Nuclear F-actin Cytology in Oral Epithelial Dysplasia and Oral Squamous Cell Carcinoma

Oral cavity cancer has a low 5-y survival rate, but outcomes improve when the disease is detected early. Cytology is a less invasive method to assess oral potentially malignant disorders relative to the gold-standard scalpel biopsy and histopathology. In this report, we aimed to determine the utility of cytological signatures, including nuclear F-actin cell phenotypes, for classifying the entire spectrum of oral epithelial dysplasia and oral squamous cell carcinoma. We enrolled subjects with oral potentially malignant disorders, subjects with previously diagnosed malignant lesions, and healthy volunteers without lesions and obtained brush cytology specimens and matched scalpel biopsies from 486 subjects. Histopathological assessment of the scalpel biopsy specimens classified lesions into 6 categories. Brush cytology specimens were analyzed by machine learning classifiers trained to identify relevant cytological features. Multimodal diagnostic models were developed using cytology results, lesion characteristics, and risk factors. Squamous cells with nuclear F-actin staining were associated with early disease (i.e., lower proportions in benign lesions than in more severe lesions), whereas small round parabasal-like cells and leukocytes were associated with late disease (i.e., higher proportions in severe dysplasia and carcinoma than in less severe lesions). Lesions with the impression of oral lichen planus were unlikely to be either dysplastic or malignant. Cytological features substantially improved upon lesion appearance and risk factors in predicting squamous cell carcinoma. Diagnostic models accurately discriminated early and late disease with AUCs (95% CI) of 0.82 (0.77 to 0.87) and 0.93 (0.88 to 0.97), respectively. The cytological features identified here have the potential to improve screening and surveillance of the entire spectrum of oral potentially malignant disorders in multiple care settings.

In vitro interaction of posaconazole and caspofungin against clinical isolates of Candida glabrata

Combinations of caspofungin and posaconazole were evaluated by fractional inhibitory concentration index against 119 Candida glabrata isolates. Synergy was seen in 18% of all isolates and in 4% of fluconazole-resistant isolates at 48 h without evidence of antagonism. This antifungal combination may have utility against this organism.

Comparison of antifungal susceptibilities to fluconazole and voriconazole of oral Candida glabrata isolates from head and neck radiation patients

The antifungal susceptibilities of 79 oral Candida glabrata isolates to fluconazole and voriconazole were compared. The MICs at which 90% of the isolates tested were inhibited were 1 microg of voriconazole/ml and 32 microg of fluconazole/ml. Oral C. glabrata isolates for which the fluconazole MICs are elevated are commonly those for which the voriconazole MICs are elevated, but these increases may be transient for voriconazole, as they are for fluconazole.

Candida glabrata sepsis secondary to oral colonization in bone marrow transplantation

Candida glabrata has emerged as a common cause of fungal sepsis in bone marrow transplant patients, particularly those receiving fluconazole prophylaxis. Colonization of the lower GI tract and indwelling catheters have been thought to be the primary sources of systemic infection with Candida. We report on a bone marrow transplant patient who developed Candida glabrata sepsis from pre-existing oral colonization.

Isolation of non-tuberculosis mycobacteria in treated dental unit waterlines

OBJECTIVE

The purpose of the study was to investigate the presence of non-tuberculosis mycobacteria (NTM) in dental unit waterlines that were being routinely treated with an intermittent use waterline cleaner.

STUDY DESIGN

The study was conducted at a hospital dentistry clinic where immunocompromised patients are seen. Water samples from two lines on one of two dental units were taken before and after routine weekend chemical treatment. Sampling was repeated on two subsequent occasions, on the same unit, at three monthly intervals. Laboratory techniques included centrifugation and membrane filtration to detect small numbers of organisms.

RESULTS

Mycobacterium simiae was isolated from one of the four pre-treatment samples and from two of the four post-treatment samples. Mycobacterium mucogenicum was isolated from one of the four post-treatment samples.

CONCLUSIONS

This pilot study found that NTM were present in DUWLs that were being routinely treated with an intermittent use chemical cleaner. Practitioners are urged to understand the limitations of available DUWL treatments, and to consider the use of sterile water for non-surgical, as well as surgical, treatment of immunocompromised patients.

Identification of Exophiala mesophila isolated from treated dental unit waterlines

Members of the genus Exophiala are often difficult to identify to the species level because of their variable morphological appearances. This paper describes the methods used to identify Exophiala mesophila and provides salient differential features for distinguishing other mesophilic members of the genus.

The role of yeasts other than Candida albicans in oropharyngeal candidiasis

Candida albicans has been recognized as the predominant infecting organism in oropharyngeal candidiasis. Yeasts other than C. albicans are commonly recognized as colonizing the oral cavity but have not been thought to be a significant cause of disease. This review will describe the emergence of yeasts other than C. albicans as causative pathogens in oropharyngeal candidiasis both as co-infecting organisms with C. albicans and as sole pathogens themselves. Diagnosis and treatment of these emerging infections will also be discussed.

Candida dubliniensis in radiation-induced oropharyngeal candidiasis

Candida dubliniensis is a recently described species that has been shown to cause oropharyngeal candidiasis in patients with HIV. We present a detailed evaluation of a patient undergoing head and neck radiation for oral cancer who developed oropharyngeal candidiasis from a mixed infection of C dubliniensis and Candida albicans. To our knowledge, this is the first described case of C dubliniensis contributing to oropharyngeal candidiasis in this patient population.

The epidemiology of non-albicans Candida in oropharyngeal candidiasis in HIV patients

Oropharyngeal candidiasis (OPC) is the most common fungal infection in patients with HIV infection. Fluconazole has been proven to be very effective in treating this infection, but decreased susceptibility of Candida to this drug has emerged. Certain non-albicans species such as C. glabrata and C. krusei are commonly less susceptible to fluconazole than C. albicans and are being isolated with increased frequency in HIV patients. The purpose of this study was to determine if the presence of non-albicans Candida with OPC in HIV patients had an impact on clinical presentation. This study shows that late-stage HIV patients have a high prevalence of Candida with decreased susceptibility to fluconazole, especially non-albicans species. OPC episodes with non-albicans isolates were more likely to require higher doses of fluconazole to achieve clinical cure. Also, the presence of non-albicans Candida was more frequently associated with severe symptoms.

Coronary artery stents: review and patient-management recommendations

BACKGROUND

Coronary artery stents are metallic scaffold devices that physically support narrowed coronary arteries to alleviate symptoms of ischemic coronary artery disease. They are placed during invasive procedures similar to that of percutaneous transluminal coronary angioplasty, and patients are maintained with antiplatelet medications to lessen the chances of stent stenosis.

METHODS

The authors provide a brief overview of coronary artery stents and discuss the dental management of patients who have received stents.

CONCLUSIONS

After stent placement, patients usually are maintained with antiplatelet regimens, which may necessitate choosing medications that do not potentiate their effects. Any discussion as to the possible need for antibiotic prophylaxis of patients with stents largely is missing from the literature. Recent literature, however, indicates that antibiotic prophylaxis, if required, may only be needed during the first few weeks after stent placement.

CLINICAL IMPLICATIONS

Dental professionals should become knowledgeable about coronary artery stents. Although these devices have a higher success rate than other procedures in alleviating symptoms of ischemic coronary artery disease, some patients are still at risk of experiencing significant cardiac events.

Epidemiology of oropharyngeal Candida colonization and infection in patients receiving radiation for head and neck cancer

Oral mucosal colonization and infection with Candida are common in patients receiving radiation therapy for head and neck cancer. Infection is marked by oral pain and/or burning and can lead to significant patient morbidity. The purpose of this study was to identify Candida strain diversity in this population by using a chromogenic medium, subculturing, molecular typing, and antifungal susceptibility testing of clinical isolates. These results were then correlated with clinical outcome in patients treated with fluconazole for infection. Specimens from 30 patients receiving radiation therapy for head and neck cancer were cultured weekly for Candida. Patients exhibiting clinical infection were treated with oral fluconazole. All isolates were plated on CHROMagar Candida and RPMI medium, subcultured, and submitted for antifungal susceptibility testing and molecular typing. Infections occurred in 27% of the patients and were predominantly due to Candida albicans (78%). Candida carriage occurred in 73% of patients and at 51% of patient visits. Yeasts other than C. albicans predominated in carriage, as they were isolated from 59% of patients and at 52% of patient visits. All infections responded clinically, and all isolates were susceptible to fluconazole. Molecular typing showed that most patients had similar strains throughout their radiation treatment. One patient, however, did show the acquisition of a new strain. With this high rate of infection (27%), prophylaxis to prevent infection should be evaluated for these patients.

Treating the discomfort of oral ulceration resulting from cancer chemotherapy

Chemotherapy-induced oral mucositis can result in inadequate oral intake, local and systemic infection, a prolonged hospital stay, and increased cost of treatment. Treatment of the pain resulting from this condition can greatly lessen these problems. Hydroxypropyl cellulose gel with benzocaine (Zilactin B) has been shown to effectively reduce the pain of mucositis for up to 3 hours.

Fluconazole disk diffusion susceptibility testing of Candida species

We describe a simple procedure for detecting fluconazole-resistant yeasts by a disk diffusion method. Forty clinical Candida sp. isolates were tested on RPMI-glucose agar with either 25- or 50-microgram fluconazole disks. With 25-microgram disks, zones of inhibition of >/=20 mm at 24 h accurately identified 29 of 29 isolates for which MICs were /=27 mm identified 28 of 29 such isolates. All 11 isolates for which MICs were >8 microgram/ml were identified by using either disk. Disk diffusion may be a useful screening method for clinical microbiology laboratories.

Treatment of oral chronic graft-versus-host disease with PUVA therapy: case report and literature review

Chronic graft-versus-host disease commonly appears with oral manifestations subsequent to allogeneic bone marrow transplantation. These manifestations include leukoplakia, mucosal atrophy, erythema, ulcers, and xerostomia. Some lesions are resistant to treatment with immunosuppressive medications. Ultraviolet A irradiation therapy with oral psoralen has been shown to be effective in treating these resistant lesions. This article presents a review of the literature and a case report.

A randomized trial of continuous or intermittent therapy with fluconazole for oropharyngeal candidiasis in HIV-infected patients: clinical outcomes and development of fluconazole resistance

PURPOSE

The effects of continuous or intermittent therapy with fluconazole on the recurrence of and the development of fluconazole resistance are not known.

PATIENTS AND METHODS

We studied human immunodeficiency virus (HIV)-positive patients with CD4 cell count <350 x 10(6)/L and oropharyngeal candidiasis in a prospective, randomized study. After initial treatment, 20 patients (16 of whom completed 3 months of follow-up) received continuous fluconazole at 200 mg/day, and 48 patients (28 of whom completed follow-up) received intermittent therapy at the time of symptomatic relapses. Oral samples were obtained weekly during episodes of infection and quarterly as surveillance cultures. Development of resistance was defined as a fourfold rise in minimum inhibitory concentration (MIC) to at least 16 microg/mL from the initial culture in the same species, the emergence of new, resistant (MIC > or =16 microg/mL) species, or a significant increase in the proportion of resistant isolates.

RESULTS

During a mean follow-up of 11 months, median annual relapse rates were lower in patients on continuous therapy (0 episodes/year) than in patients on intermittent therapy (4.1 episodes/year; P <0.001). Sterile cultures were seen in 6 of 16 (38%) patients on continuous therapy compared with 3 of 28 (11%) on intermittent therapy (P = 0.04). Microbiological resistance developed in 9 of 16 (56%) patients on continuous treatment, compared with 13 of 28 (46%) on intermittent treatment (P = 0.75). However, despite isolates with increased MICs, 42 of 44 patients responded to fluconazole in doses up to 800 mg/day.

CONCLUSIONS

In patients with frequent recurrences, continuous suppressive therapy significantly reduced relapses and colonization. Resistance occurred with both continuous and intermittent therapy; however, therapeutic responses were excellent.

Dental management and treatment of xerostomic patients

Saliva is extremely important for the health and comfort of the oral cavity. Diminution in salivary flow is accompanied by a plethora of problems. A salivary flow inadequate to protect the oral cavity may be an occult condition. Dentists should evaluate those patients presenting with a high incidence or increased incidence of dental caries for a decreased salivary flow. We have presented diagnostic aids, management techniques and treatment modalities for these patients.

Clinical evaluation and microbiology of oropharyngeal infection due to fluconazole-resistant Candida in human immunodeficiency virus-infected patients

Signs and symptoms of oropharyngeal candidiasis (OPC) were correlated with microbiology and clinical response to fluconazole in a cohort of patients with advanced human immunodeficiency virus (HIV) infection and recurrent OPC. Sixty-four HIV-infected patients with a median CD4 cell count of < 50/mm3 (range, 3-318/mm3) who presented with OPC were enrolled in a longitudinal study. Specimens for cultures were taken weekly until clinical resolution. Therapy with fluconazole was increased weekly as required to a maximum daily dose of 800 mg until resolution of symptoms and oral lesions. Resistant or dose-dependent susceptible yeasts, defined as a minimum inhibitory concentration of > or = 16 micrograms/mL, were detected in 48 (31%) of 155 episodes. Clinical resolution with fluconazole therapy occurred in 107 (100%) of 107 episodes with susceptible yeasts vs. 44 (92%) of 48 episodes with resistant or dose-dependent susceptible strains (P = .008). Patients from whom fluconazole-resistant yeasts were isolated required longer courses of therapy and higher doses of fluconazole for response, but overall, excellent responses to fluconazole were seen in patients with advanced HIV infection.

Interpretation of trailing endpoints in antifungal susceptibility testing by the National Committee for Clinical Laboratory Standards method

Trailing endpoints remain a problem in antifungal susceptibility testing using the National Committee for Clinical Laboratory Standards (NCCLS) method. For isolates for which trailing endpoints are found, MICs of < or = 1 microg/ml at 24 h and of > 64 microg/ml at 48 h are usually observed. In a study of human immunodeficiency virus (HIV)-infected patients with oropharyngeal candidiasis, we identified three patients with multiple serial isolates for which trailing endpoints were observed with fluconazole. At 24 h, MICs were generally < or = 1 microg/ml by both broth macro- and microdilution methods. However, at 48 h, MICs were > 64 microg/ml, while the organism remained susceptible by agar dilution testing with fluconazole. Most episodes of oropharyngeal candidiasis with trailing-endpoint isolates responded to doses of fluconazole as low as 100 mg/day. Two patients had both susceptible and trailing-endpoint isolates by NCCLS broth macro- and microdilution testing; these isolates were found to be the same strain by pulsed-field gel electrophoresis using restriction fragment length polymorphisms. Another patient had two different strains, one for which trailing endpoints were observed and one which was susceptible at 48 h. Trailing endpoints may be seen with selected isolates of a strain or may be a characteristic finding for most or all isolates of a strain. In addition, with isolates for which trailing endpoints are observed, reading the endpoint for the NCCLS method at 24 h may be more appropriate.

Variations in fluconazole susceptibility and DNA subtyping of multiple Candida albicans colonies from patients with AIDS and oral candidiasis suffering one or more episodes of infection

Five Candida albicans colonies from each infection in AIDS patients receiving fluconazole therapy for oropharyngeal candidiasis over a 2-year period were evaluated by antifungal susceptibility testing and DNA subtyping, and the results were correlated with clinical response to determine the occurrence of clinically significant selection of more-resistant C. albicans over multiple infections. A total of 534 C. albicans isolates were obtained from 38 patients who exhibited 84 episodes of infection. Antifungal susceptibility testing revealed that the MICs for 93% of the isolates were < or = 8.0 microg/ml and the MICs for 7% of the isolates were > or = 64 microg/ml. DNA subtyping revealed 70 different subtypes, with 78% of patients with one infection exhibiting one DNA subtype and 80% of patients with more than one infection exhibiting multiple DNA subtypes. Also, patients who had multiple infections had lower CD4 counts than those with single infections. Differences between the single-infection group and the multiple-infection group regarding the number of DNA subtypes and CD4 counts were both statistically significant. Of the 74 evaluable infections all were successfully treated with regular-dose (100-mg/day) fluconazole, except for three patients who ultimately responded to higher-dose fluconazole. Only one patient may have shown clinically significant selection of a more-resistant C. albicans strain over multiple courses of treatment. Interestingly, MICs reached only 8.0 microg/ml, even though doses of 400 mg of fluconazole were necessary for clinical cure.

Stable azole drug resistance associated with a substrain of Candida albicans from an HIV-infected patient

Oral candidiasis is one of the earliest and most frequent complications of a failing immune system in HIV-infected individuals. For several years, oral candidiasis has been treated effectively with azole drugs, the one most frequently used is fluconazole. Unfortunately, extensive use of the drug for treatment and prophylaxis has led to treatment failure in an increasing number of patients. In most of these cases, strains of C. albicans isolated from the infection are less susceptible to fluconazole. The development of azole resistance in strains of C. albicans has been studied biochemically and more recently with molecular techniques. One excellent example of the development of azole resistance in C. albicans has been documented in a series of 17 C. albicans isolates from a single patient over a 2-year period. During this time, the patient experienced 14 episodes of oral candidiasis and was treated with increasing doses of fluconazole. Molecular and biochemical analyses confirms that the isolates are the same strain of C. albicans and that the resistance in these isolates is stable over 600 generations, suggesting that the changes in this strain are genetic in nature. In addition, the development of resistance is correlated with the identification of a substrain or variant of the original strain, as identified by restriction fragment length polymorphism (RFLP) analysis with the moderately repetitive probe, Ca3. The analysis of this series of isolates demonstrates that azole drug resistance is associated with several small genetic changes, each of which contributes to the overall resistance of the strain. Clearly, continual use of azole drugs by a patient can select for genetic changes that render oral candidiasis refractory to treatment.

Detection and significance of fluconazole resistance in oropharyngeal candidiasis in human immunodeficiency virus-infected patients

The epidemiology and clinical significance of fluconazole resistance were assessed in a cohort of advanced human immunodeficiency virus (HIV)-infected patients with recurrent oropharyngeal candidiasis. Fifty patients were prospectively evaluated using a novel method of detecting fluconazole resistance with chromogenic media containing fluconazole; results were confirmed with macrobroth testing. Resistant yeasts, defined as MICs > or = 8 micrograms/mL, were detected in 16 (32%) of 50 patients: 7 (14%) had resistant Candida albicans, 7 (14%) had resistant non-C. albicans yeast, and 2 (4%) had mixed resistant yeasts. MICs were > or = 32 in 11 of 16 isolates. Previous fluconazole use and severe immunosuppression were risk factors for resistance. However, 5 of 26 patients had resistant isolates with no prior fluconazole use, and all were severely immunosuppressed. Despite the high prevalence of resistance, 48 patients clinically responded to fluconazole. Fluconazole-resistant C. albicans and non-C. albicans yeast infections are common in patients with advanced immunodeficiency, but clinical efficacy of fluconazole remains high.

Dental management of children with asthma

Asthma affects about 1 in 10 children. The condition is characterized by acute respiratory distress brought on by environmental factors. The condition is treated with medications aimed to reduce reaction to stimulants by the airway. Dental management involves attention to the status of the patient and awareness of stimulants of the reactive airway. Clinical recommendations are provided.

Simple method for detecting fluconazole-resistant yeasts with chromogenic agar

A method for detecting fluconazole-resistant yeasts was developed that uses chromogenic agar containing fluconazole. Yeasts were plated on media with fluconazole at 0, 8, and 16 micrograms/ml. On media without fluconazole, normal growth of susceptible yeasts (defined as those having a fluconazole MIC of < 8 micrograms/ml) was detected, while fluconazole-containing media suppressed susceptible strains and normal colonies of resistant yeasts (fluconazole MICs of > or = 8 micrograms/ml) were detected. This method was used to screen for resistance in oropharyngeal candidiasis. Isolates having fluconazole MICs of > or = 8 micrograms/ml and < 8 micrograms/ml were correctly predicted in 43 of 45 cultures and 115 of 116 cultures, respectively. This screening method appears to be rapid and sensitive for detection of fluconazole-resistant yeasts.

Variations in fluconazole susceptibility and electrophoretic karyotype among oral isolates of Candida albicans from patients with AIDS and oral candidiasis

DNA subtyping by pulsed-field gel electrophoresis and in vitro susceptibility testing were used to study strain variation and fluconazole resistance in Candida albicans isolates from patients with AIDS undergoing azole (fluconazole and clotrimazole) therapy for oropharyngeal candidiasis. A total of 29 patients suffered 71 episodes of oropharyngeal candidiasis. Overall, 121 isolates of C. albicans recovered throughout the course of treatment of each infection were available for further characterization. DNA subtyping revealed a total of 61 different DNA subtypes. In vitro susceptibility testing of the 121 isolates by using proposed standard methods of the National Committee for Clinical Laboratory Standards revealed MICs of fluconazole ranging from < or = 0.125 to > 64 micrograms/ml. The MIC for 50% of isolates tested was 0.25 microgram/ml, and the MIC for 90% of isolates tested was 8.0 micrograms/ml. MICs were > or = 64 micrograms/ml for only 7.4% of the isolates tested. The majority (62%) of the patients with oropharyngeal candidiasis and undergoing azole therapy were infected or colonized with more than one DNA subtype, and the introduction or selection of strains with a more resistant DNA subtype during the course of fluconazole therapy was not uncommon. With one exception, this did not appear to have an adverse effect on clinical outcome. In contrast, for patients with AIDS and oropharyngeal candidiasis infected with a single DNA subtype of C. albicans, an increase in fluconazole MICs for the infecting strain was rarely demonstrated over the course of therapy.

Radiation-induced increased platelet-activating factor activity in mixed saliva

BACKGROUND

Platelet-activating factor (PAF), a family of structurally-related phospholipid mediators of inflammation, is present in normal human mixed saliva; however, its role in oral biology and the homeostasis of oral host defense mechanisms remains to be established.

EXPERIMENTAL DESIGN

The current study was designed to evaluate the salivary levels of PAF in patients with oral mucositis that developed as a complication of head and neck irradiation for oral cancer. PAF activity was assessed in platelet bioassay and expressed relative to the activity of authentic PAF, 1-O-hexadecyl-2-acetyl-sn-glycero-3-phosphocholine (C16:0-AGEPC).

RESULTS

A significant increase in salivary PAF levels was observed in patients with mucositis (47,032 +/- 12,731 C16:0-AGEPC fmole equivalents/ml of saliva, mean +/- SE, N = 7) as compared with normal subjects (5,568 +/- 1,135 C16:0-AGEPC fmole equivalents/ml of saliva, N = 27). Phospholipid fractionation of the PAF isolated from the saliva of patients with mucositis by reverse phase high performance liquid chromatography revealed a single peak of activity that corresponded with the elution profile of C16:0-AGEPC, the most biologically active molecular species of PAF. In contrast, the PAF isolated from normal human mixed saliva contained multiple molecular species of PAF.

CONCLUSIONS

These results suggest that this potent phospholipid inflammatory mediator may play a role in the inflammation and tissue injury associated with mucositis resulting from radiation treatment for oral cancer.

Clinical evaluation of MGI 209, an anesthetic, film-forming agent for relief from painful oral ulcers associated with chemotherapy

PURPOSE

This open-label, multicenter trial evaluated the efficacy of a mucoadherent, anesthetic medication (MGI 209) for relief from painful oral ulcers associated with cytotoxic chemotherapy.

PATIENTS AND METHODS

Twenty-eight eligible cancer patients who had up to five discrete oral ulcers (total area < or = 5 cm2) completed this study. Mean age was 53.5 years (range, 21 to 81). Subjective assessments of oral discomfort before and after an orange juice pain challenge (OJPC), which was measured using a visual analog scale (VAS), and visual estimates of the amount of MGI 209 that remained on treated ulcers were collected at (1) baseline (before MGI 209 treatment); and (2) 30, 60, 120, and 180 minutes posttreatment.

RESULTS

Most subjects had low VAS scores (4 or less), which was indicative of oral discomfort, at baseline before and after the OJPC. At 30, 60, 120, and 180 minutes after MGI 209 treatment, most subjects had high VAS scores before and after an OJPC compared with baseline scores, which was indicative of a substantial increase in oral comfort; these differences were statistically significant (P < .0001). Mean percent of MGI 209 estimated to remain on ulcers at the previously mentioned times was 93.7%, 90.3%, 79.6%, and 71.3% of the total amount applied, respectively.

CONCLUSION

Benzocaine hydrochloride in combination with the protective, mucoadherent film-coating relieved discomfort for at least 3 hours even with exposure to an irritating beverage. MGI 209 treatment should allow patients with chemotherapy-induced oral ulcers to drink and eat with significantly diminished pain or no pain.

Diagnosis and management of orofacial herpes simplex virus infections

HSV disease remains a significant problem for the dental profession because of its widespread occurrence and ready transmission. Fortunately, available diagnostic techniques are highly sensitive and specific, antiviral therapy is effective in limiting the course of infection, and contemporary infection control procedures adequately safeguard dental personnel and the patient. Unfortunately, there is still a large segment of the population already infected with HSV-1 and the number of immunosuppressed latently infected patients continues to increase. Thus, patients will continue to need the help of the knowledgeable and willing dentist who can diagnose HSV-1 infection, provide effective treatment, and prevent transmission.

A comparison between fluconazole tablets and clotrimazole troches for the treatment of thrush in HIV infection

Fluconazole, a newly available triazole, has been evaluated extensively as a treatment for thrush. It has been effective in the treatment of this condition in patients with HIV infection. Clotrimazole troches have been a common treatment for thrush in patients with HIV infection for several years. This study compared the efficacy and safety of fluconazole 100 mg tablets once per day versus clotrimazole 10 mg troches five times per day in the treatment of thrush in patients with HIV infection. Patients were evaluated at baseline, day 7, 14, 28, and 42. The following parameters were evaluated: clinical cure, colonization at the end of treatment, relapse at day 28, and relapse at day 42. Side effects including liver enzyme values were also monitored. Clinical cure was superior with fluconazole tablets than with clotrimazole troches. Also, rates of colonization at the end of therapy and relapse at days 28 and 42 were less with fluconazole tablets than with clotrimazole troches. However, these differences were not statistically significant. Patient compliance with fluconazole was superior to that of clotrimazole. This difference was statistically significant. Both fluconazole tablets and clotrimazole troches are effective in treating thrush in patients with HIV infection. The avoidance of multiple-per-day dosing would appear to favor fluconazole.

The prevalence of cardiac valvular pathosis in patients with systemic lupus erythematosus

The purpose of this study was to determine the prevalence of valvular pathosis in a population of patients with SLE, to assess the candidacy of such patients for antibiotic prophylaxis before dental treatment. The hospital records of 112 patients with SLE were reviewed and screened for endocarditis, heart murmurs, and other valvular pathosis. Two of the 112 patients had confirmed cases of bacterial endocarditis. This prevalence is comparable to endocarditis prevalence rates in patients with prosthetic valves and is also three times that in patients with rheumatic heart disease. The high prevalence of endocarditis in this population of patients with SLE suggests that according to present perspectives on patient management, patients with SLE should be considered for antibiotic prophylaxis before dental therapies associated with formation of a bacteremia.

Oral herpes simplex virus infection with cardiac transplantation

Oral herpes simplex virus infection is a common complication of cardiac transplantation. Lesions are secondary to reactivation of the virus, are atypical in appearance, and can involve any oral and perioral surface. Diagnosis on clinical grounds is difficult and should be confirmed with laboratory testing. A case report and review of the literature are presented to support the features of this infection.

The use of glucocorticosteroids to lessen the inflammatory sequelae following third molar surgery

Acceptance of the use of glucocorticosteroids in density to control postsurgical inflammation has been impaired by concerns over side effects, adrenal suppression, and efficacy. The pattern of administration generally used is characterized as short-term, high-dose or pulse therapy, which has not been associated with significant side effects or adrenal suppression beyond 10 days. The selection of an appropriate glucocorticosteroid with minimal mineralocorticoid activity and extended biological activity is desirable. Oral and parenteral dosing are possible, and the latter can be administered as acetates (repository) or esters. The efficacy of glucocorticosteroids in reducing pain, swelling, and trismus after third molar surgery is difficult to ascertain because of methodological inconsistencies between investigations. In general, studies that used low dosing schedules have failed to produce dramatic and prolonged results. High-dosing intravenous (IV) studies have demonstrated significant short-term improvements, but the effects were not sustained. Combining IV administration with multiple oral dosing or a single intramuscular (IM) dose may be required to extend short-term improvement. High-dosing IM studies have shown significant and sustained anti-inflammatory effects with a single dose administered either pre- or post-operatively.

Acyclovir prophylaxis for oral herpes simplex virus infection in patients with bone marrow transplants

Reactivation of herpes simplex virus (HSV) appears to play a significant role in oral mucositis resulting from bone marrow transplantation. The acyclic guanosine derivative acyclovir has been shown to be effective in treating and protecting against HSV infection in this group. The purpose of this study was to determine the role of HSV reactivation in oral mucositis in patients undergoing bone marrow transplantation who were seronegative for HSV or who received acyclovir prophylaxis. The results suggest that HSV plays an insignificant role in oral mucositis in these patients.

Intravascular angiomatosis (Masson's lesion)

Intravascular angiomatosis, also known as Massons' lesion, is a relatively uncommon, although important, tumor because it clinically mimics such benign lesions as mucocele, pyogenic granuloma, and hemangioma, as well as malignant neoplasms such as angiosarcoma and Kaposi's sarcoma. More important is the potential for misdiagnosis at the histological level that poses a significant problem to those unfamiliar with this lesion. This article reviews the literature on perioral intravascular angiomatosis and presents five additional cases.

Systemic lupus erythematosus: a consideration for antimicrobial prophylaxis

Endothelial damage to heart valves, similar to that seen with rheumatic heart disease, occurs in 50% of all patients with systemic lupus erythematosus. Bacterial endocarditis is a consequence in 1% to 4% of these patients. This rate is greater than the incidence of endocarditis after rheumatic heart disease and compares favorably with the incidence of endocarditis in patients with prosthetic heart valves. At present, it is not possible to accurately delineate the subpopulation of patients with SLE that is at risk for this disease; hence, it is recommended that antibiotic prophylaxis (standard regimen suggested by the American Heart Association) be considered for all patients with systemic lupus erythematosus undergoing dental procedures associated with transient bacteremias.

The incidence of oral herpes simplex virus infection in patients undergoing cancer chemotherapy

Oral lesions in twenty-nine immunocompromised patients were evaluated for the incidence of herpes simplex virus (HSV) infections during either cancer chemotherapy or cancer chemotherapy plus bone marrow transplantation (BMT). Patients' HSV antibody titers were not determined, and positive diagnoses were based solely on the results of viral cultures. Fourteen patients (48%) were found to have herpetic infections, which is comparable with incidence rates of 50% to 90% in antibody-positive patients and 40% to 50% in mixed antibody populations reported in the medical literature. However, this finding is in conflict with the 10.7% to 15.1% incidence rate cited in the dental literature for patients undergoing cancer chemotherapy. This underestimation is believed to reflect insensitivity in the criteria used for diagnosis in these studies.

Relative value of screening tests of hemostasis prior to dental treatment

Identification of potential bleeders is very important prior to any dental treatment. One hundred fifty-three adult patients in the screening population at a dental school were examined by medical history and by determinations of prothrombin time, partial thromboplastin time, and bleeding time to determine if those patients with a negative bleeding history had a significant percentage of elevated laboratory values. This study was performed to see if these three tests would be of value in screening this population for bleeding disorders. The results suggest that proper medical history taking will identify a majority of potential bleeders and that these three tests are of little value in this population.

Dental management of the classic hemophiliac with inhibitors

Approximately 15 percent of patients with hemophilia A will develop inhibitors (antibodies) to Factor VIII after replacement infusion. Since Factor VIII replacement therapy is the mainstay of treatment in the hemophiliac, destruction of infused Factor VIII by inhibitors presents significant problems in the treatment of these patients. Different methods of treatment are discussed, including infusion of high doses of Factor VIII and infusion of prothrombin-complex concentrate. Two inhibitor patients who presented for dental treatment are examined. One patient had very low inhibitor titers, and the other had very high inhibitor titers. These patients show that dental treatment must be individualized according to severity of the disease process.