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5th World Workshop on Oral Health and Disease in AIDS
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ABSTRACTS
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CLINICAL
ORAL LESIONS AND MANAGEMENT OF HIV
RELATED DISEASE
A1
Oral Manifestations of HIV in Pregnant
Women Attending Antenatal Clinics in
Johannesburg.
LAO Adeyemi*1, MJ Rudolph1, AO Yusuf2, JA McIntyre3,
GE Gray3, N Martinson 3
1School
of Public Health, University of the Witwatersrand,
of Community Dentistry, University of
Pretoria, 3Perinatal HIV Research Unit, University of the
Witwatersrand, Johannesburg
2Department
L Adeyemi: [email protected]
Introduction: Although, several studies have been reported
from outside Sub-Saharan Africa on the oral manifestations
of HIV in women, no such study has yet been undertaken on
oral manifestations of HIV in pregnant women in Africa. In
some areas of South Africa, one in three pregnant women
attending public sector health facilities is HIV positive. Oral
candidiasis has been shown to be the most common oral
lesion associated with HIV infection in women.
Objective: To determine the prevalence of oral
manifestations in HIV positive pregnant women attending
antenatal clinics in Johannesburg.
Method: A cross sectional study was conducted on HIV
positive pregnant women attending antenatal clinics in three
hospitals in Johannesburg, South Africa. A calibrated
dentist determined HIV related oral lesions by doing a
clinical examination in 128 HIV positive pregnant women
using the criteria suggested by the EC/WHO. Parity,
gravidity and age of the patients were collected by means of
a self-administered structured questionnaire.
Results: The age range for the group was 17 to 42 years,
with a mean age of 27.9 years. Twenty-eight (22%) of the
group was primigravid, while 100 (78%) were multiparous.
The majority of the patients, 73 (57%) were in their second
trimester. Oral candidiasis and angular cheilitis were the
most commonly seen oral lesions in these patients with a
frequency of 78 (61%) and 51 (40%) respectively. Oral
ulceration was seen in 35 (27%) of the patients. Thirty-three
women (26%), presented with necrotizing ulcerative
gingivitis, 6(5%) had necrotizing ulcerative periodontitis
and 6(5%) had linear gingival erythema. Less than 3% of
the patients presented with herpes, which was mainly extraoral. No other HIV associated oral lesions were seen in
these patients.
Conclusion: The prevalence of oral lesions associated with
HIV infection for this particular sub-group is similar to
results of other prevalence studies conducted elsewhere on
women, though the prevalence of oral candidiasis was
slightly higher in this group. The confirmation of these
A3
findings in pregnant women emphasizes the need for
diagnosis of oral lesions by all health care workers and for
recommended treatment or referral.
A2
Common Oral Lesions Seen Amongst Seropositive Clients at a Voluntary Confidential
Counseling Testing Centre in Kaduna
Nigeria
UE Amanyeiwe-Adaka*, C Igbokwe, SO Ajike
Maxillofacial Unit, Ahmadu Bello University Teaching
Hospital, Kaduna, Nigeria
U Amanyeiwe-Adaka: [email protected]
The occurrence of common oral lesions seen amongst seropositive patients was investigated in 638 consecutive
patients attending the FRC voluntary confidential
counseling and testing (VCCT) centre from November 2002
to November 2003. Different types of oral lesions were
observed in 372 (58.3%) of subjects. The most prevalent of
these lesions was oral candidiasis observed in 263 (70.7%)
patients. The high prevalence of oral candidiasis is similar
to those reported in studies from Jos in Nigeria, Cote
D'Ivoire and South Africa. The prevalence of other oral
lesions was much lower, some patients had more than one
type of lesion. They included aphthous ulcers 67 (18%),
herpes simplex 47 (12.6%), necrotizing gingivitis 30
(8.1%), salivary gland enlargement 19 (5.1%), necrotizing
periodontitis 18 (4.8%), Kaposi sarcoma 12 (3.2%), herpes
zoster 7 (1.9%), oropharyngeal carcinoma 5 (1.3%),
melanotic hyper-pigmentation 3 (0.8%), maculo-papular
lesions 3 (0.8%) and necrotizing fasciitis 2 (0.5%). Similar
findings are reported from other studies. Management of
these seropositive patients at this VCCT Centre was mainly
symptomatic. Patients were given multivitamin supplements
and treatment for opportunistic infections. Oral candidiasis
was treated with Nystatin pastilles and lozenges, whereas
fulminating cases of mycotic infection were given systemic
fluconazole. Twelve of the 33 patients who could afford
uninterrupted ARV supply for six months had oral lesions.
Conclusion: Oral lesions occurred more frequently in
patients that presented with advanced stages of the
infection. Seropositive patients on ART presented with
fewer oral lesions. In patients with severe opportunistic
infections, commencement of ARVs combined with
symptomatic treatment of the opportunistic infections and
nutritional support, contributed to recovery. Reduced rates
of recurrence of infections, progressive rise in CD4 count
and improvement in the patients general status was noted. In
resource limited settings where facilities are not available,
oral lesions may be used as a marker for staging the clinical
progress of HIV/AIDS.
Gender Differences in Oral Manifestations among South
African HIV/AIDS Patients
E Blignaut*
________________________________________________________________________ 37
5th World Workshop on Oral Health and Disease in AIDS
Medical University of Southern Africa
E Blignaut: [email protected]
Objectives: To determine gender differences in numbers,
age and oral manifestations among black HIV/AIDS
patients attending three AIDS clinics in the Gauteng
province, South Africa.
Background: In 2002 it was estimated that 6.5 million
South Africans were living with HIV/AIDS, and that
women of child bearing age (15-49 years) constituted half
of the infected population.
Methods: A retrospective analysis was performed on data
obtained over a four year period, from the primary visit of
patients attending outpatient clinics at three hospitals in the
Pretoria region. At the time no patients had access to
antiretroviral therapy. All patients received an oral
examination, irrespective of any complaints. Surveillance
swabbing for Candida was also performed.
Results: Of the total patient population 1031 (67.4%) were
female and 498 (32.6%) male. Of the female patients 78.5%
were aged between 20 and 39 years while 76% of the male
patients were 30 years and older. Localised attachment loss
was more prevalent in males (p≤0.05), while linear gingival
erythema and a pericoronitis around an erupting third molar
was observed more frequently in females (p≤0.01 and
p≤0.05 respectively). In females a significant correlation
(p≤0.001) between pseudomembranous candidiasis and a
CD4 cell count below 200 cells/mm3 was observed. In
males erythematous candidiasis correlated significantly with
a CD4 cell count below 200 cells/mm3 (p≤0.01).
Conclusion: Twice as many females than males attended
the clinics and they were also younger than the male group.
Differences in the prevalence of oral manifestations
between males and females were demonstrated, including
differences in the correlation of some lesions with a CD4
count below 200 cells/mm3.
A
4
.
Methods: We recruited HIV+ and HIV- women from 2
prospective cohort studies (HIVNET and WHO) in Harare.
HIV serostatus was assessed at baseline. CD4 count was
measured and a standardized oral soft tissue examination
was performed at 6-month intervals by both a nurse
examiner trained in the diagnosis of HIV-related oral
lesions (using ECC criteria) and an oral surgeon. The
examinations were done within 2 weeks of each other when
possible. We report preliminary analyses conducted on
baseline data as recruitment is still ongoing. We include
only those women who were seen by both nurse and oral
surgeon within a 2-week window.
Results: 433 women 342 (212 HIV+, 130 HIV-) were seen
by both nurse and oral surgeon within a 2-week period.
Mean age was 30.2 years (range 18-47) among HIV+
women and 27.4 years (range 19-36 y) among HIVwomen. Oral candidiasis (OC), predominantly pseudomembranous, was the most common lesion diagnosed by
the oral surgeon in both HIV+ and HIV- women (28%
versus 18%; p=0.03), and by the nurses (22% versus 8%;
p=0.001). Hairy leukoplakia and Kaposi’s sarcoma were
found in 2% and <1%, respectively, of HIV+ and in none of
the HIV- women (by either nurse or oral surgeon). The
prevalence of OC diagnosed by the oral surgeon was
significantly higher among women with CD4 count <200
than in women with CD4 count 200-499 and >499 (57%,
36%, and 7%; respectively; p=0.02). The agreement rate
between nurse and oral surgeon examinations was high
among HIV+ women for the diagnosis of OC (91%
agreement on positive diagnoses and 90% agreement on
negative diagnoses). However, the agreement rate was
lower for examinations done in HIV- women as the oral
surgeon found a higher prevalence of erythematous
candidiasis in that group than the nurses.
Conclusion: OC was the most common lesion in HIVpositive Zimbabwean women and was strongly associated
with a low CD4 count. The inter-examiner agreement rate
was good for diagnoses of OC among HIV-positive women,
but erythematous candidiasis remains a diagnostic
challenge. These preliminary results suggest that
pseudomembranous candidiasis may be used as surrogate
marker of disease progression, and is reliably diagnosed by
nurses.
HIV Related Oral Diseases Among Women in
Zimbabwe
Oro-facial Manifestations in Paediatric HIV:
A Comparative Study of Institutionalized
and Hospital Out-Patients
MM Chidzonga*1, M Mwale1, L Chidzumo1, E Makura1, K
Malvin2, CH Shiboski2
A5
1University
S Naidoo*, U Chikte
of Zimbabwe, 2 University of California San
Francisco
M Chidzonga: [email protected]
Objectives: To estimate oral disease prevalence among
women in Harare in relation to HIV serostatus and CD4
count, and to assess sensitivity and specificity of oral soft
tissue examinations conducted by nurses compared to an
oral surgeon.
Background: Because biologic assays to measure HIV
disease progression are rarely accessible in sub-Saharan
African countries due to prohibitive cost, we sought to
investigate the use of HIV related oral lesions as potential
markers for HIV disease progression as an inexpensive
alternative.
University of the Western Cape, Cape Town, South Africa
S Naidoo: [email protected]
The aim of the study was to compare caries status and the
number and type of oral mucosal lesions in HIV positive
children from a hospital outpatient department and an
institutionalized setting.
Oral examinations were performed using presumptive
diagnostic criteria. The Fisher’s Exact and the MannWhitney tests were used for statistical comparison of the
two study groups. A total of 169 children were examined of
whom 42% were institutionalized and 58% hospital
outpatients. One institutionalized child presented with
________________________________________________________________________ 38
5th World Workshop on Oral Health and Disease in AIDS
Noma. 21% of the institutionalized population presented
with Molluscum contagiosum, while none of the hospital
outpatients presented with this condition.
Significantly more intra-oral mucosal lesions were observed
in the hospital compared to the institutionalized group. The
most frequently encountered oral lesion was candidiasis.
Twice as many intraoral ulcers were recorded in the
institutionalised group. Thirty nine percent of the
hospitalized patients had multiple lesions compared to 28%
in the institutionalised group. Almost three quarters of both
populations were caries-free. The mean DMFT was higher
in the hospital population. For both the permanent and
primary teeth, the decayed component made up the major
part of the DMFT/dmft, followed by the missing
component. No fillings were recorded in either the primary
or permanent teeth for both groups.
Oral lesions were common in HIV populations and were
seen in both the hospital (63%) and institutionalized (45%)
groups at high prevalence levels. HIV infected children
should be considered high risk for caries due to the use of
chronic medication, and to receive appropriate care in terms
of both treatment and services.
A6
Oral Manifestation of HIV Paediatric Cases
in Chennai, South India
R Thavarajah*1, TR Saraswathi1, U Devi1, S Solomon2, N
Kumaraswamy2, NW Johnson3, K Ranganathan1
.
Background: Of the 40 million people living with HIV
globally, children constitute 2.5 million. In India there are
4.5 million people living with HIV and children infected
with this infection constitute a major health problem. There
are very few reports of oral lesions and conditions in Indian
HIV seropositive children, even though the number of
children affected by this disease is increasing.
Methods: Our study group consisted of 37 children referred
to our tertiary HIV care center at Ragas Dental College and
Hospital and YRG CARE, Chennai, India). ELISA and
Western Blot confirmed the HIV sero status. A complete
oral examination was undertaken by a trained dental
surgeon and diagnosis of oral lesions was made on
presumptive criteria established by the EC Clearing house,
1993 and WHO.
Results: Of the 37 pediatric cases in our cohort, 22 were
males (59.5%) and 15 were females (40.5%). 84% acquired
the infection through vertical transmission and 16% through
blood transfusion. The lesions that were seen included
candidiasis, gingivitis, parotid enlargement and cervical
lymphadenopathy. The following table compares our results
with published prevalence percentages. On a 6months
follow up, all these oral lesions responded favorably to
standard treatment protocols.
Conclusion: Given the morbidity of the oral lesions it is
essential that information regarding oral lesions in pediatric
population in India should be gathered for early diagnosis
and treatment.
1Ragas
Dental College and Hospital, Chennai, 2 YRG
CARE, Chennai, 3Guy’s, King’s & St Thomas Dental
Institute, London, UK
R Thavarajah: [email protected]
Author , year
P.
E.
Candida
Candida Candida
Angular
chelitis
Cervical
Parotid
lymph
Gingivitis
swelling adenopathy
OHL
DC
Ramos – Gomez FJ
43%
et al 2000
Khongkunthian P
17.8%
6.7%
-et al 2001
Santos LC et al
22.5%
8.8%
17.5%
1.3%
2001
Magalhaes MG
18.42% 18.42%
28.94% 18.42%
13.5%
2.63%
et al 2001
Luis Gaitan –
Cepeda et al
29.2%
2.1%
4.2%
2002
Okunseri et al
2.9%
2%
1%
20.6%
19.6%
2003
Present study 2004 16.2%
5.4%
18.8%
10.8%
2.7%
5.4%
21.6%
2.7%
35.1%
P- Pseudomembranous; E- Erythematous; OHL- Oral Hairy Leukoplakia; DC- Dental Caries
________________________________________________________________________ 39
5th World Workshop on Oral Health and Disease in AIDS
A7
Classification of Oral Diseases of HIVAssociated Immune Suppression
M Glick*, SN Abel, CM Flaitz, CA Migliorati, LL Patton,
JA Phelan, DA Reznik
ODHIS Workshop Group – USA
M Glick: [email protected]
The present classification systems for HIV-associated oral
lesions were developed in the early 1990s and have been
valuable tools for both diagnostic and research purposes.
With the advent of new antiretroviral therapy, the pattern of
oral conditions is changing in the USA and a new
classification system should be evaluated. This system
should reflect changes in the epidemiology of oral lesions
that are related to HIV disease and therapeutics. In addition,
this system should take into account the association between
the development of these lesions and the patient’s immune
status. The terminology of “oral lesion” also needs to be
changed to “oral disease”. Oral disease is defined as an
abnormality characterized by a defined set of signs and
symptoms in the oral cavity, extending from the vermilion
border of the lip to the oropharynx, with the exception of
salivary gland disease. Based on a review of the recent
literature and expert opinion with majority consensus, the
following groups of oral diseases are proposed for this
revised classification system:
Group 1 ODHIS associated with severe immune
suppression (CD4 < 200 cells/mm3).
Group 2 ODHIS associated with immune suppression
(CD4 < 500 cells/mm3).
Group 3 ODHIS assumed associated with immune
suppression.
a) More commonly observed.
b) Rarely reported.
Group 4 Therapeutically-induced oral diseases.
Group 5 Emerging oral diseases.
ODHIS Workshop Group - USA does recognize that oral
diseases do not exclusively belong to one classification
Group, and that overlap exists. The use of an immune-based
classification system provides a method for identifying
undiagnosed individuals, provides an additional rationale
for HIV testing, effects access and type of HIV-related
healthcare, and provides clinical markers for therapeutic
interventions and efficacy. Despite these important
advantages, the proposed ODHIS classification should be
pilot tested and consensus developed before it is widely
disseminated among healthcare providers. Funded by the
Dental Alliance for AIDS/HIV Care (DAAC).
A8
Smoking as a Predictor of Oral
Manifestation of HIV Infection
OA Ayo-Yusuf*1, AS Bajomo2 and MJ Rudolph2.
1Department
of Community Dentistry, University of
Pretoria and 2Division of Oral Public Health, University of
Witwatersrand, South Africa.
OA Ayo-Yusuf: [email protected]
.
Oral lesions in HIV-infected individuals are potentially
useful predictors of disease progression, especially in poorly
resourced societies. It is therefore important to recognise
factors that may impact on their presentation and
management. This cross-sectional analytical study therefore
sought to determine the effect of smoking on oral
manifestation (OM) of HIV/AIDS among a South African
general hospital outpatient population. Study participants
included one hundred and seventy-five (n=175) consenting
HIV infected adults that consecutively presented at the HIV
clinic on referral for routine care and support since their
diagnosis of HIV seropositivity. Socio-demographic
information, drug-treatment status and smoking history
were obtained from the patients using a self-administered
questionnaire. A systematic oral examination was also
conducted on each patient by a trained and calibrated dental
clinician in order to record presence of HIV-related oral
lesion(s). The examiner was blinded to the completed
questionnaire. Cigarette smoking prevalence was 10%
(n=17), with male prevalence of 23%. Only one smoker
reported to have reduced consumption since knowing of
HIV status, but none had quit. Of the 76% that presented
with OM, oral candidiasis was the most common oral lesion
(72%). Adjusting for period since visiting (proxy for HIV
history) and other variables, logistic regression analysis for
presentation with OM indicated that being female (odds
ratio [OR], 3.8; 95% confidence interval [CI], 1.1-13.0) and
regular smoking (OR, 8.6; 95% CI, 1.6-46.4) was
significantly associated with higher odds of presenting with
OM. The model derived explained 12% of variance in OM.
The study findings suggest smoking is an important
predictor of OM in the studied population. However, there
is also an indication for further research.
ORAL HEALTH AND GENERAL HEALTH
A9
The Association of Peripheral Blood
Abnormalities and HIV-Associated Oral
Lesions
D Kerdpon*1, S Sretrirutchai2, A Nilmanut3, A Geater2, K
Wangrangsimakul1
1Faculty
of Dentistry, Prince of Songkla University,
Thailand; 2Faculty of Medicine, Prince of Sonkla
University, Thailand; 3Hatyai Regional Hospital, Songkla,
Thailand
D Kerdpon: [email protected]
Few data of peripheral blood abnormalities and their
association with HIV-associated oral lesions are available.
This study evaluated the prevalence of peripheral blood
values less than normal range in HIV-infected patients and
their association with number and type of HIV-associated
oral lesions. One hundred and seventeen HIV-infected
patients in a southern Thai hospital were included. Anemia
(69.2%), leukopenia (29.1%), and lymphopenia (11.1%)
were the most common haematological abnormalities.
Lymphopenia was significantly associated with an increased
number of HIV-associated oral lesions, the presence of any
HIV- associated oral lesions and oral candidiasis (OC).
Lymphopenia was not found in patients without any oral
lesions. Low mean corpuscular volume (MCV) was more
common among patients without any oral lesion than among
those with OC and oral hairy leukoplakia. More studies will
________________________________________________________________________ 40
5th World Workshop on Oral Health and Disease in AIDS
help to explain this finding. Lymphopenia might be a
practical indicator in prediction of HIV-associated oral
lesions, particularly when CD4 and viral load are not
routinely accessible.
A10
Salivary and Oral Findings in HIVpositive and HIV-negative Subjects with
Well-controlled Medication
W Nittayananta1*, B Nauntofte2, E Dabelsteen3, K Stoltze4,
N Chanowanna1, S Jealae5
.
colony forming units of Candida. However, no statistically
significant association between hyposalivation and cervical
caries (p~0.55) or number of teeth (p~0.13) was observed.
Conclusions: Our study indicated that various
medications taken among HIV-infected individuals affect
their salivary flow rates and feeling of oral dryness. Since
saliva plays a key role in maintaining oral functions and
protecting the oral hard and soft tissues, xerogenic
medications should be prescribed with special caution in
this patient group.
1Department
of Stomatology, Faculty of Dentistry and
Unit, Faculty of Medicine, Prince of
Songkla University, Thailand, 2Department of Clinical Oral
Physiology, 3Department of Oral Diagnostic Sciences and
4Department of Periodontology, School of Dentistry,
University of Copenhagen, Denmark
5Microbiological
W Nittayananta: [email protected]
Background: Salivary glands are affected during the course
of HIV infection. Many medications may have the potential
to impair salivary gland function as well as to induce
feelings of oral dryness. In particular, little is known about
intake of medication and the presence of hyposalivation and
xerostomia among HIV-infected subjects.
Objectives: The aims were to assess the prevalence of
hyposalivation and xerostomia in HIV and HIV free
subjects with a well-controled consumption of medications,
to study the relationship between unstimulated and
stimulated salivary flow rates, to identify factors associated
with hyposalivation and xerostomia, and to correlate the
presence of hyposalivation and xerostomia to the presence
of oral candidiasis, the number of colony forming units of
Candida, presence of cervical caries and number of teeth in
the group of HIV infected subjects.
Subjects and methods: A cross-sectional study was
performed in the two different regions of Thailand; in the
north and the south. One hundred and thirty-five subjects
were enrolled (56 HIV-seropositive, mean age: 34.5 years
and 79 HIV-seronegative individuals, mean age: 29.5
years). Measurement of saliva flow rate comprised both
unstimulated and wax-stimulated whole saliva using the
draining method. The effect of HIV serostatus, stage of HIV
infection; asymptomatic, and symptomatic/AIDS, and
medications on the flow rates was analyzed.
Results: The unstimulated flow rates in the HIV-positive
subjects and HIV-negative controls were 0.19 and 0.33
ml/min (p~0.0024). The stimulated flow rates were 1.45 and
1.62 mls/min (p~0.31). In the HIV-positive group the
unstimulated flow rate was significantly higher in the
asymptomatic group 0.17 ml/min, compared to the
symptomatic/AIDS group 0.11 ml/min (p~0.003) whereas
the mean stimulated flow rate values were 0.99 and 1.15
mls/min respectively. No significant difference was found.
With respect to medication, unstimulated (or stimulated)
flow rates were found to be statistically significant lower in
subjects with xerostomia-inducing drugs compared with
those with no medication (p~0.004). The following factors
were significantly associated with hyposalivation; sex, stage
of HIV infection, risks group, systemic disease, medication,
smoking habit, and alcohol consumption. Hyposalivation
was found to be significantly associated with the number of
A11
Quality of Life and Oral Mucosal
Lesions among HIV-positive Drug
Addicts
SL Sujak*, Rahimah Abdul Kadir, Roziah Omar
University of Malaya, Kuala Lumpur Malaysia
SL Sujak: [email protected]
HIV-infected people are prone to oral mucosal lesions
(OML) which can affect the quality of life of this
population. The objective of this study was to evaluate the
effect of OML on the quality of life among HIV-positive
drug addicts. A cross-sectional case-control study involving
917 male drug addicts, 509 HIV-positive (case) and 408
non-HIV (control) drug addicts was carried out. The mean
age of the sample was 31.2±6.5 years old. A single item
global rating questionnaire was used to measure the quality
of life. The prevalence of OML was measured by oral
examination. The study showed that HIV-positive patients
registered a lower quality of life experience (m=27.3±21.6
point) than non-HIV subjects (m=40.8±30.0 point). The
difference was statistically significant (p=0.00). The study
also found that 41% of the HIV-positive subjects had OML.
Pseudo-membranous candidiasis was the most common
lesion (21%) follow by hairy leukoplakia (12%) and
erythematous candidiasis (12%). These findings suggest that
the presence of OML did not affect their quality of life as
shown by Pearson chi squared test. Findings from this study
concluded that OML had a minor influence on the general
quality of life of HIV-positive drug addicts.
HEALTH CARE NEEDS
A12
Oral and Maxillofacial Surgery for the
Seropositive Patient in a Resource
Limited Setting
UE Amanyeiwe-Adaka*, C Igbokwe, SO Ajike
Family Resource Centre ABU, Old Hospital Complex,
Kaduna, Nigeria
U Amanyeiwe-Adaka: [email protected]
Surgical management of HIV sero-positive patients in
developing countries such as Nigeria is highly inadequate.
This is due to the unavailability of enabling policies and
infrastructures that empower both the clinician and the
patients. The objective of this paper is to analyze the
problems encountered by the average Oral Maxillofacial
surgeon who has to manage sero-positive patients in an
environment with little or no access to sustainable anti
________________________________________________________________________ 41
5th World Workshop on Oral Health and Disease in AIDS
retroviral drug therapies and no access to affordable post
exposure prophylaxis for the surgeon. The need to address
these issues cannot be over-emphasized in a country with a
sero-prevalence of over 5.8% and having one of the worlds
highest incidences of road traffic accidents with associated
fractures of the facial skeleton. In conclusion there is a need
for surgeons to empower themselves with scientifically
correct knowledge of post exposure chemoprophylaxis and
the strict practice of universal precautions to provide care
for HIV+ patients. This should enable patients to regain
function of their masticatory apparatus in an environment
where nutrition combined with the treatment of
opportunistic infections is the cornerstone of management
of the HIV infection.
A13
Awareness of Occupational Exposure to
HIV Infection Among Dental Surgeons in
Chennai, South India- Study of
Knowledge, Attitudes and Behaviour
(KAB)
S Balasundaram*
Ragas Dental College, Chenai, India
S.Balasundaram: [email protected]
Issues: HIV infection is a major global health problem. In
India it is estimated that there are four to five million HIV
infected patients (NACO 2003). Increasingly, dental
surgeons are treating HIV infected patients and are exposed
to body fluids that are a potential sources of HIV infection.
The present study was undertaken to ascertain the
knowledge, attitude and behavior of dental surgeons
regarding occupational exposure to HIV infection.
Description: A pre-tested close-ended questionnaire with
46 items each having 5 possible response options was
completed by 300 dental professionals from various dental
colleges in south India. The questionnaire also had an openended segment to enable them to express their opinion.
Lessons learned: The study showed that dental surgeons
had appropriate understanding of the risk of occupational
exposure. Female dental surgeons were less willing to
manage HIV infected patients than their male counterparts.
Dental surgeons who graduated after 1986 were more aware
of universal precautions to be followed in HIV infection,
than the pre-86 graduates. Although knowledge was
adequate and appropriate, and infection control procedures
were followed the analysis of attitude and behavior revealed
that dental surgeons were not willing to treat HIV infected
patients, if they had a choice.
Recommendations: the results of this study emphasizes the
importance of continuing dental education programs to
focus on motivating dental surgeons to provide dental care
for HIV infected patients.
A14
Concerns Reported to Dental Protection
Limited by Dental Healthcare Workers
Treating HIV Positive Patients: 19852002
D Croser*
VM Clinic, Hammersmith and Fulham PCT, UK
.
D Croser: [email protected]
When undertaking clinical procedures it is possible that
either dental healthcare workers (HCW) or patient could
experience problems. Good communication between the
parties will either eliminate or contain the problem. If the
patient is not satisfied with the response they may complain
formally through a lawyer or the national registration body.
Either way the HCW is likely to face a situation with
significant financial or professional ramifications. They
seek assistance from a defence organisation like Dental
Protection Limited (DPL) which has 22,500 member
dentists ie. 70% of the total number of dentists registered in
the United Kingdom and 5000 hygienists and therapists. All
new potentially litigious cases are recorded under a detailed
case headline, facilitating a review of the issues which have
concerned HCWs whilst working with HIV positive patients
over the last 18 years. The data only records situations that
either threatened or resulted in legal action. There are no
data on unreported problems resolved at practice level. The
trend over the last 18 years has been a fall in the number of
cross infection concerns registered whilst the trend has risen
for patients refused treatment, when measured over the
same time period. Three other significant concerns were
also measured: Needlestick injuries, HIV testing and
confidentiality Conclusions The incidence of concerns about
cross infection has declined. The incidence of problems
associated with refused treatment appears to be on the
increase. Litigation against healthcare workers in general is
on the increase. Financial considerations are a reality for
people living with chronic illness and the difficulty of
finding state funded (NHS) treatment in the UK may be an
underlying issue. The 3 recent cases brought against UK
HCWs hinged on poor communication rather than on a
refusal to treat. All 3 HCWs knowingly cared for other HIV
patients. Concerns about needlestick transmission are more
numerous – possibly due to the availability of effective drug
regimens and a reduction in stigma
A15
Formulation of India-specific Protocols
for Oral Aspects of HIV Care Research
and Education
E Joshua*, TR Saraswathi, M Umadevi, S Solomon, NW
Johnson, K Ranganathan
Ragas Dental College & Hospital, Chennai, India
E Joshua: [email protected]
Acquired Immunodeficiency Syndrome (AIDS)/ Human
Immunodeficiency Virus (HIV) infection is a global health
problem. India has the second highest number of HIV cases
in the world. Dentists are encountering and treating more
and more HIV patients and oral lesions are major finding in
these patients. Though there are many health initiatives and
the policies pertaining to dentistry are in its early stages and
definitive framework is need of the hour to tackle the HIV
pandemic effectively. A panel of national and international
experts; working in the field of HIV presided over a session
consisting of a group of practicing and teaching oral and
maxillofacial pathologists and dental surgeons at the
national conference of the Indian academy of Oral and
Maxillofacial Pathologists, in New Delhi, India in
December 2003. The collective experiences were
deliberated on and a 13-point recommendation was framed
________________________________________________________________________ 42
5th World Workshop on Oral Health and Disease in AIDS
to be sent to the dental council of India for follow up,
modification and implementation.
Recommendation: The guidelines for continuing dental
education programs, counselling, oral screening/testing and
relevance of alternative medicine in the screening and
treatment of HIV were: 1) Continuing professional
education programmes for dental surgeons should be made
mandatory and should include HIV/AIDS awareness,
infection control and other relevant topics. 2) Undergraduate
dental education curriculum must include a strong
component on blood-borne viral diseases and their
implications for the dental profession, for patients and for
public health. 3) Interdepartmental work in dental colleges
should be encouraged for enhanced clinical care of HIV
positive patients and the effective prevention of disease
transmission in the community. 4) Close liaison needs to be
established between the dental profession and other
professional providers of health care and disease prevention.
5) A list of the locations and contact numbers of local HIV
counseling and testing services should be available in every
dental clinical setting. 6) The use and value of the
Complementary and Alternative Medicine (CAM) approach
to the management of HIV positive patients requires welldesigned, well-funded research and evaluation. 7) Infection
control procedures, using “Universal Precautions” are
mandatory in the dental clinical setting. Understanding of
these procedures must be part of mandatory CPE/CDE.
Consideration should be given by the DCI to means of audit
and enforcement, with sanctions. 8) Dental professionals
could play a valuable role in Public education about HIV
risk factors, prevention and management. 9) Messages
relevant to oral health should be integrated into all public
health education/ health promotion programmes. 10) Public
health programmes should harness the power of “stars” of
the media, sport and fashion to promote key messages about
HIV and tobacco risks. There is an important role for faithbased organisations. 11) The Indian Dental Council should
take appropriate measures to ensure that the dentists do not
discriminate or refuse to treat patients on the grounds of
their HIV status. 12) Opportunistic screening for oral
manifestations of HIV, for oral cancer/pre-cancer and for
manifestations of other oral soft tissue and systemic diseases
is the duty of every dentist every time a patient is seen. 13)
HIV testing should only be carried out by laboratories or
individuals adequately trained in both technical and
counseling aspects. Quality assurance methods should be in
place.
A16
Association between Self Risk
Perception of Occupational HIV
Infection and Hollow Needle Stick
Injuries Amongst Kenyan Oral Health
Practitioners
M D’Lima*1, P Wanzala2, ML Chindia3
1Private
Dental Practice P.O. Box 66875 00800 Westlands,
Nairobi, Kenya 2Kenya Medical Research Institute P.O. Box
20752 00200 City Square, Nairobi Kenya, 3Department of
Oral and Maxillofacial Surgery, Faculty of Dental Sciences,
University of Nairobi, Kenya.
Melvin D Lima: [email protected]
.
Background: Clinician perception of risk of HIV infection
during dental treatment should ensure safe work practices
and compliance with universal infection control guidelines.
Since accidental exposure still occurs use of an effective
HIV vaccine may provide adjunctive protection.
Objective: To investigate the risk of accidental exposures
from hollow needle stick injuries (HNI) amongst Dentists
who perceive themselves at risk of HIV infection in the
workplace.
Methods: This was a cross sectional study conducted
among 61 Kenyan participants at a dental conference. A
simple standardized semi-structured, self administered
questionnaire was used to anonymously collect basic
demographic data, HIV infection during practice risk
perception and knowledge about the HIV vaccine and postexposure prophylaxis
Results: The majority (44.3%) of respondents was aged
between 31 and 40 years and 68.9% were male. Of these
61.7% engaged in full or part time private practice and
45.6% of them treated between 6-10 patients per day. The
majority (93.3%) felt that they were at risk of HIV infection
during dental practice. Only 21.6% had access to an
antiretroviral starter dose in their dental facility. The
questions most infrequently answered were on the
mechanism and mode of infection (84%) and the nature of
the HIV vaccine (64%). The odds ratio of hollow needle
stick injury occurring was highest in the 41-50 year old
group. (1.5,95% CI (0.85-2.64). The Maentel-Haentzel
(MH) age adjusted odds ratio was 2.02, 95% CI (0.2-15.1).
The odds ratio in males was 3.75, 95% CI (021-66.7) and in
females 1.28, 95% CI (0.07-24.4) with the MH gender
Homogeneity was
found between odds ratios stratified for type of
practice, number of patients, injury by non-hollow
sharp, knowledge on the mechanism, target and
nature of the Kenyan vaccine and participation in a
clinical vaccine trial.
adjusted Odds ratio of 2.12 (0.3-16.7).
Conclusion: Age was a confounder in the risk odds ratio
estimates. Effect modification was observed with gender
and homogeneity was observed on questions about the
vaccine. It seems that females are more cautious than males
during practice and information on the
HIV vaccine as adjunctive protection
during practice may not vary the risk
perception and safe practice.
A17
Cost of In-patient Care for HIV-Positive Paediatric
Patients at Red Cross Children's Hospital, Cape Town,
South Africa
V Yengopal, S Naidoo*
University of the Western Cape, Cape Town, South Africa
S Naidoo: [email protected]
A retrospective study was undertaken to assess the direct
treatment costs for pediatric HIV+ inpatients over a one-
________________________________________________________________________ 43
5th World Workshop on Oral Health and Disease in AIDS
year period at a large Children’s Hospital in Cape Town,
South Africa.
Clinical and demographic data for 154 randomly selected
patients (25% sample) were obtained from hospital records.
Direct costs were calculated for admissions, X-rays,
medication, laboratory and surgical procedures. Of the
16032 admissions in 2001, 616 (4%) were HIV+. The most
common conditions diagnosed clinically on admission were
failure to thrive (64%), pneumonia (54%), gastroenteritis
(43%), oral thrush (42%); 54% were found to be
underweight for their age and 87% were malnourished. The
average length of stay in hospital was 9 days (versus 4.03
for others). The average cost for each HIV+ inpatient was
R18 765.76. Admission costs formed the bulk of this
amount (84%) followed by laboratory costs (9%),
medication (3%), surgical (2%) and X-Rays (2%). HIV+
patients consumed 26% (R11.56 million) of the total budget
(R44.65 million) for direct treatment costs. Current
admission policies at the hospital appear unsustainable (4%
of the patients consume 26% of the direct treatment costs) in
the presence of the ever-increasing demand for care and
tough measures by government to force health managers to
operate within budget.
.
analysis indicated that only viral load and CD4 counts were
associated with OPC status. Analyses involving viral load
and/or CD4 counts were adjusted only for IV drug use, the
only significant covariate. Classification tree and logistic
regression models support the finding that higher viral load
is more closely associated with occurrence of OPC (OR: 2.2
[1.2, 3.6]), and is 40% less likely to misclassify OPC status
as compared with using CD4 counts (OR: 0.61 [0.33, 1.11]).
Conclusion: These data strongly suggests that viral load
may be a better predictor of OPC status than CD4 counts
A19
Chlorhexidine Mouth-rinse in
Maintenance of Oral Candidiasis-free
Period among HIV-Infected Subjects:
an Intervention Study
W Nittayananta*1, TA DeRouen2, P Areeratchakaran3, T
Laothumthut4, K Pangsomboon1, S Petsantad5, V
Vuddhakul6, H Sriplung1, MD Martin2
1Prince
of Songkla University, Thailand, 2University of
Washington, USA, 3Chulalongkorn University, Thailand,
4Mahidol University & Bamratnaradoom Hospital, Thailand
W Nittayananta: [email protected]
CLINICAL / BASIC SCIENCE
CANDIDA AND MYCOTIC INFECTIONS
A18
Assessment of Association Between
Viral Load CD4 Count and Occurrence
of Oropharangeal Candidiasis in HIV+
Patients
JE Leigh*, D Mercante, E Lilly, PL Fidel
Louisiana State University Health Sciences Center and
Center of Excellence in Oral and Craniofacial Biology, New
Orleans, LA 70112, USA
Janet E. Leigh: [email protected]
Background: OPC is the most frequently observed oral
infection in HIV+ individuals. Historically, lower CD4
counts have been associated with an increased prevalence of
OPC in HIV+ patients, but HIV viral load has also recently
been recognized as a predictive factor. Objective: The
purpose of this study was to examine the impact of viral
load versus blood CD4 cell count on the prevalence of OPC
through modern exploratory statistical analyses.
Methods: We investigated such associations in 49 HIV+
individuals from an outpatient clinic population in the city
of New Orleans. Exploratory descriptive and graphical
analyses as well as inferential methods such as logistic
regression and tree classification models were used to
explore and compare the predictive and classification ability
of viral load and CD4 cell counts for OPC status. Analyses
were adjusted for several potentially confounding variables
such as use of HAART, protease inhibitors, antibiotics, or
other medications, and status of patient with respect to IV
drug use, smoking, and engagement in a high-risk behavior.
Other covariates included age, race, and gender.
Results: The cohort consisted of virtually equal numbers of
males and females and was 59% African-American and
35% Caucasian with a mean age of 42 years. Univariate
Background: Oral candidiasis is the most common oral
lesion seen in HIV/AIDS subjects. Due to the underlying
immune deficiency, recurrence of the lesion after successful
antifungal therapy is frequently observed among the
patients.
Objective: To determine if chlorhexidine mouth-rinse can
be used as an intervention after antifungal therapy to
prolong the time to relapse of oral candidiasis among
HIV/AIDS subjects.
Subjects and methods: A double-blinded randomized
clinical trial was performed in seventy-five HIV/AIDS
subjects with a clinical diagnosis of oral candidiasis
confirmed by culture. Oral examination and oral rinse
technique to determine the number of colony forming units
(CFU) of Candida were performed at the first visit. Total
lymphocyte cell counts were recorded as the baseline data
of the immune status of the subjects. Clotrimazole troche
was used to treat oral candidiasis and the subjects were
followed up every two weeks until the lesions were
completely eradicated. The subjects were divided randomly
into two groups. They received either 0.12% chlorhexidine
mouth-rinse (n=37, aged 22-52 y, mean 34 y) or 0.9%
normal saline solution (n=38, aged 22-55 y, mean 38 y), and
were followed up every two weeks until the next episode of
oral candidiasis was observed. Multiple regression analysis
and Kaplan–Meier survival estimates, were used to analyze
the data.
Results: Although the recurrence of oral candidiasis was
slightly longer in the chlorhexidine than the saline group the
difference between the two groups was not statistically
significant (p>0.05). The following variables were
significantly associated with the time of recurrence of the
lesion; frequency of antifungal therapy (p~0.011), total
lymphocyte cell counts (p~0.017), alcohol consumption
(p~0.043), and gingival location of the lesions (p~0.048).
The subjects who had low total lymphocyte cell counts
(<1,000 cells/ml) showed shorter oral candidiasis-free
periods than those with the higher counts. The number of
________________________________________________________________________ 44
5th World Workshop on Oral Health and Disease in AIDS
CFU of Candida at the first visit was not significantly
associated with the time to recurrence of oral candidiasis
(p~0.669).
Conclusions: Chlorhexidine mouth-rinse showed a small
but not statistically significant effect in maintenance of oral
candidiasis-free period among HIV/AIDS subjects
compared to normal saline solution. This lack of
significance may be due to the small sample size. Further
study with a larger number of subjects should be performed
to achieve statistical significance for such a small effect, or
to confirm our findings.
A20
Typing and Clinical Relevance of
Candida albicans in HIV-infected
Patients
Niyombandith*1,
M
Teanpaisan2
P
Pripatnanont1,
W
Satayasanskul1,
R
1Department
of Oral and Maxillofacial Surgery,
of Stomatology, Faculty of Dentistry, Prince of
Songkla University.
2Department
M Niyombandith: [email protected]
Typing of Candida albicans is important in epidemiological
studies. However researchers have investigated the
association between genotypes and biotypes of C. albicans
and the clinical status of patients. The aim of this study was
to investigate the relationship between genotypes, biotypes
and antifungal susceptibility of C. albicans isolated from
HIV-infected patients. A total of 189 strains of C. albicans
isolated from 41 HIV-infected patients were investigated in
the genotypic study using the randomly amplified
polymorphic DNA (RAPD) method. One hundred and six
strains were biotyped with the API ZYM system, API AUX
20C system and boric acid sensitivity. In addition the
minimal inhibitory concentration (MICs) of ketoconazole
required to inhibit 94 strains was examined. The
relationship was statistically analyzed using the Chi-square
test. The result showed there was no statistic significant
relationship between biotypes, genotypes and antifungal
susceptibility. However, the biotype and antifungal
susceptibility were associated with the individual host
(p=0.001, p=0.000 respectively). This study did not find any
association between genotyping, biotyping and antifungal
susceptibility. However, it may be useful to test the
association between the biotype and antifungal
susceptibility in HIV-infected individuals.
A21
The Frequencies and Biological
Properties of Candida albicans and C.
dubliniensis from HIV-Positive and Negative Japanese
.
prevalence of C. albicans and C. dubliniensis in HIV/AIDS
patients in Japan.
Objectives: The aims of this study were to investigate the
prevalence of C. dubliniensis and C. albicans in the
Japanese and to compare the pathogenicity of these species
in this population.
Methods: A total of 581 strains were isolated from 65 HIVpositive patients and 1438 HIV-negative controls. They
appeared as green colonies on CHROM agar. They were
typed as C. albicans A, B or C, or C. dubliniensis genotype
D using PCR. In addition growth on Sabouraud's Dextrose
Agar at 300C and 420C, carbohydrate assimulation, secreted
aspartic proteinases (SAP) production and antifungal
sensitivity of C. albicans and C. dubliniensis was assessed.
Results: More than half the isolates typed as A, 10% as B
and 20% as genotype C. Genotype D was found in 10% of
HIV-positive and HIV-negative subjects except in the
Okinawa island area where this genotype formed between
30 to 50% of the strains isolated from HIV-negative
subjects. These results showed that C. dubliniensis occurred
in both HIV-positive and negative subjects, but varied from
0 to 50% dependent upon the region. The average growth
rate of C. dubliniensis on Sabouraud's Dextrose Agar
incubated at 30°C was low 0.5 (n=10) compared to C.
albicans 0.96 (n=106). The carbohydrate assimilation tests
showed no difference between the two species, although up
to 75% of strains from HIV-negative subjects showed low
levels of xylose assimilation. All strains of C. dubliniensis
grew poorly at 42°C suggesting that growth at this
temperature could be used to distinguish between the two
species. Secreted aspartic proteinases (SAPs) production
levels of C. dubliniensis was moderate (relative activity
0.20, n=40) but lower than C. albicans (0.25, n=117). Most
C. albicans from HIV-positive patients produced low level
of SAPs (0.21, n=6). Contrary to our expectation,
susceptibility of C. dubliniensis to antifungal agents was
higher than C. albicans (Fluconazole p<0.05; Miconazole
p<0.001). C albicans isolates from HIV-positive patients
showed high susceptibility especially to the azoles
(Fluconazole p<0.0001: Intraconazole p<0.01; Miconazole
p<0.01) whereas C. dubliniensis susceptibility was low
(Miconazole p<0.01) but not resistant.
Conclusion: C. dubliniensis was less pathogenic than C.
albicans. However, C. dubliniensis derived from HIVpositive patients had lower susceptibility to azoles than
isolates from HIV-negative subjects. If strains are isolated
from HIV-positve patients with candidiasis, inducible
resistance must be considered.
A22
In vitro Antifungal Activity of Dodonaea
angustifolia, a Traditional South African
Medicinal Plant
T Ohshima*, S Namikoshi, U Yasunari, H Watanabe, N
Maeda.
M Patel*, MM Coogan
Tomoko Ohshima Organisation, Tsurumi University, Japan
Oral Microbiology, Oral Health Sciences, University of the
Witwatersrand, South Africa
Tomoko Ohshima: [email protected]
Introduction: Candida dubliniensis, which was originally
classified as C. albicans, has been implicated in candidasis
in HIV/AIDS patients. However, there is little data on the
M Patel: [email protected]
Introduction: Oral Candidiasis is one of the most
frequently opportunistic infections encountered in patients
with HIV infection. Antifungal drugs are often prescribed
for these patients.
However the long-term use of
________________________________________________________________________ 45
5th World Workshop on Oral Health and Disease in AIDS
antimycotic agents leads to the development of resistance.
This has led to a search for alternative agents. The leaves of
an indigenous South African plant Dodonaea angustifolia
are used as a traditional remedy for treating oral thrush.
Several acids and flavonoids have been isolated from this
genus but no direct link has been established between these
compounds and the reported beneficial effects.
Objective: This study investigated the antifungal properties
of a crude extract of this plant.
Methods: Dodonaea angustifolia leaves were collected,
dried, milled and extracted with acetone. The minimal
inhibitory concentration (MIC) and percentage kill of the
extracts was determined by a microtitre serial dilution
technique using C. albicans ATCC 90028 and 20 oral C.
albicans strains. Ten strains were isolated from HIV positive
Candida carriers and 10 from HIV negative Candida
carriers. A chlorhexidine gluconate mouth rinse that is
recommended for oral candidiasis was used as a positive
control. The MIC was performed in triplicate whereas the
percentage kill was tested once on all the strains.
Results: Both the plant extract and chlorhexidine inhibited
the growth of all the yeast isolates that were tested. The MIC
values for the plant extract ranged from 6.25 to50 mg/ml
whereas the range for chlorhexidine was 0.008 to 0.016
mg/ml. A concentration of 50 mg/ml of the crude plant
extract killed all the isolates within 45 seconds whereas 2
mg/ml chlorhexidine killed 18 of the 20 isolates within 90
seconds. One of the resistant isolates from a HIV positive
patient was killed after 120 seconds and the other from a
HIV negative subject required 180 seconds. There was no
significant difference between the results of strains isolated
from HIV positive and negative patients.
Conclusion: These preliminary results indicate that
Dodonaea angustifolia has antifungal properties. Further
research is required to identify the active ingredient and to
test the cytotoxicity of the plant extract.
A23
Antifungal Activity of Potassium
Lawsone Methyl Ether Mouthwash in
Comparison with Chlorhexidine
Mouthwash on Oral Candida Isolated
from HIV/AIDS Subjects
J Prasirst1, T Leewatthanakorn1, U Piamsawad1, A
Dejrudee1, P Panichayupakaranant2, R Teanpaisan1, W
Nittayananta*
1Faculties
of Dentistry, 2Pharmaceutical Sciences, Prince of
Songkla University, Thailand
Nittayananta: [email protected]
Background: Lawsone methyl ether (2-methoxy-1,4naphthoquinone) was first isolated from the dried flowers of
Impatiens balsamina L and from the Gentianaceae family. It
exhibits potent antifungal activity without obvious side
effects. However, the activity of lawsone methyl ether on
Candida albicans isolated from HIV/AIDS subjects has
never been studied.
Objective: To determine the antifungal activity of 0.5%
potassium lawsone methyl ether mouthwash compared with
that of 0.12% and 0.2% chlorhexidine mouthwash on
Candida albicans isolated from HIV/AIDS subjects.
.
Methods: An inoculum of Candida albicans isolated from
51 HIV/AIDS subjects was prepared and adjusted with
0.5 McFarland standard. 0.5 ml of the adjusted inoculum
was added in four test tubes with 0.5 ml of each mouthwash,
and 0.5 ml RPMI as a control. The tubes were then
incubated at 37ºC for 48 h. The turbidity of each tube was
compared with that of the control. The number of Candida
albicans colonies was determined by culture with 100 l of
the solution from each tube. Data were analyzed with oneway ANOVA.
Results: All of the test tubes with 0.5% potassium lawsone
methyl ether, 0.12%, and 0.2% chlorhexidine mouthwash
were clear compared with the controls. Positive culture of
Candida albicans was observed in 13 out of 51 plates
(25.4%) of 0.12% chlorhexidine mouthwash, 5 of 51 plates
(9.8%) of 0.2% chlorhexidine mouthwash, and 4 of 51
plates (7.8%) of 0.5% potassium lawsone methyl ether.
The mean number of Candida albicans colonies for each
mouthwash were 3.08 (range 0-40), 0.35 (range 0-13) and
0.84 (range 0-24), respectively. Antifungal activity was
found to be statistically significant different between 0.5%
potassium lawsone methyl ether and 0.12% chlorhexidine
mouthwash, and between the two concentrations of
chlorhexidine mouthwash (p<0.05). However, no significant
difference was observed between the antifungal activity of
0.5% potassium lawsone methyl ether and 0.2%
chlorhexidine mouthwash (P>0.05).
Conclusions: Potassium lawsone methyl ether showed
potent antifungal activity against Candida albicans isolated
from HIV/AIDS subjects. Clinical trials of this mouthwash
should be conducted to determine if it can be used as an
alternative mouthwash in prophylaxis of oral candidiasis
among HIV-infected individuals.
A24
A Longitudinal Evaluation of
Oropharyngeal Candidiasis in a Cohort
of HIV Positive Patients Attending a
Dedicated Clinic in New Orleans
K Shetty*, J Leigh
Department of General Dentistry, Louisiana State
University Health Sciences Center, New Orleans, USA
K Shetty: [email protected]
Background: The most common oral opportunistic
infection (OI) studied in HIV-positive individuals, whether
pre or post HAART (Highly Active Antiretroviral Therapy)
is oropharyngeal candidiasis (OPC). OPC is often one of the
first clinical signs of underlying HIV infection and will
occur in up to 90% of all HIV-positive persons sometimes
during progression to AIDS.
Purpose: Our purpose was to conduct a longitudinal
investigation into the prevalence and biological profile of
OPC in a cohort of HIV-positive patients attending a
dedicated HIV Dental Clinic in New Orleans from 1998 to
2004.
Study Design:
Specialists in oral medicine using
established presumptive clinical criteria for OPC examined
264 infected adults, who were recruited consecutively. Data
included responses to a questionnaire, clinical examination
and a histological examination of the biopsied tissue on
every single presentation of oropharyngeal candidiasis.
________________________________________________________________________ 46
5th World Workshop on Oral Health and Disease in AIDS
Results: The prevalence of OPC decreased significantly in
patients receiving dual- or triple-therapy HAART regimens,
which included a protease inhibitor (PI) compared to
patients not receiving HAART (p<0.05). There was a higher
incidence (n=35) of pseudomembranous OPC among the
female patients who had an infrequent history of
vulvovaginal candidiasis. However there was a significant
difference in the recovery of candidal infections amongst
patients with a low CD4+ count on a HAART regimen
which included a PI (p<0.05).
Conclusion: The pattern of OPC is changing in the era of
HAART therapy. OPC still remains the most common OI in
the HIV-positive person and there appears to be several
levels of immune defenses against OPC. The full potential
for anti-fungal therapy with PI has, however, yet to be
evaluated directly, and such studies are now critical in
assessing the usefulness of these agents in isolation or as
part of combined therapy regimens.
PERIODONTAL DISEASE AND GINGIVITIS
A25
The Burden of Necrotising Ulcerative
Gingivitis and Periodontitis among
Adult Patients Attending a Sexually
Transmitted Infection Clinic in
Johannesburg
SR Mtetwa*, J Yengopal, MJ Rudolph
Division of Public Oral Health, University of the
Witwatersrand, Johannesburg, South Africa
S Mtetwa: [email protected]
Background: Necrotising ulcerative gingivitis (NUG) has
been identified as the most common oral manifestation of
HIV/AIDS seen by public sector dentists in South Africa (S
A Dent J, 54: 594, 1999). Testing for HIV sero-status in
adult patients is not undertaken routinely at Public Sector
Clinics in Johannesburg. Esselen Street clinic, which is a
sexually transmitted infections (STI) clinic based in
Hillbrow, Johannesburg, provides an ideal environment to
study the prevalence of this condition among HIV infected
adult patients, many of whom do not know their HIV status.
The patients were not self-selected for painful oral disease.
Objectives: The objectives of the study were

To measure the prevalence of NUG and
Necrotising Ulcerative Periodontitis (NUP) in a
STI clinic

To correlate the HIV status with NUG and NUP
in patients with a positive diagnosis for NUG and
NUP.
Methods: One hundred and sixty five patients whose
average age was 28.8 years (range 19 to 48 years) were
recruited between 25 November 2003 and 9 March 2004. A
questionnaire was administered to obtain demographic
details and medical and dental information and the patients
were assessed clinically to establish the absence or presence
of NUG and NUP. Patients who were taking antiretrovirals,
those with advanced HIV disease and those who were
taking Cotrimoxazole were excluded from the study. Clinic
records were checked for information on HIV status. One
hundred patients were HIV negative and 56 were positive.
.
The diagnostic criteria for HIV associated periodontal
diseases of the EC-Clearinghouse (J Oral Pathol Med, 22:
289, 1993) were used to diagnose NUG and NUP. The
diagnostic features of NUG included ulceration, necrosis
and sloughing of one or more interdental papillae and
spontaneous bleeding. Tissue destruction was limited to the
gingival tissues and did not involve alveolar bone. NUP was
characterized by advanced necrotic destruction of the
periodontium. There was a rapid loss of the periodontal
attachment, destruction or sequestration of bone, and teeth
became loose. It was accompanied by severe pain and
halitosis was evident.
Results: The prevalence of NUG and NUP at this clinic was
1.8 (3/165). One of the 56 HIV positive patients had NUG
and NUP and two of the 109 HIV negative patients had a
positive diagnosis for NUG.
Conclusion: The correlation of the HIV status with NUG
and NUP in patients not self-selected for painful oral
disease was weak in this setting.
A26
Oral and Periodontal Lesions in 1700
HIV Positive Patients in South India
M Umadevi*1, K Ranganathan1, TR Saraswathi1, N
Kumaraswamy2, NW Johnson3, S Solomon2
1Department
of Oral Pathology, Ragas Dental College and
Hospital and 2YRG CARE, VHS Hospital, Chennai, India,
3Department of Oral and Maxillofacial Medicine and
Pathology, Guy’s, King’s & St Thomas Dental Institute,
London, UK
M Umadevi:
Background: India is estimated to have about 4.5 million
people infected with HIV. Oral lesions are common and
indicative of HIV infection. Periodontal lesions form an
important part of the constellation of oral manifestations in
HIV positive patients. There are very few reports of oral
lesions, which describe the periodontal lesions from India.
Objectives and setting: This report describes the oral
lesions and periodontal lesions in particular, in 1700 HIV
positive patients presenting to us at RAGAS and YRG
CARE, a non governmental organization in Chennai, South
India since February 1998.
Methods: Clinical diagnosis of oral lesions was based on
the criteria of EC Clearing House, 1993 and WHO. The
simplified Oral Hygiene index (OHI-S) and Community
Periodontal Index For Treatment Needs (CPITN) was
recorded as described in WHO reference and reviewed by
Page and Morrison, 1994.
Results: Of the 1700 patients, there were 1251 (74%) males
and 449 (26%) females. The age ranged from 7 months to
72 years. 83% of the patients were in the 21 to 40 year age
group. 83% of the patients presented with at least one oral
lesion. Gingivitis (69%) was the most common lesion
followed by periodontitis (28%) and candidiasis (21%).
44% of patients with periodontitis were smokers.
Periodontitis was highly associated with smoking, being 1.6
times more frequent in patients who smoke than in nonsmokers (p<0.01). Patients with candidiasis were 1.7 times
more likely to have periodontitis than patients without
candidiasis (p<0.01). CD4 counts were available for 1070
patients of which 454 patients had CD4 counts <200 and
________________________________________________________________________ 47
5th World Workshop on Oral Health and Disease in AIDS
616 had CD4 counts >200. There was a statistically
significant difference in the occurrence of candidiasis,
gingivitis and periodontitis between these two groups
(p<0.05).
A28
Conclusions: Oral lesions are a feature of HIV infection.
Gingivitis and periodontitis were the most common oral
lesions in our study. Further studies are necessary to
understand the importance of periodontitis in HIV patients
in our population.
HAART THERAPY AND ORAL LESIONS
A27
The Changing Face of Oral Lesions in
HIV/AIDS Patients Undergoing Highly
Active Antiretroviral Treatment
K Shetty*, J Leigh
LSU Health Sciences Center, New Orleans, USA
K Shetty: [email protected]
Background: Human Immunodeficiency Virus (HIV)
infection is associated with oral manifestations of diagnostic
and prognostic importance. With the advent of Highly
Active Anti-retroviral Therapy (HAART) there is anecdotal
evidence to suggest that the prevalence of oral lesions has
declined. The number of prevalence studies, carried out in
the era of HAART is, however, meagre.
Purpose: The purpose of this study was to determine
temporal trends in the prevalence of oral manifestations of
human immunodeficiency virus (HIV) in a patient
population predominantly on HAART, attending a
dedicated HIV Dental Clinic in New Orleans.
Study Design: Specialists in oral medicine using
established presumptive clinical criteria for HIV-associated
oral lesions examined five hundred and seventy HIVinfected adults recruited consecutively.
Results: Overall prevalence of oral lesions (35.7%)
significantly decreased from early to late periods with some
variation by lesion type. Oral candidiasis was the most
common oral soft tissue lesion (58.5%) with a striking
increase in the erythematous variety. Prevalence of hairy
leukoplakia, Kaposi’s sarcoma and necrotizing periodontal
diseases decreased significantly (p<0.05). There was an
increase in salivary-gland disease (14.3%) and a striking
increase in warts: three-fold for patients on antiretroviral
therapy (n=14) and six-fold for those on HAART (n=28).
Conclusion: The pattern of oral opportunistic infections is
changing in the era of HAART therapy. This pattern of oral
disease suggests that an increase in oral warts could be
occurring as a result of the immune reconstitution of
patients on HAART.
BASIC SCIENCE
VIRUSES: INTERACTION AND EXPRESSION
IN HIV DISEASE
Human Papillomavirus (HPV) Type 32 Specific Serum
IgG Response in HIV-Infected Adults
.
JE Cameron*1,4, JE Leigh2,4, K Shetty2,4, N Lindsey3,4, E
Lilly1,4, PL Fidel1,4, ME Hagensee3,4
1Department
Microbiology, Immunology & Parasitology,
Dentistry, 3Medicine, 4 Center of Excellence in
Oral and Craniofacial Biology, Louisiana State University
Health Sciences Center, New Orleans, LA, USA
2General
JE Cameron: [email protected]
The incidence of oral warts has reportedly increased in
HIV-infected patients during the era of HAART. We have
identified HPV-32 as the primary cause of oral warts in the
New Orleans HIV cohort. In order to examine defects in the
host response to HPV-32, we cloned and expressed the
HPV-32 L1 major capsid gene into the vaccinia virus
system to use as antigen in HPV-32 specific immunological
assays. Serum from 7 case patients (HIV+, with oral warts)
and 50 screening patients (HIV+, without oral warts) was
tested by enzyme-linked immunosorbent assay (ELISA) for
HPV-32 specific IgG antibodies. HPV-32 specific responses
were observed in 4/5 cases with HPV-32+ oral warts and in
48% of screening patients, but not in patients with oral
warts containing other HPV genotypes. Two out of three
screening patients with asymptomatic oral HPV-32 infection
seroreacted to HPV-32 capsid antigen. Responses were
more frequently detected in men, reflecting the
demographics of patients with oral warts in the New
Orleans HIV cohort. Future studies will utilize HPV-32
capsids as antigen in ELISA and cellular immune assays to
examine peripheral and mucosal responses to HPV-32
infections, in order to identify markers of susceptibility to
HPV-32 associated disease.
A29
Local Immune Reactivity in Oral Warts
and Oral Hairy Leukoplakia of HIVinfected Persons
E Lilly, K Shetty, K Mcnulty, JE Leigh, JE Cameron, ME
Hagensee, PL Fidel*
Louisiana State University Health Sciences Center and
Center of Excellence in Oral and Craniofacial Biology, New
Orleans, LA 70112 USA
P Fidel: [email protected]
Background: Oral hairy leukoplakia (OHL) caused by
Epstein Barr virus and oral warts caused by human
papillomavirus (HPV) are common infections in HIVinfected persons. Although each pathological condition
occurs most often under reduced blood CD4 cell numbers,
the lack of concurrent pathologies suggests that each results
from unique local immune dysfunction(s).
Objective: To evaluate local immune reactivity in oral
warts and OHL through salivary cytokines and tissueassociated T cells and cytokine mRNA.
Methods: A cohort of HIV+ persons (n=48) with and
without oral warts and OHL were evaluated. Salivary Th
and proinflammatory cytokines were quantified in
unstimulated saliva by ELISA. CD3, CD4, and CD8 T cells
were identified by immunohistochemical staining of frozen
tissue biopsies. Tissue-associated cytokine mRNA was
evaluated by real-time PCR.
Results: Few differences were detected in any parameter.
Compared to matched controls (HIV+ persons without
________________________________________________________________________ 48
5th World Workshop on Oral Health and Disease in AIDS
.
lesions but positive for oral HPV or EBV DNA), those with
OHL had increased IL-1, IL-2 and IL-10 in saliva, while
those with oral warts had increased IL-1, IL-2 and decreased
IL-6. CD8 T cells predominated in the tissue but in low
numbers. No differences were detected between warts and
lesion negative sites, while CD8 T cells were greater in
lesion negative sites compared to OHL. Tissue-associated
cytokine mRNA between lesion positive and lesion negative
persons showed decreased IL-2 and increased TNF in those
with warts, and decreased IL-1 and increased IL-6 and IL15 in those with OHL
function, interactions with HIV medications or other
changes in oral health. Future studies are indicated to better
understand these clinical findings.
Conclusion: There is no pattern of changes in local
immunity to explain the susceptibility to oral warts and
OHL, and overall little evidence for local immune reactivity
in either lesion. It is anticipated that while
immunosuppression plays an indirect role in susceptibility
to infection, virologic factors are most critical to prevalence.
Louisiana State University Health Sciences Center, New
Orleans, LA and Roche Molecular Systems, USA
A30
Detailed History of HIV+ Individuals
with Oral Warts Reveals the Possibility
of Two Epidemics
ME Hagensee*, JE Cameron, JE Leigh, K Shetty, N
Lindsey, P Hickman, E Lilly, PL Fidel
Louisiana State University Health Sciences Center, New
Orleans, LA, USA
ME Hagensee: [email protected]
Background: It has been reported that oral warts have
increased in prevalence in HIV+ individuals. To better
understan this, a detailed chart history of HIV+ individuals
from New Orleans with oral warts was performed.
Methods: The medical record of individuals with biopsyconfirmed oral wart was reviewed for the initial date of
diagnosis of the oral lesion, any history of anal, hand warts
or other HPV-related pathology, detailed history of HAART
and its effectiveness and all CD4 and HIV viral load (VL)
measurements. The HPV infection was genotyped by
consensus PCR.
Results: Charts from 13 patients with oral warts were
reviewed, comprising 819 months of care. There were 12
men, 9 were Caucasian, with an average CD4 of 256 and
HIV VL of 10,683 at the time of oral wart diagnosis. HPV32 was present in 63%. Ten were on HAART but only 5
being effective (HIV VL <400). There was evidence of 2
distinct groups: chronic - 6 men, with a long history of oral
warts (8-37 months) and also having anal or hand warts, and
acute - 6 men with a short history of oral warts (2-15
months) and rare history of other warts. The chronic group
had largely uncontrolled HIV infection (5/6 had detectable
HIV VL, with frequent therapeutic changes). In contrast, the
acute group had largely controlled HIV infection (1/6 had
detectable HIV VL with more stable regimens). Both groups
had similar average CD4 counts (245 vs. 248). The only
woman had an oral wart for a short duration (2 months) but
developed invasive cervical cancer 12 months later.
Discussion: Detailed histories of HIV+ individuals with
oral warts reveal two epidemics in the New Orleans cohort.
The chronic cases indicate a generalized susceptibility to
HPV infections at any body site. The acute cases may
reflect temporary changes in HPV-specific immune
A31
Site-specific Prevalence of 27 Human
Papillomavirus (HPV) Genotypes in the
Oral Cavity of HIV+ Individuals
N Lindsey*, JE Cameron, AF Hammons, TE Beckel, K
Shetty, JE Leigh, JR Kornegay, ME Hagensee
N Lindsey: [email protected]
Incidence of oral warts has recently increased in HIV+
individuals. Since little is known about the natural history of
oral HPV infection, a comprehensive analysis of the
prevalence of all oral HPV genotypes and the infection site
was undertaken. We are examining the prevalence of 27
genotypes using sensitive consensus PCR-based detection
on DNA obtained from nine oral samples (buccal mucosa,
labia, tongue, sublingual mucosa, palate, gingival, tonsils,
saliva and gargle) in HIV+ subjects who have no oral warts.
To date, over 300 people have been enrolled with 148
subjects having all sites screened for HPV. HPV was most
prevalent in gingival (32%) and labial (29%) tissue, though
all sites were susceptible. HPV+ subjects (54%) harbored
HPV at anywhere from one site to all sites tested.
Genotyping by Roche reverse line blot identified HPV-83
and 45 as the most prevalent genotypes. There was no
apparent site-predilection associated with any genotype.
Subjects with multiple HPV+ sites frequently carried the
same genotypes in each site. 27% of HPV infections were
untypable. The ongoing development of a rapid screening
test for additional oral-specific HPV genotypes will help
identify these untypable samples and promote studies of the
natural history of oral HPV infection/disease in susceptible
hosts.
A32
Cytomegalovirus Co-infection in AIDS
associated Oral Kaposi’s Sarcoma
S Meer1, M Altini1, CC Rachanis*2, H Ali1, and H
Coleman1
Division of Oral Pathology1, and Oral Medicine &
Periodontology2, University of the Witwatersrand,
Johannesburg, South Africa
CC Rachanis: [email protected]
Introduction: In contrast to developed countries, in South
Africa we are currently experiencing an ever-increasing
frequency in the number of cases of AIDS associated oral
Kaposi’s sarcoma (KS). This may be ascribed to the later
start of the HIV epidemic in Africa, to the fact that a greater
proportion of patients is now reaching stages III and IV of
the disease and to the fact that the vast majority of patients
do not have access to HAART.
Objective: The aim of this investigation was to demonstrate
cytomegalovirus (CMV) co-infection in oral KS and to
consider its possible significance.
________________________________________________________________________ 49
5th World Workshop on Oral Health and Disease in AIDS
Methods: Twenty cases of oral KS were retrieved from the
files of the Division of Oral Pathology at the University of
the Witwatersrand. In all cases the patients had tested
positive for HIV, but their CD4 counts were not known. As
far as we know none of the patients had signs of active
CMV disease. DNA was extracted from paraffin wax
embedded tissue blocks using a modified phenol chloroform
method and amplified using 2 rounds of PCR which yielded
amplified DNA of 233 base pairs. HHV8 DNA sequences
were identified using gel electrophoresis stained with
ethidium bromide. In each case additional 4-μm sections
were cut and immunohistochemically stained after antigen
retrieval with pepsin, using the strep avidin-biotin-complex
method (Dako) and CMV antiserum (Zymed, Clone DDG4,
CCH2). Appropriate positive and negative controls were
used throughout. The results showed the presence of HHV8
DNA sequences in all cases (20/20).
Results: CMV inclusion bodies were detected in 5 cases
(5/20) appearing as enlarged cells with an “owl’s eye”
appearance. The inclusions occurred in either macrophages
or endothelial cells or both. These findings do not represent
the true frequency of CMV co-infection as the sample was
biased. CMV infection in adult populations is very common,
but although the virus is shed in many body secretions
including saliva, it usually does not cause any disease. It is,
however, a major source of morbidity and mortality in
AIDS patients where multifocal sites of infection have been
demonstrated. In the oral cavity CMV infection has been
demonstrated in persistent oral ulcers in AIDS patients
(35% to 53%). CMV has also been previously demonstrated
in KS and is apparently frequently demonstrated using EM.
Conclusion: In conclusion, the question can be asked as to
what the possible significance of this not infrequent CMV
co-infection in oral KS might be. The presence of inclusion
bodies suggests an active infection rather than a passenger
status, although there is no new evidence to support a role
for CMV in the pathogenesis of KS. Is it a chance
occurrence in line with widespread tissue infection? Does
the KS lesional tissue provide a suitable nidus for viral
replication? Is there possibly virus transactivation, or can
the KS tissue act as a reservoir for CMV facilitating spread
to other sites as immuno-suppression worsens? These and
other questions remain to be answered.
SALIVA, BREAST MILK AND MUCOSAL
FLUIDS IN HIV TRANSMISSION
A33
HIV Antibody Screening; Saliva an
Alternative to Serum
S Balasundaram*
Ragas Dental College, Chenai, India
S Balasundaram: [email protected]
Background: HIV infectiion is a major health issue in India
with 4-5 million people infected by the end of 2003
(National AIDS Control Organisation). Given the high
burden of HIV infection relaible, rapid screening procedures
are needed, Studies have shown that saliva has the potential
to be a reliable alternative to blood as a diagnostic fluid. We
present here the results, of two serum based screening tests
available in India, for saliva.
.
Methods: A case control study (25 seropositive and 25
seronegative) was undertaken on patients attending the
outpatients unit of Ragas Dental college and Hospital and
YRG CARE Chennai; India. Saliva was collected by the
'spit-method'. Salivary antibodies to HIV were investigated
using ELISA and the immuno-chromatographic test (IHC).
The ELISA values were analyzed using the cut off
prescribed by the manufacturer for the serum test. The IHC
was modified to evaluate the colour change.
Results: Our study shows a sensitivity and specificity of
100% for the ELISA method, whereas the IHC procedure
demonstrated a sensitivity of 80% and specificity of 100%.
Conclusion: The result of this study showed a sensitivity
and specificity of 100% for the ELISA method, using a
commercially available serum based kit. If similar results
can be obtained with a larger number of patients this test
could be a reliable and easy diagnostic aid in populationbased screening procedures.
A34
A Study of Salivary Flow Rate,
Subjective Symptoms of Dry Mouth and
Secretory IgA Levels in HIV
Seropositive Patients in Chennai, South
India
B Kavitha*, TR Saraswathi, MU Devi, A Bharadwaj, S
Solomon, M Kumaraswamy, N Johnson, K Ranganathan
Ragas Dental College & Hospital, Chennai, India
B Kavita: [email protected]
Background: Xerostomia is classified as a lesion less
commonly seen in HTV infection (EC Clearing house
classification, Group 2). Xerostomia has been frequently
considered synonymous to impaired salivary flow.
However, it only describes the subjective complaints of dry
mouth and may occur despite normal salivary gland
function. The role of secretory IgA in saliva has been
discussed varyingly in literature.
Methods: The study group comprised of 50 randomly
selected HIV seropositive patients attending the out patient
department of Ragas - YRG CARE and 50 HIV
seronegative patient attending outpatient department of
Ragas Dental College & Hospital. A xerostomia
questionnaire was developed, and subjective symptoms of
dry mouth recorded for each patient and analyzed. Saliva
was collected using the spit method. Secretory IgA was
estimated using radial immunodiffusion assay.
Results: There was a decreased unstimulated and stimulated
salivary flow rate and increased perception of dry mouth in
HIV sero-positive patients. Salivary secretory IgA
concentration did not show any correlation with salivary
flow rate. However there was a direct correlation between
CD4 cell counts and salivary secretory IgA levels. There
was no significant correlation between salivary secretory
IgA and the presence of oral lesions.
Conclusion: Xerostomia is a major problem in HIC
infection. Analysis of subjective symptoms should be
undertaken along with salivary flow rate estimation to
improve the management of xerostomia patients in clinical
practice.
________________________________________________________________________ 50
5th World Workshop on Oral Health and Disease in AIDS
A35
Elevation of Salivary Antimicrobial
Protein Concentrations Against
Increase of Candida Depending on
CD4+ Count in HIV-Positives
S Namikoshi*1, T Ohshima2, H Chiba1, N Maeda1
1Department
of Oral and Maxillofacial Surgery, Tokyo
Medical University, 2Dept of Opal Bacteriology, Tsurumi
University School of Dental Medicine
S Namikoshi: [email protected]
An opportunistic infection, oral candidiasis, frequently
occurs among human immunodeficiency virus (HIV)positive individuals as an initial symptom in the oral cavity,
particularly in individuals with less than 200/µl of CD4+
count. However, many antimicrobial proteins such as
secretory leukocyte protease inhibitor (SLPI), lactoferrin,
lysozyme and sIgA exist in saliva. These proteins play an
important role in maintaining oral mucosal integrity. The
relationship between salivary antimicrobial proteins and
Candida carriage in both HIV-positive patients and healthy
controls was investigated. A sample was obtained from the
dorsum of the tongue and inoculated onto a selective
medium for Candida, CHROMagarTM Candida
(CHROMagar, Paris, France) and incubated at 300C for 48
hours. For measurement of antimicrobial proteins,
stimulated whole saliva was collected using Salivette®
(Sarstedt, Köln, Germany) by chewing sterile cotton wool
according to the manufacture’s instruction. The
concentrations of SLPI, lactoferrin and sIgA were
determined by enzyme-linked immuno-sorbent assay using
commercially available kits (SLPI:Quantikine®, R&D
Systems, Minneapolis, MN, USA, lactoferrin:Bioxytech®,
OXIS, Portland, OR, USA, sIgA:EIA s-IgA test®, MBL,
Nagoya, Japan). The concentration of lysozyme was
determined by a decrease in the turbidity of a Micrococcus
lysodeikticus suspension. Candida carriage in the HIV
group was significantly higher than the healthy control, and
increased in inverse proportion to the CD4+ count. When
compared to the controls, the level of SLPI in the HIV
group was significantly lower, whereas sIgA was higher.
The levels of lactoferrin and lysozyme in both groups were
similar. Contrary to our expectation, most antimicrobial
proteins were higher in Candida-positives than negatives.
All pairs of antimicrobial proteins showed significantly
positive correlation. These results suggested that salivary
antimicrobial proteins are elevated in reaction to the
increase of Candida. When compared among HIV-positive
patients who were divided into three categories based on
CDC classification, most antimicrobial proteins were the
lowest in category 3, suggesting the suppression of innate
immunity in HIV-positive patients whose CD4+ were less
than 200/µl. These results indicated the salivary
antimicrobial proteins are important factors for protection
against several infections including oral candidiasis.
However their level was suppressed in advanced cases of
HIVinfection.
.
A36
Identifying Viral Characteristics
Responsible for Oral Transmission of
SIV through Breast Milk in Rhesus
Monkeys
J Rychert1, L Fresh2, M Ratterree2, AM Amedee*1
1Louisiana
State University Health Sciences Center, New
Orleans, LA, USA, 2Tulane National Primate Center,
Covington, LA, USA
A Amedee:
Background: Several risk factors have been identified for
breast milk transmission of HIV; however, little is known
about the specific viral properties responsible. Using SIVinfected lactating rhesus macaques as a model, we have
shown that specific viral genotypes are transmitted, and that
the level of virus expressed in milk is the most significant
correlate of transmission.
Objective: The goal of this study was to characterize orally
transmitted viral genotypes and evaluate the dynamics of
this viral phenotype in naïve lactating macaques.
Methods: Viral envelope sequences from ten breast milk
infected infants were compared with the original virus
inoculum and genotypes expressed in milk. For in vivo
characterization, virus was amplified from one infected
infant (Macaque CK35) and used to inoculate six naïve
lactating macaques.
Results: SIV envelope sequences from infants infected
through breastfeeding only differed from each other and the
parental virus stock over the envelope variable regions 1
and 4 (V1 and V4). Using pair wise comparisons, sequences
from infants were significantly longer over the V1
sequences found in the parental stock or the milk of nontransmitting mothers, and contained more potential
glycosylation sites. Naïve lactating macaques inoculated
with SIV/CK35 had peak levels of milk virus similar to
animals inoculated with the parental strain, but expression
was more persistent. Transmission occurred rapidly in 4 of
6 mother-baby pairs infected with SIV-CK35, while rapid
transmission was only observed in 2 of 14 mothers infected
with the parental virus.
Conclusion: These results indicate that specific viral
genotypes are more persistently expressed in milk, and are
capable of oral transmission through milk. As interventions
for breast milk transmission of HIV are designed, the
SIV/CK35 isolate provides a valuable tool for targeting and
deciphering the specific viral properties responsible for
transmission.
________________________________________________________________________ 51
5th World Workshop on Oral Health and Disease in AIDS
A36-1
Immunoglobulin A (IgA) Levels in
the Oral Cavity and Respiratory
Tract of HIV+ Individuals Treated
with Highly Active Antiretroviral
Therapy (HAAR)
P Chaiyarit*,1, HL Twigg III2, RL Gregory2
1Faculty
2Indiana
of Dentistry, Khon Kaen University, Thailand
University School of Medicine, Indianapolis, USA
P Chaiyarit: [email protected]
In HIV+ individuals, depletion of CD4+ T cells is
associated with a loss of immune function, and the mucosa
becomes susceptible to various opportunistic infections.
Recent studies demonstrated that HAART increased
circulating CD4+ T cells. However, limited data are
available on the effect of HAART on mucosal immune
responses. Thus, the objective of this study was to measure
the mucosal IgA levels in the oral cavities and respiratory
tracts of HIV+ individuals treated with HAART in order to
provide additional evidence for the effect of HAART on
the mucosal humoral immune responses. Mucosal IgA
levels including IgA, IgA1, IgA2, secretory IgA (S-IgA), SIgA1, and S-IgA2 collected from parotid saliva (PS),
bronchial fluid (BF) and bronchoalveolar lavage (BAL) of
HIV+ individuals were measured by enzyme-linked
immunosorbent assay (ELISA). A total of 36 human
subjects were recruited for this research, including 16 HIVsubjects, 12 HIV+ patients with HAART and 8 HIV+
patients without HAART. One-way analysis of variance
(ANOVA) was used to compare the mucosal IgA levels
among groups. There were significantly lower levels of PS
IgA in HIV+ with HAART and HIV+ without HAART
subjects than in HIV- subjects (p<0.05). However, total BF
IgA levels from both HIV+ with HAART and HIV+
without HAART subjects were significantly increased.
BAL IgA1 and S-IgA1 levels were significantly increased,
whereas BAL IgA, and S-IgA2 levels were decreased in
HIV+ subjects. In summary, our findings demonstrated no
significant differences of mucosal IgA levels in the oral
cavity and respiratory tract of HIV+ individuals with
HAART and without HAART, but there were significant
effects between HIV+ and HIV- subjects.
EPITHELIAL AND NON-SPECIFIC HOST
FACTORS
A37
HIV-1 and C. albicans Regulate
Expression of Calprotectin (S100A8/A9)
in Tonsillar Epithelial Cells
A Tangjaturonrusamee*, M Herzberg, K Ross
University of Minnesota, USA
A Tangjaturonrusamee: [email protected]
Candidiasis is a major problem in HIV-positive patients.
This may relate to the increase of Candida virulence or the
reduction of host defense to microbial invasion in HIVpositive patients. Calprotectin (S100A8/S100A9; MRP8/14)
.
is an antimicrobial cytosolic protein expressed by gingival
keratinocytes and tonsillar epithelial cells. Cytosol from
calprotectin expressing cells contains antifungal activity.
We hypothesize that calprotectin is down regulated during
HIV infection leading to a reduction of the antimicrobial
activity of oral epithelial cells. Tonsillar epithelial cells
were tested by flow cytometry to demonstrate HIV receptors
on the surface. The surfaces were negative for chemokine
receptors CXCR4 and CCR5. Heparin sulphate receptors
CD3, CD138, LFA-1, CD4, DC-SIGN, CD64, CD89 and
CD32 were also negative but the beta-4 integrin CD104 was
found on 91% of cells. Thereafter primary tonsillar
epithelial cells grown in monolayer were incubated with
either C..albicans (MOI 100:1) or HIV-1, IIIB or Ba-L,
(MOI 1:10) for 2 hours. Viral uptake in epithelial cells and
transfer to Peripheral blood mononuclear cells (PBMCs)
were observed. Total RNA was extracted using TRIZOL.
Expression of mRNA was analyzed by Real time RCP using
TaqMan probes from Applied Biosystems for S100A8,
S100A9 and TBP (Tatabox Binding Protein; endogenous
control) and compared to expression of S100A8 and A9 in
tonsillar epithelial cells alone. S100A8- and S100A9specific mRNA was upregulated 8- and 29-fold respectively
when cells were incubated with C..albicans. Tonsil cells
incubated with HIV-1, either IIIB or Ba-L, showed a
decrease in S100A8- (IIIB, 0.03 fold; Ba-L, 0.3 fold) and
S100A9- (IIIB, 0.08 fold; Ba-L, 0.12 fold). In conclusion,
this data shows that tonsillar epithelial cells respond to HIV1 and C..albicans by a decrease or increase in S100A8- and
A9-specific mRNA. Down regulation of calprotectin by
HIV-1 may play a role in candidia infection of oral
epithelial cells.
A38
Innate Host Defense in Oral Mucosal
Resistance to HIV-1
T Greenwell-Wild*, G Ma, W Jin, KJ Lei, J Swisher, G
Peng, SM Wahl
OIIB, NIDCR, NIH, Bethesda, MD 20892-4352, USA
T Greenwell-Wild:
Background: Mucosal sites are vulnerable targets for HIV1 transmission. Nonetheless, in the oral mucosa,
transmission is infrequent, and although HIV-1 RNA is
detected, identification of infectious virus is rare. Our
earlier studies comparing innate and adaptive immune
factors that might contribute to resistance revealed that
components of the adaptive immune response were not
discriminatory between oral and genital mucosa and blood,
but differences could be detected in innate host defense
molecules. Neither the levels of HIV-1 specific IgA nor IgG
correlated with the inhibition of infectious HIV-1 since Ig
titers were highest in blood where infectious virus was
highest. Levels of the innate inhibitor, thrombospondin, did
not correspond with reductions in infectious virus. By
comparison, secretory leukocyte protease inhibitor (SLPI)
was highest in the oral cavity where infectious HIV-1 was
undetectable and lowest in peripheral blood in which
infectious virus was maximal. While SLPI has been shown
to inhibit HIV-1 in vitro and the distribution of SLPI at
entry portals portends its involvement in defending the host
from pathogens, the mechanism by which it inhibits HIV-1
has remained enigmatic.
________________________________________________________________________ 52
5th World Workshop on Oral Health and Disease in AIDS
Objectives: To define the mechanisms by which
mucosally-derived SLPI influences HIV-1 infection,
particularly in macrophages, which are involved in initial
viral selection, dissemination and transmission of virus to
CD4+ T cells and serve as long term covert reservoirs of
HIV-1.
Methods: M-tropic HIV-1 was added to macrophage
cultures in the presence or absence of SLPI and infection
monitored by p24 levels. Membrane SLPI binding proteins
were isolated by gel electrophoresis, followed by mass
spectrometry and sequence analysis. The expression of the
membrane binding proteins was monitored by RNA and
protein analysis, including fluorescence microscopy and
flow cytometry.
Results: SLPI inhibited viral infection by interaction with
the host cell, rather than the virus, and blocked infection at
an early stage in the viral life cycle. Isolation of membrane
SLPI binding proteins revealed several candidates,
including a phospholipid binding protein, characterized by
immunological parameters and binding specificity. SLPI
did not block HIV-1 binding, but rather inhibited postbinding and pre-reverse transcription, a point in the viral
life cycle consistent with a proposed role for SLPI in
inhibition of a fusogenic step.
Conclusions: Macrophages represent an important antiviral target due to their involvement in viral selection,
dissemination and transmission of HIV-1 and their ability to
serve as viral reservoirs. Particularly evident is the
enormous viral burden in macrophages in the later stage
HIV-1/AIDS during opportunistic infections. Identification
of a SLPI membrane binding protein provides new insight
into its mechanism of action and reveals a new cellular
cofactor supporting macrophage HIV-1 infection. These
data suggest that innate host defense mediators present in
the mucosa may influence HIV-1 infection and/or
transmission, providing insight into potential interventional
approaches.
A39
Permissive Factors Underlying HIV-1
Infection in the Tonsil
NM Moutsopoulos*1, T Greenwell-Wild2, N Vazquez2, J
Orenstein1, SM Wahl2
1Oral
Infection and Immunity, NIDCR, NIH, Bethesda, MD,
of Pathology, GW University, Washington
2Department
D.C.
N Moutsopoulos:
Background: The tonsils represent secondary lymphoid
organs implicated in all stages of HIV-1 pathogenesis.
Shortly after HIV-1 infection occurs, the tonsils become
heavily infected both in the germinal center areas and in the
region of the lymphoepithelium. Although it is still debated
whether the tonsils are a primary, as well as secondary site
of infection, it is clear that they are highly susceptible to
infection and viral replication.
Objectives: To dissect the cellular and molecular
mechanisms underlying the enhanced susceptibility of
tonsils to HIV-1 infection in vivo and in vitro.
Methods: Tonsil tissues from HIV-1 infected and
uninfected individuals were subjected to cDNA expression
.
array and compared with peripheral blood mononuclear
cells (PBMC). Gene expression profiles were confirmed
through RNAse protection assays (RPA) and
electrophoretic
mobility
shift
assays
(EMSA).
Immunohistochemical staining of infected and uninfected
tissues was performed to identify populations associated
with disease pathogenesis. Additionally, in vitro infection
of tonsil lymphoid cells was performed in parallel with
PBMC in order to define mechanisms of susceptibility
implicated in the cDNA array analysis.
Results: Compared to PBMC, a number of genes were
differentially expressed in uninfected tonsils, including
genes involved in signal transduction, cell cycle and
transcription. Evidence for increased gene expression of the
TH2 cytokines, IL-4, IL-10 and IL-6, and the transcription
factor NFATc in the tonsil tissues was consistent with
endogenous stimulation. In the tonsils from HIV-1
seropositive patients, an increased expression of genes
encoding for antiviral, apoptotic and extracellular matrix
degradation
factors
was
observed.
Additionally,
immunoregulatory genes, including the cytokines IL-10 and
TGF- were upregulated. Analysis of in vitro infection of
tonsil lymphoid cells revealed enhanced viral susceptibility
consistent with the HIV-1 localization in vivo. Furthermore,
altered cytokine profiles in vitro reflected their tissue
expression.
Conclusions: Persistent underlying immune stimulation in
HIV-1 uninfected tonsils is consistent with their enhanced
susceptibility to infection and increased viral production.
Similarly, the gene profile in HIV-1+ tissues may reflect
unsuccessful immune clearance of the virus, which
ultimately leads to immune deterioration and local tissue
destruction.
Furthermore,
the
presence
of
immunosuppressive factors may contribute to this
ineffective antiviral response, which may suggest potential
therapeutic options, as well as furthering our understanding
of mechanisms of immune regulation.
A40
Oral Epithelial Cell Anti-Candida
Activity – Evidence Against a
Presumtive Role for Carbohydrate
J Yano*, E Lilly, PL Fidel
Louisiana State University Health Sciences Center and
Center of Excellence in Oral and Craniofacial Biology, New
Orleans, LA
J Yano: [email protected]
Background: Host defense against oropharyngeal
candidiasis (OPC) caused by the mucosal commensal
organism, Candida albicans, is poorly understood. While
cell-mediated immunity (CMI) by Th1-type CD4+ T cells is
considered a critical host defense mechanism against OPC,
innate mechanisms are considered to have protective roles
as well. Among innate anti-Candida resistance mechanisms,
oral epithelial cells inhibit the growth of Candida species in
vitro. The mechanism of action includes a strict requirement
for cell contact with no role for soluble factors or epithelial
intracellular signaling. Abrogation of activity following
treatment of the cells with periodic acid, but not inhibitors
of proteins or phospholipids, had suggested a role for a cell
surface carbohydrate. However, studies with several
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5th World Workshop on Oral Health and Disease in AIDS
carbohydrate inhibitors have failed to identify any specific
effector carbohydrate.
Objective: To further address the putative role for
carbohydrates in the antifungal activity.
Results: Results showed that a putative effector
carbohydrate released from epithelial cells by periodic acid
treatment could not be regenerated or reattached. In other
studies, the putative carbohydrate(s) released into the
supernatant of periodate treated epithelial cells could not
competitively inhibit the antifungal activity by fresh
epithelial cells. Additionally, equivalent abrogation of
antifungal activity was observed irrespective of the amount
.
of carbohydrate released by treated epithelial cells, and
abrogation of antifungal activity was similarly observed
following treatment with several other acids. Finally,
antifungal activity was minimally affected by fixing the
cells prior to coculture where the majority of cells remained
impermeable to trypan blue as a measure of viability.
Conclusion: Together, these results suggest that instead of
antifungal activity being mediated by an effector
carbohydrate, activity is dependent on contact with intact,
but not necessarily live, epithelial cells by an as yet
unidentified acid-labile mechanism.
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