Social aspects of HIV and their relationship to craniofacial problems: workshop 4C.

The oral research community needs an understanding of the social causes, consequences, and costs of disease in relation to oral health. This workshop concluded that HIV infection constitutes a special dental need requiring specific arrangements to facilitate oral care for infected persons. Oral manifestations of HIV infection affect everyday life, but more evidence is needed on the effects of interventions to alleviate these impacts. Other oral health habits add to the burden of HIV/AIDS-associated oral diseases and compete with them for resources. These problems are most acute where the prevalence of HIV is high and resources are scarce. Effective health promotion is therefore important in these areas. Without data on the utility of oral health care in developing countries, practical approaches are guided by societal and multidisciplinary principles. There are also important ethical considerations.

Self-reported oral dryness and HIV disease in a national sample of patients receiving medical care.

OBJECTIVES: We sought to analyze the relationship between self-reported oral dryness and the demographic, enabling, behavioral, clinical, and treatment characteristics among human immunodeficiency virus (HIV)-positive patients in medical care. STUDY DESIGN: The study group consisted of the HIV Cost and Services Utilization Study cohort, a nationally representative probability sample of HIV-infected adults receiving medical care in the contiguous United States. RESULTS: It was estimated that 29% of adults (64,947 individuals) with HIV infection receiving medical care in the United States have a complaint of dry mouth. A multivariate logistic analysis was carried out to explore the association between several covariates and dry mouth. It was shown that compared with whites, individuals of Hispanic ethnic origin were 61% more likely to report dry mouth (OR, 1.61; 95% CI, 1.04-2.50; P =.04). Those who were unemployed were 55% more likely to report the symptom of dry mouth than were subjects who were employed (OR, 1.55; 95% CI, 1.22-1.98; P =.001). In comparison with nonsmokers, current smokers were 36% more likely to report dry mouth (OR, 1.36; 95% CI, 1.04-1.79;P =.03). The use of antidepressant drugs and antituberculosis/anti-Mycobacterium avium (anti-TB/anti-MAC) medications had the strongest association with dry mouth complaint. Those taking antidepressants were 55% more likely to report dry mouth (OR, 1.55; 95% CI, 1.23-1.97; P =.0001); compared with nonusers, patients receiving anti-TB/MAC drugs were 46% more likely to report dry mouth (OR, 1.46; 95% CI, 1.03-2.06; P =.04]. In comparison with those with undetectable viral load, individuals with a viral load of more than 100,000/mm(3) were 151% more likely to report dry mouth (OR, 2.51; 95% CI,1.58-3.96; P =.0001). CONCLUSIONS: Our findings suggest that optimizing viral suppression, smoking cessation, and tailoring antidepressant and anti-TB/MAC medications may be promising interventions to decrease dry-mouth symptoms among HIV-infected individuals.

Occupational exposures to blood in a dental teaching environment: results of a ten-year surveillance study.

Evaluation of occupational exposures can assist with practice modifications, redesign of equipment, and targeted educational efforts. The data presented in this report has been collected as part of a ten-year surveillance program of occupational exposures to blood or other potentially infectious materials in a large dental teaching institution. From 1987 to 1997, a total of 504 percutaneous/non-intact skin and mucous membrane exposures were documented. Of these, 494 (98 percent) were percutaneous, and 10 (2 percent) were mucosal, each involving a splash to the eye of the dental care worker (DCW). Among the 504 exposures, 414 (82.1 percent) occurred among dental students, 60 (11.9 percent) among staff, and 30 (6 percent) among faculty. One hundred ninety-one (37.9 percent) exposures were superficial (no bleeding), 260 (51.6 percent) were moderate (some bleeding), and 53 (10.5 percent) were deep (heavy bleeding). Regarding the circumstances of exposure, 279 (54.5 percent) of the injuries occurred post-operatively (after the use of the device), and most were related to instrument clean-up; 210 (41.0 percent) occurred intra-operatively (during the use of the device); and 23 (4.5 percent) occurred when a DCW collided with a sharp object in the dental operatory (eight cases involved more than one circumstance). The overall exposure rate for the college was 2.46+/-0.11 SD per 10,000 patient visits. The average rate for the student population was 4.02+/-0.20 SD per 100 person-years, with the highest rates being observed among junior year students. The observed rates of occupational exposures to blood and body fluids in this report are consistent with published reports from several other educational settings. Dental teaching institutions are faced with the unique challenge of protecting the student and patient populations against bloodborne infections. Educational efforts must go beyond mere teaching of universal precautions and should include the introduction of safer products and clinical procedures that can minimize the risks associated with the hands-on aspects of the students' learning process.

Oral HIV transmission.

Although transmission of HIV through casual contact with saliva has not been shown, oral exposure to HIV-infected semen, blood, and breast milk can lead to infection. Unprotected orogenital contact, especially receptive oral intercourse, is associated with greater risk of HIV transmission than previously thought. The salivary anti-HIV properties, the local and systemic immunologic responses, the local mucosal integrity, and the level of infectious HIV present at the oral mucosal site all influence the potential for HIV infection through the oral mucosa. Although more information on the exact mechanisms of oral HIV transmission are necessary, based on the current understanding of this process, educational HIV prevention methods must focus on the potential risks associated with orogenital sexual behaviors.

E-mail-based oral medicine consultation.

A pilot study was undertaken to assess whether text-based electronic patient data transmission (e-mail) is a reliable source of information for the diagnostic decision-making process. The main objective was to determine if information contained within a transmitted text could be reliably used as basis for making general recommendations for diagnostic tests and follow-up or referral plans pertaining to a variety of oral mucosal pathologic conditions. The results suggest that face-to-face patient examination is more accurate in establishing a correct diagnosis for oral mucosal pathologies than transmitted descriptive patient data alone.

Risk of tuberculosis transmission in dentistry. Results of a retrospective chart review.

This pilot project was conducted for the purpose of performing a retrospective chart review on selected clients and using the results for evaluating purified protein derivative (PPD) conversion rates among the student population. The occupational risk of exposure to active tuberculosis was assessed in a large dental educational setting. Charts of clients seen in the College's Oral Medicine Clinic, referred out for health care consultation for one of several reasons potentially associated with active tuberculosis disease over a 1 year period, were reviewed. Data sources included the medical consultation log and the tuberculosis log, which were maintained by faculty in the Oral Medicine Clinic. Ninety-six clients met the authors' criteria. However, compiling data was severely hampered for two reasons: missing charts (19 of 96, or 19.8%) and non-returning clients (55, or 57%). Four clients with potentially active cases of tuberculosis were identified. Follow up revealed, however, that none of these four clients was contagious when seen at the Dental Center. The protocol and definition recommended by the Centers for Disease Control and Prevention 1994 Guidelines, and the results of PPD screening and chart audit conducted by the authors, suggest that the employees and students of the College of Dentistry are at low risk for workplace exposure to active tuberculosis.

Oral mucositis with features of psoriasis: report of a case and review of the literature.

An unusual case of oral mucositis with features of psoriasis is reported along with a review of the cases of oral psoriasis in the literature. The case reported involved a crusted lesion on the upper lip and erythematous lesions on the labial mucosa, buccal mucosa, and denture-bearing palatal mucosa. In addition, lesions resembling geographic tongue and ectopic geographic tongue were present. All lesions exhibited multiple small pustules. The review of the literature compares the distribution and clinical appearance of previously reported cases of oral psoriasis.

Obstacles encountered in application of the Centers for Disease Control and Prevention guidelines for control of tuberculosis in a large dental center.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration have designated five categories of workplaces as carrying higher than normal risk for exposure to tuberculosis (TB); "health care facilities" is one of these categories. To assist all health care facilities in developing an appropriate and effective control plan, the CDC has listed various components to be included in the overall plan-however, the components needed cannot be determined until the level of risk has been determined. The published criteria for risk assessment are more appropriately applicable to a hospital-based facility. In complying with CDC's guidelines and adopting the recommended components of the TB control program at a large, educational, ambulatory care dental facility, several obstacles were identified. METHODS: As part of the risk assessment for TB transmission and to determine the significance of purified protein derivative of tuberculin (PPD) skin-test conversions observed among the student and employee populations, we implemented a strategy that consisted of surveying all accredited dental schools in the country, performing a controlled PPD screening study involving predoctoral dental students in their junior year, and reviewing and evaluating all patient registration records for the same period. RESULTS: Forty-four percent of the dental schools contacted agreed to participate in the survey. Of these, 58% had no information available on student PPD conversion rates and 29% either had no data available yet or were unwilling to share their information. Three schools (12%) that had some data and were willing to share it reported PPD conversion rates for faculty, students, or staff of 1% to 2%. The student PPD study showed a 10.7% conversion rate, but the registration record reviews showed no convincing evidence of patients with active TB having been registered at the dental school for the period of the student PPD study. CONCLUSION: Development of a TB control program relies heavily on assessment of risk within a health care facility. The sporadic reports of PPD conversion rates among dental care workers are not adequate to determine the magnitude of exposure to TB in educational dental settings. Further studies are necessary to establish the true risk and to assist dental care facilities in developing TB control programs.

TB and dentistry.

Tuberculosis (TB) has reemerged as a major public health problem. Although dental care providers are considered to be at low risk of exposure to patients with active TB, they should be familiar with the recent recommendations for preventing transmission of tuberculosis in health care settings. Dental practitioners should be able to recognize and evaluate signs and symptoms of active TB in their patient population and initiate appropriate medical referrals for any patient in whom active TB is suspected. Furthermore, education of the dentist and the office staff about the transmission, signs and symptoms of the disease, and methods of protection is one of the most effective components on an overall TB control program.

Challenges associated with assessment of risk for tuberculosis in a dental school setting.

BACKGROUND: Reported risk among health care workers, related to tuberculosis exposure, motivated us to accurately assess this occupational risk at our College of Dentistry. METHODS: Our sample population included all dental students entering their junior (third) year (beginning of maximum patient exposure). Screening for tuberculosis infection, with the standardized Mantoux test (purified protein derivative [PPD]), was conducted by the authors; several variables, previously associated with inaccurate test results in the literature, were controlled for during the study. RESULTS: Among the study population of 158 students, the PPD conversion rate, as determined by one-step testing, after one academic year was 10.6%. To further investigate factors (other than possible workplace exposure) contributing to PPD conversion in the study population, the authors also examined PPD results from previous employee and student screenings and conducted a retrospective chart review of selected patients registered at the college for the same period. CONCLUSIONS: We found that being born outside of the United States and having previously received bacille Calmette-Guérin vaccine are associated with positive PPD test results. In addition, PPD conversion among the study group may not be associated with occupational exposure at the College but, in fact, may be related to other factors, including community- and hospital-based clinical exposure. Finally, we recommend further research that examines the possible systemic effects of periodic testing with PPD on test subjects.

Postexposure protocol.

This article offers an overview of the major bloodborne and communicable diseases. The organisms are classified based on the level of risk they pose to the dental care worker (DCW) in the occupational settings. Most recent epidemiologic findings and scientific information on occupational exposures are discussed. Postexposure management to bloodborne pathogens, including the counseling, date collection, serologic testing, and post-exposure prophylaxis, is described.

Nodular amyloidosis.

An unusual intraoral form of amyloidosis, the nodular form, is discussed. Attention is directed to clinical, microscopic and immunohistochemical features. More specifically, the nodular form of this condition and the specific relationship in this patient to chronic hemodialysis and associated beta-2-microglobulin deposition is highlighted. An overview of other forms of amyloidosis is provided along with the chemical identity of each.

Epipalatus: a rare intraoral teratoma.

A wide range of discrete head and neck tumors are developmental, including those termed choristoma, hamartoma, dermoid cysts, teratoid tumors, and true teratomas. In classifying various teratomas, consideration is given to the embryonal layers represented within the substance of the tumor and to their level of organizational complexity. By definition, a hamartoma is a tissue mass, present at or near the time of birth, that is benign and native to the site of origin. Growth capacity of a hamartomatous process parallels that of the host organism. A choristoma, on the other hand, is a mass of tissue that is foreign to the site of discovery and is thought to result from growth to displaced primordial tissue that is histologically normal for that tissue.

Ossifying fibroma of the mandible and maxilla: review of 18 cases.

A clinical, radiographic, histologic and follow up study of 18 cases of ossifying fibroma involving the mandible and maxilla was performed. Differences in behavior and management according to age, location, radiographic appearance and histopathology were not evident. A wide range of microscopic findings within and between cases was evident, while the radiographic finding consisting of sharp delineation was consistent in all cases. The presence or absence of cementum or cementum-like material and various types of formed elements was likewise of little clinical significance. Finally, a potential source of the neoplastic cell from the periodontal apparatus may help explain the range of histologic findings.

Osteopetrosis: a case report including gross and microscopic findings in the mandible at autopsy.

A case of juvenile osteopetrosis in a 10-year-old girl, including the skeletal, hematologic, and neurologic features, is described. Ankylosis of cementum to bone was evident in histologic sections, providing a possible explanation for the delayed or impaired eruption of teeth. A summary of the literature on the pathogenesis of osteopetrosis is presented.