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

Prevalence of oral mucosal lesions in human immunodeficiency virus-infected children attending the Pediatric Infectious Diseases Clinic in Cape Town

Objective

Investigation of the prevalence of oral mucosal lesions in human immunodeficiency virus (HIV)‐infected children undergoing highly active antiretroviral therapy (HAART).

Materials and Methods

Cross‐sectional study of 66 HIV seropositive children, comprised of 28 (42.4%) females and 38 (57.6%) males (average age of 6 years). Study participants all required data regarding CD4+ T‐helper cell counts and the viral load. All participants underwent an orofacial clinical examination by calibrated clinicians. Associations between the presence of oral mucosal lesions, CD4+ cell counts, and viral load were analyzed using Poisson regression.

Results

The prevalence of oral manifestations was detected in 21 children (31.8%). Oral lesions were detected in 16 children with viral load copies <50 cells/mm³ and 22 children with CD4+ counts >500 cells/mm³. Predominant lesions identified included angular cheilitis (36.7%), candidiasis (13.3%) and atypical oral ulcers (13.3%). The presence of one lesion was the most prevalent represented by 19 children. Oral lesions in relation to the CD4+ counts >500 resulted in; 14 children with one oral lesion, 5 with two lesions and 3 with three oral mucosal lesions. The other half of this CD4+ count patient group presented with no oral mucosal lesions. Oral lesions in relation Viral load copies <50 resulted in; 9 children with one oral lesion, 3 with two oral mucosal lesions and 4 with three oral mucosal lesions. The other half of this Viral load patient group presented with no oral mucosal lesions. No significant correlations were established between the presence of oral mucosal lesions and low CD4+ counts (p = 0.715) nor with high viral load counts (p = 0.638).

Conclusion

HIV‐related oral mucosal lesions still presented in the participants despite management with HAART. Based on the results, CD4+ counts and viral load does not appear to be suitable markers of orofacial involvement in children.

Current trends and new developments in HIV research and periodontal diseases

With the advent of combined antiretroviral therapies, the face of HIV infection has changed dramatically from a disease with almost certain mortality from serious comorbidities, to a manageable chronic condition with an extended lifespan. In this paper we present the more recent investigations into the epidemiology, microbiology, and pathogenesis of periodontal diseases in patients with HIV, and the effects of combined antiretroviral therapies on the incidence and progression of these diseases both in adults and perinatally infected children. In addition, comparisons and potential interactions between the HIV-associated microbiome, host responses, and pathogenesis in the oral cavity with the gastrointestinal tract and other areas of the body are presented. Also, the effects of HIV and combined antiretroviral therapies on comorbidities such as hyposalivation, dementia, and osteoporosis on periodontal disease progression are discussed.

Unexpected Acute Necrotizing Ulcerative Gingivitis in a Well-controlled HIV-infected Case

We herein report the case of a 41-year-old Japanese man with well-controlled HIV who presented with diagnostically difficult acute necrotizing ulcerative gingivitis (ANUG). After diet-induced weight loss, he developed oral pain and disturbance of mouth opening, and was admitted to our hospital. Based on preconceptions of HIV-associated diseases, fluconazole was initiated for candidiasis. However, no improvement was seen and ANUG was finally diagnosed. This case suggests that physicians should consider ANUG in HIV-infected individuals when several risk factors are present, even if CD4+ T-lymphocyte counts have remained stable owing to long-term anti-retroviral therapy.

(B2) Periodontal Diseases and Other Bacterial Infections

The workshop addressed the following questions with respect to periodontal diseases and bacterial infections seen in HIV infection: (1) What is linear gingival erythema? Is it prevalent only in HIV disease? A crude Delphi technique was used to ascertain whether LGE existed, but a consensus could not be reached. It was agreed that a diagnosis of LGE should be considered only if the lesion persists after removal of plaque in the initial visit. (2) Do periodontal pockets contribute to viremia in HIV infection? At present, the data are not available to answer this question. (3) Do anti-viral drugs reach the sulcular fluid in significant concentrations? No one at the workshop was aware of data that could answer this question. (4) Does concurrent tuberculosis infection modify the oral manifestations of HIV infection? Though analysis of data from the developing countries does suggest an association between tuberculosis and oral candidiasis, more data and multivariate analysis considering immunosuppression as a confounding factor are necessary, for any conclusions to be derived. (5) What pathogens are involved in periodontal diseases in HIV infection? Periodontal disease may be initiated by conventional periodontal pathogens. But the progression and tissue destruction depend upon the presence of typical and atypical micro-organisms, including viruses, their by-products, increased secretion of potentially destructive inflammatory mediators, and overwhelming host response. (6) How can we diagnose the diseases seen in HIV infection? The answer can be obtained only with data from controlled and blinded studies. It is necessary to design collaborative multi-center longitudinal studies. The results obtained from such large sample sizes can contribute eventually to interpretation of the outcome.

Current strategies for prevention of oral manifestations of human immunodeficiency virus

OBJECTIVES

Strategies to prevent new-onset and recurrent oral manifestations of human immunodeficiency virus (HIV), including fungal, viral, neoplastic, and idiopathic mucosal diseases and destructive periodontal conditions, are poorly understood.

STUDY DESIGN

A structured review of the English language literature in PubMed through March 2015 was conducted to identify current prevention strategies for initial and recurrent oral manifestations of HIV.

RESULTS

Pharmacologic approaches, including combination antiretroviral therapy or other targeted therapies for prevention of oropharyngeal candidiasis, orolabial herpes, oral hairy leukoplakia, oral Kaposi sarcoma, linear gingival erythema and necrotizing ulcerative periodontitis were found. Nonpharmacologic approaches for prevention of oropharyngeal candidiasis, orolabial herpes, oral hairy leukoplakia, and necrotizing ulcerative periodontitis are presented.

CONCLUSIONS

Current strategies for the prevention of oral manifestations of HIV include pharmacologic and nonpharmacologic therapies. Immune reconstitution inflammatory syndrome, future vaccine therapy for pathogens causing oral mucosal disease, and the possible role of oral inflammatory disease prevention in controlling HIV disease progression are discussed.

Periodontal disease in HIV/AIDS

Since the early 1990's, the death rate from AIDS among adults has declined in most developed countries, largely because of newer antiretroviral therapies and improved access to these therapies. In addition, from 2006 to 2011, the total number of new cases of HIV infection worldwide has declined somewhat and has remained relatively constant. Nevertheless, because of the large numbers of existing and new cases of HIV infection, the dental practitioner and other healthcare practitioners will still be required to treat oral and periodontal conditions unique to HIV/AIDS as well as conventional periodontal diseases in HIV-infected adults and children. The oral and periodontal conditions most closely associated with HIV infection include oral candidiasis, oral hairy leukoplakia, Kaposi's sarcoma, salivary gland diseases, oral warts, other oral viral infections, linear gingival erythema and necrotizing gingival and periodontal diseases. While the incidence and prevalence of these oral lesions and conditions appear to be declining, in part because of antiretroviral therapy, dental and healthcare practitioners will need to continue to diagnose and treat the more conventional periodontal diseases in these HIV-infected populations. Finding low-cost and easily accessible and acceptable diagnostic and treatment approaches for both the microbiological and the inflammatory aspects of periodontal diseases in these populations are of particular importance, as the systemic spread of the local microbiota and inflammatory products of periodontal diseases may have adverse effects on both the progression of HIV infection and the effectiveness of antiretroviral therapy approaches. Developing and assessing low-cost and accessible diagnostic and treatment approaches to periodontal diseases, particularly in developing countries, will require an internationally coordinated effort to design and conduct standardized clinical trials.

Necrotizing periodontal diseases in a semirural district of South Africa

Objectives. The aim of this study was to characterize the lesions of necrotizing gingivitis (NG) and necrotizing periodontitis (NP) with regard to extent and severity, and to correlate these parameters with the host HIV serostatus, CD4+ T-cell count, neutrophil count, age, and gender. Methods. Eighty-four consecutive patients, 39 black females and 45 black males aged 20-46 years, diagnosed with NG/NP were recruited to the study over a period of two years. Results. For both HIV-seropositive and -seronegative patients, the mandibular anterior gingiva was most frequently affected; 74% had NG/NP affecting ≥5 gingival tooth sites. Ninety percent of all patients had a mean severity of ≤4 mm. There was no statistically significant association between either extent or severity of NG/NP and HIV serostatus, CD4+ T-cell count, neutrophil count, age, or gender. The difference between the number of HIV-seropositive patients with NG/NP who had CD4+ T-cell counts ≤200 cells/mm(3) and those who had CD4+ T cell counts of 201-499 cells/mm(3) was not statistically significant. Conclusion. The clinical signs of NG/NP are similar in HIV-seropositive and -seronegative patients, and are not related to CD4+ T-cell count, to neutrophil count, to gender, or to age.

Cancrum oris in developed countries

Cancrum oris (or noma) is a rapidly progressive disease characterized by destructive necrosis of oral tissues and underlying bone. It is part of a multistage condition and may represent the outcome of untreated necrotizing stomatitis. Necrotising stomatitis and cancrum oris predominantly affect children in developing countries, especially in Africa. Only few cases have been reported in developed countries, and were associated with debilitating diseases and disorders of the immune system. We report a case of noma in an elderly immunosuppressed Italian patient in whom necrosis caused an external buccal communication. This case stresses the importance of an early identification and prompt management of the necrotic condition, in order to avoid diffusion of the destructive process within the oro-facial tissues.

Management of oral lesions in HIV-positive patients

HIV/AIDS is currently the leading cause of death in Africa and the fourth leading cause of death worldwide. This systematic review of the literature was conducted to evaluate the evidence for treatment of the most common oral lesions associated with HIV: oral candidiasis with or without oropharyngeal involvement (OPC), oral hairy leukoplakia (OHL), recurrent aphthous-like ulcerations (RAU), oral Kaposi's sarcoma (OKS), orolabial herpes simplex infection (HSV), oral herpes zoster infection (VZV), intraoral or perioral warts (HPV), and HIV-associated periodontal diseases. Treatment of HIV-associated salivary gland disease is addressed in a different section of this World Workshop. We found the largest body of evidence for treatment of OPC in HIV patients. Future trials will be needed to test drugs currently in development for treatment of Candida strains that are resistant to existing therapies. There were no double blind, placebo-controlled randomized clinical trials (RCT) for topical treatment of OHL, and only one RCT for systemic treatment of the lesion with desciclovir. Systemic thalidomide was the only drug tested in RCT for treatment or prevention of RAU. Only 1 double-blind RCT comparing vinblastine and sodium tetradecyl sulfate was identified for localized treatment of OKS. Three drugs (famciclovir, acyclovir, and valaciclovir) were shown to be effective in randomized, double-blind trials for treatment or suppression of mucocutaneous HSV lesions in HIV patients. In all 3 trials, the effects of these medications on orolabial HSV lesions were not reported separately. There were no double-blind, placebo-controlled RCT testing topical treatments for orolabial HSV lesions in HIV patients. No trials testing treatments of oral VZV were identified. There were no double-blind, placebo-controlled RCT for treatment of HIV-associated intraoral or perioral warts or periodontal diseases. In conclusion, there is a need for well-designed RCTs to assess the safety and efficacy of topical and systemic treatments of most oral mucosal and perioral lesions in HIV patients. There is also a need to develop newer drugs for treatment of resistant fungal and viral microorganisms. Finally, standardized outcome measures should be developed for future clinical trials to allow comparisons of studies using different populations.

Association of T CD4 lymphocyte levels and subgingival microbiota of chronic periodontitis in HIV-infected Brazilians under HAART

OBJECTIVE

The aim of this study was to determine the subgingival microbiota of HIV-infected patients with chronic periodontitis and different T CD4 lymphocyte levels under HAART.

STUDY DESIGN

64 HIV+ patients (mean age 34.5 +/- 7.3; 75% males) were distributed into Group I: chronic periodontitis (> or = 3 sites with probing pocket depth (PPD) and/or clinical attachment level (CAL) > or = 5 mm); and Group II: periodontal health (no sites with PPD > 3 mm and/or CAL > 4 mm). All subjects received conventional periodontal therapy. Periodontal clinical parameters were evaluated at 6 sites/tooth in all teeth at baseline and 4 months after therapy. The levels of T CD4 were obtained from the patient's medical record. Subgingival plaque samples were taken from the 6 sites with the largest pocket depth in each subject of Group I, and 6 randomly selected sites in subjects of Group II. The presence of 22 subgingival species was determined using the checkerboard DNA-DNA hybridization method. Significant microbiological differences within and among groups were sought using Wilcoxon signed-rank and Mann-Whitney tests, respectively. Relationships between T CD4 levels and microbiological parameters were determined using Kruskal-Wallis test.

RESULTS

Sixty-one percent of the HIV-infected patients represented AIDS cases, although 69% of them were periodontally healthy. The T CD4 lymphocyte mean level was 333 cells/mm3 and viral load was 12,815 +/- 24,607 copies/mm3. Yet, the prevalence of chronic periodontitis was relatively low (36%). Several periodontal pathogens, in particular T. forsythensis (P < .05), were more prevalent in HIV-positive patients with periodontitis than in HIV-positive subjects with periodontal health. Most of the species decreased in frequency after therapy, particularly P. gingivalis (P < .05). E. faecalis and F. nucleatum were significantly more prevalent in the subgingival microbiota of patients with chronic periodontitis and lower levels of T CD4 (P < .05), while beneficial species tended to be more frequently detected in individuals with T CD4 counts over 500 cells/mm3.

CONCLUSION

The subgingival microbiota of HIV-infected patients with chronic periodontitis include a high prevalence of classical periodontal pathogens observed in non-infected individuals. Furthermore, the severe immunosuppression seems to favor the colonization by these species, as well as by species not commonly found in the subgingival microbiota.

A TEM/SEM study of the microbial plaque overlying the necrotic gingival papillae of HIV-seropositive, necrotizing ulcerative periodontitis

The purpose of this study was to examine by transmission (TEM) and scanning electron microscopy (SEM) the supragingival microbial plaque overlying the ulcerated gingival papillae of necrotizing ulcerative periodontitis (NUP) lesions in HIV-seropositive patients. The microbiota of NUP and HIV-seropositive patients with periodontitis has been reported to be similar to that of conventional periodontitis in non-infected subjects, although several investigators have also reported high recovery rates of microbes not generally associated with the indigenous oral microbial flora. Light and electron microscopic observations and microbial culture studies indicate a similar high prevalence of spirochetes in both necrotizing ulcerative gingivitis (NUG) and NUP. In addition, several studies have reported more frequent isolation of Candida albicans from diseased periodontal sites in HIV-seropositive patients than from non-diseased sites. Ten male and six female patients, each HIV-seropositive and exhibiting NUP, constituted the study population. Two biopsies of involved gingival papillae from between posterior teeth were obtained from each patient and processed for examination by both TEM and SEM. Microscopic examination revealed a surface biofilm comprised of a mixed microbial flora of various morphotypes in 81.3% of biopsy specimens. The subsurface flora featured dense aggregations of spirochetes in 87.5% of specimens. Zones of aggregated polymorphonuclear leukocytes and necrotic cells were also noted. Yeasts were observed in 65.6% of specimens and herpes-like viruses in 56.5% of the specimens. Collectively, except for the presence of yeast and viruses, the results suggest that the microbial flora and possibly the soft tissue lesions of NUP and necrotizing ulcerative gingivitis are very similar.

The significance and management of periodontal lesions in HIV infection

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

OBJECTIVES

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

DESIGN

Traditional review.

RESULTS

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

CONCLUSIONS

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

Periodontal diseases and HIV infection

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

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.

Necrotizing ulcerative stomatitis in human immunodeficiency virus-seropositive individuals: a review of the histopathologic, immunohistochemical, and virologic characteristics of 18 cases

OBJECTIVE

The purpose of this retrospective study was to delineate the histopathologic, immunohistochemical, and virologic characteristics of 18 cases of necrotizing ulcerative stomatitis.

STUDY DESIGN

Eighteen examples or oral ulcerations in human immunodeficiency virus-seropositive individuals were identified that displayed unique histopathologic features. Immunohistochemic staining for CD1a, CD3, CD23, CD68, HLA-DR, p24, cytomegalovirus, HSV-1, and HSV-2 was performed, along with in situ hybridization for Epstein-Barr virus RNA and special staining for bacteria and fungi.

RESULTS

The lesions demonstrated ulceration, extensive necrosis, leukocytoclasia, histiocytic vasculitis with luminal fibrin clots, and a prominent infiltrate of large atypical cells with amphophilic cytoplasm, vesicular nuclei, and prominent nucleoli, interspersed with crescentic histiocytes, a histologic picture resembling extranodal Kikuchi's disease. Immunohistochemical findings suggested that the large atypical cells were histiocytes. Fifty-six percent (10/18) of the cases were immunoreactive for human immunodeficiency virus p24 within focal histiocytes, whereas Epstein-Barr virus RNA was identified in 1 (6%) of 17 cases.

CONCLUSIONS

Necrotizing ulcerative stomatitis is an inflammatory disease characterized by specific, reproducible microscopic features. We postulate that the histopathologic resemblance of necrotizing ulcerative stomatitis to extranodal Kikuchi's disease reflects a similar immune response to differing pathogens.

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.