Associated oral manifestations with HIV southeastern Brazilian patients on antiretroviral therapy.

OBJECTIVES: This study aimed to assess the prevalence of oral lesions in patients living with HIV infection and their association with CD4 count, viral load, and antiretroviral therapy in patients with HIV. METHODS: A cross-sectional study was conducted on a sample of 161 patients attending the… All the patients were examined for their oral lesions, current CD4 counts, type, and duration of the therapy. Data analyses were carried out using Chi-Square, Student T/Mann-Whitney, and logistic regression tests. RESULTS: Oral lesions were observed in 58.39% of patients with HIV. Periodontal disease with 78 (48.45%) or without mobility 79 (49.07%) was observed more frequently, followed by hyperpigmentation of oral mucosa 23 (14.29%), Linear Gingival Erythema (LGE) 15 (9.32%), candidiasis pseudomembranous 14 (8.70%). Oral Hairy Leukoplakia (OHL) was observed only in 3 (1.86%). A relationship between periodontal disease with dental mobility and smoking was found (p=0.04), as well duration of treatment (p=1.53e-3) and age (p=0.02). Hyperpigmentation was related to race (p=0.01) and smoking (p=1.30e-6). CD4 count, CD4:CD8 ratio, viral load, or type of treatment were not associated with oral lesions. Logistic regression showed that the duration of treatment has a protective effect on the periodontal disease with dental mobility (OR = 0.28 [-2.27 to -0.25]; p-value=0.03), independent of age or smoking. To hyperpigmentation, the best model included smoking (OR=8.47 [1.18-3.10], p= 1.31e-5), without race or type and duration of treatment. CONCLUSION: Among HIV patients undergoing antiretroviral treatment, oral lesions can be observed, predominantly periodontal disease. Pseudomembranous candidiasis and oral hairy leukoplakia were also observed. No relationship was found between associated oral manifestations in HIV patients and the start of the treatment, TCD4+ and TCD8+ cell count, TCD4:TCD8 ratio, or viral load. The data indicate that there is a protective effect of duration of treatment with relation to periodontal disease with mobility and that hyperpigmentation seems to be more related to smoking than type and duration of treatment. LEVEL OF EVIDENCE: Level 3 (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence").

[Oral hairy leukoplakia induced by topical steroids]. / Leucoplasie orale chevelue induite par une corticothérapie locale.

BACKGROUND: Oral hairy leukoplakia (OHL) is an EBV-associated condition of the oral mucosa, which is often painless. It is found predominantly in HIV-positive patients and is considered a clinical indicator of immunosuppression. OHL has rarely been described in HIV-negative patients, being found most often in association with iatrogenic immunosuppression. OHL induced by topical steroids remains extremely rare. PATIENTS AND METHODS: An 81-year-old HIV-negative woman, treated for 3 months with topical steroids for oral lichen planus, developed an asymptomatic white, corrugated, non-removable plaque with vertical folds on the lateral edge of the tongue. Associated oral candidiasis was noted. Based upon histological findings and in situ hybridisation showing numerous EBV-infected epithelial cells, a diagnosis of oral hairy leucoplakia was made. DISCUSSION AND CONCLUSION: To our knowledge, we report herein only the second recorded case of OHL induced strictly by topical steroids. Self-medication and poor adherence to dosage recommendations were noted in the patient's medical history. Physicians must be aware of the rare but nevertheless possible adverse events associated with topical steroid use, particularly when such medication is prescribed over a long period for inflammatory diseases of the oral mucosa.

Knowledge and attitudes about HIV/AIDS of students in H.P. Government Dental College and Hospital, Shimla, India.

The purpose of this cross-sectional survey was to assess the knowledge and attitudes towards patients with HIV/AIDS among dental students in H.P. Government Dental College, Shimla, India. In November 2011, a survey was conducted of all the dental students of the college using a forty-five-item, self-administered questionnaire. The total mean knowledge score was 68.3 percent (good knowledge). The mean knowledge score was statistically higher in the clinical group than in the preclinical group. A majority of the students were aware of the association between HIV and oral candidiasis (89.1 percent), major aphthous (83.2 percent), and Kaposi's sarcoma (68.9 percent). Only 4.9 percent had professional attitudes about treating patients with HIV/AIDS. Male students had significantly fewer negative attitudes and higher positive attitudes than female students. The overall attitude score was significantly higher in the clinical group than in the preclinical group. Although a majority of the students had good knowledge, there were some inadequacies in their knowledge; those were more frequently seen in the preclinical students. It is important that dental students, as future dentists, develop not only the necessary practical skills but also knowledge and attitudes that will prepare them to treat patients with HIV/AIDS.

Oral hairy leukoplakia in an HIV-negative patient.

We report the case of a 31-year-old woman with systemic lupus erythematosus who was found to have oral hairy leukoplakia (OHL). She was on immunosuppressive therapy but was human immunodeficiency virus (HIV)-negative. OHL has been previously reported in HIV-negative patients who were immunosuppressed for other reasons, such as solid organ or hematopoietic stem cell transplantation, hematologic malignancies, or systemic diseases. To the best of our knowledge, this is the first case of OHL in an HIV-negative patient reported in the otolaryngology literature. It adds to the growing list of cases of OHL in HIV-negative patients and serves as a reminder to physicians to include OHL in the differential diagnosis for oral cavity lesions in all immunosuppressed patients. The article also summarizes the current state of knowledge about the pathogenesis of OHL, its relation to the Epstein-Barr virus, and the treatment options.

Oral lesions associated with HIV infection before and during the antiretroviral therapy era in Ribeirão Preto, Brazil.

We estimated the prevalence of oral lesions associated with human immunodeficiency virus (HIV-OLs) before and during the antiretroviral therapy (ART) era. The first period was 1997, when many patients received two types of antiretroviral (ARV) drugs. The second study period was 2004 through 2008, when all patients were treated with ART (a combination of two or three classes of drugs, including protease inhibitors). A total of 148 and 388 seropositive participants were examined in 1997 and 2004-2008, respectively. The evaluation consisted of anamnesis and physical examination. The prevalence of HIV-OLs decreased between 1997 (60.1%) and 2004-2008 (29.9%). The HIV-OL responsible for the greatest reduction in prevalence between the two periods was oral candidiasis, of which erythematous candidiasis was the clinical form that decreased most, followed by pseudomembranous candidiasis. In conclusion, we observed a significant reduction in HIV-OLs, which was closely associated with the use of ART. In addition, among patients with a clinical diagnosis of AIDS, we confirmed a significant reduction in HIV-OL prevalence between 1997 and 2004-2008.

Prevalence, incidence, and recurrence of oral lesions among HIV-infected patients on HAART in Alabama: a two-year longitudinal study.

OBJECTIVE: Our aim was to quantify prevalence, incidence, and recurrence of oral lesions (OL) among a population in the Southeast. METHODS: A retrospective study based on chart review was conducted among patients (n = 744) who were ≥19 years of age and initiated highly active antiretroviral therapy (HAART) between January 2000 and June 2006 at the University of Alabama at Birmingham (UAB) 1917 Clinic. Patients' laboratory data and oral conditions were recorded for 2 years after enrollment into the study. RESULTS: During 2 years of follow-up, the period prevalence of individuals experienced at least one OL was 35.6% (266/744). Among all of the 374 episodes of OL, 183 were new cases, while 57 were recurrences. The OL person-visit incidence rate was 0.02 per 100 person-visits. Oropharyngeal candidiasis (OPC) was the most frequent manifestation in terms of period prevalence (74.9%) with a person-visit incident rate of 0.01 per 100 person-visits. CONCLUSIONS: Patients undergoing HAART continue to be affected by HIV-related oral conditions, especially OPC. These results clearly indicate that OL during HIV infection are still highly prevalent in spite of the improvements in medical care and the availability of HAART.

Oral manifestations of HIV infection and their correlation with CD4 count.

Human Immunodeficiency Virus (HIV)-related oral lesions can be used as markers of the immune status. The present cross-sectional study was conducted to identify the oral manifestations in HIV-infected individuals and their association with reduced Cluster of Differentiation 4 (CD4) count. The study population included known HIV-positive patients. A detailed case history of 399 HIV-positive patients was obtained and general examination was carried out. Diagnosis of oral lesions was done based on presumptive criteria of EEC Clearinghouse, 1993. The CD4 count was determined in 369 patients and correlated with oral manifestations. The prevalence of oral lesions was found to be 76.70% (n = 306). Oral candidiasis (157 (39.3%)) was the most common oral lesion associated with HIV infection. Amongst various forms of oral candidiasis, erythematous candidiasis (122 (39.3%)) outnumbered the other forms. The mean CD4 count of patients with oral lesions (207 cells/mm(3)) was less than in patients without oral lesions (291 cells/mm(3)) (P = 0.002). Oral candidiasis was found to be significantly correlated to a reduced CD4 cell count below 200 cells/mm(3) (P = 0.000; Odds ratio = 3.1; 95% Confidence interval 1.9-4.9) with good sensitivity, best specificity and positive predictive value. Oral manifestations may be used as an alternative to CD4 count at field-based settings to diagnose the immune compromised status of HIV-infected individuals.

Epstein Barr Virus detection and latent membrane protein 1 in oral hairyleukoplakia in HIV + Venezuelan patients

Purpose: To determine the prevalence of Epstein Barr Virus (EBV) in oral hairy leukoplakia lesions (OHL) inHIV+ Venezuelan patients. Material and Method: In this case study, we evaluated 21 HIV+ adult patients withclinically present OHL lesions, 11 who were undergoing antiretroviral therapy, 10 who were not undergoingtherapy and 10 HIV-negative adult patients with hyperkeratotic oral mucosal lesions. All of the subjects were assessedat the Infectious Disease Center, Faculty of Dentistry, Central University of Venezuela, and were clinicallyexamined to detect oral mucosal lesions with the confirmed histopathologic diagnosis. Nested-PCR was used todetermine the EBV infection and the latent membrane protein-1 (LMP-1) expression by immunohistochemistry.Results: Of the subjects, 16/21 (76%) of the HIV+/AIDS patients tested positive for EBV, whereas 5/10 (50%) ofthe HIV-negative subjects tested positive for EBV. Conclusions: In the present study, a higher EBV prevalence wasobserved in HIV-positive patients when compared to HIV-negative patients without oral hairy leukoplakia, confirmingthe etiologic role in this entity. The LMP-1 in OHL patients who were both HIV+ and EBV+ was highlyexpressed (60%) at the epithelial basal cells. No association between the alcohol and tobacco consumption wasobserved among the EBV-positive cases (AU)

Epstein Barr Virus detection and latent membrane protein 1 in oral hairy leukoplakia in HIV+ Venezuelan patients.

PURPOSE: To determine the prevalence of Epstein Barr virus (EBV) in oral hairy leukoplakia lesions (OHL) in HIV+ Venezuelan patients. MATERIAL AND METHOD: In this case study, we evaluated 21 HIV+ adult patients with clinically present OHL lesions, 11 who were undergoing antiretroviral therapy, 10 who were not undergoing therapy and 10 HIV-negative adult patients with hyperkeratotic oral mucosal lesions. All of the subjects were assessed at the Infectious Disease Center, Faculty of Dentistry, Central University of Venezuela, and were clinically examined to detect oral mucosal lesions with the confirmed histopathologic diagnosis. Nested-PCR was used to determine the EBV infection and the latent membrane protein-1 (LMP-1) expression by immunohistochemistry. RESULTS: Of the subjects, 16/21 (76%) of the HIV+/AIDS patients tested positive for EBV, whereas 5/10 (50%) of the HIV-negative subjects tested positive for EBV. CONCLUSIONS: In the present study, a higher EBV prevalence was observed in HIV-positive patients when compared to HIV-negative patients without oral hairy leukoplakia, confirming the etiologic role in this entity. The LMP-1 in OHL patients who were both HIV+ and EBV+ was highly expressed (60%) at the epithelial basal cells. No association between the alcohol and tobacco consumption was observed among the EBV-positive cases.

Mode of HIV transmission associated with risk of oral lesions in HIV-infected subjects in Thailand.

BACKGROUND: The aim of this study was to determine if route of human immunodeficiency virus (HIV) transmission is associated with the risk of oral lesions in HIV-infected subjects in Thailand. METHODS: A cross-sectional study was performed in 186 HIV-infected heterosexuals (aged 21-65 years, mean 32 years), and 82 HIV-infected intravenous drug users (IVDUs) (aged 16-50 years, mean 30 years). The following information was recorded: route of HIV transmission, total lymphocyte cell counts, weight, smoking habit, alcohol consumption, medications, presence of denture, plaque index, and presence of oral lesions. The association between mode of HIV transmission and the risk of oral lesions among the subjects was determined by multiple logistic regression analysis. RESULTS: Oral lesions were found in 138 HIV-infected heterosexuals (75%) and in 37 HIV-infected IVDUs (46%). Oral candidiasis (OC) was the most common lesion among both groups (44% vs. 28%), followed by hairy leukoplakia (HL) (33% vs. 10%). Multiple logistic regression analysis showed a significant association between mode of HIV transmission and the risk of oral lesions after controlling for the total lymphocyte cell counts and other confounding factors [OR 3.1; 95% CI 1.5-6.4; P = 0.002]. OC was significantly associated with heterosexual route of HIV transmission [OR 2.4; 95% CI 1.2-4.7; P = 0.014]. Similar association was also observed with HL [OR 3.7; 95% CI 1.5-9.1; P = 0.004]. CONCLUSIONS: Mode of HIV transmission is associated with the risk of oral lesions in HIV-infected subjects in Thailand. Further studies should be performed to determine if the risk of oral lesions is associated with differences in HIV-subtypes.

Cost implications for the treatment of five oral lesions commonly found in HIV/AIDS.

The objectives of this study were to determine the cost of a prescribed treatment plan; to compare the costs in an academic hospital cost with that of private pharmacy; and to determine the average treatment cost per visit. The descriptive, retrospective study that investigated the cost implications of the treatment of five oral lesions associated with HIV/AIDS: oral candidiasis, oral hairy leukoplakia, periodontal diseases, oral ulcers and Kaposi's sarcoma. One hundred and twenty four cases with oral HIV lesions were selected from the list of 181 HIV patients listed in the attendance registers of three hospitals in the selected study sites. A data capture sheet was used to obtain information related to diagnosis, investigations done, staging of the disease, treatment plan and treatment outcome. None of the patients were on antiretroviral therapy. The association between the number of hospital visits and the total cost of treatment was significant (p < 0.05). Also, there was a significant negative relationship between the outcome of treatment and the total hospital costs (p < 0.05). The lower the hospital treatment cost, the better the outcome. There was no significant association between staging of the disease and the hospital cost (p > 0.05), but the CD4 count significantly influenced the hospital cost (p<0.05). The average hospital treatment and private pharmacy cost was 207.06 and 357.85 rands respectively (16.21 euros and 28.02 euros respectively). There is a need to evaluate the current treatment protocols, as some treatments may be ineffective. Governments should endeavour to provide antiretroviral and other relevant drugs, at no cost, to HIV/AIDS patients.

Oral manifestations as predictors of immune suppression in a HIV-/AIDS-infected population in south India.

The objectives of the study are to evaluate the relationship between common HIV-related oral lesions and absolute CD4+ count, age, gender, and medication used and to assess the sensitivity, specificity, positive and negative predictive value of oral manifestations for low absolute CD4+ counts. HIV-positive patients, 200, from south India were selected, whose absolute CD4+ counts were determined within 2 weeks of oral examination. Sociodemographic data was obtained using a structured questionnaire. Oral manifestations were diagnosed according to presumptive criteria of EEC-clearinghouse classification (1993). Four or more concurrent oral lesions were statistically significant with low CD4+ counts <200 cells/mm3 (P = 0.005). The highest and lowest mean CD4+ cell counts were seen in individuals with linear gingival erythema (LGE; 172.5 cells/mm(3)) and pseudomembranous candidiasis (PC; 87 cells/mm(3)), respectively. Smoking, age (<35 years), and males had a positive association with oral hairy leukoplakia (OHL; P < 0.05). Patients with CD4+ counts < 200 cells/mm(3) were associated with 15 times greater risk of PC and four times at greater risk for occurrence of any oral manifestation. Concurrent oral manifestations (>or=4) were good predictors (80-100%) of severe immune suppression. In most resource poor countries where facilities for undertaking CD4+ counts are not available, the presence of concurrent oral manifestations may be used as an indicator of deteriorating immune status.

Patterns of oral manifestation of HIV/AIDS among 225 Nigerian patients.

OBJECTIVE: The purpose of this study was to determine the prevalence of the oral manifestations of HIV/AIDS and to correlate the prevalence of these lesions with the stages of the disease in the Ife-Ijesa zone, Nigeria. No comprehensive data were available for correlating it with the staging of HIV/AIDS in this region. SUBJECTS: The pattern of oral HIV lesions as classified by the EC-Clearinghouse was studied in 225 confirmed consecutive HIV-infected patients in this zone. METHODS: Clinical dental examinations were conducted under natural daylight on all consenting HIV patients, sitting in an upright chair, using dental mirrors and probes. RESULTS: The prevalence of oral HIV lesions was 84.0%, with lesions ranging in number from one to six. The commonest HIV lesion was pseudo-membranous candidiasis (43.1%) followed by erythematous candidiasis (28.9%), angular cheilitis (28.9%), linear gingival erythema (24.0%) and ulcerations (8.9%). Lesions less commonly found were oral hairy leukoplakia (1.3%) and salivary gland swellings (1.3%). Heterosexual intercourse was the most common mode of transmission (94.7%) and HIV-1 (96.9%) the most prevalent pathogen among the study population. The majority of the patients were in the WHO clinical stage III (59.1%) and presented late. CONCLUSIONS: The prevalence of oral HIV lesions in the present study was high.

Dental students' knowledge of human immunodeficiency virus.

OBJECTIVE: This study evaluated final year dental students' knowledge of human immunodeficiency virus (HIV), lesions associated with HIV, potential transmission routes of HIV, and their perception of the teaching received on cross-infection precautions, virology, sterilization practice and procedure, barrier dentistry and recognition of blood-borne virus risk group. METHODOLOGY: Structured questionnaires on knowledge of human immunodeficiency virus were filled by final year dental students of University of Lagos, Nigeria. A total of 35 out of 37 questionnaires were returned filled giving a response rate of 94.6%. RESULTS: Most of the students rated the teaching they received on cross-infection precautions, sterilization practice and procedure, as adequate. More than a quarter (28.5%) of the students rated the teaching they received on virology and recognition of blood-borne virus risk group to be less than adequate. Most of the students were able to recognize the association of oral Kaposi sarcoma, oral candidiasis, oral hairy leukoplakia, and salivary gland enlargement with HIV infection. There was a much lower level of knowledge of oral melanotic hyperpigmentation and idiopathic thrombocytopaenic pupura. Their knowledge of HIV and its potential transmission routes were adequate. CONCLUSION: This study revealed that final year dental students of the University of Lagos in southwestern region of Nigeria had adequate knowledge of routes of transmission of HIV in clinical practice. However, there is need for improvement in teaching of the students on virology and recognition of blood-borne virus risk group.

Oral candidiasis as a marker of HIV disease progression among Zimbabwean women.

OBJECTIVES: To estimate oral disease prevalence among Zimbabwean women by HIV serostatus and CD4 cell count and to assess accuracy of oral disease diagnoses made by nurses as compared with an oral surgeon. METHODS: Standardized oral mucosa examinations were performed by trained nurse-examiners and by an oral surgeon among women recruited in Harare, Zimbabwe. RESULTS: A total of 461 women (320 HIV-infected, 141 uninfected) were seen by nurses and an oral surgeon within a 2-week period. Oral candidiasis (OC) was the most common lesion diagnosed in nearly one quarter of HIV-infected women, whereas hairy leukoplakia and Kaposi sarcoma were found in <3%. The prevalence of OC diagnosed by nurses or the surgeon was significantly higher among women with a CD4 count <200 cells/mm than in women with a CD4 count from 200 to 499 cells/mm3 or a CD4 count >499 cells/mm3. The sensitivity of nurse examinations compared with examinations by the oral surgeon among HIV-infected women for the diagnosis of OC was 73%, the specificity was 95%, and the kappa-statistic was 0.71. CONCLUSIONS: OC was the most common lesion in HIV-infected women and was strongly associated with a low CD4 cell count. Interexaminer agreement was good for the diagnosis of OC among HIV-infected women. This study suggests that OC may play a role, in combination with other clinical indicators as a marker of disease progression in resource-poor settings.

Oral hairy leukoplakia arising in an oral lichen planus lesion in an otherwise immune-competent patient.

Oral hairy leukoplakia (OHL) presents clinically as thickened white plaques which cannot be rubbed off, and is most often found on the lateral margin of the tongue. The name is derived from its often hairy appearance. OHL has clinical significance because of its association with HIV infection, and it is rare in immune-competent people. We report on a case of unilateral OHL which arose in an oral lichen planus lesion in an immune-competent patient.

Changes in the pattern of oral lesions associated with HIV infection: implications for dentists.

Broad access to better HIV treatment has resulted in a significant reduction in the prevalence of HIV-associated oral lesions in western industrialized countries. However, a possible increased prevalence of oral warts and a potential dissociation between CD4+ T-cell counts and oral manifestations of HIV require continued vigilance by oral health care providers. Head and neck and oral examination coupled with a careful consideration of the complications associated with hyposalivation remain essential components of a comprehensive oral health care program.

Risk factors for oral hairy leukoplakia in HIV-infected adults of Brazil.

BACKGROUND: Oral hairy leukoplakia (OHL) may be an indicator of the progression of Human Immunodeficiency Virus (HIV)-induced immuno-depression, and the evaluation of risk factors leading to OHL is important in the management of these HIV-infected patients. However, there are few studies that analyze risk factors leading to OHL in the Brazilian population. The aim of this case-control study is to present data about prevalence rates and risk factors leading to OHL in a sample of HIV-infected adults in Brazil. METHODS: This case-control study included 111 HIV-infected patients treated at a clinic for sexually transmitted diseases and HIV. In the initial examinations with dentists, variables were collected from all patients. Diagnosis of OHL was performed in accordance with the International Classification System and cytological features. The Fisher and the chi-squared tests were used for statistical analysis. The proportional prevalence and odds ratio were estimated. RESULTS: Outcome presented a positive, statistically significant association among the presence of OHL and viral load of 3000 copies/mul or greater (P = 0.0001; odds ratio (OR) = 5.8), presence of oral candidiasis (P = 0.0000; OR = 11.1), previous use of fluconazole (P = 0.0000; OR = 24.6), and use of systemic acyclovir (P = 0.032; OR = 4.3). Antiretroviral medication presented a negative, statistically significant association with the presence of OHL (P = 0.002; OR = 8.4). CONCLUSIONS: Prevalence of OHL was 28.8%. Viral load, oral candidiasis, previous use of fluconazole, and systemic acyclovir were determined to be risk factors for OHL. Antiretroviral medication proved to be protective against the development of OHL.