Rapidly progressive periodontal disease associated with HIV infection: report of case

Prevalence of periodontal diseases in a multicenter cohort of perinatally HIV-infected and HIV-exposed and uninfected youth

AIMS

To compare the prevalence and severity of periodontal diseases between 180 perinatally HIV-infected (PHIV) and 118 perinatally HIV-exposed and uninfected (PHEU) youth in a cross-sectional study conducted at 11 clinical sites in the United States and Puerto Rico from the Adolescent Master Protocol study of the Pediatric HIV/AIDS cohort study (PHACS) network.

METHODS

Several analyses were conducted, employing the current CDC/AAP classification for periodontitis and incorporating a definition of gingivitis based on a bleeding on probing (BOP) threshold, and analyses based on more detailed whole-mouth, intra-oral regionally, site-based and tooth-based criteria of BOP, plaque levels, pockets depths and clinical attachment levels.

RESULTS

After adjusting for plaque control habits and behavioural and sociodemographic factors, there were no significant differences in periodontal diseases between the PHIV and PHEU youth using any of these criteria. For PHIV youth, there was no significant association between parameters of periodontal disease and current HIV status.

CONCLUSIONS

Although no significant differences in periodontal parameters were noted between the PHIV and PHEU youth, the influence of antiretroviral therapy merits further exploration in this cohort in a longitudinal study.

Treatment of Periodontal Disease with an Octenidine-based Antiseptic in HIV-positive Patients

OBJECTIVE

To evaluate the effects of a periodontal therapy with subsequent application of an octenidine (OCT)-based antiseptic in HIV-positive patients receiving highly active antiretroviral therapy.

METHODS

HIV-positive patients with a clinically diagnosed periodontal disease were randomly divided into two groups (n = 30/group). Both groups initially received a periodontal therapy. Patients in the OCT group additionally used an OCT-based mouthwash. Subgingival plaque samples and periodontal indices were analysed prior to treatment onset as well as one and 3 months post-treatment.

RESULTS

Periodontal therapy has resulted in a significant decrease in the values of all periodontal indices one and 3 months following the therapy completion (P = 0.000). The effects of the two applied therapeutic protocols differed significantly in terms of the variation in the PBI (F = 4.617; P = 0.017) and the PD (F = 3.203; P = 0.044) value. In the patients in the OCT group, a more pronounced decrease in the PBI and PD was noted at 1-month follow-up as well as a greater increase in the PD value 3 months upon treatment completion. In the OCT group, no more atypical microorganisms were detectable 1 month post-treatment, while in the control group they were found in 34.5% of patients.

CONCLUSIONS

The periodontal therapy bears good results in HIV-positive patients. Additional administration of OCT contributes to the significant decline in the PBI and DS values and eliminates atypical microorganisms within 1 month post-treatment. However, more favourable results were not noted in the OCT group at the 3-month assessment.

Longitudinal Evaluation of Loss of Attachment in HIV-Infected Women Compared to HIV-Uninfected Women

BACKGROUND

The Women's Interagency HIV Study (WIHS) is the largest, most detailed, controlled longitudinal collection of data to evaluate the influence of human immunodeficiency virus (HIV) disease and its therapies on the periodontium.

METHODS

This report evaluates periodontal probing depth (PD), attachment loss (AL), and tooth loss from 584 HIV-seropositive and 151 HIV-seronegative women, recorded at 6-month intervals from 1995 to 2002. Using the random split-mouth method, PD and AL were recorded from four sites per tooth: mesial-buccal, buccal, distal-buccal, and lingual. Influence of viral load, CD4 count, race, smoking, drug use, low income, and level of education were evaluated.

RESULTS

At baseline, AL was 1.6 versus 1.1 mm (P = 0.003) and PD was marginally deeper (2.1 versus 2.0 mm; P = 0.02) in HIV-seropositive versus HIV-seronegative women. Adjusted longitudinal analysis showed that HIV infection did not increase the mean PD (rate ratio [RR], 1.00; 95% confidence interval [CI], 0.96 to 1.04), worst PD (RR, 1.03; 95% CI, 0.98 to 1.09), mean AL (RR, 0.97; 95% CI, 0.96 to 1.02), worst AL (RR, 1.01; 95% CI, 0.94 to 1.07), or tooth loss (RR, 1.02; 95% CI, 1.0 to 1.05).

CONCLUSIONS

CD4 count and viral load had no consistent effects on PD or AL. Among HIV-infected women, a 10-fold increase in viral load was associated with a marginal increase in tooth loss. The progression of periodontal disease measured by PD and AL did not significantly differ between HIV-infected and HIV-uninfected women. The HIV-seropositive women lost more teeth. Race, smoking, drug use, income, and education level did not influence the results for either group.

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.

Herpesvirus infection of inflammatory cells in human periodontitis

Human cytomegalovirus (HCMV) and Epstein-Barr virus type 1 (EBV-1) are frequently detected in human periodontitis lesions. However, no information is available on the types of gingival cells infected by herpesviruses. The present study determined the presence of herpesviruses in polymorphonuclear neutrophils, monocytes, macrophages and T and B lymphocytes in biopsies of periodontitis lesions from 20 adults. A nested polymerase chain reaction method was employed to detect HCMV, EBV-1, EBV-2, human herpes virus-6 and herpes simplex virus (HSV) in periodontal tissue biopsy and in gingival cell fractions separated by immunomagnetic cell sorting. Tissue specimens from 18 (90%) and cell fractions from 14 (70%) patients demonstrated herpesviruses. Periodontitis-derived monocytes and macrophages revealed HCMV in cell fractions from 11 (55%) patients and HSV in cells from 1 (5%) patient. T lymphocytes harbored HCMV in cell fractions from 4 (20%) patients and HSV in cell fractions from 4 (20%) patients. B lymphocytes showed EBV-1 in cell fractions from 9 (45%) patients. Periodontal polymorphonuclear neutrophils demonstrated no herpesviruses. This study suggests that HCMV mainly infects periodontal monocytes, macrophages and less frequently T lymphocytes and that EBV-1 infects periodontal B lymphocytes. The possible etio-pathologic significance of periodontal herpesvirus infection is discussed.

Host defensive, immunological, and microbiological observations of an early-onset periodontitis patient with virus-associated hemophagocytic syndrome

Virus-associated hemophagocytic syndrome (VAHS) is a disorder characterized by benign generalized histiocytic proliferation and marked hemophagocytosis associated with systemic viral infection. An immunodeficiency which includes an extremely decreased leukocyte and platelet count together with abnormalities in the CD4/CD8 ratio are the most common features of VAHS. Here we report an early-onset periodontitis (EOP) patient with VAHS from the standpoint of host-parasite interaction to understand the effect of this systemic disorder which might possibly influence susceptibility to periodontal disease. The patient is a 16-year-old Japanese male clinically diagnosed as having generalized EOP with slight gingival inflammation and moderate bone loss. This patient manifested VAHS at 3 years of age, and then had an unusual 4 recurrences (at 5, 7, 11, and 14 years old). Laboratory tests conducted include: 1) complete blood analyses: 2) peripheral neutrophil functions (chemotaxis, phagocytosis, superoxide production, and adherence); 3) peripheral lymphocyte subpopulations and functions, T-cell proliferative activity and productivity of cytokines (interleukin-2 [IL-2], interferon gamma [IFN-gamma], and tumor necrosis factor alpha [TNF-alpha]); 4) serum cytokine levels (IL-1 beta, IL-2, soluble IL-2 receptor [sIL-2R], IL-4, IL-6, IFN-gamma, and TNF-alpha; 5) serum immunoglobulin G (IgG) antibody titers against periodontopathic bacteria; 6) serological human leukocyte antigen (HLA) typing; and 7) determination of bacterial flora of the periodontal pockets. The results indicated that the patient's neutrophil chemotaxis and random migration were below the normal range. In lymphocyte examinations, T-cell proliferative activity, IL-2, and IFN-gamma productivity were elevated. Serum IFN-gamma level was also significantly higher than normal range. No specific periodontopathic bacteria were predominant in the periodontal pockets, however, the serum IgG titer against Porphyromonas gingivalis was elevated throughout the examination period. It is suggested that VAHS might be a possible risk factor for periodontal disease, and hence may serve as a model in understanding the role of host defense mechanisms in the establishment of inflammatory periodontal disease.

Treatment of HIV-associated periodontal diseases

Three presentations of periodontal disease are associated with HIV infection: necrotising periodontal disease; forms of atypical gingivitis and exacerbated attachment loss. Necrotising disease resembling aggressive acute necrotising ulcerative gingivitis and is the most acute and painful of these. Response to treatment by debridement of lesions, irrigation with aqueous chlorhexidine solution and oral metronidazole 200 mg, tds is almost diagnostic of the condition. Affected individuals are prone to relapse. Prevention by meticulous home care and frequent hygiene recalls is advised. The forms of atypical gingivitis are classically not plaque related. This means that persistence of gingivitis in the absence of plaque is required to establish the diagnosis. There is a consensus that these diseases are related to candidiasis. Treatment with antifungals may be contraindicated due to the emergence of resistant strains of Candida spp. Exacerbated attachment loss may be the legacy of repeated episodes of necrotic disease or may be due to accelerated periodontitis. In either event the principles of treatment are to encourage and facilitate plaque removal.

The periodontal health of homosexual men with HIV infection: a controlled study

OBJECTIVE

Identify types, prevalence and severity of periodontal changes associated with HIV infection.

DESIGN

Cross-sectional controlled blinded study.

SETTING

Open access genito-urinary medicine clinic.

PARTICIPANTS

Convenience sample of 794 homosexual men aged 18-65.

OUTCOME MEASURES

Prevalence, extent and severity of probing attachment loss (PAL), pocketing, gingival ulceration, gingivitis, bleeding on probing (BOP), gingival red bands and diffuse and punctate erythema of the attached gingiva (selected a priori).

RESULTS

Prevalences in men with (n = 312) and without HIV (n = 260) were: PAL (> or = 1 site > or = 4mm), 59.6% and 28.5% respectively (P < 0.001, chi 2); pocketing (> or = 1 site > or = 4mm) 51.0% and 31.9% (P < 0.001); BOP, 96.5% and 92.3% (P = 0.038); gingival ulceration, 3.2% and 1.0% (P = 0.031), red banding, 12.2% and 10.0% (P = 0.410); diffuse erythema, 12.5% and 3.1% (P < 0.001) and punctate erythema, 9.6% and 1.1% (P < 0.001). Decreased CD4 lymphocyte counts predicted the presence, extent and severity of PAL (P = 0.023, 0.027 and 0.060) but not pocketing. Oral candidiasis predicted the extent and severity of gingivitis and the presence of diffuse and punctate erythema. (P = 0.037, 0.011, 0.002 and < 0.001).

CONCLUSIONS

Destruction of periodontal attachment is associated with progression of HIV disease whereas pocketing is associated with HIV infection but not disease progression. Gingival ulceration is associated with HIV but gingivitis and erythema of the attached gingiva are most strongly associated with oral candidiasis. Gingival red bands were not associated with HIV infection.

Comparison of periodontal disease in HIV seropositive subjects and controls (I). Clinical features

The aims of this study were to investigate the prevalence and severity of periodontal diseases in HIV seropositive and assumed HIV seronegative individuals in the Edinburgh area. 29 HIV seropositive subjects were examined at baseline and at 3-monthly intervals. Attachment loss and dichotomous indicators of periodontal disease were recorded. 27 control subjects were seen at baseline only. Although there was no significant difference between the 2 groups in terms of mean attachment loss at baseline, HIV seropositive subjects had experienced more severe attachment loss localised to the lower incisor region. HIV seropositive subjects had a significantly higher mean % of sites exhibiting suppuration and redness. A distinct subgroup of 9 HIV seropositive subjects with widespread attachment loss was detected, which included those subjects with severely affected lower incisors. Site-specific attachment loss of > or = 3 mm was observed in only 20 sites out of 2814 sites in HIV+subjects observed longitudinally. The incidence of aggressive periodontal disease in this study was lower than anticipated, despite the inclusion of patients with advanced HIV infection or AIDS.

HIV infection and the dentist. 2. The diagnosis and management of gingivitis and periodontitis

In HIV infected patients, a distinct form of gingivitis and periodontitis was reported recently. This paper reviews the clinical and microbiological features of these lesions and makes recommendations regarding their clinical management. The need for early treatment and control of periodontitis in HIV seropositive patients is emphasized.

Progression of periodontal disease in HIV seropositive patients

Data from cross-sectional studies suggest that periodontitis in HIV-infected patients is a more destructive form of disease in contrast to the slowly progressing form of adult periodontitis in the general population. We studied prospectively over an 18-month period 30 HIV infected, but asymptomatic, patients and compared the rate of periodontal attachment loss with that of a healthy control group (n = 10) matched for age and plaque index. Every 6 months, each subject was assessed for their clinical status by a physician and CD4+ cell count determined. The proliferative response of peripheral blood lymphocytes was determined by in vitro cultures with PHA and Con A. The periodontal health status was assessed by scoring with plaque index (PI), gingival index (GI), and periodontal disease index (PDI). The control subjects were assessed for periodontal status only. Of the 30 HIV-positive patients whose data were analyzed 14 received Zidovudine (AZT) while the remaining 16 did not. There was no correlation between any clinical parameter measured and periodontal status as determined by PI or GI. However, a significant difference in the change of periodontal disease index (PDI) was observed between the HIV-infected and control groups (P = 0.005). We concluded that HIV-infected patients with pre-existing periodontitis tend to experience a greater rate of attachment loss over time compared with controls.

Periodontal diseases and HIV infection. A review of the literature

There have been many references in the literature to HIV-related periodontal diseases, which although poorly substantiated, seem to have established them as part of the expected range of HIV-associated conditions. The original studies have produced conflicting reports which may stem from shortcomings in design. Consequently, the picture remains confused with respect to the classification, epidemiology, microbiology, natural history and management of HIV-related periodontal diseases. Future studies should give greater attention to sampling methods, the use of control groups and defining criteria. This will allow comparison of data between centres and facilitate study of what may be an uncommon disease.

Periodontal health in 200 HIV-positive patients

Two hundred HIV-positive subjects were surveyed to determine their periodontal health status. Particular attention was given to the occurrence of a severe and rapidly progressing form of periodontal disease designated "HIV-associated periodontitis", which has been reported as being unique to AIDS patients. Among the subjects comprising the cohort, 85 subjects had good gingival health, 59 subjects exhibited gingivitis, 49 cases of adult periodontitis were observed, 5 subjects presented with advance adult periodontitis, and 2 cases of necrotizing ulcerative periodontitis (NUP) were found within the group. The periodontitis of the patients in this survey did not have unique or pathognomonic characteristics which could set their periodontal disease apart from the periodontal disease seen in HIV negative population.

Periodontal status of HIV-seropositive and AIDS patients

Few reported studies have evaluated the periodontal status of individuals infected by human immunodeficiency virus (HIV). The majority of these reports have evaluated the periodontal status of individuals presenting to dental care facilities due to oral problems. These reports suggest that severe gingival inflammation and attachment loss are often associated with HIV seropositive patients. The purpose of this study was to evaluate the periodontal status of HIV seropositive patients without biasing the data towards those presenting to dentists with oral problems. Sixty-three consenting male patients presenting to the infectious disease clinic at the Medical College of Virginia Hospitals were examined to determine the status of their periodontal health. Gingival index, plaque index, pocket depths, and attachment loss were determined using standard indices. Participants were first grouped according to the modified CDC Classification System for HIV infection and then categorized according to HIV risk factors for purposes of statistical analysis. No significant differences could be found in the gingival or periodontal status of subjects who were HIV seropositive versus those with AIDS. Periodontal status was also not significantly different for individuals based upon risk group. Periodontal health of the participants was similar to the general population (HIV status unknown). This would indicate that, although HIV gingivitis and HIV periodontitis have been documented in a number of HIV-infected patients, the frequency of affected individuals is less than previous reports would suggest.

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

Oral lesions are common at all stages of HIV infection. This first of two articles reviews the clinical features and pathogenesis of common oral manifestations of HIV disease (candidiasis, hairy leukoplakia, Kaposi's sarcoma, and HIV-related periodontal disease) and considers current treatment measures.