Oral Lesions of HIV Disease and HAART in Industrialized Countries

The epidemiology of HIV-related oral disease in industrialized nations has evolved following the initial manifestations described in 1982. Studies from both the Americas and Europe report a decreased frequency of HIV-related oral manifestations of 10–50% following the introduction of HAART (highly active antiretroviral therapy). Evidence suggests that HAART plays an important role in controlling the occurrence of oral candidosis. The effect of HAART on reducing the incidence of oral lesions, other than oral candidosis, does not appear as significant, possibly as a result of low lesion prevalence in industrialized countries. In contrast to other oral manifestations of HIV, an increased prevalence of oral warts in patients on HAART has been reported from the USA and the UK. HIV-related salivary gland disease may show a trend of rising prevalence in the USA and Europe. The re-emergence of HIV-related oral disease may be indicative of failing therapy. A range of orofacial iatrogenic consequences of HAART has been reported, and it is often difficult to distinguish between true HIV-related oral disease manifestations and the adverse effects of HAART. A possible association between an increased risk of oral squamous cell carcinoma and HIV infection has been suggested by at least three epidemiological studies, with reference to the lip and tongue. These substantial and intensive research efforts directed toward enhancing knowledge regarding the orofacial consequences of HIV infection in the industrialized nations require dissemination in the wider health care environment.

Physical, chemical, and immunohistochemical investigation of the damage to salivary glands in a model of intoxication with aluminium citrate

Aluminum absorption leads to deposits in several tissues. In this study, we have investigated, to our knowledge for the first time, aluminum deposition in the salivary glands in addition to the resultant cellular changes in the parotid and submandibular salivary glands in a model of chronic intoxication with aluminum citrate in rats. Aluminum deposits were observed in the parotid and submandibular glands. Immunohistochemical evaluation of cytokeratin-18 revealed a decreased expression in the parotid gland with no changes in the submandibular gland. A decreased expression of α-smooth muscle actin was observed in the myoepithelial cells of both glands. The expression of metallothionein I and II (MT-I/II), a group of metal-binding proteins, which are useful indicators for detecting physiological responses to metal exposure, was higher in both glands. In conclusion, we have shown that at a certain time and quantity of dosage, aluminum citrate promotes aluminum deposition in the parotid and submandibular glands, leads to an increased expression of MT-I/II in both the glands, damages the cytoskeleton of the myoepithelial cells in both glands, and damages the cytoskeleton of the acinar/ductal cells of the parotid glands, with the submandibular glands showing resistance to the toxicity of the latter.

[A case of swelling of salivary gland due to drug treatment for threatened premature labor]

Ritodrine hydrochloride (luteonin), a beta-agonist with predominant effects on beta adrenoreceptors such as those of the uterus, is effective in suppressing premature uterine contractions. This medicine was used in drug treatment in the case of threatened premature labor. A 26-year-old female who complained of acute swelling of the bilateral salivary glands was consulted to our otorhinolaryngological department. The soft swelling of the bilateral parotid and submandibular glands had developed after intravenous administration of ritodrine hydrochloride for treatment of her threatened premature labor. In addition, serum amylase levels were elevated. The swelling of the salivary glands and the elevation of the serum amylase subsided following discontinuation of the ritodrine hydrochloride. In salivary glands, too, the beta-adrenoreceptors exist. Following stimulation of those receptors in those glands increased secretion of amylase occurs. Our findings suggested that beta-stimulation by ritodrine hydrochloride led to the swelling of the salivary glands and the elevation of the serum amylase. To our knowledge, in Japan, our case is the first otorhinolaryngological report of swelling of the salivary glands due to ritodrine hydrochloride. Otolaryngologist should therefore have full knowledge regarding swelling of salivary glands due to ritodrine hydrochloride.

Iodide mumps: sonographic appearance

Swelling of the salivary glands occurring after injection of iodine-based contrast agent is a rare late adverse reaction. Only a few cases in the literature illustrate such ultrasound findings.

Oral signs of intravenous chemotherapy with 5-Fluorouracil and Leucovorin calcium in colon cancer treatment

Several studies have shown how cytostatics may cause hypofunction of salivary glands but failed to elucidate any potentially related side effects. Keeping in mind the sialochemical assistance and the role of saliva on the homeostasis of the stomatognathic system, the aim of this study was to establish potential gland disorders in patients submitted to 5- Fluorouracil (5-Fu) and Leucovorin calcium (LV) as well as their correlation with certain oral health disorders that diminish the quality of life.

MATERIALS AND METHODS

the focus of this research was observational and longitudinal. Twenty-five patients diagnosed with colon cancer at an initial, intermediate and late phase submitted to specifically devised therapy were assessed. Clinical history, oral health indexes and basal or stimulated saliva samples were recorded.

RESULTS

Basal and stimulated flow dropped in the intermediate stage. Stimulated saliva pH decreased during treatment. On basal saliva, urea, sodium and potassium rose during the intermediate phase. Löe and Silness rates as well as simplified bleeding increased during therapy but reverted by the end of the treatment. Depth index of the vestibular gingival sulcus rose during the intermediate phase but did not return.

CONCLUSION

This treatment caused functional salivary gland disorders as evidenced by basal and stimulated hyposialia, and acidification of stimulated saliva pH during the intermediate phase. Increase in basal urea may be due to proteic catabolism arising from plasma or glands. Variation in Na+ and K+ of basal saliva concentrates might be assumed as a possible duct disorder. Recovery of bleeding and Löe and Silness rates may point to a transient inflammatory effect associated to a decrease in salivary flow. Increase in the depth rates of the periodontal vestibular sulcus could be correlated with a higher risk of periodontal disease.

[Implications of antiretroviral therapy in oral medicine--a review of literature]

The success of antiretroviral therapy leads to a chronification of HIV-infection resulting in a decline of lethality. The lifelong intake of antiinfectives, though, may result in drug side effects with clinical dental implications. Despite fundamental cellular alterations, including prolonged hemorrhage following surgical interventions, antiretrovirals of all classes, of protease inhibitors, (non-nucleoside) reverse transcriptase inhibitors and of fusion inhibitors may promote oral manifestions like oral ulcera, dysgeusia, salivary gland disorders, papilloma, (peri)oral paresthesia or aphtous stomatitis. Due to inhibitory effects especially of protease inhibitors of cy tochrome P450-isoenzyme CYP3A4 therapeutical interactions with psychotropics/sedatives, antifungal agents, corticoids and intiinfectives, particularly metronidazole, may raise. The application and prescription of systemically metabolized adjuvant drugs as well as the monitoring of the possible progression of HIV infection is a key task in the oral health care of HIV-seropositive patients calling for a close medical coordination of therapeutical interventions.

Non-neoplastic salivary gland diseases

A wide range of non neoplastic disorders can affect the salivary glands, although the more common are: mumps, acute suppurative sialadenitis, Sjögren's syndrome and drug-induced xerostomia. Salivary dysfunction is not a normal consequence of old age, and can be due to systemic diseases, medications or head and neck radiotherapy. Diagnosis of salivary disorders begins with a careful medical history, followed by a cautious examination. While complaints of xerostomia may be indicative of a salivary gland disorder, salivary diseases can present without symptoms. Therefore, routine examination of salivary function must be part of any head, neck, and oral examination. Health-care professionals can play a vital role in identifying patients at risk for developing salivary dysfunction, and should provide appropriate preventive and interventive techniques that will help to preserving a person's health, function, and quality of life. The present work provides an overview of most of the non neoplastic disorders of the salivary glands, in which the general presentation, pathology, and treatments are discussed.

A review of adverse oral reactions to systemic medications

There is no debate that oral health and general well-being are inextricably bound. Many commonly prescribed medications have associated dental and oral manifestations that often are nonspecific and can vary in significance. This article reviews many common oral manifestations of systemic drugs, including the clinical manifestations, diagnosis, and treatment of these conditions.

[The influence of HCV infection and immunomodulating therapy (interferon-alpha and ribavirin) on the condition of minor salivary glands and oral mucosa]

The aim of the study was to determine an influence of HCV infection and combination therapy with interferon - alpha and ribavirin on the condition of oral mucosa and minor salivary glands in patients with chronic hepatitis C in comparison to subjects without liver pathology on 12-month follow-up. Patients with chronic hepatitis C more commonly develop pathological changes on the oral mucosa than patients without liver pathology. Combination therapy affects the amount of pathological lesions in the oral cavity of patients suffering from chronic hepatitis C and B. The occurrence of oral lichen planus on the oral mucosa may be associated with chronic hepatitis C as well as with concomitant alpha-interferon and antiviral therapy.

A review of drug-induced oral reactions

Every drug can produce untoward consequences, even when used according to standard or recommended methods of administration. Adverse drug reactions can involve every organ and system of the body and are frequently mistaken for signs of underlying disease. Similarly, the mouth and associated structures can be affected by many drugs or chemicals. Good oral health, including salivary function, is very important in maintaining whole body health. Regarding different parts of the oral system, these reactions can be categorized to oral mucosa and tongue, periodontal tissues, dental structures, salivary glands, cleft lip and palate, muscular and neurological disorders, taste disturbances, drug-induced oral infection, and facial edema. In this article, the drugs that may cause adverse effects in the mouth and related structures are reviewed. The knowledge about drug-induced oral adverse effects helps health professionals to better diagnose oral disease, administer drugs, improve patient compliance during drug therapy, and may influence a more rational use of drugs.

The role of radioactive iodine in salivary gland dysfunction

The use of radioactive iodine has become an important adjunct to the treatment of thyroid cancer. Many normal tissues--including salivary glands, gastrointestinal mucosa, gonads, and lactating breast tissue--have the ability to concentrate radioactive iodine under normal circumstances. Although the mechanism is just beginning to be elucidated, it is this ability that might contribute to the immediate and long-term complications associated with radioactive iodine treatment. In some patients, the salivary complications can be permanent and might compromise daily functioning. In this article, we examine the salivary gland complications associated with radioactive iodine therapy, and we suggest potential protective mechanisms to circumvent these problems.

[Salivary glands swelling after the administration of a non-ionic iodized contrast medium]

Salivary gland tumefaction (iodide mumps) is a rare, but possible, reaction to endovenous administration of a contrast medium. The authors describe three cases of bilateral, iodide mumps where swelling of the submaxillary salivary glands was seen after administration of a non ionic iodized contrast medium for upper GI examination. The cases differ from what is reported in the literature in that they occurred in subjects with good renal function and who had not previously presented any other early or delayed side effects subsequent to the use of a contrast medium. The authors then discuss the pathogenic hypotheses for this disorder subsequent to the administration of the new generation, low osmolarity contrast media which are generally better tolerated than traditional media.

Oral, perioral and systemic pathosis in HgCl2-induced autoimmunity in the BN rat

Male BN rats were repeatedly skin-injected with HgCl2 solution and sacrificed after 6, 9, 14, 21, 28 or 24 days. Mononuclear cell infiltrates were observed in the oral mucosa and in lacrimal, salivary and thyroid glands from 6-9 days onwards, with a peak at 14-21 days. Immunohistochemistry identified these cells as predominantly T cells with some NK cells but very few B cells. Reversible parenchymal changes were observed but there was no obvious persistent tissue destruction. Serum titers of IgE, IgG1, anti-laminin and anti-DNP, but not IgG2a antibodies, were raised and peaked at 14-21 days. However, there was no correlation, within animals, between these titers and the extent of mononuclear cell infiltration. Mercury was histochemically detected within dendritic cells/macrophages in the connective tissue stroma of the glands and in the oral mucosa, but no correlation was found between the distribution of mercury and the degree of inflammation. We conclude that the accumulation of mononuclear cells in oral and perioral tissues of HgCl2-treated BN rats does not represent a local immune response to tissue-retained Hg. Instead, we propose that the extravasation represents an epiphenomenon that is not necessarily deleterious to the infiltrated organ.

Clozapine and the development of salivary gland swelling: a case study

BACKGROUND

Clozapine is a novel antipsychotic that is effective in 30% to 50% of treatment-resistant schizophrenia. It is known to cause sialorrhea in 23% of patients. This phenomenon is paradoxical and poorly understood since clozapine is known to have potent anticholinergic effects. We have observed the development of transient salivary gland swelling in four patients on clozapine therapy. Although not clearly related to sialorrhea, this phenomenon may share a similar pathophysiology.

METHOD

A retrospective chart review was performed on the 4 of 27 patients started on clozapine treatment during a 6-month period who developed salivary gland swelling.

RESULTS

Four patients, none of whom had previously complained of sialorrhea, developed salivary gland swelling after starting clozapine treatment. In all cases, the swelling resolved within days. A possible etiology may be the formation of a calculus that blocks the duct and causes swelling, which resolves when the stone passes.

CONCLUSION

Clinicians should be aware that salivary gland swelling may be a possible side effect of clozapine use.

Iodide mumps after contrast enhanced CT with iopamidol: a case report

We have experienced a case of iodide mumps after CT examination with 100 ml of iopamidol. The patient was a 70-year-old woman with a history of right nephrectomy due to right renal cancer. She underwent CT examination to explore local recurrence and abdominal metastases including lymph node and liver metastases. Three hours after the CT examination, she complained of nausea, vomiting, facial flushing, bilateral jaw pain, and fever. The laboratory findings 12 hours after CT examination showed increased white blood cells and elevated serum amylase enzyme. Analysis of the amylase fraction showed that 86% originated from the salivary glands. She was admitted to the hospital, and the symptoms continued for four days, with decreasing severity. Anti-inflammatory therapy was performed, and the patient was discharged six days after the event.

Iodide mumps after intravascular administration of a nonionic contrast medium. Case report and review of the literature

Swelling of the submandibular, sublingual and/or parotid glands ("iodide mumps") is an uncommon complication to intravascular administration of contrast material. The etiology remains unclear, but the reaction seems to be idiosyncratic or related to toxic accumulation of iodide in the ductal systems of the salivary glands. The introduction of nonionic contrast media has not eliminated the risk of developing iodide mumps. The first reported case of iodide mumps after intravascular administration of iopromide (Ultravist 300) is presented.

Localised autonomic failure due to botulinum toxin injection

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Submandibular salivary gland hypertrophy induced by phenytoin

A 16-year-old boy with epilepsy developed hypertrophy of the submandibular salivary glands, with high phenytoin (PHT) serum levels. The submandibular salivary glands became normal in 12 days after discontinuation of PHT. Other causes of salivary gland hypertrophy were excluded and we suggest that the hypertrophy was due to PHT.

Repetitive weekly cycles of 4-day continuous infusion of recombinant interleukin-2: a phase I study

A phase I trial was performed with a new interleukin-2 (IL-2) given as a continuous intravenous infusion in patients with solid tumors. The objectives of the study were to examine the feasibility of administering IL-2 in 4-day cycles for 4 consecutive weeks, and to investigate the response pattern of peripheral blood lymphocytes. Tumor necrosis factor (TNF) and IL-2 serum concentrations were also measured. Prior to this study, IL-2 had been tested at increasing dosages during one 4-day cycle, and it appeared that a dose of 1300 mcg/m2/day was tolerated. However, when this treatment schedule was maintained for 4 consecutive weeks, the maximum tolerated dose was 430 mcg/m2/day. In this schedule, a dose-dependent progressive increase in rebound lymphocyte count occurred after each weekly cycle, resulting in a 5-70-fold increase after the 4th cycle. Serum TNF peak concentrations also showed a tendency to increase during each subsequent cycle, while serum IL-2 peak concentrations showed a paradoxical decrease. Clinical toxicity comprised several events, which, possibly, could be ascribed to autoimmune phenomena. Myocardial infarction as a late toxicity of IL-2 is suggested. One complete response (renal carcinoma) and two partial responses (renal and breast carcinoma) were documented, one of these occurring in a patient who previously had shown a transient response on interferon therapy.

[Odontostomatological changes induced by drugs. I]

The purpose of the present review is to describe the unwanted effects of drugs or chemicals in the orofacial region. The authors take into consideration the alterations of salivation such as xerostomia and ptyalism, disturbances of sense of taste, halitosis and pain and swelling of the salivary glands. The dental surgeon who suspects that an oral alteration might be a drug reaction can play an important role in preventing the development of more severe toxic effects. All this points to the importance of the knowledge of pharmacology for dental practitioners.

Medication side effects of dental interest

Many dental patients require continuing medication. With some, the medications will have side effects that have an oral or perioral manifestation. Commonly prescribed medications and their dental side effects are listed. This information may aid patients who have oral symptoms unrelated to the needed dental care.

Estrogen induces the development of autoantibodies and promotes salivary gland lymphoid infiltrates in normal mice

There are important bidirectional interactions between the immune and the endocrine system. Sex hormones influence the immune system throughout life including postnatal and prenatal stages. For example, we find that administration of estrogen to normal mice markedly augments the ability of CD5+ B cells to express their autoimmune potential by producing increased numbers of plaque-forming cells (APFC) to bromelain-treated mouse erythrocytes (Br-ME). The effect of sex hormones on immune function at the most critical stage of development, the prenatal period, remains unstudied. We hypothesize that an imbalance of the in utero sex hormone microenvironment critically influences the fetal immune system. We have termed this influence immunological imprinting. After birth this imprinting could contribute to immune-mediated disorders. To test this hypothesis, we developed a mouse model in which normal mice were prenatally exposed to estrogens. In preliminary experiments, these mice produced higher numbers of APFC to Br-ME, particularly in the peritoneal cavity cell exudates. Furthermore, mice prenatally exposed to estrogens had accelerated development of autoimmune salivary gland lesions indistinguishable from Sjögren's syndrome (SS) in humans. Further experiments are warranted to confirm these findings. The prenatal effects of estrogen may have relevance for familial and neonatal autoimmune syndromes.

Radionuclide imaging of potassium iodide-induced sialadenitis

The authors report a rare complication of nuclear bone imaging, iodide mumps, and describe its appearance on the subsequent radionuclide salivary gland study.

Iatrogenic causes of salivary gland dysfunction

Saliva is important for maintaining oral health and function. There are instances when medical therapy is intended to decrease salivary flow, such as during general anesthesia, but most instances of iatrogenic salivary gland dysfunction represent untoward or unavoidable side-effects. The clinical expression of the salivary dysfunction can range from very minor transient alteration in saliva flow to a total loss of salivary function. The most common forms of therapy that interfere with salivation are drug therapies, cancer therapies (radiation or chemotherapy), and surgical therapy. These therapies can affect salivation by a number of different mechanisms that include: disruption of autonomic nerve function related to salivation, interference with acinar or ductal cell functions related to salivation, cytotoxicity, indirect effects (vasoconstriction/dilation, fluid and electrolyte balance, etc.), and physical trauma to salivary glands and nerves. A wide variety of drugs is capable of increasing or decreasing salivary flow by mimicking autonomic nervous system actions or by directly acting on cellular processes necessary for salivation: drugs can also indirectly affect salivation by altering fluid and electrolyte balance or by affecting blood flow to the glands. Ionizing radiation can cause permanent damage to salivary glands, damage that is manifest as acinar cell destruction with subsequent atrophy and fibrosis of the glands. Cancer chemotherapy can cause changes in salivation, but the changes are usually much less severe and only transient. Finally, surgical and traumatic injuries interfere with salivation because of either disruption of gland innervation or gross physical damage (or removal) of glandular tissue (including ducts).

Acute transient sialadenopathy associated with anesthesia

Five cases of acute transient sialadenopathy associated with the administration of anesthesia are described in this article. In each case, the patient's straining on the endotracheal tube was followed immediately by firm swelling of one or more of the salivary glands. The facial swelling was resolved within 24-four hours without treatment.

[Acute iodine poisoning associated with sialadenitis, allergic vasculitis and conjunctivitis following administration of iodine-containing contrast media]

Sialadenitis ("iodide mumps") and allergic vasculitis are rare sequelae to administration of iodinated contrast media. The condition is characterized by rapid, painless, bilateral enlargement of salivary glands following administration of iodinated contrast media. An 81-year-old female patient with moderate renal failure is described in whom marked sialadenitis, allergic vasculitis with (in part) bloody blisters developed following excretory urography and digital subtraction angiography of the renal arteries. Additional but mild symptoms included fever and conjunctivitis. All lesions subsided completely within four weeks. A relation between blood iodine concentration and extent of the lesions could be demonstrated. The highest iodine level in serum determined was 70 600 micrograms/100 ml.

[Parotid duct occlusion with prolamine--sequelae of long-term administration in the animal model]

The effects of occlusion of the parotid excretory duct, after injection of a basic aminoacid solution (prolamine), were studied in 12 rabbit parotid glands one year after prolamine application. 40% of the experimental animals present the picture of an extensive abscess-forming sialadenitis both macroscopically and microscopically. The secretory parenchyma of the gland is almost completely eliminated. Remnants of the injected prolamine solution found in the duct system could possibly be responsible for the abscess formation. At the present experimental stage therapeutic application of prolamine in the human parotid gland cannot be recommended.

Toxic and drug-induced disorders in otolaryngology

Toxic and drug-induced disorders can be identified with alarming frequency. Otolaryngologists in the past were acutely aware of the ototoxic properties of certain medications but, with today's increasing armamentarium, new problems arise that may have an iatrogenic cause.

Contrast induced sialadenitis--a case report

The authors report a rare complication of intravenous pyelography: namely "iodide mumps". A review of the literature is undertaken.

Oral manifestations of drug reactions

The clinical manifestations of oral reactions to the more commonly prescribed drugs have been presented. These reactions include the following conditions: stomatitis, ulceration and necrosis, opportunistic infections, hemorrhage, gingival hyperplasia, pigmentation, altered salivary function, and altered taste sensation. A patient who complains of any of these signs and symptoms should be thoroughly questioned regarding medication. If an offending drug can be identified, its alteration or elimination, in consultation with the prescribing clinician, will often result in resolution of the clinical problem.

Sialadenitis and systemic reaction associated with phenylbutazone

Sialadenitis is an uncommon side effect of phenylbutazone, and we report seven patients with this reaction who were admitted to Fairfield Infectious Diseases Hospital over a seven year period. In addition to salivary gland swellings, all patients had evidence of a systemic disturbance that included fever in all cases, and, in varying combinations, pericarditis, pleurisy, rash, conjunctivitis, and disturbed hepatic function. Resolution of these features occurred following cessation of phenylbutazone, but this took several weeks in some cases. Pericarditis was the most severe manifestation, and in one patient, this required corticosteroid therapy.

[Effects of contraceptive pills in the field of otolaryngology? (author's transl)]

Besides the wellknown alterations of the Eustachian tube and membrana mucosa nasi there will be discussed the effects of the contraceptive pills on salivarian glands and on inner ear. The influence of gestagen and estrogen on the regulation mechanism of the above mentioned organes is demonstrated. Especially the erectile tissue of the submandibular and parotic glands and recidiving sudden deafness and discussed. To solve the about mentioned problems the interaction of medical statistics with clinical experiences is desirable.