Rapid diagnosis of periodontal infections: findings in AIDS patients

Current trends and new developments in HIV research and periodontal diseases

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

Dental profile of a community of recovering drug addicts: Biomedical aspects. Retrospective cohort study

Objectives: to obtain a biomedical oral profile of a community of adult drug addicts in treatment by analysing their dental health, with a view to determining whether the state of their oral health could be attributed primarily to their lifestyle and the direct consequences of drug abuse on their overall condition, rather than to the effects of the drugs used. Experimental Design: the study was conducted under the terms of an agreement between the Complutense University of Madrid’s (UCM) Odontology Faculty and the City of Madrid’s Substance Abuse Institute. Seventy drug addicts and 34 control group subjects were examined. The study assessed oral hygiene habits, systemic pathology, type of drugs used and the duration of use, oral pathology, oral health indices, risk of caries based on saliva tests, oral candidiasis and periodontal microbiology. Results: statistically significant differences (p<0.05) were found between the test and control groups for practically all the variables analysed. In the drug users group, dental hygiene was wanting, systemic and oral pathology prevailed and the decayed/missing/filled teeth or surface (DMFT/S) indices denoted very poor buccodental health. The saliva tests showed a substantial risk of caries and candidiasis rates were high. By contrast, with a single exception, the microbiological studies detected no statistically significant difference between drug users and control groups periodontal flora. Conclusions: drug-dependent patients had poor oral health and a significant increase in oral pathology, essentially caries and periodontal disease. Their risk of caries was high and the presence of candidiasis was representative of their poor general and oral health. Drug users’ poor buccodental condition was more closely related to lifestyle than to drug abuse itself.

Key words:Buccal, dental, drug addicts.

Periodontal disease in HIV/AIDS

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

An update on HIV and periodontal disease

With the advent of newer pharmacological approaches to the treatment of human immunodeficiency virus (HIV) infection, the incidence and progression of both atypical and conventional periodontal diseases are changing. The incidence of necrotizing periodontitis and gingival diseases of fungal origin appears to be on the decline as a result of these therapies that have led to increased life spans for HIV patients. However, in cases where these therapies lose their effectiveness and HIV patients relapse into an immunosuppressed state, these conditions may recur. Recent evidence has shown that HIV patients with more conventional periodontal diseases such as chronic periodontitis may have increased attachment loss and gingival recession when compared to their HIV-negative counterparts. This pattern of loss of periodontal support may be due in part to a diffuse invasion of opportunistic bacterial infections, viruses, and fungi into the gingival tissue, leading to a more elevated and more diffuse destructive inflammatory response in the periodontal soft and hard tissues. While the accepted approaches to treating the spectrum of periodontal diseases in HIV patients remain essentially unchanged over the past 15 years, the impact of newer systemic therapies on patient immunocompetence may influence treatment decisions.

Periodontal disease as a specific, albeit chronic, infection: diagnosis and treatment

Periodontal disease is perhaps the most common chronic infection in adults. Evidence has been accumulating for the past 30 years which indicates that almost all forms of periodontal disease are chronic but specific bacterial infections due to the overgrowth in the dental plaque of a finite number of mostly anaerobic species such as Porphyromonas gingivalis, Bacteroides forsythus, and Treponema denticola. The success of traditional debridement procedures and/or antimicrobial agents in improving periodontal health can be associated with the reduction in levels of these anaerobes in the dental plaque. These findings suggest that patients and clinicians have a choice in the treatment of this overgrowth, either a debridement and surgery approach or a debridement and antimicrobial treatment approach. However, the antimicrobial approach, while supported by a wealth of scientific evidence, goes contrary to centuries of dental teaching that states that periodontal disease results from a "dirty mouth." If periodontal disease is demonstrated to be a risk factor for cardiovascular disease and stroke, it will be a modifiable risk factor since periodontal disease can be prevented and treated. Since the antimicrobial approach may be as effective as a surgical approach in the restoration and maintenance of a periodontally healthy dentition, this would give a cardiac or stroke patient and his or her physician a choice in the implementation of treatment seeking to improve the patient's periodontal condition so as to reduce and/or delay future cardiovascular events.

The antimicrobial treatment of periodontal disease: changing the treatment paradigm

Over the last 100 years, methods of surgical periodontal treatment have enjoyed a history of success in improving oral health. The paradigm of care is based on the "non-specific plaque hypothesis"--that is, the overgrowth of bacterial plaques cause periodontal disease, and the suppression of this overgrowth reduces disease risk. The central feature of this approach to care is the removal of inflamed gingival tissue around the teeth to reduce periodontal pocket depth, thereby facilitating plaque removal by the dentist and by the patient at home. Over the last 30 years, with the recognition that periodontal disease(s) is caused by specific bacteria and that specific antimicrobial agents can reduce or eliminate the infection, a second paradigm has developed. This new paradigm, the "specific plaque hypothesis", focuses on reducing the specific bacteria that cause periodontal attachment loss. The contrast between the two paradigms can be succinctly stated as follows: The antimicrobial therapy reduces the cause, while the surgical therapy reduces the result of the periodontal infection. The specific plaque hypothesis has two important implications. First, with the increasing attention to evidence-based models for prevention, treatment, outcome assessment, and reimbursement of care, increasing attention and financial effort will be channeled into effective preventive and treatment methods. Second, the recent observations that periodontal infections increase the risk of specific systemic health problems, such as cardiovascular disease, argue for the prevention and elimination of these periodontal infections. This review highlights some of the evidence for the specific plaque hypothesis, and the questions that should be addressed if antimicrobial agents are to be used responsively and effectively.

Alveolar bone levels in AIDS and HIV seropositive patients and in control subjects

Alveolar bone levels were studied from intraoral radiographs of 24 non-hospitalized patients with AIDS, 17 HIV seropositive subjects, and 39 matched control subjects. The AIDS/HIV subjects were seeking dental care in a faculty practice. The matched control subjects came from those non-HIV-infected patients seeking dental care at the University of Washington. Magnified intraoral radiographs were used to assess the distance between the cemento-enamel junction (CEJ) and the alveolar bone level (BL). The extent of vertical defects and furcation invasions was also assessed. The mean age of the AIDS, HIV, and control subjects was 38.9 +/- 6.6 years, 37.1 +/- 7.6, and 39.9 +/- 5.6, respectively, and was not statistically different. Among the AIDS patients, 75% were smokers, while 88.2% of the HIV subjects were cigarette smokers. Therefore, the matched control subjects were also smokers to the same extent. The mean difference in distance CEJ-BL was 0.1 mm (mesial) and 0.3 mm (distal) and greater in the HIV/AIDS group than in the control group, but not statistically different. No vertical defects > or = 3.0 mm were found in 69.2% of the control subjects and in 58.5% of the combined HIV/AIDS group. None of the HIV/AIDS subjects had more than 5 defects > 3.0 mm, while 7.6% of the control subjects had such defects. Significant associations were found between smoking and extent of alveolar bone loss (distance) (P < 0.001) as well as the number and extent of vertical defects (P < 0.01), but were not associated with HIV status. The extent of furcation invasions, as read radiographically, did not differ between groups. In conclusion, smoking but not HIV status was the primary factor for alveolar bone loss.