasia. Differential diagnosis may be difficult because of the clinical similarity of ulcerations that can represent various causes. The term "atypical ulceration" has been suggested because it may be impossible to differentiate some of the oral ulcerations from each other. Iatrogenic ulceration is seen occasionally, as the consequence of chemotherapy or irradiation.

Primary intraosseous AIDS-associated Kaposi's sarcoma. Report of two cases with initial jaw involvement

AIDS-associated Kaposi's sarcoma (KS), which in 80% of cases occurs in the oral cavity, usually presents with characteristic clinical features such as brown-bluish pigmented macules or tumorous lesions. In later stages the tumor, most probably originating from the vascular endothelium, may secondarily induce erosion of the underlying bone. The primary, intraosseous occurrence of KS has prompted the present 2 case reports. The tumor presented as extensive, diffuse osteolysis within the mandible without causing clinical symptoms. Although rare, intraosseous KS must be included in the differential diagnosis of isolated bone defects in HIV-infected patients.