Periodontal infections and pre-term birth: early findings from a cohort of young minority women in New York

The aim of this report is to provide early data from an ongoing study examining (i) the relationship between periodontal infections and pre-term low birth weight (PLBW) in a cohort of young, minority, pregnant and post-partum women; and (ii) the effect of periodontal interventions on pregnancy outcome. During the first 2 yr of the study, 213 women were enrolled and examined clinically for dental plaque, calculus, bleeding on probing, and probing depth. Birth outcome data were available for 164 women, including one group (n = 74) subjected to oral prophylaxis during pregnancy, and a second group (n=90) who received no prenatal periodontal treatment. Subgingival plaque samples were available from 145 subjects (4 samples/subject) and were analyzed by checkerboard DNA hybridization with respect to 12 bacterial species. The prevalence of PLBW was 16.5% (27 cases) in this cohort. No differences in clinical periodontal status were observed between PLBW cases and women with normal birth outcome. However, PLBW mothers had significantly higher levels of Bacteroides forsythus and Campylobacter rectus, and consistently elevated counts for the other species examined. PLBW occurred in 18.9% of the women who did not receive periodontal intervention (17 cases), and in 13.5% (10 cases) of those who received such therapy.

Oral manifestations of HIV infection in homosexual men and intravenous drug users. Study design and relationship of epidemiologic, clinical, and immunologic parameters to oral lesions

This article describes the baseline findings from a study designed to compare the oral manifestations of HIV infection in homosexual men and intravenous drug users. Both seropositive and seronegative persons were studied. A standard examination instrument was developed to record indexes of oral disease as well as to record the presence of oral lesions. The two groups differed in terms of education, race, socioeconomic status, employment status, housing, and smoking experience. The prevalence and type of oral lesions differed in the two seropositive groups. In seropositive homosexual men, white lesions on the tongue (28.4%) predominated; whereas for the seropositive intravenous drug users, oral candidiasis (43.0%) and gingival marginal erythema (33.3%) were most often detected. We also observed that seronegative intravenous drug users displayed a greater number of oral lesions than seronegative homosexual men. For seropositive homosexual men, lesion presence was significantly associated with decreased levels of CD4; positive associations were seen with current smoking, antiviral drug use, and antibiotic use, and a negative association was observed with current employment. In contrast, only exposure to antiviral drugs was significantly correlated with lesion presence for seropositive intravenous drug users. This baseline analysis from our longitudinal study suggests clear differences in oral manifestations of HIV infection between seropositive homosexual men and intravenous drug users and between seronegative homosexual men and intravenous drug users. Among other parameters, it is apparent that lifestyle, access to health care, and the condition of the oral cavity before infection influence the development of oral lesions in persons with HIV infection.

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 lesions as markers of severe immunosuppression in HIV-infected homosexual men and injection drug users

OBJECTIVES

We examined the diagnostic utility of the presence of oral lesions, individually and in combination, in identifying severe immunosuppression, defined as CD4 cell count under 200.

STUDY DESIGN

Data were collected on 82 HIV-seropositive homosexual men and 82 HIV-seropositive injection drug users who volunteered to participate in a longitudinal study of HIV infection. CD4 cell counts were measured within 24 hours of oral examination.

METHODS

Sensitivity, specificity, positive predictive value, negative predictive value, and the odds ratio were computed to assess the association between oral lesions and CD4 less than 200. In addition to the individual lesions, we studied the diagnostic properties of sets of three to six lesions. For each set of lesions, a patient was classified as positive for the set if he or she had one or more lesions in that set.

RESULTS

In homosexual men and injection drug users, individual lesions had low sensitivity, high specificity, and moderate positive and negative predictive values. Odds ratios reflected weak correlation to immunosuppression. When lesion sets were considered in homosexual men, sensitivity rose dramatically with only modest decreases in specificity. The positive and negative predictive values remained almost the same. Similar results for lesion sets were obtained in injection drug users, with greater reduction in specificity but stable positive and negative predictive values. Odds ratios indicated that for homosexual men, the more lesions included in the set, the stronger the correlation with immunosuppression. For injection drug users, strong correlations were observed for all lesion sets.

CONCLUSIONS

Analysis of sensitivities and odds ratios in homosexual men suggest that it may be valid to note the occurrence of a greater number of oral lesions than is currently done in staging patients with HIV infection. Among injection drug users, monitoring a larger number of lesions neither improves nor reduces the correlation to severe immunosuppression.

A prospective study of oral lesions and their predictive value for progression of HIV disease

OBJECTIVE

This report evaluates and compares individual oral lesions and combinations of lesions in predicting progression-free survival in a seroprevalent cohort of men and women with HIV infection.

DESIGN

This was a prospective study of HIV-infected patients, initially AIDS-free, followed for approximately 30 months.

SETTING

Patients were volunteers examined at an academic medical center and at an inner-city hospital in New York. Participants identified themselves as homosexual men or as injection drug users (IDU).

OUTCOME MEASURES

The primary outcome being assessed is time from a baseline oral examination until the development of an AIDS-defining condition or death from any cause within 12 months of the last study visit. Correlation is measured by relative risk (RR).

RESULTS

While oral lesions were not predictive of progression among subjects with CD4 > or = 200, they were highly predictive of progression among those with CD4 < 200. For subjects with CD4 < 200, the only individual lesion that was significantly associated with progression-free survival was oral candidiasis (RR = 4.12, P = 0.009). Positivity for one or more lesions in a set demonstrated greater prognostic value among those with CD4 < 200, with RR's of 6.03 (P = 0.018) for the set consisting of oral candidiasis, hairy leukoplakia, and necrotizing ulcerative gingivitis (NUG), and 8.77 (P = 0.036) for the set consisting of the above lesions plus linear gingival erythema (LGE). Analysis by cohort suggested that the improvement in correlation was stronger in homosexual men than in IDU, but this question could not be resolved conclusively with these data.

CONCLUSIONS

Lesion sets might be better prognosticators of progression-free survival than individual lesions among HIV-infected subjects with CD4 < 200. Prognostic value of the core lesion set (oral candidiasis and hairy leukoplakia) was enhanced by the addition of other lesions (NUG and LGE) not usually included in HIV staging systems. These results suggest that staging systems for HIV might be improved by the inclusion of other, survival-related oral lesions.

Oral candidiasis in HIV infection: predictive value and comparison of findings in injecting drug users and homosexual men

The objectives of this study were to compare the relationship of oral candidiasis to HIV status, cohort and CD4+ lymphocyte values in injecting drug users and homosexual men and to examine its impact on prognosis. An oral examination was added to an ongoing longitudinal study of HIV infection. Data obtained at 6-month intervals included smoking, illicit drug use, medication use, symptoms and medical diagnoses, physical examination findings and laboratory data. In this study HIV+ subjects were much more likely to present with oral candidiasis than were HIV- subjects (OR = 6.3, P < 0.01). Injecting drug users, regardless of serostatus, were more likely than homosexual men to present with oral candidiasis (OR = 3.0, P = 0.001). In both cohorts oral candidiasis was associated with low CD4+ lymphocyte counts and percent ages, and Kaplan-Meier survival estimates showed that subjects with oral candidiasis had a poorer prognosis than those without candidiasis, even after controlling for CD4+ lymphocyte count.

Inflammatory and immune mediators in crevicular fluid from HIV-infected injecting drug users

Gingival crevicular fluid (GCF) levels of the polymorphonuclear leukocyte (PMN) lysosomal enzyme beta-glucuronidase (beta G), the pro-inflammatory cytokine interleukin 1 beta (IL-1 beta), and immunoglobulins (IgA, IgG, and IgM) were examined in 16 HIV seropositive (HIV+) and 10 HIV seronegative (HIV-) injecting drug users (IDU). Each subject received a periodontal examination including assessment of probing depth, attachment level, bleeding on probing, and plaque and calculus accumulation. GCF was collected from the mesial surfaces of premolar and molar teeth using filter paper strips. Although HIV+ subjects had a significantly lower number of peripheral blood CD4+ T cells/mm3 compared to HIV- subjects, there were no significant differences in mean probing depth, percentage of sites exhibiting bleeding on probing, or plaque and calculus accumulation between HIV- and HIV+ subjects. When the GCF components were analyzed, we found no significant differences between HIV- and HIV+ subjects in GCF levels of beta G, IL-1 beta, IgA or IgM, but GCF levels of IgG were significantly increased in HIV+ subjects. When sites were categorized by probing depth, no differences in the levels of beta G, IgA, IgG, and IgM existed between sites with probing depth < or = 3 mm compared to sites with probing depth > or = 4 mm in both HIV- and HIV+ IDU. However, levels of IL-1 beta in GCF were increased in the deeper sites (> or = 4 mm) in HIV+ IDU when compared to sites with PD < or = 3 mm. Analyzing GCF constituents in relation to the CD4 cell number, no differences were found between subjects with < or = 400 or > 400 CD4 cells/mm3 with respect to the levels of IL-1 beta, IgG, and IgM. However, the level beta G was significantly decreased in the HIV+ IDU with < or = 400 CD4 cells when compared to those with > 400 CD4 cells/mm3, while levels of IgA were significantly higher in HIV+ subjects with < or = 400 CD4 cells/mm3. Our results suggest that levels of IgG, and in immunodeficient subjects IgA were increased in GCF of HIV+ IDU while decreased levels of beta G were found in immunodeficient HIV+ IDU. These findings may be local manifestations of systemic alterations and suggest that analysis of GCF may provide insight into the immune and inflammatory responses of HIV-infected individuals to periodontal microorganisms.