A Comparison of T4:T8 Lymphocyte Ratio in the Periodontal Lesion of Healthy and HIV-Positive Patients

The effect of antiretroviral therapyon the periodontal conditions of patients with HIV infection: A systematic review and meta-analysis

AIM

To assess any differences (1) in the prevalence of periodontitis and necrotizing periodontal diseases, specifically necrotizing gingivitis (NG) and necrotizing periodontitis (NP) between HIV patients receiving antiretroviral therapy (HAART) and those not receiving the therapy and (2) in the severity of periodontitis based on probing depths (PDs) and clinical attachment loss (CAL) between the two groups.

MATERIALS AND METHODS

Systematic electronic search on five databases (PubMed, Google Scholar, Scopus, Web of Science and Scielo) was conducted to identify cross-sectional and longitudinal studies reporting on prevalence of NG, NP and periodontitis among HIV patients who either receive or do not receive HAART treatment. The differences in clinical parameters of PDs and CAL among these patients were assessed.

RESULTS

Eighteen articles were considered. The meta-analysis for NG showed that the overall assessment for the relative frequency ratio in the two groups was 0.45 (n = 7; 95% confidence interval [CI]: [0.21, 0.97]; p < .042). Regarding NP, the overall assessment for the relative frequency ratio in both groups was 0.60 (n = 5; 95% CI [0.22, 1.64]; p = .321). With regard to periodontitis, the overall assessment for the relative frequency ratio in the two groups was 1.17 (n = 9; 95% CI [0.90, 1.52]; p = .248). No significant differences in PD and CAL were found between the two groups 0.00 (n = 3; 95% CI [-0.52, -0.53]; p = .985) and 0.32 (n = 3; 95% CI [-0.19, 0.82]; p = .22), respectively.

CONCLUSIONS

The prevalence of NG appeared to be significantly reduced in patients receiving antiretroviral therapy. No statistical significant difference was found in the prevalence of NP or periodontitis between the two groups.

Extremely low frequency electromagnetic fields exposure during the prenatal and postnatal periods alters pro-inflammatory cytokines levels by gender

Maternal exposure to the excessive electromagnetic fields is considered harmful to infants and associated with several health problems in life, such as neurological or immune diseases. In this present study we aimed to investigate the potential effects of extremely low-frequency electromagnetic field (ELF-EMF) exposure during the gestational and lactational period of dams on immune system parameters. The development of white blood cells (WBC), lymphocyte subpopulations (CD4⁺ T cells, CD8⁺ T cells, Natural Killer (NK) cells, and B cells) and production of T cell related cytokines were explored in the offsprings. Significant changes were found in WBC and lymphocyte counts. Although no changes in lymphocyte subunits were observed among groups, CD4⁺ cells were significantly increased in the female group exposed to ELF-EMF. Also, IL-17A and IFN-γ levels increased in plasma and spleen. The mean IL-4 level and the expression level of the IL-4 gene were not changed, in the experimental groups. But the expression of the IL-17A gene was also upregulated, which supports cytokine quantification analyses. In conclusion, ELF-EMF exposure in the prenatal and postnatal period increases the level of IL-17A in the spleen and blood of young female rats, and it upregulates IL-17 gene expression in the spleen, resulting in CD4⁺ cell proliferation and inflammation.

Cellular Profile and Expression of Immunologic Markers in Chronic Apical Periodontitis from HIV-infected Patients Undergoing Highly Active Antiretroviral Therapy

INTRODUCTION

This study tested the hypothesis that the inflammatory cell profile (CD3-, CD4-, CD8-, CD20-, and CD68-positive cells) and the expression of immunologic markers (tumor necrosis factor α, interferon-γ, interleukin-6, and interleukin-18) in chronic apical periodontitis are the same between non-HIV-infected patients and HIV-infected patients undergoing highly active antiretroviral therapy (HAART).

METHODS

Thirty-four surgically excised chronic apical periodontitis lesions were sampled from 34 patients (17 HIV-infected and 17 non-HIV-infected). The lesions were extracted from teeth with no previous endodontic treatment. All HIV-infected patients were undergoing HAART. The specimens were submitted to histopathologic and immunohistochemical analyses by using an optical microscope. Immunoexpression was graded into 2 levels, focal to weak and moderate to strong. The χ(2), Fisher exact, and Mann-Whitney tests were used to analyze all significant differences between groups.

RESULTS

Periapical cysts represented 70.6% and 52.9% of the lesions in the HIV-infected and non-HIV-infected groups, respectively; however, no statistically significant difference was observed (P = .481). There were no statistically significant differences between groups for the inflammatory cell profile and for any of the immunologic markers (P > .05).

CONCLUSIONS

There are no statistically significant differences of the cellular profile and expression of immunologic markers in chronic apical periodontitis between non-HIV-infected patients and HIV-infected patients undergoing HAART.

Periodontal disease in HIV-infected adults in the HAART era: Clinical, immunological, and microbiological aspects

The introduction of highly active antiretroviral therapy (HAART) has decreased the incidence and prevalence of several oral manifestations such as oral candidiasis, hairy leukoplakia, and Kaposi's sarcoma in HIV-infected patients. Regarding periodontal disease the findings are not clear. This disease represents a group of chronic oral diseases characterized by infection and inflammation of the periodontal tissues. These tissues surround the teeth and provide periodontal protection (the gingival tissue) and periodontal support (periodontal ligament, root cementum, alveolar bone). Clinical, immunological, and microbiological aspects of these diseases, such as linear gingival erythema (LGE), necrotizing periodontal diseases (NPD) (necrotizing ulcerative gingivitis [NUG], necrotizing ulcerative periodontitis [NUP] and necrotizing stomatitis), and chronic periodontitis, have been widely studied in HIV-infected individuals, but without providing conclusive results. The purpose of this review was to contribute to a better overall understanding of the probable impact of HIV-infection on the characteristics of periodontal infections.

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).

Association of T CD4 Lymphocyte Levels and Chronic Periodontitis in HIV-Infected Brazilian Patients Undergoing Highly Active Anti-Retroviral Therapy: Clinical Results

BACKGROUND

Controversial data regarding the association between immunosuppression and prevalence/ severity of periodontal diseases in HIV infection have been reported. Thus, the aim of this study was to test the hypothesis that lower T CD4 lymphocyte levels are not related to a higher prevalence of chronic periodontitis in HIV-infected Brazilians undergoing highly active anti-retroviral therapy (HAART).

METHODS

Sixty-four HIV-infected patients under HAART were classified as having chronic periodontitis; i.e., > or = three sites with probing depth (PD) and/or clinical attachment level (CAL) > or = 5 mm or periodontal healthy (no sites with PD > 3 mm and/or CAL > 4 mm). All subjects received conventional periodontal therapy. Bleeding on probing, plaque accumulation, PD, and CAL were registered at six sites/tooth at baseline and 4 months after therapy. Epidemiological features and levels of T CD4 lymphocytes were obtained from medical records. Significance of differences in periodontal clinical parameters within and between groups were determined using Wilcoxon signed-rank and Mann-Whitney or independent sample t tests. Associations between T CD4 levels and clinical parameters were determined using the chi square test.

RESULTS

Sixty-one percent of the HIV-infected patients represented AIDS cases, although 69% of them were periodontally healthy. The overall T CD4 lymphocyte mean levels was 333 +/- 254 cells/mm3 and viral load was 12,815 +/- 24,607 copies/mm3. Yet the prevalence of chronic periodontitis was relatively low (36%). In addition, patients with periodontitis presented a moderate disease (mean PD = 2.2 +/- 0.10; mean CAL = 2.6 +/- 0.13) and responded successfully to periodontal therapy. These subjects showed higher levels of T CD4 cells, but lower counts of neutrophils than periodontally healthy patients. Among periodontally healthy and chronic periodontitis patients, 41.7% and 22.9%, respectively, had low levels of T CD4 lymphocytes. No significant differences between periodontal status and epidemiological and immunological parameters were observed.

CONCLUSION

Based on these results, the hypothesis that lower T CD4 lymphocyte levels are not associated with higher prevalence of chronic periodontitis in HIV-infected Brazilians under HAART cannot be rejected.

Immunopathogenesis of oropharyngeal candidiasis in human immunodeficiency virus infection

Oropharyngeal and esophageal candidiases remain significant causes of morbidity in human immunodeficiency virus (HIV)-infected patients, despite the dramatic ability of antiretroviral therapy to reconstitute immunity. Notable advances have been achieved in understanding, at the molecular level, the relationships between the progression of HIV infection, the acquisition, maintenance, and clonality of oral candidal populations, and the emergence of antifungal resistance. However, the critical immunological defects which are responsible for the onset and maintenance of mucosal candidiasis in patients with HIV infection have not been elucidated. The devastating impact of HIV infection on mucosal Langerhans' cell and CD4(+) cell populations is most probably central to the pathogenesis of mucosal candidiasis in HIV-infected patients. However, these defects may be partly compensated by preserved host defense mechanisms (calprotectin, keratinocytes, CD8(+) T cells, and phagocytes) which, individually or together, may limit Candida albicans proliferation to the superficial mucosa. The availability of CD4C/HIV transgenic mice expressing HIV-1 in immune cells has provided the opportunity to devise a novel model of mucosal candidiasis that closely mimics the clinical and pathological features of candidal infection in human HIV infection. These transgenic mice allow, for the first time, a precise cause-and-effect analysis of the immunopathogenesis of mucosal candidiasis in HIV infection under controlled conditions in a small laboratory animal.

Immunity to Candida

Candida species are commensal fungal organisms as well as opportunistic pathogens of mucosal tissues. From the commensal relationship, most healthy individuals have demonstrable Candida-specific immunity. In immunocompromised persons, however, fungal infections caused primarily by C. albicans often occur. In HIV disease, up to 90% of HIV+ persons will have a symptomatic episode of oropharyngeal candidiasis (OPC) sometime during progression to AIDS, many of which become recurrent. In contrast, vulvovaginal candidiasis (VVC) and systemic Candida infections (candidaemia) are much less common during HIV disease, indicating the diversity and compartmentalization of the host response to Candida. Both innate resistance and acquired immunity play some role in maintaining C. albicans in the commensal state and protecting the systemic circulation. Polymorphonuclear leukocytes (PMNL) are critical for protection against systemic infections, whereas cell-mediated immunity (CMI) by Th1-type CD4+ T-cells is important for protection against mucosal infections. However, there is a discordant role for CMI at the vaginal versus oral mucosa, whereas little to no role for local or systemic CMI is evident at the vaginal mucosa. In contrast, there is a strong correlation between reduced blood CD4+ cells and the incidence of OPC, but it remains unclear whether systemic or local CMI is more important. Evaluation of systemic CMI in a cohort of HIV+ individuals with and without mucosal candidiasis revealed that Candida-specific CMI is not different between HIV+ persons with OPC or VVC and HIV- persons. Thus, the correlation of reduced CD4+ cell numbers to OPC may be explained by the requirement for a threshold number of systemic CD4+ cells to protect the oral mucosa together with the status of local immunity. Indeed, HIV+ persons with and without OPC had a Th2-type salivary cytokine profile suggestive of susceptibility to Candida infection compared with a protective Th0/Th1-type profile in HIV- persons. Candida-specific antibodies, although present, are controversial relative to a role in protection or eradication of infection. While studies of mucosal innate resistance are limited, we recently found that epithelial cells from saliva and vaginal lavages of healthy individuals inhibit the growth of Candida in vitro. This epithelial cell anti-Candida activity requires cell contact by viable cells with no role for soluble factors, including saliva. Interestingly, oral epithelial cells from HIV+ persons with OPC had significantly reduced activity, indicating some protective role for the epithelial cells. Taken together, these data suggest that immunity to Candida is site-specific, compartmentalized and involves innate and/or acquired mechanisms from systemic and/or local sources.

Classifications of oral lesions in HIV infection

BACKGROUND

Manifestations of immunosuppression may take the form of opportunistic infection, and neoplasia. While this paper has focused on gingival and periodontal manifestations. these tissues cannot be evaluated in isolation. The presence of involvement of other oral tissues such as the cheek or tongue with manifestations associated with HIV such as hairy leukoplakia, Kaposi's sarcoma at these sites, and candidiasis in addition to periodontal manifestations may further increase the clincal suspicion of underlying immunosuppression and/or progression of the immunosuppressive state.

DISCUSSION

The periodontist plays an essential r le in identifying the periodontal status of an individual and has an important r le to play in early recognition of signs and symptoms of HIV disease or progression of the medical condition.

CONCLUSION

Only through such recognition can appropriate definitive diagnostic testing be conducted, and appropriate therapeutic intervention for the oral condition and the systemic condition be considered.

Th1/Th2 cytokine expression in saliva of HIV-positive and HIV-negative individuals: a pilot study in HIV-positive individuals with oropharyngeal candidiasis

Current data suggest that T-helper (Th)2-type cytokine responses are often associated with progression to AIDS in HIV-positive individuals. Similarly, Th2-type cytokines are associated with susceptibility to mucosal candidiasis, of which oropharyngeal candidiasis (OPC) is one of the most common opportunistic infections in HIV-positive individuals. Although little information is available on host defense mechanisms at the level of the oral mucosa, recent studies suggest that local cell-mediated immunity (CMI) is equally or more important than that in the periphery for host defense against mucosal Candida albicans infections. This study investigated the potential presence of oral-associated CMI through the expression of Th1/Th2-type cytokines in saliva of immunocompetent and immunocompromised individuals with and without OPC. Results showed a constitutive mixed Th1/Th2 cytokine expression (Th0) in whole saliva of healthy HIV-negative individuals. In contrast, HIV-positive individuals had a dominant Th2-type salivary cytokine profile (interleukin-4 [IL-4], IL-10) (IL-2, interferon-y [IFN-gamma], IL-12) that seemingly resulted from a lack of Th1-type cytokines rather than enhanced Th2-type cytokines. Moreover, pilot analyses of those with OPC showed evidence for a more profound salivary Th2-type profile. Both HIV-positive and HIV-negative patients, irrespective of CD4 counts, had some level of positive in vitro systemic lymphocyte proliferative responses to C albicans antigens. These results suggest that the Th1/Th2 cytokine dichotomy in HIV disease is detectable in situ in oral secretions and may be a useful indicator of oral-associated CMI to better understand resistance/susceptibility of HIV-positive individuals to oral opportunistic infections, including OPC.

New concepts regarding the pathogenesis of periodontal disease in HIV infection

Periodontal manifestations of human immunodeficiency virus (HIV) infection were first described in 1987. Initially, the lesions receiving attention were HIV-associated gingivitis (now known as linear gingival erythema [LGE]) and HIV-associated periodontitis (now known as necrotizing ulcerative periodontitis [NUP]). The true prevalence of LGE was difficult to determine due to variable diagnostic criteria. Recently, LGE has been associated with intraoral Candida infection. The prevalence of NUP is low (< or = 5%), and this lesion is associated with pronounced immunosuppression. Current focus on the periodontal manifestations of HIV infection centers on rapid progression of chronic adult periodontitis in HIV+ patients. Attempts to identify the pathogenesis of the increased progression of periodontitis have not proven successful. For example, analysis of subgingival plaque for the presence of bacterial pathogens has failed to detect differences between HIV+ and HIV- patients. Recently our laboratory has identified alterations in the host response in the gingival crevice of HIV+ patients. Comparing HIV+ and HIV- injecting drug users (IDU), levels of the proinflammatory cytokine interleukin-1 beta (IL-1 beta) in gingival crevicular fluid (GCF) were slightly elevated at sites with a probing depth of 1 to 3 mm. At deeper sites (> or = 4 mm), total IL-1 beta in GCF was significantly greater in HIV+ individuals. Using the lysosomal acid glycohydrolase beta-glucuronidase (beta G) as a measure of the influx of polymorphonuclear leukocytes (PMN) into the gingival crevice, our data indicated a significant correlation of total beta G in GCF and probing depth in the HIV-IDU (r = 76; P = .02). This result was similar to what we have observed in other studies. In contrast, for HIV+ subjects, total beta G was not associated with probing depth (r = .20; NS). These data suggest that HIV+ patients have altered regulation of PMN recruitment into the gingival crevice. We have begun to investigate the conditions under which subgingival Candida may contribute total periodontal lesions in HIV+ individuals. Candida from subgingival sites has been cultured in HIV+ individuals. Subgingival Candida was distinct from Candida isolated from tongue and buccal mucosal surfaces (as indicated by genomic fingerprinting). We hypothesize the absence of adequate priming of PMN by HIV+ patients. This may be due to a reduced Th1 lymphocyte response. The inability of HIV+ individuals to adequately prime PMN may allow Candida to colonize the subgingival environment. In that milieu, it may act directly or in concert with subgingival bacterial pathogens, or as a cofactor (by inducing production of proinflammatory cytokines) to increase the occurrence of periodontal attachment loss.

CD30+ lymphocytes in chronic gingivitis from HIV-positive patients: a pilot study

Th2 type lymphocytes are characterized by high expression of CD30 glycoprotein. Increased serum levels of CD30 and Th2 IL-4 producing T-cells are found during AIDS progression. Since HIV-positive patients are more susceptible to periodontal disease, quantitative analysis of positive cells for the CD30 receptor in chronic gingivitis of both HIV-infected and non-infected patients (NSG) would help to clarify the immunoregulation of HIV-associated periodontal diseases. The purpose of this study was to evaluate CD30+ lymphocytes in gingival biopsies from sites exhibiting chronic gingivitis on HIV-positive patients (CG-HIV) and NSG. A biotin-streptavidin amplified system was used for identification of the CD30 receptor. The results demonstrated increased proportions of Th2 cells in CG-HIV as compared to NSG. Additional studies are necessary to understand the importance of these cells to the biological activity or inactivity of the disease.

Epidemiology and diagnosis of HIV-associated periodontal diseases

A review of periodontal disease as a manifestation of HIV infection suggests a shift in emphasis over the past 5 years. Initially the focus was on newly described forms of periodontal disease (i.e., HIV-associated gingivitis or linear gingival erythema (LGE); HIV-associated periodontitis or necrotizing ulcerative periodontitis (NUP). While the clinical definition of LGE varies from study to study, an association between LGE and Candida infection has been described. Furthermore, the prevalence of NUP is quite low and this disorder is associated with severe immunosuppression. In contrast, the focus today is on the accelerated rate of chronic adult periodontitis occurring in seropositive patients. While the organisms that characterize adult periodontitis in seronegative individuals are present in subgingival plaque from seropositive individuals, reports suggest that atypical pathogens are also present (i.e., Mycoplasma salivarium, Enterobacter cloacae). Recent studies from our laboratory have identified a novel strain of Clostridium isolated from the subgingival plaque of injecting drug users that has pathologic potential. This organism, however, was found in both seropositive and seronegative individuals in this cohort, suggesting an association with lifestyle rather than serostatus. In addition, data has been published examining the local host response in periodontitis in seropositive individuals. Distinctly elevated levels of IgG in gingival crevicular fluid (GCF) have been observed in seropositive patients. Furthermore, data from our laboratory examining inflammatory mediators in GCF (polymorphonuclear leukocyte lysosomal enzyme beta-glucuronidase and the pro-inflammatory cytokine interleukin-1 beta) suggests an altered response in patients with HIV infection. The alteration manifests as the absence of the expected strong correlation between polymorphonuclear leukocyte activity in the gingival crevice and clinical measures of existing periodontal disease, as well as elevated levels of interleukin-1 beta in sites with deeper probing depths. Therefore, it can be concluded that the progression of periodontal disease in the presence of HIV infection is dependent upon the immunologic competency of the host as well as the local inflammatory response to typical and atypical subgingival microorganisms.

Oral manifestations of HIV infection

The oral manifestations of HIV infection are reviewed along with evidence supporting the need for training of health-care professionals in the recognition of oral lesions. The diagnosis, prevalence, pathogenesis, and management of the most common oral lesions observed in HIV infection are described. Oral candidiasis and hairy leukoplakia are two oral lesions that have been demonstrated to have important prognostic significance. The diagnosis and management of periodontal disease in seropositive patients is emphasized, and a preventive protocol for patients at risk for periodontal pathology is recommended.

High numbers of T cells in gingiva from patients with human immunodeficiency virus (HIV) infection

A quantitative, immunohistologic evaluation of CD3+, CD4+ and CD8+ cells was carried out on gingival biopsies from 25 HIV-infected persons with gingivitis or periodontitis and 13 HIV-seronegative persons with periodontitis. CD3+ T cells were found in all biopsies. CD8+ cells were significantly more numerous and the CD4+/CD8+ ratio was significantly decreased in the gingival connective tissue of the HIV+ patients (p < 0.05). The number of CD4+ lymphocytes subjacent to the pocket epithelium was moderately lower in the HIV+ patients as compared to the HIV patients (p < 0.05). HIV+ patients with a history of necrotizing periodontal disease had fewer CD4+ cells subjacent to the oral gingival epithelium than patients without such disease (p < 0.05). The general HIV-related changes in T lymphocyte numbers were therefore reflected in inflamed gingival tissues. HIV+ patients had, however, significantly higher CD4+/CD8+ ratios in gingiva than in peripheral blood (p < 0.05), indicating that CD4+ T cells are actively recruited to gingiva, even in cases of extreme CD4+ T lymphocytopenia.

Immunohistochemical study of linear gingival erythema from HIV-positive patients

Severe forms of periodontal disease are frequent in patients with acquired immunodeficiency syndrome (AIDS). Linear gingival erythema (LGE) is a progressive disease described in HIV-positive patients and is considered to be an early stage of necrotizing periodontitis. Although clinical and microbiological differences are reported in LGE and non-specific gingivitis (NSG), a comparative immunopathological approach of both has not been performed yet. The purpose of this study was to compare relative populations of T-lymphocytes, B-lymphocytes, neutrophils, macrophages and IgG bearing plasma cells in gingival biopsies from sites exhibiting LGE and from sites exhibiting NSG. A biotin-streptavidin amplified system was used for identification of the following antigens: CD3 (T-lymphocytes), CD20 (B-lymphocytes), elastase (neutrophils), CD68 (macrophages) and IgG (plasma cell's secretors of IgG). The results have demonstrated decrease proportions of T-lymphocytes, macrophages and high percentage of neutrophils and IgG bearing plasma cells in LGE. In contrast with NSG, many neutrophils cells in LGE were found inside oral gingival epithelium. Our results highlight the idea that progressive periodontal disease is not only characterized by increased tissue inflammation, but, in addition, by significant changes in the proportion of specific inflammatory cells. The high number of neutrophils along the gingival epithelium is probably associated with the severe gingival necrosis reported in AIDS patients.

The relationship of candidiasis to linear gingival erythema in HIV-infected homosexual men and parenteral drug users

Periodontal status was evaluated in two cohorts participating in a study of the natural history of human immunodeficiency virus (HIV) infection. One cohort consisted of 77 seropositive and 44 seronegative homosexual men, and the other cohort was comprised of 44 seropositive and 39 seronegative parenteral drug users (PDU). No differences were observed between seropositive and seronegative individuals within a cohort in terms of clinical periodontal parameters (percent of sites with > or = 4 mm probing depth, percent of sites exhibiting bleeding on probing, mean oral hygiene index). The PDU displayed more existing periodontal disease than the homosexual men. Periodontal disease in the seropositive individuals in both cohorts was not strictly related to the number of CD4+ lymphocytes. Linear gingival erythema (LGE), defined as an erythematous band of at least 2 mm extending between adjacent papilla, was observed in all 4 groups. Seropositive homosexual men displayed more LGE than seronegative homosexual men (16.6% vs. 11.4%) and seronegative PDU displayed more LGE than seropositive PDU (38.5% vs. 29.5%), but neither difference was significant. LGE tended to be related to reduced numbers of CD4+ lymphocytes, but this relationship did not reach statistical significance. A statistically-significant relationship was found between the presence of intraoral candidiasis and LGE in seropositive homosexual men: 42.9% of these subjects with candidiasis had LGE, while only 12.7% of the subjects without candidiasis had LGE (P < .05). For the seropositive PDU, 35.3% of the individuals with candidiasis had LGE and 25.9% of the subjects without candidiasis displayed LGE, but the difference was not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Necrotizing ulcerative periodontitis: a marker for immune deterioration and a predictor for the diagnosis of AIDS

A multitude of oral lesions have been described in individuals infected with the human immunodeficiency virus (HIV). Few studies have attempted to correlate specific oral findings with immune status and HIV disease progression in the population reflecting the demographic profile of this epidemic. A prospective study was conducted among 700 ambulatory HIV-infected individuals seeking dental care between July 1, 1988 and June 30, 1992. Patients entered the study when they first applied for care and were followed at regular intervals unless death occurred before the conclusion of the study. The prevalence rate of necrotizing ulcerative periodontitis (NUP) was calculated for the entire population and specific to race, gender, and HIV transmission category. Survival analysis was used to estimate the cumulative probability of death within 24 months of a NUP diagnosis. The association between NUP diagnosis and CD4+ cell count below 200 cells/mm3 was also investigated, and it was found that HIV-infected individuals presenting with a diagnosis of NUP were 20.8 times as likely to have a CD4+ cell count below 200 cells/mm3 compared to HIV-infected individuals presenting without NUP. The prevalence of NUP was 6.3%. The lesion was significantly more common among men having sex with men (MSM), 8.4%, compared with non-MSM males, 1.8%. No racial difference was noted. The mean CD4+ cell count for patients with NUP was 51.8 cells/mm3 (SD +/- 71.2) while the median CD4+ cell count was 32.0 cells/mm3. The predictive value of a CD4+ cell count below 200 cells/mm3 in patients with this lesion was 95.1%. A cumulative probability of death within 24 months of a NUP diagnosis was 72.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral manifestations associated with HIV-related disease as markers for immune suppression and AIDS

BACKGROUND

Oral lesions are common findings in HIV-related disease, but little is known about their significance in predicting immune suppression among a representative group of HIV-infected persons.

METHODS

Oral examinations were performed on 454 patients who came to an outpatient dental clinic for dental care. CD4+ cell counts were obtained within 2 months of the examination.

RESULTS

In persons with a specific lesion and a CD4+ cell count below 200 cells/mm3 the corresponding mean CD4+ cell counts and predictive values were 149.5 cells/mm3 and 69.9% for candidiasis, 143.3 cells/mm3 and 70.1% for oral hairy leukoplakia, 126.0 cells/mm3 and 69.4% for xerostomia, 51.8 cells/mm3 and 95.1% for necrotizing ulcerative periodontitis, 98.7 cells/mm3 and 87.0% for long-standing herpes simplex virus infections, 66.6 cells/mm3 and 93.6% for Kaposi's sarcoma, and 33.7 cells/mm3 and 100% for major aphthous ulcers. The mean CD4+ cell count declined with increased numbers of different concurrent lesions.

CONCLUSION

The presence of specific oral manifestations and the number of different concurrent intraoral lesions among HIV-infected persons are associated with severe immune suppression and AIDS. Oral examinations are an essential component for early recognition of disease progression and comprehensive evaluation of HIV-infected patients.

Periodontal diseases in HIV-infected patients

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