Factors associated with increased frequency of HIV-related oral candidiasis

Prevalence of oral lesions in patients with AIDS: a systematic review and meta-analysis

Background Oral lesions are considered to be early clinical signs which may predict the progression of patients with acquired immune deficiency syndrome (AIDS). Due to the lack of a comprehensive study that includes oral lesions in people with AIDS, the global prevalence of oral lesions in people with AIDS was estimated by combining preliminary studies' results using meta-analysis.Material and methods Databases including PubMed, Science Direct and Scopus were searched using keywords as 'HIV', 'AIDS', 'oral candidiasis', 'Kaposi Sarcoma', 'LinearGingival Erythema' and OR operators, AND and NOT. After the elimination of duplicate documents, articles that met the inclusion criteria were selected. Quality assessment was performed based on the Newcastle-Ottawa Scale. After combining the results of preliminary studies, an overall estimate of each lesion was reported. Ninety-five studies met the criteria for inclusion in this meta-analysis.Results The global prevalence of 21 oral lesions in HIV-infected patients was estimated. The overall prevalence of oral candidiasis, pseudomembranous candidiasis, oral hairy leukoplakia, Kaposi sarcoma and erythematous candidiasis was as follows: 35% (95% CI: 28-42), 19% (95% CI: 15-22), 12% (95% CI: 11-14), 5% (95% CI: 4-6) and 18% (95% CI: 14-22).Conclusion The present meta-analysis showed that oral lesions have a high prevalence in patients with AIDS. Dentists should consider that the clinical appearance of the oral cavity reflects the overall systemic health of the patient. As such, oral lesions may be linked to underlying immunosuppression caused by AIDS.

Oral colonization by Candida species and associated factors in HIV-infected patients in Ahvaz, southwest Iran

OBJECTIVES

Oropharyngeal candidiasis is one of the most common opportunistic fungal infections among human immunodeficiency virus (HIV)-infected individuals. The most common cause is Candida albicans, followed by non-albicans Candida. This study aimed to identify colonized Candida species in HIV-infected patients from Ahvaz, Iran. Additionally, the relationships between immunity-related factors, lifestyle, and colonization of Candida spp. were studied.

METHODS

Oral swabs were taken from 201 HIV-positive patients referred for consultations at the Behavioral Modification Center. Oral Candida colonization was detected using culture-based and molecular assays. Data were assessed by descriptive statistics and analyzed to investigate the correlation between Candida colonization and various factors, including the CD4+ cell count and viral load.

RESULTS

It was found that 43.8% of patients were positive for Candida. The most common species was C. albicans (48.0%), followed by non-albicans Candida isolates, including C. dubliniensis, C. glabrata, C. tropicalis, C. parapsilosis, C. guilliermondii, C. kefyr, and C. krusei. Colonization of Candida spp. in patients was associated with a CD4 count ≤200 cells/mm3 (odds ratio [OR], 4.62; p<0.05), history of shared injections (OR, 6.96; p<0.001), and sex (OR, 3.59; p<0.05).

CONCLUSIONS

The results of this study showed that C. albicans was the dominant pathogen. The risk factors for colonization of Candida spp. were a CD4 count ≤ 200/mm3 , a history of shared injections, and sex. Other factors with potential relationships include viral load, age, and opportunistic infections, but further investigations are needed.

Antifungal Activity of Commercial Essential Oils and Biocides against Candida Albicans

Management of oral candidosis, most frequently caused by Candida albicans, is limited due to the relatively low number of antifungal drugs and the emergence of antifungal tolerance. In this study, the antifungal activity of a range of commercial essential oils, two terpenes, chlorhexidine and triclosan was evaluated against C. albicans in planktonic and biofilm form. In addition, cytotoxicity of the most promising compounds was assessed using murine fibroblasts and expressed as half maximal inhibitory concentrations (IC50). Antifungal activity was determined using a broth microdilution assay. The minimum inhibitory concentration (MIC) was established against planktonic cells cultured in a range of concentrations of the test agents. The minimal biofilm eradication concentration (MBEC) was determined by measuring re-growth of cells after pre-formed biofilm was treated for 24 h with the test agents. All tested commercial essential oils demonstrated anticandidal activity (MICs from 0.06% (v/v) to 0.4% (v/v)) against planktonic cultures, with a noticeable increase in resistance exhibited by biofilms (MBECs > 1.5% (v/v)). The IC50s of the commercial essential oils were lower than the MICs, while a one hour application of chlorhexidine was not cytotoxic at concentrations lower than the MIC. In conclusion, the tested commercial essential oils exhibit potential as therapeutic agents against C. albicans, although host cell cytotoxicity is a consideration when developing these new treatments.

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.

Oropharyngeal Candidiasis in HIV Infection: Analysis of Impaired Mucosal Immune Response to Candida albicans in Mice Expressing the HIV-1 Transgene

IL-17-producing Th17 cells are of critical importance in host defense against oropharyngeal candidiasis (OPC). Speculation about defective Th17 responses to oral C. albicans infection in the context of HIV infection prompted an investigation of innate and adaptive immune responses to Candida albicans in transgenic mice expressing the genome of HIV-1 in immune cells and displaying an AIDS-like disease. Defective IL-17 and IL-22-dependent mucosal responses to C. albicans were found to determine susceptibility to OPC in these transgenic mice. Innate phagocytes were quantitatively and functionally intact, and individually dispensable for control of OPC and to prevent systemic dissemination of Candida to deep organs. CD8+ T-cells recruited to the oral mucosa of the transgenic mice limited the proliferation of C. albicans in these conditions of CD4+ T-cell deficiency. Therefore, the immunopathogenesis of OPC in the context of HIV infection involves defective T-cell-mediated immunity, failure of crosstalk with innate mucosal immune effector mechanisms, and compensatory cell responses, which limit Candida infection to the oral mucosa and prevent systemic dissemination.

Pseudomembranous Type of Oral Candidiasis is Associated with Decreased Salivary Flow Rate and Secretory Immunoglobulin A Levels

Saliva plays an important role in maintaining microbial homeostasis in the oral cavity, while salivary gland hypofunction predisposes the oral mucosa to pathologic alteration and increases the risk for oral candidiasis. This study sought to determine the salivary flow rate (SFR) and secretory immunoglobulin A (SIgA) levels in HIV-positive and HIV-negative individuals and evaluate their relationship with the determinants of oral candidiasis. Sixty HIV-positive (30 with and 30 without oral candidiasis) and 30 healthy HIV-negative individuals were enrolled. Cotton pellet was weighed pre- and post-saliva collection for the assessment of SFR, while SIgA levels were estimated by commercial ELISA (Diametra, Italy) kit. The mean ± SD, SFR and SIgA levels in HIV-positive individuals with candidiasis, without candidiasis and HIV-negative controls were 0.396 ± 0.290, 0.546 ± 0.355 and 0.534 ± 0.214 ml/min and 115.891 ± 37.621, 136.024 ± 51.075 and 149.418 ± 31.765 µg/ml, respectively. A positive correlation between low CD4 counts (indicator of immunodeficiency) and SIgA was observed in HIV-positive individuals with candidiasis (r = 0.373, p = 0.045). We also report here for the first time the significant decrease in SFR and SIgA levels in individuals presenting with pseudomembranous type of oral candidiasis and Candida albicans infection.

Murine models of Candida gastrointestinal colonization and dissemination

Ninety-five percent of infectious agents enter through exposed mucosal surfaces, such as the respiratory and gastrointestinal (GI) tracts. The human GI tract is colonized with trillions of commensal microbes, including numerous Candida spp. Some commensal microbes in the GI tract can cause serious human infections under specific circumstances, typically involving changes in the gut environment and/or host immune conditions. Therefore, utilizing animal models of fungal GI colonization and dissemination can lead to significant insights into the complex pathophysiology of transformation from a commensal organism to a pathogen and host-pathogen interactions. This paper will review the methodologic approaches used for modeling GI colonization versus dissemination, the insights learned from these models, and finally, possible future directions using these animal modeling systems.

Methamphetamine use and dental problems among adults enrolled in a program to increase access to oral health services for people living with HIV/AIDS

OBJECTIVE

We examined the association between methamphetamine (meth) use and dental problems in a large sample of HIV-positive adults.

METHODS

We gathered data from 2,178 interviews across 14 sites of the U.S. Health Resources and Services Administration HIV/AIDS Bureau's Special Projects of National Significance Innovations in Oral Health Care Initiative from May 2007 to August 2010. We used multivariate generalized estimating equations to test the association between meth use and dental problems, adjusting for potential confounders.

RESULTS

Past and current meth use was significantly associated with more dental problems. The study also found that poor self-reported mental health status, fewer years since testing positive for HIV, a history of forgoing dental care, less frequent teeth brushing, poor self-reported oral health status, oral pain, grinding or clenching teeth, some alcohol use, more years of education, and self-reported men-who-have-sex-with-men HIV risk exposure (compared with other exposure routes) were significantly associated with dental problems.

CONCLUSION

Individuals who are HIV-positive with a history of meth use experience access barriers to oral health care and more dental problems. Our study demonstrated that it is possible to recruit this population into dental care. Findings suggest that predisposing, enabling, and need factors can serve as demographic, clinical, and behavioral markers for recruiting people living with HIV/AIDS into oral health programs that can mitigate dental problems.

Prevalence of Oral Manifestations and Their Association with CD4/CD8 Ratio and HIV Viral Load in South India

The objective of the present research was to determine the prevalence of oral manifestations in an HIV infected population from south India and evaluate their association with HIV viral load and CD4/CD8 ratio. Intraoral examination of 103 patients, whose CD4/CD8 ratio was available, were conducted. HIV viral loads were available for thirty patients only. The prevalence of oral manifestations was 80.6% (83/103). The most common oromucosal lesion was erythematous candidiasis (EC) (38.8%) followed by melanotic hyperpigmentation (35.9%). Patients having any oral manifestation had a mean CD4/CD8 ratio of 0.24. EC had positive predictive value of 85.0% for CD4/CD8 ratio <0.30. The prevalence of oral manifestations in patients taking ART was lesser (78.6%) as compared to patients not taking ART (82%). Patients having any oral manifestation had a higher HIV viral load as compared to patients not having any oral manifestations (P < 0.05). Pseudomembranous candidiasis (PC) was significantly associated with higher HIV viral loads (>20,000 copies/mL) (P < 0.05). Patients having EC had 4 times greater chance of having CD4/CD8 ratio <0.30. PC can be considered as a marker of immune suppression (HIV viral load >20,000 copies/mL).

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.

Oral fungal infections: an update for the general practitioner

Oral candidosis is the most common fungal infection encountered in general dental practice. It manifests in a variety of clinical presentations which may mimic more sinister diseases, and can occasionally be refractory to treatment requiring the attention of an oral medicine specialist. Management of oral candidosis should always include a thorough investigation of underlying predisposing conditions, as the disease often presents when the patient is systemically compromised. This update highlights the pathogenesis, clinical presentation, and management strategies of oral Candidal lesions commonly encountered in dental practice.

Management of oropharyngeal and esophageal candidiasis in patients with HIV infection

Mucocutaneous candidiasis is frequently one of the first signs of HIV infection. Over 90% of patients with AIDS will develop oropharyngeal candidiasis at some time during their illness. Although numerous antifungal agents have been developed, azoles, both topical (clotrimazole) and systemic (fluconazole, itraconazole, voriconazole and posaconazole), have replaced older topical antifungals (gentian violet and nystatin) in the management of oropharyngeal candidiasis in these patients. The systemic azoles are generally safe and effective agents in HIV-infected patients with oropharyngeal candidiasis. A constant concern in these patients are relapses, which depend on the degree of immunosuppression and are commonly encountered after topical therapy rather than with systemic azole therapy. In patients with fluconazole-refractory mucosal candidiasis, treatment options now include itraconazole solution, voriconazole, posaconazole and the newer echinocandins (caspofungin, micafungin and anidulafungin). The objective of this article is to review the epidemiology, diagnosis and newer management modalities of oropharyngeal and esophageal candidiasis in HIV-infected individuals.

Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection

Mucocutaneous candidiasis is frequently one of the first signs of human immunodeficiency virus (HIV) infection. Over 90% of patients with AIDS will develop oropharyngeal candidiasis (OPC) at some time during their illness. Although numerous antifungal agents are available, azoles, both topical (clotrimazole) and systemic (fluconazole, itraconazole, voriconazole, posaconazole) have replaced older topical antifungals (gentian violet and nystatin) in the management of oropharyngeal candidiasis in these patients. The systemic azoles, are generally safe and effective agents in HIV-infected patients with oropharyngeal candidiasis. A constant concern in these patients is relapse, which is dependent on the degree of immunosuppression commonly seen after topical therapy, rather than with systemic azole therapy. Candida esophagitis (CE) is also an important concern since it occurs in more than 10% of patients with AIDS and can lead to a decrease in oral intake and associated weight loss. Fluconazole has become the most widely used antifungal in the management of mucosal candidiasis. However, itraconazole and posaconazole have similar clinical response rates as fluconazole and are also effective alternative agents. In patients with fluconazole-refractory mucosal candidiasis, treatment options now include itraconazole solution, voriconazole, posaconazole, and the newer echinocandins (caspofungin, micafungin, and anidulafungin).

Prophylactic Role of Immunomodulators in Treatment of Systemic Candidiasis in Leukopenic Mice

In the present study, we have evaluated prophylactic role of various immunomodulators viz. lipopolysachharide, protein A and tuftsin to impart protection against experimental candidiasis in leukopenic mice. Both free as well as liposomised form of nystatin was not effective enough in offering complete cure against less susceptible isolate of Candida albicans (JNMCR) infection in immunodebilitant mice. Interestingly, the pretreatment of leukopenic mice with immunomodulators before challenging them with C. albicans increased therapeutic efficacy of the nystatin against systemic candidiasis. Efficacy of the treatment was evaluated on the basis of survival of the animals as well as fungal load in systemic circulation and various organs viz. liver, kidney, spleen and lungs of the treated animals.

Oral manifestations as predictors of immune suppression in a HIV-/AIDS-infected population in south India

The objectives of the study are to evaluate the relationship between common HIV-related oral lesions and absolute CD4+ count, age, gender, and medication used and to assess the sensitivity, specificity, positive and negative predictive value of oral manifestations for low absolute CD4+ counts. HIV-positive patients, 200, from south India were selected, whose absolute CD4+ counts were determined within 2 weeks of oral examination. Sociodemographic data was obtained using a structured questionnaire. Oral manifestations were diagnosed according to presumptive criteria of EEC-clearinghouse classification (1993). Four or more concurrent oral lesions were statistically significant with low CD4+ counts <200 cells/mm3 (P = 0.005). The highest and lowest mean CD4+ cell counts were seen in individuals with linear gingival erythema (LGE; 172.5 cells/mm(3)) and pseudomembranous candidiasis (PC; 87 cells/mm(3)), respectively. Smoking, age (<35 years), and males had a positive association with oral hairy leukoplakia (OHL; P < 0.05). Patients with CD4+ counts < 200 cells/mm(3) were associated with 15 times greater risk of PC and four times at greater risk for occurrence of any oral manifestation. Concurrent oral manifestations (>or=4) were good predictors (80-100%) of severe immune suppression. In most resource poor countries where facilities for undertaking CD4+ counts are not available, the presence of concurrent oral manifestations may be used as an indicator of deteriorating immune status.

Posaconazole for the management of mucosal candidiasis

Mucocutaneous candidiasis (MC) is one of the first signs of HIV infection. In the pre-highly active antiretroviral therapy (HAART) era, more than 90% of patients with HIV infection eventually developed some form of oral candidiasis during their illness, and an additional 10% developed esophageal candidiasis (EC). Although several antifungal agents are available, systemic azoles (e.g., fluconazole and itraconazole) have replaced older topical antifungals (e.g., gentian violet and nystatin) in the management of MC in these patients. Overall, the azoles are safe and effective agents in HIV-infected patients with MC. However, clinical relapses are extremely common in HIV patients not on HAART or who are noncompliant. The relapses are dependent on the degree of immunosuppression and are more common following treatment with clotrimazole or ketoconazole than with fluconazole or itraconazole. Posaconazole is a new extended-spectrum triazole recently approved for the management of oropharyngeal candidiasis (OPC). In vitro, posaconazole possesses potent activity against Candida species, including strains that are resistant to fluconazole. Recent clinical trials demonstrate that posaconazole is as efficacious as fluconazole in producing a successful clinical response in HIV-infected patients with OPC/EC. In addition, posaconazole has been demonstrated to be well tolerated and more effective in sustaining clinical success after treatment was discontinued. Posaconazole appears to be an effective alternative in the management of MC in these difficult-to-treat infections.

Risk indicators for HIV-associated jointly occurring oral candidiasis and oral hairy leukoplakia

Joint occurrence of two or more diseases may impact their transmission, clinical presentation, management approaches, and treatment efficacy. Although oral candidiasis (OC) and oral hairy leukoplakia (OHL) are the most commonly occurring opportunistic oral diseases of HIV-infected patients, literature describing their joint occurrence is sparse. The purpose of this project was to develop an explanatory multivariable model for joint occurrence of OC and OHL (OC-OHL). This cross-sectional study examined 631 adult dentate HIV-1 seropositive persons for OC and OHL from 1995-2000 at the University of North Carolina Hospitals in Chapel Hill, NC. Data collected from medical record review, interviews and clinical examinations were analyzed using chi(2) tests, t itests, and nonparametric tests. Multivariable proportional odds models were developed, using the likelihood ratio test and adjusting for several demographic, behavioral, and biological factors. Thirteen percent of participants had OC only; 12.8% had OHL only; 4.6% had OC-OHL; whereas 69.7% had neither. Occurrence of OC-OHL was independently associated with CD4+ counts less than 200 cells per microliter (adjusted odds ratio [OR] (95% confidence interval {CI}) = 13.4 (6.6, 27.2) and CD4+ counts 200-499 cells per microliter (OR = 3.9 [1.9, 8.1]); current smokers (OR = 2.3 [1.4, 3.8]); and whites (OR = 1.7 [1.1, 2.5]). Combination antiretroviral therapy was protective (OR = 0.5 [0.3, 0.9]). In an HIV-1-infected population, lower CD4+ cell counts and smoking were important independent risk indicators for joint occurrence of OC and OHL.

Oral manifestations in HIV/AIDS infected patients from India

OBJECTIVES

To assess types and prevalence of HIV-related oral lesions among HIV-infected individuals in south India and to correlate common oral findings with co-morbidities, gender, age and medication.

SUBJECTS AND METHODS

One hundred and one patients with HIV infection or AIDS at infectious diseases units of Attavar Hospital, Mangalore, and medical wards of Kasturba Medical College, Manipal, were selected. Sociodemographic information was obtained using a structured questionnaire. Oral lesions were diagnosed according to the presumptive criteria of EEC-Clearinghouse Classification. Clinical history was retrieved from patient's medical records.

RESULTS

Erythematous candidiasis (44.5%), melanotic hyperpigmentaion (34.6%) and xerostomia (29.7%) were among the most common oral manifestations. A significant association was found between oral candidiasis and advanced immunosuppression (P < 0.05). Oral hairy leukoplakia (OHL) was predominant in individuals <35 years (P < 0.05). Melanotic hyperpigmentation was significantly associated with highly active antiretroviral therapy (P < 0.05). OHL was more frequent in patients with HIV-associated tuberculosis. Linear gingival erythema was more predominant in females.

CONCLUSIONS

Oral hairy leukoplakia showed a positive relationship with patients younger than 35 years. Oral candidiasis can act as a marker for immunosuppression. Angular cheilitis was predominant in the symptomatic stage.

Rationale to evaluate medically supervised safer smoking facilities for non-injection illicit drug users

Many cities are experiencing ongoing infectious disease epidemics and substantial community harm as a result of illicit drug use. In an effort to reduce these public order and public health concerns, consideration has been given to the opening in Vancouver of a safer smoking facility (SSF). The present review was conducted to examine if there is a rationale to support the evaluation of a SSF in the Canadian context. Available evidence suggests that conventional drug control strategies are insufficient to address the health and community harms of non-injection drug use, and that the public order benefits of supervised injection facilities may be relevant to SSFs. In addition, there is persuasive evidence to suggest there is potential for blood-borne disease transmission through the sharing of smoking paraphernalia, and the potential for SSFs to address this concern is a pressing public health question. Also relevant to this topic are interventions to prevent transition into injection drug use, and SSFs may also be evaluated as a potential strategy to address this concern.

Colonization of Candida species in denture wearers with emphasis on HIV infection: a literature review

Candida colonization in denture wearers, especially immunocompromised patients, can be disruptive to dental treatment and may be a barrier to patient health. The surface irregularities of acrylic resin are a factor in the entrapment of microorganisms. Consequently, controlling the spread of fungal infection in HIV-infected patients who wear removable prostheses and who are more susceptible to fungal infections because of their immunosuppression is of critical importance. This article reviews the literature on the colonization of Candida species in HIV-infected denture wearers using keywords such as complete dentures, candidiasis, and HIV-infection . The source for this review was representative English-language, peer-reviewed articles between the period of 1885 to 2003 obtained using Medline, as well as a hand search.

Risk indicators for oral candidiasis and oral hairy leukoplakia in HIV-infected adults

OBJECTIVES

Oral candidiasis (OC) and oral hairy leukoplakia (OHL) are the most common oral mucosal diseases associated with HIV infection. Independent risk indicators associated with these sentinel opportunistic diseases have not been established in mixed race and gender adult populations in the southeast USA. The purposes of this study were 1) to estimate prevalence of OC and OHL among an HIV-1 positive adult population, and 2) to develop explanatory multivariable models for each disease outcome.

METHODS

This cross-sectional study evaluated 631 adult dentate HIV-1 seropositive persons examined for HIV-associated oral mucosal diseases between 1995 and 2000 at University of North Carolina Hospitals in Chapel Hill, North Carolina using data collected from medical record review, interview questionnaire and clinical examination. We analyzed the data using t-tests, anova, and unconditional logistic regression.

RESULTS

Prevalent OC was associated with low CD4+ cell count [<200 cells/microl, adj. OR = 12.7 (95%CI: 4.9-32.9)], antiretroviral combination therapy [OR = 0.6 (0.3-0.9)], and current smoking [OR = 2.5 (1.3-4.8)]. Prevalent OHL was associated with low CD4+ cell count [<200 cells/microl, OR = 7.2 (2.7-18.9)], antifungal medication use [OR = 1.8 (1.1-2.9)], current recreational drug use [OR = 2.5 (1.3-4.9)], and male gender [OR = 2.5 (1.3-4.8)].

CONCLUSIONS

While CD4+ cell count, and antiretroviral medication were important risk indicators for OC, and OHL, cigarette smoking appears to be an important risk indicator for OC in HIV-1-infected populations.

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.

Oral manifestations of HIV infection in relation to clinical and CD4 immunological status in northern and southern Thai patients

OBJECTIVES

To assess prevalence and variations in the oral manifestations of HIV in HIV-infected subjects in southern Thailand (a new HIV epidemic) and northern Thailand (a mature epidemic), and the association with age, sex, risk behaviours, CD4 count and medication used.

SUBJECTS AND METHODS

A total of 102 and 135 HIV-infected individuals were enrolled in northern and southern hospitals, respectively. Oral and haematological examination was performed after sociodemographic interview of the patients. Clinical history was retrieved from patients' medical records.

RESULTS

Oral candidiasis (OC, 55%), oral hairy leucoplakia (OHL, 21%) and HIV-associated-periodontal disease (14%) were among the most common oral lesions in southern Thailand. OHL (38%), OC (25%), HIV-associated-periodontal disease (15%) were the three most common lesions in the north. A significant association was found between any oral lesion, OC, particularly the pseudomembranous type (PC), and CD4 < 200 cells mm(-3) at both sites. A negative relationship was found between systemic antifungal treatment and OC including PC and erythematous candidiasis (EC) in the southern data. OHL showed a positive relationship with male sex and a negative relationship with antiretroviral treatment in the northern site. Younger age and being a current smoker were positively associated with oral lesions in the southern group.

CONCLUSION

OC, particularly PC, could be useful as a marker for immunosuppression, particularly where CD4 count cannot be determined routinely. Antifungal treatment is of benefit in the subjects who cannot afford highly active antiretroviral therapy (HAART).

A new method for studying the adhesion of Candida albicans to dentin in the presence or absence of smear layer

OBJECTIVES

The purpose of this study was to develop a reproducible, quantitative model of Candida albicans adhesion to human dentin through the use of a colorimetric method and to evaluate the effect of smear layer on candidal adhesion.

STUDY DESIGN

Dentin disks with or without smear layer were incubated with C albicans (10(8) cells/mL) for 4 hours. After incubation, the disks were exposed to an (2,3)-bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)-carbonyl]-2H-tetrazolium hydroxide-coenzyme Q solution for 2 hours. The color of (2,3)-bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)-carbonyl]-2H-tetrazolium hydroxide formazan in the supernatant was determined spectrophotometrically at 492 nm. To relate formazan formation to cell numbers, standard curves were generated with known numbers of yeast cells without dentin. The number of adherent cells per square millimeter was then calculated.

RESULTS

The number of attached C albicans cells was 2.4 x 10(4) per square millimeter in dentin with smear layer and 1.5 x 10(4) in dentin without smear layer (P <.05).

CONCLUSION

(2,3)-Bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino)-carbonyl]-2H-tetrazolium hydroxide assay is a potential microbiologic tool for the quantitative determination of Candida adhesion to human dentin.

Biofilm-forming ability of Candida albicans is unlikely to contribute to high levels of oral yeast carriage in cases of human immunodeficiency virus infection

An increased prevalence of candidal carriage and oral candidiasis is common in cases of human immunodeficiency virus (HIV) infection, and the reasons for this may include the enhanced ability of colonizing yeasts to produce biofilms on mucosal surfaces. The aim of the present study was therefore to examine the differences, if any, in the biofilm-forming abilities of 26 Candida albicans yeast isolates from HIV-infected individuals and 20 isolates from HIV-free individuals, as this attribute of yeast isolates from patients with HIV disease has not been examined before. Biofilm formation in microtiter plate wells was quantitatively determined by both the 2,3-bis(2-methoxy-4-nitro-5-sulfophenyl)-5-[(phenylamino) carbonyl]-2H-tetrazolium hydroxide (XTT) reduction method and the crystal violet method. Although candidal biofilm formation could be quantitatively evaluated by either technique, the better reproducibility (P < 0.05) of the XTT reduction assay compared with that of the crystal violet method led us to conclude that the former is more reliable. There were no significant quantitative differences in biofilm formation between C. albicans isolates from HIV-infected patients and isolates from HIV-free individuals during in vitro incubation in a multiwell culture system over a period of 66 h. Three of eight host factors in the HIV-infected group were found to be associated with candidal biofilm formation. Thus, yeasts isolated from older individuals and those with higher CD4-cell counts exhibited decreased biofilm formation, while the findings for yeasts from individuals receiving zidovudine showed the reverse (P < 0.05 for all comparison). Our data indicate that attributes other than biofilm formation may contribute to the increased oral yeast carriage rates in cases of HIV infection.

A 4-year longitudinal evaluation of xerostomia and salivary gland hypofunction in the Women's Interagency HIV Study participants

OBJECTIVES

Our purpose was to conduct a longitudinal investigation of xerostomia and salivary gland hypofunction in a national cohort of HIV-positive and at-risk HIV-negative participants in the Women's Interagency HIV Study. Study design. Data included responses to a dry mouth questionnaire, clinical evaluations of major salivary glands, and unstimulated and chewing-stimulated whole salivary flow rates. Repeated measures regression models were used to determine factors associated with xerostomia and salivary gland hypofunction.

RESULTS

Significant univariate associations were found between HIV status and reports of "too little saliva" (P <.0001), < or = 0.1 mL/min, unstimulated saliva (P =.01), and lack of saliva upon palpation of parotid (P =.02) and submandibular/sublingual salivary glands (P =.03). Adjusted odds of reports of "too little saliva" were significantly higher for HIV-positive participants (odds ratio [OR] = 2.44; 95% CI, 1.49 - 3.97; P =.0004) than for HIV-negative participants. Among HIV-positive women, adjusted odds of reports of "too little saliva" and of < or = 0.7 mL/min chewing-stimulated saliva were significantly higher for those with CD4 < 200 (OR = 1.58; 95% CI, 1.07-2.34; P =.022; and OR = 1.53; 95% CI, 1.05-2.23; P =.027, respectively) and for those with CD4 200-500 (OR = 1.47; 95%CI, 1.07-2.02; P = 0.016; and OR = 1.37; 95% CI, 1.01-2.31; P =.001, respectively) than for those with CD4 > 500. Also, adjusted odds of < or = 0.1mL/min unstimulated saliva and < or = 0.7 mL/min chewing-stimulated saliva were significantly higher in women on highly active antiretroviral therapy (HAART) (OR = 1.25; 95% CI, 1.05 - 1.50; P =.014) than in women not on HAART (OR = 1.34; 95% CI, 1.01 - 1.79; P =.044).

CONCLUSIONS

HIV-positive women are at a significantly higher risk for xerostomia and salivary gland hypofunction than HIV-negative women, and low CD4 cell counts and HAART use are significant risk factors for these conditions.

Fungal infections associated with HIV infection

Oral candidiasis is perhaps the commonest infection seen in HIV disease. The aim of this workshop was to provide a sketch of the multifarious aspects of the disease from a global perspective. To this end the panellists addressed issues such as the virulence of Candida, emergence of antifungal resistance, management of candidiasis and other exotic, oral mycotic diseases. An all-pervasive theme was the dramatic differences in the management of fungal infections consequential to the availability (or the lack) of anti-HIV drugs in the developed and the developing world. Further, the social stigmata associated with the HIV disease in many developing regions in Africa and Asia appears to modify the therapeutic strategies. Additionally, the lesser-known regional variations in the disease manifestations and therapeutic approaches were stark. Further work is direly needed to address these issues.

Differences in risk factors among clinical types of oral candidiasis in the Women's Interagency HIV Study

OBJECTIVES

The purpose of this study was to determine the prevalence and concurrence/associations of oral candidiasis types and multiple risk factors in women.

STUDY DESIGN

A cross-sectional analysis of baseline data for 577 human immunodeficiency virus (HIV)-seropositive and 152 HIV-seronegative women from the Women's Interagency HIV Study was conducted. Pseudomembranous candidiasis (PC) and erythematous (EC) candidiasis, angular cheilitis (AC), and denture stomatitis (DS) were studied, and bivariate and multivariate regression analyses were performed.

RESULTS

Prevalences were 8% for PC, 7% for EC, 18% for DS, and 3% for AC; all except AC usually occurred alone. HIV seropositivity was associated with PC, EC, and DS, but not AC. Among HIV-seropositive women, low CD4 cell counts were associated with PC, but not with EC or DS. Heroin/methadone use was associated with PC and EC; salivary hypofunction was associated with PC; high viral load was associated with EC, and poor oral hygiene, with EC and DS.

CONCLUSIONS

Risk factors varied among candidiasis types, suggesting differences in pathogenic mechanisms and usefulness as markers of HIV infection/progression.

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.

T cells augment monocyte and neutrophil function in host resistance against oropharyngeal candidiasis

The purpose of this study was to identify the cell populations involved in recovery from oral infections with Candida albicans. Monoclonal antibodies specific for CD4+ cells, CD8+ cells, and polymorphonuclear leukocytes were used to deplete BALB/c and CBA/CaH mice of the relevant cell populations in systemic circulation. Monocytes were inactivated with the cytotoxic chemical carrageenan. Mice were infected with 10(8) C. albicans yeast cells and monitored for 21 days. Systemic depletion of CD4+ and CD8+ T lymphocytes alone did not increase the severity of oral infection compared to that of controls. Oral colonization persisted in animals treated with head and neck irradiation and depleted of CD4+ T cells, whereas infections in animals that received head and neck irradiation alone or irradiation and anti-CD8 antibody cleared the infection in a comparable fashion. The depletion of polymorphonuclear cells and the cytotoxic inactivation of mononuclear phagocytes significantly increased the severity of oral infection in both BALB/c and CBA/CaH mice. High levels of interleukin 12 (IL-12) and gamma interferon (IFN-gamma) were produced by lymphocytes from the draining lymph nodes of recovering animals, whereas IL-6, tumor necrosis factor alpha, and IFN-gamma were detected in the oral mucosae of both naïve and infected mice. The results indicate that recovery from oropharyngeal candidiasis in this model is dependent on CD4+-T-cell augmentation of monocyte and neutrophil functions exerted by Th1-type cytokines such as IL-12 and IFN-gamma.

The prevalence of xerostomia and salivary gland hypofunction in a cohort of HIV-positive and at-risk women

The association of xerostomia and salivary gland hypofunction with HIV infection has been established for men but not for women. We investigated the prevalence of these conditions in a national cohort (n = 733) of HIV-positive and at-risk HIV-negative women. Participants in this prospective cross-sectional study were recruited from the Women's Interagency HIV Study (WIHS) at five outpatient USA clinics. Xerostomia was assessed based on "yes" responses to a dry-mouth questionnaire. Samples of unstimulated whole and chewing-stimulated whole saliva were collected under standardized conditions. The major salivary glands were also evaluated clinically. The prevalence of dry-mouth complaint, the absence of saliva upon palpation, and zero unstimulated whole saliva (flow rate = 0 mL/min) were significantly (p = 0.001) higher in HIV-positive women. Adjusted odds of zero unstimulated whole saliva were significantly (p = 0.02) higher in HIV-positive women vs. HIV-negative women (OR = 2.86; 95% CI, 1.23 to 6.63). Significant (p = 0.03) univariate association was found between zero unstimulated whole saliva and CD4 counts. Adjusted odds of zero unstimulated whole saliva were significantly (p = 0.02) higher for HIV-positive women with CD4 < 200 compared with those with CD4 > 500 (OR = 2.61; 95% CI, 1.17 to 5.85). Chewing-stimulated flow rates were not significantly different between seropositive and seronegative women. The prevalence of xerostomia and salivary gland hypofunction appears to be significantly higher in HIV-positive women relative to a comparable group of at-risk seronegative women. Immunosuppression levels measured by CD4 cell counts are significantly associated with xerostomia and salivary gland hypofunction in a population of HIV-positive women.

Impact of protease inhibitor therapy on HIV-related oropharyngeal candidiasis

OBJECTIVE

To determine the relationship between antiretroviral therapy and changes in prevalence and amount of oropharyngeal candidiasis (OPC) and skin test reactivity for delayed type hypersensitivity.

DESIGN

Observational cohort.

SETTING

University-based public hospital AIDS clinic.

PATIENTS

Adults with advanced HIV infection who had been taking nucleoside transcriptase inhibitor drugs but had not taken a protease inhibitor and who started antiretroviral treatment with ritonavir.

MAIN OUTCOME MEASURES

OPC lesions score, oral candidal colonization, oral candidal quantification, skin test reactivity for delayed type hypersensitivity (purified protein derivative, candidal and streptokinase antigens), plasma HIV RNA and CD4 cell count at weeks 8, 16 and 48 weeks.

RESULTS

In the 99 patients who entered the study, there was a significant reduction in the HIV plasma RNA (mean log decrease from baseline at 48 weeks 0.88) and a significant increase in CD4 cell counts (mean CD4 cell increase from baseline at 48 weeks 128 x 10(6) cells/l). Only 17% of patients had < 200 copies/ml HIV RNA at 48 weeks. There were significant decreases in the prevalence of OPC lesions (31% at baseline to 1% at 48 weeks; P < 0.001), and in oral candidal loads [2226 to 811 colony-forming units (CFU)/ml; P = 0.0171]. The percentage of patients with at least one positive skin test increased significantly (6 to 28%; P < 0.05). Patients whose CD4 lymphocyte count was > 200 x 10(6) cells/l at 48 weeks had significantly lower oral candidal loads and were more likely to have a positive skin test than patients whose CD4 cell count was < 200 x 10(6) cells/l.

CONCLUSION

In patients with advanced HIV infection, antiretroviral treatment including a protease inhibitor has a positive impact in the natural history of OPC. This positive impact appears to be correlated with a better immunological function and occurs despite continuous HIV replication.

Oral infections and other manifestations of HIV disease

Oral lesions are important in the clinical spectrum of HIV/AIDS, arousing suspicion of acute seroconversion illness (aphthous ulceration and candidiasis), suggesting HIV infection in the undiagnosed individual (candidiasis, hairy leukoplakia, Kaposi's sarcoma, necrotizing ulcerative gingivitis), indicating clinical disease progression and predicting development of AIDS (candidiasis, hairy leukoplakia), and marking immune suppression in HIV-infected individuals (candidiasis, hairy leukoplakia, necrotizing periodontal disease, Kaposi's sarcoma, long-standing herpes infection, major aphthous ulcers). In addition, oral lesions are included in staging systems for HIV disease progression and as entry criteria or endpoints in clinical trials of antiretroviral drugs. Recognition and management of these oral conditions is important for the health and quality of life of the individual with HIV/AIDS. In keeping with this, the U.S. Department of Health Services Clinical Practice Guideline for Evaluation and Management of Early HIV Infection includes recommendations that an oral examination, emphasizing oral mucosal surfaces, be conducted by the primary care provider at each visit, a dental examination by a dentist should be done at least two times a year, and patients should be informed of the importance of oral care and educated about common HIV-related oral lesions and associated symptoms.

Factors affecting the adherence of Candida albicans to human buccal epithelial cells in human immunodeficiency virus infection

Adherence to host surfaces is an essential prerequisite for colonization and infection. We compared the adherence of 15 oral isolates of Candida albicans harvested from human immunodeficiency virus (HIV)-infected individuals and 12 isolates from HIV-free individuals to buccal epithelial cells (BECs) from HIV-free individuals, and the adherence of a reference strain of C. albicans to BECs from HIV-infected as well as HIV-free individuals. C. albicans from HIV-infected individuals showed adherence values similar to those from HIV-free individuals. The clinical and laboratory parameters of the subjects from whom the Candida were isolated did not correlate with adherence. A reference strain of C. albicans (GDH 1957), however, adhered more readily to BECs from HIV-infected individuals than to cells from an HIV-free cohort. Several variables were found to be associated with the adherence of C. albicans to BECs from HIV-infected individuals: use of zidovudine, antibacterials and antiparasitics was associated with increased adhesion, while haemophilia, heterosexuality, bisexuality, increased age, decreased CD4 + count and use of folate were associated with a decreased candidal adhesion (all P < 0.05). Our data suggest that the quality of BECs including their receptivity to Candida may play an important part in increasing the oral yeast carriage in HIV infection.

Further characterization of human salivary anticandidal activities in a human immunodeficiency virus-positive cohort by use of microassays

Salivary anticandidal activities play an important role in oral candidal infection. R. P. Santarpia et al. (Oral Microbiol. Immunol. 7:38-43, 1992) developed in vitro anticandidal assays to measure the ability of saliva to inhibit the viability of Candida albicans blastoconidia and the formation of germ tubes by C. albicans. In this report, we describe modifications of these assays for use with small volumes of saliva (50 to 100 microl). For healthy subjects, there is strong inhibition of blastoconidial viability in stimulated parotid (75%), submandibular-sublingual (74%), and whole (97%) saliva, as well as strong inhibition of germ tube formation (>80%) for all three saliva types. The susceptibility of several Candida isolates to inhibition of viability by saliva collected from healthy subjects is independent of body source of Candida isolation (blood, oral cavity, or vagina) or the susceptibility of the isolate to the antifungal drug fluconazole. Salivary anticandidal activities in human immunodeficiency virus (HIV)-infected patients were significantly lower than those in healthy controls for inhibition of blastoconidial viability (P < 0.05) and germ tube formation (P < 0. 001). Stimulated whole-saliva flow rates were also significantly lower (P < 0.05) for HIV-infected patients. These results show that saliva of healthy individuals has anticandidal activity and that this activity is reduced in the saliva of HIV-infected patients. These findings may help explain the greater incidence of oral candidal infections for individuals with AIDS.

Antifungal effects of sodium hypochlorite and chlorhexidine in root canals

The purpose of this study was to evaluate the antifungal properties of 0.12% chlorhexidine, 1% NaOCl, and 5% NaOCl. Root sections were enlarged and the smear layer was removed in half of the specimens. The specimens were fixed in the wells of tissue culture plates. Each root canal was dispensed with an inoculum of Candida albicans. After 10 days, the root sections were treated with 3 ml of either disinfectant solution for 1 min, 5 min, 30 min, and 1 h. Then, root sections were incubated in test tubes having Sabouraud's Dextrose Broth at 37 degrees C for 24 h. In the presence of the smear layer, antifungal activity was observed only in 1-h treatment groups for all solutions. However, in the absence of the smear layer, 5% NaOCl alone started to show antifungal activity after 30 min. The antimicrobial effectiveness of irrigating solutions should be re-evaluated, particularly in patients predisposed to oral candidiasis.

Oral manifestations of HIV infection in a group of predominantly ethnic Chinese

A total of 32 HIV-infected, predominantly ethnic Chinese individuals from Hong Kong were examined for oral mucosal lesions over a period of 1 year. The commonest oral lesion found was minor aphthous ulceration (27.4%), while xerostomia (17.8%), ulceration NOS (not otherwise specified; 12.3%), hairy leukoplakia (11.0%) and erythematous candidiasis (6.9%) were less frequent; Kaposi's sarcoma was notable for its absence. When the relationship between the number of oral lesions with age, risk group, medication taken, CDC staging and CD4+ count of the study group was investigated, a significantly higher number of oral lesions was associated with use of AZT, homosexuals and CDC stage IV; in contrast, a smaller number of lesions was found in those on antiparasitics and multivitamins (all P<0.05). When compared with studies from other parts of the world, the frequency of oral lesions appeared to be less common in the current study group. However, due to a lack of similar studies from the Asian region, especially in ethnic Chinese, it is not clear whether this difference could be attributed to racial, social or geographic factors.

Oral lesions in children with perinatally acquired human immunodeficiency virus infection

Fifteen vertically HIV-infected children aged between 2 and 12 years were followed up for 1 year, weekly to monthly, to study the incidence of oral lesions. At the time of first examination, oral candidiasis (OC) was observed in nine children. Seven children presented with the erythematous type only and two with pseudomembranous oral candidiasis. Four cases of cheilitis were seen in association with the erythematous forms of oral candidiasis. One erythematous candidiasis progressed to pseudomembranous form. A second case of erythematous OC, after multiple recurrences in the form of erythematous OC, recurred as pseudomembranous OC. Another case of erythematous OC and one of pseudomembranous OC presented after multiple recurrences as a persistent, adherent pseudomembranous OC. An orofacial herpes-zoster infection, a hairy leukoplakia and a necrotic lingual ulcer were observed as second lesions and in association with oral candidiasis in three children. Erythematous oral candidiasis was the most frequent oral HIV-related lesion, was observed in different stages of HIV-infection, and in some cases progressed to pseudomembranous candidiasis. A different, selectively resistant, Candida clone was isolated in three cases of recurrent candidiasis.

Options for the management of mucosal candidiasis in patients with AIDS and HIV infection

Oropharyngeal candidiasis may be the first manifestation of human immunodeficiency viral (HIV) infection, and more than 90% of patients with the acquired immunodeficiency syndrome (AIDS) develop the disease. Although numerous antifungal agents are available, azoles, both topical (clotrimazole) and systemic (fluconazole, itraconazole), have largely replaced older topical antifungals (gentian violet, nystatin) in the management of the disease in these patients. A concern in these patients is clinical relapse, which appears to be dependent on degree of immunosuppression and is more common with clotrimazole and ketoconazole than with fluconazole or itraconazole. Candida esophagitis is also of concern, since it occurs in more than 10% of patients with AIDS. Fluconazole is an integral part of management. A cyclodextrin oral solution formulation of itraconazole has similar clinical response rates as fluconazole and is an effective alternative. In patients with fluconazole-resistant mucocutaneous candidiasis, treatment options include itraconazole and amphotericin B oral suspension and parenteral preparation.

Oral manifestations of HIV in a southeast USA population

OBJECTIVES

Examine variations in oral manifestations of HIV by gender, race, risk behaviors, substance use and immune status in a previously unstudied population in the southeast region of the USA.

DESIGN

Cross-sectional analytic study.

SETTING

Academic medical center, North Carolina, USA.

SUBJECTS

First 238 HIV-infected adults (76% male; 59% Black) enrolled in an ongoing longitudinal study.

METHODS

Oral examination, medical chart review, sociodemographic and behavioral interview. Descriptive, bivariate, and multivariable analyses.

OUTCOMES

Presence of oral manifestations of HIV.

RESULTS

50% had recent CD4 counts < 200 cells microliters-1, 48% had one or more oral lesion. Specific lesion prevalence: hairy leukoplakia (OHL) 26.5%; candidiasis (OC) 20%; HIV-associated periodontal diseases (HIV-PD) 8.8%; aphthae 4.2%; papillomas 2.5%; herpes simplex 2.1%; HIV salivary gland disease 2.1%; Kaposi's sarcoma (KS) 1.7%; other 1.3%. In bivariate analyses, OHL was associated with being male, White, having a CD4 < 200, and men who have sex with men (MSM); OC was associated with CD4 < 200 and current smoking; HIV-PD was associated with consumption of more than seven alcohol-containing drinks per week; KS was associated with being male and MSM. Significant variables in multivariable analysis for presence of any oral lesion were White, CD4 < 200, and more than seven drinks/week; for OHL were male and CD4 < 200; and for OC were White, CD4 < 200, current smoking, and not MSM.

CONCLUSIONS

MSM were at increased risk for KS and OHL, not OC, while smokers were at increased risk of OC. OC, OHL, and any oral lesion were associated with immune suppression. OHL was more likely in males independent of CD4 count.

Cross-sectional study of oral Candida carriage in a human immunodeficiency virus (HIV)-seropositive population: predisposing factors, epidemiology and antifungal susceptibility

The Candida species isolated from oral rinses of 130 human immunodeficiency virus (HIV) infected patients were compared with those of 130 healthy non-matched volunteers. The oral rinses were plated on CHROMagar Candida medium (CAC) and on CAC supplemented with 10 micrograms (CF10) and 100 micrograms (CF100) of fluconazole per ml. The prevalence of non-albicans Candida spp. in oral rinses of HIV-infected patients and their correlation with the clinical and epidemiological characteristics of the patients were studied. Susceptibility of the Candida spp. isolated was determined by a microbroth dilution method based on the NCCLS reference procedure. Results of susceptibility tests of the yeast isolates were compared with their growth at the time of isolation on CAC supplemented with fluconazole. Thirty-five (30.7%) strains of non-albicans Candida spp. were isolated from the HIV-positive population, vs. seven (15.9%) from the immunocompetent population. Growth on CF10 correlated in 96% of the cases with fluconazole minimum inhibitory concentration (MIC) > 8 micrograms ml-1. Smoking and use of azoles were significantly associated with oral carriage of non-albicans Candida spp. (P < 0.05). The prevalence of non-albicans Candida spp. in HIV-positive persons in oral rinse samples is twice as high as in the HIV-negative population. Smoking and treatment with azoles are risk factors for the oral carriage of non-albicans Candida spp. The isolation of yeasts on CAC plates supplemented with fluconazole allows combination of presumptive yeast identification and fluconazole susceptibility testing.

Oral manifestations of HIV infection by gender and transmission category in Mexico City

A cross-sectional analysis was conducted in Mexico City from September 1989 to March 1996, to determine the prevalence of HIV-related oral manifestations by gender and route of HIV transmission. The diagnosis of HIV-associated oral lesions was based on preestablished criteria. For the statistical analysis chi-squared and Fisher's exact tests were used where appropriate. Odds ratios were calculated as estimates of the relative risks. Control of confounding factors was performed by logistic regression models. Oral lesions were present in 75% of 436 HIV+ patients. Hairy leukoplakia, erythematous and pseudomembranous candidosis, angular cheilitis and oral ulcers were frequently found. Patients who contracted HIV through blood transfusion were more likely to present erythematous candidosis (P=0.005) than subjects who acquired HIV through sexual transmission. Oral ulcers were seen only in men (P=0.02) and in individuals who contracted HIV through sexual transmission (P=0.02). This study brings valuable data in regard to differences in the type and prevalence of HIV-related oral lesions by gender and the risk categories analysed, particularly blood transfusion.

Role of dentinal carious lesions in the pathogenesis of oral candidiasis in HIV infection

The authors describe a clinicopathologic study that evaluated whether dentinal carious lesions are colonized by candidal organisms--and if so, whether there is a relationship between dentinal carious lesion colonization and clinical oral candidiasis, or OC, in HIV infection. Using light microscopy, the authors examined 30 extracted teeth with dentinal carious lesions from people in each of two groups: 30 consecutively treated HIV-positive patients and 30 consecutively treated HIV-negative patients. OC was diagnosed only in HIV-positive patients (40 percent). The dentinal carious lesion pattern in both groups was similar in occlusal, root and proximal caries. Candidal colonization of carious dentinal tubules was more frequent in HIV-positive subjects than it was in HIV-negative subjects. This research shows that it may be important to restore dentinal caries in HIV-infected patients to remove a protected niche for candidal organisms.